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Early initiation of HAART why, when and how.
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Hiv.ppt

  1. 1. NATIONAL ART GUIDELINES PRESENTED BY DR SHASHANK AGRAWAL
  2. 2. NATIONAL ART GUIDELINES  globally 35 million people sufer at the end of 2013  India is the third highest no.of estimate people with HIV in world  in 2011 20.9 lakhs 86 % off where in 15 to 49 years of age  children less than 15 year accounted 7 %
  3. 3. now declining trend is observed due to a. effective prevention. b. care and treatment strategies of NACO. c. decrease In death due to anti retroviral therapy.
  4. 4. goals of ART-  CLINICAL GOALS  improve quality of life.  to reduce HIV related morbidity and mortality.  to provide maximal and durable suppresser of viral load.  to restore and preserve immune function.  the goal achieved by completely suppressing viral replication for as long as possible using well tolerated and sustainable treatment.
  5. 5. the programmatic goals are:- -To provide long term ART to eligible patients -To increase life span by at least 3 years. -50 % of patient engaged in overcome returning to their previous employment. -To encounter and report treatment and course on a quarterly basis. -To attain individual drug adharence rate of 95 % or more.
  6. 6. ART drugs are also used for  decrease risk of transmission of HIV from infected another to her child.  transmission after an accidental end needle stick injury from infected patient.  cause of sexual assault/rape etc.
  7. 7. Continue…..  Continuous high level of replication of HIV take place in the body regret from the early stage of infection.HIV destroy CD4 cells, the progressive immune system damage resulting susceptibility to differences of malignancies, neurological diseases, wastage & ultimately death  Antiviral drugs act on various stage of replication of the on HIV in the body interrupt in the process of viral replication.
  8. 8. when to start treatment……  Before ART clinical assessment to be performed to determine  classical staging of HIV infection  identify history of past illness specially related to HIV  identify currently HIV related illness requirement to treat  determining need for ART prophylaxis's  identify coexisting medical condition of patient that cause interference of choice of therapy
  9. 9. WHO STAGING stage 1 2 and 3 with the exception of moderat anaemia can be recognised clinically. stage 4 for where clinical diagnosis not possible. definate diagnostic criteria are recommended. Eg:- lymphoma and cervical cancer.
  10. 10. Stage 1 Stage 2  asymptomatic  persistant granular lymphadenopathy ->unexplained history of weight loss less than 10 % off previous measured body weight ->recurrent RT infection( sinusitis tonsillitis pharyngitis otitis media) -> herpes zoster -> angular cheilitis -> recurrent urinary infection -> recurrent oral infection -> papular pruritic eruption -> seborrhic dermatitis -> fungal nail infection
  11. 11. Stage 3  unexplained sever weight loss more than 10 % off previous measured body weight  unexplained persistent fever more than 100 degree ferehnite  persistent oral candidiasis.  oral hairy leukoplakia.  PulmonaryTB.  severe bacterial infection eg:- pneumonia bone infection meningitis bacteremia.  acute necrotizing ulcerative stomatitis gingivitis.  unexplained anaemia less than 8 gram, neutropenia or chronic thrombocytopenia .
  12. 12. Stage 4  HIV wasting syndrome  Pneumocystis pneumonia  recurrent severe bacterial pneumonia  Chronic herpes zoster infection  Oesophageal candidiasis  Kaposi sarcoma  CMV infection  Toxoplasmosis  HIV encephalopathy  Cryptococcus meningitis  recurrent septicemia  Mycosis  lymphoma  Invasive cervical carcinoma  Atypical disseminated leishmaniasis  HIV associated nephropathy and cardiomyopathy
  13. 13. ART recommendation  population.  adult to adolscent more than 10 year  adult and adolscent more than 10 years  Recommendation  initiate ART if cd4 cell count less than 350 cells /cumm  Initiate in all individuals with severe advanced hiv disease stage 3 or 4 or cd 4 count less than 350 cell /mm  initiate treatment regardless of WHO staging cd4 cells count  activeTB disease.  hepatitis B coinfection with sever CLD.  pregnancy or breastfeeding v s with HIV
  14. 14. patient with HIV and TB coinfection pulmonary or extrapulmonary  start ART irrespective of CD4 count and type ofTB ( start ATT first, initial ART as early as possible between 2 weekTB treatment is tolerated.
  15. 15. CPT prophylaxis  cotrimoxazole improve survival. by decreasing the risk of death from recurrent infection eg:-  Malaria  pneumocyctitis  severe bacteria infection  Pneumonia  toxoplasmosis  diarrhoea causing organism
  16. 16. UNDER NATIONAL PROGRAM, CPT initiated in -HIV infected adult with CD4 < 250 cells/cumm -WHO to clinical stage 3 or 4 irrespective of CD4 count.  One double strength tab or 2 single strength tab OD total daily dose 960mg ,CPT stopped.  IF patient on ART if CD4 cell count >250 for atleast 6 weeks & if on ART for 6 weeks without symptoms present is well.
