Lab diagnosis of HIV infection/certified fixed orthodontic courses by Indian ...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
Lab diagnosis of HIV infection/certified fixed orthodontic courses by Indian ...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
To create awareness from trial and error method of medical science to proper effective treatment at right time , right dosage and with reduced side effects. To create healthy world.
Lizzy Schmidt, Director of the Woman's Program at Philadelphia FIGHT's Jonathan Lax Center, presented on HIV Treatment and PrEP at the June 2015 Ryan White Part A Planning Council meeting.
Provides information on diagnosis and management of acute HIV, including clinical recommendations and key points regarding presentation, diagnosis, and management, including while on pre- or post-exposure prophylaxis (PrEP or PEP).
Find more information at https://www.hivguidelines.org/hiv-testing-acute-infection/acute-hiv/
Sponsored by the New York State Department of Health (NYSDOH) AIDS Institute (AI) and the HIV Clinical Guidelines Program
To create awareness from trial and error method of medical science to proper effective treatment at right time , right dosage and with reduced side effects. To create healthy world.
Lizzy Schmidt, Director of the Woman's Program at Philadelphia FIGHT's Jonathan Lax Center, presented on HIV Treatment and PrEP at the June 2015 Ryan White Part A Planning Council meeting.
Provides information on diagnosis and management of acute HIV, including clinical recommendations and key points regarding presentation, diagnosis, and management, including while on pre- or post-exposure prophylaxis (PrEP or PEP).
Find more information at https://www.hivguidelines.org/hiv-testing-acute-infection/acute-hiv/
Sponsored by the New York State Department of Health (NYSDOH) AIDS Institute (AI) and the HIV Clinical Guidelines Program
What are the precautionary measures for Human Immunodeficiency Virus?Lal PathLabs
A virus that attacks the immune system, the natural defense system of our body is what we consider as Human Immunodeficiency Virus. This is the one which kills the cells of the body. Here we will have a complete analysis of what this disease and also the reasons for spreading of the disease and how adversely this affects our body, along with all its possible precautions.
Current epidemiology of meningococcal disease in the African meningitis belt and new WHO outbreak response guidelines after the Meningitis Vaccine Project
http://www.meningitis.org/conference2015
Evolution and Revolution: Current Issues in HIV and HCV Co-infection
Chapter 1 – HIV-Hepatitis C Virus Co-infection: An evolving epidemic
Chapter 2 - Management of HIV infection in HIV/HCV co-infected patients
Chapter 3 - Management of HCV in co-infected patients
Chapter 4 - HCV Therapy: Direct acting antiviral agents in co-infected individuals
Chapter 5 - Drug interactions with directly acting antivirals for HCV: Overview & challenges in HIV/HCV Co-infection
Chapter 6 - Complicated cases
Chapter 7 - Future trials of Hepatitis C therapy in the HIV co-infected
Chapter 8 - HCV infection in marginalized populations
Chapter 9 - HIV/HCV Co-infection: Through the eyes of a co-infected hemophiliac
Современное лечение ВИЧ: когда начинать, чем начинать. Contemporary Managemen...hivlifeinfo
.Contemporary Management of HIV. When to Start, What to Start.2016/Современное лечение ВИЧ: когда начинать, чем начинать.
In this downloadable slideset, Daniel R. Kuritzkes, MD, and Program Director Eric S. Daar, MD review key data and optimal approaches for first-line ART with contemporary HIV regimens.
Format: Microsoft PowerPoint (.ppt)
File size: 2.53 MB
Date posted: 2/9/2016
Kathleen Brady from the Philadelphia Department of Public Health presented her annual updated on the HIV Epidemic in Philadelphia at a February 2015 combined meeting of the Philadelphia Ryan White Part A Planning Council and the HIV Prevention Planning Group.
Начало АРТ впервые.Наилучшая практика.Best Practices in Antiretroviral Therap...hivlifeinfo
Best Practices in Antiretroviral Therapy: Initiating First-line Therapy
In this downloadable slideset, Charles B. Hicks, MD, discusses data on initiating antiretroviral therapy in HIV-infected patients.
