HIV/AIDS is caused by infection with HIV which damages immune cells. There are 33.2 million people living with HIV/AIDS globally. HIV is transmitted through contact with infected bodily fluids. The progression of HIV to AIDS typically takes 9-10 years if untreated, during which time the virus progressively destroys CD4+ immune cells. This leaves individuals vulnerable to opportunistic infections like PCP, TB, and cancers like Kaposi's sarcoma. Highly Active Antiretroviral Therapy (HAART) using a combination of at least three antiretroviral drugs from two classes can suppress the virus and prolong healthy life. Proper treatment and prevention measures can control the spread of the virus.

1. A.I.D.S.
A disease of human immune
system
Caused by H.I.V 1 or 2

2. Burden- 2007
33.2 million people with AIDS
2.5 million newly infected
2.1 million deaths

3. Transmission
Direct contact of mucous membrane or
skin with infected body fluids- blood,
semen, vaginal fluid, milk

4. HIVAIDS
Progressive damage to
CD4 +ve T-cells,
macrophages, dendritic/glial cells

5. Progression
Median time from HIV infection to
AIDS- 9-10 years
Median survival after AIDS-
9-10 months, untreated

6. Effects
Increased opportunistic infection
& cancers

7. Common OI
 TB, MAC infection
 PCP- Pneumocystis jirovecii
 Esophagitis- candida or viral
 Chronic diarrhea- bacterial, fungal, viral
 Toxoplasma encephalitis
 Cryptococcal meningitis
 Progressive multifocal leucoencephalopathy
 CMV retinitis

8. Cancers
 Kaposi sarcoma- HHV-8
 High-grade B-cell lymphoma- EBV
 Hodgkin’s lymphoma- EBV
 Primary CNS lymphoma- EBV
 Cervical/Anal cancer- HPV
 HCC- HBV/HCV

9. WHO staging
 Stage I- asymptomatic HIV infection
 Stage II- minor mucocutaneous
manifestations & recurrent URTI
 Stage III- unexplained weight loss/fever,
chronic diarrhea, severe bacterial infection,
pulmonary TB, low Hb/ANC/platelets
 Stage IV- other OI or cancers
 CDC- HIV +ve with CD4 T-cell <200
or <14% of all
lymphocytes

10. Diagnosis
 HIV antibody
 p24 antigen
 PCR
 Symptomatic person- sample reactive
with 2 different kits
 Asymptomatic person- sample reactive
with 3 different kits

11. Pretreatment considerations
CD4 cell count
Viral load (?)
Patient’s readiness

12. Pre-treatment evaluation
 HIV testing
 Risk factors & exposure
 System review- H & PE
 h/o TB, STD
 h/o pregnancy & contraception
 h/o vaccination
 Treatment history- ART & other

13. Pre-treatment lab. evaluation
 Confirm HIV
 CD4 count
 CBC, LFT
 Urine- R & M
 HBsAg & HCV Ab
 Pap smear
 Optional-
Viral load, lipid profile, CxR, pregnancy
test

14. Treatment
No cure or vaccine, yet.
HAART- highly active
anti-retroviral therapy

15. Goals of ART
 Clinical- prolongation of life &
improvement in quality of life
 Virological- greatest reduction in viral
load for as long as possible
 Immunological- immune reconstitution
 Therapeutic- rational drug use to
maximise benefit & avoid resistance
 Reduction of transmission

16. Who gets HAART?
CD4 count <200
CD4 count <350 in Stage III
Stage IV, irrespective of CD4

17. HAART regime
At least 3 drugs, belonging to
2 classes of anti-retrovirals
2NRTI + 1NNRTI/PI

18. Drugs available
 NRTI- Z,L,S,D,Z,E,A,T
 NNRTI- N,E
 PI- S,R,N,I,L/R
 Fusion inhibitors- Enfuviritide, Maraviroc
 Integrase inhibitors- Raltregavir
 Maturation inhibitors- Bevirimat, Vivecon
 CCR5 inhibitors

