1

2557 ()

(Essentials of HIV/AIDS Treatment and Prevention 2014 Thailand)

2557

-


-





-

1
2557 5,800

.. 2553 .. 2557
/

2557

CD4



2557

2557

30

1

18

24

2

18

26

(Assessment of
HIV-positive Persons at Initial &
Subsequent Visits)

2

(HIV Laboratory Testing)

38

44

3 49
(When to Start Antiretroviral Therapy
in Thailand)
4

(Timing to
Start Antiretrovirals in Patients with
Active Opportunistic Infection)

50

5
(What Antiretroviral
Regimen to Start With)

52

10

54

(Antiretroviral Options after First-line
NNRTI-based Failure and Multi-class
Failure)

7
(Multi-class
Antiretroviral Treatment Failure)

56

58
(Proper Antiretroviral Options and
Adjustment during the Month of
Ramadan)

(Renal Insufficiency and

Dose Adjustment of Antiretrovirals)

60

10
64

(Liver Insufficiency and Dose
Adjustment of Antiretrovirals)

11

 11
68

(Side Effects and Complications
of Antiretroviral Therapy)
12
(Common Drug Interaction)

74

13
(Vaccination
for Adult HIV-positive Patients)

86

14
IRIS (Immune Reconstitution
Inflammatory Syndrome)

90

15 92

(Antiretroviral therapy in HIV and
Hepatitis B Coinfection)
16
(Consideration and
Contraindications in Hepatitis C
Infection Treatment)

12

95

1 98

2 100

3

102

106

108

118

142


2557

13

149

CD4 15

104

1
156


2 HAART

162

3 164


4 168

HAART

14

172

175

15

152

154

166

16

179

180

181

2
190

3 CD4

201

4 CD4

202

17



(Post-Exposure Prophylaxis PEP)

207

5
219
PrEP

(Pre-Exposure Prophylaxis PrEP)

218

6 PrEP
PrEP

(Male circumcision)

222

223

1 209

1 oPEP
oPEP

210

2 nPEP

212

3 nPEP
nPEP

214

4 oPEP
nPEP

217

18

220

19

20

21

1)

2)
algorithm

3) rapid test
algorithm

4) Window period
3 1

22

5)
(inconclusive)
2 / 1
3 inconclusive
( 1)
6) DNA PCR

EDTA
(Dried Blood Spot ; DBS)
7) HIV DNA PCR


HIV DNA PCR
( 2)

23

 1

18
1 (A1)(1)
A1_

A1+
2 (A2)(1)
A1+, A2 _

A1+, A2+

A1 A2
A1_, A2 _

A1+, A2 _

A1+, A2+
3
(A3)(1)

A1+, A2+, A3 _ A1+, A2+, A3+

(Anti-HIV Negative)

(Inconclusive)(3,4)
24

(Anti-HIV Positive)(2)

(1)
A1, A2 A3
1, 2 3
1
2 3
(2)
positive

(newly diagnosed)
2
1
(3)
(inconclusive)
2 / 1
3
A1, A2 A3
3

(4)


2 / 3


(3)
NAT neutralization p24 assay

25

26
27

(5)

(3)

2 3

Negative

2 3

Inconclusive

Inconclusive
(5)

2 3

DNA PCR

(Positive)

2 3

(4)

(Negative)

DNA PCR
4

(Negative)

DNA PCR
2

DNA PCR

(Positive)

(Negative)

(9)

(Anti - HIV Negative)(10)

(8)

(Anti - HIV Positive)

(7)

Anti - HIV
18

Anti HIV (6)

HIV DNA PCR

1 (2)
(Positive)

12 - 18

12

18 (1)

2 18


(1)

18
PCR
(2)
NAT (nucleic acid
amplification testing)

(3)

4
VL > 50 copies/mL
(4)


(5)

18
(6)
18


DNA PCR
(7)

3
3
2

28

PCR 2

24
(9)
PCR 2


(10)

6
(8)

29

Anti-HIV testing ELISA,

Agglutination
test, Dot/Line
test
HIV viral
Nucleic acid
(1)
testing
amplification
testing (NAT)
CD4 count

Flow cytometry

Clotted blood

5 mL

Serum
plasma
EDTA blood
EDTA plasma

1 mL

Dried blood spot

EDTA blood

Viral load testing Real time nucleic EDTA blood

(HIV-1 RNA)
acid amplification EDTA plasma

PPT EDTA gel

()

30

24 .

2-3 mL
1 mL

24 .
1
2-3 mL

6 .
( 18 - 25C
)
6-9 mL

2
1.5

mL
6 .
6-9 mL
( 4C)

31

2-8C

2-8C

(18-25C)

6 .
4-8C 24
.

Genotype

EDTA blood
EDTA plasma

6-9 mL

2
1.5 mL

6 .
( 4C)

., 12 ,


(1)

32

33

6 .
4-8C 24
.

34

35

(viral load, VL)
50 copies/mL


2 12
1 24 .

