ACQUIRED IMMUNODEFICIENCY

SYNDROME (AIDS)
Etiology:
Human Immunodeficiency Virus
(HIV) Infection

Clinical findings (1)

Systemic complaints/ Symptoms
Many individuals with HIV infection remain
asymptomatic for years without antiretroviral therapy
(ART/ARV) approximate 10 years between
exposure of HIV and developmen of AIDS
A combination of complains base on opportunistic
infections

Fever persistent fever

Night sweats
Weight loss
Anorexia nausea vomiting
Diarrhea

Clinical findings (2)

Signs
Physical examination may be entirely normal
Abnormal findings range from completely
nonspesific to highly spesific for HIV infection

Hairy leukoplakia of the tongue

Disseminated Kaposis sarcoma
Cutaneous bacillary angiomatosis
Oral candidiasis

Opportunistic infections

Wasting syndrome

Oral Hairy Leukoplakia

Bacillary Angiomatous

Clinical findings (3)

1. Sinopulmonary disease
Pneumocystic carinii pneumonia
Other infectious pulmonary diseases
Noninfectious pulmonary diseases Kaposis
sarcoma
Sinusitis

2. Central nervous system disease

Clinical findings (4)

2. Central nervous system disease

Toxoplasmosis
Central nervous system lymphoma
AIDS dementia complex
Cryptococcal meningitis
HIV myelopathy
Progressive multifocal leukoencephalopathy (PML)

Clinical findings (5)

3. Peripheral nervous system
4. Rheumatologic manifestation
5. Myopathy
6. Retinitis
7. Oral lesions
8. Gastrointestinal manifestations

Clinical findings (6)

8. Gastrointestinal manifestations

Oral candidiasis
Candidal esophagitis
Hepatic disease neoplasma & infection
Biliary disease cholecystitis
Enterocolitis

9. Endocrinologic manifestation
hypogonadism
10. Skin manifestations

INFEKSI OPORTUNISTIK

Clinical findings (7)

10. Skin manifestations

Herpes simplex infections

Herpes zozter
Molluscum contagiosum
Staphylococcus infections
Bacillary angiomatosis
Fungal rashes
Seborreic dermatitis
Xerosis
Psoriasis
PPE (Pruritic Papular Eruption)

11. HIV-related malignancies

Clinical findings (8)

11. HIV-related malignancies

Kaposis sarcoma
Non-Hodgkins lymphoma
Anal dysplasia & squamous cell carcinoma
Cervical dysplasia & neoplasia

12. Gynecologic manifestations

13. Inflammatory reactions (immune
reconstitution syndrome = IRIS)

Treatment
There are 5 catagories:
A. Supportive therapy
B. Opportunistic infections & malignancies
C. Prophylaxis of opportunistic infections
D. Antiretroviral treatment (ARV/ART)
E. Hematopoietic stimulating factors recormon?

A. Supportive therapy
1. Sympthomatic
2. Fluid and electrolite
3. Anti depressant

B. Therapy for Opportunistic infections &

malignancies (1)
INFECTION OR
MALIGNANCY

TREATMENT

Pneumocystic infection
(PCP)

Kotrimoxazole 14-21 days

Pentamidine 14-21 days
Trimetoprim + dapsone 14-days
Primaquine + clindamycin 14-21 days
Atovaquone 14-21 days
Trimetrexate + leucovorin
KOTRI+KLINDAMISIN+PRIMAQUIN

Mycobactrium avium
complex infection (MAC)

Clarithromycin + ethambutol
Rifabutin

Toxoplasmosis

Pyrimethamin + sulfadiazine + folic acid

Pyrimethamin + klindamisin + folic acid

Lymphoma

Combination chemotherapy

Cryptococcus meningitis

Amphotricin B

B. Therapy for Opportunistic infections &

malignancies (2)
INFECTION OR MALIGNANCY

TREATMENT

Cytomegalovirus (CMV) infection

- Valgaciclovir Valcyte 1x1 tab let (450

mg)
- Ganciclovir Cymevene IV 5 mg/kg
2x sehari
- Foscamet

Candidiasis: esophageal, vaginal

Fluconazole

Herpes simplex infection

- Acyclovir
- Famciclovir
- Valacyclovir
- Foscamet

Herpes zoster

- Acyclovir
- Famciclovir
- Falaciclovir - Foscamet

Kaposis sarcoma:
- Cutaneous
- Extensive/aggressive cutaneous
disease
- Visceral diseases

