B Y T S: 3003 /Q-BYT

CNG HO X HI CH NGHA VIT NAM c lp - T do - Hnh phc H Ni, ngy 19 thng 8 nm 2009

QUYT NH V vic ban hnh Hng dn chn on v iu tr HIV/AIDS B TRNG B Y T Cn c Ngh nh s 188/2007/N-CP ngy 27 thng 12 nm 2007 ca Chnh ph quy nh chc nng, nhim v, quyn hn v c cu t chc B Y t; Xt bin bn lm vic ca Hi ng chuyn mn nghim thu Hng dn chn on v iu tr HIV/AIDS ngy 23 thng 5 nm 2009 ca B Y t; Theo ngh ca Cc trng Cc Qun l khm, cha bnh, B Y t, QUYT NH: iu 1. Ban hnh km theo Quyt nh ny "Hng dn chn on v iu tr HIV/AIDS". iu 2. "Hng dn chn on v iu tr HIV/AIDS" p dng cho tt c cc c s khm, cha bnh. iu 3. Quyt nh ny c hiu lc thi hnh k t ngy k ban hnh. iu 4. Cc ng, b: Chnh Vn phng B; Chnh Thanh tra B; V trng cc v, Cc trng cc cc thuc B Y t; Gim c cc Bnh vin, Vin c ging bnh trc thuc B Y t; Gim c S Y t cc tnh, thnh ph trc thuc trung ng; Th trng y t cc ngnh; Th trng cc n v c lin quan chu trch nhim thi hnh Quyt nh ny./.
Ni nhn:
- Nh iu 4; - Vn phng Chnh ph (Phng Cng bo); - B trng Nguyn Quc Triu ( bo co); - Cc /c Th trng ( bo co); - Website B Y t, website Cc QLKCB; - Lu: VT, KCB, PC.

KT. B TRNG TH TRNG ( k) Nguyn Th Xuyn

B Y T

Hng dn CHn on v iu tr HIV/AIDS

(Ban hnh km theo Quyt nh s 3003/Q-BYT ngy 19/8/2009 ca B trng B Y t)

NH XUT BN Y HC H NI - 2009

MC LC PHN A:............................................................................................................ 8 CHN ON V IU TR HIV/AIDS NGI LN.......................... 8 I. CHN ON V PHN GIAI ON NHIM HIV NGI LN ...............8 1. Chn on nhim HIV: ............................................................................. 8 2. Phn giai on nhim HIV........................................................................ 8 II. QUN L LM SNG NGI NHIM HIV/AIDS............................................9 1. nh gi ban u:...................................................................................... 9 2. Ti khm:................................................................................................. 11 III. D PHNG NHIM TRNG C HI.................................................................12 1. D phng nhim trng c hi tin pht bng cotrimoxazole ................ 12 2. D phng lao tin trin bng isoniazide (INH): .................................... 13 IV. TIP CN MT S HI CHNG LM SNG THNG GP NGI NHIM HIV/AIDS...........................................................................................................15 1. St ko di............................................................................................... 15 2. H hp ..................................................................................................... 17 3. Thn kinh................................................................................................. 19 4. Nut au .................................................................................................. 21 5. Tiu chy mn tnh.................................................................................. 23 6. Hch to .................................................................................................... 25 7. Thiu mu................................................................................................ 26 8. Tn thng da v nim mc.................................................................... 28 9. Suy mn................................................................................................... 28 V. CHN ON V IU TR CC BNH NHIM TRNG C HI THNG GP.................................................................................................................30 1. Cc bnh do nm ...................................................................................... 30 2. Cc bnh do k sinh n bo.................................................................... 31 3. Cc bnh do vi khun ............................................................................... 32 4. Cc bnh do virus ..................................................................................... 33 5. Chn on, v iu tr lao cho ngi nhim HIV/AIDS ........................ 35 VI. IU TR THUC KHNG HIV (IU TR ARV)..........................................39 1. Mc ch v nguyn tc iu tr ARV .................................................... 39 2. Tiu chun bt u iu tr ARV ............................................................ 40 3. Chun b sn sng iu tr ARV: ............................................................ 40 4. Cc phc iu tr ARV bc mt: ........................................................ 41 6. Theo di iu tr ARV............................................................................. 46 7. Hi chng vim phc hi min dch ....................................................... 48 8. Tht bi iu tr ARV v cc phc bc hai ........................................ 49 9. iu tr ARV cc i tng c bit: .................................................. 52 VII- IU TR ARV PH N MANG THAI V D PHNG LY TRUYN HIV T M SANG CON................................................................................................56 1. iu tr ARV cho ph n mang thai nhim HIV.................................... 56 2. iu tr d phng ly truyn HIV t m sang con bng ARV ............... 58 3. Cc bin php can thip khc v chuyn tip m-con n cc dch v chm sc, iu tr sau khi sinh .................................................................... 59 VIII- D PHNG SAU PHI NHIM HIV: ..............................................................60
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1. D phng sau phi nhim HIV do ngh nghip ..................................... 60 2. D phng phi nhim HIV ngoi mi trng ngh nghip: .................. 62 PHN B: .......................................................................................................... 64 CHN ON, IU TR V CHM SC TR EM NHIM HIV/AIDS .......................................................................................................................... 64 I. CHN ON V PHN LOI GIAI ON LM SNG, GIAI ON MIN DCH NHIM HIV TR EM.........................................................................64 1. Chn on nhim HIV tr em .............................................................. 64 2. Phn loi giai on nhim HIV............................................................... 65 II. QUN L LM SNG TR PHI NHIM V TR NHIM HIV/AIDS.....67 1. Giai on ban u: .................................................................................. 67 2. Ti khm.................................................................................................. 69 III. D PHNG NHIM TRNG C HI, LCH TIM CHNG........................70 1. D phng NTCH tin pht bng cotrimoxazole ..................................... 70 2. Tim chng phng bnh:......................................................................... 72 IV. TIP CN MT S HI CHNG LM SNG THNG GP TR EM NHIM HIV/AIDS...........................................................................................................73 1. St ko di............................................................................................... 73 2. H hp ..................................................................................................... 75 3. Thn kinh................................................................................................. 77 4. Tiu chy ko di .................................................................................... 79 5. Ci cc v chm pht trin th cht ........................................................ 81 V. CHN ON V IU TR CC BNH NHIM TRNG C HI THNG GP TR NHIM HIV...........................................................................82 VI. IU TR BNG THUC KHNG HIV (IU TR ARV) ............................87 1. Mc ch v nguyn tc iu tr ARV .................................................... 87 2. Tiu chun bt u iu tr ARV ............................................................ 87 3. Chun b sn sng iu tr bng ARV..................................................... 87 4. Cc phc iu tr bc 1 ....................................................................... 89 5. Tc dng ph ca cc thuc ARV v cch x tr.................................... 90 7. Hi chng vim phc hi min dch ....................................................... 94 8. Tht bi iu tr phc bc 1 v i phc bc 2.............................. 96 9. iu tr ARV tr mc lao ..................................................................... 98 10. iu tr ARV tr ng nhim vim gan:............................................ 98 PH LC ........................................................................................................ 99 Ph lc 1: Tiu chun chn on lm sng v chn on xc nh cc bnh l lin quan n HIV/AIDS ngi ln............................................................. 99 Ph lc 2: Tiu chun chn on lm sng v chn on xc nh cc bnh l lin quan n HIV/AIDS tr em. ....................................................... 104 Ph lc 3: Bng tm tt cc thuc ARV ................................................... 110 Ph lc 4: Liu ARV Nhi khoa - Chun ha theo Ch s pht trin ca Tr em Vit Nam - Nhm NRTIs .................................................................... 112 Ph lc 5: Tng tc ca cc thuc ARV................................................. 117 Ph lc 6: Phn tc dng ph ca cc thuc ARV ngi ln........... 119 Ph lc 7. Phn tc dng ph ca cc thuc ARV tr em ................ 121 TI LIU THAM KHO............................................................................ 125
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BNG CC CH VIT TT Ting Vit:

BT CTM GLS HCVPHMD Hgb LTMC NTCH VGB TCMT TKT VGC VMN XN Bnh thng Cng thc mu Giai on lm sng Hi chng vim phc hi min dch Hemoglobin Ly truyn HIV t m sang con Nhim trng c hi Vim gan B Tim chch ma ty Thn kinh trung ng Vim gan C Vim mng no Xt nghim

Ting Anh:
ABC AFB AIDS ADN ALT (SGPT) anti - HBc anti - HBe anti - HCV ARN ARV TCD4 DOT ELISA HAART HBeAg HBsAg Abacavir Acid Fast Bacilli - Trc khun khng cn khng toan Acquired immunodeficiency syndrome - Hi chng suy gim min dch mc phi Acid desoxyribonucleic Alanin aminotransferase Anti - Hepatitis B core antigen - Khng th vi khng nguyn nhn ca virus vim gan B Anti - Hepatitis B envelop antigen - Khng th vi khng nguyn v nhn ca virus vim gan B Anti - Hepatitis C antibody - Khng th vi virus vim gan C Acid ribonucleic Antiretroviral - Thuc khng retrovirus. T bo lympho TCD4 Directly observed therapy - iu tr c gim st trc tip Enzyme - linked immunosorbent assay - Xt nghim hp ph min dch gn men Highly active antiretroviral therapy - iu tr khng retrovirus hiu qu cao Hepatitis B Envelop Antigen - Khng nguyn v nhn ca virus vim gan B Hepatitis B surface antigen - Khng nguyn b mt ca virus vim gan B 6

HIV HPV HSV JC LIP LPV MAC NNRTI NRTI

Human immunodeficiency virus - Virus gy suy gim min dch ngi Human papiloma virus - Virus gy u nh ngi Virus Herpes simplex Mt loi virus gy Vim no cht trng Lymphocytic interstitial pneumonia Vim phi k thm nhim lymph bo Lopinavir Mycobacterium avium complex - Phc hp Mycobacterium avium Non - nucleosid reverse transcriptase inhibitor - Thuc c ch men sao chp ngc non - nucleoside Nucleoside reverse transcriptase inhibitor - Thuc c ch men sao chp ngc nucleoside Nevirapine Pneumocystis pneumonia - vim phi do pneumocystis Polymerase chain reaction - Phn ng chui men polymerase Protease inhibitor - Thuc c ch men protease Ritonavir

NVP PCP PCR PI RTV

TB TDF TMP - SMX 3TC

Tuberculosis - Bnh lao Tenofovir Trimethoprim - sulfamethoxazol Lamivudine

PHN A: CHN ON V IU TR HIV/AIDS NGI LN

I. CHN ON V PHN GIAI ON NHIM HIV NGI LN 1. Chn on nhim HIV: Nhim HIV ngi ln c chn on trn c s xt nghim khng th HIV. Mt ngi c xc nh l nhim HIV khi c mu huyt thanh dng tnh c ba ln xt nghim khng th HIV bng ba loi sinh phm khc nhau vi nguyn l phn ng v phng php chun b khng nguyn khc nhau (theo quy nh ca B Y t). 2. Phn giai on nhim HIV 2.1 Phn giai on lm sng: Nhim HIV ngi ln c phn thnh 4 giai on lm sng, ty thuc vo cc triu chng bnh lin quan n HIV ngi nhim (Bng 1). Bng 1: Phn giai on Lm sng HIV/AIDS ngi ln Giai on lm sng 1: Khng triu chng - Khng c triu chng - Hch to ton thn dai dng Giai on lm sng 2: Triu chng nh - St cn mc va khng r nguyn nhn (< 10% trng lng c th) - Nhim trng h hp ti din (vim xoang, vim amidan, vin tai gia, vim hu hng) - Zona (Herpes zoster) - Vim kho ming - Lot ming ti din - Pht ban dt sn, nga. - Vim da b nhn - Nhim nm mng Giai on lm sng 3: Triu chng tin trin - St cn nng khng r nguyn nhn (> 10% trng lng c th) - Tiu chy khng r nguyn nhn ko di hn 1 thng. - St khng r nguyn nhn tng t hoc lin tc ko di hn 1 thng. - Nhim nm Candida ming ti din. - Bch sn dng lng ming. - Lao phi. - Nhim trng nng do vi khun (vim phi, vim m mng phi, vim a c m, nhim trng xng khp, vim mng no, nhim khun huyt). - Vim lot ming hoi t cp, vim li hoc vim quanh rng. - Thiu mu (Hb< 80g/L), gim bch cu trung tnh (< 0.5x109/L), v/hoc gim tiu cu mn tnh (< 50x109/L) khng r nguyn nhn. Giai on lm sng 4: Triu chng nng - Hi chng suy mn do HIV (st cn >10% trng lng c th, km theo st ko di trn 1 thng hoc tiu chy ko di trn 1 thng khng r nguyn nhn). - Vim phi do Pneumocystis jiroveci (PCP). - Nhim Herpes simplex mn tnh ( mi ming, c quan sinh dc, quanh hu mn, ko di hn 1 thng, hoc bt c u trong ni tng). - Nhim Candida thc qun (hoc nhim candida kh qun, ph qun hoc phi). - Lao ngoi phi. - Sarcoma Kaposi.
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Bnh do Cytomegalovirus (CMV) vng mc hoc cc c quan khc. Bnh do Toxoplasma h thn kinh trung ng. Bnh l no do HIV. Bnh do Cryptococcus ngoi phi bao gm vim mng no. Bnh do Mycobacteria avium complex (MAC) lan to. Bnh l no cht trng a tin trin (Progessive multifocal leukoencephalopathy -PML). Tiu chy mn tnh do Cryptosporidia. Tiu chy mn tnh do Isospora Bnh do nm lan to (bnh nm Penicillium, bnh nm Histoplasma ngoi phi,). Nhim trng huyt ti din (bao gm nhim Sallmonella khng phi thng hn). U lympho no hoc u lympho non-Hodgkin t bo B. Ung th c t cung xm nhp (ung th biu m). Bnh do Leishmania lan to khng in hnh. Bnh l thn do HIV. Vim c tim do HIV.

2.2. Phn giai on min dch: Tnh trng min dch ca ngi ln nhim HIV c nh gi thng qua ch s t bo CD4. Bng 2: Phn giai on min dch nhim HIV/AIDS ngi ln Mc Bnh thng hoc suy gim khng ng k Suy gim nh Suy gim tin trin Suy gim nng S t bo CD4/mm3 > 500 350 - 499 200 - 349 < 200

2.3. Tiu chun chn on nhim HIV tin trin (bao gm AIDS): - C bnh l thuc giai on lm sng 3 hoc 4 (chn on lm sng hoc xc nh) v/hoc - S lng CD4 < 350 TB/mm3 AIDS c xc nh khi ngi nhim HIV c bt k bnh l no thuc giai on 4 (chn on lm sng hoc xc nh), hoc s lng CD4 < 200 TB/mm3.

II. QUN L LM SNG NGI NHIM HIV/AIDS 1. nh gi ban u: 1.1. nh gi lm sng v xt nghim: 1.1.1. Hi bnh s v tin s bnh tt: + Tin s v xt nghim HIV: thi gian pht hin, ni xt nghim; cc yu t nguy c ly nhim HIV (tim chch ma ty, quan h tnh dc khng an ton), thi gian din ra cc hnh vi nguy c. + Tin s mc lao v iu tr lao (thi gian chn on v iu tr, ni iu tr, phc v kt qu iu tr); tin s tip xc ngun lao. + Tin s cc bnh NTCH, bnh ly truyn qua ng tnh dc; cc bnh khc; + Tin s sn khoa, ph khoa, phng php trnh thai;
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+ Tin s d ng thuc: khng sinh nh cotrimoxazole, cc thuc khng HIV (thuc ARV), v.v.. + Cc triu chng mi xut hin trong thi gian qua; din bin v p ng vi iu tr; ch cc triu chng lin quan n bnh lao. + Cc thuc dng trong thi gian qua: o Thuc iu tr d phng NTCH (cotrimoxazole ) o Thuc ARV: l do s dng, thi gian dng, phc c th, ngun thuc, vn tun th khi ung thuc; o Cc thuc ang s dng khc. + Tnh trng nghin chch ma ty v cc cht gy nghin khc, cc bin php cai nghin hay iu tr thay th (v d methadone); tin s ung ru, ht thuc l + Tin s dinh dng + Tin s nhim HIV trong gia nh: c ai trong gia nh b nhim HIV, v nu c, iu tr ARV cha, u; vn bc l tnh trng nhim HIV ca bn thn v gia nh (nu c). 1.1.2. Khm ton thn v thc th: Thc hin mt cch chi tit v h thng Cc du hiu sinh tn, cn nng, triu chng au. nh gi chc nng vn ng: lm vic c, ch i li v t phc v c, hoc nm lit ging. Cc biu hin ton thn, da v nim mc Th lc, tnh trng tai mi hng Cc biu hin thn kinh: hi chng mng no, du thn kinh khu tr Cc c quan h hp v tun hon Tnh trng bng, gan lch to, hch to v khi bt thng bng 1.1.3. Xt nghim: CTM, Hgb, ALT XQ phi, AFB m, nu nghi ng lao phi, hoc cc xt nghim thm d cn thit khc chn on lao ngoi phi, cc bnh NTCH khc CD4 (nu c iu kin). Cc xt nghim h tr la chn phc ARV nh HBsAg, anti-HCV (nu c iu kin) Xt nghim creatinin, lipid, glucose mu nu ngi bnh s dng TDF hoc cc thuc c ch protease Xt nghim pht hin mang thai khi cn. 1.1.4. Chn on NTCH v xc nh giai on lm sng: Chn on lao tin trin: (xem Chng V, phn 5: Chn on v iu tr lao ngi nhim HIV. Chn on cc NTCH khc: xem chng IV (Tip cn cc hi chng lm sng thng gp trn ngi nhim HIV/AIDS) v Chng V (Chn on v iu tr cc bnh nhim trng c hi thng gp). Xc nh giai on lm sng (xem Bng 1). 1.2. X tr: iu tr cc bnh nhim trng c hi, iu tr triu chng v cc bnh l khc iu tr d phng cc bnh nhim trng c hi nu c ch nh nh gi tiu chun iu tr ARV. Nu ngi nhim HIV c ch nh iu tr ARV: thc hin cc ni dung chun b sn sng iu tr Cho nhp vin i vi cc trng hp c bnh nng, hoc hi chn, chuyn ngi bnh ln tuyn trn khi vt qu kh nng iu tr ca c s; phi hp vi
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chuyn khoa lao, da liu, sn khoa, chng trnh d phng ly truyn t m sang con v cc chuyn khoa khc khi cn. 1.3. T vn h tr: T vn h tr c thc hin i vi tt c ngi nhim HIV bao gm c ngi cha c iu tr ARV hay ang c iu tr ARV. Ni dung t vn c thc hin da trn nh gi nhu cu ca tng ngi bnh: H tr tm l-x hi v gii thiu cc dch v h tr Cung cp kin thc v HIV/AIDS Gii thch v chm sc v iu tr lu di T vn v sng tch cc v dinh dng T vn v thai sn v cc vn lin quan n HIV T vn v cc bin php d phng ly truyn HIV v thc hnh cc hnh vi an ton T vn tun th iu tr: tm quan trng v ni dung ca tun th iu tr, c bit l i vi ngi bnh ang iu tr ARV T vn v s cn thit phi c ngi h tr iu tr khi ngi bnh c a vo chng trnh iu tr T vn h tr bc l tnh trng nhim HIV cho gia nh, bn tnh. Gii thiu cc thnh vin khc trong gia nh n cc dch v t vn v xt nghim t nguyn nu cn 1.4. K hoch theo di v nhng h tr cn thit khc 1.4.1. Ln lch ti khm c th cho tng bnh nhn: - Ngi bnh cha iu tr ARV: c th da vo giai on lm sng v s lng t bo CD4 ln lch ti khm cho ph hp. GLS 1, 2 v CD4 > 350 /mm3: hn ti khm 3 thng/ln v khi c biu hin bt thng. GLS 1, 2 v CD4 < 350 /mm3; GLS 3 v CD4>350/mm3: hn ti khm 12 thng/1 ln v khi c biu hin bt thng. Ngi bnh tiu chun iu tr ARV: hn ti khm theo lch chun b sn sng iu tr. Ngi bnh ang iu tr ARV: hn ti khm nh k theo lch. 1.4.2. Gii thch ngi bnh n c s y t ngay khi c biu hin bt thng kp thi x tr. 1.4.3. Pht thuc theo lch ca nhm chm sc v iu tr. 2. Ti khm: Ngi bnh cn n c s chm sc v iu tr HIV ti khm nh k theo lch hoc khi c biu hin bt thng. 2.1. Thm khm lm sng v xt nghim: Hi bnh s: cc biu hin mi xut hin sau ln khm trc nh st, st cn, ho, tiu chy, pht ban, v.v..; cc vn v tm l-x hi, tun th iu tr. Khm lm sng: thm khm ton thn v b phn, pht hin cc nhim trng c hi v cc bnh l khc, tc dng ph ca cc thuc d phng v iu tr. nh gi li giai on lm sng. Lm cc xt nghim theo di theo quy nh, bao gm c CD4; cc xt nghim chn on NTCH v cc xt nghim xc nh tc dng ph ca thuc v tht bi iu tr khi cn. 2.2.X tr: X tr theo tnh trng lm sng v kt qu xt nghim ca bnh nhn. iu tr NTCH v x tr cc tc dng ph ca thuc (nu c). Xt ch nh iu tr ARV nu ngi bnh tiu chun.
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 T vn tm l-x hi v h tr tun th iu tr. Chuyn gi ngi bnh n cc dch v khc c lin quan. III. D PHNG NHIM TRNG C HI 1. D phng nhim trng c hi tin pht bng cotrimoxazole Mc ch: D phng cc bnh nhim trng c hi nh PCP, vim no do Toxoplasma v ng thi d phng c bnh tiu chy, vim ng h hp do mt s loi vi khun gy nn. 1.1. Ch nh iu tr d phng cotrimoxazole Nu c xt nghim CD4, iu tr d phng nhim trng c hi bng cotrimoxazole khi: 1. Ngi nhim HIV giai on lm sng 3, 4 khng ph thuc s lng t bo CD4. 2. Ngi nhim HIV giai on lm sng 1, 2 vi CD4 < 200 TB/mm3. Nu khng c xt nghim CD4, iu tr d phng nhim trng c hi bng cotrimoxazole khi: Ngi nhim HIV giai on lm sng 2, 3, 4 Ph n mang thai c ch nh cn bt u iu tr d phng cotrimoxazole bt k giai on no ca thai. Ph n cho con b cn phi tip tc iu tr d phng cotrimoxazole. 1.2. Liu iu tr d phng Cotrimoxazole ung 960mg (SMX 800mg/TMP 160mg) 1 ln/ngy hoc 3 ln/tun Thuc thay th (trong trng hp khng s dng c cotrimoxazole): dapsone 100mg/ngy. Dapsone tc dng km hn cotrimoxazole trong d phng PCP. Lu : C cotrimoxazole v cc thuc ARV (c bit l nevirapine v efavirenz) u c th gy pht ban. Nn iu tr d phng cotrimoxazole trc khi bt u iu tr ARV 1-2 tun d dng phn bit tc dng ph do thuc no gy ra. 1.3. Chng ch nh: d ng vi cc thuc sulfamid 1.4. Tc dng ph thng gp ca cotrimoxazole: C th gp nn, bun nn, thng xy ra trong 1-2 tun u iu tr. Pht ban do cotrimoxazole c th xy ra mc nh, va, hoc nng (xem Bng 3); t gp cc tc dng ph nng vi cotrimoxazole nh thiu mu, gim bch cu ht, nhim c gan T vn cho ngi bnh v tc dng ph c th xy ra ngi bnh t theo di; dn ngi bnh n ngay c s y t khi c cc du hiu tc dng ph nng. Xt nghim cng thc mu, men gan khi nghi ng thiu mu, nhim c gan. Bng 3: Phn pht ban do cotrimoxazole v x tr:
Mc Triu chng lm sng Mc 1 Ban (Nh) Mc 2 Ban sn lan ta, trc vy kh (Trung bnh) Mc 3 (Nng) Ban phng nc kch thc nh, lot nim mc
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Khuyn ngh v x tr Tip tc iu tr d phng bng cotrimoxazole, theo di cht ch hng ngy. iu tr triu chng v khng histamine. NGNG thuc cho ti khi ht cc triu chng (thng sau 2 tun). iu tr triu chng v khng histamine

Sau CN NHC S DNG LI theo phng php gii mn cm. Vim da trc vy, hi chng Mc 4 Steven-Johnson hoc hng ban (Rt nng) a dng, trt lot da t NGNG VNH VIN co- trimoxazole iu tr triu chng v khng histamine

Gii mn cm vi cotrimoxazole: Thc hin gii mn cm i vi ngi bnh trc c d ng vi cotrimoxazole mc nh v trung bnh (1 v 2); bnh nhn d ng mc nng ( 3) cn c gii mn cm mt cch thn trng. Khng tin hnh gii mn cm vi ngi bnh trc c tin s d ng rt nng vi cotrimoxazole hoc cc thuc sulfamid khc. Tin hnh gii mn cm sau khi ngng cotrimoxazole khong 2 tun, ngi bnh khng cn cc biu hin d ng. Nn iu tr gii mn cm ti cc bnh vin, c sn cc phng tin cp cu sc phn v khi cn. Thc hin gii mn cm theo quy trnh (xem Bng 4); ch tng tip liu thuc gii mn cm nu ngi bnh khng c phn ng vi liu cotrimoxazole trc (khng pht ban d ng). Nu d ng xut hin li, cn ngng gii mn cm. Khi bnh nhn hi phc c th dng dapsone thay th. Bng 4: Quy trnh gii mn cm vi cotrimoxazole 80 SMX + 16 mg TMP (2ml dng dch ung(*)) 160 SMX + 32mg TMP (4ml dng dch ung(*)) 240 SMX + 48mg TMP (6ml dng dch ung(*)) 320 SMX + 64mg TMP (8ml dng dch ung(*)) Mt vin n 480mg Hai vin n 480mg hoc mt vin kp 960mg (*) Cotrimoxazole dng dch ung gm 200mg SMX + 40mg TMP trong 5ml. Trng hp
khng c dng dch ung, c th s dng dng vin 400mg SMX + 80mg TMP, pha v chia nh liu nh trn.

Cc bc Ngy 1 Ngy 2 Ngy 3 Ngy 4 Ngy 5 T ngy th 6

Liu dng

1.5. Thi gian iu tr d phng cotrimoxazole cho ngi ln nhim HIV: Bng 5: Thi gian iu tr d phng cotrimoxazole cho ngi ln nhim HIV Bnh nhn X tr Ngi bnh cha Duy tr d phng lu di c iu tr ARV Ngi bnh ang Ngng d phng: Ngng d phng khi ngi bnh c CD4 > iu tr ARV 200 TB/mm3 t 6 thng tr ln. Nu khng lm c xt nghim CD4, ngng d phng khi ngi bnh iu tr ARV t nht 1 nm, tun th tt, v khng c biu hin lm sng lin quan n HIV. Ti d phng: Ti d phng khi ngi bnh c s CD4 gim xung <200 TB/mm3 2. D phng lao tin trin bng isoniazide (INH): Mc tiu: d phng chuyn t nhim lao sang bnh lao
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 i tng: Tt c nhng ngi nhim HIV (ngi ln v tr em) c sng lc hin khng mc bnh lao tin trin. Phc : Isoniazide (INH) liu 5 mg/kg/ngy (liu ti a ngi ln: 300 mg/ngy); ung mt ln hng ngy trong 9 thng; phi hp vitamin B6 liu lng 25mg hng ngy. Theo di nh gi: Cp thuc hng thng v nh gi vic dng thuc t nht 1 thng/ln. Tip tc iu tr sau b tr: Nu ngi bnh b iu tr s liu t hn 50% tng liu th c th b sung cho , nu s liu b qu 50% tng liu th nn bt u iu tr t u. Tc dng ph: Nh: vim thn kinh ngoi vi. X tr bng vitamin B6 liu lng 100mg/ngy. Nng: tn thng gan (vng da, chn n, men gan tng cao). X tr: ngng INH v chuyn n cc c s y t iu tr. Khng c ung ru, bia trong thi gian dng thuc.