19. 1st
line HAART
Lamivudine-150 +
Zidovudine-300/Stavudine-30 +
Nevirapine-200/Efavirenz-600

20. NNRTI preference
Nevirapine- all & pregnant
Efavirenz- deranged LFT &
on Rifampicin containing ATT

21. Immune Reconstitution
Inflammatory Syndrome (IRIS)
 Occurrence/worsening of new/existing OI
within 6 weeks-6 months after initiating ART,
with an increase in CD4 count
 Lower the CD4 count, more likely IRIS
 Management-
 Stabilise OI, before starting HAART
 Life threatening OIstop ART
 NSAIDssteroids

22. Monitoring
 Regular counseling (adherence)
 Weight
 CD4- every 6 months
 HIV-RNA- every 6 months
 Hb- on Zidovudine
 SGPT- on Nevirapine
 RBS & lipid profile- on PI

23. Side-effects of ART
 First few weeks
N/V/D-zido./PI, Rash-NNRTI, Hepatotoxicity-NNRTI/PI,
Drowsiness/confusion-efavirenz
 First few months
Anemia/neutropenia-zido., Lactic acidosis-stavudine,
Peripheral neuropathy-stavu./didano., Pancreatitis-didanosine
 After ~12 months
Lipodystrophy-NRTI/PI, Dyslipidemia-stavu./efavirenz/PI,
IGT/DM-indinavir

24. 1st
line HAART failure
 At least after 6 months on ART
 Confirm failure-
 Clinical- new OI- stage 3 or 4, r/o IRIS
 CD4 count- persistently below 100 or fall >50% from
peak or <pre-therapy baseline after 6 months of ART
 Viral load- >1000 copies/ml
 Question adherence

25. Switch to 2nd
line ART
 CD4 &
virological failure
 WHO stage-
 1 & 2- consider switch
 3 & 4- recommend
switch
 CD4 failure
 WHO stage-
 1 & 2- don’t switch,
repeat CD4 in 3 months
 3- consider switch
 4- recommend switch

26. 2nd
line ART
Core- ritonavir boosted PI
With 2 NRTI or 1NRTI+1NNRTI
NRTI- Tenofovir, Abacavir, Didanosine

27. OI prophylaxis
 PCP- CD4<200- TMP-SMX 1 DS OD
stop when CD4>200
 Toxoplasmosis- CD4<100- TMP-SMX
stop when CD4>200
 MAC- CD4<50- Azithromycin, 1 gm OD
stop when CD4>100
 CMV retinitis- secondary only- oral Ganciclovir
stop when CD4>100
 Cryptococcal meningitis- secondary only-
Fluconazole stop when CD4>100
 Vaccination- HBV, HZV, HPV, S.pneumoniae

28. Special situations
 TB- start ATT
 CD4>350- defer ART
 CD4 200-350- ART after intensive phase ATT
 CD4<200- ART as soon as ATT is tolerated
 CLD- efavirenz, not nevirapine
 Pregnancy-
 Zido+Lami+Efavirenz (Nevirapine in 1st
TM)
 LSCS- if HIV-RNA>1000
 No ante-partum Rx-
mother-Zido+NVP, baby-Zido x6 wks ± NVP

29. Post-exposure prophylaxis
 Exposure- mild, moderate, severe
 Source- HIV +ve- symptomatic or
asymptomatic or status unknown
 Check baseline HIV, HCV, HBsAg
 Start within 2-72 hours- ideally ASAP
 PEP- Zido.+Lami.±PI (LPV/r,NLF,IND)
 Source HIV status unknown- no PEP/2 drug PEP
 Source HIV +ve- 2 or 3 drug PEP
 Duration-4 weeks
 Check HIV status- 1 & 6 months

30. Prevention
 Protected sexual intercourse- condom
 Precaution by healthcare workers to
prevent exposure to infected fluids
 Proper disposal of sharps & waste
 Needle exchange programmes for IVDU
 Perinatal treatment of mother &
newborn
 Avoid breast-feeding