This document provides guidelines for the treatment of HIV infection. It discusses that treatment is complex, requires commitment from the patient, and is lifelong. The goal of highly active antiretroviral therapy (HAART) is to inhibit viral replication, prevent complications and transmission, decrease resistance, and prolong survival. It recommends initiating ART for symptomatic patients, those with CD4 counts below 350, coinfections like HBV/HCV, and pregnant women. First line regimens combine two NRTIs with one NNRTI, including lamivudine. Guidelines are provided for treatment failure, opportunistic infections, pregnancy, and post-exposure prophylaxis. Adherence is key to treatment success.

1. HIV TREATMENT
GUIDELINES
DR CHINTAN

2. Introduction
• Treatment of HIV infection and its complications is
complex, prolonged
• Needs expertise, strong motivation and commitment of
the patient, resources and is expensive
• ‘highly active antiretroviral therapy’ (HAART) with
combination of 3 or more drugs whenever indicated
• Monotherapy is contraindicated.

3. Contd.
• None of the currently available regimens can
eradicate HIV from the body of the patient
• Goal of therapy is:
• Inhibit viral replication
• Prevent complication
• Prevent transmission to other person
• Decrease resistance
• Prolong survival

4. Initiating antiretroviral therapy
(a) All symptomatic HIV disease patients.
(b) Asymptomatic patients when the CD4 cell
count falls to 350/μl or less.
(c) All HIV patients coinfected with HBV/HCV
requiring treatment.
(d) All pregnant HIV positive women.
(e) All patients with HIV-nephropathy

5. Therapeutic regimens
• All regimens should have 2 NRTI+1NNRTI.
• Include lamivudine in all regimens.
• The other NRTI can be zidovudine or stavudine.
• Choose one NNRTI from nevirapine or efavirenz.

6. contd
• Choose efavirenz in patients with hepatic dysfunction
and in those concurrently receiving rifampin
• Do not use efavirenz in pregnant women or in those
likely to get pregnant

7. First line Regimen
Preferred regimen
1. Lamivudine + Zidovudine + Nevirapine
Alternative regimens
1. Lamivudine + Zidovudine + Efavirenz
2. Lamivudine + Stavudine+ Efavirenz
3. Lamivudine + Stavudine + Nevirapine
Other options
1. Lamivudine + Tenofovir+ Nevirapine
2. Lamivudine + Tenofovir+ Efavirenz
3. Lamivudine+ Zidovudine + Tenofovir

8. Contd.
• Stavudine is substituted for zidovudine if patient is
anaemic
• Tenofovir is included when there is toxicity or other
Contraindication to both zidovudine and stavudine
• 3NRTI regimen is only for patients unable to tolerate
both nevirapine and efavirenz.

9. Contd.
• The PI containing regimens (2 NRTI + PI or NRTI + NNRTI +
PI) are reserved for advanced cases who have failed
earlier regimens.
• Low dose ritonavir boosted PIs are preferred over higher
dose single PI due to lower pill burden and better
tolerability
• If drug toxicity develops, either the entire should be
interrupted or the offending drug should be changed. No
dose reduction should be tried.

10. Contd.
• Treatment is life-long
• Institution of HAART in patients with latent or
partially treated opportunistic infection may produce
‘immune reconstitution syndrome’
• Pregnancy in women does not contraindicate ART.
• zidovudine, lamivudine, nevirapine, nelfinavir

11. Contd.
• Durability of the regimens depends mainly on adherence
of the patient to it.
• Compliance is a major determinant of outcome.
• Multiple antiretroviral, Anti-P. jiroveci, antitoxoplasma,
anti-CMV/herpes virus, antitubercular, antifungal or
other drugs may have to be used in a patient

12. Contd.
• Combination should be avoided
Combination Reason
Zidovudine + stavudine Pharmacodynamic
antagonism
Stavudine + didanosine: Increased toxicity
(neuropathy, lactic
acidosis
Lamivudine + didanosine Clinically not additive

13. Changing a failing regimen
• Plasma HIV-RNA count is not rendered undetectable (<50
copies/μl) within 6 months therapy
• Repeated detection of virus in plasma after initial
suppression to undetectable levels
• Clinical deterioration
• Fall in CD4 cell count
• Serious opportunistic infection

14. Contd.
• Failure is due to development of resistance to one or
more components of the regimen
• failed regimen should be changed entirely

15. List of second line regimens
(in order of preference)
NRTI PI
Standard regimens
Tenofovir + Abacavir Lopinavir
Atazanavir
Saquinavir Low ritonavir
Indinavir
Nelfinavir
Didanosine + Abacavir
Tenofovir + Zidovudine
Special circumstances
1Didanosine + Zidovudine
2. Didanosine + Lamivudine

