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HIV Infection (ART - Active Antiretroviral Therapy (Basic ARV schedules (2…
HIV Infection
ART - Active Antiretroviral Therapy
Therapy with a complex set comprising at least 3 drugs aiming at long-term suppression of HIV replication
Life long therapy
ART is recommended in all adults with chronic HIV infection irrespective of CD4 counts
The lower the CD4 count the greater the urgency to start ART immediately
Assessing HIV positive person to start and maintain treatment
Clinical assessment of patient (physical examination, basic laboratory tests: such as liver, kidney function, morphology, lipid profile, abdomen usg, chest X-ray, other on need
Genotypic resistance testing is recommended prior initiation of ART, ideally at the time of diagnosis otherwise before the initiation of ART
Basic ARV schedules
2 NRTI + PI, 2NRTI + NNRTI, 2NRTI + II
Different combinations depending on a need
NRTI – nucleoside reverse transcriptase inhibitor
NNRTI – non nucleoside reverse transcriptase inhibitor
PI – protease inhibitor
II – intergrase inhibitor
Aims
Viral load suppression
Reconstruction of immunologic system
Decrease of AIDS risk and death risk
Life comfort improvement
Decrease of transmission risk
side effects
rash, hepatotoxicity, nephrotoxicity, nephrolithiasis, jaundice, dyslipidaemia.
diabetes mellitus, ischaemic heart disease, osteopenia, osteoporosis
Diagnostic methods of HIV infection in adults
2018
Initial diagnostic phase - screening test in blood
ELISA tests - 4th generation
detection of antibodies and p24 antigen
high sensitivity - almost 100%
Positive screening test needs confirmatory test!!!
Western –blot or PCR - secondary diagnostic phase
A positive screening test does not mean HIV infection
Only positive confirmatory test allows for diagnosis of HIV infection
The screening test result may occasionally be „false–positive:
Lab error, Cross reacting antibodies - autoimmune diseases
IV drug abuse, Multiple pregnancies
Recent immunization, Chronic alcoholics
Cirrhosis of liver
The „serologic window period” may result in „false – negative” screening test
The pre–test counseling is very important!
Western – blot anti HIV test - highly specific test which detects virus proteins antibodies are diagnosed
core (p17, p24, )
polymerase (p31, p51, p61)
surface glycoproteins (gp41, gp120, gp160 )
Screening test with ELISA, if positive -> perform Western blotting (confirmatory test) if Western blotting for some reason inconclusive -> PCR!
Clinical stages of HIV infection
2018
A – asymptomatic
Acute retroviral disease
Persistent generalized lymphadenopathy
No symptoms
Clinical symptoms of acute retroviral disease:
Fever (77%), Fatigue (66%)
Rush (56%), Muscle pain (54%)
Headache (51%), Pharyngitis (45%)
Lymphadenopathy (43%), Arthralgia (31%)
circumstances where immediate treatment initiation should be advice:
acute infection, sever or prolonged symptoms
neurological disaase, age > or = 50, CD$ count <350 cell/microL
B – mild disease
constitutional symptoms:
Fever >38,5o C lasting over 1 month
Diarrhea lasting over 1 month
Thrombocytopenia
Cervical dysplasia/cervical carcinoma in situ
Candidiasis (oropharyngeal, vulvovaginal)
Herpes zoster (shingles) involving at least two distinct episodes or more than one dermatome
Pelvic inflammatory disease, particularly if complicated by tubo–ovarian abscess
Peripheral neuropathy
C – AIDS (opportunistic infections)
Brain toxoplasmosis
CMV retinitis (with loss of vision)
Candidiasis - esophageal, of bronchi, trachea or lungs.
Progressive multifocal leucoencephalopathy (PML)
Kaposi sarcoma, Cryptococcosis (extrapulmonary)
Pnemocystis carinii pneumonia
Recurrent pneumonia, HIV–encefalopathy
Burkitt’s lymphoma, Immunoblastic lymphoma
Primary lymphoma of the brain, Invasive cervical cancer
Herpes simplex (chronic ulcer lasting over 1 month)
Vertical: CD4 count category (/mm3) 1: >500 2: 200-499 3: <200
Horizontal: Clinical category A: Asymptomatic or PGL (persistent generalized lymphadenopathy) or Acute HIV infection B: Symptomatic (neither A or C) C: AIDS-defining illnesses (opportunistic)
Routs of spread of HIV infection
2018
Sexual way (the risk of infection related to single sexual contact with an HIV-infected person equals 0.3%)
Contact with blood: Intravenous drug usage, Blood transfusion, Occupational exposure
Vertical transmission (Mother to child transmission) – known risk factors for transmission:
2018
High maternal viral load, Low CD4 cell count
AIDS in the mother, Vaginal delivery
Premature rupture of membranes (>4h)
Pre–term infants (<37 weeks of gestation)
Breastfeeding
- Prophylaxis of vertical HIV transmission
HIV screening of pregnant women
HIV-infected pregnant women should be treated with cART
No breastfeeding
The infant should be treated with ART during the first four weeks of life
Infectious body fluids
Blood, Semen, Vaginal secretion
Additionally, to less extent:
cerebro-spinal fluid, amniotic fluid, any inflammatory exudates (pleural, pericardial, synovial, peritoneal)
Non–infectious fluids
Urine, Stool, Sweat, Tears, Vomits, Saliva, Nasal secretion
Diagnostic methods of HIV infection in children
Up to 18 month of life – direct detection of HIV (PCR – HIV) is necessary
(ELISA and Western blot both check for antibodies which may be maternal in the newborn therefor not reliable method)
- Post-exposure prophylaxis HIV
Preferably should be started <4h after exposure and no less than 48h after exposure. Use a combination of three antiretroviral drugs, duration 4 weeks. HIV serology should be performed at 0, 2 and 4 months.