36

37

38
39

(
)

6 12 - sexual dysfunction
-

1 (Assessment of HIV-positive Person at Initial

& Subsequent Visits)

40
41

(current
lifestyle)

efavirenz


P

6 12

42
43

drug adherence

P
1

44
45

Anti-HCV

Syphilis (VDRL)

MSM 6
SW 3

: IDU
MSM

3 6
VL < 50 copies/mL

1 VL 50
copies/mL

6 12 - 6 12
CD4 > 350 cells/mm3
VL < 50 copies/mL
1

HBsAg

(viral load)

CD4

2 (HIV Laboratory Testing)

46
47

Fasting blood sugar

Urinalysis
P

Total cholesterol
Triglyceride

Creatinine

ALT

6 12

< 35
1 /
< 35
2 /
35
2 /


50 IDV
6
TDF
IDV 6

50 50 .
IDV 6

TDF
IDV 6

P
Serum cryptococcal
Ag

Drug resistance

Chest X-ray

CD4 < 100

cells/mm3

1
Anal PAP

1
Pap smear

VL > 1,000 copies/mL

6

48

3
(When to Start Antiretroviral Therapy in Thailand)

CD4
CD4 < 500 cells/mm3
CD4 > 500 cells/mm3

adherence

49

50

4-6
2-4

50
2

CD4 (cells/mm3)
> 50

2
2-8

:

2

Cryptococcosis
PCP/MAC/
CMV/PML/Cryptosporidium

(Tuberculosis)

4
(Timing to Start Antiretrovirals in Patients with Active Opportunistic Infection)

51

52
53

TDF/FTC
+

RPV
NVP

EFV

NNRTIs

NNRTIs

ATV/r

LPV/r

TDF NRTIs abacavir (ABC) + lamivudine (3TC)

zidovudine (AZT) + 3TC ABC VL < 100,000 copies/mL

efavirenz (EFV) NNRTIs
rilpivirine (RPV) nevirapine (NVP)
RPV VL VL > 100,000 copies/mL
NNRTIs 3 Protease
Inhibitors (PIs) lopinavir/ritonavir (LPV/r) atazanavir/ritonavir (ATV/r)
stavudine (d4T) d4T
VL < 50 copies/mL

ABC + 3TC
AZT + 3TC

TDF + 3TC*

NRTI backbone

5 (What Antiretroviral Regimen to Start with)

 6
(Antiretroviral
Options after First-line NNRTI-based Failure
and Multi-class Failure)

Raltegravir
NRTI backbone

(1)
NNRTI
1,000 copies/mL

(2) boosted-PI
poor adherence with transient
viremia
50 copies/mL
VL > 1,000 copies/mL

2-6
4

6

54

55

NRTI

TDF

NRTI

lopinavir/
ritonavir (LPV/r)

AZT, d4T atazanavir/

ABC
ritonavir (ATV/r),

TDF/FTC darunavir/
ritonavir (DRV/r),
TDF/3TC
raltegravir (RAL),*
dolutegravir
(DTG)

AZT/3TC

 7
(Multi-class Antiretroviral Treatment
Failure)

1.
viral load
> 1,000 copies/mL
1
viral load
10
3 viral load 50 copies/mL

4.
3
integrase inhibitor, entry inhibitor

2.
viral load > 1,000 copies/mL
3.

56

5.
1) Integrase inhibitors: raltegravir, dolutegravir
2) Protease inhibitors: darunavir
()
3) NNRTIs: etravirine, rilpivirine
()
4) CCR5 inhibitors: maraviroc

57

 8 (Proper
Antiretroviral Options and Adjustment during
the Month of Ramadan)

EFV

EFV

NVP

NVP 400 mg 24 .

OD

LPV/r

LPV/r 2 12 .
4 24 .
ATV/r

TDF

TDF

AZT d4T

TDF 24 .

VL < 50 copies/mL
TDF

3TC

3TC 1 12 . 2
24 .
58

59

60
61

200-300 mg 12 .
30 mg
12 .

AZT
d4T

125 mg
24 .

250 mg
24 .

< 60 kg

600 mg 24 .
200 mg 12 .
200 mg 12 .
25 mg 24 .

NVP
ETR
RPV

1 24 .

48 .

200 mg
24 .

15 mg
12 .

400 mg
24 .

300 mg 12 .
600 mg 24 .

100 mg
24 .(2)
300 mg
2

75 mg/24 .

15 mg
24 . AD(3)

100 mg/24 .

15 mg
24 .

Hemodialysis

50-25 mg
24 .(2) AD(3)
300 mg

7 AD(3)
100 mg 8 .
300 mg 24 .

50-25 mg
24 .(2)

< 10

100 mg
24 .

150 mg
24 .

15 mg
24 .

150 mg
24 .
300 mg
48 .

eGFR CrCl (mL/min)(1)

30-49
10-29

> 60 kg

EFV

NNRTIs

TDF/FTC

ABC

ddI(5)

300 mg 24 .

TDF(4)

30 mg
12 .

300 mg 24 .
150 mg 12 .

50

3TC

NRTIs

9
(Renal Insufficiency and Dose Adjustment of Antiretrovirals)

62
63

50

800/100 mg 24 . (nave)
600/100 mg 12 .
400/100 mg 12 .

