แนวทางการตรวจรักษาและป้องกันการติดเชื้อ...

2 3

2557 ()

(Essentials of HIV/AIDS Treatment and Prevention 2014 Thailand)

2557

-

-

-

-

4 5

()

1

2557 5,800

.. 2553 .. 2557

/

2557

CD4

6 7

2557

2557

1 22

1 16

18

2 18

18

1 28

(Assessment of

HIV-positive Persons at Initial &

Subsequent Visits)

2 34

(HIV Laboratory Testing)

3 39

(When to Start Antiretroviral Therapy

in Thailand)

8 9

4 40

(Timing to

Start Antiretrovirals in Patients with

Active Opportunistic Infection)

5 42

(What Antiretroviral

Regimen to Start With)

6 44

(Antiretroviral Options after First-line

NNRTI-based Failure and Multi-class

Failure)

7 46

(Multi-class

Antiretroviral Treatment Failure)

8 48

(Proper Antiretroviral Options and

Adjustment during the Month of

Ramadan)

9 50

(Renal Insufficiency and

Dose Adjustment of Antiretrovirals)

10 54

(Liver Insufficiency and Dose

Adjustment of Antiretrovirals)

11 58

(Side Effects and Complications

of Antiretroviral Therapy)

12 64

(Common Drug Interaction)

13 76

(Vaccination

for Adult HIV-positive Patients)

14 80

IRIS (Immune Reconstitution

Inflammatory Syndrome)

15 82

(Antiretroviral therapy in HIV and

Hepatitis B Coinfection)

16 85

(Consideration and

Contraindications in Hepatitis C

Infection Treatment)

10 11

1 86

2 88

3 90

4 94

5 96

6 106

7 130

2557

8 137

CD4 15

1 92

1 144

2 HAART 150

3 152

4 156

HAART

5 160

6 163

1 140

2 142

3 154

12 13

165

166

1 167

2 176

3 CD4 187

4 CD4 188

193

(Post-Exposure Prophylaxis PEP)

204

(Pre-Exposure Prophylaxis PrEP)

208

(Male circumcision)

209

1 oPEP 196

oPEP

2 nPEP 198

3 nPEP 200

nPEP

4 oPEP 203

nPEP

5 205

PrEP

6 PrEP 206

PrEP

1 195

14 15

1)

2)

algor i thm

3) rapid test

algorithm

4) Window period

3 1

5)

(inconclusive)

2 / 1

3 inconclusive

( 1)

6) DNA PCR

EDTA

(Dried Blood Spot ; DBS)

7) HIV DNA PCR

HIV DNA PCR

( 2)

16 17

1

18

(1) A1, A2 A3

1, 2 3

1

2 3(2) positive

(newly diagnosed)

2

1 (3) (inconclusive)

2 / 1

3

A1, A2 A3

3

(4)

2 / 3

(3)

NAT neutralization p24 assay

1 (A1)(1)

2 (A2)(1)

3

(A3)(1)

(Anti-HIV Negative)

(Anti-HIV Positive)(2)

(Inconclusive)(3,4)

A1+, A2+, A3 _ A1+, A2+, A3+

A1_, A2 _ A1+, A2 _ A1+, A2+

A1+, A2 _ A1+, A2+

A1 A2

A1_ A1+

18 19

2

1

8

(5)

(5)

(8)

(A

nti -

HIV

Pos

itive)

(Pos

itive

)

(7)

18

(

1)

12

12

- 1

8

(3)

2

3

In

conc

lusive

In

conc

lusive

2

3

2

3

DNA P

CR

DNA P

CR

2

Ant

i - H

IV

1

8

HIV

DNA P

CR

1

(2

)

Ant

i H

IV (6

)

DNA

PCR

(4

)

DNA P

CR

4

(Pos

itive

)

(Pos

itive

)

(An

ti - H

IV N

egat

ive)

(10)

(Neg

ative)

(9)

2

3

Neg

ative

(Neg

ative)

(Neg

ative)

20 21

(1)

18

PCR (2) NAT (nucleic acid

amplification testing)

(3)

4

VL > 50 copies/mL(4)

(5)

18 (6) 18

DNA PCR (7)

3

3

2

(8) PCR 2

24 (9) PCR 2

(10)

6

22 23

1

Anti-HIV testing ELISA,

Agglutination

test, Dot/Line

test

Clotted blood 5 mL

24 .

2-8C

Serum

plasma

1 mL

HIV viral

testing(1)Nucleic acid

amplification

testing (NAT)

EDTA blood 2-3 mL

24 .

2-8C

EDTA plasma 1 mL

Dried blood spot 1

CD4 + count Flow cytometry EDTA blood 2-3 mL

6 .

( 18 - 25C

)

(18-25C)

Viral load testing

(HIV-1 RNA)

Real time nucleic

acid amplification

EDTA blood 6-9 mL

6 .

( 4C)

6 .

4-8C 24

.

EDTA plasma 2

1.5

mL

PPT EDTA gel

()

6-9 mL

24 25

Genotype EDTA blood 6-9 mL

6 .

( 4C)

6 .

4-8C 24

.

EDTA plasma 2

1.5 mL

(1)

., 12 ,

26 27

(viral load, VL)

50 copies/mL

2 12

1 24 .

28 29

1

(Ass

essm

ent of

HIV

-pos

itive

Per

son

at In

itial

& Sub

sequ

ent Vi

sits

)

P

PP

(

)

P

P

PP

P

PP

P 6

12

-

sexu

al d

ysfu

nctio

n

-

30 31

PP

PP

P

(c

urre

nt

lifes

tyle)

PP

6

12

P

P

e

favire

nz

PP

32 33

PP

1

PP

PP

PP

PP

P

1

PP

drug

adh

eren

ce

P

34 35

2

(HIV

Lab

orat

ory

Test

ing)

C

D4

P 6

12

- 6

12

CD4

> 35

0 ce

lls/m

m3

VL

1,00

0 co

pies

/mL

6

Pap

sm

ear

1

1

Ana

l PAP

1

1

Cry

pto

Ag

P

C

D4

< 10

0

cells

/mm

3

3

(When to Start Antiretroviral Therapy in Thailand)

CD4

CD4 < 500 cells/mm3

CD4 > 500 cells/mm3

adherence

40 41

4

(Tim

ing

to S

tart

Ant

iretro

vira

ls in

Pat

ient

s w

ith A

ctive

Opp

ortu

nist

ic In

fect

ion)

CD4

(cel

ls/m

m3 )

50

> 50

(Tub

ercu

losis)

2

2

2-

8

Cry

ptoc

occo

sis

4-

6

PCP/M

AC/

2-

4

CM

V/PM

L/Cry

ptos

porid

ium

:

2

42 43

5

(Wha

t Ant

iretro

vira

l Reg

imen

to

Sta

rt w

ith)

NRTI

bac

kbon

e

+

NNRTI

s

NNRTI

s

TDF/

FTC*

EFV

LPV/

rTD

F/3T

C*

ABC +

3TC

AZT

+ 3

TC

RPV

NVP

ATV/

r

*

TDF

NRTI

A

baca

vir (A

BC) +

Lam

ivud

ine

(3TC

)

Zid

ovud

ine

(AZT

) + 3

TC

ef

avire

nz (E

FV)

NNRTI

s

rilp

ivirine

(RPV)

nev

irapi

ne (N

VP)

R

PV

VL

VL

> 10

0,00

0 co

pies

/mL

N

NRTI

s

3

P

rote

ase

Inhibi

tors

(PIs)

lopi

navir/rit

onav

ir (L

PV/

r)

ata

zana

vir/rit

onav

ir (A

TV/r)

stav

udine

(d4T

)

d4T

V

L <

50 c

opies/

mL

44 45

6

(Antiretroviral

Options after First-line NNRTI-based Failure

and Multi-class Failure)

NRTI

NRTI

TDF

AZT/3TC

lopinavir/

ritonavir (LPV/r)

atazanavir/

ritonavir (ATV/r),

darunavir/

ritonavir (DRV/r),

raltegravir (RAL),*dolutegravir

(DTG)

AZT, d4T

ABC

TDF/FTC

TDF/3TC

* Raltegravir NRTI backbone

(1)

NNRTI

1,000 copies/mL

(2) boosted-PI

poor adherence with transient

viremia

50 copies/mL

VL > 1,000 copies/mL

2-6

4

6

46 47

7

(Multi-class Antiretroviral Treatment

Failure)

1.

viral load

> 1,000 copies/mL

1

viral load

10

3 viral load 50 copies/mL

2.

viral load > 1,000 copies/mL

3.

4.

3

integrase inhibitor, entry inhibitor

5.

