Newly diagnosed HIV patient. Dr. Heila Redpath 06 FEBRUARY 2014
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1 Newly diagnosed HIV patient Dr. Heila Redpath 06 FEBRUARY 2014
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7 PRIMARY HIV INFECTION: SEROCONVERSION SYMPTOMATIC HIV INFECTION AND AIDS ASYMPTOMATIC LATENT INFECTION CLOSED CIRCLES: CD4 cells OPEN CIRCLES: viral load TIME : WEEKS and YEARS
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9 Opportunistic Diseases in the HIV Infected WHO Clinical Stage 1 Asymptomatic infection Persistent generalised lymphadenopathy Acute HIV Infection: Seroconversion Performance scale: asymptomatic, normal activity
10 WHO Clinical Stage 2 Unintentional weight loss of < 10% BW Minor mucocutaneous diseases: seborrheic dermatitis, prurigo, fungal nail infection, oropharyngeal ulcers, angular cheilitis Herpes zoster within the preceding 5 years Recurrent upper respiratory tract infections e.g. bacterial sinusitis Performance scale 2: symptoms but nearly fully ambulatory
11 WHO Clinical Stage 3 Unintentional weight loss of > 10% BW Chronic diarrhoea of more than 1 month Prolonged fever for > 1 month Oral candidiasis Oral Hairy Leukoplakia Pulmonary TB Severe bacterial infections Vulvovaginal candidiasis Performance scale 3: in bed < 50% of daytime but more than usual
12 WHO Clinical Stage 4 HIV Wasting Syndrome PCP Toxoplasmosis Cryptosporidiosis Isosporiasis CMV outside the liver, spleen or nodes HSV: persistent mucocutaneous or visceral > 1 month PML Disseminated fungal infections: Histoplasmosis Cryptococcus, etc Candidiasis of the oesophagus, trachea etc
13 WHO Clinical Stage 4 Non-TB mycobacterial infections: MAI Non-typhoidal Salmonella septicaemia Extra-pulmonary TB Non-Hodgkin s Lymphoma Kaposi s sarcoma HIV-encephalopathy Performance scale 4: in bed > 50 % of daytime
14 WHO NEEDS TO START HAART? WHO4: STssSRT HAART IRRESPECTIVE OF CD4 WHO3: CD4 < 350 WHO2: CD WHO1: CD4 < 250 TWICE TUBERCULOSIS: CD4 < 50: START AS SOON AS POSSIBLE CD : CAN WAIT TILL END OF IP CD4 > 200: CAN WAIT TILL END OF TB TREATMENT
15 PREPARING THE PATIENT DO FBC,CD4,LFT,VL, U&E DO CXR DO SPUTUM ( TBC&S X2) COUNCELLING
16 FIRST LINE FDC TRUVADA/RALTREGRAVIR TRUVADA/EFAVIRENZ TRUVADA/NIVERAPINE COMBIVIR/EFAVIRENS COMBIVIR/NIVERAPINE
17 1 TAB Q12HLY PO COMBIVIR
18 EFAVIRENZ DRUG DIZZINESS PSYCOSIS DEPRESSION INCREASED CHOLESTEROL TINNITIS HEPATITIS
19 EFAVIRENZ EFAVIRENZ 600MG NOCTE PO
20 STAVUDINE PERIPHERAL NEUROPATHY LACTIC ACIDOSIS PANCREATITIS/CYSTS FAT ATROPHY/REDISTRIBUTION BREAST ENLARGMENT(BILATERAL) LIVER FAILURE NAUSEA/VOMITING
21 LAMUVIDINE/3TC PRURITIS RASHES ANAEMIA SKIN PIGMENTATION NAUSEA/VOMITING MYOPATHY PANCREATITIS
22 NIVERAPINE NIVERAPINE 200MG DAILY PO ( 1 ST 2 WEEKS), THEN NIVERAPINE 200MG Q12HLY PO
23 TRUVADA 1 TAB NOCTE TRUVADA
24 TRUVADA LOOK OUT FOR: RENAL FAILURE HYPERGLYCAEMIA HYPERTRIGLISERIDEMIA PT CAN TURN YELLOW FOR A FEW WEEKS
25 PLAYING AROUND BEF0RE STARTING YOUR PATIENT ON HAART, LOOK AT THE SIDE EFFECTS/ EFECTS THEY ALREADY EXPERIENCE, THEN SEE WHICH REGIME WILL SUIT YOUR PATIENT BEST. NIVERAPINE AND EFAVIRENZ CAN BE SWITCH AROUND, ACCORDING TO THE PATIENTS CLINIC STATE.
26 SECOND REGIME TRUVADA 1 TAB Q12HLY PO Lopinavir/rotinavir 400MG Q12HLY PO, WITH MEALS
27 Lopinavir/rotinavir DIARRHOEA DIABETES DIABETIC KETO ACIDOSIS VARICOSE VEINS CUSHING S SYNDROME ALOPECIA HYPERCHOLESTEROLEMIA HYPERTRIGLYCERIDAEMIA
28 ABACAVIR/ZIAGEN ABACAVIR 300MG Q12HLY PO ON A FULL STOMACH
29 ABACAVIR/ZIAGEN HYPERSENSITIVITY REACTION FATAL LACTIC ACIDOSIS LETHARGY SWEATING
30 400MG BD PO RALTREGRAVIR
31 RALTREGRAVIR PROFILE LOWER CHOLESTEROL LOWER RISK OF DIABETES CROSSES BBB NO RENAL SIDE EFFECTS NO LIVER TOXICITY
32 MARIVEROC CCR5 RECEPTOR BLOCKER LAST LINE
33 PROPHYLACTIC DRUGS CMX: STEVENS-JOHNSON SYNDROME ANAEMIA POLYARTERITIS NODOSA HAEMATURIA INH: HEPATOTOXICITY DAPSONE:
34 FOLLOW UP OF PATIENTS 2 WEEKS FBC, LFT 6 WEEKS FBC,CD4,LFT,VL THEN EVERY 3 MONTHLY WHEN PATIENT IS STABLE AND COMFORTABLE ON HAART, EVERY 6 MONTHS
35 Clinical features of HIV-associated drug hypersensitivity Principal features o o o Morbilliform /maculopapular rash o Fever often preceding rash o Myalgias and fatigue o Mucosal ulceration Less common features Stevens-Johnson syndrome Toxic epidermal necrolysis Anicteric hepatitis Hypotension Acute interstitial nephritis Acute interstitial pneumonitis Carr A, Cooper DA Lancet 2000;356: 1423
36 HAART: drug hypersensitivity reactions cotrimoxazole Nevirapine
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38 Cotrimoxazole (CTX) Stevens Johnson Syndrome
39 HAART: Hyperpigmentation drug-related side effect cytokine- induced (MSH) Zidovudine, combivir addison s disease: adrenal failure Adams-Graves P et al Hydroxyurea-induced hyperpigmentation. NEJM (letter) 1996:334:333-4
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