1. Dr Madhu Oswal Samvad HIV AIDS Helpline Muktaa Charitable Foundation

2. Overview PEP How to monitor after diagnosis ? When to start ART? What to start? How to monitor after starting ART? When to refer?12/07/13Samvad HIV Helpline 020-26381234 3. Mayur Mr Mayur, 24 yr old, ITguy called at 10 am on Sunday morning. H/O Unprotected exposure (condom slipped) night before. Wants to know if he is HIV infected- TODAY. What to do? 12/07/13Samvad HIV Helpline 020-26381234 4. Window Period Following HIV Infection Acute HIV syndromePrimary HIV infectionAntibod AsymptomaticViremia------------------------------------ PCR P24 a.g ELISA a 0 12/07/13b 23 4 (Weeks since infection)YearsSamvad HIV Helpline 020-26381234 Source: S Conway and J.G Bartlett, 20036 5. Diagnosis in the window period After 12 weeks-antibody testsElisa/Rapid At approx 4 weeks- HIV Duo At approx 2 weeks- HIV RNA HIV DNA P24 Ag test12/07/13Samvad HIV Helpline 020-26381234 6. HIV DNA or RNA HIV DNA or RNA tests are NOT recommended fordiagnosis in adults False positive results in almost 20% of patients Costs around Rs 4000. The patients have to be subjected to antibody testing for confirmation after 6 TO 12 weeks.12/07/13Samvad HIV Helpline 020-26381234 7. What to do?Take history: was the risk significant? Explain about window period Any symptoms or signs of STD-Treat Test for baseline HIV status, Hbs Ag, ? Anti HCV Start PEP for HIV if indicated Start Heb B vaccine course, if not vaccinated or HbSAg neg. Risk reduction counselingIf woman( Mayuri), Emergency contraception 12/07/13Samvad HIV Helpline 020-26381234 8. Post Exposure Prophylaxis12/07/13Samvad HIV Helpline 020-26381234 9. Drugs for Post exposure prophylaxis Basic regimen: 1. Tenofovir 300+ Emtricitabine 200mg OD OR 2. AZT 300 mg + Lamivudine 150 mg BD Expanded regimen: 1. Above plus Atazanavir 300 + Ritonavir 100 mg OD 2. Lopinavir 400mg +Ritonavir 100 mg BDAll for 4 weeks Test after 6 weeks and 3 months for HIV and Hep B 12/07/13Samvad HIV Helpline 020-26381234 10. After 3 months.. Mayur s HIV test is Negative Risk reduction counseling .12/07/13Samvad HIV Helpline 020-26381234 11. After 3 months.. Mayur s HIV test is Positive (..May be becauseI didnt take his call on Sunday )Now what? 1. Disclose Mayur that he is HIV positive? 2. Do Western Blot test 3. Do HIV DNA/ RNA test? 4. Repeat Elisa test?12/07/13Samvad HIV Helpline 020-26381234 12. Mayur has confirmed HIV test Now what? Dont know how to break the news, so keep silent Refer to HIV specialist Manage further12/07/13Samvad HIV Helpline 020-26381234 13. Mayur goes into depression Dont turn up for 5 to 6 years 14. Then one fine day Mayur comes with .12/07/13Samvad HIV Helpline 020-26381234 15. Initial evaluation: history Fever, night sweats, weight loss, cough (any duration):TB Past H/o OIs: herpes zoster, chronic diarrhoea ARV use in past Co-morbidities: DM, HTN, CKD, Jaundice Smoking, alcohol High risk behaviourAsk if he has any sexual partner, marital status , children 12/07/13Samvad HIV Helpline 020-26381234 16. Initial evaluation: physical examination Weight Lymphadenopathy Oral cavity Hepato-spleenomegaly, doughy feel of abdomen Fundoscopic Dermatological exam12/07/13Samvad HIV Helpline 020-26381234 17. Initial evaluation: Laboratory workup CBC with differential Urinanalysis, creatinine Blood sugar Liver enzymes (optional) Chest Xray/USG abdomen (before starting ART) VDRL, TPHA HbsAg, anti-HCV CD4 Count Cervical PAP smear in MayuriCD4 to be taken after treating Herpes Zoster12/07/13Samvad HIV Helpline 020-26381234 18. Tests NOT recommended routinely Plasma viral load ARV resistance testing Fasting lipids CMV, Toxo serology sCRAG (in pts with CD4