1) Integrase inhibitors: raltegravir, dolutegravir

2) Protease inhibitors: darunavir

()

3) NNRTIs: etravirine, rilpivirin

()

4) CCR5 inhibitors: maraviroc

48 49

8 (Proper

Antiretroviral Options and Adjustment during

the Month of Ramadan)

EFV EFV

NVP NVP 400 mg 24 .

OD

1

LPV/r LPV/r 2 12 .

4 24 .

ATV/r

TDF TDF

AZT d4T TDF 24 .

VL < 50 copies/mL

TDF

3TC 3TC 1 12 . 2

24 .

50 51

9

(Ren

al In

sufficien

cy a

nd D

ose

Adj

ustm

ent of

Ant

iretro

vira

ls)

eGFR

CrC

l (m

L/m

in)(1

)

Hem

odia

lysi

s

5030

-49

10-2

9<

10

NRTI

s

3TC

300

mg

24

.

150

mg

12

.

150

mg

24

.

100

mg

24

.(2

)

50-2

5 m

g

24

.(2

)

50-2

5 m

g

24

.(2

) AD

(3)

TDF(

4)30

0 m

g

24

.

300

mg

48

.

300

mg

2

300

mg

7

AD

(3)

AZT

200-

300

mg

12

.

10

0 m

g

8

.

300

mg

24

.

d4T

30 m

g

12

.

30 m

g

12

.

15 m

g

12

.

15 m

g

24

.

15 m

g

24

.

15 m

g

24

. AD

(3)

ddI(5

)

> 60

kg

400

mg

24

.

200

mg

24

.

150

mg

24

.

100

mg/

24

.

< 60

kg

250

mg

24

.

125

mg

24

.

100

mg

24 z

.

75 m

g/24

.

ABC

300

mg

12

.

600

mg

24

.

TDF/

FTC

1

24

.

48

.

NNRTI

s

EFV

600

mg

24

.

NVP

200

mg

12

.

ETR

200

mg

12

.

RPV

25 m

g

24

.

52 53

eGFR

CrC

l (m

L/m

in)(1

)

Hem

odia

lysi

s

5030

-49

10-2

9<

10

EFV/

TDF/

FTC

1

24

.

RPV

/TDF/

FTC

1

24

.

Pro

teas

e In

hibi

tor (P

Is)

ATV

400

mg

24

.

300/

100

mg

24

.

Hem

odia

lysi

s (H

D)

: AT

V/r 30

0/10

0 m

g

24

.

AT

V

ATV

/r

DRV

800/

100

mg

24

. (

naive

)

600

/100

mg

12

.

LPV/

r40

0/10

0 m

g

12

.

HD

Inte

gase

Inh

ibito

rs

RAL

400

mg

12

.

EGV/

CO

BI/

TDF/

FTC

1

24

.

C

rCl 35

28-3

5<

28

Inte

rnat

iona

l nor

malize

d ra

tio (I

NR)

<

1.7

1.7-

2.3

> 2.

3

Pro

thro

mbi

n tim

e

(

)<

44-

6>

6

(asc

ites)

Ence

phalop

athy

*

1-2

3-4

*

1

:

2

:

3

:

rou

tabl

e

4

:

5

-6

A

, 7-

9

B

,

10

-15

C

58 59

11

(Sid

e Eff

ects

and

Com

plicat

ions

of Ant

iretro

vira

l The

rapy

)

(lif

e-th

reat

enin

g ad

vers

e eff

ects

)

Ste

vens

-Joh

nson

Syn

drom

e (S

JS)

Toxic

Epid

erm

al

Nec

rolysis

(TEN

)

NVP

0.3

-1%

, DLV

EFV

0.1

%,

ETR 2

50 c

ells/m

m3

>

400

cells

/mm

3

)

n

evira

pine

hepa

tic n

ecro

sis

NVP

C

D4

>

400

cells

/mm

3

CD4

det

ecta

ble

HIV

RNA

NVP

(> 2

50 c

ells/

mm

3

40

0 ce

lls/m

m3

)

Bas

eline

AST

ALT

H

BV

/

HCV

Lactic

acidos

is, h

epatic

stea

tosis

+/- pa

ncre

atitis

(sev

ere

mito

chon

drial

toxicitie

s)

N

RTI

s

d4T

ddI

A

ZT

0.85

%

50

%

NRTI

d4T

ddI

, AZT

B

MI

d4T

d

dI

ddI

h

ydro

xyur

ea

rib

avirin

Lact

ic a

cido

sis,

rap

idly

prog

ress

ive

asce

nding

neur

omus

cular w

eakn

ess

d4T

a

scen

ding

de

mye

linat

ing

polyne

urop

athy

Guilla

in-B

arr

syn

drom

e

d

4T

Hyp

erse

nsitivity

reac

tion

(HSR)

ABC

8

%

2

-9%

9

9

0%

6

H

LA-B

* 5701

, HLA

-DR7,

HLA

-DQ

3

H

SR

3

4

ABC 6

00 m

g

24

.

300

mg

12

. (5

%

2

%)

(se

rious

adv

erse

effec

ts)

N

VP

1

4.8%

(

1.

5%),

EFV

2

6% (

g

rade

3-4

1%

), ABC

25

0 ce

ll/mm

3

C

D4

> 40

0 ce

ll/mm

3

det

ecta

ble

VL

3

TC, F

TC, T

DF

H

BV

Nep

hrol

ithiasis,

urol

ithiasis,

cry

stalluria

ID

V/r

1

2.4%

(4.7

-34.

4%),

ATV/

r

6

.6%

n

ephr

olith

iasis

peak

IDV

A

TV

>

0.85

mg/

L

ID

V

hyp

erbiliru

bine

mia

ATV

ATV/

r 20

0/10

0 m

g

1

Nep

hrot

oxicity

ID

V, T

DF

ATV

T

DF

IDV

Pan

crea

titis

ddI,

ddI

d

4T

Rib

avirin

Hyd

roxy

urea

3T

C, d4

T

TDF

in

trace

llular

/

ser

um d

dI

p

ancr

eatit

is

hy

pertr

iglyce

ridem

ia

ddI

d

4T h

ydro

xyur

ea, r

ibav

irin

ddI

T

DF

ddI

Bleed

ing

episod

es

incr

ease

in h

emop

hilia

P

Is

PIs

hem

ophilia

(lo

ng-ter

m a

dver

se e

ffec

ts)

Lipo

dyst

roph

y

Lipo

hype

rtro

phy

PI

NNRTI

d

4T

A

ZT

Li

poat

roph

y

N

RTI

s

d4T

A

ZT, dd

I

TDF,

ABC

Bas

eline

BM

I

62 63

(lo

ng-ter

m a

dver

se e

ffec

ts) (

)

Hyp

erlip

idem

iaPIs

(

u

nboo

sted

ATV

)

47-7

5%

- PIs >

NNRTI

s (E

FV >

NVP

)

- NRTI

s: d

4T >

AZT

> A

BC >

TDF

- PIs:

RTV

-boo

sted

PIs

ATV

/r

LDL,

TG

Insu

lin res

ista

nce/

diab

etes

mellitus

d4T,

AZT

PIs

3

-5%

hy

perg

lyce

mia

Per

iphe

ral n

euro

path

ydd

I 1

2-34

%, d4

T

5

2%

m

onot

hera

py

p

erip

hera

l ne

urop

athy

,

,

d4T

d

dI

in

trace

llular ac

tivities

ddI

TDF,

hyd

roxy

urea

, rib

avirin

Ost

eone

cros

is

PIs

sym

ptom

atic o

steo

necr

osis

0.08

-1.3

3%

a

sym

ptom

atic o

steo

necr

osis 4

%

M

RI

Hyp

erlip

idem

ia

Car

diov

ascu

lar

effec

ts,

CVA

, M

I

PIs

M

I

CVA

, ABC

M

I

ddI

M

I

obs

erve

stu

dies

RCT

trial

M

I 0

.3-0

.6%

CVA

0

.1%

C

VD (s

mok

ing,

HT,

DM

,

hype

rlipi

dem

ia

)

64 65

12 (Common Drug Interaction)

ergotamine Ergotamine group,

methergin

PIs Ergot

PI/RTV

Ergot

PI

severe vasoconstriction

gangrene

Dihydropyridine

calcium channel

blockers (DCCBs)

PIs DCCBs

NVP, EFV

DCCBs

DCCB

Amiodarone PIs

amiodarone

Diltiazem PIs diltiazem

NVP, EFV

diltiazem

diltiazem 50%

ATV RTV

diltiazem

Clopidogrel ETR

clopidogrel

Warfarin PIs

warfarin

NNRTIs

warfarin

INR

Rivaroxaban PIs

rivaroxaban

PIs

66 67

HMG-CoA

reductase inhibitors

Lovastatin

simvastatin

PIs

NNRTIs

PIs

NNRTIs

Atorvastatin

rosuvastatin

PIs

EFV, ETR

Pravastatin PIs

EFV

boosted darunavir

Acid reducers H2-receptor

antagonists (HRAs)

HRAs ATV

RPV

boosted ATV /

HRAs

10 .