Format: Microsoft PowerPoint (.ppt)
File size: 2.16 MB
HELPING PEOPLE CHANGE DRUG SEEKING BEHAVIOURMadhu Oswal
DRUG ADDICTION IS A CHRONIC, RELAPSING DISEASE OF THE BRAIN AND NEEDS BEHAVIORAL INTERVENTION ALONG WITH PHARMACOTHERAPY. HERE IS WHAT A DOCTOR CAN DO IN BUSY OPD TO HELP PATIENTS QUIT DRUGS
WHY DOCTORS NEED TO LEARN ABOUT ADDICTION?Madhu Oswal
Understanding the gravity of drug Addiction in India, Who, why, what , from where-all drug related questions answered. Why a family physician need to learn about addiction medicine
PPT is for primary care physicians and oral health specialist. Gives information about gravity of Tobacco addiction problem, oral cancer and its prevention.
Universal precations for health care workersMadhu Oswal
Lecture for medical students, , doctors or ant health care workers. It gives details how a medico can protect one self while caring for patients. Without discrimination.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
2. Overview
PEP
How to monitor after diagnosis ?
When to start ART?
What to start?
How to monitor after starting ART?
When to refer?
12/07/13
Samvad HIV Helpline 020-26381234
3. Mayur
Mr Mayur, 24 yr old, IT
guy called at 10 am on
Sunday morning.
H/O Unprotected
exposure (condom
slipped) night before.
Wants to know if he is
HIV infected- TODAY.
What to do?
12/07/13
Samvad HIV Helpline 020-26381234
4. “Window Period” Following HIV Infection
Acute HIV
syndrome
Primary
HIV
infection
Antibod
Asymptomatic
Viremia
------------------------------------ PCR
P24 a.g
ELISA
a
0
12/07/13
b
2
3 4
(Weeks since infection)
Years
Samvad HIV Helpline 020-26381234
Source: S Conway and J.G Bartlett, 2003
6
5. Diagnosis in the window period
After 12 weeks-antibody tests
Elisa/Rapid
At approx 4 weeks- HIV Duo
At approx 2 weeks- HIV RNA
HIV DNA
P24 Ag test
12/07/13
Samvad HIV Helpline 020-26381234
6. HIV DNA or RNA
HIV DNA or RNA tests are NOT recommended for
diagnosis in adults
False positive results in almost 20% of patients
Costs around Rs 4000.
The patients have to be subjected to antibody testing
for confirmation after 6 TO 12 weeks.
12/07/13
Samvad HIV Helpline 020-26381234
7. What to do?
Take history: was the risk significant?
Explain about window period
Any symptoms or signs of STD-Treat
Test for baseline HIV status, Hbs Ag, ? Anti HCV
Start PEP for HIV if indicated
Start Heb B vaccine course, if not vaccinated or HbS
Ag neg.
Risk reduction counseling
If woman( Mayuri), Emergency contraception
12/07/13
Samvad HIV Helpline 020-26381234
9. Drugs for Post exposure prophylaxis
Basic regimen:
1. Tenofovir 300+ Emtricitabine 200mg OD OR
2. AZT 300 mg + Lamivudine 150 mg BD
Expanded regimen:
1. Above plus Atazanavir 300 + Ritonavir 100 mg OD
2. Lopinavir 400mg +Ritonavir 100 mg BD
All for 4 weeks
Test after 6 weeks and 3 months for HIV and Hep B
12/07/13
Samvad HIV Helpline 020-26381234
10. After 3 months……..
Mayur ‘s HIV test is Negative
Risk reduction counseling .
12/07/13
Samvad HIV Helpline 020-26381234
11. After 3 months……..
Mayur ‘s HIV test is Positive (……..May be because
I didn’t take his call on Sunday )
Now what?
1. Disclose Mayur that he is HIV positive?
2. Do Western Blot test
3. Do HIV DNA/ RNA test?
4. Repeat Elisa test?
12/07/13
Samvad HIV Helpline 020-26381234
12. Mayur has confirmed HIV test
Now what?
Don’t know how to break the news, so keep silent
Refer to HIV specialist
Manage further
12/07/13
Samvad HIV Helpline 020-26381234
14. Then one fine day Mayur comes
with …….