14

IV. TIP CN MT S HI CHNG LM SNG THNG GP NGI NHIM HIV/AIDS 1. St ko di

St ko di (a, b)

(
Hi tin s, bnh s (c) Khm lm sng (d)

H st, t vn dinh dng

Gi cc cn nguyn gy st (e):

- Biu hin h hp: Lao, PCP, vim phi do vi khun - Biu hin thn kinh: VMN do vi khun, lao, cryptococcus, vim no do Toxoplasma - Tn thng da: Penicillium - Hch to: Lao, MAC, nhim nm huyt - Tiu chy: Salmonnella, lao rut, MAC - Thiu mu: Lao, vim ni tm mc, MAC, nhim nm huyt, st rt - Tin s dng thuc: d ng

Xt nghim c bn v theo gi cn nguyn (e): - CTM, CD4 (nu c th) - TC h hp: X-quang phi, AFB m - Biu hin thn kinh: chc dch no ty Nhim khun huyt, nm Penicillium: cy mu - Hch to: chc ht hch

iu tr theo kinh nghim (e): Nhim khun huyt: khng sinh ph hp Bnh nm Penicillium: itraconazole PCP: co-trimoxazole Lao: thuc chng lao, hoc MAC nu khng p ng lao - VMN do vi khun hoc Cryptococcus: khng sinh ph hp - Vim no do Toxoplasma: co-trimoxazole -

C kt qu xc nh chn on v/hoc Ngi bnh p ng vi iu tr theo kinh nghim

Khng c kt qu xc nh chn on, ngi bnh khng p ng vi iu tr theo kinh nghim

Tip tc v hon thnh iu tr. iu tr duy tr nu c ch nh

nh gi li lm sng, cn nhc cc nguyn nhn khc, lu lao, MAC hoc st do HIV - Lm cc XN v thm d tng ng, xem Hng dn qun l st ko di: xt sinh thit hch, tu xng, CT Scan, siu m tim, v.v... - iu tr theo hng lao; nu khng tin trin, cn nhc iu tr MAC H-ng n Xemd xt ch nh iu tr ARV

15

Hng dn: (a) nh ngha: st ko di c xc nh khi st 38oC, ko di trn 14 ngy m cha xc nh c nguyn nhn. (b) Cc cn nguyn thng gp gy st ko di Cc NTCH: lao, bnh do nm Penicillium, vim mng no do Cryptococcus, nhim trng huyt do Salmonella v cc vi khun khc, MAC, v.v... Bnh c tnh lin quan ti HIV: u lympho Phn ng vi cc thuc: d ng cotrimoxazole, NVP, ABC, v.v... St do HIV, st rt Cc triu chng t cc c quan: au u (vim mng no do nm hoc lao, Toxoplasma), tiu chy (nhim trng huyt do Salmonella, MAC, v.v..), ho (lao phi), pht ban (bnh do nm Penicillium, d ng thuc), v.v.. Cc thuc s dng: cotrimoxazole , ARV, cc thuc khc. Tin s mc cc bnh NTCH v cc bnh l khc lin quan ti HIV (kh nng ti pht ca cc NTCH nu khng c iu tr d phng th pht hoc khng c iu tr ARV) Tin s d ng thuc v cc bnh l khc. Tin s tim chch ma tu (nhim trng huyt do t cu vng), quan h tnh dc khng an ton (lu, giang mai, cc bnh ly qua ng tnh dc khc) Tin s gia nh: tin s lao, ho v cc bnh truyn nhim khc

(c) Hi tin s, bnh s:

(d) Khm lm sng: Thm khm tt c cc c quan v b phn, tp trung vo nhng c quan c biu hin bnh (e) Xem cc cn nguyn gy nhim trng c hi, xt nghim v thm d xc nh chn on, v iu tr ti Chng V Chn on v iu tr cc bnh nhim trng c hithng gp

16

2. H hp

H hp (a, b)
- Hi bnh v nh gi lm sng (c) X-quang phi bnh thng hoc thm nhim lan to hoc trn kh mng phi BN kh th nh hoc trung bnh Bnh tin trin t t, BN suy gim XQ phi nghi lao Din bin mn tnh hoc bn cp Ho m, st, suy kit hoc khng Khi pht cp tnh St, ho c m, au ngc () X-quang phi: thm nhim thu Cn nhc PCP, iu tr th co-trimoxazole

Xt nghim c bn
Chp XQ phi, soi m tm AFB (d) Cc xt nghim v thm d khc AFB (-) AFB (+) iu tr lao

Cc bc chn on lao phi AFB (-) theo Hng dn quc gia

Cn nhc vim phi do ph cu. iu tr khng sinh (e) Cn nhc vim phi do t cu vim ni tm mc, iu tr khng sinh (e)

iu tr cn nguyn nu xc nh c (e)

Tin s tim chch ma tu St, kh th X-quang phi: nt m lan to, tn thng p xe

Tnh trng BN khng tin trin: - nh gi li lm sng - Lm li cc xt nghim cn thit (X-quang phi, m, cy mu, chc hch, v.v..) - iu tr theo hng lao nu trc cha iu tr - Xem xt cc cn nguyn khc (nm, CMV), iu tr thch hp

17

Hng dn: (a). Cc biu hin h hp: ho, kh th; thng i km vi st (b). Nguyn nhn: - Nguyn nhn hay gp: Lao phi-mng phi, vim phi PCP, MAC, vim phi do vi khun. - Nguyn nhn khc: bnh do nm Penicillium, Cryptococcus, Histoplasma (biu hin phi trong bnh cnh nhim nm ton thn); bnh do Cytomegalovirus; - Cc nguyn nhn khng nhim trng: u lympho, sarcoma Kaposi. (c). Nhng im cn lu khi hi bnh v khm bnh: Hi bnh: - Khi pht cp tnh, bn cp - Tnh trng kh th lin quan n gng sc - Tnh cht m - Du hiu i km: st, au ngc - Tin s tim chch ma tu - Tin s lao ca bn thn v trong gia nh Lm sng: - Tnh trng suy h hp: kh th, tm ti - Cc biu hin ton thn: st, st cn, pht ban, sng hch, v.v.. - Khm h hp: rale, rung thanh, - Du hiu khc: biu hin suy gim min dch nh nm hng, suy kit

(d). Xt nghim chn on: Da trn cc triu chng lm sng v bnh s - Xt nghim c bn, t bo CD4, - X-quang phi, soi m tm AFB; soi cy m tm cc vi khun khc. - Cy mu nu BN c st - Chc d mng phi, hch nu c trn dch mng phi hoc hch to; xt nghim dch mng phi v dch t hch - Nu c iu kin: chp ct lp lng ngc (e). Xem Chng V Chn on v iu tr cc bnh nhim trng c hi thng gp

18

3. Thn kinh (a, b)

Hi bnh s (c) Thm khm lm sng (d) Lm cc XN c bn v theo gi lm sng (e) CT s no nu c biu hin thn kinh khu tr hoc bnh

Nghi ng HC mng no

Biu hin thn kinh khu tr trn lm sng v/hoc tn thng nghi ng vim no do Toxoplasma trn phim CT Scan s

Chc dch no tu (g) XN protein, ng, t bo, Soi cy tm vi khun, soi AFB, nm

Chn on theo kt qu thm khm lm sng v xt nghim DNT (h): - VMN do Cryptococcus - VMN do lao - VMN do vi khun iu tr khng sinh ph hp Tip tc cc bin php thm d Xem xt cc cn nguyn khc (lao mng no, vim no, u lympho, v.v..) Chuyn tuyn trn nu khng lm c cc thm d cn thit

iu tr theo hng vim no do Toxoplasma (h)

C

Tin trin sau 1-2 tun iu tr

Khng

Hon thnh iu tr

19

Hng dn: (a) Cc biu hin thn kinh: au u, ri lon thc, du thn kinh khu tr. (b) Nguyn nhn: - Cc nhim trng c hi h TKT: vim no do Toxoplasma, vim mng no do Cryptococcus, lao mng no, vim mng no do vi khun - Cc nguyn nhn khc: u lympho, bnh l no do HIV, vim no cht trng a tin trin (PML) - Nguyn nhn do thuc: d4T, EFV (c) Hi bnh s: - Thi gian c triu chng - Cc biu hin km theo: st, pht ban, gy st, v.v.. - Tin s lao ca bn thn v gia nh (d) Thm khm lm sng: - Pht hin cc biu hin thn kinh: ri lon tinh thn, du hiu mng no (au u, cng gy, s nh sng), du thn kinh khu tr (lit na ngi, lit dy TK s). - Pht hin cc biu hin ton thn: st, hch to, pht ban, biu hin suy gim min dch (e) Cc xt nghim v thm d: theo gi t bnh s v thm khm lm sng - Cy mu tm vi khun v nm nu c st - Chp X-quang phi v cc xt nghim khc tm lao nu nghi ng lao mng no (f) Hnh nh vim no do Toxoplasma in hnh: iu tr theo Hng dn trong phn Nhim trng c hi. Cc tn thng khc: xem xt chn on lao mng no-no, pxe do vi khun, bnh l no do HIV, v.v..; nh gi v thm d ph hp. (g) Gi chn on phn bit theo tnh cht dch no tu:
Nguyn nhn VMN do cryptoccocus VMN do lao VMN do vi khun Vim no do Toxoplasma U lympho p lc Tng cao Tng hoc BT Tng BT BT Protein Tng nh hoc BT Tng t nh n rt cao Tng cao BT hoc tng nh BT Nhum soi Nui cy trc tip Tng nh hoc + + bnh thng Nhum mc tu T bo Tng (BC lympho) Tng BC ht BT BT +/- - +/+/+ -

h) Xem Chng V Chn on v iu tr Cc bnh Nhim trng c hi thng gp

20

4. Nut au
Nut au (a, b)

iu tr theo hng nm Candida thc qun (c)

Ci thin sau 7 ngy iu tr

C Khng

Cn nhc iu tr theo hng Herpes Khng simplex (d)

Ci thin sau 7 ngy iu tr

Khng

Chuyn ni soi thc qun

Tip tc iu tr trong 14 ngy iu tr d phng cotrimoxazole; bt u iu tr ARV

Tip tc iu tr trong 14 ngy iu tr d phng cotrimoxazole, bt u iu tr ARV

Hng dn: a. nh ngha: Nut au l cm gic au hng v au sau xng c khi ngi bnh nut thc n, c th i km vi cm gic kh nut, thng l triu chng ca vim thc qun b. Cc nguyn nhn gy nut au ngi nhim HIV: - Nm Candida - Herpes simplex - Cytomegalovirus - Lot apht - Sarcoma Kaposi, u lympho c. iu tr vim thc qun do Candida, Herpes simplex (Xem Chng V Chn on v iu tr Cc bnh Nhim trng c hi thng gp).

21

5. Tiu chy mn tnh (a, b)

Hi bnh s (c) Thm khm lm sng (d) nh gi mc mt nc, b nc v in gii, t vn ch n hp l

Soi, cy phn tm nguyn nhn, cc xt nghim v thm d khc (e)

Khng xc nh c cn nguyn hoc khng lm c xt nghim iu tr th fluoroquinolone v metronidazole (f) trong 7 ngy
Khng

Xc nh c nguyn nhn: iu tr theo nguyn nhn

Ci thin
C

Albendazole + cotrimoxazole (g) iu tr loperamide (h)

Khng Cn nhc cc nguyn nhn khc nh lao, MAC v iu tr ph hp iu tr ARV iu tr d phng co-trimoxazole

Hon thnh iu tr trong 14 ngy

Ci thin
C -

Hon thnh iu tr trong 21 ngy

23

Hng dn:
(a) nh ngha: Tiu chy mn tnh c xc nh khi ngi bnh i phn lng hoc nt trn 3 ln mt ngy, ko di trn 14 ngy (b) Cc cn nguyn gy tiu chy: - Cc bnh nhim vi khun: Salmonella, Shigella, Campylobacter - Cc bnh do k sinh n bo v giun sn: Giardia, Amip, Cryptosporidium, Isospora, Microspora, giun ln - Cc bnh do Mycobacteria: lao, MAC - Bnh do virus: CMV - Bnh c tnh lin quan ti HIV: sarcoma Kaposi, u lympho - Do HIV (c) Hi bnh s: - S ln tiu chy mi ngy, tnh cht phn - Cc triu chng km theo: st, au bng, v tr v tnh cht au - Tin s dng ARV v cc thuc khc; cc thuc khng sinh s dng iu tr tiu chy - Tin s lao v cc bnh truyn nhim khc trong gia nh (d) Thm khm lm sng: - nh gi ton trng, tnh trng mt nc, dinh dng - Cc biu hin ton thn: st, ni hch; thm khm cc c quan h hp v tun hon - Thm khm bng: pht hin au, trn dch mng bng, gan lch to, hch bng (e) Cc xt nghim v thm d: - Soi phn tm hng cu v bch cu (tiu chy xm nhp); soi tm k sinh n bo thng thng (amip, giardia), u trng giun ln, giun mc, cc loi trng giun; soi phn phng php tp trung formalin-ether v nhum kim toan ci tin tm Cryptosporidium, nhum ba mu tm Microsporidium v Isospora; soi tm AFB (lao v MAC), nu c iu kin - Cy mu nu ngi bnh c st, nghi tiu chy km nhim trng huyt do vi khun - Chp X-quang phi, xt nghim m nu c biu hin h hp hoc nghi lao - Siu m bng nu c th thc hin c, xc nh gan lch to, hch to, dch mng bng (f) Fluoroquinolone ung (ciprofloxacine 500mg, 2 ln/ngy hoc ofloxacine 200mg, 2 ln/ngy) + metronidazole ung 500 mg 2ln/ ngy. C tc dng vi Shigella, Salmonella, Campylobacter, Amip v Giardia. Lu loi tr lao trc khi iu tr fluoroquinolone (g) Albendazole 200 mg 2- 4 ln/ngy + cotrimoxazole 960 mg 1-2 ln/ngy. C tc dng vi Isospora, Microsporidia, giun ln (h) Loperamide bt u 4 mg, sau thm 2 mg sau 4 gi nu phn cha thnh khun, ti a 16 mg/ngy. Khng dng loperamide cho ngi bnh tiu chy phn c mu, m.
24

6. Hch to (a)
Hi bnh s (b) Thm khm lm sng

C cc du hiu: - S t - St cn - Hch to khng i xng - Hch tng m - Hch mm - Biu hin cc c quan
Khng

Tm bt c du hiu c gi tr chn on hoc gi lao, vi khun, nm. Lm cc XN c bn (d) Hch vim ti ch, lin quan n tim chch St, st cn, hch to ti ch hoc nhiu ni, triu chng gi bnh lao

Cn nhc iu tr nhim trng t cu (e), Cy mu nu c th

Ci thin

Sng hch ton thn ko di (c)

Chc ht t bo hch tm AFB, tn thng lao, soi cy nm, vi khun

Khng ci thin

Hon thnh iu tr

iu tr lao hch (e)

Lao hch
C

Tm thy cn nguyn

Khng

iu tr theo cn nguyn (e)

Nguyn nhn khc: vi khun, nm, MAC, u c tnh

Sinh thit xc nh nguyn nhn, cn nhc iu tr lao, MAC Chuyn tuyn trn nu khng c iu kin thc hin cc xt nghim trn

Hng dn: (a) Cn nguyn: hch to ngi bnh c triu chng thng do nguyn nhn nhim trng hoc bnh c tnh. Nguyn nhn nhim trng: Lao, nm Penicillium, Cryptococcus, t cu, c th do MAC, Nocardia, giang mai, Histoplasma, Leishmania Nguyn nhn c tnh: u lympho, Sarcoma Kaposi Do HIV (gy sng hch ton thn ko di ngi nhim HIV khng triu chng). (b) Hi bnh s: Thi gian b hch to, cc triu chng km theo: st, au vng hch sng, pht ban, ho, v.v.. Tin s mc v iu tr cc bnh nhim trng c hi (bnh do nm Penicillium, lao, v.v..) v cc bnh khc (c) Thm khm: nh gi ton trng, pht hin cc triu chng ton thn: st, suy kit, nm hng, pht ban, thiu mu, v.v.. Thm khm hch, nh gi kch thc v tnh cht hch Pht hin cc biu hin bnh cc c quan khc, pht hin hch to bng, gan lch to (d) Xt nghim c bn: cng thc mu, s t bo CD4 nu c iu kin, XQ phi (e) Xem Chng V Chn on v iu tr Cc bnh Nhim trng c hi thng gp
25

7. Thiu mu (a, b)

Hi bnh s (c) Thm khm lm sng, CTM (d)

iu tr triu chng, truyn mu khi cn thit, vitamin B12, folat, dinh dng

ang s dng cc thuc: AZT, CTX

Khng

Tm cc cn nguyn nhim trng c hi (e)

Dinh dng km, mt mu

Lao, Vim ni tm mc Nhim nm huyt St rt

Nut au, tiu chy Mt mu Khng dinh dng do khng thc n

Thay AZT bng d4T

iu tr thch hp

Khng

Ci thin
C

Hon thnh iu tr

nh gi su hn, cn nhc thiu mu do HIV iu tr ARV, khng dng AZT trong phc

26

Hng dn: (a) nh ngha: Thiu mu c xc nh khi Hgb < 120g/L i vi nam v < 100 g/L i vi n (b) Nguyn nhn: - Nhim trng: lao, bnh nm ton thn, vim ni tm mc, MAC, st rt - Thiu dinh dng, nut kh, tiu chy mn tnh - Do thuc: AZT, CTX - Mt mu, cc bnh ni khoa gy suy tu - Bnh c tnh, do bn thn HIV (c) Hi bnh s: - Thi gian b cc triu chng lin quan n thiu mu (mt mi, tai, hoa mt, chng mt) - Cc biu hin st, tiu chy, nut au, ho, pht ban, v.v.. - Tin s b cc bnh nhim trng c hi - Tin s dng cotrimoxazole , AZT v cc thuc khc - Tin s tim chch ma tu, i n vng st rt - Tin s b mt mu, ch dinh dng (d) Thm khm lm sng - nh gi mc thiu mu, dinh dng, pht hin biu hin ca cc bnh NTCH (e) Xt nghim cn lm: - CTM: Hb, cc dng t bo mu khc; th tch trung bnh hng cu (MCV) (thiu mu hng cu ln - gi thiu vitamin B12, do cotrimoxazole , AZT; thiu mu hng cu nh - gi cc bnh NTCH, mt mu) - XN tm k sinh trng st rt nu c tin s dch t. - XN chn on NTCH: soi m tm AFB, xt nghim nm - Tu , sinh thit hch, sinh thit tu xng v cc xt nghim khc nu thc hin c

27

8. Tn thng da v nim mc
Nt sn da Mn nc, bng nc
Ban dng dt hoc sn

Ban hoc thng tn da lin quan n HIV

Penicillium marneffei (sn lm c hoi t gia) U mm ly, nhim nm Cryptococcus hoc lao. Bnh mo g sinh dc: tn thng kiu mn cm

- Mn nc trong gii hn mt vng da; km theo rt bng hoc au: Herpes zoster (Zona) - Mn nc ri rc: Herpes simplex, chc

Phn ng thuc, Giang mai Gh: sn, nga nhiu, c th thy ng hm, c th gp gh Nauy

Nghi nhim nm P.marneffei: co da soi v nui cy. iu tr thch hp - Acyclovir trong vng 7-10

ngy

X tr theo cn nguyn Khng ci thin: Chuyn chuyn khoa da liu

Vim da tit b nhn (vim da du): dt c vy dc theo rnh mi m, chn tc. Vim nang lng tng bch cu i toan: ban dng trng c mt, ngc lng Pht ban sn nga Kh da v nga lin quan n HIV Vy nn: ban nga, ng vy trng. Sarcoma Kaposi

Khng ci thin: sinh thit lm m bnh hc, soi v nui cy iu tr kinh nghim i vi nguyn nhn c kh nng nht, nu trc cha iu tr

Ci thin: hon thnh iu tr Khng ci thin: chuyn chuyn khoa da liu

iu tr triu chng, phi hp chuyn khoa da liu Xem xt iu tr ARV

28

Hng dn: 1. Cc cn nguyn gy tn thng da v nim mc: - Nhim khun: vim nang nng, mn nht do cu khun, vim m mm, tn thng da do lao. - Nhim vi rt: Herpes simplex, Herpes zoster (zona), u mm ly (Pox virus), virus gy u nh ngi (HPV), bch sn dng lng (virus Epstein-Barr) - Nhim nm: Candida, Penicillium, cc loi nm da khc (hc lo, nm mng), Cryptococus, - Nhim k sinh trng: gh - Bnh c tnh: Sarcoma Kaposi, u lympho - Cc vim da khc: vim nang lng tng bch cu i toan, vim da du ban sn nga (PPE), vy nn, kh da. - Phn ng thuc: cotrimoxazol, thuc ARV c th gy pht ban, da ton thn, hng ban a dng, Hi chng Stevens-Johnson. 2. Nhng im lu khi hi v khm ngi bnh c tn thng da: Hi bnh: - Thi gian b bnh ? - Tn thng bt u mc t u? - C nga hay khng c nga? - C tin s bnh d ng nh: hen, d ng thi tit hay khng? - Cc thuc ang ung l nhng thuc g? Thi gian dng thuc c bao lu? - Cc triu chng km theo nh st, Lm sng: - Dng tn thng: dt, nt sn, mn phng, hay lot, - Phn b ca cc tn thng da - nh gi tin trin ca tn thng - Du hiu khc: biu hin suy gim min dch (nm hng, suy kit), ... - Cc biu hin i km: st, gan lch to, biu hin thn kinh,

3. Chn on v iu tr theo cn nguyn: (Xem Chng V Chn on v iu tr Cc bnh Nhim trng c hi thng gp)

27

9. Suy mn (a, b) Hi bnh s (c) Thm khm lm sng (d)

n ung khng Lo u, trm cm

Nut au, c th km nm ming

St, tiu chy hoc cc triu chng ton thn khc

Th ch n c hm lng protein v calo cao iu tr trm cm

iu tr nm candida thc qun H tr dinh dng

Tnh trng bnh khng ci thin

Thm d chn on NTCH (e) - St: xem xt lao, MAC (xem hng dn "St ko di") - Tiu chy: Chn on tiu chy

Nu khng c chn on hoc tnh trng bnh khng ci thin: nh gi li, xem xt hi chng suy mn do HIV (f) Xem xt iu tr ARV Xem xt iu tr cc thuc tng chuyn ho
28

Chn on xc nh iu tr cn nguyn H tr dinh dng

Hng dn: (a) Mc st cn do ngi bnh m t hoc so snh cn nng hin ti vi cn nng c tnh theo chiu cao. (b) Nguyn nhn: - Nhim trng: cc NTCH nh lao, tiu chy mn tnh do k sinh n bo, bnh nm ton thn v MAC - Thiu dinh dng do khng c thc n - Khng n c do nut au (vim thc qun do nm Candida) - Bnh l tm thn: lo u, trm cm (c) Hi bnh s: - Thi gian b gy st, mc st cn - Cc biu hin st, tiu chy, nut au, ho, v.v.. - Tin s b cc bnh nhim trng c hi - Ch dinh dng - Cc biu hin lo u, trm cm (d) Thm khm lm sng - nh gi mc gy st, cc biu hin ph, thiu mu - Pht hin biu hin ca cc bnh NTCH (nm hng, hch to, v.v...) (e) Xt nghim cn lm: - X-quang phi, soi m tm AFB nu nghi ng lao - Cy mu nu nghi nhim trng huyt hoc nhim nm huyt - Soi phn tm k sinh n bo (f) Hi chng suy mn do HIV: - St trn 10% trng lng c th - Km theo - a chy ko di (phn lng trn 2 ln/ngy) trong t nht 30 ngy - hoc st ko di trong t nht 30 ngy - Khng tm c cn nguyn no khc (v d lao, ung th) gii thch cho cc biu hin .

29

V. CHN ON V IU TR CC BNH NHIM TRNG C HI THNG GP Bng 6: Chn on v iu tr cc bnh nhim trng c hi thng gp
NTCH Lm sng Nm Candida ming: nhiu m hoc m gi mc mu trng, xp, mn, d bong li, li, mt trong m, vm hng, mt trc amidan, thnh sau hng. Chn on iu tr*

1. Cc bnh do nm
Da vo lm sng Ch soi cy nm khi lm sng Fluconazole 100-150 mg/ngy x 7 ngy; hoc khng in hnh hoc iu tr Ketoconazole 200 mg 2 ln/ngy trong 7 ngy. khng kt qu Fluconazole 200-300 mg/ngy x 14 ngy, hoc Itraconazole 400mg/ngy x 14 ngy; hoc Ketoconazole 200 mg 2 ln/ngy x 14 ngy Fluconazole 150-200 mg ung liu duy nht; nu ngi bnh suy gim min dch nng th dng liu cao v ko di hn, hoc: Itraconazole 100 mg ung 2 vin/ngy x 3 ngy lin tip; hoc clotrimazole 100 mg hoc miconazole 100 mg t m o 1vin/ngy x 3-7 ngy, hoc clotrimazole 500mg 1 ln, nystatin 100.000 n v, t m o 1 vin/ngy x 14 ngy. - Phc u tin: amphotericin B tnh mch 0,7mg/kg/ngy x 2 tun, sau fluconazole 800-900 mg/ngy x 8 tun. - Phc thay th: fluconazole 800-900 mg/ngy x 8 tun (cho trng hp nh khng c bin chng hoc trong trng hp khng c amphotericin B). iu tr tng p lc ni s: chc dn lu dch no tu hng ngy mt hoc nhiu ln ty mc tng p lc ni s, mi ln dn lu 15-20 ml hoc cho ti khi ngi bnh bt au u (mannitol v corticoid khng c tc dng) iu tr duy tr: fluconazole 150-200 mg/ngy, sut i; ngng s dng khi ngi bnh iu tr ARV c s CD4 > 200 TB/mm3 6 thng

Bnh do nm Candida

Ch yu da trn lm sng. Soi thc qun: nu ngi bnh Nm thc qun: nut au c iu tr nh nm thc qun m khng . Nm sinh dc: Ch yu da trn lm sng. Ngi bnh c biu hin nga, rt; kh Soi ti tm nm hoc nui cy h ng thnh mng trng nh vng phn loi: nu lm sng khng sa. m h-m o , ph n v au. in hnh hoc iu tr khng Bnh hay ti pht. hiu qu.

Bnh do nm Cryptococcus

Nhim nm huyt: st, tn thng da dng sn hoi t, thm nhim phi, vim mng no Vim mng no: au u, s nh sng, hi chng mng no, ri lon thc, du thn kinh khu tr; st

Sinh thit da hoc chc ht hch soi tm nm, cy mu Xt nghim dch no ty, nhum mc tu v cy tm nm

30

Bnh do nm Penicillium marneffei

- Tn thng da n thun: cc mn sn trn da, lm trung tm, hoi t to vy en, khng au, khng nga, mt, hoc ton thn. - Nhim nm huyt: st, tn thng da, thiu mu, gan lch to, hch to, suy kit. - Nm phi: ho khan, st, c th c kh th mc nh v va. Chn on phn bit vi lao k v PCP Ho, kh th, st, ra m hi m Din bin bn cp 1- 2 tun

- Da vo cc triu chng lm sng nh trn. - Soi ti bnh phm da, tu xng, hch v cy tm nm. - Cy mu v nui cy cc bnh phm trn trong mi trng Sabbouraud 25-37oC. Da vo lm sng XQ phi bnh thng trn 90% bnh nhn; in hnh: thm nhim k lan ta hai bn p ng vi iu tr th bng cotrimoxazole c th c s dng chn on Nu c iu kin: ly dch ra ph qun nhum Giemsa, nhum bc, min dch hunh quang tm P. jiroveci.

- Phc u tin: amphotericin B (0,7 mg/kg/ngy) trong 2 tun sau itraconazole 200 mg 2 ln/ngy x 8- 10 tun - Phc thay th (cho trng hp nh hoc khng c amphotericin B): itraconazole 200 mg 2 ln/ngy x 8 tun iu tr duy tr: itraconazole 200 mg/ngy, sut i; ngng khi ngi bnh iu tr ARV c s CD4 > 200 TB/mm3 6 thng. Cotrimoxazole: liu da trn TMP (15mg/kg/ngy chia 4 ln) x 21 ngy; ngi bnh < 40 kg: TMP- SMX 480 mg, 2 vin/ln x 4 ln; ngi bnh > 40 kg: TMP- SMX 480 mg, 3 vin/ln x 4 ln. Trong trng hp suy h hp: prednisolon (ung hoc tnh mch) (40mg x 2 ln/ngy x 5 ngy, sau 40mg x 1 ln/ngy x 5 ngy ri 20 mg x 1 ln/ngy x 11 ngy). iu tr duy tr: cotrimoxazole 960mg ung hng ngy cho n khi ngi bnh iu tr ARV c CD4 >200 TB/mm3 ko di 6 thng Phc thay th: Clindamycin 600 mg tim tnh mch hoc 450 mg ung ngy 3 ln + primaquine 15 mg ung 1 ln/ngy trong 21 ngy nu d ng sulfamid Cotrimoxazole: liu da trn TMP 10 mg/kg/ngy tim tnh mch hoc ung trong 6 tun hoc Pyrimethamine (200 mg liu tn cng, sau 50-75 mg 1 ln/ngy) + sulfadiazine (2-4g/liu u sau 1- 1,5 g 6 gi /1 ln) trong 6 tun. iu tr duy tr: Pyrimethamine (25-50 mg/ngy) + Sulfadiazine (1g x 6 gi/ ln/ngy); ngng khi ngi bnh iu tr ARV c CD4 trn 100 TB/mm3 6 thng. iu tr ARV l tt nht Tiu chy do Microsporidia v Isospora c th p ng vi albendazole 400 mg ung 2 ln/ngy trong 3 tun v cotrimoxazole 960 mg ung 2 ln/ngy trong 10 ngy

Vim phi do Pneumocystis (PCP)

Vim no do Toxoplasma

au u, chng mt, co git, tn Du hiu thn kinh khu tr thng thn kinh khu tr Tn thng chon ch mt hoc St nhiu trn CT hoc MRI s no (nu c) p ng vi iu tr th c th c s dng chn on Soi phn tm k sinh trng

2. Cc bnh do k sinh n bo

Tiu chy do k Tiu chy mn tnh sinh n bo Nn, au bng (Cryptosporidium, Microsporidia Isospora)

31

3. Cc bnh do vi khun
St ko di hoc ti pht, st cn, mt Phn lp c MAC trong mu Phc u tin: clarithromycin ung 500mg x 2 ln/ngy + mi, thiu mu, gan lch, hch to. Cn hoc v tr khc, thng kh thc ethambutol ung 15mg/kg/ngy. chn on phn bit vi lao. hin Phc thay th: azithromycin ung 500mg/ngy + Bnh do phc hp ethambutol rifabutin ung 300mg/ngy; hoc Cn nhc chn on MAC nu azithromycin ung 500mg/ngy + ethambutol hoc Mycobacterium avium (MAC) ngi bnh khng p ng vi ciprofloxacin 500mg x 2 ln/ngy. iu tr lao sau 2-4 tun Phi kt hp vi iu tr ARV. Ch ngng iu tr MAC khi ngi bnh c iu tr ARV v c s CD4 tng >100 TB/mm3 >6 thng. - Vi khun gy bnh: t cu vng, lin - Chn on da vo lm sng; - Cn nh gi mc : nh dng khng sinh ng ung, cu; hay gp ngi tim chch ma tu - Soi v cy tm vi khun trong nng dng khng sinh ng tim truyn. Chn cc khng - Lm sng: vim da m, vim nang dch m nu c th thc hin sinh c tc dng vi t cu, lin cu: oxacilin, Vim a c m lng, vim m mm, abscess c v m cephalosporin th h I (cephalothin, cephazolin v.v...), cc c mm; st hoc khng; cc biu hin khng sinh khc. ton thn v cc c quan khc. - Ra, v sinh ti ch nu tn thng lot. Dng cc thuc gim vim, gim ph n Vi khun gy bnh: ph cu, t cu, H. Lm sng c trng. Cephalosporin th h 3 ng tnh mch (cefotaxime, influenzae P.aeruginosae, S. aureus,...; Cn lm sng: bch cu mu v ceftriaxone); khng sinh chng t cu nu vim phi do t cc vi khun him gp nh R.equi, t l bch cu trung tnh tng; cu; khng sinh chng trc khun m xanh nu ngi bnh Vim phi v Nocardia cc loi; Chp X-quang phi c tin s bnh do trc khun m xanh hoc giai on suy mng phi - Lm sng: khi pht t ngt, st, Soi v cy m, cy mu; chc gim min dch nng; cotrimoxazole trong trng hp bnh rt run, au ngc, ho khc m c, d mng phi, soi v cy vi do Nocardia, v.v... c th c kh th; thm khm c hi khun, nu c iu kin; chng ng c hoc hi chng ba gim, rales phi; - Vi khun gy bnh: ph cu, cc vi Da vo lm sng; iu tr theo kinh nghim bng ceftriaxone tnh mch 3khun khc, bao gm c cc vi khun Chc d dch no tu, xt 4g/ngy; iu chnh khng sinh theo vi khun phn lp him gp nh R.equi, nghim sinh ho, t bo, soi v c v kt qu khng sinh . Trong trng hp khng Vim mng no Chryseobacterium meningosepticum, cy dch no ty, phn lp c vi khun, iu chnh khng sinh theo phn v.v... Cy mu nu c th; on v cn nguyn trn c s cc triu chng v biu hin vi khun - Lm sng: khi pht t ngt, hoc Chp CT s no nu nghi ng bnh km theo. bn cp, st, au u, hi chng mng abscess no v nu c iu kin no; c th c abscess no. 32

Nhim trng huyt

Cc bnh tiu chy do vi khun

- Vi khun gy bnh: Salmonella cc loi, S. aureus, E.coli, Proteus mirabilis, Serratia marcescens, P. aeruginosa, R.equi, v cc loi vi khun khc - Lm sng: st, rt run, tiu chy (Salmonella cc loi, E.coli), vim m mm (S. aureus), abscess phi v cc c quan ni tng (S. aureus, R.equi, Nocardia cc loi, P. aeruginosa), vim mng no v/hoc abscess no (R.equi), v.v... - Vi khun: Salmonella, Shigella, Campylobacter v mt s vi khun ng rut khc - Lm sng: st, i ngoi nhiu ln phn nc hoc c nhy mu km theo; c th c au qun bng, mt rn. Thng din bin nng, ko di v hay i km vi nhim khun huyt; c th c cc di bnh phi, khp, gan mt, ty xng.