HRAs 12 .

4 .

RPV

Proton-pump

inhibitors (PPIs)

PPIs ATV

RPV

ATV

PIs ,

PIs PPIs

12 . ATV

boosted ATV

RPV

68 69

Benzodiazepines Midazolam,

triazolam

PIs EFV

Alprazolam,

diazepam

PIs

ETR

diazepam

benzodiazepine

ETR

diazepam

Lorazepam,

oxazepam,

temazepam

CYP450

Antidepressants Sertraline Boosted darunavir

EFV

sertraline

sertraline

Trazodone PIs

trazodone

trazodone

Tricyclic

antidepressants

(TCAs)

PIs TCAs TCAs

70 71

Corticosteroids Dexamethasone Dexamethasone

PIs, NVP, EFV,

ETR, RPV

RPV

dexamethasone

Fluticasone,

budesonide (inhaled

intranasal

RTV boosted

PIs

Phosophodiesterase

type 5 inhibitors

Sildenafil PIs sildenafil

ETR sildenafil

PIs

ETR

Alpha-adrenergic

blockers

Tamsulosin PIs

tamsulosin

tamsulosin dose

5-alpha-reductase

inhibitors

Finasteride PIs

finasteride

finasteride

Ethinyl estradiol

(EE), progestin,

norgestimate,

norethindrone

EFV EE AUC

Levonogestrel

AUC 83%Norelgestromin

AUC 64%Etonogestrel (implant)

possible

levonogestrel, norelgestromin,

etonogestrel

ETV EE 22%;Norethindrone:

no significant effect

72 73

()

NVP EE 20%;Norethindrone: 19%

Depomedroxy

progesterone acetate:


RPV EE 14%;Norethindrone:


IDV EE: AUC 25%; Norethindrone:

AUC 26%

NFV EE: AUC 47%;Norethindrone:

AUC 18%

ATV/r EE: ;Progestin,

norgestimate:

EE

35 g

progestin norgestimate

norethindrone

DRV/r EE: AUC 44%;Norethindrone:

AUC 14%

LPV/r EE 42%;Norethindrone:

AUC 17%

74 75

Opioid antagonist Methadone Boosted PI

R-methadone (active

form methadone)

LPV/r :

methadone 26-53%

ATV/r, DRV/r

methadone

( methadone

16-18%)

methadone withdrawal

methadone

NNRTIs: EFV NVP

methadone

41-52%

methadone

withdrawal

methadone

ETR

methadone

AZT

29-43%

AZT

ATV = atazanavir; EFV = efavirenz; ETR = etravirine; NNRTIs = non-nucleoside reverse transcriptase inhibitors;

NVP = nevirapine; PIs = protease inhibitors; RPV = rilpivirine; RTV = ritonavir, AZT: zidovudine

76 77

13

(Vac

cina

tion

for A

dult HIV

-pos

itive

Patie

nts)

:

(liv

e-at

tenu

ated

vacc

ine)

mea

sles

, m

umps

, va

ricella, zo

ster

, ye

llow

fev

er

Hep

atitis A vac

cine

(HAV

)

2

:

HAV

(M

SM

)

(

H

BV/

HCV)

c

lotti

ng f

acto

r co

ncen

tratio

n

H

AV

se

rum

HAV

IgG

2

:

2

6-

12

Hep

atitis B vac

cine

(HBV)

3

H

BV

HBsA

g, a

nti-H

Bs,

anti-

HBc

3

:

,

2

1

,

3

2

2

4

(

2

3

1

6

)

anti-

HBs

3

1

anti-

HBs

10

IU/L

1

anti-

HBs

1

2

anti-

HBs

1

78 79

Hum

an

Pap

illom

aviru

s

Vacc

ine

(HPV)

3

H

PV

4

(qua

drivalen

t)

9-2

6

19-

26

(MSM

)

H

PV

(ana

l can

cer)

Influ

enza

1

n

asal s

pray

Teta

nus

and

diph

ther

ia tox

oid

(Td)

Tet

anus

toxo

id (T

T)

1

1

10

T

etan

us, d

ipht

heria

and

per

tuss

is (T

dap)

T

d

TT

1

23-v

alen

t

pneu

moc

occa

l

polysa

ccha

ride

(PPV-

23)

1

C

D4

> 20

0 ce

lls/m

m3

1

5

65

65

PCV-

13

P

PV-

23

1

13-v

alen

t

pneu

moc

occa

l

conjug

ate

(PCV-

13)

1

C

D4

> 20

0 ce

lls/m

m3

P

PV-

23

P

CV-

13

2

80 81

14 IRIS (Immune Reconstitution Inflammatory Syndrome)

Definition

IRIS

IRIS 2

Unmasking IRIS

3-6

Paradoxical IRIS

mycobacterium (TB MAC)

Cryptococcus

3-6

CD4

50-100 cells/mm3

mycobacterium (TB MAC)

Cryptococcus

3-6

()

CD4 50-

100 cell/mm3

-

- CD4

IRIS

(Graves disease)

IRIS

-

IRIS IRIS

Paradoxical IRIS

NSAIDs short course corticosteroids

IRIS

-

-

systemic corticosteroids

82 83

15

(Ant

iretro

vira

l The

rapy

in H

IV a

nd H

epat

itis

B C

oinf

ectio

n)

/

H

IV

Bac

kbon

e: T

enof

ovir

(TDF)

+ L

amivud

ine

(3TC

)

Em

tricita

bine

(FTC

)

3TC

F

TC

T

DF

HBV

F

TC, 3

TC

TDF

h

epat

ic fl

are

ente

cavir

(

3TC

ente

cavir

1

mg/

day)

h

epat

ic fl

are

/

HIV

F

TC, 3

TC

TDF

TDF,

3TC

FTC

T

DF

T

DF

FTC

3TC

A

ZT

d4T

TDF

V

L <

50 c

opies/

mL

FTC

, 3TC

TDF

eG

FR

9

e

GFR

< 3

0 m

l/min/1

.73

m2

ente

cavir (

3TC

ente

cavir

1

mg/

day)

T

DF

84 85

/

(

)

TDF

aba

cavir

liver

ultr

asou

nd

> 4

0

> 5

0

16

(Con

side

ratio

n an

d Con

traindi

catio

ns in

Hep

atitis

C In

fect

ion

Trea

tmen

t)

*

18

6

H

CV

RNA

5,0

00 IU

/mL

3

H

IV R

NA

100

,000

copi

es/m

l

CDC c

ateg

ory

B,

C

W

HO sta

ge 3

, 4

CDC c

ateg

ory

B,

C

W

HO sta

ge 3

, 4

< 1

1 -

< 3

3 -

< 5

5

- 1

5

C

D4

%CD4

CD4

CD4

CD4

< 25

%

< 1,

000

cells

/mm

3

CD4

< 25

%

< 75

0 ce

lls/m

m3

-

CD4

< 35

0

cells/m

m3

-

CD4

350-

500

cells

/mm

3

*

< 1

*

> 1

%

CD4

15

-24%

C

D4

%CD4

3

%CD4

15

88 89

2

< 1

1 -

< 3

3 -

12

> 1

2

(pre

ferred

reg

imen

s)

AZT

(

ABC* ) +

3TC +

LPV/

r**AZT

(

ABC* ) +

3TC +

LPV/

r

AZT

(

ABC* )

+

3TC +

EFV

$TD

F +

3TC +

EFV

$

(alte

rnat

ive re

gim

ens)

AZT

(

d4T

# ) +

3TC +

NVP

@-

AZT

(

ABC* )

+ 3T

C +

NVP

- d4T

# + 3TC

+

LPV/

r (

N

VP)

- AZT

+ 3

TC +

NVP

- TD

F +

3TC +

EFV

(

NVP

)

- d4

T#+

3TC +

EFV

(

NVP

)

- AZT

+ 3

TC +

EFV

(

NVP

)

- ABC +

3TC

+ E

FV

(

NVP

)

* Aba

cavir

(ABC)

> 3

h

yper

sens

itivity

HLA

-B*5

701

(

4.0)

ABC

HLA

-B*5

701

A

BC

6

2

(

1)

(2)

(3)

(4)

cre

atine

phos

phok

inas

e

lym

phop

enia

** Lo

pina

vir/rit

onav

ir (L

PV/

r)

1

4

4

2

LPV/

r

3

NVP

L

PV/

r

1

2

H

IV R

NA 1,000 copies/mL

genotyping

94 95

4

(firs

t-lin

e re

gim

en)

(sec

ond-

line

regi

men

)

