AIDS2010Guidelineไทย

Chapter 2 Laboratory [16/3/2553]

CD4
CD4 viral load

2.1 (HIV counseling)

voluntary
testing
(pre-test counseling)
(post-test counseling) voluntary counseling and testing (VCT)

WHO

opt-out
provider-initiated counseling and testing (PICT)
PICT

PICT
pre-test counseling

post-test counseling

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VCT PICT

( 18 )

13-18

(stigma and discrimination)

(couple counseling and testing)

anti-HIV
( p24 Ag HIV-RNA, HIV-DNA)
anti-HIV

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-
-
-
-
-
-
-
-
-
-
-
- ( )

-
2
- 3 window period
/ 3 seroconversion
-
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2.2
2
antigen
2.2.1
2

.
p24 Ag
p24 Ag
p24 Ag
.

(qualitative RNA)1 (proviral DNA)
antibody
antibody 18
antibody

(7-14
) antibody
:
positive
negative

-
-

-
2.2.2 antibody
antibody

35 2550
99.5 99.0
. ELISA (Machine Based Immunoassay)
. Simple test agglutination

. Rapid test DOT line immunoassay
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positive negative

1.8 (..2545)

antibody 3
WHO 2[1]
2[1] 18
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(1) A1, A2 A3 antibody 1, 2 3 antigen 1

2 3
(2) (newly diagnosis) 2 antibody
1
(3) indeterminate 2 / 3
6 antibody

simple test rapid test
ELISA

(A1, A2 A3) antigen

antigen
(A1) sensitivity 3
2 (A2) 3 (A3)

- negative non-reactive
- positive reactive 3
2 1
- indeterminate 3
2 3 6
antibody (negative)
18
antibody
antibody 18
18 antibody

AZT
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antibody 18 2
2 [1] 18
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1. antibody
18
2. NAT (Nucleic Acid amplification Testing)

3. antibody 18
4. 18 antibody 3

5. antibody 3 3 2

6. 6

antibody antigen (HIV
Ag/Ab) p24 Ag
HIV Ag/Ab antibody / p24 Ag
antibody
positive p24 Ag p24 Ag
blocking antibody
antigen antibody
positive
18
2.3

CD4 (CD4 cells counts)
(viral load)
(HIV drug resistance testing)
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2.3.1 CD4 (CD4 cells counts)

CD4 T-lymphocyte
CD4 800 cells/mm3

CD4
-
-
-
-
CD4 flow cytometer single
platform/dual platform
CD4 (absolute)
EDTA
6
CBC
CD4 = %CD4 x WBC x % Lymphocyte

10,000
NRBC CD4
CD4
%CD4
CD4 6
%CD4
CD4
- (analytical variation)

- CD4

-
steroids CD4
CD 4
- CD 4
-
CD4 2
- CD4 350-500 cells/mm3
CD4 3 CD4 <350 cells/mm3
CD 4 <200 cells/mm3
1

25 C
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2.3.2 (viral load)

viral load RNA
viral load copies/ml log10

equivalence
viral load
viral load

-
(analytical variation)
-
viral load 10
viral load
viral load
- viral load
1
- 1
- 6 12
- 1
- 3 6
EDTA
6

viral load 3 Reverse
Transcription Polymerase Chain Reaction (RT-PCR), Nucleic Acid Sequence Based
Amplification (NASBA), branched DNA (b-DNA) signal amplification

real time RT- PCR real time NASBA viral
load 2
1
2.3.3 (HIV drug resistance testing)

-
-
-

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10

-

2
- viral load
viral load >2,000 copies/ml
3 genotypic drug resistance testing,
phenotypic drug susceptibility testing virtual phenotype
genotypic drug resistance testing

(in-house)

3
NRTIs,
NNRTIs PIs FIs INSTIs
,
2 [3]
2 [1]
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2.4

ISO15189

2
CD4
4
CD4 dual platform
CBC
viral load
2
11

2[1]
Anti-HIV testing
ELISA , Simple Test

Rapid test
Nucleic acid
amplification testing
(NAT)
Flow cytometry
Clotted blood
Serum Plasma
EDTA blood
EDTA Plasma
Dried Blood Spot
EDTA blood
5 ml
1 ml
2-3 ml
1 ml
Viral load testing

(HIV-1 RNA)
RT-PCR, NASBA, bDNA Real Time

PCR
Genotypic Drug
Resistance
testing
Sequencing Analysis
HIV viral testing
CD4+ T-cell
count
24
2 8
24
1
2 8
2-3 ml
6
( 18-25 C )
EDTA blood
EDTA Plasma
6-9 ml
2
1.5 ml
6
( 4 C)
EDTA blood
EDTA Plasma
6-9 ml
2
1.5 ml
6
( 4 C)
(18-25 )
4-8
24

6
4-8
24
12
2[2]
2
2
2
2
1.

2. 6
3. Electrolyte, BUN, Cr, creatinine clearance.
2
3
4
5
6
7
CD4 count
HIV viral load
HIV drug resistance
Hepatitis B and C
Basic chemistry 3
ALT
CBC
Lipid profile
(TC TG LDL HDL)
Fasting glucose
Urinalysis
Pap smear
Pregnancy test
12
1
4. Cr 6 TDF IDV
5. NNRTIs
6. TDF IDV
7. 1
8. EFV
13
2[3]
TruGene
ViroSeq
No evidence
None
(mutation)
of resistance
Possible resistance
Possible resistance
mutation
Resistance
Resistance
mutation
Stanford (in-house)
Susceptible
Low level resistance
Intermediate resistance
High level resistance
14
1.
2.
3.
4.
HIV assays: operational characteristics (Phase 1): report 15 antigen/antibody ELISAs.

http://www.who.int/diagnostics_laboratory/publications/en/HIV_Report15.pdf. Accessed December
14, 2009.
Guidance on provider-initiated HIV testing and counselling in health facilities.
http://whqlibdoc.who.int/publications/2007/9789241595568_eng.pdf. Accessed December 14, 2009.
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral
agents in HIV-1-infected adults and adolescents. Department of Health and Human Services.
December 1, 2009; 1-161. http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.
Accessed December 14, 2009.
.. 2549/2550.
ISBN 978-974-297-262-2.
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Chapter 3 Adult [16/3/53]
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3.1

( comprehensive and continuum care)

1

HIV/ARV

CD4

3.1.1
CD4
CD4
CD4
CD4
CD4 (51-150 cells/mm3)
(351-450) 5.6 2 3.8
3
CD4 CD4 3-6

3.1.2
a. Hepatitis B

3,4
9% (6-14 %)5
HBV
4 (liver enzyme >10 upper limit)6
3 4
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anti-HBc, anti-HBs HBS-Ag

b. Hepatitis C
HIV/ART
3
8 ( 72-95)
( 1-12) ( 9-27)5
957 ( 500,000 IU/ml)
2
8

anti-HCV

c.

2 2
(atypical manifestation)9

neurosyphilis 10,11

RPR
1 ( 2-4 )10 RPR titer > 1:32
CSF RPR neuosyphilis11
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-
12

13 2 neuosyphilis
( OIs 6)
a.
latent infection primary

tuberculosis 10 ( life
time risk) 50% 5-10 %

14

CXR

3.1.3
b.
20%17
HPV CD4
18

pap smear 6
1
c.

11-36 19 HPV
CD4 18 pap
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smear 6 20
21

anal Pap smear 6

1
d. CMV retinitis
CMV
CD4 100 cells/mm3
(sensitivity 7%)22
23
indirect ophthalmoscope 1 CD4 100 cells/mm3
3.1.4
a.

(
3.1.2) ( 5)
a.1

17-30 %
HIV/ART 24 25 26
(11-58 )27
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a.2

28

5
b.

BMI (kg/m2) 17
BMI >18.5 2 29
30
PIs

1

6
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3.2 (acute HIV infection)
40 90 acute retroviral
syndrome 3[1]

, infectious
mononucleosis, , streptococcus, syphilis,

viral load ( 100,000 copies/ml)
anti-HIV negative indetermined

qualitative HIV-RNA p24 Ag

viral set point

3 [1] acute retroviral syndrome
22
23
24
25
(erythematous maculopapular rash)

)

(thrush)
( aseptic meningitis, peripheral neuropathy, facial palsy,
Guillain-Barre Syndrome, brachial neuritis cognitive impairment)
96
74
70
70
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3.3 (nave)
3.3.1
1
) CD4 viral load
2
) CD4
..2549/2550 3[2]
3
) viral load
CD4
(AIDS-related illness)

CBC, CD4 count, viral load ( ), FBS, AST,
ALT, Lipid profile (TC, TG, LDL), HBsAg, antiHCV, VDRL, urine analysis, CXR, pap smear
TDF IDV serum
creatinine creatinine clearance
fundoscopy (eye ground) CD4 50 cells/mm3
CMV retinitis
IRIS
12
13
14
15
16
17
18
19
20
21
22
23
3[2]
(AIDS-defining illness)*
**
24
25
26
CD4 (cells/mm3)
<350
CD4 6

CD4 >350 cells/mm3
>350
* (AIDS-defining illness)
** (Pruritic Papular Eruptions: PPE)
14 10 3 herpes zoster 2 dermatomes
27
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CD4 350
cells/mm3 (special consideration for ART initiation)
1) (HBV) (HCV)
HBV HCV 3.12.4
2) 50 (CD4 350 - 500 cells/mm3)

3) discordant couples, HIV-associated nephropathy
3.3.2
5
1. Nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs or NtRTI) zidovudine
(AZT), stavudine (d4T), lamivudine (3TC), emtricitabine (FTC), didanosine (ddI), abacavir (ABC),
tenofovir (TDF) fixed-dose combination AZT/3TC 300/150 mg, d4T/3TC
30/150 mg, TDF/FTC 300/200 mg (FTC fixed-dose combination TDF )
2. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) nevirapine (NVP), efavirenz
(EFV), etravirine (ETV) NVP fixed-dose combination NRTIs d4T/3TC/NVP
30/150/200 mg AZT/3TC/NVP 250/150/200 mg
3. Protease inhibitors (PIs) indinavir (IDV), ritonavir (RTV), nelfinavir (NFV), saquinavir
(SQV), lopinavir/ritonavir (LPV/r), atazanavir (ATV), darunavir (DRV)
4. Integrase inhibitors (INSTIs) raltegravir (RAL)
5. Fusion inhibitors (FIs) enfuvirtide (ENF)
NNRTIs-based regimen
NNRTIs PIs-based regimen
..2549/2550 3[3]
3[3]
NRTIs
Preferred
ABC + 3TC
d4T + 3TC4
ddI + 3TC5
PIs
Preferred
AZT + 3TC
TDF + 3TC/FTC2
Alternative
NNRTIs
EFV6
NVP7
NNRTIs
LPV/r8
Alternative
ATV/r
DRV/r9
SQV/r
30
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foot notes
1
AZT + 3TC NRTIs
2
TDF NtRTIs creatinine clearance
HBV TDF + 3TC/FTC
3
ABC + 3TC NRTIs AZT,
d4T, ddI TDF ABC hypersensitivity reaction NVP
ABC NVP
4
d4T + 3TC NRTIs d4T
AZT, TDF
6-12 d4T
5
ddI + 3TC AZT, d4T TDF

6
EFV NNRTI
NVP EFV
7
NVP NNRTI AZT+3TC

CD4 250 cells/mm3
8
LPV/r PI nave
800/200 24 . 400/100 12 .
9
DRV/r nave 800/100 24 .
IDV, IDV/r IDV 400 mg +
RTV 100 mg 12 .
3.3.3
1) NRTIs 2

2) d4T + AZT antagonism
3) FTC + 3TC resistance profiles
4) TDF + ddI
5) d4T + ddI peripheral neuropathy, pancreatitis, hyperlactatemia
lactic acidosis 2
6) TDF + 3TC + ABC
7) EFV
8) 2 NNRTIs combination
9) unboosted SQV, DRV
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10) ATV + IDV hyperbilirubinemia

3.3.4 d4T phase out plan
d4T NRTIs 15
generic d4T, 3TC NVP (
GPO-VIR S)
d4T
lipoatrophy/lipodystrophy, peripheral neuropathy, hyperlipidemia treatment guidelines
d4T list preferred ARV regimen
d4T
d4T
d4T
d4T d4T
d4T
d4T
d4T GPO-VIR S
lipoatrophy/lipodystrophy
viral load 50 copies/ml
GPO-VIR S TDF + 3TC + NVP TDF + 3TC + EFV
d4T GPO-VIR S
lipoatrophy/lipodystrophy GPO-VIR Z viral load 50

copies/ml GPO-VIR S
..2554 AZT lipoatrophy/lipodystrophy
GPO-VIR Z 6 TDF + 3TC + NVP
TDF + 3TC + EFV
d4T GPO-VIR S d4T 30 mg
60 kg d4T
(
nave)
GPO-VIR S
(Hb<8.5 g/dl) AZT CD4 100 cells/mm3

GPO-VIR S 6
GPO-VIR Z viral load 50 copies/ml
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3.4
NRTIs

NtRTI
TDF
NNRTIs PIs

CrCl

Child-Pugh
score
3 [4]

3[4a] NRTIs
ABC
ddI
300 mg 24
>60 kg
400 mg 24
<60 kg
250 mg 24
3TC
CrCl (ml/min)
>60 kg
<60 kg
30-59
200 mg
125 mg
10-29
125 mg
100 mg
<10
125 mg
75 mg
CAPD HD : CrCl <10 ml/min
300 mg 24
150 mg 12
d4T
30 mg 12
TDF
300 mg 24
CrCl (ml/min)
30-49
15-29
5-14
<5 HD*
CrCl (ml/min)
26-50
10-25 HD*
CrCl (ml/min)
30-49
10- 29
ESRD HD*
150 mg 24 .
150 mg 100 mg 24 .
150 mg 50 mg 24 .
50 mg 25 mg 24 .
15 mg 12 .
15 mg 24 .
300 mg 48 .
300 mg 2
300 mg 7
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TDF/FTC
1 24

CrCl (ml/min)
30-49
1 48 .
<30
AZT
200-300 mg
(CrCl <15 ml/min) HD*: 100 mg
12
8 . 300 mg 24 .
CrCl = Creatinine Clearance; HD = hemodialysis; CAPD = chronic ambulatory peritoneal dialysis;
ESRD = end stage renal disease; HD* = dialysis dialysis
3[4b] NNRTIs
EFV
600 mg 24
EFV/TDF/FTC
CrCl <50 ml/min
ETV
200 mg 12
200 mg 12
NVP
Child-Pugh Class A B
Child-Pugh Class C
Child-Pugh Class B C
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3[4c] PIs INSTIs
PIs
ATV

400 mg 24
300 mg + RTV 100 mg

24

HD
(nave) HD:
300 mg + RTV 100 mg 24 .
(experienced) HD:
ATV RTV-boosted ATV
Child-Pugh Score
7-9
300 .
>9
RTV boosting
DRV
800 mg + RTV 100 mg

24 (nave)
600 mg + RTV 100 mg
12
IDV
400-800 mg + RTV 100 mg

12
400/100 mg 12
800/200 mg 12
(nave)
1,000 mg + RTV 100 mg
12
: IDV 400 .
+ RTV 100 . 2

400 mg 12
SQV
INSTIs
RAL
LPV/r
DRV
Creatinine Clearance:
: (140-) x (kg)
72 x serum creatinine
: (140-) x (kg) x 0.85

72 x serum creatinine
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3.5 (drug interaction)

