TREATMENT OF HIV/AIDS

1. TREATMENT OF HIV/AIDS BY DR C.C. ONYEDUM

2. PRE –TREATMENT ASSESSMENT • -Complete History and Physical Examination • -Staging of the Disease • -Documentation of Relevant Past Medical History • -Documentation of concomitant medications • -Identification of coexisting medical conditions • -Weight • -Assessment of patients readiness for therapy • -Check laboratory results

3. PRE-TREATMENT ASSESS. CONTD -Provide all Supportive measures -Development of patient’s specific adherence strategy.

4. INFORMATION FOR THE PATIENT • -Discuss goals of Therapy • -The chance of achieving these in 6 months • -Common side effects of the ARVs • -The necessity of regular monitoring • That ARVS interact with each other and with other medications

5. GOALS OF THERAPY • Prolong life • Reduce morbidity • Enhance quality of life • Reduce transmission of HIV • Maximally suppress HIV RNA • Enhance Immunity

6. GOALS CONTD • Provide the most convenient HAART regimen • Select regimen with few side effects • Choose the most forgiving regimen

7. CRITERIA FOR INITIATION OF HAART • -WHO stage 4 • WHO stage3 with CD4 count of<350 • WHO stage 1or 2 with CD4 count of <200 • HIV RNA > 30,000

8. CRITERIA CONTD • IF CD4 is not available • WHO stage 3 and 4 irrespective of TLC • WHO stage2 with TLC of <1200

9. ANTI RETROVIRAL DRUGS -Currently six classes • Nucleoside Reverse Transcriptase Inhibitors (NRTI) e.g. Zidovudine, Lamuvidine, Abacavir • Nucleotide Reverse Transcriptase Inhibitors e.g. Tenofovir • Non nucleoside Reverse Transcriptase Inhibitors(NNRTI) e.g. Nevirapine , Efavirenz • Protease Inhibitors (PI) e.g. saquinavir , ritonavir etc

10. ARDs CONTD • Fusion Inhibitors(Entry Inhibitors) e.g. enfurvitide(T-20), T-1249. • Integrase Inhibitors- still being developed

11. SIDE EFFECTS OF ARDs • Reverse transcriptase inhibitors • NRTI- marrow depression • Reverse transcriptase inhibitors • NRTI- marrow depression • Reverse transcriptase inhibitors • NRTI- marrow depression • Reverse transcriptase inhibitors • NRTI- marrow depression, • - myopathy, Lipoatrophy, Peripheral Neuropathy,Hepatitis, Pancreatitis, Lactic Acidosis, Cardiomyopathy (rare) • NNRTI- Rashes- Steven Johnson's Syndrome, CNS side effects esp. with efavirenz

12. SIDE EFFECTS CONTD • Protease inhibitors- Lipoatrophy, Protease punch( crix belly), Buffalo Hump (dorso cervical pad), Gynaecomastia, Hyperinsulinaemia, hypertriglyceridaemia, Hypercholesterolaemia.

13. HAART/HEART • -Combination Therapy. • -2 NRTI and either a NNRTI or a PI • -There is no place for monotherapy

14. OTHER TREATMENT MODALITIES • Provision of good nutrition • Psychosocial support • Prophylaxis of opportunistic infections- CPT and IPT • Treatment of opportunistic infections- TB , thrush etc

15. TB and HAART • -Avoid Nevirapine if using Rifampicin-based anti-TB drugs • Use Efavirenz if on rifampicin • Advised to start anti-Kochs first

16. MONITORING OF PATIENT ON HAART • Symptoms/ Signs of potential toxicities • Adherence to treatment • Response to therapy • Weight Gain Laboratory Tests

17. TREATMENT FAILURE • CLINICALLY- • Occurrence of new OI or malignancy • Recurrence of OI • Onset or recurrence of WHO stage 3 defining conditions

18. TREATMENT FAILURE CONTD • IMMUNOLOGICALLY—(using CD4 levels) • Return of CD4 count to pre therapy baseline or below • 30% fall from on-therapy CD4 peak level • Failure to achieve CD4 of 50-100/year

19. TREATMENT FAILURE CONTD • VIROLOGICALLY; Viral loads not suppressed to undetectable levels after 4-6 months of therapy • Viral loads reduced by <10 fold after 8 weeks • A persistent increase in viral load following a period of adequate suppression

20. OTHER ISSUES • IMMUNE RECONSTITUTION SYNDROME • SALVAGE THERAPY • TREATMENT OF HIV2 INFECTION • HIV VACCINE- ?YES/ NO

21. CONCLUSION • ARV Drugs are toxic • Drug-Drug interaction abound • Ask of best trial • There is no place for monotherapy • HAART is taken for life

22. THANK YOU!!!