HIV resident survival guide

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HIV Resident Survival Guide Microchapters
Overview
Classification
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kanwal Khamuani, B.B.B.S.

Synonyms and Keywords:

Overview

Human Immunodeficiency Virus, the agent causing Acquired Immunodeficiency Syndrome, is one of the leading infectious burdens globally and the fifth leading cause of disability in people of all ages. Belonging to the family of Retroviridae, it particularly infects the immune system cells such as CD4+ T cells, dendritic cells and macrophages. It has 2 serotypes with HIV-1 being most virulent and pathogenic. It is transmitted via sexual fluids(vaginal and semen), blood by percutaneous inoculation, Placenta(vertical transmission from mother to fetus) and breast milk. Due to competency of Antiretroviral therapy, it is now considered as a chronic illness seen most commonly in mono-sexual men. Initially, the symptoms are nonspecific until it develops into the last stage AIDS where the patient present with opportunistic infections due to suppressed immunity. It is diagnosed by PCR, ELISA, western blot and Rapid antigen testing. ART and vaccines have shown promising results in treatment and prevention respectively. As prevention is the foundation, CDC recommends screening mono-sexual men, pregnant women, drug abusers ad sexually active heterosexuals. Despite better treatment, it remains a serious disease that requires more effort by health care providers in terms of surveillance and education.

Classification

WHO and CDC classify the HIV infected individuals on the basis of CD count:[1]

  • STAGE A- Asymptomatic (CD count > 500/μl)
  • STAGE B- Mild symptoms to symptoms of AIDS-related complex (CD count between 400/μl and 200/μl)
  • STAGE C- AIDS defining illness (CD count <200/μl)

DISEASE PRESENTATION IN WEEKS[1]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

DISEASE PRESENTATION IN MONTHS AND YEARS

Patients develop opportunistic infections and neoplasms when CD count becomes <200/μl.[1]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Diagnosis

Patient with high suspicion of having HIV in a highly prevalent region should have following diagnostic approach.[2]

Abbreviations: RDTs: Rapid diagnostic tests; EIAs: enzyme immunoassays; CLIAs: chemiluminescence immunoanalysers;ELAs: electrochemiluminescence immunoanalysers;HIV: Human immunodeficiency virus

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IF REACTIVE
 
 
IF NON REACTIVE
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirm with second line assay from any other serological fourth generation assays
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Report HIV negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
if positive
 
 
if negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Report HIV positive and retest prior to starting ART
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat both first line and second line assay testing
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
if same results
 
 
if both negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Report HIV negative OR retest if high risk features present
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform third line assay
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If positive-ask patient to return for testing in 14 days
 
 
if negative-report HIV negative
 

Treatment

The most effective treatment regimen is HAART that includes combination of 2 NRTIs and 1 drug from different class.[3] [4] [5]

Abbreviations: HIV: Human immunodeficiency virus; NRTIs: nucleoside reverse transcriptase inhibitor; NNRTIs: non nucleoside reverse transcriptase inhibitor;TDF: tenofovir disoproxil fumarate;TAF: tenofovir alafenamide;CCR5: C-C motif chemokine receptor 5

HIV DRUG CLASSES
DRUG CLASS EXAMPLES
NRTIS Abacavir, emtricitabine, zidovudine, lamivudine, TDF, TAF
NNRTIs Efavirenz, etravirine, neviripine, rilpivirine
INTEGRASE STARND INHIBITOR Daltegravir, raltegravir,elvitegravir,bictegravir
PROTEASE INHIBITOR Atazabavir, darunavir, ritonavir, tipranavir
FUSION INHIBITOR Enfuviritide
CCR5 antagonist Maraviroc
POST ATTACHMENT INHIBITOR Ibalizumab
PHARMOCOKINETIC ENHANCER Cobicistat
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
RECOMMENDED INITIAL REGIMENS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If Integrase inhibitor is an option
 
 
 
 
 
 
 
 
 
 
 
 
 
If integrase inhibitor is not an option
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dolutegravir/Abacavir/Lamivudine
 
Dolutegravir/TAF/Emtricitabine
 
 
 
Elvitegravir/Cobicistat/TAF/Emtricitabine
 
Raltegravir/TAF/Emtricitabine
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Darunavir/TAF OR TDF/Emtricitabine
 
Efavirenz/TDF/Emtricitabine
 
Rilpivirine/TAF OR TDF/Emtricitabine

Do's

  • HLAB*5701 testings should be performed before starting Abacavir.
  • Monitor CBC with differentials when prescribing zidovudine.
  • Monitor GFR when starting TAF or TDF.

Don'ts

  • Do not give Tenofovir in renal impairment or bone disease.
  • Do not give nevirapine in hepatic impairment.

References

  1. 1.0 1.1 1.2 German Advisory Committee Blood (Arbeitskreis Blut), Subgroup ‘Assessment of Pathogens Transmissible by Blood’ (2016). "Human Immunodeficiency Virus (HIV)". Transfus Med Hemother. 43 (3): 203–22. doi:10.1159/000445852. PMC 4924471. PMID 27403093.
  2. Korean Society for AIDS (2019). "The 2018 Clinical Guidelines for the Diagnosis and Treatment of HIV/AIDS in HIV-Infected Koreans". Infect Chemother. 51 (1): 77–88. doi:10.3947/ic.2019.51.1.77. PMC 6446007. PMID 30941943.
  3. Prokofjeva MM, Kochetkov SN, Prassolov VS (2016). "Therapy of HIV Infection: Current Approaches and Prospects". Acta Naturae. 8 (4): 23–32. PMC 5199204. PMID 28050264.
  4. Arts EJ, Hazuda DJ (2012). "HIV-1 antiretroviral drug therapy". Cold Spring Harb Perspect Med. 2 (4): a007161. doi:10.1101/cshperspect.a007161. PMC 3312400. PMID 22474613.
  5. Gibert CL (2016). "Treatment Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents: An Update". Fed Pract. 33 (Suppl 3): 31S–36S. PMC 6375413. PMID 30766213.