Lm sng v cy mu nu c iu kin [mt s vi khun cn mi trng c bit hoc thi gian nui cy ko di (Nocardia)]; Chp X-quang hoc siu m nu c di bnh (phi, gan, lch, v.v..); Chc d cc di bnh (abscess m mm hoc ni tng, vim mng no), soi v cy bnh phm tm vi khun gy bnh. - Soi phn c hng cu v/hoc bch cu (tiu chy xm nhp) - Cy mu ; cy phn; cy m hoc dch t di bnh

iu tr theo kinh nghim theo gi t lm sng (khng sinh c tc dng vi vi khun Gram (-) nu ngi bnh c st v tiu chy; khng sinh c tc dng vi t cu nu ngi bnh c tim chch, c vim m mm v tn thng phi, v.v...). iu chnh khng sinh theo kt qu phn lp vi khun v khng sinh .

- Nu phn lp c vi khun: iu tr theo khng sinh - Trong trng hp khng phn lp c vi khun gy bnh, c th cho iu tr theo kinh nghim bng ciprofloxacin hoc mt thuc quinolone mi khc. Theo di p ng vi iu tr (st, tnh trng phn)

4. Cc bnh do virus
Herpes simplex m phng in hnh, thng b Lm sng in hnh phn sinh dc, mt. C th c biu hin ton thn (vim no do HSV) Acyclovir 200mg x 5 ln/ngy (hoc 400mg x 3 ln/ngy) x 7 ngy Bi ti ch tm gentian hoc chlorhexidine

Herpes zoster Cytomegalovirus (CMV)

Tn thng nt phng thnh tng m, Lm sng in hnh Acyclovir 800 mg x 5 ln/ngy x 7 ngy au, phn b dc theo dy thn kinh b. Bi ti ch tm gentian hoc chlorhexidine C th mt Zona mt: nh thuc m acyclovir - Vim vng mc: nhn m, c nhng Vim vng mc: chn on trn Giai on cp: m en hoc chm en di ng, lm sng bng soi y mt. + Tim ni nhn ganciclovir 2 mg trong 0,05-0,1 ml/ tun 2 33

nhng im ti trc mt; s nh sng; tin trin ti bong vng mc v m hon ton nu khng iu tr. C th 1 bn mt, hoc lan sang mt cn li.. Cc tn thng vng mc khng th phc hi c. - Vim i trng. - Vim thc qun - Vim d dy - Vim no - Vim a r thn kinh - Tn thng da.

Tn thng y mt: cc m hoi t vng mc (mu trng) c hoc khng km theo xut huyt vng mc, n c hoc nhiu m lan to. chn on cc bnh l khc do CMV, nu c c th ly bnh phm sinh thit no, dch no tu, tn thng da, mu lm xt nghim nui cy t bo hoc chn on PCR.

U mm ly

Si mo g sinh dc (do HPV)

Tn thng cc c cung, thng c Lm sng mt, b phn sinh dc, c, nch Biu hin: Cc u nh ging sp l, mu Ch yu da vo lm sng; hng ti, mm, c chn hoc c cung, khng au, d chy mu. - Nam: si rnh qui u, bao da v thn dng vt, c khi ming so. - N: si m vt, mi nh, quanh l niu o, tng sinh mn. - Nhim HPV sinh dc c th lm tng nguy c ung th b phn sinh dc.

ln trong 3 tun, sau duy tr tun 1 ln. Cn thc hin phi hp vi bc s nhn khoa. + Ganciclovir truyn tnh mch 7,5 -10 mg/kg/ngy chia 2 ln trong 21 ngy lin tip hoc lu hn nu khng p ng C th s dng cc thuc di y nu c: + Foscarnet: liu 60 mg/kg/8gi, nu hiu qu dng liu 60120mg/kg/ngy, + Valganciclovir 900mg ung 2 ln/ngy x 21 ngy; hoc + Valganciclovir ni nhn 6 thng mt ln + ganciclovir TM hoc valganciclovir ung nh trn Cy ganciclovir ni nhn 6 thng mt ln iu tr duy tr: Ganciclovir 5/kg/ngy hng ngy, hoc 6mg/kg/ngy iu tr 5 ngy/tun; hoc Valganciclovir ung 900mg/ngy,hoc Foscarnet 90-120mg/kg tnh mch mi ngy; hoc Cy ganciclovir 6-9 thng/ln + ganciclovir 1-1,5g ung 3 ln/ngy Xem xt ngng iu tr khi CD4>100 TB/mm3 Cc bnh l khc do CMV: iu tr tng t bng cc thuc nh trn. Khot b hoc p lnh, chch ti trung tm v bi phenol p ng khi iu tr ARV - Hi chn vi chuyn khoa Da liu. iu tr ti ch theo ch nh ca chuyn khoa bng podophyllin, axt trichloroacetic, t lnh bng ni t lng, laser ccbonnc hoc t in. - p ng vi iu tr bng ARV

* Lu tng tc gia cc thuc iu tr NTCH v cc thuc ARV (xem Ph lc 5)

34

5. Chn on, v iu tr lao cho ngi nhim HIV/AIDS Qun l ngi bnh ng nhim lao/HIV c thc hin theo quy trnh Phi hp trong chn on, iu tr v qun l ngi bnh lao/HIV Quyt nh s 3116/QBYT ngy 21 thng 8 nm 2007 ca B trng B Y t 5.1. Chn on lao: 5.1.1. Sng lc lao: Sng lc lao da trn cc triu chng cho ngi nhim trong tt c cc ln n khm ti cc c s y t. Nghi ng mc lao khi c 1 trong cc du hiu sau: Ho khc m, c th c ho ra mu St ko di Gy st Ra m hi ban m trn 2 tun. Ngi nghi lao cn c khm lm sng, chp X-quang phi v xt nghim m tm AFB chn on lao phi v lao ngoi phi. 5.1.2. Chn on lao phi 5.1.2.1. Chn on lao phi AFB (+) Ngi nhim HIV c t nht 1 tiu bn xt nghim m AFB (+) c coi l lao phi AFB (+) v cn c ng k v iu tr cng sm cng tt (quy trnh chn on). 5. 1.2.2. Chn on lao phi AFB (-) Lao phi AFB (-) ngi nhim HIV c xc nh theo quy trnh chn on v tho mn cc iu kin sau y: 2 tiu bn m AFB (-), hnh nh X-quang phi nghi lao tin trin v bc s chuyn khoa quyt nh.

35

S 1: Quy trnh chn on lao phi ngi nhim HIV

NGI C HIV (+) NGHI LAO v KHNG C DU HIU NGUY HIM a

Xt nghim m tm AFB Chp Xquang phi

AFB dng tnhb iu tr lao, d phng cotrimoxazole, nh gi HIVd C kh nng mc lao

AFB m tnhc XN AFB v cy me , nh gi lm sng, phim X-quangf

t kh nng mc lao

iu tr PCP nh gi HIVd

iu tr khng sinh ph rng g CPTd, nh gi HIVd

p ngh

Khng/t p ng nh gi li chn on lao

p ngh

Ch thch: a Ngi bnh n khng c du hiu nng (t i li c, khng kh th, khng st cao, mch di 120/pht). b Lao phi AFB (+) khi c t nht mt ln xt nghim AFB m dng tnh, c AFB m tnh khi c 2 mu m AFB(-). d nh gi HIV bao gm: phn loi lm sng, xt nghim m CD4 v xem xt iu tr HIV/AIDS (bao gm c iu tr ARV). e Nu c iu kin nui cy f Phim chp X-quang sn c t ln khm u tin, nu c phim chp cc ln trc y so snh cng tt. Ngi bnh c nh gi k v lm sng v X-quang phi chn on xc nh hoc loi tr. g Khng sinh ph rng (tr nhm Quinolone): iu tr theo kinh nghim bng khng sinh ph rng h nh gi li theo quy trnh nu triu chng ti xut hin.

36

S 2: Quy trnh chn on lao phi vi ngi bnh nng c nhim HIV
NGI C HIV (+) NGHI LAO v C DU HIU NGUY HIM a

Chuyn ln tuyn trn Khng sinh tim ph rngb XN AFB v cy m, Xquang phiC

Khng th chuyn ngay Khng sinh tim ph rngb iu tr PCP XN AFB, Xquang phic

Khng lao

Lao

AFB dngd

AFB md

Chm sc, iu tr lao/HIV

Ci thin sau 3-5 ngy nh gi li kh nng chn on laoe

Khng ci thin sau 3-5 ngy Bt u iu tr lao Kt thc khng sinh Chuyn chm sc iu tr lao /HIV

Lng gi li cc bnh lin quan HIV

Kh nng khng mc lao

Ch thch: a C mt trong cc du hiu sau: nhp th >30/pht, st >39oC, mch >120/pht v khng t i li c. b Khng sinh ph rng tr nhm Quinolon. c Cc xt nghim ny cn c thc hin sm tng tc chn on. d AFB dng tnh c xc nh khi c t nht mt ln dng tnh, AFB m tnh - khi c 2 hay nhiu hn cc mu AFB m tnh. e nh gi li lao bao gm xt nghim AFB v nh gi lm sng. 5.1.3. Chn on lao ngoi phi Chn on da trn: - Mt bnh phm t c quan ngoi phi soi trc tip AFB (+) hoc nui cy dng tnh vi Mycobacterium tuberculosis hoc - C chng c m bnh hc t bo hay lm sng ph hp vi chn on lao ngoi phi tin trin v c bc s chuyn khoa quyt nh.

37

Bng 7: Tm tt gi chn on lao ngoi phi thng gp ngi nhim HIV

LAO HCH (NGOI VI) Gi chn on lao: - Kch thc 2 cm - Khng i xng - Sng khng au - Chc/mm/c l d - V tr c, khu tr - St cn, ra m hi m, st Gi loi tr lao: - i xng (c l l lymphoma hay bnh hch lin quan HIV) - au, vim, c m (vi khun hay nm) - V tr ngoi c Xt nghim thit yu - Soi m nu ho - Chc ht XN T bo v AFB X tr ngay - Chc ht chn on t bo hc v XN AFB - Sinh thit hch nu cn TRN DCH MNG PHI Gi chn on lao: - Trn dch mt bn - Dch trong, vng chanh Gi loi tr lao: - Trn dch 2 bn (c th l suy tim hay vim phi) - Lm sng ca ung th - Dch c / c m (c l l m mng phi) - Dch mu Xt nghim thit yu - Xquang phi - Soi m tm AFB nu ho - Chc ht v xem xt dch (sinh ho, t bo) - Sinh thit mng phi, soi mng phi (nu cn) X tr ngay Lao - Bt u iu tr lao Cha chn on lao - Tm nguyn nhn khc - Dch vng chanh, sau 7 ngy khng c chn on khc iu tr nh lao. LAO LAN TA Gi chn on lao: - St cn, st v ho - Bt thng phim phi (c th c lao k) - Gan lch to - m hi m - Thiu mu Gi loi tr lao: - Xem xt Salmonella, ph cu, st rt, Cryptoccocus - St c rt run - Th nhanh (th trn 30 ln/pht) - Tiu chy nng - Mu trong phn Xt nghim thit yu - Xquang phi - Pht mu st rt - Soi m tm AFB - Cy mu, cng thc mu, v KN cryptococus X tr ngay Lao: Bt u iu tr lao (+ khng sinh nu rt nng) Cha chn on lao - Kho st thm cc nguyn nhn khc - Bt u iu tr lao v khng sinh nu ngi bnh rt nng (bao vy) TRN DCH MNG NGOI TIM Gi chn on lao: - St cn, ra m hi m, st - Bng chng lao ni khc - Hai ph trng sng (c th c trn dch 2 bn), bng tim to i xng Gi loi tr lao: - Cc ng m ph huyt qun hay bng tim khng i xng (c th do suy tim) - Huyt p tng - in tim gi nguyn nhn khc ca tim to (tng huyt p, bnh mch vnh, van tim, c tim, ) - St c rt run (vim mng ngoi tim vi khun Gr(-) Xt nghim thit yu - X quang ngc - Soi m tm AFB nu ho - in tim (nu khng c siu m) - Siu m tim, mng tim (l tng) X tr ngay Lao: Bt u iu tr lao - Chuyn vin ht dch cp cu nu rt kh th Cha chn on lao - Tm nguyn nhn khc - Nu siu m xc nhn trn dch mng ngoi tim v khng c chn on khc trong vng 7 ngy iu tr nh lao. VIM MNG NO LAO Gi chn on lao: - St cn, ra m hi m, st - Dch no ty trong vi protein cao, glucose thp v t bo lympho - KN Cryptoccocus / mc tu / cy nm (-) dch no ty - Bng chng lao ni khc Gi loi tr lao: - Dch no ty c hay c bch cu trung tnh trn knh hin vi (c l l vim mng no m) - KN Cryptoccocus (+) - Khi pht nhanh - p lc dch no ty cao (c th l cryptococcus) Xt nghim thit yu - Chc d ty sng - Soi hin vi (nhum gram v AFB) / protein / glucose dch no ty - XN KN v nhum cryptoccoccus - Soi m tm AFB nu ho X tr ngay Lao: Nhp vin v iu tr lao Khng phi lao - iu tr cryptococcus nu XN cryptococcus(+) hay khng c chn on khc.

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5.2. iu tr lao
- Ngi nhim HIV cn c ng k v iu tr lao sm ngay sau khi c chn on lao. - iu tr lao theo phc ca Chng trnh chng lao quc gia ging nh ngi bnh lao khng nhim HIV - Cn phi hp vi iu tr d phng nhim trng c hi khc bng Cotrimoxazole. iu tr ARV cn c xem xt sm v ch n tng tc gia ARV v rifampicin, INH. 5.2.1. Cc thuc chng lao thit yu (hng 1):: Chng trnh chng lao Quc gia quy nh 5 loi thuc chng lao thit yu: Isoniazid (H), Rifampicin (R), Pyrazinamid (Z), Streptomycin (S) v Ethambutol (E). 5.2.2 Ch nh phc iu tr lao: Phc I: 2S (E)HRZ/6HE hoc 2S(E)RHZ/4RH (Ch p dng khi thc hin kim sot trc tip c giai on duy tr): Giai on tn cng ko di 2 thng, gm 4 loi thuc dng hng ngy, E c th thay th cho S. Giai on duy tr ko di 6 thng gm 2 loi thuc l H v E dng hng ngy hoc 4 thng gm 2 loi thuc R v H dng hng ngy. Ch nh: Cho cc trng hp ngi bnh lao mi (cha iu tr lao bao gi hoc tng iu tr lao nhng di 1 thng). Phc II: 2SHRZE/1HRZE/5H3 R3 E3: Giai on tn cng ko di 3 thng, 2 thng u tin vi c 5 loi thuc chng lao thit yu (SHRZE) dng hng ngy, 1 thng tip theo vi 4 loi thuc (HRZE) dng hng ngy. Giai on duy tr ko di 5 thng vi 3 loi thuc H, R v E dng 3 ln mt tun. Ch nh: Cho cc trng hp ngi bnh lao ti pht, tht bi phc I, iu tr li sau b tr, mt s th lao nng v phn loi khc (phn phn loi theo tin s iu tr). Phc III: 2HRZE/4HR hoc 2HRZ/4HR: Giai on tn cng ko di 2 thng, gm 4 loi thuc (HRZE) hoc 3 loi thuc (HRZ) dng hng ngy, iu tr cho tt c cc th lao tr em. Giai on duy tr ko di 4 thng gm 2 loi thuc l H v R dng hng ngy. Ch nh: Cho tt c cc th lao tr em. Trong trng hp lao tr em th nng c th cn nhc dng phi hp vi S. VI. IU TR THUC KHNG HIV (IU TR ARV) 1. Mc ch v nguyn tc iu tr ARV 1.1. Mc ch ca iu tr ARV: - c ch s nhn ln ca virus v km hm lng virus trong mu mc thp nht. - Phc hi chc nng min dch, gim nguy c mc cc bnh nhim trng c hi. - Ci thin cht lng sng v tng kh nng sng st cho ngi bnh 1.2. Nguyn tc iu tr ARV: - iu tr ARV l mt phn trong tng th cc dch v chm sc v h tr v y t, tm l v x hi cho ngi nhim HIV/AIDS. - iu tr ARV ch yu l iu tr ngoi tr v c ch nh khi ngi bnh c tiu chun lm sng, v/hoc xt nghim v chng t sn sng iu tr. - Bt c phc iu tr no cng phi c t nht 3 loi thuc. iu tr ARV l iu tr sut i; ngi bnh phi tun th iu tr tuyt i m bo hiu qu v trnh khng thuc.

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Ngi nhim HIV c iu tr ARV vn phi p dng cc bin php d phng ly nhim virus cho ngi khc. - Ngi nhim HIV c iu tr ARV khi tnh trng min dch cha phc hi cn tip tc iu tr d phng cc bnh nhim trng c hi. 1.3. Cc nhm thuc ARV c s dng ti Vit nam: - Nhm c ch men sao chp ngc nucleoside v nucleotide (NRTI). - Nhm c ch men sao chp ngc khng phi l nucleoside (NNRTI). - Nhm c ch men protease (PI). Chi tit cc nhm thuc ARV thng dng xem Ph lc 4. 2. Tiu chun bt u iu tr ARV Da vo giai on lm sng v s lng t bo CD4 Nu c xt nghim CD4, ch nh iu tr ARV khi: 3. Ngi nhim HIV giai on lm sng 4, khng ph thuc s lng t bo CD4 4. Ngi nhim HIV giai on lm sng 3 vi CD4 < 350 TB/mm3 5. Ngi nhim HIV giai on lm sng 1, 2 vi CD4 < 250 TB/mm3 Nu khng lm c xt nghim CD4, ch nh iu tr ARV khi ngi nhim HIV giai on lm sng 3, 4 3. Chun b sn sng iu tr ARV: Qu trnh chun b iu tr ARV cn phi c tin hnh ngay t khi ngi bnh c qun l ti c s iu tr; cc ni dung chun b sn sng iu tr c th lng ghp trong cc ln khm m bo ngi bnh c iu tr kp thi ngay khi tiu chun iu tr. 3.1. nh gi trc iu tr ARV: Cc ni dung nh gi trc iu tr i vi ngi bnh HIV tiu chun iu tr ARV v lm sng v/hoc CD4, Ghi nhn giai on lm sng v s CD4 (nu c) trc iu tr. Sng lc lao v cc bnh nhim trng c hi; iu tr lao v cc bnh NTCH cp tnh nu c; phi hp vi cc dch v y t khc (lao, sn, da liu, v.v..) khi cn. Lm cc xt nghim c bn v xt nghim la chn phc nh: CTM/Hgb v men gan (ALT); xt nghim HBsAg v anti-HCV (nu c iu kin) Hi tin s dng thuc ARV trc : l do s dng, ni cung cp, phc c th, lu tin s dng cc phc khng ng (phc hai thuc); s tun th, tin trin trong qu trnh iu tr, v.v nh gi mong mun c iu tr ca ngi bnh v kh nng c ngi h tr iu tr D kin phc ARV thch hp cho bnh nhn; xem xt tng tc gia cc thuc ARV v cc thuc iu tr nhim trng c hi ng thi v cc thuc khc (Ph lc 6) Thng bo v k hoch chun b iu tr ARV cho bnh nhn iu tr d phng cotrimoxazole ; cc d phng khc nu c ch nh . 3.2. Cung cp thng tin v T vn v iu tr ARV: Tin hnh cung cp thng tin theo nhm v din bin nhim HIV, d phng ly nhim HIV, sng khe mnh, dinh dng v iu tr ARV sau t vn c nhn. Mi ngi bnh cn c t vn trc khi iu tr ARV 3 ln.

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T vn c th v iu tr ARV, phc iu tr ca tng bnh nhn, tm quan trng ca tun th iu tr v k hoch h tr tun th iu tr cng nh x tr cc vn ny sinh trong qu trnh iu tr nh qun thuc, tc dng ph, T vn cc ni dung c th, thch hp cho cc ngi bnh cn s dng ma ty, ph n c thai. 3.3. nh gi sn sng iu tr: nh gi hiu bit ca ngi bnh v nhim HIV, v iu tr ARV v tm quan trng ca tun th iu tr v cch x tr khi qun ung thuc. nh gi hiu bit ca ngi bnh v cch s dng thuc, cc tc dng ph thng gp v hng x tr. nh gi kh nng tun th iu tr ca ngi bnh qua vic tham gia cc bui t vn y , ti khm ng hn, tun th iu tr d phng cotrimoxazole, c k hoch tun th iu tr (lch ung thuc, cc bin php nhc nh ung thuc, c ngi h tr tun th iu tr); v ngi bnh ng v cam kt tham gia iu tr. Kim tra li cc yu t khc nh: ni c tr, kh nng lin lc khi cn Ngi bnh tiu chun v sn sng iu tr: bt u iu tr ARV Lu : i vi ngi bnh c tnh trng nng (giai on lm sng 4, hoc CD4 < 100 TB/mm3), hoc ngi bnh l ph n c thai: Rt ngn thi gian chun b iu tr, t vn tun th iu tr cho ngi h tr iu tr v hoc cho ngi bnh vo cc ln thm khm tip theo hoc khi ngi bnh n nh 3.4. Bt u iu tr: Hng dn li cch s dng thuc, lch cp thuc, lch hn ti khm; m bo ngi bnh c k hoch tun th iu tr v bit cch x tr khi gp kh khn. Ch nh phc bc mt cho ngi nhim HIV mi bt u iu tr ARV; Ngi nhim HIV c tin s dng cc thuc ARV trc hoc iu tr gin on, cn c nh gi lm sng v xt nghim quyt nh s dng phc bc 1 thch hp hoc chuyn phc bc 2 nu c tht bi iu tr.
-

4. Cc phc iu tr ARV bc mt: 4.1. Phc chnh

AZT + 3TC + NVP hoc d4T + 3TC + NVP

Ch nh: S dng mt trong hai phc ny cho tt c cc ngi bnh bt u iu tr ARV a. Phc AZT + 3TC + NVP: Liu lng: - AZT 300 mg 2 ln/ngy - 3TC 150 mg 2 ln/ngy - NVP liu 200mg 1ln/ngy trong 2 tun u sau tng ln 2 ln/ngy Ung cch nhau 12 gi, c th ung thuc lc i hoc lc no. Xt nghim Hgb, ALT trc iu tr, sau 1 thng v sau 6 thng/ln hoc khi nghi ng c thiu mu hoc ng c gan Khng bt u iu tr phc ny cho ngi bnh khi Hgb < 80 g/l; thn trng khi s dng NVP trn ngi bnh c ATL > 2,5 ln tr s bnh thng, ngi bnh iu tr lao phc c rifampicin, ph n c CD4 >250/mm3.
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b. Phc d4T + 3TC + NVP: Liu lng: - d4T 30 mg 2 ln/ngy - 3TC 150 mg 2 ln/ngy - NVP liu 200mg 1ln/ngy trong 2 tun sau tng ln 2 ln/ngy Ung thuc cch nhau 12 gi, c th ung thuc lc i hoc lc no. Xt nghim ALT trc iu tr, sau 1 thng v sau 6 thng/ln Thn trng khi s dng NVP trn ngi bnh c ATL > 2,5 ln tr s bnh thng, ngi bnh iu tr lao phc c rifampicin, ph n c CD4 >250 /mm3. 4.2. Phc thay th 4.2.1. Phc AZT + 3TC + EFV hoc d4T + 3TC + EFV Ch nh: S dng mt trong hai phc ny khi ngi bnh khng s dng c NVP a. Phc AZT + 3TC + EFV Liu lng: - AZT 300 mg 2 ln/ngy - 3TC 150 mg 2 ln/ngy - EFV 600 mg 1 ln vo bui ti Ung AZT + 3TC cch nhau 12 gi, EFV vo bui ti. Khng dng EFV cng thc n c nhiu cht bo Xt nghim Hgb trc iu tr, sau 1 thng v sau 6 thng/ln hoc khi nghi ng c thiu mu. Khng bt u iu tr phc ny cho ngi bnh khi Hgb < 80 g/l v hoc ph n c thai trong 3 thng u. Khng dng EFV cho ngi bnh tm thn (hin ti hoc tin s). b. Phc d4T + 3TC + EFV: Liu lng: - d4T 30 mg 2 ln/ngy - 3TC 150 mg 2 ln/ngy - EFV 600mg 1 ln vo bui ti Ung d4T + 3TC cch nhau 12 gi, ung EFV vo bui ti. Khng dng EFV cng thc n c nhiu cht bo Khng iu tr phc c EFV cho ph n c thai trong 3 thng u. Khng dng EFV cho ngi bnh tm thn (hin ti hoc tin s). 4.2.2. Phc TDF + 3TC+ NVP hoc TDF + 3TC+ EFV Ch nh: S dng mt trong hai phc ny khi ngi bnh khng dng c c AZT v d4T a. Phc TDF + 3TC + NVP: Liu lng v cch s dng: 3TC, NVP: ging nh trn. TDF: liu lng 300 mg ung 1 ln/ngy Xt nghim creatinin/ thanh thi creatinin trc khi iu tr v nh k 6 thng/1 ln v iu chnh liu khi ngi bnh c suy thn
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> 50ml/pht

thanh thi creatinin v liu TDF 30 - 49 ml/pht 10- 29 ml/pht < 10 ml/pht Khng c ch nh iu tr

Ngy ung 1n Hai ngy ung 1 ln 3- 4 ngy ung 1n 1vin TDF 300 1 vin TDF 300 mg 1 vin TDF 300 mg mg (tun 2 vin)

b. Phc TDF + 3TC + EFV: Liu lng v cch s dng: 3TC, EFV: ging nh trn. TDF: liu lng 300 mg ung 1 ln/ngy Xt nghim creatinin/ thanh thi creatinin trc khi iu tr v nh k 6 thng/1 ln v iu chnh liu khi ngi bnh c suy thn (nh trn). 4.2.3. Phc AZT+ 3TC+ TDF Ch nh: S dng phc ny khi ngi bnh khng dng c c NVP v EFV Liu lng v cch s dng: i vi AZT, 3TC: ging nh trn. TDF: liu lng 300 mg ung 1 ln/ Xt nghim creatinin/ thanh thi creatinin trc khi iu tr v nh k 6 thng/1 ln v iu chnh liu khi ngi bnh c suy thn (nh trn). Xt nghim Hgb trc iu tr, sau 1 thng v sau 6 thng/ln hoc khi nghi ng c thiu mu. 5. Tc dng ph ca cc thuc ARV v x tr Phn loi mc tc dng ph ca cc thuc ARV v x tr. Xem ph lc 5.1. Tc dng ph nh ca thuc ARV: xut hin sm v c th t khi. Bng 13: Nhng tc dng ph nh ca cc thuc ARV v x tr Cc triu chng Cch x tr Bun nn Nn ung thuc cng vi thc n Tiu chy B nc v in gii. C th s dng loperamid au u Dng paracetamol. Nu lin tc trong 2 tun cn khm li Mt mi Thng ch ko di 4-6 tun, nu lu hn cn thm khm li Kh chu bng Nu xut hin lin tc cn khm li Ni mn nh iu tr bng thuc khng histamine. Nu nng xem xt kh nng c phn ng qu mn vi thuc Bun ng Ung thuc trc khi i ng Mt ng C th dng thuc h tr. Nu ngi bnh mt ng nhiu do EFV, c th chuyn EFV sang ung bui sng nhng khng nn s dng my mc hoc li xe c mng, chng mt Thng xy ra khi ung EFV v ko di khng qu 3 tun
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5.2. X tr mt s tc dng ph ch yu trong iu tr ARV bc 1: 5.2.1. Thiu mu do AZT - Thiu mu thng xy ra trong 4-6 tun u s dng AZT. - Cn loi tr cc nguyn nhn khc gy ra thiu mu hoc suy tu. - Xc nh mc thiu mu v x tr: Hgb X tr Mc 80 - 94 g/l Mc 1 (Nh) Tip tc dng AZT. B sung vi cht: vitamine B12, vin st, acid folic, t vn v ch n. 70 - 79 g/l Mc 2 (Trung Xt nghim CTM mu li sau 1, 3 thng. Nu bnh) tnh trng ngi bnh n nh hoc ci thin th tip tc dng AZT v t vn v khu phn n thch hp. 65 - 69 g/l Mc 3 (Nng) Thay AZT bng d4T hoc TDF sau khi loi tr cc nguyn nhn khc c th gy thiu mu hoc suy tu. Mc 4 (Nng e Hgb <65 g/l Truyn khi hng cu hoc mu ton phn da tnh mng) B sung vi cht, vitamine B12, vin st, acid folic 5.2.2. Pht ban do NVP - Thng xy ra trong 2-8 tun u iu tr. - Theo di ngi bnh cht ch v nh gi mc pht ban. T vn cho ngi bnh n ti khm ngay khi pht ban nng ln, hoc pht ban km theo triu chng ton thn nh st, mt mi,... - iu tr triu chng, s dng khng histamine hoc steroid ty mc v theo di cht ch din bin lm sng v xt nghim ALT. - X tr v iu tr ARV theo mc pht ban nh sau: Mc Biu hin X tr Mc 1 Ban , khng km theo Tip tc NVP, c th tr hon vic tng liu NVP thm vi ngy n khi tnh trng pht (Nh) cc triu chng khc ban c ci thin (ch khng nn s dng Mc 2 Ban sn lan ta hoc (Trung bnh) bong trc da kh khu tr NVP 200mg/ngy qu 3 tun). Mc 3 Ban ton thn hoc NGNG ngay NVP. Tip tc ung 2 thuc (Nng) bng nc phng rp cn li trong 7 ngy sau thay NVP bng hoc trc da t EFV nu pht ban ci thin hoc Nu sau 7 ngy pht ban cha ci thin hon ton, nn ngng tip 2 thuc cn lai. Khi ngi bnh hi phc, thay NVP bng EFV v tip tc dng hai thuc cn li. . Mc 4 Tn thng c nim mc Ngng ton b cc thuc, nhp vin hoc (Nng e da v cc hc t nhin, chuyn tuyn. tnh mng) Hi chng Steven Ch iu tr ARV li khi ngi bnh hon Johnson, ton hi phc. Thay NVP bng EFV hoc Ban a dng TDF hoc LPV/r .

