1. Presented by: Siti Rohaizah bt Othman

2. Arv DRUGS AVAILABLE IN UMMC Combivir (Lamivudine + Zidovudine) Stocrin (Efavirenz 600mg) Kaletra (Lopinavir 200mg + Ritonavir 50mg) Retrovir (Zidovudine 100mg) 3TC (Lamivudine 150 mg) Nevirapine(200 mg) D4T(Stavudine 30mg) Zeffix (Lamivudine 100 mg) Ten-EM (Tenofovir 300mg + Emtricitabine 200mg) Raltegravir ( 400 mg)-under study Indinavir (400 mg) Ritonavir (100mg) SLN(S-30.mg L-150mg, N-200mg) Darunavir (300 mg)-under study Atazanavir (200mg)-under study

3. OVERVIEW What is HIV? What is AIDS? How do you get infected? How does treatment work? Treatment Options When to Start Patient Counselling

4. WhaT IS HIV? Human Immunodeficiency Virus (HIV) Is caused by a retrovirus known as lentiviruses. It infects CD4-T cells and begins to replicate rapidly. Then, HIV disables the immune system which could lead to AIDS.

5. What is AIDS? Acquired Immuno Deficiency Syndrome Prolong weakening of immune system due to HIV infection AIDS as HIV-infected persons with fewer than 200 CD4+T cells and/or persons with HIV who develop certain opportunistic infections.

6. OPPORTUNISTIC INFECTIONS

8. Transmission

9. Transmission YOU CANNOT GET HIV FROM; HUGGING, MOSQUITO BITES, SNEEZING, SHAKING HANDS AND SHARING FOOD

10. Nucleoside analog reverse transcriptase inhibitors (NRTIs) for HIV/AIDS Eg.Combivir,(Lamivudine/Zidovudine),d4T(Stavu dine).3TC(lamivudine), TEN_EM(tenofovir/emtricitabine) Non-nucleoside reverse transcriptase inhibitors (NNRTIs) for HIV/AIDS E.G: Efavirenz, Nevirapine, HOW THE TREATMENTS WORK ?

11. Protease inhibitors (PIs) Eg. Indinavir Sulfate, Ritonavir Integrase Inhibitor Raltegravir Fusion Inhibitor Maraviroc, enfuvirtide

12. What to use in firstline therapy? Either an NNRTI OR a Protease Inhibitor OR an Integrase Inhibitor] PLUS [a dual- NRTI component] Combivir(Lamivudine + Zidovudine)+ Efavirenz ten-em + Efavirenz --who art guideline 2010

13. What to use in second-line therapy ritonavir-boosted protease inhibitor (PI) plus two NRTIs Eg: one of which should be AZT or TDF, based on what was used in first-line therapy. Ritonavir-boosted atazanavir (ATV/r) or lopinavir/ritonavir (LPV/r) are the preferred PIs. -who art guideline 2010

14. UMMC guidelines Examples of some possible combinations ◦ Stavudine +Lamivudine+Efavirenz ◦ Kaletra+Indinavir+ Ritonavir ◦ Combivir(Zidovudine+Lamivudine)+Efavirenz ◦ Combivir(Zidovudine+Lamivudine)+Indinavir +Ritonavir

15. Hiv Life cycle

16. When to start arv?

17. HIV Symptoms CD4 cells/ μ l Start Treatment YesAnyYes <350Yes No>=350Yes

18. Laboratory monitoring CD4 cell–count test HIVRNA (viral-load) Drug toxicity

19. Goal of treatment Inhibit viral replication, re-establishment & persistence of an effective immune response that will prevent or delay HIV- related morbidity. Fully undetectable levels of virus (< 50 c/ml) is the target of therapy for ALL patients, regardless of stage of disease or number / type of prior regimens The lower the viral RNA can be driven, the lower the rate of accumulation of drug resistance mutations & the longer the therapeutic effect will last.

20. Anaemia Rash Liver damage-can be seen as dark colored stools or urine or yellow coloration of eye whites. Hyperglycemia and insulin resistance Lactic acidosis-nausea, vomiting, belly pain Dyslipidemia Osteonecrosis Fat redistribution

22. Adherance and compliance to ART therapy and follow up report any side effects the doctor during follow up. Patient must change lifestyle to reduce cardiovascular risk- consistent monitoring of lipid profile and glucose HbA1c, smoking cessation Prevention of secondary transmission-Safe sex- reduce high risk behaviour, eg; the usage of condoms

23. Stop sharing needles- needle exchange programme Bring potentially infection partners for HIV screening, if initial screening shows negative, bring partner for screening again in 6 months in case of window period of infection Reduce or avoid contact people who are ill as there is the potential of opportunistic infection. Follow up every 3-6 months with CD4 cell count or viral load testing to ensure treatment success and detect possible therapeutic failure.

24. references The Sanford Guide To Antimicrobial Therapy 2010 Package insert http://www.aids.gov.nih.my UMMC guidelines