NNRTIs PIs CYP450
CYP3A4 isoenzyme drug interaction

Drug interaction
1. CYP inducer CYP450
CYP450 rifampicin CYP inducer
NNRTIs PIs EFV
PIs ( 3.6
[ ])
2. CYP inhibitor CYP450
CYP450 RTV CYP inhibitor PIs
Drug interaction ( [ ])
( [ ]) PIs
CYP450 P-glycoprotein NVP substrate CYP450
CYP inducer EFV CYP inducer CYP inhibitor
NRTIs CYP450 drug interaction ddI
hydroxyurea, ribavirin, TDF serious drug
interaction
Serious drug interaction 6

1) Ergotism
peripheral vascular vasoconstriction ergot derivative
ergotamine
peripheral vascular
vasoconstriction leg ischemia
ergot CYP450
CYP inhibitor ergot clarithromycin, ketoconazole PIs
RTV
LPV/r ergotamine

cyanosis gangrene
vasodilator drug prostaglandin analogue
36
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2) Torsades de Pointes
ventricular arrhythmia QT prolong sudden
death PIs ATV QT prolong
CYP inhibitor RTV QT prolong cardiac
arrhythmia terfenadine, astemizole, cisapride, pimozide CCBs diltiazem
antiarrhythmic drugs flecainide, propafenone, amiodarone, flecainide, propafenone,
quinidine
3) Rhadomyolysis
acute renal failure CYP inhibitor

RTV rhabdomyolysis antihyperlipidaemics
simvastatin fibrate HMG coA
rhabdomyolysis HMG coA
pravastatin fluvastatin fibrate derivative fenofibrate
gemfibrozil
4) Symptomatic hypotension
CYP inhibitor RTV antihypertensions
dihydropyridine CCBs felodipine, nifedipine, amlodipine - blocker
symptomatic hypotension
sidenafil boosted PIs LPV/r
sidenafil 11 25 mg 48 sidenafil
nitrate vasodilatation , acute myocardial infarction
5) Excessive sedative
benzodiazepines midazepam, triazolam,
alprazolam diazepam sedative

lorazepam
CYP 450
6) Cushing syndrome
cushing syndrome adrenal insufficiency RTV
fluticasone
3.6

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33
34
35
36
37

IRIS ( IRIS
3.7)

10% IRIS PCP
34
OI
1) PCP Cryptococcosis

CD4<100
cells/mm3
2) / CMV ( ,
) disseminated MAC
3)
microsporidium
39, 40
41
,cryptosporidium
, Kaposis sarcoma , wasting syndrome, progressive
42
multifocal leucoencephalopathy
CD4 500 cells/mm3

100 cells/mm3 CD4 100 cells/mm3
CD4 IRIS
35

/ (TB screening in PLWHA)
CXR
1) 2
2)
3)
4) (
/)
5)

AFB
Page | 16
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

1) Rifampicin CYP450 enzyme
efflux multi-drug transporter P-glycoprotein NNRTIs
PIs
2) IRIS
IRIS
IRIS
3)
4)
5)

1) WHO 3[5]
2) rifampicin 3.2
3) rifampicin EFV 600 mg/day
60 kg 800 mg/day 60 kg
4) EFV NVP (400 mg/day)
rifampicin ( lead-in NVP)
5) EFV NVP
( CD4 <100 cells/mm3)
rifampicin PIs-based regimen
6) NVP-containing HAART
rifampicin NVP EFV
3[5]
CD4
(cells/mm3)
< 200
200 - 350
>350
26
27
28
29
30
31
32
33
34
2-8
2
CD4 6
IRIS
Page | 17
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
3.7 (Immune Reconstitution Inflammatory Syndrome, IRIS)

IRIS
IRIS
IRIS

3[6]
IRIS 3[6]
IRIS Mycobacterium (TB or MAC)
IRIS 3
IRIS
CD4 50-100 cells/mm3
IRIS
IRIS
CD4
IRIS

IRIS

1) IRIS ( )
(paradoxical IRIS) (unmasking IRIS)

IRIS
IRIS 3[7]
2) ()
(complete blood count with differential), , Cr, , CD4, viral
load, , acid fast (TB MAC) CXR

3) IRIS 2-4
()
(non-steroidal drugs systemic
corticosteroids ) IRIS
IRIS IRIS

Page | 18
2
3
4
5
6
7
8
9
10
11
12
13
14
15

corticosteroids
4)
maintenance
maintenance
5) IRIS
CD4
6)

IRIS

3[6] IRIS
Tuberculosis
Paradoxical reaction [Prolong fever ( 38.6C), increasing respiratory symptoms, increasing

lymphadenopathy, cutaneous lesions, ascites, CXR worsening] after initiation of HAART,
tuberculoma, inflammatory bowel perforation, serositis, psoas abscess
MAC and other atypical Localized lymphadenitis, necrotizing subcutaneous nodules, endobronchial tumors, small bowel
mycobacteria
involvement, paravertebral abscesses, osteomyelitis, arthritis, focal brain lesion, Ileitis
CMV
Viral hepatitis (B,C)

Parvovirus B19
Herpes Simplex
Varicella zoster virus
Kaposi Sarcoma
PML
BK virus
Cryptococcus
PCP
Skin yeasts
Sarcoidosis
Toxoplasmosis
CMV retinitis despite rise in CD4 cells after initiation of HAART, immune recovery vitreitis, immune
recovery uveitis, early and unusual CMV pneumonitis, pseudotumoral colitis, adenitis, encephalitis,
cutaneous ulceration
Worsening hepatitis
Encephalitis, worsening anemia
Erosive herpes simplex, encephalitis
Acute retinal necrosis early after effective HAART regimen, increase rate of shingles after HAART
Worsening KS lesion with inflammation and edema
Inflammatory PML variant
Hemorrhagic cystitis
Recurrence of meningitis early after effective HAART, pulmonary cryptococcosis, cutaneous
cryptococcosis (recurrent abscesses), necrotizing mediastinal and cervical lymphadenitis,
intracranial cryptococcoma, intramedullary abscess, necrotizing pneumonitis
Pneumonitis (patchy aveolar or reticulonodular infiltrates)
Folliculitis
Worsening of sarcoidosis, pulmonary infiltrates, erythrema nodosum, lymphadenopathy, interstitial
nephritis
Encephalitis
Page | 19
Leshmaniasis
Vitreitis, uveitis, post-Kala-Azar dermal leshmaniasis
Bartonella henselae
Leprosy
Microsporidia
Chlamydia trachomatis
Non infectious etiology
Granulomatous splenitis
Leprosy cutaneous lesions
Keratoconjunctivitis
Reiters syndrome
Grave diseases, SLE, vasculitis, relapsing Guillain-Barres syndrome, rheumatoid arthritis,
polymyositis, alopecia universalis, cerebral vasculitis, hyperergic reaction (against tatoos, foreign
bodies), pre-eclampsia, multiple eruptive dermatofibromas, eruptive cheilitis, peyronies disease
3[7] IRIS
Paradoxical IRIS

1.
2. 1

Unmasking IRIS

1.
2.
3.
4. 1
3

1
2
3
Page | 20

3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
IRIS
IRIS
cryptococcus MAC
1) IRIS paradoxical worsening

CD4 <100 cells/mm3 2-4
, ,

unmasking
corticosteroids
MDR-TB, MAC
corticosteroids
prednisolone 30 mg/day 24-48
IRIS rifampicin
IRIS prednisolone 8
IRIS
2) Cryptococcal meningitis IRIS 30%

paradoxical worsening

localizing signs
cryptococcal meningitis un-masking meningitis

cryptococcal antigen
paradoxical worsening cryptococcal

meningitis cryptococcal meningitis
6
cryptococcal antigen india ink cryptococcal antigen
cryptococcus india ink
meningitis
1
2
Page | 21
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36

cryptococcal meningitis
IRIS
prednisolone
lumbar puncture shunt
prednisolone 30-60 mg
prednisolone
3) Mycobacterium avium complex IRIS un-masking HAART
MAC wasting, chronic diarrhea, lymphadenitis non-caseating granuloma
(HAART) necrosis
MAC

peritonitis
MAC

prednisolone 30 mg/day
prednisolone
3.8

viral load CD4 viral load
CD4

viral load 50 copies/ml 6
viral load 50 copies/ml viral load
CD4 CD4
clinical failure
viral load 6 1

1
viral load
. .
Page | 22

1
2
3
4
5
6
7
8
9
10
11
12
CD4
CD4 CD4
(OI prophylaxis)
CD4 6
CD4 100-150
cells/ CD4
CD4 CD4 25 50

CD4 viral load 50 copies/ml
3[8]
FBS
ALT
Cr*
Lipid profile
(TC, TG, LDL, HDL)
Urinalysis
13
14
15
16
17
18
19
20
6, 12
-
6, 12

CBC, CD4
Viral load
-
3 6
6, 12
12
( 6 )
12
6, 12
6, 12
6, 12
3
NNRTIs
6 TDF
IDV
6 TDF
IDV
CXR
Pap smear
12
12
* creatinine clearance
** AST statin 6 12 6
rhabdomyolysis
Page | 23

1
3.9
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
3.10
3.10.1 (diagnosis of treatment failure)
(virological failure)
virological failure
virological failure viral load
viral load 400 copies/ml
6 viral load 50 copies/ml
12 viral load 50 copies/ml viral load
50 copies/ml

6 viral load 50 copies/ml viral load 51-1,000
copies/ml ( viral blip) (
) genotypic resistance testing
viral load 2,000 copies/ml

( immunological failure)

CD4 viral load 50
copies/ml viral load
Immunological failure CD4

CD4 CD4 50 cells/mm3
1 CD4 30 %CD4 3 CD4

( clinical failure)
clinical failure virological
failure immunological failure

IRIS 3
Page | 24
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
3.10.2 (Management of Treatment Failure)

1) drug interaction
2)
3) (adherence)
4) (genotypic resistance testing)
2
5) viral load (viral load<50 copies/ml)
6)
1) 2 viral load 50 copies/ml
2)

3)
3 3
2 viral load 3

5) NNRTIs NNRTIs
NVP EFV 2 boosted PIs (boosted PI-based regimens)
5.1) boosted PIs LPV/r NRTIs 2
5.2) NRTIs 1 LPV/r NRTIs 1

3TC
5.3) NRTIs
Page | 25

1
2
3
4
5
6) PIs NRTIs PIs (

boosted) boosted PIs new boosted PIs NRTIs NNRTIs
2 ( 3[8])
3[8] 2
2 NRTIs + NNRTI
2 NRTIs + PI
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1) 3 viral load 50 copies/ml

2)

3) 2

CD4
4) NRTIs, NNRTIs, PIs

boosted PIs DRV/r ETV
(NNRTIs ) RAL ( INSTIs)
5)
3 TC +/- NRTIs viral load
3TC CD4
6
7
2
Boosted PI + 2 NRTIs ()
New boosted PI + 2 NRTIs ()
2) New boosted PI + 1 NNRTI + 1 NRTI ()
3) NNRTI + 2 NRTIs ()
3 NRTIs 2 NNRTIs
monotherapy duotherapy
3.11

3
(1) (life-threatening adverse effects)
(2) (serious adverse effects)
(3) (long-term complications)

Page | 26

4[5]
/
(1) (life-threatening adverse effects)

NVP 200 mg 24 .
EFV 0.1 fluid depletion bacterial

1-2 APV, fungal superinfection multiorgan failure
2
200 mg 12 .

corticosteroids
NVP
IDV, LPV/r, ATV, AZT, ddI, ABC

(Hepatic 1 3 18
NVP CD4
CD4
events, Nevirapine-associated (>250 cells/mm3 , >250 cells/mm3 CD4 >400
symptomatic events, Including
cells/mm3
>400 cells/mm3 )
hepatic necrosis)

NVP fulminant hepatic failure SGOT SGPT NVP
4 ( encephalopathy
2
2.5 - 11 ) 50 HBV /
11

HCV
CD4 >250 cells/mm3
DRESS
NVP
0.9 CD4 <250 syndrome

cells/mm3 6.3
NVP
CD4 >400 cells/mm3
SGOT SGPT
2.3
SGOT SGPT 2
CD4 <400 cells/mm3
cotrimoxazole
supportive care local
wound care intravenous hydration cross reaction
parenteral nutrition
NNRTIs

superinfection
corticosteroids IVIG
NVP ( 3TC, FTC NVP

TDF HBV
)
supportive care

NNRTIs EFV
NVP
NVP
2-3 2-3
Stevens-Johnson
Syndrome skin eruption mucosal ulcerations (
(SJS) Toxic Epidermal

)
Necrolysis (TEN)
blister/bullae
NVP epidermal detachment necrosis
0.3-1 ,DLV
1 3
Page | 27

/
(Lactic acidosis ,
Hepatic steatosis +/-pancreatitis

(Severe mitochondrial toxicities))
NRTI
nonspecific gastrointestinal
d4T > ddI >
serum lactate

lactate
supportive care
IV bicarbonate
hemofiltration
hemodialysis

serum
lactate
AZT > 3TC, TDF, ABC

d4T
ddI

body mass index
prodrome

d4T ddI
ddI
hydroxyurea ribavirin
NRTIs
d4T ddI
AZT
0.85
50%
( serum
:
lactate >10 mmole/L)
Lactate ( >5 mmole/L)
Arterial pH (<7.0)
CO2, Albumin
Anion gap
Transaminases, prothrombin time, bilirubin
amylase
lipase
Histology microvesicular
macrovesicular steatosis
lactate
CO2 anion gap

lactate

mechanical ventilation
IV thiamine /
riboflavin
lactate
NRTIs
mitochondrial toxicities
ABC, TDF, 3TC, FTC
serum lactate
NRTI-sparing
regimens boosted PIs+NNRTI
IDV/r+EFV, LPV/r+EFV (
LPV/r 500/125 600/150 mg 12
. EFV 600 mg 24 .)
Page | 28

/
(Lactic acidosis /
ascending
demyelinating polyneuropathy
d4T
Guillain-Barr syndrome

Rapidly progressive ascending

neuromuscular weakness)
d4T
88
69
d4T
d4T
supportive care
lactic acidosis
plasmapheresis high
dose
corticosteroid
intravenous
immunoglobulin carnitine acetylcarnitine
:
Serum lactate
Arterial pH
CO2
Anion gap
Creatine phosphokinase
9 90 HLA-B*5701 HLA-
(Hypersensitivity reaction [HSR])
DR7 HLA-DQ3
HSR
6

ABC

8
HSR

( 2-9)
ABC grade 3 4
ABC 600 mg 24

. 300 mg
12 . ( 5
ABC 2)
ABC
ABC
viral syndromes HSR
ABC
ABC 48

supportive care

Page | 29

/
anaphylaxis
NVP
NVP 200 mg 24 . 2
rash
EFV

mucous membrane involvement
TPV/r
corticosteroids NVP dose

escalation
NNRTIs
NNRTIs
antihistamine

blisters mucous
membrane involvement
2-3 advanced
HIV
AZT
AZT
NRTI
bone

marrow
CBC 3 (
)
(2) (serious adverse effects)

NVP
14.8 (1.5), EFV
26 ( grades 3- 4
1), ABC <5
HSR, ATV
2.1 (< 1)
2-3
diffuse maculopapular
(skin rash)

NVP 18

serum
transaminases
(Bone marrow suppression)
AZT
neutropenia
1.1-4.0 neutropenia
1.8-8.0
neutropenia

cotrimoxazole,
ganciclovir
ribavirin,
(Hepatotoxicity, NNRTIs 60 12 HBV/HCV

Clinical hepatitis or Symptomatic
serum transaminase elevation)