- Observasion, intralesional vimblastine

- Systemic chemotherapy
- Combination chemotherapy

C. Prophylaxis of opportunistic infections

OI

Primary prophylaxix

Pneumocystis carinii

Cotrimoxazole, pentamidin,
dapson, atovaquone

Secondary prophylaxix

Kaposiss sarcoma
Oesophagyal
candidiasis

Fluconazole, Itraconazole,
Voriconazole

Mycobacterium avium Azithromycin, Clariromycin,

complex (MAC)
Rifabutin

Azithromycin, Clariromycin,
minus Rifabutin

Mycobacterium
tuberculosis

Isoniazid for 9-12 months

or rifabutin+ pyrazinamide
for 2 months

Toxoplasmosis

Cotrimoxazole, Dapsone 50
mg+ pyrimethamine 50-100
mg

Sulfasiazine 2 g +
pyrimethamine 25 mg or
clindamycin 1.2 g+
pyrimethamine 25 mg

Cryptococcosis

Fluconazole 100-200 mg

Fluconazole 200-400 mg

Cryptosporidiosis

Clarithromycin, rifabutin

Cytomegalovirus

Convenience, gansciclovir

Microsporidiosis

Albendazole

???

MANAGEMENT OF OPPORTUNISTIC INFECTIONS (1)

OI

MANAGEMENT

Pneumocystis carinii

Cotrimoxazole, dose is depend on the

degree of severity of diseases,
pentamidine, clindamycin + primaquine

Kaposiss sarcoma

ART will lead to quiescence of KS

Oesophagyal candidiasis

Fluconazole 100-200 mg/daily;

itraconazole 200 mg; amphotericine B
(0.3-0.5 mg/kg/daily; voriconazole 2 x
200 mg

Mycobacterium avium complex Clarithromycin 2 x 500 mg/daily;

(MAC)
etambuthol 15 mg/kg/day rifabutin 300
mg/daily; azithromycin 450 mg/daily;
ciprofloxacin
Mycobacterium tuberculosis

Rifampicin/rifabutin+isoniazid+pyrazina
mide+ethambutol (with pyridoxin) for 912 months

MANAGEMENT OF OPPORTUNISTIC INFECTIONS (2)

Toxoplasmosis

Sulfadiazin 4-6 g/day or clindamycin 4x600

mg/day + pyrimethamine 100-200 mg 50-75
mg/daily

Cryptococcosis

Amphotericine B (0.5-0.8 mg/kg/day

flucytosine 14 days fluconazole 400 mg/ daily
for 8-10 weeks

Cryptosporidiosis

There is no therapeutic agent

Cytomegalovirus

Valganciclovir, iv ganciclovir, foscarnet,

cidofovir

Microsporidiosis

Albendazole 2 x 400 mg

Natural History HIV

Viral Load

Window period

Source of Infection

uninfectious

All blood product

tears

Vaginal discharge

feces

Semen man

urine

Pericardial fluid

saliva

Pleural fluid

nose secrettion

Cerebrospinal fluid

sputum

Amnion fluid birth

vomit

Peritoneal fluid

sweat

Sinovial fluid

Clothes CAKAR

Breast-feed

kitchenware

D. Antiretroviral treatment
ANTIRETROVIRAL(ARV) DRUGS
1. Nucleoside reverse transcriptase inhibitors
(NRTI)
2. Nonnucleoside reverse transcriptase
inhibitors (NNRTIs)
3. Nucleotide reverse transcriptase inhibitors
4. Protease inhibitors (PIs)
5. Entry inhibitor

1. Nucleoside reverse transcriptase inhibitors

(NRTI)
DRUGS

DOSE

SIDE EFFECTS

Zidovudine (AZT) 2 x 300 mg/daily Anemis,neutropenia,nausea,malaise

,headache,insomnia,myopathy
Didanosine (ddI)

400 mg/daily

PN, pancreatitis, dry mouth,

hepatitis

Zalcitabine (ddC)

3 x 0375-0.75
mg/daily

PN, aphthous ulcers, hepatitis,

pancreatitis

Stavudine (d4T)

2 x 40 mg/daily

PN, hepatitis, pancreatitis

Lamivudine (3TC) 2 x 150 mg

Rash, PN

Emtricitabine

1 x 300 mg/daily Skin discoloration /soles (mild)

Abacavir (ABC)

2 x 300 mg/daily Rash, fever if occur may be fatal

PN: pheripheral neuropathy

2. Nonnucleoside reverse transcriptase

inhibitors (NNRTIs)
DRUGS

DOSE

SIDE EFFECTS

Nevirapine
(Viramune)

200 mg/daily for 2

weeks, then 2 x
200 mg/daily

Rash

Delavirdine
(Rescriptor)

3 x 400 mg/daily

Rash ???