CrCl < 70 mL/min

CrCl < 50 mL/min

HD

Hemodialysis (HD)
: ATV/r 300/100 mg 24 .
ATV ATV/r

eGFR CrCl (mL/min)(1)

Hemodialysis
30-49
10-29
< 10

creatinine clearance:
: (140 - ) x (kg)
: (140 - ) x (kg) x 0.85
72 x serum creatinine
72 x serum creatinine
(2)
150 mg loading dose
(3)
AD:
(4)
chronic kidney disease (CKD)
(5)
TDF

(1)

Integrase Inhibitors
RAL
400 mg 12 .
EVG/
COBI/
1 24 .
TDF/FTC

LPV/r

DRV

EFV/TDF/
1 24 .
FTC
RPV/TDF/
1 24 .
FTC
Protease Inhibitor (PIs)
ATV
400 mg 24 .
300/100 mg 24 .

64
65

Child-Pugh Score
7-9 B

10 C

300 mg 24 .

RTV boosting

200 mg 12 .

DRV
LPV/r
Integrase inhibitor
RAL
EVG/COBI/TDF/FTC

ETR
RPV
EFV/TDF/FTC
RPV/TDF/FTC
Protease Inhibitor (PIs)
ATV

NRTIs
3TC
TDF
AZT
d4T
ddI
ABC
TDF/FTC
NNRTIs
EFV
NVP

5-6 A

10
(Liver Insufficiency and Dose Adjustment of Antiretrovirals)

66
67

< 1.7
<4

International normalized ratio (INR)

Prothrombin time ()
(ascites)
Encephalopathy*

3-4

1-2

>6

> 2.3

< 28

>3

4-6

1.7-2.3

28-35

2:
3: routable
4:
5-6 A, 7-9 B, 10-15 C

> 35

(g/L)

2-3

* 1:

<2

(Total Bilirubin) (mg/dL)

Child-Pugh Score

68
69

Lactic acidosis, rapidly d4T

progressive ascending
neuromuscular weakness
ascending
demyelinating polyneuropathy
Guillain-Barr syndrome
Hypersensitivity reaction ABC 8%
(HSR)
2-9%
9 90%
6
(serious adverse effects)

NVP 14.8% ( 1.5%), EFV

26% ( grade 3-4 1%), ABC < 5%
HSR, ATV 2.1% ( < 1%),
TDF, LPV, AZT, 3TC

AZT 1.1-4.0%
neutropenia 1.8-8.0%
2-3

Advanced HIV, AZT

neutropenia
cotrimoxazole,
ribavirin, ganciclovir

NVP

EFV

HLA-B*5701, HLA-DR7, HLA-DQ3

HSR 3 4 ABC 600 mg
24 . 300 mg 12 . (5%
2%)

d4T

NVP CD4 detectable HIV RNA

NVP
(> 250 cells/mm3 , > 400 cells/mm3 )

CD4 detectable HIV RNA NVP
(> 250 cells/mm3 > 400 cells/mm3 )
Baseline AST ALT
HBV / HCV

Lactic acidosis, hepatic NRTIs d4T NRTI d4T ddI, AZT
steatosis +/- pancreatitis ddI AZT 0.85%
BMI
(severe mitochondrial
50%
d4T ddI
toxicities)
ddI hydroxyurea ribavirin

(life-threatening adverse effects)

Stevens-Johnson
NVP 0.3-1%, DLV EFV 0.1%,
Syndrome (SJS) ETR < 0.1% 1-2 AZT,
Toxic Epidermal
ddI, ABC, IDV, LPV/r, ATV, DRV
Necrolysis (TEN)
NVP CD4

nevirapine
hepatic necrosis

11
(Side Effects and Complications of Antiretroviral Therapy)

70
71

nephrolithiasis

peak IDV ATV > 0.85 mg/L
IDV

hyperbilirubinemia
ATV

TDF
IDV
ddI, ddI d4T intracellular / serum ddI
ribavirin hydroxyurea
pancreatitis
3TC, d4T TDF hypertriglyceridemia
ddI d4T, hydroxyurea, ribavirin
ddI TDF ddI
PIs
PIs hemophilia

IDV, TDF ATV

HBV/HCV


NVP
CD4 > 250 cell/mm3 CD4 > 400 cell/mm3
detectable VL
3TC, FTC, TDF HBV

Bleeding episodes
increase in hemophilia
(long-term adverse effects)
Lipodystrophy
Lipohypertrophy PI Baseline BMI
NNRTI d4T AZT
Lipoatrophy NRTIs
d4T AZT, ddI
TDF, ABC

Pancreatitis

Nephrotoxicity

(serious adverse effects) ()

Hepatotoxicity, clinical NNRTIs, PIs, NRTIs
hepatitis
NNRTIs 60% 12
symptomatic serum

transaminase elevation
50% NVP hepatitis
NRTIs d4T, ddI, AZT

PIs


Nephrolithiasis,
IDV/r 12.4% (4.7-34.4%),
urolithiasis, crystalluria ATV/r 6.6%

72
73

PIs

symptomatic osteonecrosis 0.08-1.33%

asymptomatic osteonecrosis 4%
MRI

hyperglycemia

peripheral neuropathy,
, d4T ddI
intracellular activities ddI
TDF, hydroxyurea, ribavirin

hyperlipidemia

- PIs: RTV-boosted PIs ATV/r
LDL, TG

Cardiovascular effects,
CVD (smoking, HT, DM,
CVA, MI
PIs MI CVA
hyperlipidemia, , )
ABC MI
ddI MI observational studies
RCT
MI 0.3-0.6%
CVA 0.1%

