HIV / AIDS – TA

Introduction

Worldwide. Sexually transmitted infections have been known since ancient times, they remain a major public health problem which was compounded by the appearance of HIV/AIDS around 1980. Since the early cases of AIDS that was reported among male homosexuals in Los Angeles, United States of America, in 1981, extensive research and investigations have been actively carried out worldwide.

In 1983, HIV the virus that is capable of destroying the immunologic capacity of an individual was identified.

Causative agent: Retrovirus with name of Human Immune-Deficiency Virus (HIV)

Transmission: HIV is transmitted through sexual intercourse, transfer of infected blood or blood products and vertical transmission from infected mothers to their newborn.

Unprotected heterosexual intercourse is the main mode of transmission (70%), unprotected homosexual intercourse accounts for another 5-10%. The use of contaminated injection equipment by drug users accounts for 5-10% of all adult HIV infection and its growing.

Transfusion of HIV contaminated blood or blood products and transplants with HIV infected tissues and organs accounts for 5-10% of HIV infection. Mother to child transmission (vertical transmission) accounts for more than 90% of all HIV infections among the infants and children. Between 25-35% of all infants born to HIV infected mothers become infected before or during the birth process or later through breast feeding.

Incubation period: 3 weeks to 6 months (possibly longer)

Sign & Symptoms

  • Asymptomatic or may be accompanied by a glandular fever-like illness following which antibodies to the virus can be found in the blood. There may follow a further period of symptom free infection when the immune system is apparently healthy.
  • The first major symptoms may present as Persistent Generalized Lymphadenopathy (PGL). The characteristics signs are enlarged lymph nodes and perhaps enlargement of the spleen and liver.
  • Later symptoms suggestive of HIV infection include tiredness, night sweats, diarrhea, weight loss and infections such as herpes simplex, tuberculosis in young/middle age person and oral candidiasis. This symptomatology became known as ARC (AIDS Related Complex) and may occur with or without PGL.
  • These early stages of infection used to be considered separately from the terminal stage which was sometimes called full-blown AIDS. Characterized with opportunistic infections and/or malignancies such as Pneumocystis carinii (a protozoan), Kaposi’s sarcoma, Lymphomas and Carcinomas.

The Spectrum Of HIV Infection

Acute Infection ? HIV Carrier ? ARC ? AIDS

AIDS in an adult is defined by the existence of at least 2 of the major signs associated with at least 1 minor sign, in the absence of known causes of immuno-suppression such as cancer or severe malnutrition or other recognized aetiologies.

    1. Major signs
    2. Weight loss > 10% of body weight

 

    1. Chronic diarrhea > 1 month

 

    1. Prolonged fever > 1 month (intermittent of constant)

 

    1. Minor signs
    2. Persistent cough for > 1 month

 

    1. Generalized pruritic dermatitis

 

    1. Recurrent Herpes zoster

 

    1. Oro-pharyngeal candidiasis

 

    1. Chronic progressive and disseminated Herpes simplex infection

 

    Generalized lymphadenopathy

The presence of generalized Kaposi’s sarcoma or cryptococcal meningitis are sufficient by itself for the diagnosis of AIDS

Complication

Pneumonia and recently a primary neurological disease have been noted due to HIV crossing the blood brain barrier. These caused damage brain cells causing dementia, coma and death.

Treatment

The decision to initiate or change antiretroviral treatment must be guided by the laboratory parameters of both plasma HIV RNA (viral load) and CD4 + T cell count, and by assessing the clinical condition of the patient.

The drugs are toxic and treatment must be life long. Adherence is critical for the success of the treatment. A successful treatment is not a cure but suppresses the viral replication.

Table 1: When to start antiretroviral therapy for adolescent and adults

Target population 2010 ART guideline 2006 ART guideline

HIV+ asymptomatic

ARV-naive individuals

CD4 ?350 cells/mm3 CD4 ?200 cells/mm3

HIV+ symptomatic

ARV-naive individuals

WHO clinical stage 2 if CD4 ?350 cells/mm3 OR

WHO clinical stage 3 or 4 irrespective of CD4 cell count

WHO stage 2 or 3 and CD4 ?200 cells/mm3

WHO stage 3 if CD4 not available

WHO stage 4 irrespective of CD4 cell count

Consider treatment for WHO clinical stage 3 and CD4 cell count between 200 and 350 cells/mm3

HIV+ pregnant women

CD4 ?350 cells/mm3 irrespective of clinical symptoms OR

WHO clinical stage 3 or 4 irrespective of CD4 cell count

WHO stage 1 or 2 and CD4 ?200 cells/mm3

WHO stage 3 and CD4 ?350 cells/ mm3

WHO stage 4 irrespective of CD4 count

HIV/TB coinfection

ARV-naive individuals

Presence of active TB disease, irrespective of CD4 cell count

Presence of active TB disease and CD4 ?350 cells/mm3

ART Initiation can be delayed if CD4 ?200 cells/mm3

HIV/HBV coinfection

ARV-naive individuals

Individuals who require treatment for their HBV infection*, irrespective of CD4 cell count No specific recommendation

 