Folic acid supplement
NVP
liver enzymes hepatotoxicity

2, 4 Hepatitis B
Page | 30
NVP-associated
hepatic events
CD4 >250 cell/mm3
CD4 >400
mitochondrial toxicity
cell/mm3
3TC, FTC, TDF HBV
PIs

hepatic decompensation
TPV/r

(nephrolithiasis/urolithiasis/
nephrolithiasis
crystalluria)

peak IDV
IDV pyuria, hematuria, crystalluria
IDV
12.4 serum creatinine
4.7-
1 3 36
liver
enzymes 3-4
50 NVP
NNRTIs, PIs, NRTIs
NRTIs
AZT, ddI, d4T
lactic acidosis microvesicular
macrovesicular hepatic steatosis
3TC, FTC TDF

B

serum
transaminases
SGPT >5-10

serum transaminases
1.5-2
urinalysis serum creatinine

3-6

IDV
34.4
(nephrotoxicity)
IDV
IDV
IDV TDF

TDF
supportive care
electrolytes
Page | 31

/

nephrogenic diabetes
insipidus Fanconi syndrome
:
IDV: Cr pyruria hydronephrosis
serum creatinine urinalysis

serum potassium phosphorus
(pancreatitis)
1-7
ddI
4-5
ddI
hydroxyurea
ddI
ribavirin
ddI d4T
3TC,
d4T TDF

(bleeding episodes-increase
in hemophiliac patients)
renal atrophy
TDF: Cr proteinuria, glycosuria
,hypokalemia, hypophosphatemia, non-anion gap,
metabolic acidosis
intraceullar
/ serum ddI
Amylase lipase

pancreatitis

hypertriglyceridemia
ddI d4T,
ddI
pancreatitis
ddI d4T,
ddI TDF

amylase lipase
pancreatitis
bowel rest IV hydration pain control
ddI TDF
ddI
2-3
PIs
hemophilia
NNRTI-based regimen Factor VIII

PIs
Page | 32

/
(3) (long-term adverse effects)
d4T AZT, ddI

hyperlipidemia

(Hyperlipidemia)
PIs LDL, TC TG
PIs
( ATV)
47-75
d4T, EFV
HDL
d4T TG
PIs: LPV/r, RTV >
LDL TC EFV
NFV,
APV > IDV, SQV >
NVP HDL TG
ATV
NNRTIs: PIs
NRTIs: d4T > AZT
TDF
glitazones metformin
baseline body mass

(Lipodystrophy, Fat accumulation
index
and Lipoatrophy)
(fat accumulation)

1.
(fat (dorsocervical fat pad buffalo hump)
accumulation) PIs (lipoatrophy)
d4T
2. (lipoatrophy)
Injectable poly-L-lactic acid

restorative
d4T
PIs
cardiac risk factors
ATV
lifestyle modifications
fasting lipid profile

3-6
hyperlipidemia

LDL >220 mg/dL
LDL>130 mg/dL

TG
200-500 mg/dL
statins
pravastatin,
Page | 33

/
atorvastatin
2 10

10 LDL>160
mg/dL
TG >500 mg/dL:
gemfibrozil
micronized
fenofibrate

polyuria, polydipsia, polyphagia, fatigue
PIs

3-5
(Peripheral neuropathy)
ddI 1234, d4T 52
monotherapy
hyperglycemia

PI-sparing
FBS , 1-3 NNRTIbased regimen

3-6

(Insulin
resistance/Diabetes mellitus)
metformin, glitazones, sulfonylurea

insulin
peripheral
neuropathy

neuropathy
advanced HIV
painful neuropathy disease d4T
ddI

intracellular activities

Gabapentin, TCA, lamotrigine,
oxycarbamazepine, topiramate, tramadol,
narcotic analgesics, capsaicin cream
,topical lidocaine

ddI
.
periarticular pain
(Osteonecrosis)
85
PIs
femoral head
Advance AIDS Conservative management:
CD4 <200 steroid

cells/mm3

15 bony head

Surgical Intervention:
Page | 34

/

PIs 0.4
/ MRI
symptomatic osteonecrosis
0.08-1.33 asymptomatic
osteonecrosis 4
5
steroids

MRI 3-6 1
6 1
early stages core

decompression / bone grafting
severe debilitating
disease total joint arthroplasty
hyperlipidemia
PIs
ATV
0.3-0.6
premature coronary artery disease
cardiovascular disease

hyperlipidemia
coronary

artery disease
premature

coronary artery disease
non-PIs
hyperlipidemia, hypertension
(Cardiovascular effects)
based
regimen
hyperlipidemia
hyperglycemia
lifestyle modification
insulin resistance / diabetes mellitus

lifestyle modifications

cardiovascular effects
NNRTI ATV-based regimen
d4T
Page | 35
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
3.12
3.12.1
2 (AIDS-defining
neoplasms) Kaposis sarcoma, lymphoma Burkitts immunoblastic
2 2 non-Hodgkins
(primary central nervous system lymphoma)
invasive CD446
2 Hodgkins

primary effusion lymphoma, plasmablastic lymphoma
basal cell carcinoma , seminoma, Hodgkins
leiomyosarcoma

CD4 viral load Kaposis sarcoma Burkitts
immunoblastic 2
invasive

Hodgkin's non-small cell
47
CD4
48 CD4 200 cells/mm3

CD4 >200 cells/mm3

(drug interaction)
Page | 36
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

AZT peripheral neuropathy d4T ddI

HBV, HCV
3.12.2

3[11]
3[11]
viral load 2-3
(elective)
NNRTI
PIs
NNRTIs 7-10 NRTIs

NNRTIs boosted PIs 7-10
22
23
24
25
Page | 37
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
3.12.3

TDF, 3TC, EFV TDF viral load<50
copies/ml HBV (HBsAg)
EFV
1-2
3[12]
EFV
EFV
NVP
NVP 400 mg 24 .
LPV/r
LPV/r 12 . 24 .
LPV/r ATV/r
IDV/r
LPV/r 24 . ATV/r
TDF
TDF
ddI
ddI 1 .
2 .
AZT d4T
AZT d4T 12 . TDF 24 .
viral load<50 copies/ml HBV (HBsAg)
3TC
3TC 12 . 24 .
3.12.4
HIV/HBV co-infection
HBV liver function test, alfafetoprotein, HBeAg HBV-DNA

HBV
HAV IgG
HIV HBV
HIV TDF 3TC FTC

backbone HBV HBV
Page | 38
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
HIV HBV TDF 3TC FTC

backbone HBV HBV
HBV 3 TDF
3TC/FTC backbone pegylated interferon-alpha
FTC, 3TC TDF

hepatic flare adefovir dipivoxil telbivudine
hepatic flares
HIV/HCV coinfection
HCV
HCV
HCV
HIV/HCV coinfection

NVP, d4T, ddI
AZT, d4T, ddI ribavirin
SGPT SGOT 1 3
5 upper limit laboratory reference range

HAV/HBV
Child-Turcotte-Pugh classification system
3.12.5 methadone

HCV
drug interaction methadone
adherence, HIV/HCV coinfection (
3.12.4) drug interaction ( 3[13])
33
34
35
36
Page | 39

1
3[13] PIs methadone
methadone
RTV-boosted PI
ATV/r
R-methadone 16%
DRV/r, IDV/r
LPV/r
SQV/r 1000/100 mg BID
5
6
7
8
9
10
11
12
13
14
methadone 40%
methadone
methadone
methadone withdrawal
methadone
NNRTI
EFV
methadone 60%
methadone
methadone
methadone
ETR
R-methadone = active form methadone methadone
R-methadone 16%
methadone
methadone 26%-53%
methadone
methadone 19%
methadone
PI without RTV
ATV
IDV
NFV
NVP
2
3
methadone
NVP
3.12.6

AZT 28
NVP
mutations NNRTIs
NRTIs 2 (dual NRTIs)

HAART
dual NRTIs HAART
- viral load 50 copies/ml
NNRTI 1 boosted-PI 1 NRTIs
NRTIs
Page | 40
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
viral load 2,000 copies/ml

genotypic resistance testing
- viral load 50 2,000 copies/ml
NRTIs 2 NRTIs boosted-PI 1
NNRTI 1 boosted-PI 1
- 1
genotypic resistance testing NNRTI 1
boosted-PI 1
HAART
NNRTI-based regimen
-
viral load 1
viral load
PI-based regimen
- NNRTIs PIs

- first line
second line failure
genotypic resistance testing

3.13

CD4
CD4

3 [13]
31
32
33
34
35
36
Page | 41

1
3[14]
Vaccine
3 - HBV HBsAg, antiHBs,

antiHBc
- 3 : , 1 , 6
- antiHBs 3
Tetanus and Diphtheria 1 - 1 10

toxoid (Td) vaccine
- Tetanus, Diphtheria, and Pertussis (Tdap)

Hepatitis A vaccine
2 - :
(HAV)
( HBV/HCV)
serum HAV IgG
- 2 : 2 6-12
Human papuloma virus 3 - 9-26
(HPV) vaccine
-
- 3 : , 1 , 6
Measles,Mumps,Rubella
1-2 - serum measles IgG, mumps IgG,
(MMR) vaccine
rubella IgG
- CD4 <200 cells/mm3
-
-
Varicella (VAR) vaccine
2 - serum Varicella IgG
- CD4 <200 cells/ mm3
- 2 : 2 4-8
Polysaccharide
1 - i CD4 <200 cells/ mm3
2 CD4 >200 cells/ mm3
pneumococcal vaccine
Influenza
1 -
- nasal spray
Hepatitis B vaccine
2
3
4
5
6
7
8
3.14

Page | 42
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
1.

2.
3.

1. :

2. :

Protease inhibitors
ritronavir non-nucleoside reverse transcriptase inhibitors nevirapine
EE 30 microgram
3.
a. (copper IUD)
b. levonorgestrel (LNG)

Page | 43

1
2
3
4
/
3[15]
Oral contraceptive
Vaginal ring
Injectables Implants
copper IUD
LNG
Combined
Mini pill
pill

1
1
1
1
2
2
2
2
1
1
1
1
2
2
2
2
1
1
1
1
3
2
3
2
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
4
1
2
3
4
1 2 3 4

3.15 (post-exposure prophylaxis)
3.15.1 (HIV
Occupational Post-Exposure Prophylaxis, HIV OCC-PEP)

0.39 ( 95 0.2 - 0.5) 0.09
( 95 0.006 - 0.5) 0.09
1) HIV OCC-PEP 3[1] 3[1]
HIV OCC-PEP ( 1-4 ) 48-72
4
2)
standard precaution

72 anti-HIV 6 12 6 (
HCV anti-HIV 12
)
/
Page | 44
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
HIV OC C-PEP
3[16]
3.14.2 (HIV Sexual Post-exposure
Prophylaxis, HIV SEX-PEP)
( receptive)
(insertive) ( 3[17] )
(
) /
(
)
2-5

1) HIV SEX-PEP 3[2] 3.13[18]
HIV SEX-PEP 3 () ( 3[16])

3 2 /
2
() ( 3[16]) HIV SEX-PEP ( 1-2 )
72 4
2) 3[19]
27
28
29
30
31
32
33
34
35
36
Page | 45

1
2
3
4
3[1]
5
6
7
8

70% alcohol betadine solution
5% chlorhexidine gluconate
11
12
13
14
15
16
17
anti-HIV
( 24 . )

anti-HIV
()
anti-HIV
HIV
anti-HIV
10
HIV OCC-PEP
HIV OCC-PEP
3.9 [1 - 3]
Page | 46

3[16a] HIV OC-PEP

2d
3 **
3 **
3 **

1c
2 *
( anti-HIV )
2 * 2 *
2 * 2 *
(solid needle) (superficial injury) b

c
viral load<1,500 copies/ml d (symptomatic) (acute seroconversion) viral load
* (basic regimens) ** (expanded regimens)
3[16b] HIV OC-PEP

1c
( anti-HIV)

2d
2 *
2 *
2 *
3 **
2 *
2 *

2-3 b c viral load<1,500 copies/ml

d
(symptomatic) (acute seroconversion) viral load
* (basic regimens) ** (expanded regimens)
Page | 47

3[16c] HIV OCC-PEP HIV SEX - PEP ( ..
2551)
Preferred basic regimens 2
AZT + 3TC *
TDF + 3TC
TDF + FTC *
Alternative basic regimens 2
3TC + d4T *
3TC + ddI
Expanded regimens 2
1 PIs NNRTIs
PIs
NNRTIs
LPV/r
IDV/r
EFV
ATV/r
SQV/r
* fixed drug combination: AZT + 3TC: TDF + FTC: 3TC + d4T
1. (drug interaction) 3.4 3.5

2. EFV IDV
3. EFV
4. NVP ( )
3[17] HIV OC-PEP
AZT
EFV
LPV/r, IDV, ATV, SQV
IDV
CBC
Lipid profile, liver function test
FBS, lipid profile, liver function test
Cr, urinary analysis
3[17] *
10,000
50
10
6.5
0.5
*
Page | 48

3[2]
( )
72
HIV SEX-PEP
anti-HIV
3.9 [6]
3.9 [7 - 8]
3[18a] HIV SEX-PEP anti-HIV

/ (viral load , ,
, , )

HIV SEX-PEP
Page | 49

3[18b] HIV SEX-PEP
( 15 )
HIV SEX-PEP

/ (, ,
, )
3[18c] HIV SEX-PEP

(
15)

/ (, ,
, )

HIV SEX-PEP
Page | 50

3[19] HIV SEX-PEP*
Anti-HIV
Complete blood count
Serum transaminase
Blood urea nitrogen/creatinine
Sexually transmitted
diseases screening
(gonorrhea, chlamydia,
syphilis)
Hepatitis B serology
Pregnancy test
()
E, S
E
E
E
E
E
E
E, S
E
E
E, S
E
4-6
*
E = (exposed patient), S = (source)
HIV antibody HIV