Osteonecrosis

(long-term adverse effects) ()

Hyperlipidemia
PIs ( unboosted ATV)
47-75%
- PIs > NNRTIs (EFV > NVP)
- NRTIs: d4T > AZT > ABC > TDF
Insulin resistance/
d4T, AZT PIs 3-5%
diabetes mellitus
Peripheral neuropathy ddI 12-34%, d4T 52%
monotherapy

 12
(Common Drug Interaction)

ergotamine Ergotamine group,

methergin
Dihydropyridine

calcium channel

blockers (DCCBs)
Amiodarone

EFV, PIs
Ergot
PI/RTV

Ergot PI
EFV
severe vasoconstriction
gangrene

PIs DCCBs, DCCBs

NVP, EFV
DCCBs

PIs
amiodarone

Diltiazem

PIs diltiazem diltiazem 50%

NVP, EFV ATV RTV
diltiazem

diltiazem

Clopidogrel

ETR
clopidogrel

Warfarin

PIs INR
warfarin
NNRTIs
warfarin

Rivaroxaban

PIs
rivaroxaban

74

PIs
75

Lovastatin

HMG-CoA
simvastatin
reductase inhibitors

Acid reducers

76

PIs PIs
NNRTIs NNRTIs

Atorvastatin
rosuvastatin

PIs

EFV, ETR
atorvastatin

Pravastatin

PIs
EFV boosted darunavir

H2-receptor
antagonists (HRAs)

HRAs ATV boosted ATV /

RPV
HRAs
10 .
HRAs 12 .
4 .
RPV

Proton-pump
inhibitors (PPIs)

PPIs ATV ATV

RPV
PIs ,
PIs PPIs
12 . ATV
boosted ATV
RPV
77

Benzodiazepines

Antidepressants

78

Midazolam,
triazolam

PIs EFV

Alprazolam,
diazepam

PIs benzodiazepine
ETR

diazepam
ETR
diazepam

Oxazepam,
temazepam

CYP450

Sertraline

Boosted darunavir
EFV
sertraline

sertraline

Trazodone

PIs
trazodone

trazodone

Tricyclic
antidepressants
(TCAs)

PIs TCAs

TCAs

79

Corticosteroids

Dexamethasone

Fluticasone,
budesonide (inhaled
intranasal)

Phosophodiesterase Sildenafil
type 5 inhibitors

Alpha-adrenergic Tamsulosin
blockers
5-alpha-reductase Finasteride
inhibitors
Ethinyl estradiol
(EE), progestin,
norgestimate,
norethindrone

80

Dexamethasone RPV
PIs, NVP, EFV,
ETR, RPV

dexamethasone

RTV boosted
PIs
PIs sildenafil
ETR sildenafil PIs

ETR
PIs
tamsulosin dose
tamsulosin

PIs
finasteride

finasteride

EFV: EE
AUC, levonogestrel

AUC 83%,

norelgestromin

AUC 64%,
levonogestrel, norelgestromin,
etonogestrel etonogestrel
(implant)

ETR: EE 22%;

norethindrone:
no significant effect
81

()

NVP: EE 20%;
Norethindrone:
AUC 19%
Depot medroxy
progesterone acetate:
no significant effect
RPV: EE 14%;
Norethindrone:
no significant effect
IDV: EE: AUC 25%;
Norethindrone:
AUC 26%
NFV: EE: AUC 47%;
Norethindrone:
AUC 18%
ATV/r: EE ;
Progestin,
norgestimate:

EE
35 g

progestin norgestimate
norethindrone
DRV/r: EE: AUC 44%;
Norethindrone:

AUC 14%
LPV/r: EE 42%;
Norethindrone:

AUC 17%
82

83

Opioid antagonist Methadone

Boosted PIs methadone withdrawal

R-methadone (active methadone
form methadone)
LPV/r
methadone 26-53%
ATV/r, DRV/r
methadone
( methadone
16-18%)
NNRTIs: EFV NVP methadone
methadone withdrawal
41-52%
methadone
ETR

methadone AZT
AZT
29-43%
ATV = atazanavir; EFV = efavirenz; ETR = etravirine;
NVP = nevirapine; PIs = protease inhibitors;

84

NNRTIs = non-nucleoside reverse transcriptase inhibitors;

RPV = rilpivirine; RTV = ritonavir, AZT: zidovudine

85

86
87

Hepatitis B vaccine
(HBV)

Hepatitis A vaccine
(HAV)

HBV HBsAg, anti-HBs,

anti-HBc
3 : , 2 1 , 3
2 2 4 (
2 3 1 6 )
anti-HBs 3 1
anti-HBs 10 IU/L 1
anti-HBs 1
2 anti-HBs
1

:
HAV (MSM) (
HBV/HCV) clotting factor concentration
HAV serum
HAV IgG
2 : 2 6-12

: (live-attenuated
vaccine) measles, mumps, varicella, zoster, yellow fever

13 (Vaccination for Adult HIV-positive Patients)

88
89

13-valent
pneumococcal
conjugate (PCV-13)

23-valent
pneumococcal
polysaccharide
(PPV-23)

