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NATIONAL ART GUIDELINES
DR SHASHANK AGRAWAL
NATIONAL ART GUIDELINES
globally 35 million people sufer at the end of
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 %
now declining trend is observed
a. effective prevention.
b. care and treatment strategies of NACO.
c. decrease In death due to anti retroviral
goals of ART-
improve quality of life.
to reduce HIV related morbidity and mortality.
to provide maximal and durable suppresser of
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.
the programmatic goals
-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.
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.
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.
when to start treatment……
Before ART clinical assessment to be performed
classical staging of HIV infection
identify history of past illness specially related
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
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
Eg:- lymphoma and cervical cancer.
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
unexplained sever weight loss more
than 10 % off previous measured
unexplained persistent fever more
than 100 degree ferehnite
persistent oral candidiasis.
oral hairy leukoplakia.
severe bacterial infection eg:-
pneumonia bone infection meningitis
acute necrotizing ulcerative
unexplained anaemia less than 8
gram, neutropenia or chronic
adult to adolscent more than 10
adult and adolscent more than 10
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
initiate treatment regardless of
WHO staging cd4 cells count
hepatitis B coinfection with sever
pregnancy or breastfeeding v s
HIV and TB
start ART irrespective of
CD4 count and type ofTB (
start ATT first, initial ART as
early as possible between 2
weekTB treatment is
cotrimoxazole improve survival. by
decreasing the risk of death from recurrent
severe bacteria infection
diarrhoea causing organism
UNDER NATIONAL PROGRAM,
CPT initiated in
-HIV infected adult with CD4 < 250 cells/cumm
-WHO to clinical stage 3 or 4 irrespective of
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.
If come below 250 reintroduce secondary
prophylaxiss is nedded to prevent recurrent
Cotrimoxazole prophylaxis- to every one with
CD4 cell count < 350 cells/cumm or with
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
Block bounding of HIV virus to target cells
( fusion inhibitors)
Block viral RNA cleavage and one that inhibit
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
Inhibit the budding of viral from host cells.
First level regime
Zidovudine + lamivudine 150ml
Terofovir 300ml+ lamivudine 150ml
Zidovudin + lamivudine + niverapine
E favireuz 600ml
FDCS( FIXED DOSE COMBINATIONS) are
preferreed and easy to use
bd regime of FDCS are well tolerated and
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
ALTERNATE PREFERED REGIME AZT +3TC+ EFV
SPECIAL CIRCUMSTANCES- ABE,
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
Follow up patient on ART
FOLLOW UP 15 DAY,1MONTH, 2MONTH, 6
IRIS- OCCURANCEOR MANIFESTATIONOF
NEW OIS OR EXISTING OISWITH IN SIX
WEEKSTO SIX MONTHAFTERWATCHING
ARTWITH AN INCREASE IN CD4 COUNT.
Follow up patient on ART
3. physical exam
Behaviour, psychosocial assassment
educational level, emplyoment, financial
Social and family support
Use of condom
Routine blood ,urine , b.sugar , LFT, RFT, CD4
Pregnancy test, HBV,HCV screening
15th day- clinical and adherence counselling .
Hb, weight, LFT
1st month –do-
2nd month- clinical and adherence counselling
. Hb, weight, LFT
6th month- clinical and adherence counselling
. Hb, weight, LFT, RFT, LFT, urine & CD4 cell
HIV viral load testing is performed, bit not
recommended in national program viral load,
at 6 month of ART & then yearly for
If not then CD4 & clinical monitoring
Decrease CD4 count predicts higher mortality
If CD4 between 350 & 400 and pt not on
ART repeat CD4 cell count after 1 month
and consider treatment in asymptomatic
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
When to change THE THERAPY
1. adverse effect
2. treatment failure
3. inconvenient regime
4. occurance of activeTB
In adult recurrent clinical events indicating
severe immuno deficiency ( stage 4)
CD4 cell count falls to the baseline or
persisting below 100 cell/cumm, 50% fall in
CD4 from on going peak value
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