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    Antiretroviral Treatment

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    Stanley Tatenda Mukono
    This document provides guidelines on when to start ART, what first and second line drugs to use, monitoring response, diagnosing treatment failure, common drug toxicities, and drug interactions. It recommends that all adults, pregnant/breastfeeding women, adolescents, and children of any clinical stage start ART immediately. The preferred first line regimen is DTG-based. Common adverse effects, monitoring parameters, and management of treatment failure are also outlined.

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    Antiretroviral Treatment

    Uploaded by

    Stanley Tatenda Mukono
    16 views32 pages
    This document provides guidelines on when to start ART, what first and second line drugs to use, monitoring response, diagnosing treatment failure, common drug toxicities, and drug interactions. It recommends that all adults, pregnant/breastfeeding women, adolescents, and children of any clinical stage start ART immediately. The preferred first line regimen is DTG-based. Common adverse effects, monitoring parameters, and management of treatment failure are also outlined.

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    This document provides guidelines on when to start ART, what first and second line drugs to use, monitoring response, diagnosing treatment failure, common drug toxicities, and drug interactions. It recommends that all adults, pregnant/breastfeeding women, adolescents, and children of any clinical stage start ART immediately. The preferred first line regimen is DTG-based. Common adverse effects, monitoring parameters, and management of treatment failure are also outlined.

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    16 views32 pages

    Antiretroviral Treatment

    Uploaded by

    Stanley Tatenda Mukono
    This document provides guidelines on when to start ART, what first and second line drugs to use, monitoring response, diagnosing treatment failure, common drug toxicities, and drug interactions. It recommends that all adults, pregnant/breastfeeding women, adolescents, and children of any clinical stage start ART immediately. The preferred first line regimen is DTG-based. Common adverse effects, monitoring parameters, and management of treatment failure are also outlined.

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    of 32

    ART GUIDELINES

    Dr Michelle Munyoro
    MBChB, MSC (UZ)
    WHEN TO START ART
    WHEN TO START ART

    ADULTS (>19 YEARS)

    • All adults regardless of WHO clinical stage and at any CD4


    cell count.

    • (test and treat)


    WHEN TO START ART

    PREGNANCY / BREASTFEEDING

    • All pregnant and breastfeeding mothers regardless of


    WHO clinical stage and at any CD4 cell count and
    continued lifelong.
    WHEN TO START ART

    PREGNANCY / BREASTFEEDING

    • All of them regardless of WHO clinical stage and at any


    CD4 cell count and continued lifelong.

    ADOLESCENTS (10-19 YEARS)

    • All adolescents regardless of WHO clinical stage and at


    any CD4 cell count.
    WHEN TO START ART
    CHILDREN < 10 YEARS

    • All of them regardless of WHO clinical stage and at any


    CD4 cell count.

    • All children who test positive at birth testing


    WHEN TO START ART

    ADULTS / CHILDREN WITH TB

    • All TB patients living with HIV, regardless of CD4 cell


    count.
    • TB treatment should be initiated first, followed by ART as
    soon as possible ( 2 weeks post initiation of anti Tbs)
    • ART is NOT an emergency.
    • Cd4 <50 cells- defer ART upto 8 weeks
    WHAT TO START
    FIRST LINE DRUGS
    DECEMBER 2018 UPDATE

    • Dolutegravir (DTG) -based regimen is recommended as the


    preferred first-line regimen for adults, adolescents, infants
    and children.
    • Raltegravir (RAL)-based regimen may be recommended as an
    alternative first-line regimen for infants and children for
    whom approved DTG dosing is not available.
    • RAL-based regimen is recommended as the preferred
    first-line regimen for neonates.
    DTG IN PRECONCEPTION / PREGNANCY

    • DTG appears to be safe when started later in pregnancy:

    after the period of risk of neural tube defects, after the

    first trimester.

    • EFV-based regimen is recommended at conception and

    up to the end of the first trimester.

    • EFV based regimen can be continued throughout

    pregnancy and BF
    OLD GUIDELINE NEW GUIDELINE

    Adults TLE TLD

    Adolescents TLE TLD

    Pregnancy TLE TLE -> TLD

    Child 3-10 years ALE ALD

    Child <3 years A/Z+L+LPV/r ALD

    Neonate A/Z+L+LPV/r ZLRal


    SECOND LINE DRUGS
    INFANT PROPHYLAXIS

    • No changes in recommendations.
    • High risk infants should receive dual prophylaxis with AZT
    (twice daily) and NVP (once daily) for the first 6 weeks of
    life, whether they are breastfed or formula fed.
    • High risk breastfed infants should continue infant
    prophylaxis for an additional 6 weeks (total of 12 weeks
    of infant prophylaxis) using either AZT (twice daily) and
    NVP (once daily) or NVP alone.
    INFANT PROPHYLAXIS
    Nevirapine for 6 weeks

    If PCR neg at 6 weeks – stop NVP – give CTX until 6 weeks post
    cessation of Breastfeeding and retest

    If PCR positive at anytime, start ART


    RISK STRATIFICATION FOR NEONATES
    * HIGH RISK*
    • Mothers who received neither antepartum nor intrapartum
    ARV drugs
    • Mothers who received only intrapartum ARV
    drugs
    • Mothers who received antepartum and intrapartum ARV
    drugs but who have detectable viral loads near delivery,
    particularly when delivery was vaginal
    • Mothers with acute or primary HIV infection
    during pregnancy or breastfeeding
    * LOW RISK *

    Mothers who received ART during pregnancy with sustained


    viral suppression (defined as a confirmed HIV RNA level < 50
    copies/ml) near delivery and no concerns related to
    adherence
    PEP
    DECEMBER 2018 UPDATE

    • Regimen with two ARV drugs is effective, but three drugs

    are preferred.

