Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Antiretroviral Treatment of Adult with HIV
Infection
The guidelines of International Antiviral
Society - USA Panel
Present...
Brain storm
Which statement about initiating Anti Retroviral therapy (ART) according to (WHO)
and International Antiviral ...
Which statement about initiating drug therapy (ART) according to (WHO) and International
Antiviral Society - USA Panel rec...
 40 years old male , diagnosed 3 years ago with HIV , he was doing well with CD4
count 725 copies/ml at the time of diagn...
 A-Darunavir/r plus abacavir/lamivudine
 B-Lopinavir/r plus tenofovir
 C- tenofovir/emtricitabine
 D-Efavirenz/tenofov...
Classify the following Antiretroviral Agent by its action: efavirenz
 A.Nucleoside reverse transcriptase inhibitors
 B.N...
Classify the following Antiretroviral Agent by its action: efavirenz
 A.Nucleoside analog reverse transcriptase inhibitor...
Recommendation and Rationale
MAIN RECOMMENDATION
The New recommendations for HIV patient care include offering ART to all ...
 In the HIV-CAUSAL collaboration Study , there was a significant and steady
decrease in AIDS-free survival as the CD4 cel...
What is the Benefits from Early Start
ART .
 Prevention of progressive immune dysfunction (reduced immune activation)
 D...
What is the Risk from Early Start ART
 Reduced quality of life
 Development of drug resistance if adherence is suboptima...
Strength and quality of evidence are highest
with
 CD4 count < 500 cells/µL
 Pregnancy
 HBV or HCV co infection
 HIV-a...
 CD4 < 500 cells/µL (AIa)
 CD4 > 500 cells/µL (BIII)
 Pregnancy (AIa)
 Chronic HBV (AIIa)
 HCV (may delay until after...
Summary of New WHO
Recommendations June 2013
 As a priority, ART should be initiated in all individuals with severe or ad...
 All pregnant and breastfeeding women with HIV should initiate triple ARVs (ART), which
should be maintained at least for...
Baseline assessment
 Evaluate for HBV or HCV coinfection, diabetes mellitus, hyperlipidemia, cardiovascular disease,
smok...
Important considerations
 ART is recommended and should be offered to persons during the acute phase
of primary HIV infec...
 ART is recommended in all HlV-infected persons with tuberculosis (TB) and should
be started within 2 weeks of TB treatme...
CLASS OF HAARTs
Nucleoside RTIs
• Zidovudine (ZDV)
• Didanosine (ddI)
• Stavudine (d4T)
• Lamivudine (3TC)
• Abacavir (ABC...
Protease Inhibitors
• Saquinavir (SQV)
• Ritonavir (RTV)
• Indinavir (IDV)
• Nelfinavir (NFV)
• Lopinavir/r (LPV/r)
• Ataz...
The Initial Regimen
 Tenofovir/emtricitabine (TDF/FTC) OR Abacavir/lamivudine (ABC/3TC)
With third agent (NNRTI, boosted ...
2NRTIs + NNRTIs
 Efavirenz/tenofovir/emtricitabine (AIa)
 Efavirenz plus abacavir/lamivudine (AIa) in HLA-B*5701-negativ...
2 NRTIs + PIs
 Darunavir/r plus tenofovir/emtricitabine (AIa)
 Atazanavir/r plus tenofovir/emtricitabine (AIa)
 Atazana...
Alternative to Initial Antiretroviral
Regimens
NNRTI plus nRTIs
 Nevirapine plus tenofovir/emtricitabine or abacavir/lami...
Important Notes
Efavirenz
 once daily dose .
 must be taken on an empty stomach, preferably at bedtime ( increased
efavi...
 Women of childbearing potential should undergo pregnancy testing before
initiation of efavirenz (EFV) and receive counse...
Especial Considerations
 Severe hepatotoxicity and rash with nevirapine are more common in initial
therapy when CD4 cell ...
 In patients with reduced renal function, tenofovir should be avoided, or if
treatment for HBV coinfection is needed, dos...
 The recent recommendation for use of a 3-month, once-weekly regimen of isoniazid with
rifapentine for treatment of laten...
Patient Monitoring
 Plasma HIV-1 RNA levels should be monitored at least every 3 months after
treatment is initiated or c...
 Detectable HIV-1 RNA (>50 copies/mL) during therapy should be confirmed in a
subsequent sample between 2 and 4 weeks aft...