Page | 51
1. .
. 1. : ; .. 2547.
2. When To Start Consortium. Timing of initiation of antiretroviral therapy in AIDS-free HIV-1-infected
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5. Miriam J. Alter. Epidemiology of viral hepatitis and HIV co-infection Journal of Hepatology 44 (2006) S6
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6. Wit FW, Weverling GJ, Weel J, Jurriaans S, Lange JM. Incidence of and risk factors for severe
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7. .
. 2005 Jan-Feb;14(1)165-173.
8. Jrgen Rockstroh, L Peters, V Soriano, and others. High HCV Is Associated with an Increased Risk for
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(CROI 2009). Montreal, Canada. February 8-11, 2009. Abstract 101.
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11. Galia Karp, Francisc Schlaeffer, Alan Jotkowitz, Klaris Riesenberg. Syphilis and HIV co-infection.
European Journal of Internal Medicine 20 (2009) 913
12. .
. 1 . : ; ..
2550.
13. . .
1. : .. 2549.
14. World Health Organization. TB/HIV A Clinical Manual. Second edition. WHO/HTM/TB/2004.329.
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16. World Health Organization. Tuberculosis Care with TB-HIV Co-management Integrated Management Of
Adolescent and Adult Illnedd (IMAI). WHO/HTM/TB/2007.380
7
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2, p.104107
18. International AIDS SocietyUSA. Perspective Human Papillomavirus Infection in HIV-infected Persons.
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19. Elizabeth Stier. Human Papillomavirus Related Diseases in HIV-infected Individuals. Curr Opin Oncol.
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20. Shehla Arain, Ann E Walts, Premi Thomas, Shikha Bose. The Anal Pap Smear: Cytomorphology of
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21. Morten Frisch, et al. Sexually Transmitted Infection as a Cause of Anal Cancer. NEJM. Nov 6 1997.
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23. Prez-Blzquez E, Redondo M I, Gracia T. AIDS and Ophthalmology: a Contemporary View. An. Sist.
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27. Hugonnet S, Mosha F, Todd J, Mugeye K, Klokke A, Ndeki L, Ross D, Grosskurth H, Hayes RJ. Incidence
of HIV Infection in Stable Sexual Partnerships: a Retrospective Cohort Study of 1802 Couples in Mwanza
Region, Tanzania. Acquir Immune Defic Syndr. 2002 May 1;30(1):73-80.
28. . : 1 .
: ; .. 2549.
29. Paton NI., Sangeetha S., Earnest A., Bellamy R. The Impact of Malnutrition on Survival and the CD4 Count
Response in HIV-Infected Patients Starting Antiretroviral Therapy. HIV Medicine (2006), 7, 323330.
30. Schwenk A., et al. Clinical Risk Factors for Malnutrition in HIV-1- Infected Patients. AIDS 1993, 7:12131219.
31. Giuseppe G., Erika Ferrari Rafael da Silv. Cardiovascular complications in the acquired
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32. Modified from Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of
antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human
Services. November 3, 2008; 1-139. Available
at http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed (Novemver 7, 2009)
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33. Modified from Gilbert DN, Moellering RC, Eliopoulos GM, Saag MS, and Canbers HF Eds. The Sanford
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34. Zolopa A, Anderson J, Komarow L, et al. Early antiretroviral therapy reduces AIDS progression/Death in
individuals with acute opportunistic infections multicenter randomized strategy trial. PLoS ONE,
2009;4:e5575.
35. Abdool Karim S, Naidoo K, Grobler A, et al. Initiating ART during TB treatment significantly increases
survival: results of a randomized controlled clinical trial in TB/HIV-coinfected patients in South Africa
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11, 2009; Montreal, Canada. Abstract 36a
36. Clinical Trials gov. Early vs late introduction of antiretroviral therapy in nave HIV infected Patients with
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15, 2009.
37. ClinicalTrials.gov. A strategy study of immediate versus deferred initiation of antiretroviral Therapy for HIv
infected persons treated for tuberculosis with CD4 less than 200 cells/mm3. Available at
: http://clinicaltrials.gov/ct2/show/NCT00108862. Accessed June 15,2009.
38. Gilks C, Victoria M. Antiretroviral therapy for HIV infection in adults and adolescents: recommendations
for a public health approach. WHO; 2006:
39. Carr .A , Marriott D, Field A, et al. Treatment of HIV-1 associated microsporidiosis and Cryptosporidiosis
with combination antiretroviral therapy. Lancet 1998; 351: 256-61.
40. Foudraine NA, Weverling GJ, van Gool T, et al. Improvement of chronic diarrhea in patients with
advanced HIV-1 infection during potent antiretroviral therapy. AIDS 1998; 12: 35-41.
41. Murdaca G, Campelli A, Setti M, et al. Complete remission of AIDS/Kaposis sarcoma after Treatment
with a combination of two nucleoside reverse transcriptase inhibitors and one non-nucleoside Reverse
tran-scriptase inhibitor [ Letter ]. AIDS 2002; 16 :304-5.
42. Tantisiriwat W, Tebas P, Clifford DB, et al. Progressive multifocal leukoencephalopathy in Patients with
AIDS receiving highly active antiretroviral therapy. Clin Infect Dis. 1999; 28: 1152-4
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43. Antiretroviral therapy for HIV infection in adults and adolescents : recommendations for a public health
approach. 2006 rev
44. Manosuthi W , Sungkanuparph S, Tantanathip P, Lueangniyomkul A, Mankatitham W, Prasithsirikul W,
Burapatarawong S, Thongyen S, Likanonsakul S, Thawornwan U, Prommool V, Ruxrungtham K, for the
N 2 R Study Team
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Rifampicin (The N 2 R Study) Clin Infect Dis 2009, 48(12):1752-1759.
45. Manosuthi W, Sungkanuparph S, Tantanathip P, Mankatitham W, Lueangniyomkul A, Thongyen S,
Eampokarap B, Uttayamakul S, Suwanvattana P, Kaewsaard S, Ruxrungtham K Body Weight Cutoff for
Daily Dosage of Efavirenz and 60-week Efficacy of Efavirenz-based Regimen in Co-infected HIV and
Tuberculosis Patients Receiving Rifampicin Antimicrob Agents Chemother 2009; 53(10):4545-8.
46. Ledergerber B, Telenti A, Egger M. Risk of HIV related Kaposi's sarcoma and non-Hodgkin's lymphoma
with potent antiretroviral therapy: prospective cohort study. Swiss HIV Cohort Study. BMJ 1999;319:23-4.
47. Ledergerber B, Egger M, Erard V, et al. AIDS-related opportunistic illnesses occurring after initiation of
potent antiretroviral therapy: the Swiss HIV Cohort Study. JAMA 1999;282:2220-6.
48. Clifford GM, Polesel J, Rickenbach M, et al. Cancer risk in the Swiss HIV Cohort Study: associations with
immunodeficiency, smoking, and highly active antiretroviral therapy. J Natl Cancer Inst 2005;97:425-32.
49. Besson C, Goubar A, Gabarre J, et al. Changes in AIDS-related lymphoma since the era of highly active
antiretroviral therapy. Blood 2001;98:2339-44.
50. Chiao EY, Krown SE. Update on non-acquired immunodeficiency syndrome-defining malignancies. Curr
Opin Oncol 2003;15:389-97.
51. Bonnet F, Lewden C, May T, et al. Malignancy-related causes of death in human immunodeficiency virusinfected patients in the era of highly active antiretroviral therapy. Cancer 2004;101:317-24.
52. Bonnet F, Lewden C, May T, et al. Malignancy-related causes of death in human immunodeficiency virusinfected patients in the era of highly active antiretroviral therapy. Cancer 2004;101:317-24.
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patients. HIV Med 2007;8:322-3.
54. Carbone A, Gloghini A. AIDS-related lymphomas: from pathogenesis to pathology. Br J Haematol
2005;130:662-70.
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in adults. JAMA 2001;285:1736-45.
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57. Ensoli B, Barillari G, Salahuddin SZ, et al. Tat protein of HIV-1 stimulates growth of cells derived from
Kaposi's sarcoma lesions of AIDS patients. Nature 1990;345:84-6.
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Page | 56
Chapter 4 Pediatric [16/3/53]
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
4
(Management of HIV-Infected Children)

15,000-20,000 8 .. 2551
0.74 6,000

4.1
3
1)
2)
3)

1
2
3
4
4.1.1

(
)
4.1.2.

Pneumocystis jiroveci (PCP)

CD4
( 1a-1c)
2
3
4
5
6
7
8
9
10
11
12
13
14

- - (MMR)
CD4 MMR CDC stage C WHO stage IV %CD4
15 (IPV/OPV)
(BCG)

- (VAR) %CD4 15 2 3
-
- conjugate (PCV)
polysaccharide 23 valent (PS23) 2
-

immunoglobulin (TIG)
(RIG)
4[1a] 2551
-- 2
3
BCG
HBV1
HBV2
DTwP1
DTwP2
HBV3
DTwP3
OPV1
or IPV1
OPV2
or IPV2
OPV3
--
5
12
18
2-2
DTwP4
OPV4
4-6
11-12
DTwP5
dT
OPV5
or IPV4
or IPV3
MMR1, (MMR2)
JE1, JE2
4
JE3
--
( 4 DTaP, 4 ;Tdap)2
5
6 (Hib: PRP-T, PRP-OMP)
7
8
9
10
(PCV PS23)
11
DTaP1
Hib1
DTaP2
Hib2
DTaP3
DTaP4
Hib3
(PRP-T)
DTaP5
Tdap
JE4
Hib
(4-5 JE3)
HAV1, HAV2 6-12

VAR 2 3
Influenza vaccine 6
PCV1
PCV2
PCV3
PCV4
12-15
PS23 2 3-5
HPV 3
0,1-2,6
9-26
Chapter 4 Pediatric [CrossCutting 4/2/53]
4[1b] Hib
4
5
6
4[1c] PCV
2-6
3 6-8
7-11
2 6-8
12-23
2 6-8
24-59
1
2 6-8
1.
7
8
2.
3.
10
11
4.
12
13
14
5.
15
6.
16
17
18
7.
19
8.
20
9.
21
PRP-OMP
0, 2, Booster
0, 2, Booster
12-15
12-15
2
3
PRP-T, HbOC
2 - 6
0, 2, 4, Booster
7 - 11
0, 2, Booster
>12 - 59
Booster 2 2
BCG

DTP (Tdap) 1
Polio vaccine IPV OPV IPV
MMR (clinical stage C %CD4 15)

MMR2 1 MMR1 4-6
JE 1 3 4-5
Hib 2 1 12-18
2
HAV 1 2 6-12
VAR 1 %CD4 15 2 3
Influenza vaccine 9 2 1

10.
2
3
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
11.
HPV 3 0, 1-2, 6 9 26

( 4[2] 4[3])

6 %CD4 15

PCV 2 3 2 12-15
PS23 2 PCV 2
PS23 1 3-5
4[2] 1-6 [4]
1
0
dT1, OPV/IPV1, MMR, BCG
2
1
HBV1, JE1
3
2
dT2, JE2, OPV/IPV2, HIB2
4
7
HBV3
6
12
dT3, OPV/IPV3, JE3
P
4[3] 7-18 [4]
1
0
dT1, OPV/IPV1, MMR, BCG
2
1
HBV1, JE1
3
2
dT2, JE2, OPV/IPV2, HIB2
4
7
HBV3
6
12
dT3, OPV/IPV3, JE3
P
PCP
PCP 2-3 (
) PCP
CD4 co-trimoxazole (TMP-SMX) 150 mg/m2
P
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
TMP 1-2 3
(level I) TMP-SMX 4 6 [1] PCP
(level I)
6 [2](level III)

12
12
[1](level II)
12 %CD4 15
[1](level II)
TMP-SMX dapsone 2 mg/kg ( 100

mg) 4 mg/kg ( 200 mg)
desensitization TMP-SMX

PPD skin test

1)
2)

3)

4)
5)
6)
7)
8) /

9)
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
4.1.3.

PCP

PCR 1-2
PCR 1-2 PCR
2 [3]
PCR 1-2 4 2

anti-HIV 18 PCR
anti-HIV anti-HIV
12 5-10 antibody
anti-HIV 12
anti-HIV 18 [3]
antibody antigen (HIV Ag/Ab)
antibody 18
PCR antibody
18 antibody antibody
antibody 24
(definitive exclusion of HIV infection)

1) PCR 2 1
4
2) anti-HIV 6 2
3) PCR 1 4 anti-HIV 1
6

CD4
33
34
35
36
(presumptive exclusion of HIV infection)

1) PCR 2 14
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
1
2) PCR 1 2
3) anti-HIV 6 1

CD4
4.2 (ARV therapy in nave
HIV-infected children)

4.2.1
1) (medical evaluation)
1.1)
IRIS
latent infection
1.2) CD4

TMP-SMX

TMP-SMX
1.3) CBC, ALT, AST, CD4
CD4
CD4 viral load

CXR PPD skin test
PPD skin test

HBsAg

36
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
3) (adherence counseling)
4.10
18
19
20
4.2.2

21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
2) (ARV counseling)
2.1)

2.2) ( 6 )

2.3)

2.4)

1)
(symptomatic)
1

1
[5] 1 CD4
2) 2
2.1) CDC clinical classification ..2537 category A, B, C
CDC category B C
2.2) WHO ..2549 WHO stage 1, 2, 3, 4
WHO stage 3 4
WHO stage 1 2 7 20 [6]
3) CD4 %CD4 HIV prognostic marker collaborative
4,000 [7]
2,500 [8] CD4 %CD4
9
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
CD4 %CD4
4 1 (12-month mortality risk)
CD4 %CD4 CD4
%CD4 CD4 %CD4 6
4[4] (Level II)
< 1
1-5
> 5
CDC category B, C
CDC category B, C
WHO stage 3, 4
WHO stage 3, 4
CD4
%CD4 CD4

%CD4 <25
CD4 <350cells/mm3
CD4

- CD4 %CD4 CD4 %CD4
CD4
-
CD4 %CD4
CD4 %CD4
4.2.3 (antitretroviral nave)

[9] (Level II)
(preferred regimens)
(alternative regimens)
19
20
21
22
23
2NRTIs + NNRTI
1-3
> 3
AZT + 3TC + NVP
AZT + 3TC + EFV
d4T + 3TC + NVP
AZT + 3TC + NVP

d4T + 3TC + EFV
d4T + 3TC + NVP
NRTIs AZT + 3TC d4T + 3TC

AZT + 3TC d4T + 3TC
lipodystrophy (Hb <8-9 g/dL) d4T + 3TC
6-12 AZT + 3TC
10
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
40 kg
TDF + 3TC adherence
NNRTI NVP EFV

EFV 3 EFV
[10]
NVP d4T + 3TC +
NVP (GPO-VIR S) AZT + 3TC + NVP (GPO-VIR Z250)
15[11] hypersensitivity
P
4.2.4 NVP
12
(Level III)
P
2NRTIs + PI
(preferred regimens)
AZT + 3TC + LPV/r
(alternative regimens)
d4T + 3TC + LPV/r
NVP
NNRTIs 20- 57[12, 13]
2NRTIs + PI(Level II) [14]
NVP NVP EFV NNRTIs
NVP
NNRTIs
2NRTIs + LPV/r 12 viral load LPV/r
NNRTIs[15] (Level II) viral load 6
LPV/r
NVP
1 2NRTIs +PI 2NRTIs + NNRTI
2NRTIs +NNRTI viral load 6 viral
load PI
P
31
11
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
4.2.5
(antiretroviral therapy in children with opportunistic infection)

drug interaction
IRIS CD4
CD4 IRIS 20[16]
2 TB, MAC, PCP,
cryptococcosis cryptosporidiosis, microsporidiosis
2 8
(Level III) 8
[17] ( CD4)

[1] (Level V)

1)
2)

3) rifampicin NNRTIs
PIs PIs
NNRTIs
1
2
[1, 18] (Level V)

1) CD4
2) CD4 2 8
IRIS
CD4 CD4

1) NNRTIs ( rifampicin)
12
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
EFV EFV 25
EFV[19](Level III) EFV
3 EFV NVP [20] (Level II)
2) NNRTIs PIs
2.1) rifampicin
quinolones aminoglycoside PIs
2.2) rifampicin
2 maintenance
rifampicin PIs PIs
rifampicin 2 ( rifampicin )
3) NNRTIs triple NRTIs AZT
d4T/3TC/ABC[18] rifampicin
NNRTIs PIs ABC

1) NNRTIs
NVP

2)
PIs PIs PIs
2 (induction period)
PIs maintenance rifampicin
rifampicin quinolones aminoglycoside
PIs

CXR PPD skin test supporting
evidence
INH 10 mg/kg/day 9 PPD skin test [1]
P
4.3

4.3.1
2-3 2-3
13
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
1) (new clinical events)

IRIS
2)
(secondary sex
characteristics)
3) (neurodevelopment) (OFC)
2
4.3.2
1) (safety monitoring)
CBC 6 AZT 3
WBC
Chemistry liver enzyme, renal function, lipid profile 6
NVP ALT 2-4
IDV TDF urine analysis ( IDV
WBC, RBC ; TDF glucosuria, proteinuria) creatinine
2-3

2) (immunological and virological monitoring)

2.1) CD4 %CD4 6 (level II)
2.2) viral load
6
viral load 6 1
CD4 %CD4
viral load (level II)
27
28
29
30
31
14

4.4
4[5]
- routine
serum lactate
-

bicarbonate
thiamine, riboflavin, oral antioxidant (L-carnitine,
coenzyme Q, vitamin C)
- NRTIs TDF
ABC AZT 3TC (Level
serum lactate
fluorideoxalate tube
lab 4
-
- serum amylase
- NRTIs
pancreatitis AZT ABC
(Level II)[22]
-
- ( therapeutic range)
- NRTIs AZT
ABC (Level II) [22]
ddI
d4T
- lipohypertrophy
- (
1) Mitochondrial dysfunction
Lactic acidosis
:
NRTIs
ddI, d4T
Pancreatitis
:
NRTIs
ddI, d4T 3TC
Peripheral
neuropathy
:
d4T, ddI
- 4
1-20
- ,
-

