HIV resident survival guide
Human Immunodeficiency Virus, the agent causing Acquired Immunodeficiency Syndrome, is one of the leading infectious burden globally and 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 chronic illness seen most commonly in mono-sexual men. Initially the symptoms are non specific until it develops into the last stage AIDS where 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 require more efforts by health care providers in terms of surveillance and education.
WHO and CDC classify the HIV infected individuals on the basis of CD count:
- 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
DISEASE PRESENTATION IN MONTHS AND YEARS
Patients develop opportunistic infections and neoplasms when CD count becomes <200/μl.
Patient with high suspicion of having HIV in a highly prevalent region should have following diagnostic approach.
|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|
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
|NRTIS||Abacavir, emtricitabine, zidovudine, lamivudine, TDF, TAF|
|NNRTIs||Efivirenz, etravirine, neviripine, rilpivirine|
|INTEGRASE STARND INHIBITOR||Daltegravir, raltegravir,elvitegravir,bictegravir|
|PROTEASE INHIBITOR||Atazabavir, darunavir, ritonavir, tipranavir|
|POST ATTACHMENT INHIBITOR||Ibalizumab|
- HLAB*5701 testing should be performed before starting Abacavir.
- Monitor CBC with differentials when prescribing zidovudine.
- Monitor GFR when starting TAF or TDF.
- Do not give Tenofovir in renal impairment or bone disease.
- Do not give neviripine in hepatic impairment.
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- 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.