 Therapeutic drug monitoring is not recommended in routine care; however,
selected patients (eg, pregnant women, children...
Conclusions
Recommendation to begin therapy earlier in asymptomatic persons is informed by
 Increased evidence of the har...
 ART should be started as soon as possible, preferably within the first 2 weeks of
diagnosis, in patients with opportunis...
 ART is recommended in all HlV-infected persons with TB and should be started
within weeks of TB treatment when CD4 cell ...
Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS.
KAMC--NGHA-RIYADH
Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel
Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel
Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel
Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel
Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel
Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel
Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel
Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel
Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel
Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel
Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel
Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel
Upcoming SlideShare
Loading in …5
×

Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel

439 views

Published on

Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel

Published in: Health & Medicine
  • I never believed in spells,not until i contacted this great man.I'M CHRIS Sthole . I've been on Drugs since 2002,I was tested HIV+. 2.Due to some Family Issues, I had misunderstanding with my husband,and we went separate ways. But as i speak now I'm now HIV-, negative my husband is back with me and we are very happy again. I'm Very sure this Man can help every-one with HIS/HER problems.To me there is no problem that Dr.Tebe can't solve. HIS MAIL ADDRESS: drtebe2@gmail.com or call/whatsapp +2348140544262
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel

  1. 1. Antiretroviral Treatment of Adult with HIV Infection The guidelines of International Antiviral Society - USA Panel Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH IM-Infectious Diseases Division March 2014
  2. 2. Brain storm Which statement about initiating Anti Retroviral therapy (ART) according to (WHO) and International Antiviral Society - USA Panel recommendation is most TRUE?  A. Treat if CD4 count is <200.  B. consider treatment if CD4 count is <350 and initiate ART before CD4 count falls below 200.  C. Treat irrespective of CD4 count.  D. Do not treat till CD4 count is < 100.  E-Treat if CD4 count is < 500 . Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  3. 3. Which statement about initiating drug therapy (ART) according to (WHO) and International Antiviral Society - USA Panel recommendation is TRUE?  A. Treat if CD4 count is <200.  B. consider treatment if CD4 count is <350 and initiate ART before CD4 count falls below 200.  C. Treat irrespective of CD4 count.  D. Do not treat till CD4 count is < 100.  E-Treat if CD4 count is < 500 . Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  4. 4.  40 years old male , diagnosed 3 years ago with HIV , he was doing well with CD4 count 725 copies/ml at the time of diagnoses , he missed follow up with HIV Specialist , now he came with feeling of fatigue and generally unwell , CD4 count is 455 copies/ml , Viral load is 11800 copies /ml , other investigations all are normal , you decided to start ART after disused and agreed by patient , what will be the initial regimen of ART ?  A-Darunavir plus abacavir/lamivudine  B-Lopinavir/r plus tenofovir  C- tenofovir/emtricitabine  D-Efavirenz/tenofovir/emtricitabine  E- Efavirenz plus Darunavir/r. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  5. 5.  A-Darunavir/r plus abacavir/lamivudine  B-Lopinavir/r plus tenofovir  C- tenofovir/emtricitabine  D-Efavirenz/tenofovir/emtricitabine (AIa) .  E- Efavirenz plus Darunavir/r. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  6. 6. Classify the following Antiretroviral Agent by its action: efavirenz  A.Nucleoside reverse transcriptase inhibitors  B.Non-nucleoside reverse transcriptase inhibitors  C.Protease Inhibitors  D- Integrase Inhibitor Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  7. 7. Classify the following Antiretroviral Agent by its action: efavirenz  A.Nucleoside analog reverse transcriptase inhibitors  B.Non-nucleoside reverse transcriptase inhibitors  C.Protease Inhibitors  D- Integrase Inhibitor Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  8. 