RECENT ADVANCES IN TREATMENT OF AIDS / HIV PATIENTS

               RECENT ADVANCES IN TREATMENT OF HIV/AIDS PATIENTS                          

                                                                                                                                  -----DR.D.R.NAKIPURIA

                               AIDS is acquired immunodeficiency syndrome comprises of many symptoms and signs (different complains of patients and many thing evaluated by Doctor on examination)of Patient suffering from HIV,Hunam Immunedeficiency Virus.AS THE NAME SUGGEST OUR DEFENCE SYSTEM or Immune system is paralysed or made less responsive(measured in this infection by determining CD4 Count from Blood examination as a type of Lymphocyte fighting with invasion of HIV in our Body) whenever any infection of Bacteria,Virus,Fungus or parasite invade our body as a result infection can occur in any part of our body and as primary resistance from our Body System is weak,infection spreads more and more resulting in further growth of invading microbes and this HIV virus too(measured by Viral Load as Copies of Virus in Blood and susceptibility to drugs by sensitivity test).Therefore development of Anti Retro Virus (as HIV is Retrovirus) medicines has developed which once started raise immune system CD4 count by checking further growth of HIV virus and prevent infection by other Microbes(Oppurtinistic Infections) but as we know more and more about these medicines and their side effects and different Oppurtinistic Infections,WHO put some best guidelines when to start these medicines in HIV patients as in Year 2006 ART was to be started if CD4 count is below or 200 but in 2010 it is upto 350 But Amercan Journal suggest it upto 500 when patient is symptomatic or in stage I and II as per WHO staging(Patients with less grade of infections)but in stageIII and Stage IV patients or patients with severe form of disease or seriously ill as suffering from TB,Meningitis,Kidney or Cardiomyopathy,Chest or GI tract infections does not require any estimation of CD4 count as this is presumed and fact that their CD4 count is below 350 or 200 and ART or Better called HAART Medicines immediately.In case of TB patients ATT should be started after start of ART generally within 2-8 wks to avoid IRIS or any adverse reaction,those on HAART developing TB ,ART should be started immediately(with efavirenz except children below 03 yrs of age and first trimester pregnancy).In case of Pregnant Patient same module is practised ,in patients suffering with Hepatitis B or C patients,like TB, ART should be started immediately without any staging or delay of 2-8 wks.In case of Childrens too now same strategy is applied but here CD4 count varies according to age groups,we can start ART immediately in stage III and IV in infant or children upto 12 yrs of age but in Infants and children up to 2yrs of age no need of checking CD4 count start ART if patient is sytomatic or is diagnosed as HIV patients,even in infants now ART may be started if we strongly clinically suspect HIV (As Mother strongly positive or both parents positive or breast fed positive mother children etc) but in early age from 2-5 yrs reduction of CD4 count up to 750 or % of CD4 count below 25 but above 05 yrs criteria is 350 for stage I and II . In Developed countries Art is being started CD4 count  upto 500 or less above 05 yrs and adult.CD4 count was previously estimated every 06 months but now at every 03 months and if it is not raising considered as immunological failure and Viral load to be done before starting therapy and also at 3-6 months to see copies below 5000/ml it is raising then drug sensitivity test is done and if not possible then IInd Line drug is started,if IInd line drug started then now a days IIIrd line drug is started.In pregnancy either mother exposed to AER earlier or not ART started in first trimester(avoiding Efavirez) with drug regime and is continued life long unlike nevirapine during labor or Zidovudine regime only,Zidovudine and Nevirapine found good in CD4 count between 250-350.

                                 Now HAART medicines has been slightly modified,Two NRTIs and one NNRTIs is still practised to check drug resistance by Virus mutation but instead of dT4(Stavudine 30 or 40 as per wt above or below 60kg causing severe  lididolysis or peripheral neuropathy,pancreatitis ) now3TC(Lamivudine)+AZT/ZDV(Zadivudine causing severe anaemia or neutropenia ) or 3TC + TDF(Tedofil,causing nephropathy and calcinosis ) or TDF + FTC (Emcritabine),AZT+ FTC(causing hepatitis) so 3TC+ AZT+NVP(causing hepatitis and stevenson Zhonson syndrome) or 3TC+AZT+EFV (Efavirenz)or 3TC+TDF+NVP(Nevirapine) or EFV is preferred ,even Simple FTC+NVP or FTC+ EFV is preferred.here Abacavir (ABC) or Diadanosine (ddi) is also used as NRTIS but combination like Stavudine+Zaduvidine,3TC+FTC or AZT+TDF or dt4+Abacavir is not used . Incase of Tuberculosis patients,Efavirenz is given not NVP except when patient is child below 03 yrs or Ist trimester pregnant or under Psychotic condition or medicines.If possible and patient can afford Rifabutine may be started in ATT instead of Rifampcin but mostly if patient is not renal compromised or under hepatic pathology simple ATT is good.In Resistant cases(increase in viral load,less cd4 count or drug resistance)IInd line drug of 03 drugs combination is started here one protease inhibitor(Liponavir(LPV)  / Squanavir(SQR)/ Indinavir(IDV)  /Atazanavir(ATV) /Fosamprenavir(FPV) / Darunavir(DRV) /Etarvine(ETV) with boosted Ritonavir(r)or plain Ritonavir(RTV) is used and along with this in   TB  patients with Rifampcin dose of protease inhibitor like Lopinavir+ boosted ritonavir(LPV/r)  or Squanavir +Boosted Ritonavir or Indinavir + boosted Ritonavir is increased but with Rifabutine no dose adjustment is done.Instead of using NRTIS used in past as for dt4 or 3TC ,AZT + TDF or TDF + FTC or simply replacing 3TC by TDF or FTC or ABC or ddi is done,if any drug produce complication or side effect as mentioned above it is also replaced.In case of Hepatitis B TDF +3TC is used with NNRTIS or Protease Inhibitor.Revebrine and Pregylated Interferon is used with ART in Hepatits C patients.If after IInd line treatment CD4 count is increased third line treatment using one NNRTIS ,one Protease inhibitor as newly added ATV,DRVor FPV with Integrase inhibitor Raltegravir(RAL) is used.

           Cotrimoxazole is added to prophylaxis below 350 to prevent malaria,bacterial,PNeumocystis Jivorecii or Campylobacter Diarrhoea and Toxoplasmosis.STD clinic for any sexual inflicted persons like commercial or flying sex worker (counselling and promoting use of condom )and treatment and screening of suspected highly prone patients like IDUs,drug users,(not sharing needle)migratory labours,Truck drivers etc., at target Intervention clinic is backbone to control it and every suspect should be submitted for HIV screening ,Similiarly every TB patient and in ICTC every Blood donor and PTCT pregnant mother is screened for HIV.Proper counselling of these patients with advise and regular follow up of these persons at primary or semi primary or assisting ART centre is must by doing off and on viral load and CD4 count examination. Every oppurtunistic infection should be controlled and here medicines shold be contined for a long time to prevent recurrence and continuation of ART medicine of great importance.Adhrence,compliance and continued taking medicines with proper counselling during IRIS or any other drug reaction  is most important of HIV treatment.