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5.2.3. Nhim c gan do NVP - Xt nghim ALT trc khi iu tr. Xt nghim HBsAg v antiHCV nu c iu kin. - Cc biu hin: ALT tng cao, c th km hoc khng km theo cc triu chng lm sng nh pht ban, st, kh chu, nn, bun nn, hong n, au bng. Hay gp nht sau khi iu tr ARV c vi tun n vi thng, - Nguy c nhim c gan cao (1) PNMT c CD4 >250 TB /mm3, (2) ngi bnh c ALT trc iu tr cao, (3) ngi bnh ng nhim HIV v vim gan B hoc C v (4) ngi bnh Lao ang iu tr bng phc c rifamicine. - Theo di cht ch chc nng gan i vi ngi bnh s dng NVP, c bit l i vi ngi bnh c yu t nguy c ni trn. - Tu theo mc ALT m x tr iu tr ARV tng trng hp c th nh sau.: Mc ALT X tr Mc 1 (Nh) Tng 1,25 - 2,50 ln Tip tc s dng NVP. so vi bnh thng Theo di cht ch ALT 2 tun/ln Mc 2 Tng 2,5 - 5 ln so (Trung bnh) bnh thng Mc 3 Tng 5 - 10 ln so NGNG ngay NVP. Tip tc ung 2 thuc cn (Nng) bnh thng li trong 7 ngy sau thay NVP bng EFV nu ALT ci thin hoc Nu nh ALT vn cha ci thin th ngng tip 2 thuc cn li. Ch iu tr li ARV v thay NVP bng EFV khi ALT ci thin. Mc 4 Tng > 10 ln so Kt hp cht ch gia ALT v lm sng c (Nng e da bnh thng quyt nh ph hp. tnh mng) C th ngng ton b cc thuc, nhp vin hoc chuyn tuyn. Tu tng trng hp c th bt u iu tr li ARV v thay NVP bng EFV, hoc TDF hoc LPV/r 5.2.4. Bnh l thn kinh ngoi bin do d4T - Bnh l thn kinh lin quan d4T c th xut hin sau 3-12 thng iu tr, thng thng sau 6 thng iu tr. - Biu hin ri lon thn kinh ngoi bin: t b, rt bng, au, gim cm gic, thng bt u t u cc chi (ch yu l chi di, bt u t cc ngn chn), nu nng ngi bnh hn ch i li, mt cm gic nhiu ni trn c th. a phn cc tn thng thn kinh c th tn ti vnh vin - Hi bnh s v nh gi s thay i phn x gn xng, cm gic rung, cm gic, lon dinh dng do thn kinh trong cc ln ti khm pht hin sm cc biu hin bnh l thn kinh ngoi bin - Thay d4T bng AZT sau 12 thng k t khi bt u iu tr nu c iu kin hoc thay d4T bng AZT hoc TDF bt c khi no c du hiu ca bnh l thn kinh ngoi bin. - Khi iu tr phc c d4T pht hin ngi bnh c du hiu ri lon thn kinh ngoi bin cn lu : + Kim tra xem ngi bnh c ang dng cc thuc khc cng gy c vi thn kinh. Nu ngi bnh ang iu tr bng isonazid cn m bo l ngi bnh c ung thm pyridoxin 50mg hng ngy (vitamin B6), khng ngng isonazid. + Nu c th, nn ngng cc thuc khc gy c vi thn kinh.
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5.2.5. Ri lon phn b m - Nguyn nhn do iu tr bng cc thuc nhm NRTI, thng thng nht l do d4T Thng xut hin sau iu tr t 6-12 thng hoc c th lu hn. - Biu hin: Teo m di da mt, tay, chn, mng v/hoc tng tch t m bng, ngc, v, vai, c (thng thng khng hi phc). Nu nng c th gy ri lon chuyn ho nh tng m mu hoc tiu ng. - X tr: o Theo di cht ch cc du hiu ca teo m . o Xt nghim m mu, ng mu o Thay d4T bng AZT sau 12 thng k t khi bt u iu tr nu c iu kin hoc thay d4T bng AZT hoc TDF bt c khi no c du hiu ca ri lon phn b m. 5.2.6. Cc tc dng ph khc v x tr: Thuc c tnh, tc dng ph X tr ARV hay gp c tnh vi thn Gim liu khi c suy thn. Thay TDF TDF nh hng ln s pht trin bng AZT hoc ABC hoc d4T. xng Trnh s dng cho PNMT v tr em Nhim c nng dai dng h Thay EFV bng NVP hoc TDF hoc thn kinh trung ng. LPV/r. C th gp chng v to nam EFV Pht ban, ng c gan Tng t nh i vi NVP. Mc 3, 4: thay EFV bng TDF hoc LPV/r Gy d dng thai ph n Khng s dng EFV trong 3 thng u. mang thai (xem phn s dng ARV cho PNMT) Toan lactic: tin trin chm v Ngng ton b thuc ARV. khng c hiu, biu hin: Nhp vin mt mi, kh th, au bng, iu tr ARV li sau khi ngi bnh bun nn, nn, chn n v st hi phc hon ton. Thay d4T bng TDF cn. Xt nghim: tng axit lactic, D4T ALT, LDH, CPK v thiu ht anion Vim ty: au bng, bun Ngng iu tr ARV, iu tr h tr v nn, nn, st; tng amylase theo di xt nghim. iu tr ARV li mu vi thuc t nguy c gy vim tu cp nh AZT, TDF, ABC. 6. Theo di iu tr ARV - Ngi bnh bt u iu tr ARV cn c ti khm v pht thuc nh k - Thm khm thng xuyn trong giai on u c t vn, h tr tun th v theo di tc dng ph khi bt u iu tr. - Khi ngi bnh tun th v dung np thuc tt, cc triu chng lm sng c ci thin, thi gian gia cc ln ti khm v pht thuc l 1 thng, mt s trng hp c hon cnh c bit c din bin lm sng, tun th tt th thi gian gia cc ln ti khm c th 2 thng v do nhm iu tr quyt nh, mt s trng hp cn theo di thng xuyn hn ti c s iu tr nu ngi bnh c cc nhim trng c hi
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mi xut hin, c tc dng ph ca thuc hoc phi thay thuc, v khi ngi bnh tun th km. Mi ln ti khm, ngi bnh c nh gi tin trin lm sng, lm cc xt nghim cn thit, cung cp t vn v h tr cn thit. Cc thng tin u phi c ghi li trong bnh n v s khm bnh ca phng khm

6.1. Theo di tin trin lm sng Mi ln ti khm, ngi bnh cn c nh gi tin trin lm sng, pht hin v x tr cc tc dng ph hoc cc nhim trng c hi mi, c th: - Theo di cn nng, nhit , mch, huyt p v kh nng vn ng. - Theo di cc du hiu lm sng lin quan n tc dng ph ca thuc - Pht hin cc nhim trng c hi mi, ti pht; phn bit nguyn nhn phc hi min dch hay tht bi iu tr c hng x tr ph hp. - nh gi li giai on lm sng - nh gi kh nng mang thai thay thuc ARV khi cn (khng dng efavirenz cho ph n c thai trong 12 tun u ca thai k) Cc du hiu lm sng chng t ngi bnh p ng vi iu tr ARV: - Tng cn, thm n tr li v n ngon ming, chc nng vn ng tt hn - Ht cc du hiu lin quan n cc NTCH v bnh l lin quan n HIV 6.2. Theo di xt nghim Bng 9: Theo di xt nghim cho ngi bnh iu tr ARV Trc khi Thi gian iu tr Cc xt nghim thng quy bt u 4 6 12 6 thng iu tr tun thng thng mt ln CD4 CTM/Hgb, ALT CTM/Hgb, khi phc c AZT ALT, khi phc c NVP Creatinin, khi s dng phc c TDF Lipid v glucose mu lc i, khi s mi nm mt ln hoc khi ngi dng phc c PI hoc cc phc bnh c biu hin lon dng m khc o ti lng virus * (nu c iu kin)

Ghi ch: - Khi theo di iu tr nu ngi bnh c biu hin bt thng, bc s c th yu cu lm thm cc xt nghim cn thit khc chn on v x tr kp thi. 6.3. Theo di s tun th iu tr: nh gi li v s tun th iu tr trong tt c cc ln ti khm - nh gi tun th da trn m s thuc cn li, t bo co ca bnh nhn, s nh t ghi, bo co ca ngi h tr iu tr (nu c) v nh gi v din bin lm sng v XN - Kim tra li cch dng thuc, cch x tr khi qun ung thuc. Nu ngi bnh tun th khng tt, tm hiu l do. Ngi bnh cn c t vn v cch khc phc cc ro cn tun th v nhn c s h tr kp thi m bo s tun th tt.
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Hng dn khi ngi bnh qun ung thuc: Khi pht hin ra qun ung thuc theo lch, ngi bnh phi ung ngay liu thuc va qun. Tip theo tnh thi gian ung liu k tip theo lch nh thng l: - Nu thi gian n liu ung k tip cn trn 4 ting, ung liu vo ng thi gian theo lch nh bnh thng. - Nu thi gian n liu ung k tip cn di 4 ting, KHNG C ung liu k tip theo lch c m phi i trn 4 ting mi c ung. - Nu qun hn 2 liu trong mt tun, ngi bnh phi bo cho bc s iu tr c hng dn. 7. Hi chng vim phc hi min dch 7.1. Khi nim: Hi chng vim phc hi min dch (PHMD) l hin tng tnh trng lm sng ca ngi nhim HIV xu i mt cch bt thng sau khi bt u iu tr ARV do c s phc hi ca h min dch. Bn cht ca hi chng vim PHMD l p ng vim qu mc ca h min dch mi c phc hi vi cc tc nhn vi sinh vt ang tn ti trong c th hoc khng nguyn cn li ca cc tc nhn ny. Cc biu hin ca hi chng vim PHMD c th bao gm: - S xut hin ca cc bnh NTCH cha pht hin c trc khi iu tr ARV (lao, MAC, vim mng no do cryptococcus, v.v...) - S ti pht qu mc cc bnh NTCH c iu tr trc khi bt u ARV - S ti pht ca cc bnh ng nhim (VGB, VGC) v cc bnh t min (vy nn, vim da, v.v..). Thi im xut hin: Thng 2-12 tun sau khi bt u iu tr ARV nhng c th mun hn 7.2. Tn sut xut hin v yu t nguy c: Hi chng vim PHMD gp khong 10% s bnh nhn c iu tr ARV. Cc yu t lin quan ti tn sut hi chng vim PHMD l: - S t bo CD4 thp trc khi bt u iu tr ARV (hi chng vim PHMD xut hin khong 25% s bnh nhn c CD4<50 TB/mm3 khi bt u iu tr). - Tin s mc cc NTCH trc iu tr ARV. Thi im bt u iu tr ARV cng gn vi iu tr NTCH, nguy c c hi chng vim PHMD cng cao. - S dng phc ARV c thuc c ch protease tng cng bng ritonavir. d phng HCPHMD ngi bnh cn c sng lc cc bnh NTCH trc khi bt u iu tr ARV, c bit l sng lc v iu tr lao. 7.3. Cc biu hin ca hi chng vim phc hi min dch Cc bnh NTCH v cc bnh khng nhim trng lin quan n hi chng vim PHMD: - Cc bnh do Mycobacteria: lao (l biu hin hay gp nht), bnh do phc hp mycobacterium avium (MAC). - Cc bnh nm: bnh do C.neoformans, P.marneffei, P.jiroveci - Virus: bnh do CMV, Herpes simplex, Herpes zoster, vim gan virus B v C, vim no cht trng a tin trin - Bnh do k sinh n bo: vim no do Toxoplasma, bnh do Leishmania - Cc bnh khng nhim trng: vy nn, vim tuyn gip trng
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7.4. Chn on Hi chng vim phc hi min dch - Cn ngh n hi chng PHMD khi ngi bnh bt u iu tr ARV v tun th iu tr tt nhng lm sng xu i, nht l trn ngi bnh c iu tr ARV giai on mun, CD4 thp hoc c bnh NTCH trc iu tr V + Loi tr cc biu hin do tc dng ph ca thuc, biu hin NTCH mi + Loi tr tht bi iu tr nu ngi bnh iu tr ARV c hn 6 thng 7.5. X tr Hi chng vim phc hi min dch - Mt s Hi chng vim PHMD din bin nh v t khi, khng cn can thip. - Tip tc iu tr ARV nu ngi bnh vn dung np c thuc. - iu tr cc nhim trng c hi mi bc l theo cn nguyn; iu chnh phc ARV v liu ARV nu c tng tc gia cc thuc ARV v cc thuc iu tr NTCH (v d: thay NVP bng EFV nu iu tr lao bng phc c rifampicin v nu EFV sn c). Quay tr v phc ARV c khi kt thc iu tr bng cc thuc c tng tc - Ch ngng iu tr ARV nu tnh trng ngi bnh nng v khng dung np c thuc. Thc hin quy trnh chung ngng phc ARV c cc thuc NNRTI (ngng NVP hoc EFV trc, tip tc cc thuc NRTI trong 7 ngy ri ngng hn). Bt u li cc thuc ARV khi hi chng vim gim v ngi bnh dung np c thuc. - Xem xt iu tr corticosteroid trong cc trng hp vim PHMD t mc va n nng: Prednisolone hoc methylprednisolone ung hoc tim, liu 0,5-1,0 mg/kg/ngy cho n khi tnh trng ngi bnh ci thin, sau gim dn liu trong 1-2 tun. - Ch nh cc can thip khc nu cn, v d dn lu hch ho m, ap-xe , phu thut gim chn p trong trng hp tc rut hoc chn p kh qun. 8. Tht bi iu tr ARV v cc phc bc hai 8.1. nh gi tht bi iu tr: Ch xem xt tht bi iu tr khi ngi bnh ung ARV ng phc 3 thuc trong t nht 6 thng; ngi bnh tun th tt. Cc biu hin xut hin trong vng 6 thng sau khi bt u iu tr ARV thng l nhim trng c hi, hi chng vim phc hi min dch, hoc cc tc dng ph ca thuc. Tiu chun dnh gi tht bi iu tr: Bng 15: Tiu chun nh gi tht bi iu tr ARV Tht bi v lm sng Tht bi v min dch hcc Xut hin mi hoc ti pht cc bnh l giai on lm sng 4 sau iu tr t nht 6 thng a, b CD4 gim xung bng hoc di mc CD4 ban u trc iu tr, hoc CD4 gim di mt na so vi mc CD4 cao nht t c (nu bit gi tr ny), hoc CD4 di 100 t bo/mm3 mu lin tc trong 1 nm lin, khng tng Ti lng virus o c trn 5.000 phin bn /ml

Tht bi v virus hcd

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Mt s lu : a. Mt s bnh l giai on 4 nh lao hch, lao mng phi, nm candida thc qun, vim phi ti pht khng c coi l ch im tht bi iu tr. iu tr cc bnh l ny, nu p ng tt, tip tc phc bc mt. b. Mt s bnh l giai on lm sng 3 (nh lao phi, nhim vi khun nng) c th l ch im ca tht bi iu tr. Lao xut hin sau 6 thng iu tr ARV c coi l tht bi iu tr khi i km vi tht bi v min dch hc hoc tht bi v virus hc. Nu khng thc hin c cc xt nghim ny, xem xt tht bi iu tr nu ngi bnh c cc bnh l khc thuc giai on 3, 4, hoc ngi bnh b lao lan to. c. Cc bnh l km theo thng lm gim tm thi s CD4; iu tr cc bnh l ny trc, lm xt nghim CD4 khi tnh trng ngi bnh n nh. d. o ti lng virus l xt nghim chnh xc nht khng nh hoc loi tr tht bi iu tr. Thay i phc khi ti lng virus >5.000 phin bn/ml trong hai ln xt nghim cch nhau t nht 1 thng 8.2. Cc bc tin hnh khi nghi ng ngi bnh b tht bi iu tr: nh gi li tnh tun th iu tr ARV ca bnh nhn. Nu ngi bnh c biu hin km tun th, cn tin hnh cc bin php tng cng t vn v h tr; xem xt li tiu chun tht bi iu tr sau khi ngi bnh tun th tt. nh gi li tin s iu tr ARV ca ngi bnh xem liu ngi bnh c bao gi dng phc khng ng (liu khng , phc 2 thuc) Kim tra phc hin ti xem c tng tc g vi thuc NTCH, thuc d phng hay cc thuc ung km khc. Kim tra xem ngi bnh c yu t no khin hp thu thuc km, v d tiu chy, nn, bun nn, tc dng ph nh gi cc NTCH v bnh km theo v iu tr kp thi. Loi tr gim CD4 lin quan n cht lng my nh lng CD4 hoc do lm XN t cc my khc nhau. Khi c tht bi lm sng v min dch hc, tt nht o ti lng vi rt nu c iu kin quyt nh chuyn phc bc 2. Tin hnh hi chn khi chn on tht bi iu tr v chuyn phc bc 2 8.3. Quyt nh thay i phc iu tr Quyt nh thay i phc iu tr c a ra trn c s xem xt cc tiu chun lm sng, min dch hc v virus hc (nu c). Bng 16: Quyt nh thay i phc iu tr trn c s kt hp tiu chun lm sng, min dch v virus hc Tiu chun tht bi Tht bi v CD4 (khng c xt nghim virus hc) Giai on lm sng 1-2 Khng thay i phc . Theo di ngi bnh xem c tip tc xut hin cc biu hin lm sng mi hay khng. Giai on lm Giai on lm sng 3 sng 4 Xem xt thay Thay sang phc sang phc bc hai. bc hai.

Lm li xt nghim CD4 sau 3 thng.

Tht bi v CD4 Thay sang phc bc hai. v virus hc
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Thay sang phc Thay sang phc bc hai. bc hai.

8.3.1. La chn phc bc hai

Bng 17: La chn phc iu tr ARV bc hai

Phc bc 1

Phc bc 2

d4T/AZT + 3TC + NVP hoc TDF + 3TC (+ AZT) hoc ddI + ABC EFV TDF + 3TC + NVP/EFV ddI + ABC hoc AZT + 3TC
AZT hoc d4T + 3TC + TDF hoc ABC EFV hoc NVP + ddI

LPV/r

PI thay th LPV/r: ATV/r dng vin chu nhit khng cn bo qun lnh. Nu ngi bnh dng nhiu loi thuc trong phc bc mt, virus c th khng vi cc thuc trong phc bc hai. Lm xt nghim khng thuc, nu c iu kin, v la chn phc ph hp c tnh ca mt s thuc ARV trong phc bc hai v cch x tr Thuc c tnh, tc dng ph hay gp X tr ARV c tnh vi thn Gim liu khi c suy thn. Thay TDF TDF nh hng ln s pht trin xng bng ABC. Trnh s dng cho PNMT v tr em Toan lactic Ngng iu tr ARV, iu tr h tr v theo di xt nghim. Vim ty iu tr ARV li khi tnh trng ngi Bnh l thn kinh ngoi bin ddI Ri lon chuyn ha m: teo m m bnh n nh, thay ddI bng thuc (chn, mng, tay v mt); tch t m NRTI ph hp. (ni tng, v, c); tng lipid mu; ri lon chuyn ha glucose Qu mn: thng trong 6 tun u Ngng vnh vin ABC v khng iu iu tr; biu hin: pht ban ri rc tr li bng ABC (iu tr li ABC (c th khng c ban); st; mt mi; gy tru mch v t vong). iu tr ABC bun nn, nn, tiu chy; kh th, triu chng ho, au hng; tng men gan, phosphatasa kim, LDH Vim gan nh gi mc tng men gan (ph lc 7). Tng mc 1, 2: tip tc phc v theo di; tng mc 3: thay NVP bng EFV (nu c); tng mc 4: ngng ARV v theo di; khi hi phc c th bt u li ARV, LPV/r thay LPV/r bng mt thuc PI khc Ri lon chuyn ha m: tch t m Tng cholesterol v triglyceride mc (ni tng, v, c); tng lipid mu; 1 hoc 2 - p dng ch n ri lon chuyn ha glucose (tiu king, tp luyn, theo di; tng mc ng khng insulin, tng nguy c 3 hoc 4 - cho dng cc thuc mc bnh tim mch, vim tu) fibrate (fenofibrate 600mg 1-2
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Tng bilirubin gin tip trong mu Ri lon chuyn ha m: tch t m (ni tng, v, c); tng lipid mu; ri lon chuyn ha glucose (tiu ng khng insulin, tng nguy c mc bnh tim mch, vim tu) Block nh tht 1 (PR ko di trn in tim)

ln/ngy); iu tr tng cholesterol bng cc thuc statin (trnh dng simvastatin v lovastatin do c tng tc thuc) Thng khng c triu chng, hoc gy vng mt nh m khng tng ALT. Thay ATV bng mt PI khc X tr tng t nh i vi ri lon chuyn ha m do LPV/r

ATV/r

S dng thn trng ngi bnh c ri lon dn truyn tim tim tng hoc ngi bnh s dng ng thi cc thuc gy PR ko di

8.3.2. Liu dng v cch dng ca cc thuc bc hai: Trc khi chuyn sang phc bc hai, cn: - T vn li cho ngi bnh v tun th iu tr; cho iu tr phc mi khi chc chn ngi bnh c kh nng tun th tt - iu tr cc biu hin lm sng (giai on 3 hoc 4) - T vn k v phc mi Liu lng v cch dng ca cc thuc phc bc 2 - Tenofovir (TDF): 300mg ung 1ln /ngy - Abacavir (ABC): 300mg ung 2 ln/ngy, cch nhau 12 ting hoc 600mg ung 1 ln/ngy - Didanosin (ddI): cn nng <60kg - 250mg/ngy; cn nng 60kg - 400mg /ngy. - Lopinavir/Ritonavir (LPV/r): 400mg/100mg ung 2 ln/ngy, cch nhau 12 gi. LPV/r vin nang nn ung khi no; LPV/r vin nn c th ung lc i hoc lc no. - Atazanavir/Ritonavir (ATV/r): 300mg/100mg ung 1 ln/ngy - Lamivudine (3TC) v Zidovudine (AZT): liu lng v cch dng nh trong phc bc mt 8.4. Theo di ngi bnh iu tr phc bc 2: m bo tun th iu tr Theo di cc tng tc thuc khi dng LPV/r nh gi p ng v lm sng v min dch (CD4) tng t nh i vi phc bc mt. 9. iu tr ARV cc i tng c bit: 9. 1. iu tr ARV cho ngi bnh lao/HIV - Ngi bnh lao/HIV lun c nguy c t vong cao hn nhng ngi nhim HIV khng b lao, do vy cn c ch nh iu tr ARV kp thi. - Cn t vn v vic ung nhiu vin thuc, lu vn tng tc gia cc thuc ARV vi cc thuc chng lao nh rifampicin v nguy c ng c gan. 9.1.1. Bt u iu tr ARV trn ngi bnh mc lao ng nhim HIV
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9.1.1.1. Tiu chun iu tr a. Ngi bnh cha iu tr ARV v c kt qu CD4: Bng 18: Bt u iu tr ARV ngi bnh lao c xt nghim CD4 CD4 CD4 >350 TB/mm3 X tr iu tr lao trc. nh gi ch nh iu tr ARV sau giai on tn cng hoc sau khi hon thnh iu tr lao. Nu ngi bnh c giai on lm sng 4 bt u iu tr ARV ngay sau khi ngi bnh dung np cc thuc lao (trong vng 2 n 8 tun) iu tr lao trc Bt u iu tr ARV sau khi hon thnh iu tr lao tn cng. Nu ngi bnh c giai on lm sng 4 bt u iu tr ARV ngay sau khi ngi bnh dung np cc thuc lao (trong vng 2 n 8 tun) Bt u iu tr ARV cng sm cng tt, ngay sau khi ngi bnh dung np cc thuc lao (trong vng 2 n 8 tun)

CD4 250- 350 TB/mm3

CD4 < 250 TB/mm3

b. Ngi bnh cha iu tr ARV v cha c xt nghim CD4: Bng 19: Bt u iu tr ARV ngi bnh lao khng c xt nghim CD4 X tr - Hon thnh iu tr lao tn cng, sau xem xt iu tr ARV - iu tr lao trc - Bt u iu tr ARV sau khi hon thnh iu tr lao tn cng - iu tr lao trc - Bt u iu tr ARV cng sm cng tt, ngay sau khi ngi bnh dung np cc thuc lao (trong vng 2 n 8 tun) 9.1.1.2. Cc phc bc 1 cho ngi bnh lao/HIV bt u iu tr ARV Bng 20: Cc phc bc 1 cho ngi bnh lao/HIV bt u iu tr ARV Ngi bnh ang iu tr lao phc c rifampicin v bt u iu tr ARV: Phc chnh: AZT hoc d4T + 3TC + EFV Phc thay th: Khi khng c EFV, hoc ph n c thai trong 3 thng u v CD4 < 250 TB/mm3, AZT hoc d4T + 3TC + NVP Ph n c thai 3 thng u v CD4 > 250 TB/mm3: AZT + 3TC + NVP v theo di cht ch tc dng ph NVP hoc AZT + 3TC + ABC hoc AZT + 3TC + LVP 400 mg/ RTV 400 mg Ngi bnh khng s dng c NVP v EFV: AZT + 3TC + TDF
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Tnh trng lm sng Ch c lao phi (khng c du hiu lm sng giai on 3 khc hoc 4) Lao phi v ngi bnh c hoc c cc bnh l khc thuc lm sng giai on 3 Lao phi v ngi bnh c hoc c cc bnh l khc thuc lm sng giai on 4 Lao ngoi phi

Lu : Trnh s dng phc ny cho ph n c thai, nu c th Liu lng v cch dng ging nh ngi nhim HIV khng mc lao, tr RTV tng ln t 100 mg ln 400mg. Ngi bnh ang iu tr lao giai on khng c rifampicin: La chn phc bc 1 ging nh ngi nhim HIV khng mc lao 9.1.2. Ngi bnh ang iu tr ARV mc lao: Ngi bnh ang iu tr ARV mc lao c th do hi chng vim phc hi min dch (trong 6 thng u iu tr) hoc do mc lao mi, hoc tht bi iu tr 9.1.2.1. Ngi bnh ang iu tr ARV mc lao - iu tr lao theo hng dn iu tr lao quc gia. iu chnh cc thuc trong phc iu tr ARV nu cn Bng 21: iu tr ARV cho ngi bnh ang iu tr lao c rifamycin Phc iu tr ARV hin ti Phc iu tr ARV bc 1 D4T hoc AZT + 3 TC + EFV d4T hoc AZT + 3 TC + NVP Phc iu tr ARV khi ngi bnh mc lao iu tr phc c rifampicin Tip tc phc c EFV - Thay NVP bng EFV - Nu khng c EFV, hoc ngi bnh c thai, hoc khng dung np EFV, tip tc iu tr vi phc c c NVP liu thng thng nhng khm lm sng v theo di men gan cht ch nh k 2 tun/1 ln. hoc - Thay sang phc :AZT + 3TC + TDF

Chuyn sang hoc tip tc (nu ang s dung) phc bc 2 c LVP 400 mg/ RTV 400 mg Nu tnh trng ca ngi bnh nng v khng th tip tc cc thuc ARV, ngng tm thi iu tr ARV iu tr lao. Khi ngi bnh n nh, bt u iu tr li ARV bng phc ang dng trc , lu tng tc thuc (Ph lc 5). - Sau khi kt thc iu tr rifampicin, c th cn nhc s dng li NVP v dng ngay liu NVP 200 mg x 2 ln/ngy. 9.1.2.2. Ch nh phc bc 2 cho ngi bnh lao ang iu tr ARV phc bc 1 c tht bi iu tr: - Phc bc 2 khi iu tr phc lao c rifampicin tng t nh phc cho ngi bnh khng mc lao v tng liu ritonavir: LVP 400 mg/ RTV 400 mg - Theo di cht ch lm sng v xt nghim pht hin nhim c gan 9.2.iu tr ARV cho ngi bnh ng nhim HIV v vim gan B, C - Tiu chun iu tr ARV trn ngi bnh vim gan B v C cng ging nh i vi cc ngi bnh khc. - Lu cc vn tng tc thuc v ng c gan la chn phc ARV cho ph hp 9.2.1. iu tr ARV cho ngi bnh ng nhim HIV vi vim gan B 9.2.2.1. La chn phc iu tr ARV cho ngi bnh ng nhim HIV vi vim gan B: Phc chnh: AZT hoc d4T + 3TC + EFV Phc thay th: AZT hoc d4T + 3TC + NVP
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Phc iu tr ARV bc 2 2 NRTI + LPV/r