8. Recommendation and Rationale MAIN RECOMMENDATION The New recommendations for HIV patient care include offering ART to all patients regardless of CD4 cell count . Rationale  Patients starting ART when CD4 counts are < 350/μL have greater morbidity and mortality than those starting when CD4 counts are < 500/μL  Increasing evidence of detrimental effects of uncontrolled viremia at CD4 cell counts > 500/µL  Uncontrolled HIV replication, immune activation and inflammation associated with increase risk of ‘non-AIDS’ illnesses like Cardiovascular, hepatic, renal diseases and malignancies and ART with high CD4 associated with decreased incidence of diseases . Thompson et al, JAMA, 2012 Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  9. 9.  In the HIV-CAUSAL collaboration Study , there was a significant and steady decrease in AIDS-free survival as the CD4 cell count threshold for initiation of therapy decreased .  There was an estimated 38% increase in the hazard of AIDS or death when therapy was initiated below a CD4 cell count of 350/µL compared with 500/µl.  The COHERE study of 75 336 individuals examined the prognostic value of the CD4 cell count after virologic suppression by ART and noted that higher CD4 cell count was associated with incremental decreases in the risk of new AIDS events, all- cause mortality, and non AIDS mortality . Thompson MA, Aberg JA. Antiretroviral Treatment of Adult HIV Infection 2012 Recommendations of the International Antiviral Society–USA Panel. The Journal of American Medical Assocation. 2012.;308(4) . Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  10. 10. What is the Benefits from Early Start ART .  Prevention of progressive immune dysfunction (reduced immune activation)  Delayed progression to AIDS and prolonged survival  Decreased risk of non-AIDS/HIV-related morbidity (HIVAN, malignancies, neurocognitive dysfunction, cardiovascular disease, etc)  Decreased drug resistance  Decreased risk for some ARV toxicities  Decreased HIV transmission Thompson et al, JAMA, 2012 Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  11. 11. What is the Risk from Early Start ART  Reduced quality of life  Development of drug resistance if adherence is suboptimal  Limitation in future choices of ART if drug resistance occurs  Uncertain long-term toxicities and duration of effectiveness for some drugs/regimens  Possible transmitted drug resistance Thompson et al, JAMA, 2012 Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  12. 12. Strength and quality of evidence are highest with  CD4 count < 500 cells/µL  Pregnancy  HBV or HCV co infection  HIV-associated nephropathy  Active or high risk for cardiovascular disease  Opportunistic infections, including tuberculosis and meningitis  Age older than 60 years  Primary HIV infection  High risk for HIV transmission Thompson et al, JAMA, 2012.
  13. 13.  CD4 < 500 cells/µL (AIa)  CD4 > 500 cells/µL (BIII)  Pregnancy (AIa)  Chronic HBV (AIIa)  HCV (may delay until after HCV treatment if CD4 > 500) (CIII)  Age older than 60 (BIIa)  HIV-associated nephropathy (AIIa)  Acute phase of primary HIV infection, regardless of symptoms (BIII). Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  14. 14. Summary of New WHO Recommendations June 2013  As a priority, ART should be initiated in all individuals with severe or advanced HIV clinical disease (WHO clinical stage 3 or 4) and individuals with CD4 count ≤350 cells/mm3 .  ART should be initiated in all individuals with HIV with CD4 count >350 cells/mmsup>3 and ≤ 500 cells/mmsup>3 regardless of WHO clinical stage .  ART should be initiated in all individuals with HIV regardless of WHO clinical stage or CD4 cell count in the following situations: 1- Individuals with HIV and active TB disease . 2- Individuals coinfected with HIV and HBV with evidence of severe chronic liver disease . 3- Partners with HIV in serodiscordant couples should be offered ART to reduce HIV transmission to uninfected partners . Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  15. 15.  All pregnant and breastfeeding women with HIV should initiate triple ARVs (ART), which should be maintained at least for the duration of mother-to-child transmission risk. First-line ART should consist of two nucleoside reverse transcriptase inhibitors (NRTIs) plus a non-nucleoside reverse-transcriptase inhibitor (NNRTI).  TDF + 3TC (or FTC) + EFV as a fixed-dose combination is recommended as the preferred option to initiate ART .  If TDF + 3TC (or FTC) + EFV is contraindicated or not available, one of the following options is recommended: 1-AZT + 3TC + EFV 2- AZT + 3TC + NVP 3- TDF + 3TC (or FTC) Consolidated ARV guidelines, June 2013. WHO, HIV/AIDS.2013http://www.who.int/hiv/pub/guidelines/arv2013/intro/rag/en/index4.html.