12/07/13
Samvad HIV Helpline 020-26381234
15. Initial evaluation: history
Fever, night sweats, weight loss, cough (any duration):
TB
Past H/o OI’s: herpes zoster, chronic diarrhoea
ARV use in past
Co-morbidities: DM, HTN, CKD, Jaundice
Smoking, alcohol
High risk behaviour
Ask if he has any sexual partner, marital status , children
12/07/13
Samvad HIV Helpline 020-26381234
17. Initial evaluation: Laboratory workup
CBC with differential
Urinanalysis, creatinine
Blood sugar
Liver enzymes (optional)
Chest Xray/USG abdomen (before starting ART)
VDRL, TPHA
HbsAg, anti-HCV
CD4 Count
Cervical PAP smear in Mayuri
CD4 to be taken after treating Herpes Zoster
12/07/13
Samvad HIV Helpline 020-26381234
18. Tests NOT recommended routinely
Plasma viral load
ARV resistance testing
Fasting lipids
CMV, Toxo serology
sCRAG (in pts with CD4<200)
TB ELISA
Tuberculin testing
IGRA assays( TB Gold, Quantiferon)
12/07/13
Samvad HIV Helpline 020-26381234
19. Rule out TB
Need to screen all HIV patients for TB
Thorough history and physical to identify “TB suspects”
CXR and sputum AFB for all “TB suspects”
Need to screen all TB patients for HIV
Active promotion and routine offering of VCT
19
20. Mayur LOOKS very gloomy- as he he has given up on
his life
He has been keeping well for last 5 -6 years. No OI or
co –morbidity.
But he has taken to smoking and alcohol
No abnormal findings on physical examination
He has never married (He feels he won’t live long
anyway).
He has a girlfriend, whom he has not disclosed his
status.
All reports are normal.
CD4 count 325 cells/ml
12/07/13
Samvad HIV Helpline 020-26381234
21. What to do next?
1. Start ART?
2. Wait till CD4 falls upto 250 and start
Septran
3. Start ayurvedic treatment or Amway
products?
4. Refer?
12/07/13
Samvad HIV Helpline 020-26381234
22. Reassurance!! Reassurance!!!!Reassurance !!!!!!!
HIV is a chronic manageable disease like Diabetes,
like Hypertension, like asthma.
One can expect a near NORMAL lifespan with HIV
infected individuals
There is no cure, but with regular medicines one can
lead a normal life
12/07/13
Samvad HIV Helpline 020-26381234
23. More than just medicines…
Mental health
Diet
Hygiene-water, air
Exercise
Lifestyle
Addictions
Financial security
Disclosure / testing of partner, if indicated
12/07/13
Samvad HIV Helpline 020-26381234
25. When to start ART?
All Pt with hx of AIDS-defining condition
All patients with CD4 T-cell count of <350 cells/mm3
All Pt that are pregnant, HIV nephropathy, HBV co-
infection when HBV Rx is needed
Recommended for all Pt with 350-500 cells/mm3
Optional for Pt with >500 cells/mm3
DSHS,January 10, 2011
12/07/13
Samvad HIV Helpline 020-26381234
26. Benefits of ART
The survival after development of advanced HIV
disease increased from 18 months to over 25 years for
those who can access medicines.
Prevention of transmission
Secondary prevention
Post-exposure prophylaxis
Occupational and non-occupational
Mother to child transmission
Pre-exposure prophylaxis
12/07/13
Samvad HIV Helpline 020-26381234
27. Fusion
RNA
Reverse
transcriptase
ZDV, ddI,
ddC, d4T,
3TC, ABC,
TDF, FTC
DLV, NVP,
EFV, ETV
12/07/13
Viral protease
ENF
CCR5 antag.
maraviroc
RNA
Proteins
RT
RNA
RNA
RT
DNA
DNA
DNA
Samvad HIV Helpline 020-26381234
Provirus
Integrase
raltegravir
SQV
RTV
IDV
NFV
fAPV
LPV
ATV
DRV
TPV
30. First line regimens
Preferred
TDF/XTC/EFV or NVP( Trustiva, Effoday, )
Alternative
AZT/3TC/EFV or NVP
No options available
d4T/3TC/EFV or NVP
12/07/13
Samvad HIV Helpline 020-26381234
31. How to monitor when on ART?
1.