  17. 17. Continue…  If come below 250 reintroduce secondary prophylaxiss is nedded to prevent recurrent OIS  Cotrimoxazole prophylaxis- to every one with CD4 cell count < 350 cells/cumm or with staging 3&4.
  18. 18. ART agents and optional regime  Different classes of art drugs act on different stages on HIV late cycle .Theoretically ART drugs can act on following ways during different stages of viral replication These include:-  Block bounding of HIV virus to target cells ( fusion inhibitors) Block viral RNA cleavage and one that inhibit reverse transcriptase
  19. 19. Continue…..  Block the enzyme integrase which help in the incorporation of the proviral DNA into host cell chromosome (integrase inhibitor).  Block the RNA to prevent viral protein production.  Inhibit the budding of viral from host cells.
  20. 20. Drugs available  Nucleuside reverse transcriptase inhibitors(NRTI)  Zydovudine (AZT)  Lamividudase (3TC)  Didanosure(ddi)  Zalcitabvie(ddc)  Abacavir(abc)  Eutricltabure(ftc)
  21. 21. Non nucleoside reverse trans crephase inhibitors  Nivirapura (NVP)  Efaverienz (EFV)  Delavirdure (DLV)  Fusion inhibiters (FI)  Erifavirtide (T-20)  Integrase inhibiters  Raltegravir
  22. 22. Protease inhibitors  Sequinavir (SQV)  Ritonavir (RTV)  Nelfuravir (NFV)  Amprenavir (APV)  Iuduravir (INV)  Lopuravir/ retonavir (LPV)  Foseamprenavir (LPV)  Atazanavir(ATV)  Tepranavir(TPV)
  23. 23. First level regime  Zidovudine + lamivudine 150ml  Terofovir 300ml+ lamivudine 150ml  Zidovudin + lamivudine + niverapine  E favireuz 600ml  Niverapine 200ml  FDCS( FIXED DOSE COMBINATIONS) are preferreed and easy to use  bd regime of FDCS are well tolerated and easily completed
  24. 24. PRINCIPLE FOR SELECTION  CHOOSE 3TC IN ALL REGIME (LAMIVUDINE)  CHOOSE 1 NRTITO WITH 3TC (AZT ORTDF)  CHOOSE OVER NNRTI.( NVP/EFV)  FIRST LEVEL PREFERED REGIMETDF +3TC +EFV  ALTERNATE PREFERED REGIME AZT +3TC+ EFV  TDF+ 3TC+NVP  SPECIAL CIRCUMSTANCES- ABE, D4T+BOOSTED PIS
  25. 25. Continue…  DO NOT START IF ONE PRESENTWITHTB. TREATATT FIRST FOR 2-8WEEKSTHEN STARTARTWITH EFV CONTINUE REGIME  AS PROPHYLAXISIS SINGLE DOSE OF NIVEROPINE IN ANTINATAL/ONSETOF LABOUR/DELIVERYTO BABY SOONAFTER BIRTH.
  26. 26. ADVRESE DRUG REACTION  TDF - RENAL DYSFUNCTION ,FOATAL GROWTH,BONE DENSITY  AZT- HEADACHE,NAUSEA,ANEMIA, NEUTROPENIA  3TC-LOW GENETIC BARRIERTO REESISTANCE  ABC- HYPERSENSTIVETY REACTION  EFV- CONTRAINDICATED IN PREGNANCY  NVP- HEPATOTOXICITY
  27. 27. Follow up patient on ART  FOLLOW UP 15 DAY,1MONTH, 2MONTH, 6 MONTH  INVERSE RECONSTITUTION INFLAMMATORY SYNDROME  IRIS- OCCURANCEOR MANIFESTATIONOF NEW OIS OR EXISTING OISWITH IN SIX WEEKSTO SIX MONTHAFTERWATCHING ARTWITH AN INCREASE IN CD4 COUNT.
  28. 28. Follow up patient on ART  Base line  1. symptoms  2.screen forT.B  3. physical exam  4.X-ray chest  Behaviour, psychosocial assassment educational level, emplyoment, financial resourse
  29. 29.  Social and family support  Disclosure status  Nutritional assessment  Family members  Use of condom Routine blood ,urine , b.sugar , LFT, RFT, CD4 cell count Pregnancy test, HBV,HCV screening 15th day- clinical and adherence counselling . Hb, weight, LFT 1st month –do-
  30. 30.  2nd month- clinical and adherence counselling . Hb, weight, LFT  6th month- clinical and adherence counselling . Hb, weight, LFT, RFT, LFT, urine & CD4 cell count  MONITORING  HIV viral load testing is performed, bit not recommended in national program viral load, at 6 month of ART & then yearly for treatment failure.  If not then CD4 & clinical monitoring  Decrease CD4 count predicts higher mortality
  31. 31. If CD4 between 350 & 400 and pt not on ART repeat CD4 cell count after 1 month and consider treatment in asymptomatic patient CD4 Follow up  CD4 of any value between 350 & 500 and not on ART.  >500 and not on ART  Every 6 month & Repeat at 3 month Repeat at 6 month
  32. 32. When to change THE THERAPY  1. adverse effect  2. treatment failure  3. inconvenient regime  4. occurance of activeTB  5.pregnancy
  33. 33. TREATMENT FAILURE CLINICAL FAILURE  In adult recurrent clinical events indicating severe immuno deficiency ( stage 4) IMMUNOLOGICAL FAILURE  CD4 cell count falls to the baseline or persisting below 100 cell/cumm, 50% fall in CD4 from on going peak value
  34. 34. Continue.... Virological failure  Defined by a persistently detectable, viral load, exceeding 5000 copies /mm ( i.e. two consecutive viral load measurement with in a 3 months interval and adherence support after at least 6 month of using ART drugs 2nd line thearpy  2NRTI + 1PI
  35. 35. Thank you
  • JoushanLulu

    Aug. 28, 2021
  • adriantilubuza

    Aug. 29, 2018
  • FaithIgbalagh

    Jul. 3, 2018
  • ssuserd04df4

    Jan. 11, 2017

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