    • Adults: TDF + 3TC (or FTC) + DTG

    • Children: AZT + 3TC + DTG

    • If DTG Not available -> ATV/r, DRV/r, LPV/r and RAL are

    alternatives for both groups.


    WHAT TO EXPECT IN
    FIRST MONTHS OF ART
    • Clinical & immunological improvement

    • Viral suppression

    • OIs & IRIS

    • Drug hypersensitivity (ADR)


    IRIS
    • Paradoxical clinical deterioration after ART initiation.

    • IRIS are OIs occurring within 12 weeks of ART initiation.

    • M/C signs: HSV infection, HZ infection, MC.

    • Unless life threatening, continue ART.

    • If severe, temporarily D/C ART (+/- steroid) and re-start.


    MONITORING RESPONSE &
    DIAGNOSING FAILURE
    FAILURES
    • Clinical failure = New/recurrent clinical event (stage 4) after

    6 months of treatment.

    • Viral failure = Viral load > 1000 copies/mL (in 2 tests done

    within 3 months) after 6 months of starting ART.

    • Immunological failure = CD4 count ≤ 250 cells/mm3

    following clinical failure or persistent CD4 ≤ 100


    cells/mm3
    TOXICITIES
    DRUG TOXICITY RISK FACTOR
    TDF CKD, AKI, ↓BMD, Lactic acidosis, severe Uncontrolled DM, SHTN,
    hepatomegaly. ↓lying renal disease, >50
    years, BMI < 18.5.

    AZT Severe anemia, neutropenia, lactic acidosis, CD4 count ≤ 200 cells/mm3,
    hepatomegaly, lipoatrophy, lipodystrophy, BMI > 25.
    myopathy.
    EFV CNS toxicity, mental symptoms, convulsions, Depression, MR, SD, ↓lying
    hepatotoxicity, severe skin and hepatic disease, HBV, HCV
    hypersensitivity reactions. co-infection.
    NVP Hepatotoxicity, severe skin rash, ↓lying hepatic disease,
    hypersensitivity reaction (SJS). HBV, HCV co-infection, high
    baseline count.
    ABC Hypersensitivity reactions HLA-B*5701 allele
    DTG Hepatotoxicity, severe skin and HBV, HCV co-infection, liver
    hypersensitivity reactions, nausea, diarrhoea. disease
    RAL Rhabdomyolysis, myopathy Statins
    LPV/r ECG changes, hepatomegaly, pancreatitis, ↓lying hepatic disease,
    dyslipidemia, diarrhoea. HBV, HCV, CVS disorders.
    DRUG INTERACTIONS
    1. Anti TBs
    • PIs are C/I with Rifampicin; Rifabutin used instead.
    • Rifampicin significantly lowers conc. of DTG; BD dosing can
    be used instead of OD.

    2. Hep C Virus
    • PIs and NRTIs are C/I with Simeprevir.
    • PIs and NRTIs have many interactions with Daclatasvir & to
    be used with caution.
    • AZT with Ledipasvir and Sofosbuvir have an increased risk of
    anemia and hepatic decompensation.
    3. ANTI-FUNGAL
    • NVP decreases conc. of Itraconazole and Ketoconazole.

    4. ANTIMALARIAL
    • EFV increases conc. of Artesunate and Amodiaquine and
    causes elevated transaminases.
    • PIs are C/I with Halofantrine and Lumefantrine.

    5. OPIOIDS
    • EFV decreases Methadone concentration.

    6. STATINS
    • PIs increase conc. of lovastatin and simvastatin.
    6. ANTI-HISTAMINES
    • PI+NNRTI with astemizole and terfenadine cause severe life-
    threatening reactions like cardiac arrythmias.

    7. OTHER INTERACTIONS
    • DTG is C/I with simultaneous use of cation-containing
    antacids, laxatives, multivitamins and mineral supplements
    due to risk of chelation.
    • If DTG is used, it should be given 2 hours before or 6 hours
    after the medications containing polyvalent cations.
    REFERENCES
    1. WHO, Consolidated guidelines on the use of antiretroviral
    drugs for treating and preventing HIV infection, 2016.
    2. WHO, Updated recommendations on first-line and second-
    line antiretroviral regimens and post-exposure prophylaxis
    and recommendations on early infant diagnosis of HIV,
    December 2018.
    3. Bhushan Kumar, Sexually Transmitted Infections.

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