Efavirenz (Sustiva)

600 mg/ daily

Neurologic
disturbances

3. Nucleotide reverse transcriptase inhibitors

DRUG

Tenofovir (TDF)

DOSE

1 x 300 mg/daily

SIDE EFFECTS

Gastrointestinal distress

4. Protease inhibitors (PIs) VIR

DRUGS

DOSE

SIDE EFFECTS

Saquinavir hard gel

(Invirase)

2 x 1000 mg+2x100 mg Rironavir

orallly /daily

Gastrointestinal
distress

Saquinavir soft gel

(Fortovase)

3 x 1200 mg/daily

Gastrointestinal
distress

Ritonavir (Norvir)

2 x 600 mg or 1-2 x 100 mg/dailt fot

boosting pther PIs

Gastrointestinal
distress, PN

Indinavir (Crixivan)

3 x 800 mg

Kidney stones

Nelvinavir (Viracept)

3 x 750 mg/daly

Diarrhea

Amprenavir (Agenerase)

2 x 1200 mg

Gastrointeratinal,
rash

Fosamprenavir (Lexiva)

2 x 1400 mg or 1 x 1400 mg +
ritonavir 1x 200 mg/daily

Same as
amprenavir

Lopinavir/ ritonavir
(Kaletra)

400 mg/ 2 x 100 mg/daily

Diarrhea

Atazanavir (Reyatas)

1 x 400 mg

Hyperbilirubinemia

5. Entry inhibitor
DRUGS
Enfuvirtide
(Fuzeon)

DOSE

SITE EFFECTS

2 x 90 mg subcutaneous/ Injection site pain

daily
& allergic reaction

1st and 2nd line ARV Drugs

1st Line
Start

2nd line

Substitute

Switch

Salvage

DUVIRAL

AZT, d4T,
3TC, NVP
EFV
Recommended 1st Line
ARV Drugs

ABC,
TDF
Frequently
Recommended as 2nd
line drugs, but also as
alternative drugs in 1st
line regimens

ddI,
PI/r

Recommended as 2nd Line

Drugs

30
25
No therapy

% of
20
patients
progressing

Monotherapy
Dual therapy

15

10
Triple therapy

5
0
0

months

10

11

12

13

14

15

1st LINE ARV FORMULARY

NVP

d4T
X

AZT

3TC
EFZ

Switching to
second line drugs in Indonesia

LPV/r
TDF
10 x more expensive than first line
Renal toxicity, metabolic complications
More drug interactions

ddI

Available drugs and dosage

ARV Drug

PACK

DOSAGE

Tenofovir
(TDF)

300 mg/tab

300 mg / day

Didanosine
(ddI)

100 mg/ tab

400 mg / day (250 mg / day if <60 kg)

(250 mg / day if w TDF)

Lopinavir/rito 133.3/33.3
navir (LPV/r) mg/cap

400 mg/100 mg /12 hrs , (533 mg/133

mg /12 hrs if combine w EFV or NVP)

Time to Start ARV Therapy

Condition Treatment
CD4 < 200

Start anti TB therapy.

ARV after anti TB is tolerated (2-8 weeks)

CD4 200350

Start anti TB therapy.

ARV after anti TB finished vs after tolerance

CD4 > 350

Start anti TB until finish

delayed ARV, CD4 monitor

There is no Start anti TB

CD4 facility ARV was given based on clinical signs of immune deficieny

Recommended regimen: AZT/d4T+3TC+EFV

WHO, 2003

E. Hematopoietic stimulating factors

Erythropoietin (Epoetin alfa):
HIV infected patients with anemia
Anemia secondary to zidovudine use trans?

Human G-CSF (filgrastim) and granulocyte

macrophage colony-stimulating factor
(GM-CSF [sargramostim]) to increase the
neutrophil counts of HIV-infected patients

To slow AIDS wasting

Fever control antipyretic drugs

Food supplementation with hight-caloric drinks
Total parentral nutrition (NTN)
Progestational agent: megestrol acetate
TRACETATE
Antiemetic agent: dromabinol marjuana
Growth hormone
Anabolic steroid testosteron for 2-4 weeks
Nausea weight loss metoclopramide,
dromabinol
Antideppresant

Prognosis
With improvements in therapy, patients are living
longer after the diagnosis of AIDS. This has
resulted in dramatic decreases in AIDS deaths.
Despite new therapeutic options, people
continue to die from HIV infection.
Depend on:
The stage of HIV/AIDS (I, II, III, IV)
The Adherence of ARV
The number of CD4 count

Myelomeningocele in efavirenzexposed newborn

Fundaro et al. AIDS 2002; 16:299300

SJS AZT/Zidovudin

Steven Johnson Syndrome (SJS)

SJS

Steven Johnson syndrome

Hypersensitivity reaction- severe

NEVIRAPINE

Hypersensitivity reaction- severe

NEVIRAPINE

Hypersensitivity reaction- severe

NEVIRAPINE

Lipodystrophy
d4T atau PI

Peripheral fat loss

Lipodystrophy
Fat accumulation
central obesity

d4T atau PI

Buffalo hump fat accumulation as part of

lipodystrophy

KUKU BERWARNA UNGU PASCA TERAPI ARV