Look for IRIS: Immune reconstitution inflammatory
syndrome
2. Look for adverse effects- clinical and lab
investigations
3. Watch for drug drug interaction
4. Monitor response to ART: CD4 and Viral load
12/07/13
Samvad HIV Helpline 020-26381234
32. How to monitor when on ART?
IRIS: Immune reconstitution inflammatory
syndrome
Iris is occurrence or manifestations of new OIs
within six weeks to six months after initiating
ART; with increase in CD4 count
Two types: Unmasking and Paradoxical
12/07/13
Samvad HIV Helpline 020-26381234
33. IRIS
3 weeks after ART
(TDF+3TC+EFV)
12/07/13
Samvad HIV Helpline Source: Dr.Rajasekaran, Superintendent, GHTM,Chennai
020-26381234
33
35. How to monitor when on ART?
TDF: Renal, bone( Do urine R, S creat)
AZT: Anemia( Hb)
EFV: CNS
Nev: HSR, Hepatitis( LFT if symptomatic)
d4T: Neuropathy, lactic acidosis
12/07/13
Samvad HIV Helpline 020-26381234
36. Nevirapine (NVP)
Rash
Hepatitis
Risk
is greatest in first 6 weeks of therapy
Could be benign or fatal
Increased risk if started in women with CD4
above 250 and men with CD4 above 400
Not to use in concomitant Anti TB drugs
12/07/13
Samvad HIV Helpline 020-26381234
38. Efavirenz Toxicity
CNS Changes (excessive sleep or loss of sleep,
delusions, nightmares)
Rash
Hepatotoxicity (
Contraindicated during pregnancy
Teratogenic—Class D?
Useful in TB with HIV
Useful when stsrting ART in higher CD4 count
12/07/13
Samvad HIV Helpline 020-26381234
39. Long term Toxicity (After few
years)
Bone Marrow Suppression Myalgia
Anemia
Myopathy
Neutropenia
Pigmentation of nail
Peripheral Neuropathy
beds
Lipoatrophy
Lactic acidosis, fatty
Fat accumulation
Osteoporosis
Metabolic syndrome
liver
Pancreatitis
Cardiovascular side effects
Renal dysfunction
Hepatic dysfunction
12/07/13
Samvad HIV Helpline 020-26381234
42. Side effects/Toxicity of ART
Acute side effects: Rash, headache, nausea, vomiting,
loose motions, jaundice, anemia, excessive sleep or
loss of sleep, delusions, nightmares.
Chronic toxicity: Lipodystrophy- i.e change in body
shape with reduces fat on face and extremities and
increased fat deposition on abdomen and nape of
neck. Diabetes, bone loss, increased fats in blood,
tingling numbness in limbs
12/07/13
Samvad HIV Helpline 020-26381234
43. Test
On starting
ART
2-8 weeks after
starting ART
Every 3 to 6
months
Heamogram
√
√ (If on ZDV)
√
Urine R
√
√ (If on TDF,
esp in DM, HT)
√
BSL -F
√
ALT, AST ,S-bili
√
√
√
S. creatinine
√
√
√
S elec, S Ca, S
Phos, Cr Cl
√
√
√
Lipid profile
√
CD4 count
√
√
√( If very
stable and
high counts)
Viral load
√
√
√( If stable and
adherent)
12/07/13
Every year
√
Samvad HIV Helpline 020-26381234
√(If last report √ (If last report
abnormal)
normal)
45. Uses of CD4 Cell Count
Decision to initiate ARV
Guide in initiating OI prophylaxis
Assess progression of disease
Measure response to treatment (prognostication)
Detect immunologic treatment failure
Pneumocystis pneumonia
CD4 <200
TLC <1200
Toxoplasmosis
CD4 <100 and positive Toxoplasma serology
Cryptococcal meningitis
CD4 <100
12/07/13
Samvad HIV Helpline 020-26381234
46. CD4 COUNT
Normal CD4 count is 800-1050 cells/cu.mm
CD4 decreases at a rate of 40-60 cells per yr in an HIV
infected person.