-
-
-

-
- metabolic
acidosis
anion gap>16
- serum lactate
>5 mmol/L
-
hyporeflexia
1
2
IV)[21]
Serum amylase
lipase
- routine
serum amylase lipase

2) Metabolic abnormality
Fat maldistribution
: NRTIs
- lipohypertrophy

15
Hyperglycemia
insulin resistance
: PIs
Hyperlipidemia
: PIs
NNRTIs
EFV
hyperlipidemia
NVP
PIs
- lipoatrophy

NRTIs d4T ddI
AZT
-

-
d4T, AZT ABC, TDF (Level I)[23]
- FBS> 126
mg/dl
- random blood
sugar
200
mg./dL.
- FBS
OGTT
- Fasting
Cholesterol >
200 mg/dl
- Fasting LDL
> 130 mg/dl.
- Fasting TG >
200 mg/dl
- PIs
FBS
- random blood
sugar FBS 6
- ,
-
- Fasting Cholesterol,
HDL, LDL TG
6
1.
(Level II)
2. 6-12
pancreatitis TG > 500
mg/dl
PIs NNRTIs
NNRTIs ATV (Level II)[24, 25]
3.
cholesterol statin
d4T
- PIs
boosted PIs
- Cholesterol, LDL
arterosclerosis
- TG
pancreatitis
16
3) Hepatic toxicity ()
:
- NRTIs
- NNRTIs NVP
EFV
- PIs
RTV, IDV, ATV
- liver enzyme
()
-
NVP
- Reversible asymptomatic indirect
hyperbilirubinemia ( IDV, ATV)
4)
:
-
AZT
- Pravastatin < 8
8-13 20mg 1
14-18 40 mg 1
10 mg 4

- ATV cholesterol
< 6
>6 10-20 mg 1
TG gemfibrozil approved
150-300 mg
2
- AZT RBC
MCV ()
- Neutrophil
WBC
W
BC
- ALT /
AST
10
upper normal
limit
- bilirubin
-

6
- NVP
liver enzyme 2-4

- 10 upper
normal limit
-
-
NVP ABC (level II)[26]

hepatitis A,B,C
cytomegalovirus
- Hb
7-8 g/dl
- absolute
neutrophil count
< 500 cells/mm3
- CBC 6
- AZT
CBC 3 6
6
-
TMP-SMX
- AZT 20%
AZT NRTIs d4T,
ddI ABC
17
(< 250 cells/mm3)

- Pletelet count

(severe < 250

cells/mm3)
- platelet count <
100,000 /mm3
:
-

NVP
- maculopapular urticaria
2-4 (
2-3
8 )
- NVP
SJS, erythema multiforme, toxic
epidermal necrolysis, exfoliative
dermatitis DRESS
2-8
-

TMP-SMX
- NVP
2
- NVP liver
enzymes
2-4
6
Hypersensitivity
reaction
: ABC,
NVP
- ABC

mucositis,
myocarditis , hepatitis nephritis
shock
6
- NVP , ,
1-2
- atypical
lymphocytosis ,
eosinophilia,
thrombocytopeni
a, creatinine,
CPK liver
- IVIG steroid platelet

count <20,000 cells/mm3

TMP-SMX,
ganciclovir
5) Allergic reaction
- antihistamine

- mucous membrane involvement
systemic
NVP
NVP EFV
cross reaction
(Level IV)[27]
- SJS DRESS corticosteroid
- -
NVP EFV
-

HLA B*5701 ( hepatic toxicity) (Level
ABC[28] (Level II) III)[29]
18
hypersensitivity reaction
TMPSMP, lactam
enzymes
-
-
( Mitochondrial dysfunction
hepatic toxicity)
6) Gastrointestinal toxicity
7)
ddI
RTV
hematuria

:
- IDV
nephrolitiasis
urolithiasis
nephrotoxicity
- TDF
fanconi syndrome,
decrease creatinine
clearance
- IDV serum
creatinine
pyuria
hematuria
hydronephrosis
- TDF serum
creatinine
proteinuria
glycosuria
hypophosphate
mia hypokalemia
- IDV
urine analysis 3-6
- TDF
UA, creatinine, electrolyte,
serum phosphate
1
2
3
19
- IDV
PIs

IDV RTV
230-300
mg/m2/dose RTV
100 mg 12
(Level IV)
[30]
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
4.5 Immune Reconstitution Inflammatory Syndrome (IRIS)

Immune restoration syndrome (IRS) Immune Reconstitution Inflammatory Syndrome (IRIS)

CD4 viral load
IRIS (typical
manifestation) herpes zoster, mucocutaneous herpes simplex
(atypical) nontuberculous Mycobacteria, herpes simplex
cytomegalovirus meningoencephalitis
( CD4 5)
IRIS 19 1-6 ( 2-12 )
nontuberculous Mycobacteria ( Mycobacterium bovis BCG strain ) herpes simplex Cryptococcus
acute respiratory distress syndrome ( tuberculous nontuberculous
Mycobacteria), herpes simplex meningoencephalitis IRIS CD4
viral load
[31] (Level II)
IRIS 1
4[1] IRIS
(Clinical events)
(1)
IRIS paradoxical
(worsening)
(3)
CD4 /
(2)

(5, 7)
(OI)

(common childhood illness)
IRIS unmasking
(4)
35
36
37
20

(6, 7)
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
(1) ( clinical events) :

(typical manifestation) herpes zoster mucocutaneous
herpes simplex (atypical)
nontuberculous mycobacteria herpes simplex cytomegalovirus meningoencephalitis
(2) CD4 ( 5 2
7 ) / viral load ( 2 log 10 50 copies/mm3)
(3) Paradoxical (worsening) type: IRIS
IRIS cryptococcal meningitis IRIS

(4) Unmasking type: IRIS

nontuberculous mycobacteria human herpes virus

(5) :
cryptococcal associated IRIS

(6) : mycobacterium
tuberculous nontuberculous
(7)
corticosteroid prednisolone(1-2
mg/kg/day) 1-4 ( IRIS
5)
4[6] IRIS [32] (Level II)
26
27
28
29
30
31
21
NSAIDs
Corticosteroid /
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
4.6 (diagnosis of treatment failure in HIV-infected children)

NRTIs 1-2
NVP
NNRTIs
4.6.1 (Level III)[3]
3 virological failure, immunological failure clinical failure
viral load CD4
viral load CD4
viral load CD4 CD4
viral load
CD4 clinical failure
1) Clinical failure

clinical failure
2) Immunological failure
immunological failure CD4 2
1 immunological failure
viral load virological failure
CD4 immunological failure

1
- 5 %CD4 15
1 %CD4 5
- 5 CD4 200 cells/mm3
1 CD4 50
cells/mm3
36
37
22
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

- %CD4 15
%CD4 5 (
15% 10%)
- CD4 30 6
3) Virological failure

- 1 viral load >50 copies/ml
12
- 1 viral load>50 copies/ml
6
viral load viral load
(undetectable) viral load>1000 copies/ml virological failure
viral load ( 50-1000 copies/ml)
viral load
1-3
23

1
2
3
4.6.2
4[2]
%CD4, CD4, Hb,

viral load
IRIS
clinical failure immunological failure virological failure
3
5
6
24

1
2
3
4.7
3
4[3]
adherence
- adherence
-
- CD4
- viral load
- 1
- adherence
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
-
adherence
- genotyping viral load >2000 copies/mL
genotyping
Adherence
4.7.1 genotyping[33]
1) genotyping viral load
< 2,000 copies/ml 1
2) NRTIs 3TC (mutation)

thymidine analog mutation TAM TAM 4 NRTIs
NRTIs TAMs 4 NRTIs TDF, ddI
ABC multi-NRTI mutation (Q151M, 69i) NRTIs ( Q151M
TDF ) K65R TDF
NRTIs RTV-boosted PI NRTIs
3) 3TC NRTIs
M184V M184I 3TC 3TC
M184V (less fit)
22
25

4) genotyping no evidence of resistance, possible resistance
resistance mutations genotyping
6
possible resistance resistance
NRTIs (recycle)
1
2
3
4
4[7] genotyping NRTIs [33] ()

NRTIs
Mutations
AZT or d4T
- TAMs: M41L, D67N,
K70R, L210W,
T215YF, K219QE
- Multi-NRTI: Q151M
complex (A62V, V75I,
F77L, F116Y,
Q151M), 69 insertion
ddI
3TC
TDF
9
10
11
12
13
14
15
- TAMs < 4 NRTIs

D67N, K70R,
K219Q/E M41L,
L210W, T215Y/F
- TAMs 4 multi-NRTI
NRTIs 3TC
- Q151M TDF
NRTI
- TAMs < 4: ddI

ABC TDF
- Q151M: TDF
- TAMs > 4 69 ins :
NRTIs
NRTIs

TDF, ABC, ddI
- L74V, K65R:
AZT
5
6
7
8
- L74V, K65R +/- TAMs
- ddI
- ABC TAMs
L74V, K65R
- M184V, M184I
- 3TC M184V, I - 3TC

3TC NRTIs
viral load
- K65R TDF
- AZT K65R
- TAMs 4 TDF
- K65R
- TAMs
- Multi-NRTI ( Q151M)
4[8] genotyping NNRTIs2

NNRTIs
NVP, EFV
Mutations
Y181C/I, K103N, G190S/A,
L100I, V106M/A, V108I,
Y188CLH, P225H
mutation NVP
EFV
NNRTIs etravirine mutation score

[33] NVP, EFV mutation score etravirine
26
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
4.7.2 genotyping PIs

PIs NRTIs NNRTIs PIs
RTV (boosting) PIs PIs
PIs
1) mutation major mutation
minor mutation PIs major mutation cross resistance
LPV/r RTV
2) mutation
mutation 5 mutation
(genetic barrier ) DRV/r[33]
4.7.3 2 NRTIs + 1 NNRTI (Level II)
2NRTIs + 1 NNRTI (NVP EFV)
1) : 2 NRTIs ( genotyping) + LPV/r[34]

2) :
2.1) 2NRTIs ( genotyping) + ATV/r ATV
6 [35]
2.2) Double boosted PIs LPV/r/SQV[36] / LPV/r/IDV[30]
NRTIs NRTIs NNRTIs
TDF

adherence
double boosted PIs
double boosted PIs viral suppression 1

single boosted PI + 2/3NRTIs
1 NRTIs
2 NRTIs resistance testing 4
2NRTIs AZT + d4T, d4T + ddI, TDF + ddI
1: (mutation) TAMs 4
NRTIs (recycling NRTIs) ddI + AZT, ddI + 3TC, ABC + 3TC
2: TDF TAMs
4 Q151M 69i K65R
(tanner stage>4 ) 30 kg TDF TDF + 3TC
TDF + ABC TDF + AZT AZT NRTI 3 TDF + 3TC + AZT
27

TDF + ABC + AZT AZT K65R TDF
1
2
3
3: TDF TAM>4
Q151M 69i K65R NRTIs
NRTIs ddI+ABC, ddI+3TC ddI+
AZT NRTIs double boosted PIs 3TC
4
5
6
4[9] NRTI
NRTI
[37]
TDF
- TAMs
-
ABC
10
11
12
13
14
15
16
17
18
19
-
- 18
-
-
30 kg
Tanner stage >4 [38]
-

7
8
9
-
lipodystrophy
-
-
- hypersensitivity 1-2
ABC HLA-B*5701
genotype HLA-B*5701
ABC
-
TDF 2553
www.ClinicalTrial.gov NCT00352053 www.ClinicalTrial.govNCT00528957
2 1 PI
LPV/r
PI IDV/r
LPV/r
3 double boosted PIs LPV/r IDV
SQV
20
21
22
23
28

4[10] PIs
PI
LPV/r
-
-
- PI RTV

-
ATV/r
RTV ATV
-
- 6
- LPV/r IDV/r
- 43%
-
-
-
- RTV
-
-
conduction system defect prolong PR
interval
- indirect hyperbilirubinemia
-
- RTV
-
-
- double boosted PIs
PIs 50 mg/kg 12
.
-
- RTV
-
- double boosted PIs
PIs 220300 mg/m2/ 12 .
- 2
trough 0.1 g/L
2 10 g/L
SQV/r
RTV SQV

- LPV/r IDV
- LPV/r double
boosted PIs
IDV/r
RTV IDV

- LPV/r double
boosted PIs
2
3
29

1
4[4]
2
3
d4T AZT + 3TC + NVP EFV
4
5
6
7
genotyping viral load >1000 copies/ml
6
2 2NRTIs genotype + 1 boosted PI
8
9
2NRTIs2
10
11
12
14
15
16
17
18
19
20
21
22
23
24
25
26
27
1
TAMs < 4
Q151M, 69i, K65R
2
TAMs > 4 Q151M 69i
K65R Tanner > 4
> 30 kg
3
TAMs > 4 69i K65R
Tanner < 4
< 30 kg
13
ddI+3TC, ddI+AZT,
ABC+3TC
Tanner > 4 TDF+3TC,
TDF+AZT, TDF+ABC
TDF+3TC TDF+ABC TDF+AZT

AZT NRTI 3
TDF+3TC+AZT TDF+ABC+AZT
1 boosted PI
: LPV/r
: ATV/r
viral load 3-6

- single boosted PI NRTIs
ddI+ABC, ddI+3TC
ddI+ AZT LPV/r ATV/r
- double boosted PIs SQV/LPV/r
IDV/LPV/r 3TC, AZT+3TC, ABC+3TC
28
29
30
31
32
33
34
35
36
37
30
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
4.7.4 3 NRTIs, NNRTIs PIs[39] (Level III)

3 2
drug resistance

FTC
(NNRTI), DRV/r (PI), RAL (INSTIs), maraviroc (CCR5 inhibitor) DRV/r
6 viral load 6 viral load
>1,000 copies/ml

CD4 CD4 3TC
mutation CD4 ( 3 )
4.7.5 NRTIs 2 (dual NRTIs therapy)

1-2
NRTIs viral load<50 copies/ml
2NRTIs+NNRTI viral load genotype
4.7.6 dual NRTIs (Level III)

1) : 2NRTIs genotyping + RTV-boosted PI NRTIs
PIs 2NRTIs+NNRTI
2) 2
2.1) 2NRTIs + NNRTI TAMs< 4 multi NRTI mutation
NNRTIs NRTIs
2.2) NNRTI+ RTV-booosted PI + 1/2NRTIs (recycle) NRTIs
TAMS 4 multi-NRTI mutation
NNRTIs PIs
4.7.7
1) 1 3
adherence PIs metabolic
lipid profile 2 TDF IDV urinalysis, Cr (
creatinine clearance) blood sugar 6
2) 1 3 2-3
CD4 3-6 6 viral load 6
viral load >1,000 copies/ml 6
31

3) PIs 2
PIs double boosted
PIs IDV/r SQV/r
25 kg PIs 2

1
2
3
4
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
4.8

T cell B cell
CD4
[40-45] (Level II)

%CD4 <15
CD4 25% 350
cells/mm3 ( > 5 ) 6 [40-45] (level II) %CD4>15 viral suppression <400 copies/ml
1 (Level III)
CD4
%CD4 15

5
6
7
4[11] %CD4 15
1 2 6
HBV vaccine
HBV1
HBV2
HBV3
3
JE vaccine*
JE1
JE2
2
Measles vaccine**
MMR1
1
dT vaccine
10
>7
*
** MMR
4 9.