Tetanus and
diphtheria toxoid
(Td) Tetanus
Toxoid (TT)

Influenza

Human
papillomavirus
vaccine (HPV)

CD4 > 200 cells/mm3

PPV-23 PCV-13
2

CD4 > 200 cells/mm3

1 5
65 65
PCV-13 PPV-23
1

3 HPV 4 (quadrivalent)
9-26
19-26 MSM
HPV
(anal cancer)

1
nasal spray
1 1 10
Tetanus, diphtheria and pertussis (Tdap) Td TT
1

 14 IRIS
(Immune Reconstitution Inflammatory Syndrome)

()

IRIS

- CD4

IRIS
(Graves disease)

IRIS 2

Unmasking IRIS

3-6
Paradoxical IRIS

IRIS

-

Definition

mycobacterium (TB MAC)

Cryptococcus
3-6
CD4
50-100 cells/mm3

90

IRIS IRIS

Paradoxical IRIS
NSAIDs short course corticosteroids
IRIS
-
-

systemic corticosteroids
91

92
93

Backbone: Tenofovir (TDF) + Lamivudine (3TC) Emtricitabine (FTC)

3TC FTC TDF HBV

FTC, 3TC TDF eGFR 9

eGFR < 30 mL/min/1.73 m2 entecavir ( 3TC
entecavir 1 mg/day) TDF

AZT d4T VL < 50 copies/mL

TDF

TDF FTC 3TC

TDF

HIV FTC, 3TC TDF, 3TC FTC

TDF

FTC, 3TC hepatic flare

TDF
entecavir ( 3TC

entecavir 1 mg/day) hepatic flare

HIV

15
(Antiretroviral Therapy in HIV and Hepatitis B Coinfection)

94
95

-
-

(decompensated cirrhosis)

interferon ribavirin

AZT, d4T ddI ribavirin

18
6
HCV RNA 5,000 IU/mL
3
HIV RNA < 50 copies/mL

16
(Consideration and Contraindications in Hepatitis C Infection Treatment)

> 40 > 50
liver ultrasound

() TDF
ABC

96

97

98
99

1 - < 3

3 - < 5

5 - 15

< 1

3 - < 5

5 - 15

* < 1
* > 1 %CD4 15-24%
CD4 %CD4 3 %CD4
15

%CD4 -
CD4
CD4 CD4 < 25% CD4 < 25% CD4 < 350

< 1,000 cells/mm3

< 750 cells/mm3
cells/mm3
-
CD4 350-500
cells/mm3

1 - < 3

-
CDC category CDC category B, CDC category B,
*
B, C WHO stage C WHO stage 3, 4 C WHO stage 3, 4
3, 4
-
category A
VL > 100,000
copies/ml

CD4

< 1

100
101

**

1 - < 3
AZT ( ABC*) +
3TC + LPV/r
- AZT ( ABC*)
+ 3TC + NVP
- d4T# + 3TC + LPV/r
( NVP)

3 - 12
AZT ( ABC*) +
3TC + EFV$
- AZT ( ABC) +
3TC + NVP
- TDF + 3TC + EFV
( NVP)
- d4T#+ 3TC + EFV
( NVP)

- AZT + 3TC + EFV

( NVP)
- ABC + 3TC + EFV
( NVP)
- TDF + 3TC + NVP
- TDF + 3TC + RPV

> 12
TDF + 3TC + EFV$

(2) (3) (4)

creatine
phosphokinase lymphopenia

Lopinavir/ritonavir (LPV/r) 14 42
LPV/r 3 NVP
LPV/r 12 HIV RNA < 50 copies/mL LPV/r
NVP LPV/r
NVP 6 HIV RNA
VL < 50 copies/mL LPV/r
AZT d4T lipodystrophy (Hb < 8-9
g/dL) d4T 6 AZT
NVP AZT + 3TC + NVP (GPO-VIR Z250)
EFV EFV 3 NVP
EFV 3 - 3 3.5

Abacavir (ABC) > 3 hypersensitivity

HLA-B*5701 (
4.0) ABC HLA-B*5701
ABC 6 2 (1)

< 1

AZT ( ABC*) +
(preferred regimens) 3TC + LPV/r**

- AZT ( ABC) +
(alternative regimens) 3TC + NVP@
- d4T# + 3TC + LPV/r
- d4T# + 3TC + NVP

NNRTI

PI NNRTI

- rifampicin

2NRTI
+ NNRTI 2-8
(CD4
< 15% CD4 count < 200
cells/mm 3) 2-4

4-8
- rifampicin
NNRTI

- rifampicin 2-8
PI (CD4 < 15%
CD4 count < 200 cells/mm3)
2-4 4-8

- PI
rifampicin ( quinolone aminoglycoside
rifampicin 2 ) continuation phase
3 INH + quinolone + ethambutol
PZA
- 12-18

-
rifampicin
2NRTI + NNRTI

- CD4 > 200 cells/mm3 PI

( 3TC M184V)
rifampicin (intensive
phase) 2 (continuation
phase) rifampicin 3 INH
+ quinolone + ethambutol PZA
PI rifampicin 2
- CD4 < 200 cells/mm3
rifampicin quinolone
aminoglycoside rifampicin intensive phase
PI continuation phase
3 INH + quinolone + ethambutol PZA
- 12-18