Table 2: What antiretroviral therapy to start

Target population 2010 ART guideline 2006 ART guideline
HIV+ ARV-naïve adults and adolescents No change, but in settings where d4T regimens are used as the principal option for starting ART a progressive plan to move towards AZT-based or TDF-based first-line regimens should be developed, based on an assessment of cost and feasibility AZT or TDF + 3TC (or FTC) + EFV or NVP
HIV+ pregnant women

AZT preferred but TDF acceptable

EFV included as a NNRTI option (but do not initiate EFV during first trimester)

Benefits of NVP outweigh risks where CD4 count is 250?350 cells/mm3

In HIV+ women with prior exposure to MTCT regimens, see ART recommendations in section 13.2

AZT + 3TC + NVP
HIV/TB coinfection

No change

ART should be initiated as soon as possible in all HIV/TB coinfected patients with active TB (within 8 weeks after the start of TB treatment)

AZT or TDF + 3TC (or FTC) + EFV
HIV/HBV coinfection NNRTI regimens that contain both TDF + 3TC (or FTC) are required

TDF + 3TC (or FTC) + EFV

 

Table 3: Recommended second-line antiretroviral therapy

Target population 2010 ART guideline* 2006 ART guideline
HIV+ adults and adolescents If d4T or AZT used in first-line therapy TDF + 3TC (or FTC) + ATV/r or LPV/r

ABC + ddI or

TDF+ ABC or

ddI +3TC or

TDF + 3TC

(± AZT) plus

ATV/r or FPV/r

or IDV/r or LPV/r

or SQV/r

If TDF used in first-line therapy AZT + 3TC (or FTC) + ATV/r or LPV/r
HIV+ pregnant women Same regimens as recommended for adults and adolescents

ABC + ddI or

TDF+ ABC or

ddI +3TC or

TDF + 3TC

(± AZT)

plus LPV/r or

NFV or SQV/r

HIV/TB coinfection

If rifabutin available (150 mg 3 times/week)

Same regimens as recommended for adults

ABC + ddI or

TDF+ ABC or

ddI +3TC or

TDF + 3TC

(± AZT) plus

LPV/r or SQV/r

with adjusted

dose of RTV

(LPV/r 400

mg/400 mg

twice a day

or LPV/r 800

mg/200 mg

twice a day

or SQV/r 400

mg/400 mg

twice a day)

If rifabutin not available

Same NRTI backbones recommended for adults plus LPV/r or SQV/r with adjusted dose of RTV

(LPV/r 400 mg/400 mg twice a day or LPV/r 800 mg/200 mg twice a day or SQV/r 400 mg/400 mg twice a day)

HIV/HBV coinfection AZT + TDF + 3TC (or FTC) + ATV/r or LPV/r 3TC- and/or TDF-containing regimens

 

Note:

NNRTI = Non-nucleoside reverse transcriptase Inhibitor

NRTI = Nucleoside/nucleotide reverse transcriptase inhibitor

PI = Protease Inhibitor

IDU = Injecting Drug user

AZT = Azidothymidine, Zidovudine

EFV = Efavirenz

NVP = Nevirapine

LPV = Lopinavir

RTV = Ritonavir

TDF = Tenofovir

3TC = Lamivudine

RMP = Rifampicin

RFB = Rifabutin

HBV = Hepatitis B virus

* If using RMP in the TB regimen, LPV/r + extra dose of RTV is the recommended PI option, based on pK interactions. If RFB or an alternative TB regimen without RMP is used, any boosted PI at its conventional dosage can be used.
** If long term anti-HBV therapy is still needed, consider maintaining 3TC and/or TDF, in addition to the new 2 NRTI backbone.

Prevention & Precautions

Travelers should be advised that they are at risk if they:-

  • Have sexual contact (heterosexual or homosexual) with an infected person.
  • Use or allow the use of contaminated, unsterilized syringes or needles for any injections or other procedures that pierce the skin, including acupuncture; use of illicit drugs; steroid or vitamin injections; medical or dental procedures; ear or body piercing; or tattooing.
  • Receive infected blood, blood components, or clotting factor concentrates. HIV infection by this route is rare in countries or cities where donated blood and plasma are screened for antibodies to HIV.

To reduce their risk of acquiring HIV, travelers should be advised to:-

  • Avoid sexual encounters with persons who are infected with HIV or whose HIV infection status is unknown, or who are at high risk for HIV infection, such as intravenous drug users, commercial sex workers (both male and female), and other persons with multiple sexual partners.
  • Use condoms consistently and correctly if sexually active, especially if engaging in vaginal, anal, or oral-genital sexual contact with a person who is HIV-infected or whose HIV status is unknown.
  • Avoid using intravenous drugs.
  • Avoid sharing needles or other devices that can puncture skin for any purpose.
  • Avoid, if at all possible, blood transfusions or use of blood-clotting factor concentrates.

References organisation/ support

International Travel & Health, WHO 2006

Control of Communicable Diseases Manual, 18th Edition by David L. Heymann, MD, Editor, 2004

HIV/AIDS Prevention, Treatment and care in the Health Sector, WHO (HIV/AIDS Department), 2008.

http://travelhealth.co.uk/

Last Reviewed : 26 April 2012
Writer : Dr. Norhayati bt. Rusli
Accreditor : Dr. Zainal Che Me
Reviewed : Dr. Norhaya Mohd Razali