(sa

lvag

e re

gim

en)

g

enot

ype

AZT

+ 3

TC +

NVP

or

EFV

TDF

+ 3T

C +

LPV/

r1

1 NRTI

+ D

RV/

r

(ETR

/

RAL

/

MVC

)

TDF

ABC +

3TC

+

NVP

EFV

AZT

+ 3

TC +

LPV/

r2

1 NRTI

+ D

RV/

r

(ETR

/

RAL

/

MVC

)

AZT

+ 3

TC +

LPV/

r

NNRTI

:

TDF

+ 3T

C +

EFV

3 (

D

RV/

r

NRTI

)

NNRTI

:

TDF

+ 3T

C +

DRV/

r

1

NRTI

+ b

oost

ed P

I

(ETR

/

RAL

/

MVC

)

(firs

t-lin

e re

gim

en)

(sec

ond-

line

regi

men

)

(sa

lvag

e re

gim

en)

g

enot

ype

ABC +

3TC

+ L

PV/

r

NNRTI

:

TDF

+ AZT

+ EF

V4 (

D

RV/

r

NRTI

)

NNRTI

:

TDF

+ AZT

+ D

RV/

r

1

NRTI

+ b

oost

ed P

I

(ETR

/

RAL

/

MVC

)

1

TD

F +

AZT

TDF

+ ABC

B

oost

ed P

I

A

TV/r

2

ABC +

3TC

ABC

B

oost

ed P

I

A

TV/r

3

TD

F +

AZT

ABC

T

DF

TDF

2

4

TD

F +

3TC

AZT

+ 3

TC

K

65R

96 97

5

Nuc

leos

ide

analog

ue rev

erse

tra

nscr

ipta

se in

hibi

tor (N

RTI

)

Zido

vudi

ne (A

ZT)

:

10

mg/

mL

(

60

mL)

: 10

0 m

g

: 30

0 m

g

6

(

):

180-

240

mg/

m2 /do

se

12

.

(

300

mg/

dose

)

> 4

(

)

:4

- <

9 kg

: 12

mg/

kg

12

.

9-30

kg:

9 m

g/kg

12

.

30

kg:

300

mg

12

.

-

-

-

Lam

ivud

ine

(3TC

):

10

mg/

mL

(

60

mL)

: 15

0, 3

00 m

g

4

4 m

g/kg

12

. (

150

mg/

dose

)

16

50

kg

300

mg

-

(

30

)

-

AZT

+ 3

TC (fi

xed

dose

com

bina

tion)

: AZT

300

mg

+ 3T

C 1

50 m

g

30

kg

1

12

.

30

-60

kg

A

ZT

2

00 m

g/do

se

Sta

vudi

ne (d

4T)

:

1 m

g/m

L

: 15,

20,

30

mg

1

4

1 m

g/kg

12

.

(

30

mg/

dose

)-

30

Aba

cavir (A

BC)

:

20

mg/

mL

: 30

0 m

g8

mg/

kg

12

.

(

300

mg/

dose

)1

6

600

mg

24

.

-

Teno

fovir (T

DF)

: 30

0 m

g2-

< 1

2 8

mg/

kg

24

.

12

30

kg 3

00 m

g

24

.

Teno

fovir

14

- 25

-35

kg L

PV/

r 30

0/75

mg

12

.

-

(

> 25

C)

-

LPV/

r

LPV/

r

H

IV

RNA

< 50

cop

ies/

mL

> 25

-35

kg: LP

V/r 20

0/50

mg

12

.

Lopi

navir

+ rit

onav

ir (L

PV/

r) (

)

> 35

kg

LPV/

r 40

0/10

0 m

g

12

.

HIV

RNA

35-5

0 kg

: LP

V/r 30

0/75

mg

12

.

>

50 k

g: L

PV/

r 400

/100

mg

12

.

Ata

zana

vir (A

TV)

: 10

0, 1

50, 20

0,

300

mg

> 6

24

.

RTV

100

mg

15 -

< 20

kg

ATV

150

mg/

r 100

mg

20 -

< 32

kg

ATV

200

mg/

r 100

mg

32 -

< 40

kg

ATV

250

mg/

r 100

mg

40

kg

ATV

300

mg/

r 10

0 m

g

-

asym

ptom

atic in

dire

ct

hy

perb

ilirub

inem

ia

.

ATV

200

m

g

30

0 m

g

20-5

0 kg

AT

V 20

0 m

g/r 1

00

mg

104 105

Dar

unav

ir (D

RV)

: 7

5, 1

50, 4

00, 6

00

mg

3

2

15

- <

30 kg

DRV

375

mg/

r 50

mg

30 -

< 40

kg

DRV

450

mg/

r 60

mg

> 40

kg

ATV

600

mg/

r 10

0 m

g

.

300

mg

12 -

< 15

kg

DRV

300

mg

+ RTV

50

100

mg

12

.

15

- 1

2

> 25

kg

Film

-coa

t tab

let

400

mg

1

2

106 107

6

1)

LP

V/r

1-

6

LPV/

r

1

6)

se

rum

lact

ate

> 5

mm

ol/L

ro

utine

seru

m la

ctat

e

IV

fluid

NRTI

s

TDF

seru

m

lact

ate

fluor

ide-

oxalat

e

tube

4

.

ABC

AZT

3TC

Panc

reatitis

NRTI

s

ddI,

d4T

3

TC

Ser

um a

mylas

e

lipas

e

ro

utine

seru

m a

mylas

e

lipas

e

seru

m a

mylas

e

ddI

d4T

110 111

N

RTI

s

A

ZT

ABC

Perip

heral

neuro

pathy

d4T,

ddI

hypo

refle

xia

d4T

ddI

N

RTI

s

AZT

ABC

3)

Fat m

aldistr

ibution

N

RTI

s

d4T

P

Is

bo

oste

d PIs

lip

ohyp

ertro

phy

P

Is

d4T

(

wai

st-

to-h

ip rat

ioz-

scor

e) >

3.5

BM

I

/

P

Is

NNRTI

d4T

wai

st-t

o-hip

ratio

(

)

ht

tp://

ww

w.

rihes

.cm

u.a

c.th

/Ped

_HIV

/10-

BM

I-W

HR

_z_score

/ inde

x.ht

m

112 113

Fat m

aldistr

ibution

()

lip

oatro

phy

N

RTI

s

d4T

ddI

AZT

/

d

4T

AZT

ABC

T

DF

4)

met

abol

ic s

yndr

ome

insu

lin res

ista

nce

( ty

pe 2

diabe

tes

im

paire

d fa

sting

gluc

ose

10

0 m

g/dL

impa

ired

gluc

ose

tolera

nce

test

)

2

130

/85

mm

Hg

BM

I

(trig

lyce

rides

1

50

mg/

dL

HDL

chol

este

rol

126

mg/

dL

ra

ndom

BS >

200

mg/

dL

or

al

gluc

ose ch

alleng

e te

st (O

GTT

)

FB

S

6

3

60

114 115

Insu

lin re

sist

ance

FB

S 1

00-1

25

mg/

dL

10

im

paire

d O

GTT

met

form

in

Hype

rlipide

mia

P

Is

N

NRTI

s

EFV

NVP

N

RTI

s

d4T

Cho

lest

erol

,

LDL

athe

rosc

lero

sis

TG

panc

reat

itis

Fa

sting

chol

este

rol

> 20

0 m

g/dL

Fa

sting

LDL

> 13

0 m

g/dL

Fa

sting

TG

> 20

0 m

g/dL

fa

sting

chol

este

rol,

HDL,

LDL

TG

6

6

-12

TG

> 50

0 m

g/dL

ARV

ATV/

r

NNRTI

s

Fib

rate

T

G

> 50

0 m

g/dL

gem

fibro

zil

150-

300

mg

2

Sta

tin

Pra

vast

atin

8-1

3

20

mg

14-

18

116 117

F

ibra

te

8-

10

LDL

> 19

0m

g/dL

LDL

> 16

0 m

g/dL

stat

in

40

mg

1

0 m

g

4

at

orva

stat

in

> 6

10

-20

mg

5)

(hepa

totox

icity)

ARV

N

NRTI

s

(NVP

EFV)

liver

enz

yme

(

)

NVP

ALT

/

AST

10

uppe

r

norm

al li

mit

AST

/

ALT

ARV

6

NVP

2

-4

NVP

NVP

ALT

AST

>

5-1

0

uppe

r

norm

al lim

it

ARV

fluco

nazo

le

hepa

titis A

, B,

C, EB

V, C

MV

118 119

hype

rsen

sitiv

ity

NRTI

s

lact

ic

acid

osis

6

ALT

AST

5-1

0

uppe

r

norm

al li

mit

lact

ic a

cido

sis

AZT

, d4

T, d

dI

Indire

ctHy

perbil

irubine

mia

IDV,

ATV

liver

enz

yme

bilir

ubin

indi

rect

bilirub

in

/

AZT

P

Is

/

ARV

adhe

renc

e

/

120 121

P

Is

buffe

red

ddI

/

6)

A

ZT

he

art

failu

re

Hb

< 7-

8 g/

dL

AZT

CBC

6

A

ZT

CBC

3

6

6

MAC, TB

AZT

A

RV

d

4T

TDF

122 123

(neutr

open

ia)

A

ZT

abso

lute

neut

roph

il

( 12 - 59

Booster 12-18

2

PCV

2 - 6 3

6-8

12-15

7 - 11 2

6-8

12-15

12 - 23 2

6-8

24 - 59

-

-

1

2

6-8

PPSV2

3 2

5

6

134 135

1. BCG

BCG

BCG BCG

2.