102

103

adherence*

CD4
< 200 cells/mm3

1
CD4
plasma HIV viral load

adherence
4

adherence

HIV genotyping viral load > 1,000 copies/mL
genotyping

104

105

106
107

ABC + 3TC + LPV/r

(first-line regimen)

(salvage regimen)
genotype

1 NRTI + DRV/r
(ETR / RAL / MVC)
1 NRTI + boosted PI
(ETR / RAL / MVC)

NNRTI:
1 NRTI + boosted PI
TDF + AZT+ EFV4 ( DRV/r (ETR / RAL / MVC)
NRTI )
NNRTI:
TDF + AZT + DRV/r

(second-line regimen)

TDF ABC + 3TC + AZT + 3TC + LPV/r2

NVP EFV
AZT + 3TC + LPV/r
NNRTI:
TDF + 3TC + EFV3 ( DRV/r
NRTI )
NNRTI:
TDF + 3TC + DRV/r

(salvage regimen)
genotype

1 NRTI + DRV/r
(ETR / RAL / MVC)

TDF + AZT TDF + ABC Boosted PI ATV/r

2
ABC + 3TC ABC Boosted PI ATV/r
3
TDF + AZT ABC TDF TDF 2
4
TDF + 3TC AZT + 3TC K65R

(second-line regimen)

AZT + 3TC + NVP or TDF + 3TC + LPV/r1

EFV

(first-line regimen)

108
109

Tenofovir (TDF)

Abacavir (ABC)

Stavudine (d4T)

4 4 mg/kg 12
. ( 150 mg/dose)
16 50 kg
300 mg

6 ( ):
180-240 mg/m2/dose 12 .
( 300 mg/dose)
> 4
():
4 - < 9 kg: 12 mg/kg 12 .
9-30 kg: 9 mg/kg 12 .
30 kg: 300 mg 12 .

-
(
30 )
-

30 kg 1 12 . 30-60 kg

AZT
200 mg/dose
: 1 mg/mL
14 1 mg/kg 12 . -
: 15, 20, 30 mg ( 30 mg/dose)
30
: 20 mg/mL
8 mg/kg 12 .
-
: 300 mg
( 300 mg/dose)

16 600 mg 24 .
: 300 mg
2- < 12 8 mg/kg 24 .
12 30 kg 300 mg
24 .
Tenofovir
14 - < 20 kg: 150 mg
20 - < 30 kg: 225 mg
30 kg: 300 mg

: 10 mg/mL
( 60 mL)
: 150, 300 mg

: 10 mg/mL
( 60 mL)
: 100 mg
: 300 mg

AZT + 3TC (fixed : AZT 300 mg +

dose combination) 3TC 150 mg

Lamivudine (3TC)

Zidovudine (AZT)

Nucleoside analogue reverse transcriptase inhibitor (NRTI)

110
111

Etravirine (ETR)

Efavirenz (EFV)

: 100 mg

: 50, 200 mg
: 600 mg

- Rifampicin NVP
20-30%
NVP
- EFV NVP
12 .
lead-in

-
(

50%)
-

> 6 -
16 - < 20 kg 100 mg 12 . -
20 - < 25 kg 125 mg 12 . 1-2
25 - < 30 kg 150 mg 12 . NNRTI
30 kg 200 mg 12 .
ETR

>3

3.5 - < 5 kg 100 mg 24 .

5 - < 7.5 kg 150 mg 24 .
7.5 - < 15 kg 200 mg 24 .
15 - < 20 kg 250 mg 24 .
20 - < 25 kg 300 mg 24 .
25 - < 32.5 kg 350 mg 24 .
32.5 - < 40 kg 400 mg 24 .
40 kg 600 mg 24 .

Nonnucleoside reverse transcriptase inhibitor (NNRTI)

Nevirapine (NVP) : 10 mg/mL
< 8 200 mg/m2 12 .
: 200 mg
8 120-150 mg/m2 12 .
( 200 mg/dose)
(Lead-in) 14
24
.

12 .
14

112
113

> 12 > 40
kg: 1
> 12 > 35
kg: 1
> 12 > 40
kg: 1

AZT 250 mg + 3TC 150 NVP

mg + NVP 200 mg 160-200 mg/m2 12 .
- WHO guideline
10 - < 14 kg 12 .
14 - 25 kg 12 .
1
> 25 kg 1 12 .

ABC 600 mg + 3TC

300 mg
Truvada
TDF 300 mg + FTC
Ricovir-EM, Teno-EM 200 mg
Atripla
TDF 300 mg + FTC
200 mg + EFV 600 mg

Kivexa

GPO-VIR Z250

Fixed dose combined pill of NRTI and NNRTI

GPO-VIR S30
d4T 30 mg + 3TC 150 GPOvir S30
mg + NVP 200 mg
NVP 160-200 mg/m2 12
.
- WHO guideline
10 - < 14 kg 12 .
14-25 kg 12 .
1
> 25 kg 1 12 .

(Lead-in)
NVP
14 GPO-VIR
Z250 AZT
+ 3TC 14

GPO-VIR
Z250 12 .

(Lead-in)
NVP
14 GPO-VIR
d4T + 3TC
14

GPO-VIR 12
.

