HIV infection - AIDS

HIV infection - AIDS

 
Definition  

    Infection by the human immunodeficiency virus (HIV), the causal agent of acquired immunodeficiency syndrome (AIDS), a disease characterized by the destruction of the human immune system

    AIDS is a clinical diagnosis characterized by seropositivity for HIV infection in combination with evidence of advanced immunosuppression, demonstrated either by the occurrence of specific opportunistic infections and neoplasms or by a CD4+ lymphocyte count less than 200/mm3.

 

 
Assessment and monitoring of HIV infection  

* Absolute CD4 count procedure: The CD4+ count is the most important test on which to base treatment decisions, predict disease progression, and assess opportunistic infections risk .

 
Monitoring HIV infection and evaluating treatment for HIV  

* HIV viral load: Plasma HIV viral RNA levels are necessary to assess disease activity and response to therapy; steady-state levels are prognostic of disease progression .

    
Treatment planning and evaluation of suspected drug resistance in HIV infection  

* HIV genotyping: Drug resistance testing using HIV genotyping is recommended prior to initial treatment and when changing regimens due to virologic failure .

 
Initial evaluation of HIV-infected patient  

* Complete blood count

* Electrolytes measurement, serum

* Hepatic function panel

* Biochemical evaluation of blood urea/renal function

* Fasting blood glucose measurement

* Fasting lipid profile

* Urinalysis

* Serologic test for syphilis

* Hepatitis A virus antibody measurement

* Hepatitis B surface antigen measurement

* Hepatitis C antibody measurement

* Tuberculosis screening

* Serologic test for Toxoplasma gondii

* Microscopic examination of cervical Papanicolaou smear

 

 
Children  

 
Monitoring of HIV-infected patients and response to therapy  

* Absolute CD4 count procedure

* HIV viral load

 
Evaluation of virologic failure and suboptimal treatment response  
* HIV phenotyping

 
Monitoring of HIV-infected patients  

* Complete blood count

* Electrolytes measurement, serum

* Hepatic function panel

* Biochemical evaluation of blood urea/renal function

* Tuberculosis screening

 
Monitoring of HIV-infected patients  

* Serologic test for syphilis

* Chlamydia trachomatis nucleic acid assay

* Neisseria gonorrheae nucleic acid amplification test

* Hepatitis C antibody measurement

* Microscopic examination of cervical Papanicolaou smear

 
Medical History  

* Men who have sex with men

* Multiple sexual contacts

* Substance Abuse

* Prostitution

* Sexually transmitted infectious disease

* Intravenous blood transfusion

* Occupational Exposure

 
Findings  

* Fatigue

* Fever

* Lymphadenopathy - Acute

* Weight loss

* Night sweats

* Muscle atrophy

* Myalgia

* Rash - Acute

* Urticaria - Acute

* Headache

* Pharyngitis - Acute

* Diarrhea

* Hepatosplenomegaly

* Oral candidiasis

* Nuchal rigidity

* Oral hairy leukoplakia

* Ulcer of mouth

* Impaired cognition

* Facial palsy

* Paralysis

* Radicular pain

* Paresthesia

* Heart failure

* Vulvovaginitis

* Purpuric disorder

 
Tests  

 
Suspected HIV infection  

* Human immunodeficiency virus antibody titer measurement: A repeatedly reactive ELISA or rapid test for HIV antibody suggests the diagnosis of HIV infection, but requires confirmatory testing .

 
Suspected HIV infection  

* Rapid HIV test: A positive result on a rapid HIV assay suggests HIV infection and requires repeat confirmatory testing for diagnosis .

 
Confirmatory testing for suspected HIV infection  

* HIV-1 Western blot assay: A Western blot is positive for HIV-1 infection when antibodies are present (positive bands) to at least 2 of the viral antigens p24, gp41, and gp120/160 .

 
Suspected HIV infection  

* HIV p24 antigen test: Repeatedly positive p24 antigen tests along with a positive viral neutralization test may diagnosis acute HIV infection earlier than antibody testing .