Mt s lu : - EFV l la chn tt nht iu tr cho ngi bnh ng nhim HIV/vim gan B hoc khi c biu hin lm sng vim gan hoc men gan tng - Khi khng c EFV, s dng NVP khi ngi bnh c men gan cao nhng phi theo di cht ch. - Ngi bnh ang iu tr phc c NVP m men gan tng mc 3, 4 cn thay NVP bng EFV, TDF hoc LPV/r 9.2.2.2. X tr t bng pht vim gan B khi ang iu tr ARV: t bng pht vim gan B d xy ra trn ngi bnh ng nhim HIV/VGB trong vi thng u tin iu tr ARV, c th l biu hin ca hi chng vim phc hi min dch, hoc do ngng ARV c tc dng iu tr vim gan B (3TC, TDF) - Biu hin: men gan tng cao v nhanh, km theo cc triu chng ca vim gan cp (mt mi, au bng, vng da). i khi kh chn on phn bit vi ng c gan do ARV - Nu men gan tng mc 3 v tnh trng ngi bnh n nh, tip tc iu tr ARV, s dng cc thuc t c hn vi gan nh EFV ; theo di cht ch men gan (2 tun/ln) v cc du hiu lm sng. - Cn theo di cht ch ngi bnh ng nhim HIV/VGB khi phi ngng cc thuc ARV trong c 3TC, TDF. 9.2.3. iu tr ARV cho ngi bnh ng nhim HIV vi vim gan C iu tr ging nh ngi nhim HIV khng mc vim gan C, tt nht s dng phc c EFV Lu khi s dng ARV trn ngi bnh ng nhim vim gan C: - Cc thuc iu tr ARV khng c tc dng iu tr vim gan C - iu tr vim gan C nu c iu kin bng interferon, ribavirin (RBV). Nng AZT tng khi s dng ng thi AZT v RBV; theo di cht ch c tnh AZT. Ngi bnh p ng tt vi iu tr vim gan C khi s CD4 trn 200 TB/mm3. 9.2.4. iu tr ARV trn ngi bnh c ALT ban u cao hoc khng bit tnh trng nhim vim gan B, C - Xt nghim men gan theo quy nh cho tt c cc ngi bnh trc khi bt u iu tr ARV. - Xt nghim HBsAg, anti- HCV trc iu tr hoc khi men gan tng, nu c iu kin. - Khi men gan tng, bit hoc khng bit tnh trng nhim vim gan B, C, nn s dng phc c EFV. 9.3. iu tr ARV cho ngi nghin chch ma ty 9.3.1. Nguyn tc iu tr ARV cho ngi NCMT - Tiu chun bt u iu tr ARV cho ngi NCMT nh cho cc ngi bnh khc - Khng tr hon iu tr ARV cho ngi v ang NCMT - m bo sn sng iu tr cho ngi bnh v ngi h tr iu tr bao gm tun th iu tr v t vn v h tr tun th iu tr trong sut qu trnh iu tr. - Lu vn tng tc gia ARV vi cc thuc iu tr thay th opioid (nh methadone) v nguy c ng c gan, c bit trn ngi bnh NCMT ng nhim vim gan B, C 9.3.2. Phc iu tr ARV cho ngi nhim HIV NCMT. La chn phc bc 1 tng t nh cc ngi bnh khc, Phc chnh: AZT hoc d4T + 3TC + NVP Phc thay th: AZT hoc d4T + 3TC + EFV
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Lu : - Xt nghim HBsAg v anti-HCV nu c iu kin trc khi iu tr ARV. Nu ngi bnh c men gan tng v hoc c HBsAg v hoc antiHCV (+): xem phn iu tr ARV cho ngi bnh ng nhim HIV, vim gan B, C. - EFV/NVP lm gim nng methadone trn ngi bnh ang iu tr methadone d gy hi chng cai. Xem xt tng liu methadone. - La chn phc bc 2 tng t nh cc ngi bnh khc, lu LPV, RTV lm gim nng methadone gy ra hi chng cai nhng ngi bnh ang iu tr methadone. 9.3.3. H tr iu tr - H tr n nh cuc sng v h tr tun th iu tr qua gia nh, nhm t lc v nhn vin y t, cc t chc x hi, cc dch v h tr kinh t x hi, chng trnh o to ngh v chng trnh vay vn, h tr vic lm. - S dng liu php DOT (iu tr quan st trc tip) nu c iu kin v khi cn thit, c th thc hin ti trung tm cha bnh, lao ng v bo tr x hi - Gii thiu cc dch v can thip gim hi nh tip cn cng ng, s dng bao cao su, bm kim tim sch, cung cp iu tr thay th opioid nh methadone - Phi hp vi trung tm cha bnh, lao ng v bo tr x hi, nh t m bo iu tr lin tc cho nhng ngi bnh ang iu tr ARV ti cng ng khi vo cc c s ny. VII- IU TR ARV PH N MANG THAI V D PHNG LY TRUYN HIV T M SANG CON Nguyn tc - Cn pht hin sm tnh trng nhim HIV ph n mang thai (PNMT) p dng cc bin php can thip d phng ly truyn HIV t m sang con (DPLTMC), bao gm d phng bng ARV, dng sa thay th cho con v gii thiu cc dch v chm sc v iu tr sau sinh. - PNMT nhim HIV cn c hi chn vi c s chm sc v iu tr HIV/AIDS xem xt iu tr bng ARV hay iu tr DPLTMC. - PNMT c u tin iu tr ARV khi tiu chun; qu trnh chun b sn sng iu tr c th rt ngn vic d phng bng ARV kp thi v hiu qu - Cn s dng phc DPLTMC hiu qu nht. Ngi ph n sau khi sinh cn c nh gi li v lm sng v min dch xem xt ch nh iu tr ARV. Nu khng c ch nh, iu tr ARV c dng li hon ton; nu c ch nh, s dng phc ARV ph hp nh nhng ngi ln khc. 1. iu tr ARV cho ph n mang thai nhim HIV iu tr ARV: S dng lu di cc thuc ARV iu tr cho bn thn ngi PNMT nhim HIV cng nh d phng ly truyn HIV t m sang con 1.1. Bt u iu tr ARV cho PNMT 1.1.1. Ch nh iu tr ARV cho PNMT Ngi PNMT nhim HIV c ch nh iu tr ARV tng t nh nhng ngi ln nhim HIV khc, c th nh sau: Ch nh iu tr ARV cho ph n c thai: - Giai on lm sng 4: iu tr ARV bt k s CD4 l bao nhiu - Giai on lm sng 3: iu tr ARV khi s CD4 < 350 t bo/mm3 - Giai on lm sng 1, 2: iu tr ARV khi s CD4 < 250 t bo/mm3 Nu khng lm c xt nghim CD4, ch nh iu tr khi PNMT nhim HIV giai on lm sng 3, 4
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1.1.2. Phc iu tr ARV cho PNMT nhim HIV Phc u tin: AZT + 3TC + NVP S dng trong sut thi gian mang thai, trong khi sinh v sau khi sinh. Liu dng ca cc thuc ARV cho PNMT ging nh ngi nhim HIV ngi ln khc. Theo di cht ch chc nng gan, nht l PNMT c CD4 t 250 n 350 t bo/mm3. Xt nghim ALT lc bt u iu tr, 2 tun mt ln trong thng u tin, 1 thng 1 ln t thng th 2 n thng th 4, v sau t 1 n 3 thng 1 ln. Thay sang phc ph hp khi c c tnh vi gan. Phc thay th: - Khi khng s dng c AZT: Thay AZT bng d4T hoc ABC - Khi khng s dng c NVP do pht ban v ng c: p dng 1 trong cc la chn sau theo th t u tin: + AZT + 3TC + EFV (nu thai > 12 tun); hoc + AZT + 3TC + LPV/r hoc + AZT + 3TC + ABC

Lu :
PNMT nhim HIV mc lao tin trin c iu tr lao bng phc c rifampicin cn lu n tng tc thuc vi NVP hoc v c tnh ca EFV trong 3 thng u khi la chn phc iu tr ARV (xem phn iu tr ARV cho ngi bnh lao/HIV v Ph lc 5) - Sau khi sinh m c th tip tc phc ang s dng hoc chuyn v phc bc 1 chnh 1.2. Ngi ph n ang iu tr ARV th c thai Ngi ph n ang iu tr ARV th c thai: tip tc iu tr ARV v lu : - Nhng ngi ph n ang s dng phc c EFV v thai <12 tun: thay EFV bng NVP (cho ngay liu 200mg x 2 ln/ngy) hoc cc phc thay th ph hp. T vn v nguy c nh hng n thai v tho lun v k hoch gi thai hoc khng gi thai vi PNMT... - C th tip tc s dng phc c EFV trong 3 thng gia v 3 thng cui ca thai k, nu c ch nh. 1.3. Phc iu tr d phng cho tr sinh ra t cc b m iu tr ARV Nu m iu tr ARV trc sinh trn 4 tun: Siro AZT 4mg/kg hai ln mt ngy x 7 ngy; Nu m iu tr ARV trc sinh cha 4 tun: Siro AZT 4mg/kg hai ln mt ngy x 4 tun 1.4. Phc iu tr ARV cho ngi ph n sau sinh con c tin s c d phng ly truyn m con bng liu n NVP: - Nu c ch nh iu tr ARV trong vng 6 - 12 thng sau sinh: + C th ch nh phc bc 1 nh i vi cc ngi bnh HIV khc (xem phn iu tr ARV cho ngi ln VI). + S dng phc : AZT + 3TC + TDF, hoc thay NVP hoc EFV bng LPV/r, nu c iu kin trnh khng thuc - Nu c ch nh iu tr ARV sau 6- 12 thng sau sinh: ch nh phc bc 1 nh i vi cc ngi bnh HIV khc.
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2. iu tr d phng ly truyn HIV t m sang con bng ARV iu tr DPLTMC bng ARV: S dng ngn hn cc thuc ARV d phng ly truyn HIV t m sang con. 2.1. Cc i tng cn iu tr DP LTMC bng ARV PNMT nhim HIV cha tiu chun iu tr ARV (giai on lm sng 1-2 v CD4>250 t bo/mm3, giai on lm sng 3 v CD4>350 t bo/mm3), hoc PNMT nhim HIV tiu chun iu tr ARV nhng khng c iu kin iu tr ARV, hoc PNMT nhim HIV khng c qun l trong thi k mang thai hoc pht hin nhim HIV mun khi chuyn d v khi . Tr sinh ra t nhng ngi m nhim HIV 2.2. Cc phc ARV cho m v con trong PLTMC 2.2.1. Phc u tin AZT + liu n NVP: Thc hin cho cc PNMT nhim HIV c qun l trong thi gian trc sinh v c ch nh iu tr d phng ly truyn HIV t m sang con. Bng 22: Phc d phng ly truyn m-con bng AZT + liu n NVP M Khi mang thai Khi chuyn d AZT 300mg x 2 ln/ngy, ung hng ngy t tun thai th 28 (hoc ngay khi pht hin nhim HIV sau tun thai 28) n khi chuyn d Khi bt u chuyn d: NVP 200mg + AZT 600mg + 3TC 150mg Sau 12 gi mt ln AZT 300 mg + 3TC 150mg cho n lc (AZT 300mg + 3TC 150mg) 12 gi mt ln x 7 ngy M iu tr AZT trc sinh trn 4 tun: NVP liu n 6mg, ung mt ln ngay sau khi sinh + AZT 4mg/kg ung 2 ln mt ngy x 7 ngy M iu tr AZT trc sinh cha 4 tun: NVP liu n 6mg, ung mt ln ngay sau khi sinh + AZT 4mg/kg ung 2 ln mt ngy x 4 tun

Sau Con

Lu : AZT c th gy thiu mu ph n mang thai, tuy khng ph bin. Theo di tnh trng thiu mu lm sng, xt nghim hemoglobin thng xuyn, iu tr thiu mu nu c. 2.2.2. Phc d phng LTMC khi ngi PNMT c pht hin nhim HIV trong lc chuyn d: Ch nh khi ngi PNMT nhim HIV khng c qun l trong thi k mang thai, hoc c pht hin nhim HIV mun khi chuyn d v khi .

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Bng 23: Phc d phng ly truyn m-con khi ngi PNMT c pht hin nhim HIV trong lc chuyn d M Khi chuyn d Sau Con Khi bt u chuyn d: NVP 200mg + AZT 600mg + 3TC 150mg Sau 12 gi mt ln AZT 300 mg + 3TC 150mg cho n lc (AZT 300mg + 3TC 150mg) 12 gi mt ln x 7 ngy NVP liu n 6mg, ung mt ln ngay sau khi sinh + AZT 4mg/kg ung 2 ln mt ngy x 4 tun

Lu : a. i vi PNMT c xt nghim sng lc HIV dng tnh khi chuyn d: t vn v cho iu tr d phng ngay, lm chn on khng nh sau. Nu xt nghim khng nh m tnh, ngng cc can thip d phng b. Khng s dng ARV d phng cho m khi tin lng m s sinh trong vng 1 gi; Trong trng hp m khng c s dng ARV vn thc hin phc d phng ARV cho con nh trn. c. Khi khng sn c AZT, vn s dng NVP liu n cho m khi chuyn d v NVP liu n cho con ngay sau sinh. 3. Cc bin php can thip khc v chuyn tip m-con n cc dch v chm sc, iu tr sau khi sinh 3.1. Cc can thip i vi ngi m: a. Trc : T vn y trc v sau xt nghim HIV T vn dinh dng khi mang thai v nui dng tr sau sinh T vn h tr tinh thn Tp hun sn sang iu tr bng ARV v thc hnh tun th thuc ARV b. Trong cuc : m bo cc nguyn tc v khun trong sn khoa Hn ch cc th thut: bm i, m ly thai, t in cc, rch mng i sm. Tm cho tr ngay sau sinh c. Sau cuc : Cp pht liu thuc ARV cho m nu m v tr c xut vin sm Chuyn tip n c s chm sc v iu tr HIV dnh cho ngi ln m c chm sc v iu tr lu di. 3.2. Cc can thip i vi tr a. Cp pht liu thuc ARV cho tr v hng dn m hoc ngi chm sc thc hnh tun th iu tr ARV. Trong trng hp cn thit, hn ti khm cp thuc v t vn thm b. Can thip nui dng tr: T vn v li ch ca sa m v nguy c ly nhim HIV qua sa m. Nu c iu kin (ngun sa, nc sch, v sinh n ung) nn dng sa thay th. Nu tr b m cn t vn y v: + T th b, cch ngm bt v v x tr khi nt nm v, p xe v. + Cai sa cng sm cng tt hn ch nguy c ly truyn HIV t m sang con.
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c. Gii thiu chuyn tr n: Cc c s chm sc v iu tr HIV dnh cho tr em c chm sc v theo di lu di, khi tr c 4-6 tun tui. Nu tr m ci, ng vin gia nh tip tc chm sc hoc gii thiu tr n cc trung tm chm sc tr m ci. VIII- D PHNG SAU PHI NHIM HIV: 1. D phng sau phi nhim HIV do ngh nghip Phi nhim vi HIV do tai nn ngh nghip l tip xc trc tip vi mu v cc dch c th c nhim HIV dn n nguy c ly nhim HIV. 1.1. Cc dng phi nhim: - Do kim m khi lm cc th thut tim truyn, ly mu lm xt nghim, chc d - Vt thng do dao m v cc dng c sc nhn khc c dnh mu hoc dch c th ca ngi bnh. - Tn thng qua da do cc ng ng mu hoc dch ca ngi bnh b v m vo. - Mu, cht dch c th ca ngi bnh bn vo cc vng da b tn thng (chm, bng, vim lot t trc) hoc nim mc (mt, mi, hng). - Khc: phi nhim vi mu c HIV do b ngi khc dng kim tim cha mu m vo hoc trong khi lm nhim v ui bt ti phm v.v.. 1.2. Quy trnh x tr sau phi nhim:Bao gm cc bc sau: 1. X l vt thng ti ch 2. Bo co ngi ph trch v lm bin bn (ch ghi y cc thng tin yu cu trong H s phi nhim) 3. nh gi nguy c phi nhim theo mc tn thng v din tch tip xc. 4. Xc nh tnh trng HIV ca ngun gy phi nhim. 5. Xc nh tnh trng HIV ca ngi b phi nhim. 6. T vn cho ngi b phi nhim. 7. iu tr d phng bng thuc ARV. a. X l vt thng ti ch: - Tn thng da chy mu: + Xi ngay vt thng di vi nc. + vt thng t chy mu trong mt thi gian ngn, khng nn bp vt thng. + Ra k bng x phng v nc sch, - Phi nhim qua nim mc mt: Ra mt bng nc ct hoc nc mui NaCl 0,9% lin tc trong 5 pht. - Phi nhim qua ming, mi: + Ra, nh mi bng nc ct hoc dung dch NaCl 0,9 %. + Xc ming bng dung dch NaCl 0,9 % nhiu ln. b. Bo co ngi ph trch v lm bin bn: Nu r ngy gi, hon cnh xy ra, nh gi vt thng, mc nguy c ca phi nhim. Ly ch k ca nhng ngi chng kin v ch k ca ngi ph trch. c. nh gi nguy c phi nhim: C nguy c: + Tn thng do kim c cha mu m xuyn qua da gy chy mu: kim nng rng c to, cha nhiu mu, m su nguy c cao hn kim nng nh, cha t mu v m xuyn nng.

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+ Tn thng da su do dao m hoc cc ng nghim cha mu v cht dch c th ca ngi bnh b v m phi. + Mu v cht dch c th ca ngi bnh bn vo cc vng da, nim mc b tn thng vim lot hoc xy st t trc (thm ch ngay c khi khng bit c b vim lot hay khng): nu vim lot hoc xy st rng th nguy c cao hn. Khng c nguy c: mu v dch c th ca ngi bnh bn vo vng da lnh. d. Xc nh tnh trng HIV ca ngun gy phi nhim. Ngi bnh c xc nh HIV (+): Tm hiu cc thng tin v tin s v p ng i vi thuc ARV Nu cha bit v tnh trng HIV ca ngun gy phi nhim: T vn v ly mu xt nghim HIV Trng hp khng th xc nh c (b phi nhim trong trng hp ang lm nhim v, i tng trn thot). e. Xc nh tnh trng HIV ca ngi b phi nhim. T vn trc v sau khi xt nghim HIV theo quy nh Nu ngay sau khi b phi nhim, ngi b phi nhim c HIV(+): b nhim HIV t trc, khng phi do phi nhim. Nu HIV (-): kim tra li sau 3 v 6 thng. g. T vn cho ngi b phi nhim: Nguy c nhim HIV, vim gan B, C Ngi b phi nhim cn c cung cp cc thng tin v c t vn thch hp v d phng phi nhim, li ch v nguy c. Gii thiu cc tc dng ph ca thuc v triu chng ca nhim trng tin pht: st, pht ban, bun nn hoc nn, thiu mu, ni hch v.v... T vn Phng ly nhim cho ngi khc: ngi b phi nhim c th lm ly truyn HIV cho ngi khc d xt nghim HIV m tnh (thi k ca s), v vy cn phi thc hin cc bin php d phng ly nhim. T vn tun th iu tr v h tr tm l h. iu tr d phng bng ARV cho ngi b phi nhim: Ch nh: Tin hnh iu tr bng thuc ARV cng sm cng tt t 2-6 gi v trc 72 gi sau khi b phi nhim cho tt c cc trng hp phi nhim c nguy c, ng thi tin hnh nh gi tnh trng HIV ca ngun gy phi nhim v ngi b phi nhim. Nu ngun gy phi nhim c xt nghim HIV (+): tip tc iu tr theo hng dn. Nu ngun gy phi nhim c xt nghim HIV (-): c th xem xt dng iu tr. Nu nghi ng ngun gy phi nhim c yu t nguy c ly nhim v ang trong giai on ca s th tip tc tc iu tr theo hng dn. Nu ngi b phi nhim c xt nghim HIV (+): khng iu tr d phng sau phi nhim, chuyn n cc c s chm sc v iu tr HIV/AIDS c theo di v iu tr nh nhng ngi nhim HIV khc. Nu ngi b phi nhim c nguy c v xt nghim HIV (-): tip tc iu tr theo hng dn. Phi nhim khng c nguy c: khng cn iu tr Trng hp khng xc nh c tnh trng HIV ca ngun gy phi nhim: x l nh l trng hp phi nhim vi ngun HIV (+).
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Bng 24: iu tr d phng sau phi nhim HIV bng thuc ARV Cc thuc s dng Phc iu tr 2 thuc AZT + 3TC hoc d4T + 3TC (Phc c bn) Phc iu tr 3 thuc AZT + 3TC hoc d4T + 3TC cng vi: LPV/r Thi gian iu tr 4 tun Ch nh Tt c cc trng hp phi nhim c nguy c Trong trng hp ngun gy phi nhim v ang iu tr ARV v nghi c khng thuc.

i. K hoch theo di - Theo di tc dng ph ca ARV: - Ngi c iu tr ARV d phng cn c t vn l c th thuc ARV gy ra cc tc dng ph, khng ngng iu tr khi c tc dng ph nh v thong qua, v n cc c s y t ngay khi c cc tc dng ph nng. - Xt nghim cng thc mu v chc nng gan (ALT) khi bt u iu tr v sau 4 tun. - Xt nghim HIV sau 1, 3 v 6 thng. - H tr tm l nu cn thit 2. D phng phi nhim HIV ngoi mi trng ngh nghip: 2.1. nh ngha Phi nhim khng do ngh nghip l nhng trng hp phi nhim vi mu, dch c th c kh nng lm ly nhim HIV khng lin quan n ngh nghip. 2.2. Cc tnh hung phi nhim ngoi mi trng ngh nghip: Phi nhim tnh dc: quan h tnh dc khng s dng bao cao su hoc bao cao su b v- rch, b cng dm. S dng chung kim tim i vi ngi nghin chch ma tu(ch mt ln); Vt thng do m phi kim hoc cc vt sc nhn vt ra cc khu vc cng cng v c dnh mu nhn thy c Vt thng do ngi nghi nhim HIV cn gy chy mu. 2.3. Cc tnh hung khng c xem xt iu tr d phng: Khng iu tr d phng sau phi nhim cho nhng trng hp phi nhim lin tc vi HIV nh c quan h tnh dc vi ngi nhim HIV hoc gi mi dm nhng him khi s dng bao cao su, ngi nghin chch ma tu thng xuyn s dng chung bm kim tim.. 2.4. Cc yu t cn nh gi i vi ngi c kh nng b phi nhim vi HIV ngoi mi trng ngh nghip. Tnh trng nhim HIV. Phm vi, tn sut v thi gian c nguy c phi nhim. C gng bit c tnh trng nhim HIV ca ngun ly nhim. T vn trc xt nghim HIV. Tin hnh xt nghim HIV, th thai nu cn
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2.5. nh gi tnh trng HIV ca ngun ly Nu cha bit tnh trng nhim HIV ca ngun ly, cn c gng t vn v xt nghim HIV cho ngun ly. C th bt u d phng sau phi nhim, sau dng li nu xc nh ngun ly khng nhim HIV. Khi ngun ly c bit t nhm ngi c t l nhim HIV cao (v d nh tnh dc ng gii, lng tnh, nghin chch ma tu, hoc hot ng mi dm), b cng dm, tnh trng HIV ca ngun ly kh hoc khng th xc nh c, cn tin hnh d phng sau phi nhim sau khi nh gi nguy c v t vn cho ngi b phi nhim. 2.6. iu tr d phng sau phi nhim bng thuc ARV iu tr d phng sau phi nhim ngoi mi trng ngh nghip bng ARV tng t nh d phng sau phi nhim ngh nghip; bt u ARV cng sm cng tt, trong vng 72 gi sau khi b phi nhim v tip tc trong 28 ngy. Ch nh phc 2 thuc. Khi ngun ly hin ti hoc trong tin s s dng ARV, hoc c bit l tht bi vi phc bc 1, khuyn co s dng phc 3 thuc. T vn v tc dng ph v tun th iu tr trc khi dng thuc 2.7. Theo di v t vn h tr Hng dn k hoch theo di v lm xt nghim li sau 1, 3, 6 thng, t vn tun th trong qu trnh iu tr d phng ARV T vn v vic khng uc cho mu, phi c quan h tnh dc an ton, thc hnh tim chch an ton, v khng cho con b cho n khi xc nh hoc loi tr c tnh trng nhim HIV

T vn tim vc xin vim gan B nu c nhn cha b nhim VGB, cha c tim chng, hoc cha c khng th vi vim gan B.
T vn v trnh nguy c phi nhim tip tc vi HIV

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PHN B: CHN ON, IU TR V CHM SC TR EM NHIM HIV/AIDS

I. CHN ON V PHN LOI GIAI ON LM SNG, GIAI ON MIN DCH NHIM HIV TR EM. 1. Chn on nhim HIV tr em 1.1. Chn on xc nh nhim HIV tr di 18 thng tui Chn on xc nh nhim HIV tr di 18 thng tui, bao gm tr phi nhim (tr sinh ra t ngi m b nhim HIV) v tr c biu hin nghi ng nhim HIV, bng xt nghim PCR (Polymerase Chain Reaction) pht hin DNA hoc RNA ca vi rt. Thc hin xt nghim chn on theo quy trnh chn on nhim HIV cho tr di 18 thng tui ca B y t ban hnh. 1.1.1. Chn on xc nh nhim HIV cho tr phi nhim di 9 thng tui Ch nh xt nghim vi rt khi tr c 4-6 tun tui, hoc ngay sau la tui ny cng sm cng tt. Nu kt qu xt nghim PCR ln 1 dng tnh, cn lm ngay xt nghim PCR ln hai khng nh chn on nhim HIV, ng thi nh gi tnh trng lm sng v chun b sn sng iu tr bng ARV. Nu kt qu xt nghim PCR ln 1 m tnh, hoc xt nghim PCR khng nh chn on (ln 2) c kt qu m tnh, cn tip tc theo di v lm xt nghim pht hin khng th khng HIV khi tr 18 thng tui khng nh chn on. Nu kt qu xt nghim PCR ln 1 m tnh nhng tr ang b m (hoc thi b m trc khi lm xt nghim cha 6 tun) nn lm li xt nghim PCR sau khi tr thi b m hon ton trn 6 tun. Trong qu trnh theo di, nu tr c du hiu hoc triu chng nghi ng nhim HIV cn lm xt nghim pht hin khng th khng HIV. Trong trng hp xt nghim khng th dng tnh lm ngay xt nghim PCR. 1.1.2. Xt nghim chn on xc nh nhim HIV cho tr phi nhim t 9 thng n 18 thng tui Cn lm xt nghim pht hin khng th khng HIV trc. Nu xt nghim khng th dng tnh ch nh lm xt nghim PCR nh i vi tr di 9 thng tui khng nh chn on. 1.1.3. Chn on xc nh nhim HIV cho tr di 18 thng tui khng r phi nhim nhng c biu hin nghi ng nhim HIV. p dng nh i vi tr phi nhim t 9 n 18 thng tui.

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1.2. Chn on lm sng bnh HIV/AIDS nng (giai on 4) tr di 18 thng tui Chn on lm sng bnh HIV/AIDS nng c p dng khi cha lm c xt nghim vi rt, nhng tr c: - Xt nghim khng th khng HIV dng tnh, v trn lm sng c triu chng sau: - C mt trong cc bnh ca giai on lm sng 4 nh vim phi do pneumocystis (PCP), vim mng no do Cryptococcus, vim no do Toxoplasma, gy mn nng khng gii thch c nguyn nhn, lao ngoi phi (tr trng hp lao hch nch do bin chng ca BCG), nm Candida thc qun. HOC - Tr c t nht 2 trong ba biu hin: 1. Nm ming ( tr trn 1 thng tui). 2. Vim phi nng do vi khun. 3. Nhim trng huyt nng. Cc yu t khc h tr cho chn on lm sng bnh HIV/AIDS nng nh: M mi t vong do bnh lin quan ti HIV, hoc M c bnh HIV/AIDS tin trin, hoc T l CD4 < 20% Cn tin hnh chn on xc nh bng xt nghim vi rt cng sm cng tt. 1.3. Chn on xc nh nhim HIV tr 18 thng tui Chn on xc nh nhim HIV cho tr trn 18 thng tui bng xt nghim pht hin khng th khng HIV. Chn on nhim HIV khi mu huyt thanh lm xt nghim dng tnh c ba ln, bng ba loi sinh phm khc nhau, vi nguyn l phn ng v phng php chun b khng nguyn khc nhau Lu : Ch nhng phng xt nghim c B Y t cho php mi c quyn thng bo kt qu xt nghim HIV. 2. Phn loi giai on nhim HIV Tr c chn on xc nh nhim HIV cn c nh gi v giai on lm sng mi ln ti khm v giai on min dch 6 thng/ln (tr c chn on lm sng bnh HIV/AIDS nng cng cn lm xt nghim min dch). 2.1. Phn loi giai on lm sng: Tr nhim HIV c phn loi vo 1 trong 4 giai on lm sng, ty thuc vo cc triu chng v bnh c lin quan n HIV nng nht m tr tng mc. Bng 1: Giai on lm sng HIV/AIDS tr c xc nh nhim HIV Giai on lm sng 1: Khng triu chng Khng c triu chng Hch to ton thn dai dng Giai on lm sng 2: Cc triu chng nh Gan lch to dai dng khng xc nh c nguyn nhn1. Pht ban sn nga Nhim nm mng Vim khe ming vin li
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Nhim virus mn cm lan ta (do HPV) U mm ly lan ta Lot ming ti din Sng tuyn mang tai dai dng khng xc nh c nguyn nhn1 Herpes zoster (Zona) Nhim trng ng h hp trn mn tnh hoc ti din (vim tai gia, chy m tai, vim xoang, hoc vim amydal) Giai on lm sng 3: Cc triu chng tin trin Suy dinh dng hoc gy st mc va phi khng xc nh c nguyn nhn khng p ng ph hp vi iu tr thng thng Tiu chy dai dng (trn 14 ngy) khng xc nh c nguyn nhn1 St dai dng khng xc nh c nguyn nhn1 (st trn 37.5C lin tc hoc ngt qung, ko di hn 1 thng) Nm Candida ming dai dng (sau 6-8 tun tui) Bch sn dng lng ming Vim lot, hoi t li hoc t chc quanh cung rng (nha chu) cp Lao hch Lao phi Vim phi vi khun nng ti din Vim phi k xm thm nhim lympho bo c triu chng Bnh phi mn tnh lin quan n HIV, bao gm c gin ph qun. Thiu mu (<80 g/L), gim bch cu ht (<0,5 x 109 t bo/L) hoc gim tiu cu (<50 x 109 t bo/L) mn tnh khng xc nh c nguyn nhn1 Giai on lm sng 4: Cc triu chng nng Suy kit, gy mn nng hoc suy dinh dng nng khng xc nh c nguyn nhn, khng p ng vi iu tr thng thng Vim phi do Pneumocystis jiroveci (hoc PneumoCystis Pneumoniae.PCP) Nhim trng nng ti din do vi khun (nh trn m mng phi, vim c m, nhim trng xng khp, tr vim phi). Nhim Herpes simplex mn tnh (herpes mi ming hoc da ko di hn 1 thng hoc herpes ni tng bt c ni no) Nhim nm Candida thc qun (hoc Candida kh qun, ph qun hoc phi) Lao ngoi phi (tr lao hch) Sarcoma Kaposi Nhim Cytomegalovirus (CMV): vim vng mc hoc nhim CMV c quan khc, xut hin khi tr > 1 thng tui. Bnh do Toxoplasma h thn kinh trung ng (sau 1 thng tui). Nhim nm Cryptococcus ngoi phi (bao gm c vim mng no) Bnh l no do HIV Nhim nm lan ta (nm lu hnh ti a phng nh Penicillium, Histoplasma) Nhim Mycobacteria khng phi lao, lan ta. Bnh do Cryptosporidium mn tnh (c tiu chy) Bnh do Isospora mn tnh U lympho no hoc u lympho khng Hodgkin t bo B Bnh l no cht trng a tin trin Bnh l thn hoc bnh l c tim c triu chng, lin quan n HIV
1

Khng xc nh c nguyn nhn tc l khng gii thch c bng cc nguyn nhn khc

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2.2. Phn loi giai on min dch Phn loi tnh trng min dch ca tr nhim HIV thng qua m s lng hoc tnh t l phn trm (%) t bo CD4 (tr em di 5 tui nh gi bng t l %). Bng 2: Phn loi giai on min dch tr nhim HIV/AIDS Suy gim min T l % t bo CD4 (hoc s lng t bo CD4/mm3) dch lin quan 11 thng 12-35 thng 36 -59 thng 5 tui n HIV
Khng suy gim Suy gim nh Suy gim tin trin Suy gim nng >35 % 30-35 % 25-29 % >30 % 25-30 % 20-24 % >25 % 20-25 % 15-19 % > 500 t bo/mm3 350 - 499 t bo/mm3 200 - 349 t bo/mm3 <15% < 200 t bo/mm3

<25 % <20 % <15 % <1500 tbo/mm3 <750 t bo/mm3 <350 t bo/mm3

Nu khng lm c xt nghim CD4, i vi tr nhim HIV t giai on lm sng 2 tr ln, c th nh gi tnh trng suy gim min dch nng da vo tng s t bo lympho (nhng khng s dng tng s t bo lympho theo di iu tr ARV). Bng 3: Chn on suy gim min dch nng theo tng s t bo lympho Tng s t bo lymph theo la tui ca tr/ mm3 Giai on suy gim min dch nng lin quan n HIV Tng s t bo lymph T bo CD4 <11 thng tui <4.000 <1.500 12- 35 thng 36- 59 thng tui tui <3.000 <750 <2.500 <350 5 tui <2.000 <200