[46] [47]
P
32

4.9.1 [48]

4 1) 2)
3) 4)

2
3
4
5
6
7
8
4.9.2 [49, 50]

10

[51]
P
9
10
11
12
13
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
4.10
(adherence to antiretroviral treatment in children)

adherence 95[52] (Level
III)

adherence 5
1 :

2 :
1- 2
DOT TMP-SMX
2-4
3 :
(fixed dose combination)
TDF+3TC+EFV

4 ( ) :

5 : adherence

P
14
15
16
17
33
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
4.11
(5Ds)
1) D1:
9-10 1. 2.
3. 4.
5. [53]
2) D2: 13[54]

3) D3:

4) D4:
9-12
12-14
5) D5:
[55]
P
[56]

27
28
29
30
31
32
33
34
35
36
37
38
34
1. CDC. Guidelines for the prevention and treatment of opportunistic infections among HIV-exposed and HIV-infected children.
Recommendaions from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of
America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. MMWR Morb Mortal Wkly Rep 2009 ;58
(No. RR-11).
2. Chokephaibulkit K, Wanachiwanawin D, Chearskul S, et al. Pneumocystis carinii severe pneumonia among human immunodeficiency
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3. Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children. Guidelines for the use of antiretroviral
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November, 2009. .
4.
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..
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5. Violari A, Cotton MF, Gibb DM, et al. Early antiretroviral therapy and mortality among HIV-infected infants. N Engl J Med
2008;359:2233-44
6. Walker AS, Mulenga V, Sinyinza F, et al. Determinants of survival without antiretroviral therapy after infancy in HIV-1-infected
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7. Markers for predicting mortality in untreated HIV-infected children in resource-limited settings: a meta-analysis. Aids 2008;22:97-105
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9. WHO
antiretroviral
therapy
for
infants
and
children
2008 ;
April
2008. http://www.who.int/hiv/pub/paediatric/WHO_Paediatric_ART_guideline_rev_mreport_2008.pdf; Access November 24, 2009.
10. Puthanakit T, Aurpibul L, Oberdorfer P, et al. Sustained immunologic and virologic efficacy after four years of highly active
antiretroviral therapy in human immunodeficiency virus infected children in Thailand. Pediatr Infect Dis J 2007;26:953-6
11. Lapphra K, Vanprapar N, Chearskul S, et al. Efficacy and tolerability of nevirapine- versus efavirenz-containing regimens in HIVinfected Thai children. Int J Infect Dis 2008;12:e33-8
12. Eshleman SH, Hoover DR, Hudelson SE, et al. Development of nevirapine resistance in infants is reduced by use of infant-only
single-dose nevirapine plus zidovudine postexposure prophylaxis for the prevention of mother-to-child transmission of HIV-1. J Infect
Dis 2006;193:479-81
13. Chalermchockcharoenkit A, Culnane M, Chotpitayasunondh T, et al. Antiretroviral resistance patterns and HIV-1 subtype in
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mother-infant pairs after the administration of combination short-course zidovudine plus single-dose nevirapine for the prevention of
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14. Palumbo P, Violari A, Lindsey J et al. Nevirapine (NVP) vs lopinavir-ritonavir (LPV/r)-based antiretroviral therapy (ART) in single
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Society Conference on HIV Pathogenesis, Treatment and Prevention, Cape Town, South Africa, 19-22 July 2009 ( Abstract
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15. Coovadia A, Abrams E, Strehlau R et al. Randomized clinical trial of switching to nevirapine-based therapy for infected children
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Town, South Africa, 19-22 July 2009 (Abstract MOAB103).
16. Puthanakit T, Aurpibul L, Oberdorfer P, et al. Hospitalization and mortality among HIV-infected children after receiving highly active
antiretroviral therapy. Clin Infect Dis 2007;44:599-604
17. Velasco M, Castilla V, Sanz J, et al. Effect of simultaneous use of highly active antiretroviral therapy on survival of HIV patients
with tuberculosis. J Acquir Immune Defic Syndr 2009;50:148-52
18. WHO. Guidance for National Tuberculosis Programmes on the management of tuberculosis in children
2006. http://www.who.int/child_adolescent_health/documents/htm_tb_2006_371/en/index.html; Access 24 November, 2009.
19. Manosuthi W, Mankatitham W, Lueangniyomkul A, Chimsuntorn S and Sungkanuparph S. Standard-dose efavirenz vs. standarddose nevirapine in antiretroviral regimens among HIV-1 and tuberculosis co-infected patients who received rifampicin. HIV Med
2008;9:294-9
20. Manosuthi W, Sungkanuparph S, Thakkinstian A, et al. Plasma nevirapine levels and 24-week efficacy in HIV-infected patients
receiving nevirapine-based highly active antiretroviral therapy with or without rifampicin. Clin Infect Dis 2006;43:253-5
21. Lonergan JT, Barber RE and Mathews WC. Safety and efficacy of switching to alternative nucleoside analogues following
symptomatic hyperlactatemia and lactic acidosis. Aids 2003;17:2495-9
22. Van Dyke RB, Wang L and Williams PL. Toxicities associated with dual nucleoside reverse-transcriptase inhibitor regimens in HIVinfected children. J Infect Dis 2008;198:1599-608
23. Moyle GJ, Sabin CA, Cartledge J, et al. A randomized comparative trial of tenofovir DF or abacavir as replacement for a thymidine
analogue in persons with lipoatrophy. Aids 2006;20:2043-50
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25. Mobius U, Lubach-Ruitman M, Castro-Frenzel B, et al. Switching to atazanavir improves metabolic disorders in antiretroviralexperienced patients with severe hyperlipidemia. J Acquir Immune Defic Syndr 2005;39:174-80
26. Shah I. Adverse effects of antiretroviral therapy in HIV-1 infected children. J Trop Pediatr 2006;52:244-8
27. Tebruegge M, Ritz N, Connell T and Curtis N. Human immunodeficiency virus-infected boy with Stevens-Johnson syndrome
caused by nevirapine. Pediatr Infect Dis J 2008;27:1041-2
28. Mallal S, Phillips E, Carosi G, et al. HLA-B*5701 screening for hypersensitivity to abacavir. N Engl J Med 2008;358:568-79
29. Hetherington S, McGuirk S, Powell G, et al. Hypersensitivity reactions during therapy with the nucleoside reverse transcriptase
inhibitor abacavir. Clin Ther 2001;23:1603-14
30. Plipat N, Cressey TR, Vanprapar N and Chokephaibulkit K. Efficacy and plasma concentrations of indinavir when boosted with
ritonavir in human immunodeficiency virus-infected Thai children. Pediatr Infect Dis J 2007;26:86-8
31. Puthanakit T, Oberdorfer P, Akarathum N, Wannarit P, Sirisanthana T and Sirisanthana V. Immune reconstitution syndrome after
highly active antiretroviral therapy in human immunodeficiency virus-infected thai children. Pediatr Infect Dis J 2006;25:53-8
32. Boulware DR, Callens S and Pahwa S. Pediatric HIV immune reconstitution inflammatory syndrome. Curr Opin HIV AIDS
2008;3:461-467
33. Johnson VA, Brun-Vezinet F, Clotet B, et al. Update of the Drug Resistance Mutations in HIV-1. Top HIV Med 2008;16:138-45
34. Ramos JT, De Jose MI, Duenas J, et al. Safety and antiviral response at 12 months of lopinavir/ritonavir therapy in human
immunodeficiency virus-1-infected children experienced with three classes of antiretrovirals. Pediatr Infect Dis J 2005;24:867-73
35. Macassa E, Delaugerre C, Teglas JP, et al. Change to a once-daily combination including boosted atazanavir in HIV-1-infected
children. Pediatr Infect Dis J 2006;25:809-14
36. Bunupuradah T, van der Lugt J, Kosalaraksa P, et al. Safety and efficacy of a double-boosted protease inhibitor combination,
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saquinavir and lopinavir/ritonavir, in pretreated children at 96 weeks. Antivir Ther 2009;14:241-8
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as salvage therapy for pediatric HIV infection. Pediatrics 2005;116:e846-54
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42. Puthanakit T, Aurpibul L, Yoksan S, Sirisanthana T and Sirisanthana V. Japanese encephalitis vaccination in HIV-infected children
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, , . . : , 2545:325-31.
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49. . . : , ,
, . Advances in Pediatrics. : , 2552:205-13.
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: , 2552.
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Intern Med 2000;133:21-30
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HIV-infected children in Thailand. J Paediatr Child Health 2006;42:283-8
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Physicians AIDS Care (Chic Ill) 2009 OnlineFirst, published on July 13, 2009 as doi: 10.1177/1545109709341082.
55. Oberdorfer P, Charnsil C, Louthrenoo O et al. What HIV-infected adolescents think and feel about moving to an adult HIVclinic.5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, Cape Town, South Africa, 19-22
July 2009 (Abstract TUPED086).
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37
Chapter 5 PMTCT [16/03/53]

5
(Prevention of Mother-to-Child Transmission)

25-40
..2531
..2543
( voluntary counseling and testing, VCT)

1

..2551 0.7 22
..2550 2.83

5.63
563
CD4
543
954
12 395
873
19 6 1 4 28 6
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
CD4 CD4 > 350 cells/mm3

WHO

..20157

NNRTIs

..2547 ..2552
AZT + single-dose NVP (SD NVP) CD4 200 cells/mm3 AZT +
Page | 1

3TC 7 NNRTIs
NNRTIs
AZT + SD NVP 1.98
HAART 19
Health Intervention and
Technology Assessment Program (HITAP)
() 3 (highly active antiretroviral therapy, HAART)
HAART 4

CD4 250 cells/mm3 . HAART
AZT+SD NVP CD4 250 cells/mm3. 10
.
HAART 255411

1 HAART CD4 350 cells/mm3

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
5.1
5.1.1

5.1.2 * 1

2
5.1.3 anti HIV
12
- Hct/CBC, VDRL, HBsAg, blood gr, Rh, anti HIV, thalassemia screening
- anti HIV, VDRL, thalassemia screening ( thalassemia)
5.1.4

Page | 2
1
2
3
4
5
6
7
8
9
10
*

13
12

5[1]
(/)
negative

positive
/
window period
11
PMTCT
-
3
negative
positive
negative
- window period
3 6
-
Page | 3
1
2
3
4
5
6
7
8
9
10
5[2]
negative
positive
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

2(b)
window period
36
13 -
14 -
17
1(a)
12 -
16
(d)
11
15
3(c)
negative
positive

-
-
-
-

2
(a)
rapid test 1
(b)
2
rapid test
(c)
1 2 ( x)
(d)
rapid test
Anti-HIV rapid
test 48
Page | 4
1
2
3
4
5
6
7
8
9
10
11
12
13
5.2
( )

CD4

5.2.1.
1 CD4
1
5[1]
350*
>350
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
CD4 count
(cells/mm3)
AZT + 3TC 12 +
LPV/r** 2 12
AZT + 3TC 12 +
LPV/r** 2 12
14
* CD4 >250 cells/mm3 NVP CD4 <250 cells/mm314-18

LPV/r HAART HAART
EFV d4T+ddI
** LPV/r 3 19
#
14 CD4 14
CD4 14-24
( 3 )
AZT (200-300 mg) = Zidovudine 200-300 mg 12

3TC (150 mg) = Lamivudine 150 mg 12
NVP (200 mg) = Nevirapine 200 mg 24 2 200 mg 12
LPV/r (200/50) = Lopinavir 200 mg + Ritonavir 50 mg 2 12
EFV (600 mg) = Efavirenz 600 mg 24
GPO-VIR Z 250 = AZT 250 mg + 3TC 150 mg + NVP 200 mg
Page | 5

AZT/3TC Zilarvir Combid = AZT 300 mg + 3TC 150 mg
HAART
AZT + 3TC + LPV/r LPV/r AZT + 3TC + EFV
( EFV )
AZT d4T
EFV LPV/r HAART
AZT monotherapy 14
SD NVP 21 AZT+3TC 7
NVP
2 CD4
viral load

(detectable viral load viral load 1,000 copies/ml
6 ) ()

- AZT AZT AZT

- EFV AZT +
3TC + LPV/r EFV
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
3 5.2.4
5.2.2
AZT 300 mg
3 AZT 600 mg
AZT AZT SD
NVP AZT monotherapy 21
ergot methergine ( oxytocin ) LPV/r
EFV severe vasoconstriction
Page | 6

5.2.3
CD4 1
AZT syrup 4 mg/kg/dose 12 4 SD NVP

SD NVP
<30 AZT syrup 2 mg/kg/dose 12
4 30-35 2 mg/kg/dose 12 2
3 mg/kg/dose 12 2 22
5.2.4 (no ANC)
25 -40

2

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34

NVP 200 mg AZT 300 mg 3 AZT 600
mg AZT + 3TC + LPV/r CD4
CD4 > 350 cells/mm3 AZT + 3TC +

LPV/r 4 NVP23
CD4 350 cells/mm3
AZT + 3TC + EFV
2 NVP
NVP AZT 3 AZT 600 mg
AZT CD4
CD4 350 cells/mm3
NVP syrup 2 mg/kg 24 7

4 mg/kg 24 7 ( NVP 2 ) AZT syrup 4 mg/kg/dose 12 3TC
syrup 2 mg/kg/dose 12 4 24 48
48
25
Page | 7
Chapter 5 PMTCT [CrossCutting 4/2/53]

5[2]
Antepartum
1. HAART
Intrapartum
- CD4 350 cells/mm3 :

AZT/3TC 1 12 . + LPV/r (200/50) 2 12
. ()
Postpartum
+ AZT 300 mg 3
. 600 mg
cotrimoxazole 2 24 .)
( CD4 <200 cells/mm3 cotrimoxazole 2 24 .

OD)

( CD4 <200 cells/mm3
- CD4 >350 cells/mm3 AZT/3TC 1 12 . + LPV/r

(200/50) 2 12 .
( GA 14 )
CD4
- CD4 GA 14
AZT/3TC 1 12 . + LPV/r (200/50) 2 12
.
Newborn ( + )
1. GA 35
AZT (syr) 4 mg/kg/dose
12 . x 4
( 1 . )
2. Preterm
2.1 GA < 30

12 . x 4
2.2 GA 30-35

12 . x 2
3 mg/kg/dose
12 . x 2

2 ()
Antepartum
Intrapartum
2. HAART
Postpartum
Newborn ( + )
AZT EFV
- AZT:
AZT ( AZT + AZT 300 mg 3 .
600 mg
- EFV (First trimester)
AZT/3TC 1 12 .+ LPV/r
(200/50) 2 12 .
EFV 2
3. No ANC
- 2
(see Intrapartum)
AZT 300 mg 3 . 600 mg
- 2
(see Intrapartum)
AZT 300 mg 3 . 600 mg

+ SD NVP 1
AZT + 3TC + LPV/r CD4

.
-
CD4 >350 cells/mm3 AZT + 3TC + LPV/r

4
CD4 350 cells/mm3
AZT (syr) 4mg/kg

12 . + 3TC (syr) 2mg/kg
12 . 4
NVP (syr) 2 mg/kg )
24 . x 7
4 mg/kg 24 .
7 ( NVP 2 )
1. HAART

AZT AZT
wild type
2.