DTP-HBV

2, 4, 6

3. DTwP DTaP (Tdap)

7 1

4. IPV OPV

IPV

5. --

(clinical stage C CD4

15) CD4 15

- 9 -12

2 4-6

( 9 )

1

( 12 )

1

- 2 2

-

4

3

- --

- (MMRV)

6. 3

1 0, 1 , 1

1 3 4-5

(

6 CD4 > 15%

2 3-12 )

7. 2

1 12-18

2

Hib

8.

1 2 6-12

9. 1

CD4 15 2 dose

1 2 4-6

2 4

3

136 137

10.

9 2 1

3

dose (0.25 .)

11. (PCV)

2 3 2

12-15

PCV

PPSV23 2 PCV

2 PPSV23

1 5 14-59

PCV7 4

PCV13 1 PCV7

8

6-18 PCV13

1 dose PCV7 PPSV23

12. 3 0, 1-2, 6

9 26

11-12

13. 2, 4

( 6 pentavalent vaccine)

8

CD4

15

1

2

6

HBV vaccine1 HBV1 HBV2 HBV3 3

JE vaccine

()2JE1 JE2 2

Measles vaccine3 MMR1 1

dT vaccine

> 7 4 10

1.

1

3 dose

()

CD4 15%

1 anti-HBs Ab > 10 mIU/ml 2

anti-HBs Ab

138 139

anti-HBs Ab < 10 mIU/mL

3 dose (

)

anti-HBs Ab 10-100 mIU/mL

1 dose

CD4

anti-HBs Ab > 100 mIU/mL

2.

2 dose 1

CD4

6

1

3. --

1 CD4

6 MMR

4. -- (DTwP, DTaP Tdap)

< 7 DTwP DTaP

7 dT Tdap

140 141

1

3

2

sam

e da

y te

st res

ult

3

CD4

-

-

-

-

1

PM

TCT

windo

w p

erio

d

-

windo

w p

erio

d

1

-

-

-

C

D4

(

/

)

142 143

2

1

Reactive(a)

(c)

Positive

Positive

2 1 3

(b) (b)

Negative

Anti-HIV

Negative

window period 1

Non Reactive(a)

2(a)

(rapid test)

(b)

rapid test

anti-HIV

rapid test

48

(c)

rapid test

144 145

1

Antepartum Intrapartum PostpartumNewborn

( + )

1 HAART

( CD4@)

: TDF (300 mg) + 3TC (300 mg)

+ EFV (600 mg)

#

: (AZT + 3TC) 1 + LPV/r (200/50)

2 12 .

: TDF (300 mg) + 3TC (300 mg)

+ LPV/r (200/50) 2

12 .

+

AZT* 300 mg 3 . 600

mg

$

o LPV/r-based

HAART

o TDF + 3TC +

EFV

EFV TDF +

3TC 7-10

AZT (syr) 4 mg/kg

12 . 4

(

1 .

)

3

(

6

3

3)

146 147


( + )

2 HAART

VL < 50 copies/mL

+

AZT* 300 mg

3 . 600

mg

EFV

3 (No ANC)

2 . AZT 300 mg

3 . 600

mg

AZT (syr) 4 mg/kg

12 . + 3TC

(syr) 2 mg/kg

12 .+ NVP (syr)

4 mg/kg 24

. 6

3

148 149


( + )

2 . AZT 300 mg

3 . 600

mg +

NVP 1

(SD NVP)

TDF + 3TC +

EFV

CD4 > 500 cell/mm3

$

AZT + 3TC + LPV/r

4 (tail)

3

@ CD4 < 200 cells/mm3 TMP-SMX 2 24

.# LPV/r-based HAART 1)

NNRTI

AZT+SD NVP

2) CD4 > 500 cells/mm3

tail

regimen NNRTI

* AZT VL < 50 copies/mL$

/ : CD4

< 500 cell/mm3,

,

150 151

2

HAART

AZT

TDF

(300

mg

24

)

TDF

AZT

(300

mg

12

)

LPV/

r

EFV

(600

mg

24

)

EFV

LPV/

r (2

00/5

0) 2

12

LPV/

r

EF

VNVP

CD4

coun

t

< 25

0 ce

ll/m

m3

C

D4

> 25

0 ce

ll/m

m3

NVP

LPV,

EFV

, NVP

boos

ted

ataz

anav

ir (A

TV/r

300

/100

mg

)

EFV,

LPV/

r, NVP

ATV

/r

A

ZT m

onot

hera

py

A

ZT

NVP

200

mg

1

(SD N

VP)

(HAART)

tail r

egim

en

T

ail

regi

men

*

NVP

* Ta

il re

gim

en:

AZT

+ 3

TC

7

AZT

+ S

D N

VP

4

tai

l

regi

men

A

ZT +

3TC

+ L

PV/

r

4

152 153

3

(g)

AZT

(10

mg/

mL)*

3TC

(10

mg/

mL)

NVP

(10

mg/

mL)

(

)

4 m

g/kg

1

2

2 m

g/kg

1

2

4 m

g/kg

(sim

plifi

ed d

osin

g)

4000

- 4

499

18

. (1

.8 m

L

)

9 .

(0.9

mL

)

18

. (1

.8 m

L

)

3500

- 3

999

16

. (1

.6 m

L

)

8 .

(0.8

mL

)

16

. (1

.6 m

L

)

3000

- 3

499

14

. (1

.4 m

L

)

7 .

(0.7

mL

)

14

. (1

.4 m

L

)

2500

- 2

999

12

. (1

.2 m

L

)

6 .

(0.6

mL

)

12

. (1

.2 m

L

)

2000

- 2

499

10

. (1

.0 m

L

)

5 .

(0.5

mL

)

10

. (1

.0 m

L

)

1500

- 1

999

8 .

(0.8

mL

)

4 .

(0.4

mL

)

8 .

(0.8

mL

)

*

3

0-35

:

AZT

2

mg/

kg

12

.

8

.

2

*

32 )

()

window

period

no ANC

window period

GA < 36 GA > 36

156 157

HAA

RT

4

HAART

CD4

coun

t

6

Vira

l loa

d-

3

6

*

4

CBC

Hb

< 8

g/dL

Hct

< 2

4%

AZT

TDF

A

ZT 4

-8

Hb

< 8

g/dL

Hct

< 2

4%

A

ZT T

DF

Cre

atinine

c

reat

inine

clea

ranc

e <

50

mL/

min

T

DF

T

DF

3

6

c

reat

inine

clea

ranc

e <

50

mL/

min

TDF

A

ZT

ALT

2.5

uppe

r lim

it

N

VP

2.5

uppe

r lim

it

N

VP

E

FV

LPV/

r

158 159

Urin

e su

gar

u

rine

suga

r

LPV/

r

E

FV

50 g

GCT**

LPV/

r

bloo

d su

gar

14

0

mg/

dL

100

g O

GTT

***

LPV/

r

2

4-28

L

PV/

r

4

b

lood

sug

ar

14

0 m

g/dL

100

g O

GTT

*

HAART

8

-12

V

L <

1,00

0 co

pies

/mL

VL

3

6

4

VL >

1,00

0 co

pies

/ml

V

L >

50 c

opies/

ml

3

A

ZT/3

TC/N

VP

6

** 50

g G

CT

(gluco

se c

halle

nge

test

)

gluco

se

50

g

50%

gluc

ose

100

mL

b

lood

gluco

se

gluco

se 1

*** 1

00 g

OG

TT (o

ral g

luco

se to

lera

nce

test

)

8

f

astin

g bl

ood

gluc

ose

gluco

se

100

g

bloo

d gl

ucos

e 1

, 2

3

gluco

se

160 161

5

(artificial rupture of membranes)

4

(elective

caesarean

section)

4 .