16. Prophylaxis of HIV infection
Post-exposure prophylaxis (PEP)
• Indication:
Health care workers and others who get
accidentally exposed to:
– the risk of HIV infection by needle stick
– or other sharp injury

17. Contd.
AIM
• Suppress local viral replication prior to dissemination
• Not necessary when the contact is only with intact
skin, or with mucous membrane by only a few drops
for short duration

18. Contd.
Basic (2 drug) regimen (for low risk)
Zidovudine 300 mg +
Lamivudine 150 mg
Twice daily
for 4 weeks
Expanded (3 drug) regimen (for high risk)
Zidovudine 300 mg + Twice daily
Lamivudine 150 mg
4 weeks
+
Indinavir 800 mg(Another PI) : Thrice daily

19. Contd.
Low risk
• When the source is HIV positive, but asymptomatic
with low HIV-RNA titer and high CD4 cell count.
• Exposure is through mucous membrane, or
superficial scratch, or through thin and solid needle

20. Contd.
High risk
• When the source is symptomatic AIDS patient with
high HIV-RNA titer or low CD4 count.
• Exposure is through major splash or large area
• Contact of longer duration with mucous membrane

21. Prophylaxis after sexual exposure
• No data to evaluate the value of prophylaxis after
sexual exposure, the same regimen as for needle
stick may be used.

22. Perinatal HIV prophylaxis
• The first line NACO regimen for pregnant
women is:
• Zidovudine + Lamivudine + Nevirapine

23. Contd.
 In HIV-positive women who are not taking ART:
• Zidovudine (300 mg BD) started during 2nd trimester
and continued through delivery to postnatal period
• With treatment of the neonate for 6 weeks
• Has been found to reduce mother-to-child
transmission by 2/3rd.

24. Contd.
• AZT administered during labour and then to the
infant is also substantially protective.
• Breastfeeding by HIV-positive mother is
contraindicated,

25. MCQ
• Ganciclovir is preferred over acyclovir in the
following condition:
• (a) Herpes simplex keratitis
• (b) Herpes zoster
• (c) Chickenpox
• (d) Cytomegalovirus retinitis in AIDS patients

26. • Drug of choice for herpes simplex virus
infection is:
• (a) Acyclovir
• (b) Zidovudine
• (c) Indinavir
• (d) Ribavarin

27. • Drug of choice for chronic hepatitis –B is
• (a) Lamivudine
• (b) IFN-alpha
• (c) Ribavirin
• (d) Zidovudine

28. • Drug of choice for swine flu:
a. Acyclovir
b. Oseltamivir
c. Gancyclovir
d. Interferon alfa

29. • Which of the following is a reverse
transcriptase inhibitor?
• (a) Ritonavir
• (b) Saquanavir
• (c) Amprenavir
• (d) Tenofovir

30. • Pancreatitis is a common complication of
which one of the following
• (a) Zidovudine
• (b) Didanosine
• (c) Zalcitabine
• (d) Stavudine

31. • Which one of the following is not an
antiretroviral drug:
• (a) Saquinavir
• (b) Ganciclovir
• (c) Indinavir
• (d) Atazanavir

32. • Peripheral neuropathy not caused by which
antiretroviral drug?
• (a) Lamivudine
• (b) Didanosine
• (c) Zidovudine
• (d) Zalcitabine

33. • Integrase inhibitor
a. Raltegravir
b. Maraviroc
c. Zidovudine
d. Neverapine

34. • All of the following drugs are protease
inhibitors EXCEPT:
• (a) Nelfinavir
• (b) Saquinavir
• (c) Abacavir
• (d) Ritonavir

35. • Nevirapine is:
• (a) Non-nucleoside reverse transcriptase
inhibitor(NNRTI)
• (b) Nucleoside reverse transcriptase inhibitor
(NRTI)
• (c) Protease inhibitor
• (d) Fusion inhibitor

36. • The basis of combining ritonavir with
lopinavir:
• (a) Pharmaceutical compatibility
• (b) C4P3A4 inhibition by ritonavir
• (c) Long elimination half life of ritonavir
• (d) Ability to counteract side-effects of
lopinavir

37. • Bone marrow depressive drugs in the
treatment of AIDS patient are:
• (a) Didanosine
• (b) Zalcitabine
• (c) Zidovudine
• (d) Cotrimoxazole

38. • Select the drug that is active against both HIV
and hepatitis B virus:
• (a) Lamivudine
• (b) Indinavir
• (c) Didanosine
• (d) Efavirenz

39. 06-08-2021