114
115

Atazanavir (ATV)

Lopinavir + ritonavir
(LPV/r) ()

- (

> 25C)
-

LPV/r
LPV/r HIV
RNA < 50 copies/mL


> 25-35 kg: LPV/r 200/50 mg
12 .

2 - 12
LPV 300 mg/m2 + RTV 75 mg/m2
12 .
12 - 18 :
LPV 230 mg/m2 + RTV 57.5
mg/m2 12 .
( LPV 400 mg + RTV
100 mg)
LPV/r

15-25 kg LPV/r 200/50 mg

12 .
> 25-35 kg LPV/r 300/75 mg
12 .

-
asymptomatic indirect
hyperbilirubinemia

. ATV 200
mg 300 mg
20-50
kg ATV 200 mg/r 100
mg

> 35-50 kg: LPV/r 300/75 mg

12 .
> 50 kg: LPV/r 400/100 mg
12 .

> 35 kg LPV/r 400/100 mg

12 .
HIV RNA < 50 copies/
mL

: 100, 150, 200, > 6

300 mg
24 .
RTV 100 mg

15 - < 20 kg ATV 150 mg/r 100 mg

20 - < 32 kg ATV 200 mg/r 100 mg
32 - < 40 kg ATV 250 mg/r 100 mg
40 kg ATV 300 mg/r 100 mg

Protease Inhibitor (PI)

Lopinavir + ritonavir : LPV 80 mg/ml +
(LPV/r)
RTV 20 mg/ml
:
LPV 200 mg + RTV
50 mg,
LPV 100 mg + RTV
25 mg
(
15 kg)

116
117

Raltegravir

Darunavir (DRV)
()

Darunavir (DRV)

Film-coat tablet 400 mg > 12

> 25 kg Film-coat tablet
400 mg 1 2

: 75, 150, 400, 600 3

mg

2
15 - < 30 kg DRV 375 mg/r 50 mg
30 - < 40 kg DRV 450 mg/r 60 mg
> 40 kg ATV 600 mg/r 100 mg

15-40 kg: DRV 600 mg + RTV

100 mg
> 40 kg: DRV 900 mg + RTV
100 mg

.
300 mg

12 - < 15 kg DRV 300 mg + RTV
50 100 mg 12 .
15 - < 30 kg DRV 450 mg
+ 300 mg + RTV 50
100 mg 12 .
30 - < 40 kg DRV 450 mg +
RTV 100 mg 12 .
40 kg DRV 600 mg + RTV
100 mg 12 .
darunavir-associated
mutation

118
119

EFV

1-2

Absence

1-6
LPV/r

1)

2-4

LPV/r
< 2

< 42

4 mcg/mL
(

120
121

ABC

AZT 3TC

Pancreatitis
Serum amylase


lipase routine
ddI d4T
serum amylase
NRTIs
lipase
ddI, d4T

3TC

serum amylase

Lactic acidosis 1-20 metabolic

serum

acidosis
routine

lactate
NRTIs
(anion gap > 16) serum lactate
IV
d4T,
serum lactate

fluid fluoride-oxalate
> 5 mmol/L
ddI

tube

4 .

NRTIs

TDF

2) Mitochondrial dysfunction

122
123

rihes.cmu.ac.th/
Ped_HIV/10-BMIWHR_z_score/
index.htm

waist-tohip ratio (

)
http://www.

NRTIs
AZT
ABC

NRTIs

AZT

d4T ABC
ddI

3)
Fat maldistribution lipohypertrophy

/

NRTIs

d4T
PIs
PIs

NNRTI

(waist-
boosted PIs
PIs to-hip ratio

d4T
d4T
z-score) > 3.5



BMI

Peripheral

neuropathy

d4T, ddI

hyporeflexia

124
125

d4T

AZT

ABC TDF

4) metabolic syndrome insulin resistance ( type 2 diabetes

impaired fasting glucose 100 mg/dL impaired glucose tolerance test) 2
130/85 mmHg BMI (triglycerides 150
mg/dL HDL cholesterol < 40 mg/dL) albuminuria metabolic syndrome
atherosclerosis
Hyperglycemia,

FBS
insulin resistance, fasting blood
6

diabetes
sugar > 126

mg/dL

NRTIs

random BS >200

d4T, ddI, AZT

mg/dL
3

60
PIs
oral

LPV/r
glucose challenge

(ATV/r, DRV/r
test (OGTT)
)

Fat maldistribution lipoatrophy

()

NRTIs
d4T
ddI
AZT

126
127

Insulin resistance
FBS 100-125
mg/dL

Hyperlipidemia Cholesterol, Fasting

LDL cholesterol
PIs

> 200 mg/dL

atherosclerosis Fasting LDL

> 130 mg/dL

NNRTIs Fasting TG
EFV TG
> 200 mg/dL
NVP

NRTIs pancreatitis
d4T

10
impaired
OGTT

metformin

fasting
cholesterol,

HDL, LDL
TG 6

6-12
TG
> 500 mg/dL

ARV
ATV/r
NNRTIs

Fibrate

TG
> 500 mg/dL
gemfibrozil
150-300 mg

2
Statin
Pravastatin
8-13
20 mg

14-18

128
129

Fibrate

8-10
LDL > 190
mg/dL LDL
> 160 mg/dL

statin

40 mg

10 mg
4

atorvastatin
> 6
10-20 mg

5)