AZT/3TC/EFV AZT/3TC/LPV/r
AZT 14 +SD NVP 21
3. 4 viral load >1,000
copies/ml 36
elective C/S HAART no ANC ( 2)
4. negative
positive
3
rapid
test (36 )
window period
HIV antigen

no ANC ( 2)
- HIV antigen
HIV DNA/RNA assay 1-2 26
o HIV DNA/RNA PCR (qualitative)
o Viral load 26
1
HIV antibody
HIV Ag/Ab test

2 26 anti HIV HIV Ag/Ab
test HIV antibody
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
10

2
/
no ANC ( 2) HIV antibody

5. HIV antibody (indetermine)
viral load 4
6. SD NVP HAART
AZT + 3TC + LPV/r CD4

NVP
1
2
3
4
5
6
7
8
9
10
11
11
3
FDA
pregnancy
category*
NRTIs
AZT
C
-
-
-
- Hb <8 g/dl Hct <24% AZT d4T
3TC
C
d4T
C
NRTIs
-
- Lactic acidosis (
ddI)
TDF
B
NRTIs
ddI
-
-
- Lactic acidosis (
d4T)
NRTI
NNRTIs
NVP
- (
)
- antihistamine
chlorpheniramine, hydroxyzine topical steroid
12
CBC ( 4)

3TC
- (
)
-
TDF
-


- (
/
)
D
PIs
LPV/r
-
-
-

EFV
0.1%TA cream/lotion ALT

LPV/r
- ALT 2.5
LPV/r
-
NVP
- 2-4
2
EFV
-

-

EFV
- 2-4
- urine sugar 50 gm glucose challenge

test ( 4)
-

- glucose challenge test
- ergot methergine
*Food and Drug Administration (FDA) Pregnancy Categories:

A ( 2 3)
B
C
D
X
13
1
2
3
4
5
5.3
6
7
8
9
CD4 <100 cells/mm3 cryptococcal meningitis

fluconazole
5.4 HAART
5[4] HAART
CD4 count
Viral load
CBC
ALT
Urine sugar
Glucose
challenge test
(GCT) 50 gm **
11
12
13
14
15
16
17
18
-
- 1 24
CD4 count >350 cells/mm3.*
-
- Hb <8 g/dl Hct <24%
AZT d4T
-
- 2.5
NVP
-
- LPV/r
- 6
- 36
10
CD4 < 200 cells/mm3. PCP

cotrimoxazole 2 1
cotrimoxazole folic
acid 1 1 27
- AZT 4-8
- Hb <8 g/dl Hct <24% AZT d4T
AZT 3
-
- 2.5 EFV
LPV/r NVP
-
- LPV/r 24-28
LPV/r 4 blood sugar 1
. 140 mg% OGTT ***
HBs Ag
* VL 1 36 CD4350 cells/mm3
CD4>350 cells/mm3 viral load 10,000 copies/ml 14
** GCT (Glucose challenge test) 50 gm glucose 50 gm 50% glucose 100 ml
blood sugar 1 glucose
*** OGTT (Oral glucose tolerance test) FBS glucose 100
gm blood sugar 1, 2 3 glucose 5
14
5[5] GCT OGTT
Glucose challenge test 28
Oral glucose tolerance test29,
30
Plasma Glucose (mg%)
1 glucose*
140
FBS
105
1 glucose**
190
2 glucose**
165
3 glucose**
145
* glucose 50 gm 24-28
glucosuria
** glucose 100 gm
OGTT
1) 1
( gestational diabetes
mellitus, GDM) OGTT 32-36
GDM
2) glucose 2
( GDM)
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
5.5
5.5.1
fetal scalp electrode, forceps extraction, vacuum
extraction ()
4
5.5.2 (elective caesarean section)

HAART 4 VL 36
>1,000 copies/ml 38 AZT 300 mg 3
2 600 mg 4
15

5.6

hypothermia

( 4.2.3 4.2.4 2)
vitamin K BCG vaccine HBV vaccine
5.7
5.7.1.

4 6 pap smear (
1 )

CD4 6

5.7.2.
5.7.3.

-

-
-
- 2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
16

5.7.4. positive

5.7.5.
3
5.7.6.
2

18 (
)

( 3 3.13)
TMP-SMX prophylaxis ( TMP 150 mg/m2 SMX 750 mg/m2
) 3 4-6
PCR 6
1 CD431 (
3)
PCR ( 3)
( 3)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
17
1.
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3.
Naiwatanakul T, Punsuwan N, Kullerk N, et al. Reduction in HIV transmission risk following
recommendations for CD4 testing to guide selection of prevention of mother-to-child (PMTCT) regimens,
Thailand, 2006-2007. In: 5th IAS Conference on HIV Pathogenesis and Treatment. Capetown, South Africa.
4.
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5.
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Available
at http://www.saiyairakhospital.com/newdemo/admin/user_report.html. (Last accessed Dec 23, 09).
6.

2
2552 .
7.
Guidance on global scale-up of the prevention of mother-to-child transmission of HIV. Towards
universal access for women, infants and young children and eliminating HIV and AIDS among children. InterAgency Task Team on Prevention of HIV Infection in Pregnant women, mothers and their children. WHO 2007.
8.
Lallemant M, Jourdain G, Le Coeur S, et al. Single-dose perinatal nevirapine plus standard
zidovudine to prevent mother-to-child transmission of HIV-1 in Thailand. The New England journal of medicine
2004;351(3):217-28.
9.
Palombi L, Marazzi MC, Voetberg A, Magid NA. Treatment acceleration program and the experience
of the DREAM program in prevention of mother-to-child transmission of HIV. AIDS (London, England) 2007;21
Suppl 4:S65-71.
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(HITAP).
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UNFPA. HIV
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13.
Centers for Disease Control and Prevention. Couples HIV Counseling and Testing Intervention and
Curriculum; Centers for Disease Control and Prevention National Center for STD HIV Viral Hepatitis and TB
Prevention, Global AIDS Program, November 2007.
14.
Timmermans S, Tempelman C, Godfried MH, et al. Nelfinavir and nevirapine side effects during
pregnancy. AIDS (London, England) 2005;19(8):795-9.
15.
Jamisse L, Balkus J, Hitti J, et al. Antiretroviral-associated toxicity among HIV-1-seropositive
pregnant women in Mozambique receiving nevirapine-based regimens. Journal of acquired immune
deficiency syndromes (1999) 2007;44(4):371-6.
16.
Marazzi MC, Germano P, Liotta G, et al. Safety of nevirapine-containing antiretroviral triple therapy
regimens to prevent vertical transmission in an African cohort of HIV-1-infected pregnant women. HIV
medicine 2006;7(5):338-44.
17.
Kondo W, Carraro EA, Prandel E, et al. Nevirapine-induced side effects in pregnant women:
experience of a Brazilian university hospital. Braz J Infect Dis 2007;11(6):544-8.
18.
Phanuphak N, Apornpong T, Teeratakulpisarn S, et al. Nevirapine-associated toxicity in HIV-infected
Thai men and women, including pregnant women. HIV medicine 2007;8(6):357-66.
19.
Van de Lugdt J and HIV-NAT 093 team. The pharmacokinetics and safety of generic
lopinavir/ritonavir (200/50 mg tablets) 400/100 mg every 12 hours in Thai HIV-infected pregnant women.
(unpublished data).
20.
Jourdain G, Mary JY, Coeur SL, et al. Risk factors for in utero or intrapartum mother-to-child
transmission of human immunodeficiency virus type 1 in Thailand. The Journal of infectious diseases
2007;196(11):1629-36.
21.
WHO. Rapid advice. Use of antiretroviral drugs for treating pregnant women and preventing HIV
infection in infants. November 2009.
22.
Capparelli EV, Mirochnick M, Dankner WM, et al. Pharmacokinetics and tolerance of zidovudine in
preterm infants. The Journal of pediatrics 2003;142(1):47-52.
23.
Russell VD, Jourdain G, Shapiro D, et al. A Phase II Study of the Incidence of Nevirapine Resistance
Mutations in HIV-infected Thai Women Receiving a Single Intrapartum Dose of NVP followed by a Postpartum
Tail of ZDV/ddI or ZDV/ddI/LPV/r: IMPAACT P1032 (Abstract number 95aLB). In: CROI 2009. Montreal.
24.
de Ruiter A, Mercey D, Anderson J, et al. British HIV Association and Children's HIV Association
guidelines for the management of HIV infection in pregnant women 2008. HIV medicine 2008;9(7):452-502.
25.
Wade NA, Birkhead GS, Warren BL, et al. Abbreviated regimens of zidovudine prophylaxis and
perinatal transmission of the human immunodeficiency virus. The New England journal of medicine
1998;339(20):1409-14.
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26.
Fiebig EW, Wright DJ, Rawal BD, et al. Dynamics of HIV viremia and antibody seroconversion in
plasma donors: implications for diagnosis and staging of primary HIV infection. AIDS (London, England)
2003;17(13):1871-9.
27.
Forna F, McConnell M, Kitabire FN, et al. Systematic review of the safety of trimethoprimsulfamethoxazole for prophylaxis in HIV-infected pregnant women: implications for resource-limited settings.
AIDS reviews 2006;8(1):24-36.
28.
American Diabetes Association. Gestational Diabetes Mellitus. Diabetics Care 2003 26: S104.
29.
Diagnosis and classification of diabetes mellitus. Diabetes care 2004;27 Suppl 1:S5-S10.
30.
O'Sullivan JB, Mahan CM. Criteria for the Oral Glucose Tolerance Test in Pregnancy. Diabetes
1964;13:278-85.
31.
Mofenson LM, Brady MT, Danner SP, et al. Guidelines for the Prevention and Treatment of
Opportunistic Infections among HIV-exposed and HIV-infected children: recommendations from CDC, the
National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the
Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. MMWR Recomm Rep
2009;58(RR-11):1-166.
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Chapter 6 OI [16/3/53]
6
(Opportunistic Infections: Prophylaxis and Treatment)
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6.1 Candidiasis
Candidiasis mucosal candidiasis oropharyngeal candidiasis,

cervicovaginal candidiasis, esophageal candidiasis diaper dermatitis invasive candidiasis
advance AIDS
Primary prophylaxis
1. Oropharyngeal candidiasis
Clotrimazole oral troches 10 mg 4-5 7-14
1. Nystatin oral solution 500,000 5

2. Fluconazole 100 mg
3. Itraconazole capsule 100 mg
4. Itraconazole oral solution 100 mg
5. Amphotericin-B 0.3-0.5 mg /kg/day 7-14
2. Esophageal candidiasis
Fluconazole 200 mg 14-21
1. Itraconazole capsule 200 mg 2

2. Itraconazole oral solution 200 mg 2
3. Amphotericin-B 0.3-0.5 mg/kg/ 14-21
3. Cervicovaginal candidiasis
Clotrimazole vaginal cream 5 gm/day clotrimazole vaginal suppository tablet 100 mg

3-7
1. Miconazole cream 5 gm/day miconazole vaginal suppository tablet 100 mg

7
2. Fluconazole 150-200 mg
2
3
4
2
3
4
5
6
7
8
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3. Itraconazole capsule 200 mg 3

4. Itraconazole oral solution 200 mg 3
5. Ketoconazole 200 mg 5-7
1.
fluconazole itraconazole
teratogenic effect amphotericin-B
2.
oropharyngeal candidiasis CD4 <100 cells/mm3, viral load
WBC <500 cells/mm3
Disseminated candidisis candida
esophagitis herpes simplex virus CMV candidemia
non-albicans
Candidia spp. fluconazole
- oropharyngeal candidiasis
clotimazole troches oral polyenes (
nystatin) fluconazole 3-6 mg/kg itraconazole 2.5 mg/mg
2 7-14 ( itrconazole
) ketoconazole 5-10 mg/kg 1-2 14 (
ketoconazole )
- esophageal candidiasis fluconazole 6 mg/kg
3-6 mg/kg 14-21
itraconazole 2.5 mg/kg 2 5 mg/kg
14-21 amphotericin B 0.3 mg/kg
7
- invasive disease
amphotericin B 0.5-1.5 mg/kg
. 14-21 fluconazole 6
mg/kg 3-6 mg/kg 14-21
echocardiogram, renal abdominal ultrasound
Secondary prophylaxis
- mucosal candidiasis /
-
2
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fluconazole 100-200 mg itraconazole oral solution 100-200 mg
fluconazole 3 6 mg/kg ( 200 mg) itraconazole 5 mg/kg

( 200 mg)
CD4 >200 cells/mm3 CD4 CDC

immune category 2 1
6.2 Tuberculosis

AFB
nontuberculous mycobacteria

tuberculin
negative

Directly Observed Therapy (DOT)

CD4 (< 50 cells/mm3)
MAC
Primary prophylaxis
1. TST

TST
mantoux tuberculin 5 unit intradermal positive (induration > 5 mm)

2.
TST ( TST
( BCG vaccine)
3
2
3
4
5
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( )
TST
3.
( )
INH 300 mg INH 10 15 mg/kg ( 300 mg)

9 INH
rifampicin 10 20 mg /kg ( 600 mg) 4 6
2IRZE / 4-7IR
Dose
1. INH (I) 5-8 mg/kg (300 mg)
2. Rifampicin (R) 10 mg/kg (450-600 mg)
3. Pyrazinamide (Z) 20-30 mg/kg (1.0-1.5 gm)
4. Ethambutol (E) 15-20 mg/kg (800-1000 mg)
5. Streptomycin 10-15 mg/kg ( 1 gm)
Streptomycin rifampicin rifampicin Pls
rifampicin
2 4 INH rifampicin 2 47 2
9 6-9
9-12
rifampicin 4 2 ( rifampin
drug interaction )
1. INH ethambutol 18
2. INH ethambutol quinolone ofloxacin
12-18
3. DOT ...
pyridoxine 25-50 mg INH
1. Kanamycin 15 mg/kg ( 1 gm) 1 3-4
2
3
4
5
6
7
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2.
3.
4.
5.
6.
7.
8.
Amikacin 15 mg/kg ( 1 gm) kanamycin

Ethionamide 15 mg/kg (500-750 mg/day) 2-3
Cycloserine 10 mg/kg (500-750 mg/day) 2-3
PAS 150 mg/kg (8-12 gm/day) 2
Ofloxacin 600-800 mg/day
Levofloxacin 500-750 mg/day
Moxifloxacin 400 mg/day

(Multi Drug Resistant TB or MDR-TB)
INH rifampicin 3-4 1
amikacin streptomycin

Extensively Drug Resistant TB (XDR-TB)

1.
streptomycin, kanamycin ethionamide
quinolone, cycloserine, PAS pyrazinamide
2.