3.Tiu chun chn on nhim HIV tin trin (bao gm AIDS) C bt k bnh l no thuc giai on lm sng 3 hoc 4 (chn on lm sng hoc xc nh) v/hoc T bo CD4 (hoc tng s t bo Lymph, nu khng lm c xt nghim CD4) mc suy gim tin trin v suy gim nng ca giai on min dch, theo la tui AIDS c xc nh khi tr c bt k bnh l no thuc giai on lm sng 4 hoc c t bo CD4 mc suy gim nng theo la tui. II. QUN L LM SNG TR PHI NHIM V TR NHIM HIV/AIDS 1. Giai on ban u: 1.1. Khm lm sng v lm xt nghim: 1.1.1. Hi bnh s v tin s bnh tt: - Tin s HIV ca m, b v bin php d phng ly truyn m-con - Tin s dng thuc ARV m v tr (l do s dng, thi gian dng, phc c th, tun th khi ung thuc) - Nu tr c xt nghim khng nh nhim HIV cn lu ni tr kt qu xt nghim HIV, thi gian v phng php lm xt nghim. - Tin s d phng cotrimoxazole, tim chng
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- Tin s mc cc bnh NTCH v tin s lao trong gia nh - Tin s d ng thuc cotrimoxazole, cc thuc ARV, v.v.. - Tin s nui dng, pht trin v th cht v tr tu. - Cc triu chng v du hiu bnh mi xut hin trong thi gian gn y. 1.2.2. Khm ton thn v thc th: - nh gi tnh trng chung ca tr, s pht trin th cht, tinh thn, nhn thc. - Biu hin ton thn, da v nim mc. - Khm v nh gi tnh trng cc c quan: h hp, tun hon, tiu ho, thn kinh ... v tnh trng tai - mi - hng, th lc. 1.1.3. Xt nghim: - i vi tr di 18 thng tui sinh ra t ngi m nhim HIV v tr nghi ng nhim nhng cha xc nh c tnh trng nhim HIV: + Ch nh xt nghim chn on nhim HIV ph hp theo tui ca tr, cng sm cng tt (xt nghim vi rt, v khng th khng HIV). + T vn trc xt nghim: v li ch ca xt nghim, cch thc tin hnh, thi im lm xt nghim. Nu tr b m cn t vn lin quan gia b m vi vic thc hin xt nghim v kt qu xt nghim + Ly mu xt nghim v vn chuyn n c s xt nghim theo quy nh + T vn sau khi c kt qu xt nghim v x tr theo quy trnh - i vi tr c chn on xc nh nhim HIV, hoc c chn on lm sng bnh HIV/AIDS nng, cn lm: + Xt nghim cng thc mu, tng s t bo lympho, men gan + Xt nghim sng lc lao (XQ phi, tc mu lng, phn ng da, nhum AFB m...). + Xt nghim t bo CD4. - Nu tr ang c bnh nhim trng c hi hoc cc bnh khc km theo cn ch nh cc xt nghim h tr thch hp. 1.1.4. Chn on NTCH v xc nh giai on lm sng: - Chn on lao tin trin: (xem chng V: Chn on v iu tr cc bnh nhim trng c hi thng gp tr em nhim HIV). - Chn on cc NTCH khc: xem chng IV (Tip cn cc hi chng lm sng thng gp tr em) v chng V (Chn on v iu tr cc bnh nhim trng c hi thng gp tr em nhim HIV). - Xc nh giai on lm sng i vi tr c chn on xc nh nhim HIV (xem chng I, mc 2.1). 1.2. X tr: - Hng dn cch cho n bng sa thay th (nu c iu kin), hoc b m v cc chm sc dinh dng theo nhu cu la tui. Nu tr c kt qu xt nghim vi rt HIV dng tnh, tip tc hng dn nui con bng sa m. - iu tr d phng cotrimoxazole, tim chng theo ch nh - iu tr cc bnh nhim trng c hi, triu chng, cc bnh l khc v x tr cc tc dng ph ca thuc, nu c.
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iu tr bng ARV nu tr tiu chun v lm sng v xt nghim. Nu tr c bnh nhim trng c hi cp cn c iu tr trc, bnh ci thin bt u iu tr bng ARV. Tr c kt qu PCR ln 1 dng tnh cn tin hnh chun b sn sng iu tr ngay. i vi tr c chn on lm sng bnh HIV nng cn iu tr ngay khng cn ch kt qu xt nghim PCR. - Nu tr ang c iu tr bng ARV: nh gi phc ang iu tr. Nu phc iu tr cha ng, cn hi chn li. - Nhp vin i vi trng hp c NTCH nng hoc c tc dng ph nng ca thuc. - Khm hoc hi chn cc chuyn khoa c bnh lin quan (da liu, lao..), hoc chuyn ln tuyn trn trong trng hp vt qu kh nng iu tr ca c s. 1.3. T vn h tr: Gia nh tr phi nhim HIV v tr nhim HIV cn c t vn nhng vn sau: - Tin trin ca nhim HIV, tm quan trng ca chm sc v iu tr lu di, s cn thit phi theo di nh k v xt nghim cn lm cho tr. - Xc nh ngi chm sc chnh v ngi chm sc h tr. - Tim chng v iu tr d phng NTCH. - T vn dinh dng bao gm li ch sa m v nguy c ly truyn HIV qua sa m, ch dinh dng theo tui, cc loi sa thay th, khng nui kt hp gia sa thay th vi b m v cai sa khi tr c 6 thng tui gim nguy c ly truyn HIV. - V sinh c nhn, v sinh n ung. - T vn v chm sc hc ng, vic gi b mt v bc l tnh trng nhim HIV ca tr, cc bin php d phng ly truyn HIV. - T vn tm l x hi v h tr tun th iu tr. - Gii thiu dch v chm sc iu tr HIV cho tr nhim HIV v gia nh. - Tho lun gii php h tr i vi tr m ci v tr b b ri. 1.4. K hoch theo di v nhng h tr cn thit khc - C lch ti khm c th: t 1-3 thng/ln tu theo tnh trng sc kho ca tr, kh nng tun th d phng bng cotrimoxazole, kh nng chm sc tr ca ngi chm sc, giai on lm sng v giai on min dch ca tr. - Nu tr n khm khng ng hn cn tm hiu l do v c cc bin php h tr nh t vn thm, gi in nhc nh, h tr ca nhm ng ng, thm nh... - Hn khm li bt c khi no nu c cc biu hin bt thng. - Pht thuc theo ch nh. - Kt hp cc h tr ca gia nh, cng ng v cc dch v sn c. 2. Ti khm Tr phi nhim v nhim HIV cn c ti khm nh k v khi c cc biu hin bt thng. Ngoi cc yu cu nh phn trn cn lu : 2.1. Thm khm lm sng v xt nghim: - Hi v cc biu hin mi xut hin sau ln khm trc nh st, st cn, ho, tiu chy, pht ban, v.v..; cc vn v tm l-x hi, tun th iu tr. 69

Khm lm sng: nh gi s pht trin v th cht, tinh thn, thm khm ton thn v b phn, pht hin NTCH v cc bnh l khc, tc dng ph ca cc thuc d phng v iu tr. nh gi li giai on lm sng. - i vi tr c chn on xc nh nhim (bao gm c tr c chn on lm sng bnh HIV/AIDS nng) cn lm cc xt nghim thng quy, v xt nghim CD4 mi 6 thng mt ln; cc xt nghim khc, nh chn on NTCH, nh gi mc tc dng ph ca thuc, c lm khi c ch nh. Thng xuyn nh gi kt qu iu tr i vi tr c iu tr bng thuc ARV theo ng quy trnh. 2.2- X tr: X tr theo tnh trng lm sng v kt qu xt nghim ca tr - iu tr NTCH v x tr cc tc dng ph ca thuc (nu c). - Ch nh iu tr ARV khi tr tiu chun. - Tip tc t vn dinh dng, tm l x hi v h tr tun th iu tr. - Chuyn tuyn hoc hi chn vi cc chuyn khoa v dch v lin quan, nu cn thit. III. D PHNG NHIM TRNG C HI, LCH TIM CHNG. 1. D phng NTCH tin pht bng cotrimoxazole a. Mc ch d phng cc bnh nhim trng c hi nh PCP, vim no do Toxoplasma v d phng c bnh tiu chy, vim ng h hp do mt s loi vi khun gy nn. b. Ch nh iu tr d phng tin pht. Bng 4: Ch nh d phng bng cotrimoxazole cho tr phi nhim v tr nhim HIV
Tr em phi nhim HIV < 1 tui Tr em khng nh nhim HIV 1-5 tui 5 tui

Ch nh d phng cotrimoxazole rng ri cho tr t tun th 4-6 sau khi sinh v duy tr n khi loi tr nhim HIV. Nu xc nh nhim HIV, xem ct bn

C xt nghim CD4: Giai Giai on lm on lm sng 3, 4 khng sng 2, 3 v 4 ph thuc s lng t bo khng ph thuc CD4 Ch nh Giai on lm sng 1, 2 vo t bo CD4 iu tr d Hoc vi CD4 < 200 TB/mm3 phng cho tt
c tr nhim CD4 < 25% khng ph thuc Khng c xt nghim vo giai on CD4: lm sng Giai on lm sng 2, 3, 4

c. Liu cotrimoxazole iu tr d phng: Cotrimoxazole gm 2 thnh phn: trimethoprim (TMP) v sulfamethoxazole (SMX). Liu iu tr d phng 5mg/kg/ngy tnh theo TMP, ung mt ln trong ngy. C th tnh liu lng theo bng sau:

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Bng 5: Liu cotrimoxazole iu tr d phng cho tr phi nhim V tr nhim HIV

Cn nng (hoc din tch da) Xi r (ml) Vin nn ca tr (8 mg TMP/40 mg SMX/1ml)(80 mg TMP/ 400 mg SMX) 3,5 - 4,9 kg (0,21 - 0,28 m2) 2,5 ml 2 5,0 - 6,5 kg (0,28 - 0,33 m ) 4 2 6,6 - 8,0 kg (0,34 - 0,40 m ) 5 1/2 2 8,1 - 10, kg (0,41 - 0,47 m ) 6 1/2 10,1 -11,9 kg (0,48 - 0,54 m2) 7 1/2 2 12,0 - 14,9 kg (0,55 - 0,64 m ) 8 1 2 15,0 - 16,9 kg (0,65 - 0,71 m ) 10 1 17,0 - 19,9 kg (0,71 - 0,83 m2) 11 1 2 20,0 - 24,9 kg (0,83 - 0,98 m ) 1,5 2 25 - 29,9 kg (0,99 - 1,15 m ) 2 2 30,0 - 35,0 kg (> 1,15 m ) 2

d. Thuc thay th: Dapson liu 2mg/kg/ngy, ung hng ngy hoc 4mg/kg/ln, ung 1 ln/tun khi d ng vi cotrimoxazole. Dapson tc dng km hn cotrimoxazole trong phng PCP v khng d phng c Toxoplasma. e. Ngng iu tr d phng: Khi tr c iu tr bng ARV v trong 6 thng lin tc c s lng t bo CD4 trn 25% i vi tr t 1-5 tui; v trn 200 t bo i vi tr trn 5 tui g. Ti iu tr d phng: khi s lng t bo CD4 gim n tiu chun cn c iu tr d phng ca la tui. h. Chng ch nh: D ng vi nhm sulfamid (cotrimoxazole, sulphadoxinepyrimethamine). i. Tc dng ph ca cotrimoxazole: C th gy nn, bun nn, pht ban xy ra trong 1- 2 tun u iu tr, hoc tc dng ph nng nh: thiu mu, gim bch cu ht, pht ban, ng c gan. T vn cho ngi chm sc v tr v cc tc dng ph, cch x tr v cn n khm ti cc c s y t khi nghi ng c tc dng ph nng. Lm xt nghim cng thc mu, men gan khi c nghi ng thiu mu, ng c gan Pht ban do cotrimoxazole v cch x tr Bng 6: Phn loi mc pht ban do cotrimoxazole v x tr
Mc Mc 1 (nh) Mc 2 (Trung bnh) Mc 3 (Nng) Mc 4 (Rt nng) Triu chng lm sng Ban X tr Tip tc iu tr d phng bng cotrimoxazole, theo di bnh nhn cht ch. iu tr triu chng v khng histamine. Tip tc iu tr d phng bng cotrimoxazole, theo di cht ch. iu tr triu chng v khng histamine. Nhp vin iu tr h tr NGNG VNH VIN s dng cotrimoxazole

Ban sn lan ta, trc vy kh

Ban phng nc, lot nim mc Vim da trc vy, Hi chng Steven Johnson hoc Hng ban a dng, bong da t

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2. Tim chng phng bnh:

Vcxin BCG Bch hu-Ho g-Un vn Bi lit ung Vim gan B Si Vim no Nht bn Vcxin t chn Haemophilus influenzae B Thy u Quai b Rubella Tr phi Tr nhim HIV giai Tr nhim HIV giai on nhim on lm sng 1, 2 v 3 lm sng 4 Theo lch Theo lch Theo lch Theo lch Theo lch Theo lch Theo lch Theo lch Theo lch Theo lch Khng tim Theo lch Theo lch Theo lch Theo lch Theo lch Theo lch Theo lch Theo lch Theo lch Khng tim Theo lch Ch dng vcxin tim, nu c. Theo lch Khng tim Theo lch Theo lch Khng tim Khng tim Khng tim

Vcxin trong Chng trnh Tim chng m rng

Lu : - Tim BCG cho tt c tr phi nhim. C th tr hon cho n khi loi tr nhim i vi nhng tr phi nhim HIV, nu: Tr c nguy c ly nhim HIV cao: M v con khng c d phng ly truyn HIV t m sang con. Hoc Tr c du hiu hoc triu chng gi nhim HIV. Hoc Tr c cn nng khi sinh thp (di 2500 g), non. - Bnh do BCG c th gp sau tim phng BCG. Biu hin sng hch nch tri hoc h thng n tri, gan lch to, suy kit. Cn hi chn vi chuyn khoa Lao nh gi v iu tr.

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IV. TIP CN MT S HI CHNG LM SNG THNG GP TR EM NHIM HIV/AIDS 1. St ko di

St ko di (a, b)
H st, b nc, dinh dng Hi tin s, bnh s (c) Khm lm sng (d)

Gi cc cn nguyn gy st (e): - C biu hin h hp: Lao, PCP, vim phi do vi khun hoc vi rt - C biu hin thn kinh: VMN do vi khun, lao, cryptococcus, vim no do Toxoplasma, st rt - C tn thng da: Penicillium, Cryptococcus - C hch to: Lao, MAC, nhim nm huyt - C tiu chy: Salmonnella, lao rut, MAC - C thiu mu: Lao, MAC, nhim nm huyt - Tin s dng thuc: d ng - v.v...

Xt nghim c bn v theo triu chng v cn nguyn (e): - CTM, CD4 (nu c th) - Biu hin h hp: X-quang phi, AFB m - Biu hin thn kinh: chc dch no ty - Nhim khun huyt, nm penicillium: cy mu - Hch to: chc ht hch - Siu m bng v.v...

iu tr theo kinh nghim (e): - Nhim khun huyt: khng sinh ph hp - Bnh nm Penicillium: Itraconazole - PCP: cotrimoxazole - Lao: thuc chng lao - VMN do vi khun hoc Cryptococcus: khng sinh ph hp - Vim no do Toxoplasma: cotrimoxazole - v.v...

C kt qu xc nh chn on v/hoc Tr p ng vi iu tr theo kinh nghim

Khng c kt qu xc nh chn on, tr khng p ng vi iu tr theo kinh nghim

Tip tc v hon thnh iu tr. iu tr duy tr nu c ch nh

nh gi li lm sng, cn nhc cc nguyn nhn khc, lu lao, MAC hoc st do HIV Lm cc XN v thm d tng ng, xem xt sinh thit hch, tu xng,... iu tr theo hng lao; MAC Xem xt ch nh iu tr ARV

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Hng dn:

a) nh ngha: st ko di c xc nh khi st trn 3705 v ko di trn 14 ngy. (b) Cc cn nguyn thng gp gy st ko di - Cc cn nguyn hay gp trong nhim HIV v suy gim min dch: o Lao, MAC, bnh do nm Candida, Penicillium, vim mng no v nhim nm huyt do Cryptococcus, nhim trng huyt do Salmonella v cc vi khun khc, bnh do CMV, ... o Bnh c tnh lin quan vi HIV: u lymph, o St do HIV gy nn, st rt - Phn ng vi cc thuc: cotrimoxazole hoc ARV (nh NVP, ABC, v.v...). (c) Hi tin s, bnh s: - Thi gian b bnh, c im khi pht (cp tnh hoc bn cp) - Cc triu chng cc c quan: au u, tiu chy, ho, pht ban, v.v.. - Cc thuc s dng: cotrimoxazole, ARV, cc thuc khc - Tin s mc cc bnh NTCH v cc bnh l khc lin quan ti HIV (kh nng ti pht cc NTCH, nu khng c iu tr d phng th pht hoc khng c iu tr bng ARV). - Tin s d ng thuc v cc bnh l khc. - Tin s gia nh: tin s lao v cc bnh truyn nhim khc (d) Khm lm sng: - Thm khm cc c quan, tp trung vo nhng c quan c biu hin bnh - Nu tr c t l CD4 thp cn ch khm mt (soi y mt) tm tn thng ca CMV, toxoplasma v cy mu tm nguyn nhn nm, vi khun. (e) Tm cc cn nguyn gy nhim trng c hi: lm cc xt nghim v cc thm d xc nh chn on, iu tr (xem thm Chng V: Chn on v iu tr cc bnh nhim trng c hi thng gp tr em nhim HIV)

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2. H hp
Biu hin h hp: ho, st +/- kh th (a) Khi pht cp tnh St, ho c m X-quang phi: m ri rc hai ph trng
Khng C

Cn nhc vim phi do vi khun. iu tr khng sinh (d)

Hi bnh v nh gi lm sng (b)

Lm cc xt nghim chn on (c)

Xt nghim c bn Chp XQ phi, soi, cy m tm AFB, vi khun,.. Cc xt nghim v thm d khc

Khng st hoc st nh, kh th, rt lm lng ngc, thng khng c ran phi, SpO2 <90%. XQ phi: thm nhim lan to Tin trin cp/ suy gim min dch nng
Khng

Cn nhc PCP, iu tr bng cotrimoxazole (d)

Xc nh c cn nguyn

Khng

Din bin mn tnh hoc bn cp C tip xc ngun lao XQ: hch to rn phi hoc cnh kh qun hoc thm nhim phi, nh phi
Khng

Lao phi tin pht (d)

Lm sng thng ho khan, ngn tay di trng, hch to, gim Oxy mu XQ phi: thm nhim k nt li 2 bn
Khng

iu tr theo hng vim phi k lympho (d)

iu tr cn nguyn nu xc nh c (d)

St cao, kh th, co ko c h hp, nghe 2 phi khng r ran hoc c ran ph qun XQ phi tn thng k

C Vim phi vi rt: Chm sc h tr

Tnh trng tr khng tin trin: - nh gi li lm sng v cc xt nghim cn thit (X-quang phi, m, chc hch, v.v..) - Xem xt iu tr lao - Hi chn hoc chuyn tuyn

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Hng dn: (a) Nguyn nhn: - Nguyn nhn hay gp: Vim phi do vi khun, PCP, lao phi tin pht, vim phi k thm nhim lympho, vim phi vi rt - Nguyn nhn khc: bnh do nm, cc nguyn nhn khng nhim trng (b) Nhng im lu khi hi v khm bnh: Hi bnh: Lm sng: - Khi pht cp tnh, bn cp - Tnh trng suy h hp: kh th, tm ti - Ho khan hay ho c m - Cc biu hin ton thn: st, st cn, pht ban, sng hch, ngn tay du trng, v.v.. - Du hiu i km: st, st cn, ra m hi trm - Khm h hp: rale, rung thanh, - Tin s lao ca bn thn v - Du hiu khc: pht trin tinh thn, th trong gia nh cht, biu hin suy gim min dch (nm hng, suy kit). (c) Xt nghim chn on: Da trn cc triu chng lm sng v bnh s - Xt nghim c bn, t bo CD4, - X-quang phi, soi m, dch d dy tm AFB; soi cy m tm cc vi khun khc. - Cy mu nu tr c st - Chc d mng phi, hch nu c trn dch mng phi hoc hch to lm xt nghim. - Nu c iu kin: chp ct lp phi (d) Xem thm Chng V Chn on v iu tr cc bnh nhim trng c hi thng gp tr em nhim HIV.

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3. Thn kinh
Tr c biu hin bt thng h thn kinh (a)

Ri lan chc nng vn ng v thc duy tr v tin trin

C Bnh l no do HIV duy tr hoc tin trin iu tr nh bnh no do HIV Chm sc h tr iu tr ARV

Khng C C Chc dch no tu ?

Giai on cp Hi chng mng no

Dch no ty gi nhim trng c th (c): VMN do vi khun VMN nm cryptocuccus

VMN do lao

iu tr theo cn nguyn (d)

Cn nguyn khc Khng

Khng Khng Chuyn tuyn hoc iu tr th nh VMN vi khun (d) Khng Chm sc h tr iu tr nh bnh no do HIV (d) v bt u iu tr ARV C

Tng p lc dch no ty

Nghi ng chy mu no hoc tn thng chon ch

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Hng dn: a. nh ngha: cc bnh l h thn kinh tr em bao gm: - Bnh l no tin trin: gim dn chc nng vn ng, nhn thc, ngn ng. Biu hin chm pht trin hoc khng t c cc cc mc pht trin; thng khi pht sm trong nm u, nhng cng c th bt c thi im no. - Bnh l no duy tr: ri lon chc nng vn ng v thiu nng pht trin cc loi mc nng khc nhau, nhng thng khng tin trin qua cc thi k thm khm. - Bnh l no duy tr do HIV: c xc nh khi khng tm thy cc cn nguyn khc gy chm pht trin, ri lon chc nng thn kinh (nh non, ngt lc sinh, sang chn s no hoc do nh hng thuc v ru khi mang thai). - Nhim trng cp tnh: khi pht cp vi biu hin co git, lit khu tr v c hi chng mng no, v d hay gp do vim mng no do vi khun, vim mng no nm cryptocuccus, vim mng no do lao. b. Biu hin cp tnh c th xy ra tr nhim HIV khe mnh hoc trn tr c bnh l no HIV. c. Da vo kt qu xt nghim dch no ty: sinh ha, t bo, soi cy tm vi khun v nm xc nh d. Cn nguyn v iu tr: Xem thm Chng V Chn on v iu tr cc bnh nhim trng c hi thng gp tr em nhim HIV

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4. Tiu chy ko di (a)

Hi bnh s, Thm khm lm sng (b, c) B nc v in gii, t vn ch n hp l iu tr suy dinh dng nu c

Soi, cy phn tm nguyn nhn, cc XN v thm d khc (d) Khng Khng

Xc nh c cn nguyn

iu tr theo nguyn nhn (e)

Gi do tc nhn vi khun xm nhp: phn c mu

Khng C

iu tr theo phc trong 5 ngy

Gi do tiu chy do vi rt
Khng Khng

iu tr h tr Ci thin
C
Khng

Hon thnh iu tr

Gi do tiu chy do ri lon hp thu, iu tr cc thuc gim tiu chy c tc dng

Khng

iu tr h tr, ch n
Tin hnh nh gi su hn tm cn nguyn Cn nhc iu tr theo nguyn nhn iu tr ARV iu tr d phng cotrimoxazole

Gi do tiu chy do k sinh trng hay n bo

iu tr thuc dit KST hay n bo

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Hng dn: (a) nh ngha: Tiu chy ko di c xc nh khi tr i phn lng trn 3 ln mt ngy, ko di trn 14 ngy (b) Hi bnh s: - S ln i ngoi mi ngy, tnh cht phn - Cc triu chng km theo: st, au bng, v tr v tnh cht au - Tin s dinh dng ca tr - Tin s lao v cc bnh truyn nhim khc trong gia nh (c) Thm khm lm sng: - nh gi ton trng, tnh trng mt nc, dinh dng - nh gi tnh trng pht trin - Cc biu hin ton thn: st, ni hch, st cn; - Thm khm cc c quan h hp v tun hon. - Thm khm bng: pht hin au bng, trn dch mng bng, gan lch to, hch bng (d) Cc xt nghim v thm d: - Xt nghim phn: o Soi phn tm hng cu v bch cu (tiu chy do l v mt s loi vi khun khc); k sinh n bo (amip, giardia, u trng giun ln, giun mc, cc loi trng giun); tm AFB (lao v MAC), o Dng phng php tp trung formalin-ether v nhum kim toan ci tin tm Cryptosporidium, nhum ba mu tm Microsporidium v Isospora; nu c iu kin - Cy mu nu bnh nhn c st, nghi tiu chy km nhim trng huyt do vi khun - Chp X-quang phi, xt nghim m nu c biu hin h hp hoc nghi lao - Siu m bng xc nh gan lch to, hch to, dch mng bng (e) Cn nguyn v iu tr: Xem thm Chng V Chn on v iu tr cc bnh nhim trng c hi thng gp tr em nhim HIV

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5. Ci cc v chm pht trin th cht

nh ngha. Km pht trin mc trung bnh: trng lng 60-80% trng lng bnh thng tng ng vi tui/chiu cao; km pht trin mc nng: trng lng 60% trng lng trung bnh tng ng vi tui/chiu cao, hoc 60-80% trng lng bnh thng v c ph km theo Nguyn nhn hay gp: nhim trng ti pht hoc nhim trng kn, nhim nm candida ming hoc thc qun, hoc nhim trng khc ti hng ming, khng c kh nng cung cp thc phm/nng lng, hp thu km v tiu chy, nn, nhim HIV mn tnh, lao hoc MAC mng bng. Bnh s: mc st cn, cc triu chng ca nhim trng kn, tin s tiu chy hoc nn, tin s n ung ca tr Khm lm sng: Cn nng v chiu cao, thm khm y pht hin cc triu chng thc th ca nhim trng kn iu tr h tr ban u: b nc v h tr dinh dng. Bt u nh gi iu tr ARV nu tr tiu chun iu tr

Tin s khng n ung y

Tin s nm hoc lot ming

Tr suy dinh dng hoc mt nc trm trng?

Tin s st hoc tiu chy?

Th cho tr n vi ch n c nhiu nng lng v b sung vitamin trong 7 ngy

iu tr nm hoc HSV (nu c lot)

Cho nhp vin h tr v dinh dng, truyn dch thay th, b sung vitamin v mui khong

Nu ci thin, tip tc iu tr kt hp theo di st

Khng ci thin

Xt nghim cng thc mu v cng thc bch cu, albumin, cy mu, chp phi, loi tr lao, xt nghim phn tm vi khun, trng v k sinh trng. nh gi tng t nh bnh nhn c tiu chy, st. Siu m bng c th gi gan, lch, hch to

- Cn nhc nhp vin h tr dinh dng - nh gi li i vi nhim trng kn - Cn nhc iu tr ARV nu t tiu chun ch nh iu tr

Khng

Tm thy cn nguyn?

iu tr nguyn nhn

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V. CHN ON V IU TR CC BNH NHIM TRNG C HI THNG GP TR NHIM HIV

NTCH Biu hin lm sng Cc bnh do nm Candida Bnh thng xut hin giai on suy gim min dch nng, din bin nng, dai dng v hay ti pht. Nhim nm candida ming, hng, thc qun: Nhiu m hoc m gi mc trng, d bong, kh tr li, li, nim mc ming - hng. Nu tn thng lan xung hng v thc qun, tr thng c triu chng nut kh v/hoc au khi nut. Cryptococcus Nhim nm cryptococcus t gp tr nh, thng xut hin tr > 6 tui Vim mng no: mt mi, st, au u dai dng, km theo bun nn, nn, ri lon tm thn, ng kinh, hn m; du hiu mng no thng kn o; c th c ri lon th gic, gim thnh lc, v.v.. Ban trn da: nt - sn, sn hoi t trung tm, sn c lot, mn m. Vim phi: vim phi k lan to. Cc c quan khc nh xng, thn, gan, hch cng c th b nhim nm. Bnh thng xut hin khi bnh nhn c suy gim min dch nng. Biu hin: St, sng hch, gan lch to, st cn, thiu mu. Ban trn da: sn hoi t, lm trung tm; phn b ch yu u, mt, phn trn thn mnh v chi trn hoc ri rc khp c th. Chn on Da vo lm sng. Soi th c qun: Ch nh khi cc triu chng khng thuyn gi m sau i u tr thu c khng n m. Soi t i tm n m khi bnh nhn khng p ng v i iu tr Nui cy phn loi nu biu hin trn lm sng khng in hnh. iu tr* Bnh nhim nm candida ming: Thu c u ng: Fluconazole 3-6 mg/kg x 1ln/ngy x 7-14 ngy; Ti ch:Daktarin oral gel (miconazole) hoc Nystatin X 5 ln ngy x 7-14 ngy. Bnh nhim nm candida thc qun: Fluconazole 3-6 mg/kg x 1ln/ngy x 14 - 21 ngy hay Ketoconazole 5mg/kg ung chia 1-2 ln trong ngy trong 2-3 tun Bnh nm candida xm nhp: Amphotericin B 0,5-1,5 mg/kg/ngy trong 2-3 tun iu tr tn cng: Ch nh bt buc cho vim mng no th nng (bnh nhn c ri lon thc, biu hin ph no, soi dch no ty c nm, v.v..) Phc u tin: Amphotericin B pha long, truyn tnh mch 0,7-1,5 mg/kg/ngyx 2 tun sau iu tr cng c: Fluconazole 5 - 6 mg/kg/ngy x 8 tun Nu vim mng no th nh c th dng fluconazole 5 - 6 mg/kg/ngy x 8 tun ung iu tr duy tr: bng fluconazole 3mg/kg/ngy hoc Itraconazole 3 mg/ngy. Dng iu tr nu bnh nhn c iu tr ARV v CD4>200 t bo/mm3 ko di trn 6 thng iu tr tn cng: Phc phi hp: Amphotericin B tnh mch, 0,7-1,5mg/kg ngy trong 2 tun; 8 tun tip dng itraconazole 5- 6 mg/kg X2 ln/ngy. iu tr duy tr: Itraconazole 3 mg/ngy, duy tr sut i. Dng iu tr nu bnh nhn c iu tr ARV v CD4>200 TB/mm3 ko di trn 6 thng.

- Dch no ty trong, p lc tng; ng v protein t bin i; t bo tng nh, ch yu bch cu lympho. Nhum dch no tu bng mc tu, soi tm nm. - Nui cy nm t dch no tu, mu, t chc. - Sinh thit bnh phm da, soi, cy tm nm. - Pht hin khng nguyn trong huyt thanh v dch no tu.

Penicillium marneffei

Da vo lm sng nu bnh nhn c st v tn thng da c hiu Soi ti bnh phm da, tu xng, hch tm nm. Cy mu v nui cy cc bnh phm trn trong mi trng Sabouraud 25-37oC. Sinh thit da.

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Vim phi do Xut hin tr nh di 1 tui, din bin Da vo lm sng Chn on xc nh: soi tm P.jiroveci trong Pneumocystis nng v nguy c t vong cao. m (kch thch tit m tng nhy), B nh kh i pht c p tnh ho c bn c p: (PCP)
st, ho, th nhanh, tm ti; thm khm c ran hai y phi. C th triu chng khng in hnh nh ho, khng st, kh th, b n, st cn. Xt nghim: thng thiu oxy mu va n nng (PaO2 thp), bch cu cao, LDH cao > 2 ln bnh thng. X-quang: thm nhim k lan to hai bn, c th tn thng thy phi, tn thng k hoc bnh thng.

iu tr tn cng Phc u tin: TMP - SMX 20mg/kg/ngy (tnh theo TMP) chia 6-8 gi 1 ln trong 21 ngy dch ra ph qun, ph qun-ph nang. Cc Phc thay th: Clindamycin 20 - 40mg/kg/ngy phng php nhum: Giemsa, thm bc, min chia 4 ln tim tnh mch + Primaquin 15dch hunh quang. 30mg/ngy ung. iu tr h tr steroid nu c suy h hp, PaO2< 70 mm Hg. Liu prednisone 2mg/kg/ngy chia 2 ln x 5 ngy, sau 1 mg/kg/ngy x 5 ngy, tip theo 0,5 mg/kg/ngy t ngy 11 n ngy 21, dng iu tr theo tnh trng ca bnh nhi. iu tr duy tr d phng PCP th pht: 5mg/kg/ngy tnh theo liu TMP. Ngng iu tr d phng khi: Tr c iu tr bng ARV v trong 6 thng lin tc c CD4 trn 25% i vi tr t 1- 5 tui; v trn 200 t bo i vi tr trn 5 tui Ti iu tr d phng: CD4 gim n tiu chun cn c iu tr d phng ca la tui.