38

38

VL 36

> 1,000 copies/mL

4

VL

(emergency

caesarian

section)

1. methergin

ergotamines

protease inhibitor EFV protease inhibitor

potent CYP3A4 enzyme inhibitors

ergotamines

vasoconstriction EFV

CYP3A4 enzyme inhibitors inducer

methergin

2. AZT 600 mg

( NVP 200 mg )

4

(prophylactic antibiotic)

ampicillin cefazolin

162 163

1 3

18

TMP-SMX prophylaxis ( TMP 150 mg/m2/day

SMX 750 mg/m2/day) 3

4-6

PCR

1

( :

)

AZT + 3TC + LPV/r

AZT + 3TC + NVP

NVP LPV/r

( :

)

6

*@

(standard

risk)

(HAART)

> 4

50 copies/mL

HIV DNA PCR

2 1

2-4

#

AZT

4

(high risk)

4

> 50 copies/mL

HIV DNA PCR

3 1, 2 4 3

(AZT + 3TC + NVP)

1

3

6

* (dried blood spot)

(

164 165

)

HIV DNA PCR 1-2

DNA PCR

@

anti-HIV 18

( :

)# 1

HIV DNA PCR

2

6-9

12

directly observed therapy

CD4 50 cells/mm3 2

CD4 > 50 cells/mm3

2

2-8

rifampicin

rifampicin

EFV EFV

NVP RAL

PI

rifampicin

166 167

co-trimoxazole Pneumocystis

pneumonia (PCP)

CD4 < 200 cells/mm3 %CD4 < 14

oropharyngeal candidiasis AIDS-defining

illness () PCP

primary prophylaxis

cryptococcosis, penicilliosis, histoplasmosis

Mycobacterium avium complex (MAC)

CD4 (

prophylaxis)

1

Tube

rculos

isDru

g su

scep

tible

2

HRZE

/4-7

IRIson

iazid

5-8

mg/

kg(3

00 m

g) P

O

Rifa

mpi

cin

10 m

g(450

-600

mg) P

O

Etha

mbu

tol 1

5-20

mg

(800

-1,2

00 m

g)PO

Pyr

aido

xine

20-

30 m

g(1

,000

-2,0

00 m

g)PO

Sec

ond

line

drug

Stre

ptom

ycin 1

5 m

g/kg

(

1

,000

mg)

IM

Kan

amyc

in 1

5 m

g/kg

(

1

,000

mg)

IM

Am

ikac

in 1

5 m

g/kg

(

1

,000

mg)

IM

Ethion

amid

e 15

mg/

kg (5

00-7

50 m

g/da

y) P

O

2

-3

Cyc

lose

rine

10 m

g/kg

(500

-750

mg/

day) P

O

2

-3

4-

aminos

alicyli

c ac

id (P

AS) 2

00 m

g/kg

(8,0

00-1

2,00

0 m

g/da

y) P

O

2

Oflo

xacin

600-

800

mg/

day

PO

Levo

floxa

cin

500-

750

mg/

day

PO

Mox

iflox

acin 4

00 m

g/da

y PO

(

.. 2

555

)

168 169

Pneu

mocys

tis pn

eum

onia

(PCP)

Tr

imet

hopr

im-s

ulfa

met

hoxa

zole

(TM

P-S

MX)

TM

P 1

5-20

mg/

kg/d

ay

S

MX

75-1

00

mg/

kg/d

ay

3

-4

21

Clin

dam

ycin 6

00 m

g IV

6

.

9

00 m

g IV

8

.

300

mg

PO

6

.

450

mg

PO

8

. +

Prim

aquine

30

mg

PO

21

Pen

tam

idine

iset

hion

ate

3-4

mg/

kg

IV

21

TM

P -

SM

X

(80-

400

mg

sing

le s

treng

th,

SS T

ablet)

PO

2

Dap

sone

100

mg

PO

Cry

ptoc

occo

sis

(cry

ptoc

occa

l

men

ingi

tis

diss

eminat

ed)

Indu

ctio

n ph

ase:

Am

phot

ericin B

0.7

-1.0

mg/

kg/

day IV

+ fluc

onaz

ole

800

mg/

day

IV

P

O

1

4

Am

phot

ericin B

1.0

mg/

kg/d

ay

IV

1

4

Fluc

onaz

ole

1,20

0 m

g/da

y IV

PO

14

Fluc

onaz

ole

200-

400

mg

PO

Itr

acon

azole

200

mg

PO

Con

solid

atio

n ph

ase:

Fluc

onaz

ole

400-

800

mg/

day

PO

8-1

0

Itr

acon

azol

e 40

0 m

g/da

y PO

8-1

0

Can

didi

asis

Oro

phar

ynge

al

cand

idiasis

Clo

trim

azol

e or

al tr

oche

s 10

mg

4

-5

7

-14

Fluc

onaz

ole

100

mg/

day

Po

7-1

4

Nys

tatin

ora

l sol

utio

n 50

0,00

0

5

7-1

4

Itr

acon

azol

e ca

psule

100

mg/

day

PO

7-1

4

Itr

acon

azol

e or

al s

olut

ion

100

mg/

day

PO

7-1

4

Am

phot

ericin B

0.3

-0.5

mg/

kg/d

ay IV

7-1

4

170 171

Es

opha

geal

cand

idiasis

Cer

vicov

aginal

cand

idiasis

Fluc

onaz

ole

200

mg/

day

Po

14-

21

Clo

trim

azol

e va

gina

l cre

am5

mg/

day

Clo

trim

azol

e va

gina

l sup

posito

ry tab

let 10

0 m

g

3-7

Fluc

onaz

ole 20

0 m

g Po

Itrac

onaz

ole ca

psule 40

0 m

g/da

y

2

14-

21

Itr

acon

azol

e or

al s

olut

ion

400

mg/

day

2

14-

21

Am

phot

ericin B

0.3

-0.5

mg/

kg/d

ay IV

14-

21

M

icon

azol

e cr

eam

5 m

g/da

y

micon

azol

e va

gina

lsu

ppos

itory

tab

let 10

0 m

g

7

Itrac

onaz

ole

caps

ule

200

mg/

day

PO

3

Itrac

onaz

ole

oral s

olut

ion

200

mg/

day

PO

3

Toxo

plas

mos

is

Pyr

imet

ham

ine

200

mg

1

50

mg/

day

(. 6

0

kg)

75

mg/

day

(. >

60

kg)

+ s

ulfa

diaz

ine

1,00

0 m

g

(.

6

0 kg

)

1,5

00 m

g

(.

> 60

kg)

4

+

folin

ic a

cid

10-2

5 m

g/da

y

6

TM

P-SM

X (TM

P 5-

10 m

g/kg

/day

)

IV o

r PO

2

6

Pyr

imet

ham

ine

+ c

linda

myc

in 6

00 m

g

6

Pyr

imet

ham

ine

+

azith

rom

ycin

1,00

0-1,

250

mg/

day

Pyr

imet

ham

ine

25-5

0 m

g/da

y +

sulfa

diaz

ine

500-

1,00

0 m

g

4

+

folin

ic a

cid

10-2

5 m

g/da

y

Pyr

imet

ham

ine

25-5

0 m

g/da

y +

clinda

myc

in 6

00

mg

PO

8

.

+ fo

linic a

cid

TM

P-S

MX

SS

tabl

et 2

P

O

172 173

Pen

icilli

osis/

Histo

plas

mos

is

Indu

ctio

n ph

ase

Am

phot

ericin B

0.6-

0.7

mg/

kg/d

ay IV

Con

solid

atio

n ph

ase

Itr

acon

azol

e 20

0 m

g PO

2

1

0-12

Itr

acon

azol

e 20

0 m

g PO

3

3

200

mg

2

14

Am

phot

ericin B

0.4

-0.5

mg/

kg/d

ay IV

10-1

2

Fluc

onaz

ole

800

mg

PO

10-

12

Itr

acon

azole

200

mg

PO

Fluc

onaz

ole

400

mg

PO

Am

phot

ericin B

0.6-

0.7

mg/

kg/d

ay

IV

CM

V

Gan

ciclov

ir 5

mg/

kg

12

.