- INH 10-15 mg/kg ( 300 mg)
- Rifampicin 10-20 mg/kg ( 600 mg)
- Pyrazinamide 20-40 mg/kg ( 2 gm)
- Ethambutol 15-25 mg/kg ( 2.5 gm) streptomycin 20-40
mg/kg ( 1 gm)

- Amikacin 15-30 mg/kg ( 1gm)
- Ethionamide 15-20 mg/kg ( 1 gm) 2-3
- Capreomycin 15-30 mg/kg ( 1 gm)
- Cycloserine 10-20 mg/kg ( 1 gm)
- Ofloxacin 10-15 mg/kg ( 1.5 gm/day) 2
2 4 INH rifampicin 2
6 -9
miliary 12 prednisolone 1-2 mg/day 6-8
military
endobronchial TB
2
3
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3-6 2

6.3 Pneumocytis pneumonia (PCP)
PCP
Pneumocytis jiroveci

PCP 6
CD4
6-12
P. jiroveci 30-65
Primary prophylaxis
1. CD4<200 cells/mm3 <14% oropharyngeal candidiasis

AIDS-defining illness () (>37.7 oC) 2
2. TMP-SMX PCP
4-6 CD4

12 CD4
(CDC immunological category 3) CD4500 cells/mm3 1-5
3. 5 CD4<200 cells/mm3 %CD4<15

PCP CD4
clinical category C
1. TMP-SMX single-strength tablet (SS) 2

2. TMP-SMX 1 2 CD4<100 cells/mm3
toxoplasmosis
3. trimetroprim 5 mg/kg 150 mg/m2/day sulfamethoxazole 750
mg/m2/day ( TMP-SMX, 320/1,600 mg) 2 3
4. TMP-SMX
6
2
3
4
5
6
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13
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19
20
21
22

(desensitization) / 70
5. TMP-SMX
1. Dapsone 100 mg
2. 1 dapsone 2 mg/kg ( 100
mg) 4 mg/kg ( 200 mg)
3. Pentamidine 5 300 mg
4. Atovaquone 1-3 2 30 mg/kg
4-24 45 mg/kg
5. PCP Toxoplasma gondii dapsone
pyrimethamine
6. clindamycin primaquine
PCP
ARV CD4 > 200 cells/mm3 3

primary prophylaxis PCP CD4 < 200 cells/mm3
primary PCP prophylaxis HAART 6
CD4 15 % 200 cells/mm3 6 CD4 15% 500 cells/mm3 1-5
3 1 CD4
23
24
25
Co-trimoxazole trimetroprim 15-20 mg/kg/ sulfamethoxazole 75 mg/kg/

1
3-4 21

1. Clindamycin 600 mg 8 . 300-450 mg 6 +

primaquine 30 mg/ 21
2. Pentamidine 3-4 mg kg 1 1 .
PCP PaO 2 < 70 mgHg (A-a) gradient > 35 mgHg prednisolone
40 mg 2 5
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40 mg 5 20 mg 11
methylprednisolone prednisolone 1 mg/kg 12 . 1-5
0.5 mg/kg 12 . 6-10 0.5 mg/kg 21

1.
PCP
co-trimoxazole kernicterus
bilirubin
2.
20 HIV PCP
PCP co-trimoxazole
co-trimoxazole
Stevens-Johnson syndrome neutropenia
thrombocytopenia, megaloblastic anemia aplastic anemia hepatitis interstitial nephritis

50
co-trimoxazole 5-7 pentamidine isethionate
4 mg/kg/ 60-90
atovaquone 30-40 mg/kg/day - 21
co-trimoxazole rapid desensitization
Rapid desensitization co-trimoxazole

1.
anaphylaxis adrenaline
5 mg trimetroprim (TMP) 40 mg sulfamethoxazole (SMZ)
200 mg
2.
1 ml 9 ml ( A)
A 1 ml 9 ml ( B)
B 1 ml 9 ml ( C)
C 1 ml 9 ml ( D)
32
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8

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TMP/SMZ (mg)
0.004 / 0.02
0.04 /0.2
0.4 / 2
4 /20
40 / 200
160 / 800
(ml)
5
5
5
5
5
20
PCP
Primary prophylaxis
CD4 > 200 cells/mm3 3 ARV

CD4 < 200 cells/mm3 L
PCP CD4 > 200 cells/mm3 secondary prophylaxis

CD4 ARV
primary chemoprophylaxis PCP prophylaxis
1 prophylaxis PCP
PCP CD4
1
2
D
C
B
A
Cryptococcosis
Cryptococcosis Cryptococcus neoformans

3
cryptococcal meningitis
cryptococcal Ag Cryptococcus

Primary prophylaxis

fluconazole primary prophylaxis HIV/AIDS
primary prophylaxis
9
1. CD4 < 100 cells/mm3

2. Cryptococcus neoformans
3. Cryptococcal antigen ()
Fluconazole 400 mg 1
1
2
3
4
5
6
7
Induction phase: 2
Amphotericin B 0.7-1.0 mg/kg/ (maximum 50 mg/dose) 14
1. Amphotericin B 0.7-1.0 mg/kg/ + Fluconazole 400 mg/

14
2. Fluconazole 400-800 mg/ 14 Cryptococcal infection
without meningitis cryptococcal meningitis amphotericin B
Consolidation phase : 8-10 CSF
: Fluconazole 400 mg/
: Itraconazole 200 mg/ 2

1.
Fluconazole Itraconazole Teratogenic effect
2 Amphotericin B
2.
Amphotericin B 0.7-1.0 mg/kg 1
14 Fluconazole 12 mg/kg 6-12 mg/kg/
8
isolated pulmonary cryptococcosis Fluconazole 12 mg/kg
6-12 mg/kg ( 600 mg)
Fluconazole 5-6 mg/kg 8
Cryptococcosis induction consolidation
secondary prophylaxis
Fluconazole 200 mg/ 6 mg/kg ( 200 mg)
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10
Itraconazole 200 mg/ 5 mg/kg ( 200 mg)
Cryptococcosis
Cryptococcosis ARV CD4 > 200 cells/mm3 6

6 HAART 6 CD4 200/3
1
2
3
4
5
6
7
8
10
11
12
13
14
15
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18
Penicilliosis Histoplasmosis
Penicilliosis Histoplasmosis Systemic mycoses CD4 < 100

cells/mm Penicilliosis papulonecrotic skin
lesions Histoplasmosis
Wright stain
Histoplasmosis Penicilliosis
65
3
27
Primary prophylaxis
1.
CD4 <100 cells/mm3
2.
Itraconazole 5 mg/kg 200 ( itraconazole

histoplasmosis penicilliosis fluconazole cryptococcosis )
ARV CD4 >100-150 cells/mm3 6
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Induction phase
Amphotericin B 0.6-0.7 mg/kg/ 7-14
Itraconazole 200 mg 3 3 200 mg

2 14
Consolidation phase
11
2
3
4
5
6
7
8
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11
12
13
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Itraconazole* 200 mg 2 10-12
Amphotericin-B 0.4-0.5 mg/kg/ 10-12

*Itraconazole capsule Itraconazole solution

1.
Itraconazole Itraconazole
Teratogenic effect Amphotericin B
2.
- histoplasmosis itraconazole 6-8 mg/kg/ 3-12
amphotericin B 1 mg/kg 4-6
itraconazole 5 mg/kg
- penicilliosis amphotericin B 0.7 mg/kg 2 itraconazole 10 mg/kg/
2 10 amphotericin B
2
Penicilliosis Histoplasmosis
Itraconazole 200 mg Itraconazole 5 mg/kg
Amphotericin B 0.6-0.7 mg/kg/ Malabsorption
ARV CD4 >100-150 cells/mm3 6
Toxoplasmic encephalitis
Toxoplasmic encephalitis mass lesion

Primary prophylaxis
CD4 <100 cells/mm3

12
2
3
4
5
6
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IgG antibody toxoplasma
1. Co- trimoxazole single strength tablet 2 double strength 1

3
2. co- trimoxazole 150/750 mg/m2/ 6/30 mg/kg/ 2
1. Dapsone 50 mg + pyrimethamine 50 mg folinic acid (leucovorin)

25 mg/
2. Dapsone 200 mg + pyrimethamine 75 mg folinic acid 25 mg/
: co-trimoxazole Primary prophylaxis PCP
Toxoplasmosis dapsone
Pyrimethamine 200 mg 1 50 mg/ (BW < 60 kg) 75 mg/ (BW > 60 kg) +
sulfadiazine 1 (BW < 60 kg) 1.5 (BW > 60 kg) 4 folinic acid 10-25
mg/ 6
1. Co-trimoxazole 5-10 mg/kg/ trimetroprim

2. Pyrimethamine + clindamycin 600 mg 6-8
3. Pyrimethamine + azithromycin 1000-1250 mg/
1.

hyperbilirubinemia kernicterus
2.
Toxoplasmosis
HIV Toxoplasmosis
Congenital toxoplasmosis Pyrimethamine 2 mg/kg/ 2 1 mg/kg/
2-6 1 mg/kg 3 / sulfadiazine
50 mg/kg 2 /
folinic acid 12
acquired CNS ocular or systemic toxoplasmosis pyrimethamine 2 mg/kg/ 3
1 mg/kg/ folonic acid 10-25 mg/ sulfadiazine 25-50 mg/kg 4 /
13
1
2
3
4
5
6
sulfadiazine clindamycin 5-7.5 mg/kg 4 / (

600 mg/) pyrimethamine folinic acid
dexamethasone

7
9
10
11
12
13
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20
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toxoplasma
Pyrimethamine 25-50 mg/ + sulfadiazine 500-1,000 mg 4 folinic acid 10-25

mg/ co-trimoxazole
6 2-4
Sulfadiazine 85-120 mg/kg/ 2-4 /
pyrimethamine 1 mg/kg 15 mg/m2 ( 25 mg) leucovorin 5 mg
3
Pyrimethamine 25-50 mg/ + clindamycin 300-450 mg 6-8 folinic acid 10-25

mg/ Clindamycin 20-30 mg/kg/ 4
pyrimethamine 1 mg/kg leucovorin 5 mg 3
ARV CD4 > 200 cells/mm3

6
Cytomegalovirus infection
Cytomegalovirus (CMV)
CD4 < 50 cells/mm3 retina

CMV
1

CMV retinitis HIV CD4 <100
cells/mm3
14
1
2
3
4
5
6
fundus HIV
CD4 <15% 4-6
Primary prophylaxis

1. Ganciclovir 5 mg/kg 12 . 2-3

3-6
2. Valganciclovir 900 mg 2 2-3
1. Ganciclovir intravitreous 200 g/ 2-3 / 2-3

1-2 / 3-6
2. Ganciclovir implant 4.5 mg
vitreous 6-8 ganciclovir
Retinitis CMV
3. Valganciclovir 900 mg
ART CD4
CMV CMV
ganciclovir ARV
CD4
1.
2.
- CMV CMV retinitis ganciclovir 5 mg/kg
12 2-3 congenital CMV infection
6
- ganciclovir foscarnet 60 mg/kg 8
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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29
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36
CMV retinitis
CD4
15
1
2
3
4
5
6
7
8
Valganciclovir 900 mg
Ganciclovir 5 mg/kg
Ganciclovir intravitreous 200 g 1-2
retinitis ARV CD4 >100

cells/mm3 3-6
9
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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27
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35
Mycobacterium avium complex (MAC) infection
MAC nontuberculous mycobacterium

AIDS CD4 <50 cells/mm3
MAC AIDS
mycobacteria
MAC

10
Primary prophylaxis
1. CD4 < 50 cells/mm3
2.
- 6 CD4 < 50 cells/mm3
- 2-5 CD4 < 75 cells/mm3
- 1 2 CD4 < 500 cells/mm3
- 1 CD4 < 750 cells/mm3
1. Clarithromycin 500 mg 2 7.5 mg/kg/

2. Azithromycin 1000-1,250 mg 20 mg/kg/
( 1,200 mg) Azithromycin 5 mg/kg ( 250 mg)
> 6 ARV CD4 > 100

cells/mm3 3 2-6 CD4 > 200 cells/mm3
16
< 2 CD4
1
2
3
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
Clarithromycin 500 mg 2 Ethambutol 15 mg/kg/
Azithromycin 500 mg / 1 Ethambutol 15 mg/kg/

4-8
Quinolones (Ciprofloxacin 500-750 mg 2
Levofloxacin 500 mg Moxifloxacin 400 mg ) Amikacin 15
mg/kg

1. Clarithromycin
Azithromycin
2.
- 3-4 2-3
1
- Clarithromycin 7.5-15 mg/kg ( 500 mg) 2
Azithromycin 10-12 mg/kg (500 mg) Ethambutol 15-25 mg/kg
( 2.5 g)
- Quinolone Ciprofloxacin 10-15 mg/kg ( 1.5 g)
2 Moxifloxacin 10 mg/kg ( 400 g)
Aminoglycoside Amikacin 15-30 mg/kg ( 1.5 g)
Clarithromycin Cytochrome P3A4

Cytochrome P3A4 ARV PI drugdrug interaction Clarithromycin Rifampin Ergot alkaloids carbamazepine
cisapride Azithromycin Rifampin
disseminated MAC
17
MAC 12 MAC
ARV CD4 6 i > 6 CD4 >

100 cells/mm3 2- 6 CD4 > 200 cells/mm3 <2
CD4
3
4
5
8
9
10
CD4 primary secondary prophylaxis

> 6
OI
Primary prophylaxis
PCP
CD4 > 200 cells/mm3 3
Toxoplasmosis CD4 > 200 cells/mm3 3
Cryptococcosis CD4 > 100 cells/mm3 3
Penicilliosiis/
CD4 > 100-150 cells/mm3 6 CD4 > 100-150 cells/mm3 6
Histoplasmosis
MAC
CMV
Not applicable
CD4 > 100 cells/mm3 3-6
6
7
CD4 primary secondary prophylaxis

1- 6
OI
Primary prophylaxis
PCP
CD4 >500 cells/mm3 > 15% 3
Toxoplasmosis %CD4 > 15 3
%CD4 > 15 6
Cryptococcosis Not applicable
%CD4 > 15 6
Penicilliosiis/
Not applicable
%CD4 > 15 6
Histoplasmosis
MAC
2-6 CD4>200 cells/mm3 2-6 CD4>200cells/mm3 6
3
< 2 CD4
< 2 (1-2 <500 cells/mm3,
CD4 (1-2 <500 1 <750 cells/mm3) 6
cells/mm3, 1 <750 cells/mm3)
3
CMV
Not applicable
CD4>15% or >500 cells/mm3 3-6
11
18

AIDS2010Guidelineไทย

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Chapter 2 Laboratory [16/3/2553]

Chapter 2 Laboratory [16/3/2553]

(couple counseling and testing)

Chapter 2 Laboratory [16/3/2553]

Chapter 2 Laboratory [16/3/2553]

. Simple test agglutination

Chapter 2 Laboratory [16/3/2553]

(1) A1, A2 A3 antibody 1, 2 3 antigen 1

Chapter 2 Laboratory [16/3/2553]

Chapter 2 Laboratory [16/3/2553]

Chapter 2 Laboratory [16/3/2553]

2.3.1 CD4 (CD4 cells counts)

Chapter 2 Laboratory [16/3/2553]

CD4 = %CD4 x WBC x % Lymphocyte

2.3.2 (viral load)

viral load copies/ml log10

Chapter 2 Laboratory [16/3/2553]

Chapter 2 Laboratory [16/3/2553]

Chapter 2 Laboratory [16/3/2553]

ELISA , Simple Test

Viral load testing

RT-PCR, NASBA, bDNA Real Time

HIV viral testing

Chapter 2 Laboratory [16/3/2553]

Chapter 2 Laboratory [16/3/2553]

Chapter 2 Laboratory [16/3/2553]

HIV assays: operational characteristics (Phase 1): report 15 antigen/antibody ELISAs.

Chapter 3 Adult [16/3/53]

CD4 CD4 3-6

Chapter 3 Adult [16/3/53]

anti-HBc, anti-HBs HBS-Ag

Chapter 3 Adult [16/3/53]

latent infection primary

Chapter 3 Adult [16/3/53]

anal Pap smear 6

indirect ophthalmoscope 1 CD4 100 cells/mm3

Chapter 3 Adult [16/3/53]

Chapter 3 Adult [16/3/53]

3.2 (acute HIV infection)

anti-HIV negative indetermined

3 [1] acute retroviral syndrome

(erythematous maculopapular rash)

Chapter 3 Adult [16/3/53]

Chapter 3 Adult [16/3/53]

Chapter 3 Adult [16/3/53]

Chapter 3 Adult [16/3/53]

10) ATV + IDV hyperbilirubinemia

lipoatrophy/lipodystrophy GPO-VIR Z viral load 50

d4T GPO-VIR S d4T 30 mg

(Hb<8.5 g/dl) AZT CD4 100 cells/mm3

Chapter 3 Adult [16/3/53]

Chapter 3 Adult [16/3/53]

CrCl <50 ml/min

Chapter 3 Adult [16/3/53]

300 mg + RTV 100 mg

800 mg + RTV 100 mg

400-800 mg + RTV 100 mg

: (140-) x (kg) x 0.85

Chapter 3 Adult [16/3/53]

3.5 (drug interaction)

Serious drug interaction 6

Chapter 3 Adult [16/3/53]

acute renal failure CYP inhibitor

Chapter 3 Adult [16/3/53]