Diurnal variation.
Treat OI before testing for CD4 count.
Sample :3 ml in EDTA bulb
CD4 count increases > 50 cells/mm3 at 4-8 weeks
after ART and then increases an additional 50 – 100
cells / mm3 per year thereafter.
Change more than 30% is significant.
Ideally CD4 count to be measured every 6 months.
12/07/13
Samvad HIV Helpline 020-26381234
48. Viral Load test of RNA PCR test
Commercial methods/kits in use:
Amplicor
B-DNA
NASBA
Preferable use the same kit/ method for repeat
testing
Sample :3 ml in EDTA bulb
Viral load should be below detectable level after 6
months of effective ART
12/07/13
Samvad HIV Helpline 020-26381234
49. Viral Load Monitoring
Where available, PCR or NASBA monitoring provide
valuable information about ART effectiveness
Viral load should be checked:
Every 3-6 months when not on ART
6 months after starting ART
Every 6 -12 months in stable ART patients
12/07/13
Samvad HIV Helpline 020-26381234
51. Detection of Treatment Failure
Immunological failure: If the CD4 cell count fail to
rise, increase < 25-50 in 1st yr, decline after previous
increase; return to pre-ART baseline.
Viral load testing : Failure to achieve undetectable
viral load within first 4-6 months of ART or rise after
achieving a stable, low level of persistent virus
In cases of 1st line treatment failure, refer to HIV
specialist.
12/07/13
Samvad HIV Helpline 020-26381234
52. Drugs with Potential to Interact
with
PIs or NNRTIs
Statins (simvistatin &
lovastatin)
Azole antifungals
Anticonvulsants
Anti-TB (Rifampicin)
Warfarin
52
Midazolam, trizolam
Alternative medicine
Clarithromycin
Oral contraceptives
Amitriptyline
54. 3 years after starting ART…..
Mayur has undetectable
viral load, CD4 945
cells/cu mm
No toxicity
Mayur comes with Mayuri,
his girl friend who wants
to marry him , pretty well
knowing his positive
status. She is HIV
negative.
12/07/13
Samvad HIV Helpline 020-26381234
55. What would you ADVISE?
Its illegal. They cannot marry.
2. She would get infected
3. They won’t have an option of having children
4. They can marry provided they are ready to adopt
safer methods.
1.
12/07/13
Samvad HIV Helpline 020-26381234
56. HPTN O52: The effectiveness of antiretroviral drugs in
reducing sexual transmission of HIV, by up to 96% in
serodiscordant couples.
Prep trials ((iPrEx study, Partners PrEP, and TDF2, FEMPrEP)
Circumcision : Male circumcision is associated with lower
risk for HIV. May reduce female to male
transmission( 50 to 60 %).
12/07/13
Samvad HIV Helpline 020-26381234
57. Advise for discordant couple
who want to have a child
If male positive
Undetectable viral load
Sperm washing with IUI
Timed intercourse with Prep
If female positive
Undetectable viral load
IUI or Timed intercourse with Prep
ART at-least from 14th weeks of pregnancy, till she stops
breast feeding her child
ART drugs for newborn for 4 to 6 weeks
12/07/13
Samvad HIV Helpline 020-26381234
58. Mayur and Mayuri have a cute
little baby girl
To test or not to test?
When to test and which tests to use?
12/07/13
Samvad HIV Helpline 020-26381234
59. Diagnosis in child born to HIV +ve
mother
After 18 months-
Before 18 months-
12/07/13
Antibody tests
(Elisa/Rapid/WB)
Antigen test
(HIV DNA PCR)
Samvad HIV Helpline 020-26381234
60. Advise for PPTCT
ART throughout pregnancy
If viral load undetectable close to labour, no need of
Caesarian section
Breast feeding advisable , but mother should
continue ART
ART drugs for newborn for 4 to 6 weeks
Chances of baby getting infection below 5% .
AIDS FREE GENERATION
12/07/13
Samvad HIV Helpline 020-26381234
62. Will AIDS really end?
Most unlikely.