 
Suspected recent HIV infection and diagnostic testing in infants less than 18 months of age  
* HIV 1 nucleic acid assay

 
Differential Diagnosis  

* Streptococcal pharyngitis - Acute

* Infectious mononucleosis - Acute

* Influenza

* Viral hepatitis

* Syphilis - Acute

 

 

 

Treatment  

 

Drug Therapy  

 

 

Nucleoside analog reverse transcriptase inhibitors (NRTIs) for HIV/AIDS  

 

ABACAVIR SULFATE  

Adult and adolescent: 300 mg orally twice daily or 600 mg orally once daily

Pediatric (age ?3 months): 8 mg/kg orally twice daily; maximum, 300 mg orally twice daily

All patients should be tested for the HLA-B*5701 allele prior to initiating therapy due to increased risk of serious hypersensitivity

 

DIDANOSINE

Adult and adolescent (?60 kg): 400 mg orally once daily (capsules) OR 200 mg orally twice daily (oral solution); reduce dose to 250 mg orally once daily if given with tenofovir

Adult and adolescent (<60 kg): 250 mg orally once daily (capsules) OR 125 mg orally twice daily (oral solution); reduce dose to 200 mg orally once daily if given with tenofovir

Pediatric (age 6 to 18 years, weight ?20 kg, delayed-release capsule): 200 mg orally once daily if weight 20 kg to less than 25 kg; 300 mg orally once daily if weight 25 kg to less than 60 kg; 400 mg orally once daily if weight 60 kg and greater

Pediatric (age 3 to 21 years, treatment-naïve, oral solution): 240 mg/m2 body surface area orally once daily; maximum, 400 mg

Pediatric (age >8 months, oral solution): 120 mg/m2 body surface area orally twice daily

Pediatric (age 2 weeks to 8 months, oral solution): 100 mg/m2 body surface area orally every 12 hours

Significant dose reduction is required in the setting of impaired renal function .

 

ZIDOVUDINE  

Adult: 300 mg orally twice daily (preferred) or 200 mg orally 3 times daily

Pediatric (6 weeks to <18 years, ): 300 mg orally twice daily if ?30 kg; 9 mg/kg orally twice daily if 9 kg to < 30 kg; 12 mg/kg orally twice daily if 4 kg to < 9 kg OR 240 mg/m2 every 12 hours or 160 mg/m2 every 8 hours

Pediatric (<6 weeks, treatment or prevention of transmission): 1.5 mg/kg IV every 6 hours OR 2 mg/kg orally every 6 hours

Pediatric (premature birth, treatment or prevention of transmission): 1.5 mg/kg IV every 12 hours OR 2 mg/kg orally every 12 hours; increase to every 8 hours at 2 weeks of age (neonates ?30 weeks gestation) or at 4 weeks of age (neonates <30 weeks gestation)

 

TENOFOVIR DISOPROXIL FUMARATE  

Adult: 300 mg orally once daily

Significant dose reduction is required in the setting of impaired renal function .

 

LAMIVUDINE  

Adult: 150 mg orally twice daily OR 300 mg orally once daily

Pediatric (age 30 days and older): 4 mg/kg orally twice daily; maximum, 150 mg orally twice daily

Pediatric (age <30 days): 2 mg/kg orally twice daily

Significant dose reduction is required in the setting of impaired renal function .

 

EMTRICITABINE  

Adult: 200 mg orally once daily (capsules) OR 240 mg orally once daily (oral solution)

Pediatric (>33 kg and able to swallow capsules): 200 mg orally once daily

Pediatric (age ?3 months to 17 years, oral solution): 6 mg/kg orally once daily; maximum, 240 mg orally once daily

 

STAVUDINE  

Adult: 30 mg orally twice daily if <60 kg; 40 mg orally twice daily if >60 kg

Pediatric (adolescent, ?30 kg): 30 mg orally twice daily if <60 kg; 40 mg orally twice daily if >60 kg

Pediatric (age 14 days up to weight of 30 kg): 1 mg/kg orally every 12 hours

Pediatric (birth to age 13 days): 0.5 mg/kg orally every 12 hours

Significant dose reduction is required in the setting of impaired renal function .

 

 

Nonnucleoside reverse transcriptase inhibitors (NNRTIs) for HIV/AIDS  

 

EFAVIRENZ  

Adult: 600 mg orally once daily at or before bedtime; take on empty stomach

Pediatric (age ?3 years and weight ?10 kg): 600 mg orally once daily if ?40 kg; 400 mg orally once daily if 32.5 to <40 kg; 350 mg orally once daily if 25 to <32.5 kg; 300 mg orally once daily if 20 to <25 kg; 250 mg orally once daily if 15 to <20 kg; 200 mg orally once daily if 10 to <15 kg

 

NEVIRAPINE  

Adult: 200 mg orally once daily for 14 days, then 200 mg orally twice daily

Avoid initiating in women with CD4+ count >250 cells/mm3 or men with CD4+ count >400 cells/mm3