IV

2

-3

Va

lgan

ciclov

ir 90

0 m

g PO

2

2

-3

G

anciclov

ir intra

vitre

ous 2,

000

g/d

ose

1

G

anciclov

ir im

plan

t

6-8

Va

lgan

ciclov

ir

900

mg

PO

G

anciclov

ir 5

mg/

kg IV

G

anciclov

ir

intra

vitre

ous

2,00

0 g

1

2-4

MAC

Clarit

hrom

ycin 5

00 m

g PO

2

+

eth

ambu

tol 1

5

mg/

kg/d

ay

Azith

rom

ycin 5

00 m

g PO

+ e

tham

buto

l 15

mg/

kg/d

ay

174 175

Quino

lone

s:

cipr

oflox

acin 5

00-7

50 m

g

PO

2

levo

floxa

cin

500

mg

PO

m

oxiflox

acin 4

00 m

g

PO

amikac

in 1

5 m

g/kg

IV

IM

176 177

2

Tube

rculos

isDru

g-su

scep

tible

TB

Inte

nsiv

e ph

ase

IN

H 1

0-15

mg/

kg/d

ose

(

3

00 m

g)

Rifa

mpi

cin

10-2

0 m

g/kg

/dos

e (

6

00 m

g)

Pyr

azinam

ide

30-4

0 m

g/kg

/dos

e (

2

,000

mg)

Et

ham

buto

l 15-

20 m

g/kg

/dos

e (

1

,000

mg)

PI

rifam

picin

q

uino

lone

s

am

inog

lyco

side

Con

tinua

tion

phas

e

INH 1

0-15

mg/

kg/d

ose

(

3

00 m

g)

Sec

ond-

line

drug

Am

ikac

in 1

5 m

g/kg

/dos

e (

1

,000

mg)

Kan

amyc

in 1

5 m

g/kg

/dos

e (

1

,000

mg)

O

floxa

cin

15-2

0 m

g/kg

/dos

e (

8

00 m

g)

Lev

oflox

acin 7

.5-1

0 m

g/kg

/dos

e(

7

50 m

g)

Et

hion

amid

e 15

-20

mg/

kg/d

ay (

1

,000

mg)

2-3

Cyc

loce

rine

10-2

0 m

g/kg

/dos

e (

1

,000

mg)

1-2

Par

a-am

inos

alicylic a

cid

200-

300

mg/

kg/

day

(

1

0 g)

3-4

Rifa

mpi

n 10

-20

mg/

kg/d

ose

(

6

00 m

g)

2

6

-9

m

iliary

1

2

PI

cont

inua

tion

phas

e

rifam

picin

q

uino

lone

s

pyr

azinam

ide

etha

mbu

tol

1

2-18

p

redn

isolon

e 2

mg/

kg/d

ay (

6

0 m

g)

4

-6

m

iliary

e

ndob

ronc

hial T

BDru

g-re

sist

ant TB

(

)

3-6

18-2

4

(sec

onda

ry p

roph

ylax

is)

178 179

(sec

onda

ry p

roph

ylax

is)

PCP

TM

P-S

MX

TM

P 1

5-20

mg/

kg/d

ay

S

MX

75-1

00

mg/

kg/d

ay

1

.

4

21

seco

ndar

y pr

ophy

laxis

Pen

tam

idine

iset

hion

ate

4

mg/

kg/d

ay

60-

90

daps

one

2

mg/

kg/d

ay

ato

vaqu

one

30-4

0

mg/

kg/d

ay

1-2

21

TM

P 5

mg/

kg

150

mg/

m2 /da

y

SM

X

750

mg/

m2 /da

y

(

T

MP 3

20

mg

SM

X

1,60

0 m

g)

1

-2

3

Dap

sone

2 m

g/kg

(

1

00 m

g)

4 m

g/kg

(

2

00 m

g)

(sec

onda

ry p

roph

ylax

is)

c

ortic

oste

roid

s

P

aO2

70

mm

Hg

roo

m a

ir

alveo

lar- a

rteria

l (A-a

) gr

adient

35 m

mHg

7

2

pre

dnison

e 1

mg/

kg/d

ose

2

1

-5

0.5

1 m

g/kg

/dos

e

2

6

-10

0.5

mg/

kg/d

ose

1

1-21

met

hylp

redn

isol

one

1 m

g/kg

/dos

e

6

1-7

1 m

g/kg

/dos

e

2

8

-9

0.5

mg/

kg/d

ose

2

1

0-11

1 m

g/kg

/dos

e

1

216

TMP-S

MX

rapi

d de

sens

itiza

tion

180 181

(sec

onda

ry p

roph

ylax

is)

Cry

ptoc

occo

sis

Lo

caliz

ed

dise

ase,

isol

ated

pulm

onar

y di

seas

e

Fluc

onaz

ole

12 m

g/kg

/dos

e

6-1

2 m

g/kg

/dos

e (

6

00 m

g)

CNS

dise

ase,

Disse

minat

edIn

duct

ion

ther

apy:

Amph

oter

icin B

1-1

.5 m

g/kg

/dos

e

fl

ucon

azol

e 12

mg/

kg/d

ose

10-

12 m

g/kg

/dos

e (

8

00 m

g)

14

Con

solid

atio

n th

erap

y

Fluc

onaz

ole

12 m

g/kg

/dos

e

10-

12

mg/

kg/d

ose

(

8

00 m

g)

8

se

cond

ary

prop

hylaxis

Fluc

onaz

ole

6 m

g/kg

(

2

00 m

g)

Itr

acon

azol

e5

mg/

kg(

2

00 m

g)

(sec

onda

ry p

roph

ylax

is)

Can

didi

asis

Oro

phar

ynge

al

cand

idiasis

Es

opha

geal

cand

idiasis

Clo

trim

azol

e tro

ches

10

mg

4-5

Nys

tatin

46

mL

4

-5

fluco

nazo

le 6

12

mg/

kg/d

ose

(

4

00 m

g)

7-1

4

Fluc

onaz

ole

6-12

mg/

kg/d

ose

(

6

00 m

g)

itra

cona

zole 2

.5

mg/

kg/d

ose

2

3

Itr

acon

azol

e (

) 2.5

mg/

kg/d

ose

2

ket

ocon

azol

e 5-

10

mg/

kg/d

ay

1-2

Am

phot

ericin B

0.3

0

.7

mg/

kg/d

ose

Fluc

onaz

ole

3-6

mg/

kg (

200

mg)

Itr

acon

azol

e

5 m

g/kg

(

2

00 m

g)

182 183

(sec

onda

ry p

roph

ylax

is)

Toxo

plas

mos

is

Con

genita

l

toxo

plas

mos

is

Pyr

imet

ham

ine

2 m

g/kg

/dos

e

2

1 m

g/kg

/dos

e

2-6

1 m

g/kg

/dos

e

3

s

ulfa

diaz

ine

50 m

g/k

g/d

ose

2

fo

linic a

cid

10 m

g/da

y

1

2

sulfa

diaz

ine

clinda

myc

in 5

-7.5

mg/

kg/d

ose

(

6

00

mg/

dose

)

4

pyrim

etha

mine

folin

ic

acid

TM

P 5

-10

mg/

kg/d

ay

SM

X 25

-50

mg/

kg/d

ay

2

Sulfa

diaz

ine

85 -1

20 m

g/kg

/day

2

-4

pyrim

etha

mine

1 m

g/kg

15

mg/

m2 (

2

5

mg)

folin

ic a

cid

5 m

g

3

Clin

dam

ycin

20-3

0 m

g/kg

/day

4

pyrim

etha

min

e

1 m

g/k

g

fol

inic

acid

5 m

g

3

(sec

onda

ry p

roph

ylax

is)

Acq

uire

d

CNS o

cular

sys

tem

ic

toxo

plas

mos

is

Pyr

imet

ham

ine

2 m

g/kg

/dos

e (

5

0 m

g)

3

1

mg/

kg/d

ose

(

2

5 m

g)

sulfa

diaz

ine

25-5

0 m

g/kg

/dos

e (

1-1.

5 g/

dos

e)

4

folin

ic a

cid

10-2

5 m

g/da

y

6

d

exam

etha

sone

C

SF

prot

ein

( >

1,00

0 m

g/dL

)

(

pyrim

etha

min

e

CBC

)

TM

P 5

mg/

kg

150

mg/

m2 /da

y

S

MX

750

mg/

m2 /da

y (

TM

P 3

20

mg

SM

X

1,60

0 m

g)

1

-2

3

184 185

(sec

onda

ry p

roph

ylax

is)

Pen

icilli

osis

Am

phot

ericin B

0.7

mg/

kg/d

ose

2

(

)

itrac

onaz

ole 10

mg/

kg/d

ay

2

1

0

Itr

acon

azol

e

5 m

g/kg

Fluc

onaz

ole

6

mg/

kg

(

2

00 m

g)

Cytom

egalo

virus

(CM

V)

Con

genita

l

CM

V

G

anciclov

ir 6

mg/

kg/d

ose

12

.

6

G

anciclov

ir 5

mg/

kg/d

ose

57

(sec

onda

ry p

roph

ylax

is)

Disse

minat

ed

CM

V or

CM

V

retin

itis

G

anciclov

ir 5

mg/

kg/d

ose

12

.