  16. 16. Baseline assessment  Evaluate for HBV or HCV coinfection, diabetes mellitus, hyperlipidemia, cardiovascular disease, smoking, renal disease, other comorbid conditions  Consider drug interactions  Perform resistance testing  Assess for pregnancy  Patient readiness for treatment should be considered when deciding to initiate ART. Thompson et al, JAMA, 2012. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  17. 17. Important considerations  ART is recommended and should be offered to persons during the acute phase of primary HIV infection, regardless of symptoms (BIII)  ART should be started as soon as possible, preferably within the first 2 weeks of diagnosis, in patients with opportunistic infections (AIa)  The optimal timing for patients with cryptococcal meningitis is less certain, but initiating ART early during cryptococcal treatment may be associated with higher mortality; therefore, ART initiation in these patients should be managed in consultation with experts (BIII) Thompson et al, JAMA, 2012
  18. 18.  ART is recommended in all HlV-infected persons with tuberculosis (TB) and should be started within 2 weeks of TB treatment when the CD4 cell count is below 50/µL and by 8 to 12 weeks for those with higher CD4 cell counts (Ala).  The optimal timing for patients with TB meningitis is less certain, but ART should be started within the first 2 to 8 weeks of diagnosis and managed in consultation with experts (BIII). Thompson et al, JAMA, 2012. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  19. 19. CLASS OF HAARTs Nucleoside RTIs • Zidovudine (ZDV) • Didanosine (ddI) • Stavudine (d4T) • Lamivudine (3TC) • Abacavir (ABC) • Emtricitabine (FTC)
  20. 20. Protease Inhibitors • Saquinavir (SQV) • Ritonavir (RTV) • Indinavir (IDV) • Nelfinavir (NFV) • Lopinavir/r (LPV/r) • Atazanavir (ATV) • Fosamprenavir (Fos-APV) • Tipranavir (TPV) • Darunavir (DRV) Fusion Inhibitor • Enfuvirtide (T-20) CCR5 Antagonist • Maraviroc (MVC)
  21. 21. The Initial Regimen  Tenofovir/emtricitabine (TDF/FTC) OR Abacavir/lamivudine (ABC/3TC) With third agent (NNRTI, boosted PI, or InSTI):  Efavirenz OR  Atazanavir/r OR  Darunavir/r OR  Raltegravir Thompson et al, JAMA, 2012. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  22. 22. 2NRTIs + NNRTIs  Efavirenz/tenofovir/emtricitabine (AIa)  Efavirenz plus abacavir/lamivudine (AIa) in HLA-B*5701-negative patients with baseline plasma HIV-1 RNA <100,000 copies/Ml. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  23. 23. 2 NRTIs + PIs  Darunavir/r plus tenofovir/emtricitabine (AIa)  Atazanavir/r plus tenofovir/emtricitabine (AIa)  Atazanavir/r plus abacavir/lamivudine (AIa) in patients with plasma HIV-1 RNA <100,000 copies/mL 2 NRTIs + Integrase Inhibitor Raltegravir plus tenofovir/emtricitabine (AIa) .
  24. 24. Alternative to Initial Antiretroviral Regimens NNRTI plus nRTIs  Nevirapine plus tenofovir/emtricitabine or abacavir/lamivudine (BIa)  Rilpivirine/tenofovir/emtricitabine (or rilpivirine plus abacavir/lamivudine) with baseline plasma HIV-1 RNA < 100,000 copies/mL (BIa) PI/r plus nRTIs  Darunavir/r plus abacavir/lamivudine (BIII)  Lopinavir/r plus tenofovir (BIa) (or abacavir/lamivudine) (BIa) InSTI plus nRTIs  Raltegravir plus abacavir/lamivudine (BIIa)  Elvitegravir/cobicistat/tenofovir/emtricitabine** (BIb) Thompson et al, JAMA, 2012
  25. 25. Important Notes Efavirenz  once daily dose .  must be taken on an empty stomach, preferably at bedtime ( increased efavirenz concentrations observed following administration with food may lead to an increase in frequency of adverse reactions ) .  Dosing at bedtime may improve the tolerability of nervous system symptoms  Psychiatric symptoms, including insomnia, nightmares, confusion, memory loss, and depression, are common , and more serious symptoms such as psychosis may occur in patients with compromised liver or kidney function. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  26. 26.  Women of childbearing potential should undergo pregnancy testing before initiation of efavirenz (EFV) and receive counseling about the potential risk to the fetus and desirability of avoiding pregnancy while on EFV-based regimens(AIII).  Because the risk of neural tube defects is restricted to the first 5 to 6 weeks of pregnancy and pregnancy is rarely recognized after 4 to 6 weeks of pregnancy Federally approved HIV/AIDS medical practice guidelines. Aids Information. http://aidsinfo.nih.gov/drugs/269/efavirenz/0/professional. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  27. 27. Especial Considerations  Severe hepatotoxicity and rash with nevirapine are more common in initial therapy when CD4 cell count is >250/µL in women and >400/µL in men.  Tropism assay to confirm R5 virus should be done before prescribing maraviroc. Maraviroc is not effective in persons who have X4 or dual/mixed X4/R5 virus infection. Few data are available for maraviroc with tenofovir/emtricitabine or abacavir/lamivudine  In patients with or at high risk of cardiovascular disease, avoiding use of abacavir, lopinavir/r, or fosamprenavir/r might be considered (BIIa) Thompson et al, JAMA, 2012. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  28. 28.  In patients with reduced renal function, tenofovir should be avoided, or if treatment for HBV coinfection is needed, dosing should be adjusted according to the prescribing information (AIIa)  Given the increased risk of fragility fractures, it may be prudent to avoid tenofovir as part of initial therapy in postmenopausal women (BIIa)  The recommended initial ART regimen in the setting of rifampin based tuberculosis treatment is efavirenz plus 2 nRTls (AIa) Thompson et al, JAMA, 2012.