Pediatric (age ?15 days): 150 mg/m2 (maximum 200 mg) orally once daily for the first 14 days, then 150 to 200 mg/m2 orally twice daily (maximum, 400 mg/day)

Pediatric (?14 days; transmission prophylaxis only): 2 mg/kg orally given as a single dose between birth and age 3 days

 

DELAVIRDINE MESYLATE  

Adult: 400 mg orally 3 times daily

 

 

Protease inhibitors (PIs) for HIV/AIDS  

 

INDINAVIR SULFATE  

Adult: 800 mg orally every 8 hours

Pediatric (adolescent): 800 mg orally every 8 hours

 

INDINAVIR SULFATE - RITONAVIR  

Adult: Indinavir 800 mg AND ritonavir 100 to 200 mg, both orally twice daily

 

LOPINAVIR/RITONAVIR  

Adult: Lopinavir 400 mg/ritonavir 100 mg orally twice daily OR lopinavir 800 mg/ritonavir 200 mg orally once daily in treatment-naive patients (do not use once-daily dosing in pregnancy)

Pediatric (age 6 months to 18 years, receiving concomitant efavirenz, nevirapine, fosamprenavir, or nelfinavir): Lopinavir 300 mg/m2 orally twice daily and ritonavir 75 mg/m2 orally twice daily; maximum, lopinavir 533 mg/ritonavir 133 mg orally twice daily OR lopinavir 13 mg/ritonavir 3.25 mg per kg orally twice daily if <15 kg; lopinavir 11 mg/ritonavir 2.7 mg per kg orally twice daily if 15 to 40 kg; lopinavir 400 to 600 mg/ritonavir 100 to 150 mg orally twice daily if ?40 kg

Pediatric (age 6 months to 18 years, not receiving concomitant efavirenz, nevirapine, fosamprenavir, or nelfinavir): Lopinavir 230 mg/m2 orally twice daily and ritonavir 57.5 mg/m2 orally twice daily; maximum lopinavir 400 mg/ritonavir 100 mg orally twice daily OR lopinavir 12 mg/ritonavir 3 mg per kg orally twice daily if <15 kg; lopinavir 10 mg/ritonavir 2.5 mg per kg orally twice daily if 15 to 40 kg; lopinavir 400 mg/ritonavir 100 mg orally twice daily if ?40 kg

Pediatric (age 14 days to 6 months): Lopinavir 16 mg/ritonavir 4 mg per kg orally twice daily OR lopinavir 300 mg/ritonavir 75 per m2 orally twice daily

 

RITONAVIR  

Adult: 600 mg orally every 12 hours when used as sole PI

Pediatric (adolescent): Initial dose 300 mg orally twice daily, increasing over 5 days to 600 mg orally twice daily

Pediatric (age >1 month): Full dose 350 to 450 mg/m2 twice daily (maximum dose, 600 mg) in the unusual situation of use as sole PI; dose should be started lower and increased over several days to minimize gastrointestinal toxicity

 

SAQUINAVIR MESYLATE - RITONAVIR  

Adult: Saquinavir (tablet or hard-gel capsule) 1000 mg orally twice daily AND ritonavir 100 mg orally twice daily

Pediatric (age >16 years): Saquinavir (tablet or hard-gel capsule) 1000 mg orally twice daily AND ritonavir 100 mg orally twice daily

 

DARUNAVIR ETHANOLATE - RITONAVIR  

Adults: Darunavir 800 mg orally once daily AND ritonavir 100 mg orally once daily, taken with food

Pediatrics (6 to <18 years, weight ?20 kg): Darunavir 375 mg orally twice daily AND ritonavir 50 mg orally twice daily if 20 to <30 kg; darunavir 450 mg orally twice daily AND ritonavir 60 mg orally twice daily if 30 to <40 kg; darunavir 600 mg orally twice daily AND ritonavir 100 mg orally twice daily if ?40 kg

 

TIPRANAVIR - RITONAVIR  

Adult: Tipranavir 500 mg orally twice daily AND ritonavir 200 mg orally twice daily

Pediatric (age 2 to 18 years): Tipranavir 14 mg/kg orally twice daily (maximum dose, 500 mg) AND ritonavir 6 mg/kg orally twice daily (maximum dose, 200 mg) OR tipranavir 375 mg/m2 orally twice daily and ritonavir 150 mg/m2 orally twice daily

 

FOSAMPRENAVIR CALCIUM  

Adult: 1400 mg orally twice daily

Pediatric (2 to 18 years): 30 mg/kg orally twice daily; maximum dose, 1400 mg)

 