No.s will fall for some time
It will restrict itself again among those who practice
risky behaviour, eg People practicing risky behaviour;
Sex workers; MSM
But complacency will bring it back again as our track
record against any STD is poor.
First line- Second line-Third line –Salvage regimen
12/07/13
Samvad HIV Helpline 020-26381234
Please refer to the Ethiopian DACA for current availability of drugs.
Notes: showing features of ascites, hepaotmegaly, and cervical lymphadenopathy.
Hepatotoxicity
If occurs in first 8 weeks: appears to be a hypersensitivity reaction and may be accompanied by drug rash, eosinophilia, and systemic symptoms.
Some patients have presented with nonspecific symptoms of hepatitis and progressed to hepatic failure.
Some patients on NVP develop hepatotoxicity later in the course of treatment. This form of hepatitis is more benign and similar to hepatitis seen with other anti-HIV drugs.
Most commonly appears on the body and arms
Two forms
Milder form – erythematous, maculopapular rash
continue medication with close observation
antihistamines may be administered
Severe form – with mucous membrane involvement, SJS & TEN
DRESS: Drug rash, eosinophilia, systemic symptoms
D/C if fever, blisters mucous membrane, conjunctivitis, edema, arthalgias
Usually appears within the first month of therapy, although occasionally it may start a few weeks later.
Patients that do experience a rash during the 2-week lead-in should not increase the dose until the rash has resolved (mean duration of rash is 14 days).
If the patient experiences rash and stops nevirapine on their own, provider would not reintroduce nevirapine with the dose escalation until the rash has resolved.
Patients should call their provider or pharmacist or return to clinic if they develop a rash or have any blistering in the mouth, and if they develop fever, arthralgias, or myalgias.
Rash
Usually morbiliform
Symptoms can be treated as needed (e.g., hydrocortisone cream and antihistamines for itching).
If patient develops a more serious rash (blistering of mucous membranes or skin, seen in about 1%-2% of cases; or SJS) EFV should be discontinued.
Median time of onset of the rash is 11 days and the duration is 14 days.
Hepatotoxicity
Rate is less frequent and less severe than seen with NVP.
Increase risk of occurrence if co-infected with HCV or also taking other hepatotoxic medications
Bioavailability (F): 40%-45% with or without food.
CSF Levels: .25%-1.2% of serum levels (these levels are above the IC95 for wild-type HIV)
T1/2: 40-55 hours
Elimination: Metabolized by CYP450 3A4. 14% to 34% excreted in urine as glucuronide metabolites and 16% to 61% in stool. Do not need to adjust dose for renal or hepatic compromis.
Nausea
Most common side effect for AZT
Eating prior to dose helps reduce nausea
Macrocytosis is common and not associated with anemia, see increase in MCV of 25-40 units after 6-24 weeks, serves as crude indicator of adherence.
Characterized by thinning of the buccal fat pad. May result or exacerbate stigma associated with HIV.
Appears to be most common with long-term stavudine use.
Usually not reversible, but changing medications may prevent progression.
This slide puts “CD4 cells” in context of all cellular blood elements.
CD4 cells are identified in the lab by a process called “flow cytometry.”
Accurate and reliable enumeration of CD4 T cell counts is crucial for monitoring the rate of progression to AIDS, both for initiating prophylaxis for opportunistic infections as well as monitoring the impact of antiretroviral therapy (ART).
Methodologies used to determine viral load.
Changes in CD4 count that would be evidence of treatment failure include:
Decline after previous increase; return to pre-ART baseline; failure to rise when ART is started
Changes in viral load that would be evidence of treatment failure include:
Possibilities: failure to achieve 1 log drop in viral load within first 4 weeks treatment; failure to achieve undetectable viral load within first 4-6 months of ART; persistent detectable virus after becoming undetectable; rise after achieving a stable, low level of persistent virus
Resistance testing should be ordered when:
available, a change in ART is being considered, and while patient is still taking the failing regimen
Pharmacists play a critical role in detecting drug interactions, before they happen.
Pharmacists need to ask patients what other medications they are currently taking whenever dispensing a new medication to avoid potential interactions. Be aware that changing or discontinuing medications may result in altered drug levels and potential adverse outcomes.