  29. 29.  The recent recommendation for use of a 3-month, once-weekly regimen of isoniazid with rifapentine for treatment of latent TB infection is not recommended for HlV-infected patients receiving ART (BIII).  The ART regimen for HIV- and HBV coinfected persons should include tenofovir and emtricitabine or lamivudine as the nRTI background (AIIa) Thompson et al, JAMA, 2012. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  30. 30. Patient Monitoring  Plasma HIV-1 RNA levels should be monitored at least every 3 months after treatment is initiated or changed for virologic failure to confirm suppression of viremia below 50 copies/mL (AIa).  CD4 cell count should be monitored at least every 3 months after initiation of therapy, especially among patients with less than 200/µL, to determine the need for primary opportunistic infection prophylaxis (BIII).  Once viral load is suppressed for 1 year and CD4 cell count is stable at 350/µL or greater, HIV-1 RNA and CD4 cell count can be monitored at intervals of up to 6 months in patients with dependable adherence (CIII). Thompson et al, JAMA, 2012.
  31. 31.  Detectable HIV-1 RNA (>50 copies/mL) during therapy should be confirmed in a subsequent sample between 2 and 4 weeks afterward and prior to making management decisions (BIII)  Sustained elevation of HIV-1 RNA between 50 and 200 copies/mL should prompt evaluation of factors leading to failure and consideration of switching of ART (BIII)  Baseline genotypic testing for resistance should be performed in all treatment- naive patients (AIIa) and in cases of confirmed virologic failure (AIa) Thompson et al, JAMA, 2012. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  32. 32.  Therapeutic drug monitoring is not recommended in routine care; however, selected patients (eg, pregnant women, children, and patients with renal or liver impairment) might benefit from this intervention (BIII)  Health care practitioners and health systems should initiate strategies to monitor and improve entry into and retention in care and ART adherence and to incorporate and analyze quality-of-care indicators (CIII) Thompson et al, JAMA, 2012. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  33. 33. Conclusions Recommendation to begin therapy earlier in asymptomatic persons is informed by  Increased evidence of the harmful effects of uncontrolled viremia and its associated immune activation and inflammation, even at higher CD4 cell counts  Evidence that all HIV-infected adults may benefit from ART  Data showing ART reduces likelihood of transmission of HIV.  ART is recommended and should be offered regardless of CD4 cell count(BIII).  ART is recommended and should be offered to persons during the acute phase of primary HIV infection, regardless of symptoms (BIII). Thompson et al, JAMA, 2012. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  34. 34.  ART should be started as soon as possible, preferably within the first 2 weeks of diagnosis, in patients with opportunistic infections (other than cryptococcal and tuberculous meningitis),with attention to drug interactions and the potential for immune reconstitution inflammatory syndrome (IRIS) (AIa).  The optimal timing of ART initiation in patients with cryptococcal meningitis is less certain, but initiating ART early during cryptococcal treatment may be associated with higher mortality; therefore, ART initiation in patients with cryptococcal meningitis should be managed in consultation with experts (BIII). Thompson et al, JAMA, 2012. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  35. 35.  ART is recommended in all HlV-infected persons with TB and should be started within weeks of TB treatment when CD4 cell count is below 50/µL and by 8 to 12 weeks for those with higher CD4 cell counts (AIa).The optimal timing for patients with TB meningitis is less certain, but ART should be started within the first 2 to 8 weeks of TB treatment and managed in consultation with experts (BIII). Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH
  36. 36. Presented by : Dr Hythum Salah Hassan –MBBS-AAHIVS. KAMC--NGHA-RIYADH

×