FOSAMPRENAVIR CALCIUM - RITONAVIR  

Adult: Fosamprenavir 700 mg orally twice daily AND ritonavir 100 mg orally twice daily OR fosamprenavir 1400 mg orally once daily AND ritonavir 100 to 200 mg orally once daily

Pediatric (>6 years): Fosamprenavir 18 mg/kg orally twice daily, maximum 700 mg AND ritonavir 3 mg/kg orally twice daily, maximum 100 mg

 

ATAZANAVIR SULFATE  

Adult: 400 mg orally once daily

Pediatric (age ?13 years, weight >39 kg): 400 mg orally once daily

 

ATAZANAVIR SULFATE - RITONAVIR  

Adult: Atazanavir 300 mg once daily AND ritonavir 100 mg once daily

Pediatric (age 6 to 18 years, weight ?15 kg): Atazanavir 150 mg once daily AND ritonavir 80 mg once daily if 15 to less than 25 kg; atazanavir 200 mg once daily AND ritonavir 100 mg once daily if 25 to <32 kg; atazanavir 250 mg once daily AND ritonavir 100 mg once daily if 32 to <39 kg; atazanavir 300 mg once daily AND ritonavir 100 mg once daily if ?39 kg

 

NELFINAVIR MESYLATE  

Adult: 1250 mg orally twice daily OR 750 mg orally 3 times daily

Pediatric (age >13 years): 1250 mg orally twice daily OR 750 mg orally 3 times daily

Pediatric (age 2 to 13 years): 45 to 55 mg/kg orally twice daily OR 25 to 35 mg/kg orally 3 times daily

 

 

Fusion inhibitors for HIV/AIDS  

 

ENFUVIRTIDE  

Adult: 90 mg subQ twice daily

Pediatric (age >16 years): 90 mg subQ in upper arm, anterior thigh, or abdomen twice daily

Pediatric (age 6 to 16 years): 2 mg/kg subQ in upper arm, anterior thigh, or abdomen twice daily; maximum, 90 mg

 

 

CCR5 antagonists for HIV/AIDS  

 

MARAVIROC

Adult (concomitant potent CYP3A inhibitors, including most protease inhibitors, delavirdine, ketoconazole, itraconazole, clarithromycin, nefazadone, and telithromycin, with or without a CYP3A inducer): 150 mg orally twice daily

Adult (concomitant tipranavir/ritonavir, nevirapine, all NRTIs, enfuvirtide): 300 mg orally twice daily

Adult (concomitant CYP3A inducers, including efavirenz, etravirine, rifampin, carbamazepine, phenobarbital, and phenytoin, without a strong CYP3A inhibitor): 600 mg orally twice daily

Pediatric (?16 years, concomitant potent CYP3A inhibitors, including most protease inhibitors, delavirdine, ketoconazole, itraconazole, clarithromycin, with or without a CPY3A inducer): 150 mg orally twice daily

Pediatric (?16 years, concomitant tipranavir/ritonavir, nevirapine, all NRTIs, enfuvirtide): 300 mg orally twice daily

Pediatric (?16 years, concomitant CYP3A inducers, including efavirenz, rifampin, carbamazepine, phenobarbital, and phenytoin, without a strong CYP3A inhibitor): 600 mg orally twice daily

 

 

Integrase inhibitors for HIV/AIDS  

 

RALTEGRAVIR POTASSIUM  

Adults: 400 mg orally twice daily

Pediatric (age ?16 years): 400 mg orally twice daily

 

 

Antiretroviral therapy to prevent maternal-child transmission in HIV/AIDS  

 

ZIDOVUDINE  

Adult (intrapartum): Initial dose 2 mg/kg IV infusion over 1 hour during labor; follow with continuous infusion of 1 mg/kg per hour until delivery

Pediatric (term newborn, ?35 weeks gestation): 2 mg/kg per dose orally (syrup) every 6 hours OR 1.5 mg/kg IV every 6 hours if unable to tolerate oral intake; start within 6 to 12 hours after birth; continue treatment for the first 6 weeks of life

Pediatric (preterm newborn, between 30 and 35 weeks gestation): 1.5 mg/kg IV OR 2 mg/kg orally (syrup) every 12 hours, advancing to every 8 hours at 2 weeks of age; continue treatment for the first 6 weeks of life

Pediatric (preterm newborn, <30 weeks gestation): 1.5 mg/kg IV OR 2 mg/kg orally (syrup) every 12 hours, advancing to every 8 hours at 4 weeks of age; continue treatment for the first 6 weeks of life

 

Non-Procedural Therapy  

 
HIV infection  
* Exercise