Cc bnh do k sinh n bo Vim no do Nhim Toxoplasma tr c th xy ra Xt nghim huyt thanh tm IgM, Ig A, iu tr ban u Toxoplasma trc khi sinh (bm sinh) hoc sau khi sinh. IgE trong 6 thng u v IgG cho tr hn Nhim Toxoplasma bm sinh: Cotrimoxazole: liu Cc triu chng sm ca nhim 12 thng. Nhim Toxoplasma dng vim da trn TMP 10-15 mg/kg/ngy tim tnh mch toxoplasma: st, au hng, au c, sng no c th huyt thanh chn on m tnh. hoc ung, hoc Pyrimethamine 2 mg/kg/ngy ung 1 hch lympho, pht ban, gan lch to; Phn lp tc nhn hoc xt nghim PCR ln/ngy x 2 ngy, sau 1 mg/kg/ngy trong 2-6 trong mu, dich no ty, nc i hay m thng, sau 1 mg/kg/ngy ung 3 ln/tun + Cc triu chng mun: vim no, st, l bnh. Sulfadiazine 50 mg/kg/ngy ung chia 2 ln/ngy + ln, co git, v tn thng vng mc. Chn on hnh nh CT, MRI scan s no Acid folinic 10-25 mg/ ngy. Thi gian iu tr do thy c th thy tn thng c hiu ca thuc c kinh nghim v bnh Toxoplasma xc nh. Toxoplama Nhim Toxoplasma sau khi sinh: Phc u tin: Cotrimoxazole: liu da trn TMP Pyrimethamine ung, liu tn cng 2mg/kg cn nng/ngy x 3 ngy, sau gim xung 1mg/kg/ngy + acid folinic ung 10-25 mg/ngy + sulfadiazin ung, 120mg/kg/ngy chia 4 ln/ ngy x 6-8 tun. Phc thay th: Pyrimethamine + clindamycin

10-15 mg/kg/ngy tim tnh mch hoc ung, hoc

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iu tr duy tr: Cotrimoxazole liu da trn TMP 5 mg/kg/ngy Pyrimethamine 1 mg/kg/ngy + acid folinic 5 mg/kg 3 ngy/tun + sulffadiazin 85-120 mg/kg/ngy chia 2 n 4 ln, hoc Pyrimethamine + acid folinic + clindamycin Cryptosporidium Tiu chy te nc cp hoc bn cp Nhum phn phng php khng cn-toan iu tr ARV l cch c hiu qu duy nht kim sot thng lin quan n au qun bng, bun c bin i thy cc kn trng nh ng nhim Cryptosporidium dai dng. nn v nn. knh 4-6 m. iu tr h tr, gm b nc in gii, b sung dinh dng. Nitazoxanide c chp nhn iu tr (tr t 1-3 tui: 100 mg, ngy 2 ln, tui t -11: 200 mg, ngy 2 ln) Cc bnh do vi khun Bnh lao - Cn hi k tin s, bnh s, ngun ly + Tuberculin test (Mantoux): phn ng iu tr lao tr nhim HIV: - Cng thc: 2RHZE/4RH (Chng trnh chng lao quc - Khm lm sng: dng tnh > = 5 mm + Ho ko di, st ko di trn 2 tun, + Chn on hnh nh: Xquang phi, gia) st cn (hoc khng tng cn), ra m CT, MRI, siu m... - Cc th lao nng (lao k, lao mng no, lao xng hi trm... + Chc ht sinh thit cc tn thng: khp,...) b sung Streptomycin trong 2 thng tn cng, + Hch c khng au c d hoc khng hch, apxe lnh... ko di thi gian iu tr duy d + Xt nghim dch no tu, dch mng - Ch tng tc gia Rifampicin v Nevirapine (thay + Vim mng no khng p ng vi phi, mng bng... th Efavirenz), theo di chc nng gan trong qu trnh iu tr khng sinh, din bin bn cp + Tm vi khun lao (bng cc phng iu tr. tnh hoc tng p lc s no. php khc nhau: AFB, PCR, nui cy...) Thuc Liu lng + Trn dch mng phi, mng bng, trong cc bnh phm c th ly c: Hng ngy 3 ln/tun mng tim m, dch d dy, dch ph qun, dch mg/kg mg/kg + Sng khp, g ct sng cc mng, hch, apxe lnh... Isoniazid 5 (4-6) 10 (8-12) Rifampicin 10 (8-12) 10 (8-12) Pyrazinamid 25 (20-30) 35 (30-40) Ethambutol 20 (15-25) 30 (25-35) Streptomycin 15 (12-18) 15 (12-18) - Cc thuc cha lao Bin chng do - p xe v tr tim, hch xut hin nhiu Chc hch lm xt nghim gii phu bnh, - Nhng trng hp ny bt buc phi iu tr t nht vi BCG tr v tr cng bn tim chng. Bnh c th nui cy nu c th c. 4 loi thuc: Isoniazid, Rifampicin, Pyrazinamid, nhim HIV biu hin nhiu v tr trn c th , t Ethambutol, Ofloxacin hoc Ciprofloxacin. (Bnh do BCG): l t vong cao (75%). - Thi gian iu tr t nht 9 thng v cn nhc iu tr ARV

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Cc bnh do St, m hi trm, mt mi, st cn, tiu Phn lp vi trng hay kt qu gii phu iu tr kt hp thuc: Mycobacteria chy v au bng ko di bnh Clarithromycin: 7,5 - 15mg/kg X2 l n trong ngy (t i a khng in hnh Xt nghim: Bch cu gim, phosphatase 500mg/liu) + Ethambutol 15 - 25mg/kg X1 l n ngy (MAC) kim tng, LDH tng (t i a 1000mg) + Rifampicin 10-20mg/kg, ung 1ln/ngy. Nhim vi trng Vim phi l bnh thng thy, l nguyn Lm sng c trng. Cn lm sng: bch Khng sinh thng c chn: nng v ti din nhn gy t vong tr nhim HIV/AIDS. cu mu v t l bch cu trung tnh tng; - Ceftriaxone 80 - 100mg/kg chia 1 - 2 ln trong ngy Ngoi ra c th gp nhim trng huyt, chp X-quang phi, soi v cy m, cy - Cefotaxime 150 - 200mg/kg chia 3 -4 ln trong ngy vim m mng phi, vim xng, vim mu, chc d mng phi, soi v cy vi Khi nghi ng nhim trng Gram m ng rut dng - Ceftazidime 150 - 200mg/kg chia 3 -4 ln trong ngy hch m, vim m t bo, vim mng khun, nu c iu kin; - Ciprofloxacine 20 - 30 mg/kg chia 2 ln trong ngy no Khi nghi ng nhim t cu khng methicilline: Lm sng: - Vancomycin: 40 - 60 mg/kg chia 3 -4 ln trong ngy St km biu hin ca c quan b tn - Clindamycin: 10 - 20 mg /kg chia 3 -4 ln trong ngy thng nh: ho, kh th, du mng no, Cn iu tr kt hp cotrimoxazole nu khng loi tr hch sng vim phi do PCP Xt nghim: thng bch cu mu khng Nu khng p ng sau 7 - 10 ngy lm xt nghim loi cao, cc xt nghim chn an c quan tn tr lao v nm thng: X quang phi, dch no ty Nn cy mu, cy dch no ty, cy m mng phi xc nh tc nhn. Vim phi k Thng gp tr nhim HIV ln, t gy Da vo lm sng Bnh ci thin tm thi khi iu tr bng prednisolon liu 1thm nhim t vong, nhng din bin ko di v c th XQ phi: c tn thng thm nhim phi 2mg/kg/ngy (nu PaO2 < 85-90 mm Hg); gim liu sau khi lympho bo gy suy h hp mn tnh. Khi pht t t; ging lao hoc PCP. c p ng lm sng. (LIP) v c biu hin sau: Cc triu chng thng ti xut hin sau khi ngng Ho khan, kh th, ngn tay di trng, prednisolon v n nh khi c iu tr thuc ARV. vim tuyn mang tai, sng hch lympho Khng s dng prednisolon khi c bnh khc km theo Thiu oxy mu, nht l khi tr mc cc c chng ch nh bnh nhim trng h hp km theo Xt nghim: X-quang phi c thm nhim nt-li lan to, gin ph qun Cc bnh do vi-rt Herpes zoster Zona c th xut hin khi CD4 cn tng Lm sng thng in hnh v khng cn Acyclovir 20mg/kg ung X 4 ln /ngy x 7-10 ngy (Zona) i cao xt nghim h tr. iu tr ti ch cc thuc chng bi nhim nh xanh methylen, milian. Mn nc dnh chm, thng lm gia, phn b mt vng da, mt bn ca c th, thng vng lin sn, ngc, u, mt, theo ng i ca dy thn kinh. Tr c cm gic au rt vng da tn

85

thng, i khi ko di d tn thng lin, cn gi l au thn kinh sau zona. C th c st. Thng lu khi, hay ti pht, c th b nhiu vng da v c hai bn Herpes simplex Biu hin da - nim mc: mn nc mc Da trn biu hin lm sng thnh chm, khi v li vt trt hoc lot; Chn on t bo Tzanck t thng tn thng c quan sinh dc, hu mn, quanh mn nc c t bo khng l; nui cy hu mn, c khi trc trng v rut gi, virus hoc xt nghim khng th min dch ming v quanh ming, i khi lan n thc hunh quang, PCR, nu lm c. qun gy kh nut, nut au, c th lan sang kh - ph qun. Bnh hay ti pht v nng hn so vi ngi khng nhim HIV. Vim no do Herpes: Biu hin khng in hnh, tn thng thy trn - thi dng. Bnh do CMV thng xut hin khi Soi y mt khi nghi vim vng mc. TCD4<50/mm3. B Sinh thit no, dch no tu, tn thng da, Cc biu hin chnh ca bnh do CMV mu lm xt nghim nui cy t bo hoc tr: vim vng mc, vim thc qun, vim chn on PCR. gan, vim phi, vim no, vim i trng; Tr c t l CD4 thp cn khm mt cn thn st, chm ln, chm pht trin, gim thnh cn nhc gia iu tr CMV v ARV, v lc; thiu mu, h tiu cu, tng LDH. phng hi chng phc hi min dch Ung Acyclovir 20 mg/kg X3 ln/ngy x 5 -10 ngy trng hp nh; Truyn tnh mch Acyclovir 5 -10mg/kg mi 8 gi x 10 ngy i vi nhng trng hp nng bao gm c vim no; hoc Famciclovir 125 mg ung 2 ln/ngy x 5 -10 ngy; iu tr ti ch chng bi nhim bng dung dch xanh methylene hoc tm gentian. Phc u tin cho bnh ton thn v vim vng mc: Gancyclovir 10 - 15 mg/kg/ngy, tim tnh mch chia 2 ln trong 14 - 21 ngy, sau duy tr 5 10 mg/kg/ngy x 5-7 ngy/tun. Phc thay th: Foscarnet 180 mg/kg/ngy chia 3 ln x 14-21 ngy, sau duy tr 90-120 mg/kg/ngy. Vim vng mc tr > 3 tui: Ganciclovir tim ni nhn kt hp vi gancyclovir ung 90 mg/kg/ngy chia 3 ln. Duy tr sut i bng ganciclovir 5 mg/kg/ngy tim tnh mch 1 ln, sau bnh ton thn do CMV. iu tr duy tr cho vim vng mc l ganciclovir ni nhn 69 thng mt ln + ganciclovirr ung 90 mg/kg/ngy chia 3 ln. Ngng iu tr nu iu tr bng ARV v t l CD4 > 15% ko di trn 6 thng.

Cytomegaloviru s (CMV)

* Lu tng tc gia cc thuc iu tr NTCH v cc thuc ARV (xem Ph lc 6)

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VI. IU TR BNG THUC KHNG HIV (IU TR ARV) 1. Mc ch v nguyn tc iu tr ARV 1.1. Mc ch ca iu tr ARV tr em nhim HIV: - c ch s nhn ln ca vi rt v km hm lng vi rt trong mu mc thp nht. - Phc hi chc nng min dch, gim nguy c mc cc bnh nhim trng c hi. - Ci thin cht lng sng v tng kh nng sng st cho tr - Duy tr s pht trin bnh thng cho tr c v th cht v tr tu 1.2. Nguyn tc iu tr ARV: - iu tr ARV l mt phn trong tng th cc dch v chm sc, dinh dng, h tr y t, tm l v x hi cho tr nhim HIV/AIDS. - Bt c phc iu tr no cng phi c t nht 3 loi thuc. - iu tr ARV l iu tr sut i; tr cn phi tun th iu tr tuyt i m bo hiu qu iu tr v trnh khng thuc. - Tr nhim HIV c iu tr ARV khi tnh trng min dch cha phc hi cn c tip tc iu tr d phng cc bnh NTCH. 1.3. Cc nhm thuc ARV c s dng ti Vit nam: - Nhm c ch men sao chp ngc nucleoside v nucleotide (NRTI). - Nhm c ch men sao chp ngc khng phi l nucleoside (NNRTI). - Nhm c ch men protease (PI). Chi tit cc nhm thuc ARV v cch s dng, xem ph lc 3. 2. Tiu chun bt u iu tr ARV Tiu chun bt u iu tr bng ARV tr em cn da vo tnh trng chn on nhim HIV, la tui, giai on lm sng v giai on min dch ca tr. 1. Tr c chn on xc nh nhim HIV: Tr < 12 thng tui: iu tr ngay, khng ph thuc vo giai on lm sng v t bo CD4. Tr t 12 thng tui tr ln, ch nh khi: - Giai on lm sng 4, khng ph thuc t bo CD4. - Giai on lm sng 3, khng ph thuc t bo CD4; Tuy nhin tr mc lao, LIP, bch sn dng lng ming, gim tiu cu nn iu tr trc v tr hon ARV nu t bo CD4 cn trn ngng Suy gim nng theo la tui; nu khng lm c xt nghim t bo CD4 xem xt iu tr ARV. - Giai on lm sng 2 v t bo CD4 (hoc tng s t bo lympho) di ngng Suy gim nng theo la tui - Giai on lm sng 1 v t bo CD4 di ngng Suy gim nng theo la tui 2. Tr di 18 thng tui cha c chn on xc nh nhim HIV bng xt nghim virus, nhng c chn on lm sng bnh HIV/AIDS nng 3. Chun b sn sng iu tr bng ARV Qu trnh chun b sn sng iu tr ARV cn tin hnh t khi tr c qun l ti c s iu tr; cc ni dung chun b sn sng iu tr nn lng ghp trong cc ln ti khm m bo tr c iu tr kp thi khi tiu chun iu tr . 3.1. nh gi trc iu tr. Cn tin hnh nhng bc nh sau cho tr tiu chun iu tr bng ARV + nh gi li giai on lm sng v giai on min dch (t l CD4 hoc tng s t bo lympho, nu khng c xt nghim CD4).
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+ Sng lc lao v cc bnh nhim trng c hi khc, khm hoc hi chn vi cc dch v y t khc (lao, da liu, v.v..) khi cn. iu tr ngay cc bnh nhim trng c hi cp tnh v lao, nu c + Lm cc xt nghim c bn chn phc ph hp: CTM/Hgb, men gan + Hi tin s dng thuc ARV ca m v ca tr, l do s dng (d phng ly truyn m con hay iu tr cho m), phc c th; s tun th, tin trin trong qu trnh iu tr, v.v + nh gi tnh trng dinh dng, hon cnh gia nh ca tr, s mong mun c iu tr ca gia nh/ngi chm sc tr + D kin phc ARV thch hp cho tr + Thng bo v k hoch chun b iu tr ARV cho gia nh/ngi chm sc tr + iu tr d phng cotrimoxazole v cc d phng khc nu c ch nh. 3.2. T vn trc iu tr T vn cho cha m/ngi chm sc v cho tr (nu tr ln) v Kin thc iu tr bng thuc ARV bao gm: - Tin trin ca nhim HIV, li ch ca iu tr v cc thuc ARV ch nh cho tr. - Tm quan trng ca tun th iu tr, cc bin php tng cng s tun th - Phc iu tr, cch chia v ong thuc, cch bo qun thuc - Cch gii quyt tnh hung tr nn sau ung thuc, cc tc dng ph ca thuc v cch x tr - K hoch chm sc v theo di ti c s iu tr, ti nh 3.3. nh gi sn sng iu tr nh gi hiu bit ca cha, m/ngi chm sc tr v nhim HIV, iu tr ARV v tm quan trng ca tun th iu tr m bo tr s ung thuc ng yu cu iu tr. T vn li nu cha m/ngi chm sc cha kin thc. Rt ngn thi gian t vn trong trng hp tr c tnh trng nng v cn iu tr ARV sm. Kim tra li cc thng tin: ni c tr, a ch lin lc khi cn, h tr ca cng ng Cha, m/ngi chm sc tr k cam kt tham gia iu tr cho tr Lu : Nu tr cn c iu tr ngay, cp thuc ARV iu tr v lp k hoch t vn cho tng ln khm tip theo, hoc cho nhp vin. 3.4.- Bt u iu tr Ch nh phc bc 1 cho tt c tr em bt u c iu tr. Cn ch tin s tip xc vi NVP (m hoc tr c DPLTMC bng phc c NVP trong vng 12 thng) la chn phc ph hp; Cp thuc ARV v hng dn li cho cha, m/ngi chm sc v cc loi thuc tr c iu tr, cch s dng, lch cp thuc, lch hn ti khm. m bo cha m/ngi chm sc c k hoch tun th iu tr v bit cch x tr khi gp kh khn. Hng dn cch bo qun thuc ti nh. Ring i vi d4T v LPV/r dng nh dch, cn bo qun lnh. Chn dng thuc (nc, vin) ph hp cho tng tr v theo la tui, cn nng. Tr < 10 kg nn s dng dng thuc nc; dng thuc vin phi hp liu c nh c tc dng tng cng kh nng tun th iu tr ca tr.

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 Liu lng thuc c tnh theo cn nng hoc din tch da (xem ph lc 4). Cn tnh liu chn vin thuc c hm lng ph hp vi cn nng ca tng tr, khng nn ct vin thuc nh hn 1/2vin Lu cc tng tc thuc khi la chn phc (xem ph lc 5) 4. Cc phc iu tr bc 1 4.1. Phc cho tr em bt u c iu tr bng ARV (tr trng hp tr tip xc vi NVP qua DPLTMC trong vng 12 thng). 4.1.1. Phc chnh AZT + 3TC + NVP Ch nh: Cho tt c tr em bt u iu tr ARV cha tip xc vi NVP hoc tip xc (qua DPLTMC) cch y trn 12 thng. Lu : o Liu NVP ban u bng na liu iu tr, cn tng liu sau 2 tun iu tr. o Ung cch u 12 gi, c th ung thuc lc i hoc lc no. o Xt nghim Hgb, ALT trc iu tr, sau 1 thng v sau 6 thng/ln hoc khi nghi ng c thiu mu hoc ng c gan o Khng iu tr phc ny cho tr c Hgb < 80 g/l; Nu ang iu tr Hgb < 70 g/l cn thay AZT o Thn trng khi s dng NVP trn tr c ATL tng gp 2,5 ln tr s bnh thng v tr ang iu tr lao bng phc c rifampicin 4.1.2. Cc phc thay th a. Phc d4T + 3TC + NVP Ch nh: S dng phc ny khi tr khng dng c AZT. Lu : o Liu NVP ban u bng na liu iu tr, cn tng liu sau 2 tun iu tr. o Ung cch u 12 gi, c th ung thuc lc i hoc lc no. o Xt nghim ALT trc iu tr, sau 1 thng v sau 6 thng/ln o Thn trng khi s dng NVP trn tr c ATL > 2,5 ln tr s bnh thng v tr ang iu tr lao bng phc c rifampicin. b. Phc AZT + 3TC + EFV Ch nh: S dng phc ny cho tr khng dng c d4T v NVP, hoc ang iu tr lao phc c rifampicin nhng trn 3 tui v cn nng >10kg Lu : o Ung AZT + 3TC cch nhau 12 gi , EFV ung mt ln vo bui ti, cch ba n 2-3 gi. o Xt nghim Hgb trc iu tr, sau 1 thng v sau 6 thng/ln hoc khi nghi ng c thiu mu. o Khng iu tr phc ny khi Hgb < 80 g/l. Nu ang iu tr, Hgb < 70 g/l, thay AZT.
89

o Khng iu tr phc ny cho tr di 3 tui hoc cn nng <10kg, tr n v thnh nin c thai trong 3 thng u, hoc tr b bnh tm thn (tin s v hin ti). c. Phc d4T + 3TC + EFV Ch nh: S dng phc ny cho tr khng dng c NVP v AZT, hoc ang iu tr lao phc c rifampicin nhng trn 3 tui v cn nng >10kg. Lu : o Ung d4T + 3TC cch nhau 12 gi , EFV ung mt ln vo bui ti, cch ba n 2-3 gi. o Khng iu tr phc ny cho tr di 3 tui hoc cn nng <10kg, tr n v thnh nin c thai trong 3 thng u, hoc tr b bnh tm thn (tin s v hin ti). d. Phc ba thuc NRTI: AZT hoc d4T + 3TC + ABC Ch nh: S dng phc ny cho tr khng s dng c NVP v EFV hoc ang iu tr lao bng phc c rifampicin nhng di 3 tui v cn nng <10kg. Nn hn ch dng phc ny. 4.2. Phc cho tr di 12 thng tui tip xc vi NVP (m hoc tr c iu tr DPLTMC bng phc c NVP): 4.2.1. Phc chnh: AZT + 3TC + LPV/r Ch nh: S dng phc ny cho tt c cc tr di 12 thng tui tip xc vi NVP qua DPLTMC 4.2.2. Phc thay th: a. d4T + 3TC + LPV/r Ch nh: S dng phc ny cho tr c chng ch nh hoc khng dung np c AZT. b. ABC + 3TC + LPV/r Ch nh: S dng phc ny cho tr c chng ch nh hoc khng dung np c AZT, d4T c. AZT + 3TC + NVP hoc d4T + 3TC + NVP Ch nh: S dng phc ny khi khng c LPV/r 5. Tc dng ph ca cc thuc ARV v cch x tr 5.1. Tc dng ph ca thuc ARV: tc dng ph ca thuc ARV tr em chia lm 4 mc nh, va, nng, v nng e do tnh mng, tng t nh ngi ln. Phn tc dng ph ca cc thuc ARV tr em c trnh by trong Ph lc 7. Mc 1(nh): iu tr triu chng, khng i phc . Mc 2 (va): Ri lon phn b m hoc bnh l TK ngoi bin (d4T): thay thuc. Tc dng ph khc: tip tc phc ARV v iu tr triu chng, nu khng ci thin thay thuc gy c. Mc 3 (nng): Khng dng ARV, thay thuc gy tc dng ph.
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 Mc 4 (nng e da tnh mng): Ngng ngay thuc ARV, x l cc triu chng. Khi triu chng gim, thay thuc ARV gy c tnh Lu khi x tr cc tc dng ph ca thuc ARV: 1. Xc nh mc nng ca c tnh trn c s lm sng v xt nghim cn thit 2. Xem xt cc thuc tr ang dng, xc nh c tnh do ARV hay thuc khc 3. Loi tr cc bnh l c th l nguyn nhn gy tnh trng tr xu i 4. X tr theo mc tc dng ph 5. Nhn mnh tm quan trng ca tun th iu tr. 5.2. Mt s tc dng ph hay gp ca cc thuc ARV v cch x tr Cn xc nh mc nng tc dng ph ca thuc ARV da vo biu hin lm sng v xt nghim quyt nh x tr ph hp. Bng 8. Cch x tr mt s tc dng ph hay gp v tc dng ph nng ca thuc ARV tr em.
Biu hin lm sng Xt nghim X tr Pht ban /Hi chng Stevens Johnson (Nhm NNRTI, c bit l NVP, t gp hn l EFV) - Thng xy ra trong vng - Tng men gan cc - Pht ban mc 1 hoc 2, c th mc khc 6-8 tun u iu tr. tip tc iu tr ARV, iu tr nhau (xem ph triu chng, nhng phi theo di - Pht ban mc 1,2. lc 7) st. - Pht ban mc 3 - Pht ban mc 3: thay thuc - Pht ban mc 4 e do gy c, iu tr triu chng. tnh mng (Hi chng Stevens Johnson hoc - Pht ban nng e do tnh mng phi ngng tt c thuc ARV v hoi t ly thng b iu tr triu chng. nhim c). Khi cc triu chng n nh, bt u li ARV nhng thay NVP bng PI hoc thay bng phc 3 NRTI (xem thm chng VI, mc 4). KHNG nn dng li NVP cho tr trong tng lai Thiu mu, gim bch cu trung tnh (AZT) nh gi tnh trng: - Hgb v bch cu Truyn mu khi c ch nh. trung tnh gim Ngng AZT khi Hgb< 70g/l v thay - Da, nim mc (xem ph lc 7). th bng d4T hoc ABC - Nhp tim - Kh nng hot ng (mt mi nhiu) Ng c h thng thn kinh trung ng nng v ko di: do EFV Ri lon gic ng, trm cm, Ko di 2- 4 tun Thay sang NVP thay i hnh vi Vim gan cp do nhm NNRTI, c bit l NVP, him hn l EFV; cc NRTI hoc nhm PI Ty theo mc c th: - Thng xy ra trong vng - Tng men gan v bilirubin cc 6-8 tun. - Theo di v iu tr triu chng mc (xem nu mc 1 hoc 2 - Vng da ph l c 7). - Thay thuc gy c nu mc - Gan to 3 (xem thm chng VI, mc - C triu chng tiu ha 10). - Mt mi 91

cc triu chng n nh: o Bt u li ART nhng thay thuc gy c, v d thay NVP bng EFV, hoc o C th bt u li phc ARV hin dng nhng theo di st; nu cc triu chng xut hin li, thay thuc gy c. Vim tu cp (Nhm NRTI, c bit l d4T, ddI; him hn l 3TC) nh gi tnh trng: - Men amylase v Nu mc 4 e da tnh mang: lipase ca ty - Bun nn v nn - Ngng tt c cc thuc ARV cho tng theo cc ti khi cc triu chng n nh. - au bng mc (xem - Theo di amylase, lipase huyt - C th kt hp vi nhim ph lc 7). thanh, nu c th, . toan lactic - Khi cc triu chng n nh, tip tc iu tr nhng thay bng thuc NRTI khc khng c c tnh vi ty Phn ng qu mn (ABC hoc NVP) - ABC: cc triu chng tin - Tng cc men Mc 3: Thay thuc gy c v trin xu i ngay sau khi gan, s lng t iu tr triu chng dng ABC, thng xy ra bo i toan cc Mc 4 e da tnh mng: trong vng 6-8 tun. Tr mc khc - Ngng ngay tt c cc thuc c st, bun nn, nn, a nhau (xem ph ARV v iu tr triu chng . chy, au bng, vim lc 7).. - Khi cc triu chng n nh, tip hng, ho, kh th; pht tc iu tr nhng thay thuc gy ban d ng (, nga); tc dng ph (ABC hoc NVP) - NVP: Triu chng ton thn bng thuc ARV khc. gm st, au c, au - KHNG nn dng li NVP hoc khp, vim gan, pht ban ABC cho bnh nhn trong tng hoc khng nhng c lai. nga. Lon dng m (d4T; cc PI) Mt m v/hoc tch t m cc Thay i cc mc Theo di lm sng cht ch c bit vng ring bit trn thn mnh: khc nhau ca: sau 6 - 12 thng iu trj. o Tng m quanh bng, - Triglycerid mu; Nu c biu hin lon dng m: m sau lng, ph i - Cholesterol mu; thay d4T bng ABC hoc AZT. tuyn v. - Mc HDL thp; Thay th PI bng NVP hoc EFV. o Mt m cc chi, mng, - ng mu. mt, xy ra cc mc khc nhau. Bnh thn kinh ngoi vi nng (d4T, ddI; him hn 3TC) - Khng Theo di lm sng cht ch c bit - au, nga, t cng bn sau 6 -12 thng iu trj. tay hoc bn chn, khng i c. Nu c biu hin ri lon thn kinh ngoi vi: thay d4T bng AZT hoc - Mt cm gic phn xa ABC ca chi - Yu c nh v mt phn x gn xng c th xy ra. Nhim toan lactic (Nhm NRTI, c bit l d4T) 92

C th c cc biu hin qu mn (pht ban, st, cc triu chng h thng),

Nu mc 4 e da tnh mng: ngng tt c ARV v theo di; khi

Mt mi C biu hin: bun nn, nn, a chy, gan to, chn n, chm ln cn hoc st cn t ngt khng gii thch c. C th c biu hin vim gan hoc vim ty Cc triu chng thn kinh (bao gm yu c).

- Tng khong trng anion - Nhim toan lactic - Tng cc men gan - CPK, LDH

Mc nng: Thay thuc gy c iu tr triu chng Mc nng e da tnh mng: - Ngng tt c cc thuc ARV v iu tr triu chng. - Khi cc triu chng n nh, bt u li iu tr ARV nhng thay d4T bng ABC hoc AZT).

6. Theo di tr c iu tr bng thuc ARV Tr c iu tr ARV cn c ti khm v pht thuc nh k 1- 2 thng/ln Khi bt u iu tr tr cn c hn ti khm sm t vn, h tr tun th v theo di cc tc dng ph ca thuc. Khi m bo tr tun th v dung np thuc tt, lm sng ci thin, thi gian gia cc ln ti khm c th ko di hn; Vic ti khm cng thng xuyn hn nu tr c nhim trng c hi mi, phi thay thuc hoc tun th gim st. Trong mi ln ti khm, tr c nh gi v tin trin lm sng, s pht trin tinh thn v th cht, nh gi tun th iu tr, cung cp t vn h tr v lm cc xt nghim cn thit. 6.1.Theo di tin trin lm sng Trong mi ln ti khm, tr cn c nh gi v tin trin lm sng, pht hin v x tr cc tc dng ph ca thuc hoc cc nhim trng c hi mi, c th: nh gi cc mc pht trin tinh thn, th cht Theo di, pht hin cc du hiu lm sng lin quan n tc dng ph ca thuc, cc nhim trng c hi mi hoc ti pht; phn bit hi chng vim phc hi min dch v tht bi iu tr. Cho nhp vin, hi chn, hoc chuyn tuyn, khi cn. nh gi kh nng mang thai i vi tr n v thnh nin thay thuc ARV khi cn (khng dng efavirenz trong 12 tun u ca thai k). 6.2. Theo di xt nghim Bng 7: Theo di xt nghim trong qu trnh iu tr ARV cho tr em
Ni dung Lc bt u iu tr 4 tun Thi gian iu tr 6 12 6 thng thng thng mt ln Khi nghi ngh

CD4 v t l % CD4
CTM/Hgb, ALT CTM khi dng phc c AZT ALT khi s dng phc c NVP XN thai cho tr n v thnh nin

o ti lng virus

(nu c iu kin)

Ghi ch: Trong qu trnh theo di iu tr bng ARV, nu tr c cc biu hin bt thng cn lm cc xt nghim cn thit chn on v x tr kp thi.

