HIV- Management

HIV- Management 
In HIV infection there is intense and persistent viral replication which leads to gradual depletion of CD4 cells. The primary goal in managing the HIV patients is to prevent this process of replication to as low as possible and to maintain it as long as possible.  With this there is lower risk of clinical progression of the disease and prevention of opportunistic infection.
Classes of ANTIRETROVIRAL DRUGS: Anti retroviral drugs act by inhibiting the multiplication of the virus. The drugs mainly target 2 key enzymes the virus requires to multiply.These are PROTEASE , REVERSE TRASCRIPTASE. Drugs inhibiting the Reverse Transcriptase enzyme are divided into two types – Neucleoside Reverse Transcriptase Inhibitors (NRTIs) & Non-Neucleoside Reverse Transcriptase Inhibitors (NNRTIs).
Combination Therapy: HIV virus has the ability of developing resistance if any one drug is used alone. Hence current guidelines are to use at least 3 antiretroviral drugs in combination. This is the same principle used in the treatment of tuberculosis. This triple drug regime is commonly called HAART ( Highly Active Antiretoviral Therapy). HAART has been shown to inhibit viral replication to levels below the limit of detection.

Antiretroviral Drugs                                                                Incomplete list

Nucleoside Reverse Transcriptase Inhibitors (NRTIs) Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs) Protease Inhibitors (PIs)
Zidovudine  Nevirapine  Indinavir 
Stavudine  Efavirenz  Nelfinavir 
Lamivudine  Delavirdine  Ritonavir 
Didanosine   Saquinavir
Zalcitabine Amprenavir 
   Abacavir  Lopinavir / Rotinavir 
Initiating Antiretroviral Therapy: The antiretroviral therapy is started in persons with sign of compromised immune system or indication of presence of Opportunistic infection.
CD4+ cell count less than 500 cells/ micoliter or increase of viral load to more than 5,000 – 10,000 copies/ milliliter. are indications of reduced immune strength. All symptomatic patients with symptoms suggestive of active infection – wasting, thrush or unexplained fever for > 2 wks. should be started with antiretroviral drugs irrespective of the viral load. Proper counseling of the patients is also very important before commencing the therapy. Patients is told about the fact that the therapy has to be life long and it is not curative. Cost of the therapy and side effects should be known to the patient. Adherence to the treatment process should be thoroughly stressed. The patient should know that even if he or she is keeping fine transmission of the infection to others is possible and safe sex methods should be practiced.  

Commonly used initial Antiretroviral regimens

Antiretroviral drug regimens are comprised of one choice each from column A and B. 

Column A

Column B

Efavirenz Stavudine + Didanosine
Indinavir Stavudine + Lamivudine
Nelfinavir Zidovudine + Lamivudine
Nevirapine Zidovudine + Didanosine
Saquinavir
HIV positive patients should be kept up to date on immunizations.
Pneumococcal vaccine: Booster at 5 years.
Hepatitis B vaccine.
Influenza vaccine: yearly.

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