2-3

5 m

g/kg

/dos

e

5

7

s

econ

dary

pro

phylax

is

Myco

bacte

rium

avium

com

plex

(MAC

) (

seve

re

diss

eminat

ed

dise

ase)

Clarit

hrom

ycin 7

.5-1

5

mg/

kg/d

ose (

500

mg/

dose

)

2

etha

mbu

tol 1

5-25

mg/

kg/d

ose

(

2

,500

mg)

1

Azith

rom

ycin 1

0-12

mg/

kg/d

ose

(

5

00 m

g)

clar

ithro

myc

in

186 187

(sec

onda

ry p

roph

ylax

is)

Disse

minat

ed

dise

ases

quinolon

e

c

ipro

floxa

cin

10-1

5 m

g/kg

/dos

e (

1

,500

mg)

2

levo

floxa

cin

500

mg

amikac

in 1

5-30

mg/

kg/d

ose

(

1

,500

mg)

3

C

D4

PCP

CD4

> 20

0 ce

lls/m

m3

3

CD4

> 20

0 ce

lls/m

m3

3

Toxo

plas

mos

isCD4

> 20

0 ce

lls/m

m3

3

CD4

> 20

0 ce

lls/m

m3

6

Cry

ptoc

occo

sis

CD4

> 10

0 ce

lls/m

m3

3

*

sec

onda

ry p

roph

ylax

is

1

CD4

1

00 c

ells/m

m3

3

Pen

icilli

osis/

Histo

plas

mos

is

CD4

> 10

0-15

0 ce

lls/m

m3

6

*

CD4

> 10

0 (

pen

icilli

osis)

>

150

(

h

isto

plas

mos

is) c

ells/m

m3

6

MAC

CD4

> 10

0 ce

lls/m

m3

3

*

MAC

1

2

CD4

> 10

0 ce

lls/m

m3

6

CM

V re

tinitis

CM

V re

tinitis

3-6

CD4

> 10

0 ce

lls/m

m3

3-6

*

prim

ary

prop

hylaxis

188 189

4

CD4

PCP

< 1

:

1-5

: C

D4

5

00 c

ells/m

m3

15%

3

6

: CD4

2

00 c

ells/m

m3

1

5%

3

6

< 1

:

1-5

: CD4

> 50

0 ce

lls/m

m3

15

%

3

6

: CD4

> 20

0 ce

lls/m

m3

1

5%

3

(

p

rimar

y pr

ophy

laxis)

Toxo

plas

mos

is<

1 :

1 -

< 6

: CD4

1

5%

3

6

: CD4

> 20

0 ce

lls/m

m3

> 1

5%

3

6

< 1

:

1 -

< 6

: CD4

1

5%

6

6

: CD4

> 20

0 ce

lls/m

m3

1

5%

6

6

TE

Cry

ptoc

occo

sis

6

C

D4

> 10

0 c

ells/m

m3

u

ndet

ecta

ble

vira

l loa

d

-

3

12

Pen

icilli

osis/

Histo

plas

mos

is

6

itrac

onaz

ole

1

CD4

> 10

0 ce

lls/m

m3

pen

icillios

is (

>

150

cells/m

m3

hist

oplasm

osis)

6

MAC

< 2

:

2-5

: C

D4

> 20

0 ce

lls/m

m3

3

> 6

:

CD4

> 10

0 ce

lls/m

m3

3

6

< 2

:

2-5

: CD4

> 20

0 ce

lls/m

m3

6

> 6

: C

D4

> 10

0 ce

lls/m

m3

6

6

MAC

1

190 191

CM

V

<

1 :

1-5

: CD4

1

5%

6

6

: CD4

> 10

0 ce

lls/m

m3

6

6

***

ret

initis

3

- 6

r

elap

se

i

mm

une

rest

orat

ion

uveitis

192 193

(Post-Exposure Prophylaxis PEP)

PEP 2

- Occupational PEP (oPEP)

( )

( )

( )

194 195

- Non-occupational PEP (nPEP)

1

body uids

body uids

70%alcohol betadine

solution 5% chlorhexidinegluconate

source HIV source

source anti-HIV

source

anti-HIV

24 .

body uids

0.9% NSS

body uids

0.9% NSS

oPEP

source anti-HIV -ve

oPEP

4

source anti-HIV +ve

HIV

source

HIV body uids

HIV

196 197

1

oPEP

o

PEP

Sou

rce

Bas

elin

e

1

3

Ant

i-HIV

(rap

id tes

t)1P

PP

2P

P

CBC, Cr,

SG

PT

-P

P3

--

HIV

-PCR o

r vira

l loa

d-

-P

2-

-

HBsA

gP

PP

4-

P5

Ant

i-HBs

-P

6-

--

Ant

i-HCV

PP

--

P5

1 -

anti-

HIV

s

ourc

e

k

now

n HIV

+ve

case

-

s

ourc

e H

CV

infe

ctio

n

d

elay

ser

ocon

vers

ion

anti-

HIV

1

2

-

anti-

HIV

sour

ce

oPEP

o

PEP

2

an

ti-HIV

HIV

-PCR

v

iral loa

d

a

cute

HIV

infe

ctio

n

3

4

a

cute

hep

atitis

B in

fect

ion

5

3

6

s

ourc

e

HBV

/

HCV

infe

ctio

n6

198 199

2

n

PEP

H

IV

nP

EP

H

IV

1.

nPEP

/

2.

1

.

n

PEP

H

IV

nPEP

2.1

H

IV

H

IV

>

1,5

00 c

opies/

mL

H

IV

nP

EP

H

IV

2.2

2.3

2.4

3.

n

PEP

(

)

(

lanc

et

)

200 201

3

nPEP

n

PEP

1

Bas

elin

e

1

3

Ant

i-HIV

(rap

id tes

t)2P

P3

PP

CBC, Cr,

SG

PT

PP

4-

-

HIV

-PCR o

r vira

l loa

d-

P3

--

HBsA

gP

P5

-P

6

Ant

i-HBs

P7

--

-

Ant

i-HCV

P-

-P

6

VDRL

or R

PR

-P

8-

P9

Pre

gnan

cy tes

t

(for ch

ild-b

earin

g ag

e fe

male)

P-

P9

-

1

iden

tify

sour

ce

an

ti-HIV

, VD

RL

RPR

anti-

HIV

sour

ce

nPEP

n

PEP

2

an

ti-HIV

1

2

sou

rce

H

CV

infe

ctio

n

d

elay

ser

ocon

vers

ion

3

an

ti-HIV

HIV

-PCR

v

iral loa

d

a

cute

HIV

infe

ctio

n

4

5

a

cute

hep

atitis

B in

fect

ion

6

3

6

s

ourc

e H

BV

/

HCV

infe

ctio

n7

8

VD

RL

RPR

9

202 203

oPEP nPEP

oPEP nPEP

source

source known HIV +ve case

source VL resistance

testing ()

source VL detectable VL

source NNRTI-based regimen TDF

+ 3TC FTC + boosted PI source PI-based

regimen NNRTI resistance

TDF + 3TC FTC + raltegravir ( 4)

source undetectable VL

source 4

4

oPEP

*

nP

EP

**

TD

F 30

0 m

g +

3TC 3

00 m

g O

D

TDF

300

mg

+ FT

C 2

00 m

g O

D

+

Rilp

ivirine

25

mg

OD

/

AT

V/r 30

0/10

0 m

g O

D

/

LP

V/r 40

0/10

0 m

g BID

b

oost

ed P

I

A

TV/r

L

PV/

r

e

rgot

amine

c

afer

got

TDF

300

mg

+ 3T

C 3

00 m

g O

D

TDF

300

mg

+ FT

C 2

00 m

g O

D

+

Ralte

grav

ir 40

0mg

BID

EF

V 60

0 m

g O

D

E

FV

e

rgot

amine

c

afer

got

AZT

300

mg

BID

T

DF

A

B

C

r clea

ranc

e <

60 m

L/m

in

*

3

**

sou

rce

patie

nt

drug

-res

ista

nt H

IV

204 205

1-2 72

( 72

) 28

(Pre-Exposure Prophylaxis PrEP)

(Pre-Exposure

Prophylaxis PrEP)

44% 49%

62-75%

PrEP

92%

PrEP

PrEP

5

PrEP

PrEP

o Sero-negative partner serodiscordant couples

VL

o post-exposure prophylaxis

o

o

o

3

o

206 207

6 PrEP

PrEP

PrEP

anti-HIV

acute HIV infection

nucleic acid testing

anti-HIV

Cr Cr clearance

calculated Cr clearance

60 mL/min (Cockroft-Gault formula)

HBV

HBsAg anti-HBs

HBV

urine pregnancy test

PrEP

PrEP

PrEP

PrEP FTC/TDF

200/300mg 1

3

Methadone Maintenance Treatment (MMT)

anti-HIV 2-3

Cr 3

6

urine pregnancy test

PrEP

PrEP

PrEP

4

anti-HIV PrEP

PrEP

anti-HIV

active hepatitis B

PrEP hepatitis B

208 209

(Male circumcision)

51-60

HSV-2 HPV

o

o

Grams stain, Wet Smear nucleic acid

amplification test

o

o

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