93

6.3. Theo di s tun th iu tr nh gi li s tun th iu tr trong tt c cc ln tr n ti khm.da vo: - Bo co ca cha m/ngi chm sc tr v vic cho tr ung thuc, t cc cu hi kim tra li cch cha m/ngi chm sc cho tr ung thuc v cch x tr khi qun cho tr ung thuc. - m s thuc cn li, khm nh gi v tin trin lm sng v xt nghim. Nu tr tun th cha tt cn tm hiu l do. Cha m/ngi chm sc tr cn c t vn v cch khc phc cc ro cn tun th v c h tr kp thi m bo tun th tt. Hng dn khi qun cho tr ung thuc: Khi pht hin ra vic qun cho tr ung thuc theo lch th iu u tin l phi cho tr ung ngay liu thuc va qun. Tip theo tnh thi gian ung liu k tip theo lch nh thng l: - Nu thi gian n liu ung k tip cn trn 4 ting, cho tr ung liu vo ng thi gian theo lch nh bnh thng. - Nu thi gian n liu ung k tip cn di 4 ting, KHNG C cho tr ung liu k tip theo lch c m phi i trn 4 ting mi cho ung. - Nu qun cho tr ung hn 2 liu trong mt tun, hy bo cho bc s ca tr c hng dn.
6.4. nh gi hiu qu iu tr ARV

Cc du hiu biu hin tr c p ng vi iu tr ARV: - Pht trin th cht v tinh thn tt: tng cn v chiu cao, vn ng tch cc, t c cc mc pht trin v tr tu - Gim v khng mc cc nhim trng c hi - S lng hoc t l % CD4 tng (thng 24 tun sau khi bt u iu tr ARV) Nu tr p ng tt vi iu tr: - Tip tc phc iu tr ARV, iu chnh liu theo chiu cao v cn nng ca tr - Tip tc t vn, h tr v tun th v dinh dng - Pht thuc v ln lch ti khm Nu tr khng p ng vi iu tr hoc c biu hin lm sng mi: - T vn li v nh gi tun th iu tr, tng cng cc bin php h tr tun th - T vn v dinh dng, tng cng cc bin php h tr dinh dng - Tm hiu cc nguyn nhn dn n khng p ng iu tr, c bit khi c biu hin lm sng mi. Cn phn bit r do tc dng ph ca thuc, tng tc thuc hoc biu hin ca hi chng vim phc hi min dch, hoc tht bi iu tr; lm cc xt nghim h tr cn thit v x tr ph hp. 7. Hi chng vim phc hi min dch 7.1. Khi nim: Hi chng vim phc hi min dch (PHMD) l tnh trng ngi bnh xu i mt cch bt thng sau khi bt u iu tr ARV do c s phc hi ca h thng min dch. Bn cht ca hi chng vim PHMD l p ng vim qu mc vi cc tc nhn gy bnh ang tn ti trong c th hoc cc khng nguyn cn li ca cc tc nhn ny khi h min dch mi c phc hi. Cc biu hin ca hi chng vim PHMD c th bao gm:

94

S xut hin ca cc bnh NTCH cha pht hin c trc khi iu tr ARV (lao, MAC, vim mng no do cryptococcus, v.v...) - S ti pht qu mc cc bnh NTCH c iu tr trc khi bt u ARV - S ti pht ca cc bnh ng nhim (VGB, VGC) v cc bnh t min (vy nn, vim da, v.v..). Thi im xut hin: Thng 2-12 tun sau khi bt u iu tr ARV nhng c th mun hn 7.2. Tn sut xut hin v yu t nguy c Hi chng vim PHMD gp khong 10% s bnh nhn c iu tr ARV. Cc yu t lin quan ti tn sut xut hin hi chng vim PHMD l: - S t bo CD4 thp trc khi bt u iu tr ARV. - Tin s mc cc NTCH trc iu tr ARV. Thi im bt u iu tr ARV cng gn vi iu tr NTCH, nguy c c hi chng vim PHMD cng cao. - S dng phc c thuc c ch protease tng cng bng ritonavir. d phng hi chng vim PHMD cn sng lc cc bnh NTCH trc khi bt u iu tr ARV, c bit l sng lc v iu tr lao nn c u tin trc. 7.3. Cc biu hin hi chng vim PHMD Cc bnh NTCH v bnh khng nhim trng lin quan n hi chng vim PHMD: - Cc bnh do Mycobacteria: lao (hay gp nht), bnh do phc hp mycobacterium avium (MAC). - Cc bnh do nm: Cryptococcus neoformans, Penicillium marneffei, Pneumocystis jiroveci - Cc bnh do vi rt: CMV, Herpes simplex, Herpes zoster, vim gan virus B v C, vim no cht trng a tin trin - Cc bnh do k sinh n bo: vim no do toxoplasma, bnh do leishmania - Cc bnh khng nhim trng: vy nn, vim tuyn gip trng 7.4. Chn on hi chng vim PHMD - Cn ngh n hi chng vim PHMD khi tr c iu tr ARV trn 2 tun, tun th iu tr tt nhng lm sng xu i, c bit khi tr c iu tr ARV giai on mun, c CD4 thp hoc c bnh NTCH trc iu tr. Cn chn on phn bit vi: + Tc dng ph ca thuc, hoc tng tc thuc + Biu hin ca bnh NTCH mi + Tht bi iu tr (khi iu tr ARV c hn 6 thng) 7.5. X tr Hi chng vim PHMD - Mt s hi chng vim PHMD din bin nh v t khi, khng cn can thip. - Tip tc iu tr ARV nu tr vn dung np thuc. - iu tr cc nhim trng c hi mi theo cn nguyn; iu chnh phc v liu ca ARV nu c tng tc gia cc thuc ARV v cc thuc iu tr NTCH (v d: thay NVP bng EFV nu iu tr lao bng phc c rifampicin v nu EFV sn c). Quay tr v phc ARV c khi ngng cc thuc c tng tc - Ch ngng iu tr ARV nu tnh trng tr nng v khng dung np c thuc . Bt u li cc thuc ARV khi hi chng vim PHMD thuyn gim v tr dung np thuc.
95

Xem xt iu tr corticosteroid khi hi chng vim PHMD nng: prednisolone hoc methylprednisolone ung hoc tim, liu 0,5-1,0 mg/kg/ngy cho n khi tnh trng tr ci thin, sau gim dn liu trong 1-2 tun.

8. Tht bi iu tr phc bc 1 v i phc bc 2 8.1. nh gi tht bi iu tr: a. Nguyn tc - Ch xem xt tht bi iu tr khi tr iu tr ARV ng phc 3 thuc trong t nht 6 thng v m bo tun th tt. - Cn loi tr hi chng vim phc hi min dch, hoc tc dng ph ca thuc, hoc cc nguyn nhn gy hp thu thuc km. b. Tiu chun tht bi iu tr: Lm sng Tr ngng tng trng v chiu cao v cn nng mc d trc y c p ng vi iu tr - Mt cc mc pht trin v thn kinh hoc xut hin bnh l no - Xut hin cc NTCH hoc bnh l c tnh, hoc ti pht cc bnh nhim trng, nm v khng p ng vi iu tr - CD4 gim xung di mc suy gim min dch nng theo la tui sau khi c p ng phc hi ban u Hoc - CD4 bt u gim nhanh xung di mc suy gim min dch nng theo la tui, c khng nh bng t nht hai ln xt nghim CD4 lin tip Hoc - CD4 gim xung bng hoc di mc CD4 trc khi iu tr Hoc - CD4 gim trn 50% so vi mc CD4 t c cao nht k t khi iu tr bng ARV

Min dch

Lu : Mt s bnh l giai on 3 nh lao hch, lao phi, vim phi do vi khun c th

khng phi l ch im tht bi iu tr v khng i hi phi thay i phc .

8.2. X tr khi nghi ng tht bi iu tr phc bc 1 Tip tc phc bc 1 v nh gi li kt qu iu tr sau 1 thng, nu: Tr cha tun th iu tr y : cn tng cng t vn v h tr gia nh, ngi chm sc v tr tun th y . Tr c hi chng vim phc hi min dch, hoc tc dng ph ca thuc, hoc cc nguyn nhn gy hp thu thuc km: cn pht hin v x tr nguyn nhn. nh gi cc NTCH v bnh km theo; iu tr kp thi v d phng y . Phi kt hp lm sng vi xt nghim CD4 (hoc o ti lng vi rt nu c iu kin) v hi chn y khng nh tht bi iu tr, nhm hn ch trng hp i phc trong khi vn cn hiu lc.

96

Bng 9: Quyt nh thay i phc iu tr trn c s kt hp tiu chun lm sng v min dch hc
Biu hin lm Xt nghim sng mi hoc nh gi tht bi ti pht iu tr Cc biu hin Khng c CD4 giai on 1 hoc C CD4 2 Cc biu hin Khng c CD4 giai on 3 C CD4 Cc biu hin Khng c CD4 giai on 4 C CD4 X tr Khng thay i phc iu tr Tng cng theo di lm sng v CD4 nu CD4 tin gn n mc suy gim min dch nng Xem xt thay i phc ch khi t nht c hai ln xt nghim CD4 thp hn mc suy gim min dch nng theo la tui Xem xt thay i phc Tng cng theo di lm sng v CD4 nu CD4 tin gn n mc suy gim min dch nng Thay i phc nu CD4 di mc suy gim min dch nng, nht l khi tr tng p ng tt v mt min dch hc vi iu tr ARV Thay sang phc bc 2 Thay sang phc bc 2

8.3 La chn phc bc 2 Bng 10: Cch thay phc ARV bc 1 sang phc bc 2 Cch thay phc Phc bc 2 thay th Phc bc 1 ang iu tr AZT hoc d4T + 3TC + NVP ddI + ABC + LPV/r AZT hoc d4T + 3TC + EFV AZT hoc d4T + 3TC + ABC ddI + EFV + LPV/r ddI + NVP + LPV/r ABC + 3TC + NVP hoc EFV AZT + 3TC (c th thm ddI) + LPV/r d4T + 3TC + LPV/r Cch dng ca cc thuc phc bc 2 - PI thay th LPV/r l ATV v ch dng ATV cho tr trn 6 tui - Xem hng dn v tc dng ph ca cc thuc ph lc 3, liu lng ph lc 4 v tng tc thuc ph lc 5. - Didanosin (ddI): ung 1 ln/ngy hoc 2 ln/ngy. Ung thuc lc i, trc khi n t nht 1 gi, hoc sau khi n sm nht 2 gi. - Lopinavir/Ritonavir (LPV/r): ung 2 ln/ngy, cch nhau 12 gi. LPV/r vin nang nn ung khi no; LPV/r vin nn c th ung lc i hoc lc no. - Atazanavir/Ritonavir (ATV/r): ung 1 ln/ngy 8.4. Theo di tr iu tr phc bc 2 T vn cng c tun th iu tr cho ngi chm sc v tr (nu l tr ln). T vn k v phc mi. Ch cc tc dng ph: qu mn (abacavir), suy thn (tenofovir), vim tu (didanosine), tng lipid mu v tiu ng khng insulin (cc thuc PI). Theo di cc tng tc thuc. nh gi p ng v lm sng v min dch (CD4) tng t nh i vi phc bc mt.
97

9. iu tr ARV tr mc lao 9.1. Tr c pht hin lao trc khi iu tr ARV Tr mc lao cn phi c iu tr lao 2 - 8 tun trc khi iu tr ARV. iu tr ARV tr ang iu tr lao c rifampicin: + Tr 3 tui v cn nng < 10kg: AZT hoc d4T +3TC + ABC hoc xem xt dng AZT+3TC+NVP (nu khng sn c ABC); + Tr > 3 tui v cn nng > 10kg: AZT hoc d4T +3TC + EFV Lu : C th s dng li phc c NVP khi iu tr lao bng phc c rifampicin kt thc. 9.2. Tr c pht hin lao trong khi iu tr ARV - Cn xc nh lao c phi l hi chng phc hi min dch khng. Nu c cn nh gi v iu tr nh hi chng phc hi min dch. - Tip tc iu tr ARV ng thi vi iu tr lao - La chn phc : o Nu tr ang dng phc bc1 khng c NVP, tip tc phc dng o Nu tr ang dng phc bc 1 c NVP Thay NVP bng ABC nu tr 3 tui hoc cn nng di 10 kg; Thay NVP bng EFV nu tr > 3 tui v cn nng trn 10 kg v quay v phc chun d4T + 3TC + NVP khi kt thc iu tr lao Nu khng c ABC hoc EFV tip tc dng NVP o Nu tr ang iu tr phc c LPV/r: tng liu ritonavir bng liu lopinavir 10. iu tr ARV tr ng nhim vim gan: Nu c iu kin nn lm xt nghim xc nh ng nhim vim gan vi rt B v C. Tiu chun iu tr ARV cho tr c ng nhim vim gan B v C cng nh mi tr khc. Trc khi iu tr ARV, kim tra men gan theo quy nh. Nu men gan tng 2,5 ln bnh thng, o i vi tr trn 3 tui: Tt nht, s dng phc AZT (hoc d4T) + 3TC + EFV o i vi tr di 3 tui hoc khng c EFV: S dng phc AZT (hoc d4T) + 3TC + NVP; theo di st xt nghim ALT. Khng iu tr bng phc c NVP khi ALT > 5 ln tr s bnh thng Cn theo di cht ch men gan trong giai on vim gan ang tin trin: Nu ALT 5 ln ch s bnh thng, vn tip tc iu tr. Nu ALT tng t 5-10 ln ch s bnh thng, tip tc phc iu tr nhng phi theo di cht ch, lm xt nghim men gan 1 - 2 tun/ln; Nu ALT tng >10 ln, hoc tng gp 5 ln km theo vng da cn thay NVP bng EFV hoc bng PI. 3TC c tc dng iu tr vim gan B. Trong trng hp cn thay i phc iu tr nn tip tc 3TC trong phc mi trnh bng pht vim gan B. Cc thuc iu tr ARV khng c tc dng iu tr vim gan C.

Lu :

- t bng pht vim gan B d xy ra khi c ng nhim HIV/VGB trong vi thng u tin iu tr ARV, c th l biu hin ca hi chng vim phc hi min dch, hoc do ngng ARV c tc dng iu tr vim gan B (3TC, TDF). - Biu hin: men gan tng cao v nhanh, km theo cc triu chng ca vim gan cp (mt mi, au bng, vng da). i khi kh phn bit vi ng c gan do ARV. - Cn theo di lm sng v xt nghim men gan cht ch khi phi ngng cc thuc ARV trong c 3TC, TDF.
98

PH LC
Ph lc 1: Tiu chun chn on lm sng v chn on xc nh cc bnh l lin quan n HIV/AIDS ngi ln.
Bnh l Giai on lm sng 1 Khng c triu chng Bnh l hch lympho ton thn dai dng Giai on lm sng 2 St cn mc trung bnh Nhim trng ng h hp trn ti pht (t 2 ln tr ln trong 6 thng gn nht) Zona Vim khe ming Lot ming ti din (t 2 ln tr ln trong 6 thng qua) Pht ban sn nga Vim da b nhn Nm mng Giai on lm sng 3 St cn mc nng khng gii thch c (trn 10% trng lng c th) Tiu chy mn tnh khng r nguyn nhn trn 1 thng Chn on lm sng Chn on xc nh

Khng c triu chng lin quan n HIV v khng c du hiu g khi thm khm. Khng yu cu Hch > 1cm khng au, t hai v tr tr ln khng tip gip nhau, khng c Xt nghim t chc hc nguyn nhn v ko di trn 3 thng. St cn nhng khng r nguyn nhn. Ph n c thai khng tng cn. Gm nhiu triu chng, v d au mt v chy nc mi mt bn (vim xoang) hoc au sng mng nh (vim tai gia), ho c m m (vim ph qun), au hng, vim amidan khng c c im ca nhim vi rt(v d nh ho hay s mi) Ban dng mn nc au, phn b theo vng da tng ng vi dy thn kinh nhng khng vt qu ng gia Vt nt hoc rn gn kho ming, khng do thiu st hay vi tamin v thng p ng vi thuc chng nm Lot apt in hnh c qung vim v gi mc mu vng xm Tn thng sn nga, thng i km vi tng sc t da sau vim Tnh trng da nhn v nga, c bit cc vng c lng (trn, nch, na ngi trn v bn) Vim quanh mng (nn mng sng v au) hoc bong mng (mng tch khi nn mng) cc ngn tay v chn (mng tay v chn chuyn mu trng, c bit l phn cui mng, i km vi tnh trng mng dy v tch khi nn mng). Gim <10% trng lng c th c bng chng. Xt nghim cn lm sng, nu c, v d cy cc dch c th tng ng Chn on lm sng Chn on lm sng Chn on lm sng Chn on lm sng Chn on lm sng Nui cy nm t mng hoc t chc mng

St cn khng gii thch c (> 10% trng lng c th), ngoi mun, c th St > 10% so vi trng lng c th. nhn bit c mt, eo lng v chi, gy st r rt hoc ch s khi c th <18,5 kg/m2; ph n c thai st cn c th kh pht hin Tiu chy mn tnh (i phn lng hoc phn nc t 3 ln tr ln trong mt ngy) Quan st thy thy ngi bnh i ngoi t v ko di trn 1 thng. 3 ln tr ln trong mt ngy, phn khng thnh khun v xt nghim t 2 ln tr ln khng thy nguyn nhn gy bnh St dai dng khng r nguyn St hoc ra m hi m ko di trn 1 thng, khng lin tc hoc lin tc, khng St trn >37.5 oC, cy mu m tnh, 99

Bnh l Chn on lm sng Chn on xc nh nhn (khng lin tc hoc lin p ng vi khng sinh v thuc chng st rt, khng pht hin c bnh r nhum Ziehl-Nielsen (ZN) m tnh, lam tc v ko di trn 1 thng) rng khi thm khm; loi tr st rt cc vng st rt. st rt m tnh, XQ phi bnh thng hay khng thay i, khng c nhim trng r rng Nm candida ming ko di Cc mng trng c kiu sa ln men, gt mt (gi mc), hoc cc m trn Chn on lm sng li, khu ci hoc nn ming, thng au hoc nhy cm vi au (th nim mc) tn ti ko di hoc ti pht. Bch sn dng lng ming Cc tn thng dng vch nh mu trng ra bn ca li, khng co b c Chn on lm sng Lao phi hin tai Biu hin ko di hoc trn 2- 3 tun: ho, ho ra mu, kh th, au ngc, st cn, Phn lp M.tuberculosis t m hoc xt nghim t chc hc phi (cng vi triu st, ra m hi m v mt mi, chng ph hp) CNG VI Lam m dng tnh hoc m tnh, V Phim X-quang phi ph hp (bao gm nhng khng ch c thm nhim thy trn, tn thng hang, x phi. Khng c bng chng lao ngoi phi. Nhim vi khun nng (vim St km theo du hiu hoc triu chng ti nhim trng, p ng vi khng Phn lp vi khun t bnh phm ph hp phi, vim mng no, vim m sinh thch hp (thng l v tr v trng) mng phi, vim c m, vim xng, khp, nhim trng huyt v vim tiu khung nng) Vim lot li hoi t hoc vim au nhiu, lot nh li, rng lung lay, chy mu t pht, ming hi, v mt nhanh Chn on lm sng quanh cung rng hoi t cp xng v/hoc m mm. Thiu mu (<8 g/dl), gim bch Khng chn on s b trn lm sng. Chn on da vo XN v khng tm 9 cu(<5 x10 /l) v hoc gim tiu c nguyn nhn khc ngoi nhim HIV, cu (<50x 109/l) mn tnh (ko khng p ng vi iu tr bng thuc di hn 1 thng, khng gii thch kch thch to mu, thuc st rt hoc c thuc ty giun theo cc hng dn tng ng ca quc gia, hng dn qun l phi hp cc bnh tr em ca TCYTTG hoc cc hng dn khc. 100

Giai on lm sng 4 Hi chng suy mn

St cn ngoi mun khng gii thch c (>10 % trng lng ban u), gy r rt hoc ch s khi c th <18,5; CNG VI Tiu chy mn tnh khng r nguyn nhn (i phn nt hoc lng t 3 ln tr ln trong mt ngy) v ko di trn 1 thng HOC St hoc ra m hi m ko di 1 thng khng c nguyn nhn no khc, khng p ng vi khng sinh hoc thuc st rt; loi tr st rt cc vng st rt

Vim phi PCP

Vim phi do vi khun ti pht (t bnh hin ti cng vi mt hoc nhiu t trong 6 thng cui) Nhim hespes simplex mn tnh (mi ming, sinh dc, hoc hu mn, trc trng) ko di trn 1 thng, hay herpes ni tng bt k thi gian l bao nhiu) Nm candida thc qun

Kh th khi gng sc hoc ho khan, bt u trong thi gian gn (trong vng 3 thng cui), th nhanh v st; V thm nhim k phi lan ta hai bn trn phim X-quang V khng c bng chng ca vim phi do vi khun; nghe phi c rale n hai bn, c hoc khng c gim thng kh t bnh hin ti cng vi mt hoc nhiu t mc trc trong trong 6 thng qua; khi pht t ngt (<2 tun), cc triu chng nng (nh st, ho, kh th v au ngc) xut hin cp tnh (< 2 tun) CNG VI vng ng c mi xut hin qua thm khm lm sng hay trn phim X-quang; p ng vi iu tr khng sinh. Lot hu mn sinh dc hoc mi ming, au, tin trin; cc tn thng do nhim herpes ti pht, v tn ti ko di hn 1 thng. Tin s b cc t trc . Nhim herpes simplex ni tng cn c chn on xc nh

St cn c bng chng (> 10% trng lng c th); CNG VI Xt nghim t nht hai mu phn lng khng tm thy tc nhn gy bnh HOC St trn >37.5oC khng c cn nguyn gy bnh no khc, cy mu m tnh, lam st rt m tnh, XQ phi bnh thng hay khng thay i Kch thch tit m hoc ra ph qun v xt nghim t bo hc hoc nhum min dch hunh quang hoc sinh thit t chc phi.

Nui cy hoc xt nghim khng nguyn dng tnh vi cn nguyn ph hp.

Phn lp virus hoc xt nghim ADN (phng php PCR) dng tnh vi virus herpes hoc xt nghim t chc hc hoc t bo hc ph hp. Hnh nh trn ni soi tiu ho hoc ni soi ph qun, soi vi sinh hoc m bnh hc.

au sau xng c hoc nut kh (nut thc n v dch), xut hin trong thi gian gn y, km theo nm ming. 101

Lao ngoi phi

Sarcoma Kaposi

Bnh ton thn (nh st, ra m hi m, mt v st cn. Bng chng ca lao ngoi phi hay lao lan to ph thuc vo v tr lao: tn thng mng phi, mng tim, mng bng, mng no, hch trung tht hoc hch bng, hoc vim xng. Lao hch ring r ngoi vi (c bit l hch c) c coi l dng nh nht ca lao ngoi phi. Biu hin in hnh trn da hoc nim mc hng ming l cc tn thng tn ti dai dng, lc ban u phng, c mu hng hoc tm, cc tn thng da thng tin trin thnh m hoc nt Vim vng mc do CMV c th do cc bc s c kinh nghim chn on. Tn thng mt in hnh khi soi y mt: cc m trng ring r trn vng mc c ranh gii r, tin trin v ngoi vi, thng theo cc mch mu, i km vi vim mch vng mc, xut huyt v hoi t. Cc biu hin thn kinh khu tr mi xut hin, ph hp vi bnh l ni s, hoc gim thc V p ng vi iu tr c hiu trong vng 10 ngy.

Phn lp M.tuberculosis hoc m bnh hc ph hp t v tr tng ng hoc bng chng lao k trn X-quang (tn thng dng k hoc cc nt m nh lan ta ng u trn phim X-quang lng ngc) Hnh nh tn thng trn ni soi hoc soi ph qun, hoc m bnh hc. Chn on xc nh phi bng m bnh hc

Bnh do cytomegalovirus (ngoi ra gan, lch hoc hch lympho) Bnh do toxoplasma h thn kinh trung ng

Bnh l no do HIV

Tn thng m bnh hc ph hp hoc cytomegalovirus c xc nh trong dch no tu qua phn lp virus hoc phn ng chui polymerase Khng th toxoplasma huyt thanh dng tnh V (nu c th) mt hoc nhiu tn thng chon ch trn thm d hnh nh h thn kinh (chp ct lp vi tnh hoc chp cng hng t). Ri lon chc nng nhn thc v/hoc chc nng vn ng nh hng n sinh Chn on loi tr; v (nu c th) thm hot hng ngy, tin trin trong vi tun hoc vi thng, m khng c bnh l no d hnh nh thn kinh (chp ct lp vi tnh khc ngoi nhim HIV c th gii thch cho bnh l ny. hoc chp cng hng t). . .

Vim mng no: thng bn cp, st km au u nng tin trin, du hiu mng Phn lp cryptococcus neoformans v tr no, l ln, thay i hnh vi v p ng tt vi iu tr cryptococcus. ngoi phi hay xt nghim khng nguyn cryptococcus dch no ty hoc mu dng tnh. Bnh do cc mycobacteria khng Khng chn on s b trn lm sng Chn on da vo pht hin thy cc phi lao lan to ton thn chng mycobacteria khng in hnh t phn, mu, dch c th, hoc cc m c th khc tr phi. 102

Bnh do cryptococcus ngoi phi (bao gm vim mng no)

TI LIU THAM KHO 1. B Y t: Quyt nh s 06/2005/Q-BYT ngy 7/3/2005 ca B trng B Y t v Hng dn chn on v iu tr nhim HIV/AIDS. 2. B Y t: Quyt nh s 2051/Q-BYT ngy 9/6/2006 ca B trng B Y t v Quy trnh iu tr ARV. 3. B Y t: Quy trnh chm sc v iu tr d phng ly truyn t m sang con ca BYT (quyt nh s 4361/Q -BYT). 4. B Y t: Quy trnh phi hp trong chn on, iu tr v qun l ngi bnh lao/HIV ca BYT (quyt nh s 3116/Q -BYT). 5. Gi o to v chm sc v iu tr HIV/AIDS ca TCYTTG khu vc Ty Thi bnh Dng- Thng 5 nm 2005 6. Hng dn thc hin chm sc v iu tr HIV/AIDS- TCYTTG khu vc Ty Thi bnh Dng- 2005 7. T chc Y t th gii (TCYTTG): Chm sc HIV mn tnh: iu tr ARV v d phng. Hng dn x tr cho ngi ln (IMAI). 2007 8. T chc Y t th gii (TCYTTG): iu tr ARV cho ngi ln v tr v thnh nin: khuyn co tip cn cng ng, thng 8/2006. 9. T chc Y t th gii (TCYTTG): Hng dn iu tr ARV cho tr em 2007, 2008 10. T chc Y t th gii (TCYTTG): Hng dn iu tr d phng bng Cotrimoxazole - khuyn co tip cn cng ng, 2006 11. T chc Y t th gii (TCYTTG): Hng dn iu tr phng ly truyn m con (PLTMC) - khuyn co tip cn cng ng, 2006 (TCYTTG) 12. T chc Y t th gii (TCYTTG): La chn Cc thuc Khng virus bc hai cho Ngi ln v V thnh nin: Tip cn Y t Cng cng. Bo co ca Hi ngh Chuyn , Thng 5/2007. 13. T chc Y t th gii (TCYTTG): Bo co ca Hi ngh Nhm Chuyn gia Hng dn Chm sc HIV v iu tr ARV Nhi khoa, Thng 4/2008. 14. T chc Y t th gii (TCYTTG)/T chc lao ng quc t: D phng phi nhim ngh nghip, 2007. 15. T chc Y t th gii (TCYTTG):: nh ngha nhim HIV v phn giai on lm sng v min dch tr em v ngi ln, 2007. 16. T chc Y t th gii khu vc ng Nam chu (SEARO): Qun l nhim HIV v iu tr ARV ngi ln v tr v thnh nin; cm nang lm sng 17. T chc Y t th gii (TCYTTG): Ci thin chn on v iu tr lao phi AFB m tnh v lao ngoi phi ngi ln v v thnh nin, 2007 18. T chc Y t th gii (TCYTTG): Qun l ng nhim lao/ HIV. Hng dn x tr cho ngi ln (IMAI). 2007 19. T chc Y t th gii (TCYTTG): Khung thc hin ng nhim lao/HIV chnh sa 2008. 20. T chc Y t th gii (TCYTTG): Nhng Hnh ng Thit yu Kim sot Nhim trng Lao hiu qu.

21. Trung tm kim sot v d phng bnh tt Hoa k (CDC). Chn on HIV sm tr em. 2007 22. Hng dn cp nht tim phng BCG cho tr c nguy c nhim HIV. Weekly Epidemiological Record, No 21, 25 May 2007. 23. Trung tm Kim sot v Phng nga Bnh tt Hoa K (CDC): Hng dn cp nht ca B Y t Hoa K v X tr Phi nhim Ngh nghip vi virus vim gan B, vim gan C, v HIV, v Khuyn co D phng sau phi nhim, 2001. 24. D phng sau phi nhim bng thuc khng virus sau phi nhim tnh dc, tim chch ma ty hoc cc phi nhim ngoi mi trng ngh nghip khc vi HIV Hoa K. Khuyn co ca B Y t v Dch v con ngi Hoa K, Trung tm Kim sot v Phng nga Bnh tt, 2005. 25. Hng dn s dng thuc khng HIV Ph n mang thai nhim HIV v sc khe ngi m v Cc can thip gim ly truyn HIV chu sinh Hoa K, 2008. 26. Hng dn D phng Cc bnh Nhim trng c hi ngi ln v v thnh nin nhim HIV. Khuyn co ca Vin Y t Quc gia, Trung tm Kim sot v Phng nga Bnh tt, v Hi Y hc HIV, Hi Bnh Truyn nhim Hoa K, 2002. 27. iu tr Bnh Nhim trng c hi ngi ln v v thnh nin nhim HIV. Khuyn ngh ca Vin Y t Quc gia, Trung tm Kim sot v Phng nga Bnh tt, v Hi Y hc HIV, Hi Bnh Truyn nhim Hoa K, 2004. 28. Hng dn s dng thuc khng virus ngi ln v v thnh nin nhim HIV-1. B Y t v Dch v Con ngi. Ngy 3 thng 11, 2008. 29. John Barlett. S tay b ti. iu tr nhim HIV/AIDS cho ngi ln. 2006. 30. Conway S., Barlett J.G.: Hng dn Qun l nhim HIV. 2007/2008.