ALT / AST /
(hepatotoxicity)
liver enzyme
AST ALT

ARV
NVP
ARV ( ) NVP
10 6

ARV

upper
NVP

NNRTIs
normal limit

(NVP

ALT
EFV)

2-4
AST > 5-10 fluconazole

upper

normal limit
NVP

hepatitis A, B,

C, EBV, CMV

130
131

hypersensitivity

NRTIs
lactic
acidosis

ALT
AST 5-10
upper
normal limit

lactic acidosis

AZT, d4T, ddI

AZT
PIs

/
/

ARV adherence

Indirect
bilirubin
Hyperbilirubinemia

liver enzyme
indirect

IDV, ATV
bilirubin

132
133

AZT

Hb < 7-8 g/dL

heart
failure

6)

PIs
buffered ddI

AZT

CBC 6
MAC, TB

AZT
AZT ARV
CBC
d4T
TDF
3 6

6

134
135

CBC: absolute CBC 6

neutrophil count

< 500 cells/mm3 AZT

(severe < 250
CBC
3
cells/mm )
MAC
3 6

6

ARV

7) Allergic reaction/ Hypersensitivity

maculo-papular 2-8

antihistamine
rash

2-3
ABC

2-4

hypersensitivity

TMP-SMX,

NVP ABC

(rechallenge)
systemic

hypersensitivity

systemic
systemic

(

(neutropenia)

AZT

absolute
neutrophil
(< 250
cells/mm3)

136
137

systemic

8)
Impaired renal U/A, Cr. 6

function

eGFR < 60
TDF
mL/min/1.73 m2
IDV
Fanconi
renal
, syndrome
cortical atrophy acute tubular
acute renal necrosis,
amino
failure interstitial
acid, glucose

Cr.

eGFR

EFV

Stevens Johnson ARV

syndrome (SJS)/


erythema

TMP-SMX
multiforme (EM)

major/toxic


epidermal

IV
necrolysis (TEN)
TMP-SMX fluid

TMP-SMX,
1-2
NNRTIs

NVP
ARV
steroid

(blister/bulla)
NVP
AZT, ddI, LPV/r,

ATV

2
NVP

eGFR
Schwartz
FEP = [(Urine
phosphate/serum
phosphate)/(urine
creatinine/plasma
creatinine)]*100

138
139

IDV, ATV
()

uric

serum glucose

acidosis, sodium,
potassium

phosphate
wasting
phosphate

urine
fractional excretion
of phosphate

TDF

UA


microscopic

UA
hematuria

hematuria
creatinine

6
ARV
IDV

nephritis,
proximal renal
tubulopathy,
nephrogenic
DI, Cr.
,


phosphate

140
141

(osteopenia
osteoporosis)

TDF
d4T
PIs

9)

absorptiometry) steroid

medroxyproges (bone
terone
mineral density)

ARV

12

(BMD z-score)

-1

-2 Z-score serum
Vitamin D
DEXA (dual

energy x-ray

(peak bone mass)

142
143

1
2
4
6
9
12
18
2
4-6 11-12

--
DTaP1 DTaP2 DTaP3
DTaP
DTaP Tdap
( 4
1
2
3
DTaP, 7 Tdap)
6
JE4
(4-5

JE3)
7

Hib1 Hib2
Hib3
Hib4
(Hib: PRP-T, PRP-OMP)
HAV1, HAV2 6-12
8 (HAV)
9
VZV1
VZV2
(VZV)

2
4
6
9
12
18
2
2 4-6 11-12
1

BCG
2

HBV1
DTwP- DTwP- DTwPHBV1 HBV2 HBV3
--
DTwP
DTwP dT
3
1
2
4
OPV1 OPV2 OPV3
OPV
OPV

IPV
IPV
IPV1 IPV2 IPV3
1
2
5
--
MMR1
MMR2
6

JE1, JE2
JE3
1

7
2557

HPV
3

9-26

PPSV23 2 5

Rota 1 Rota 2 (Rota 3)

pentavalent
144

(Rota)13

12 (HPV)

PCV1 PCV2
11
(PCV PPSV23)

10 (influenza)

PRP-T

2 - 6

0, 2, 4, Booster

7 - 11

0, 2, Booster

> 12 - 59

Booster 12-18
2
PCV3

11-12

4-6

1
2
4
6
9
12
18
2

Hib

PCV

2 - 6

3
6-8

12-15

7 - 11

2
6-8

12-15

12 - 23

2
6-8

24 - 59
-

1
2
6-8

145


1. BCG

BCG

BCG BCG

2.
DTP-HBV
2, 4, 6
3. DTwP DTaP (Tdap)
7 1
4. IPV OPV
IPV

5. --
(clinical stage C CD4
15) CD4 15

- 9 -12
2 4-6
( 9 )
1
( 12 )
1
- 2 2

-
4
3
- -- (MMRV)

6. 3
1 0, 1 , 1
1 3 4-5
(

6 CD4 > 15%
2 3-12 )
7. 2
1 12-18
2

Hib
8.
1 2 6-12
9. 1
CD4 15 2 dose
1 2 4-6
2 4
3

146

147

10.

9 2 1
3
dose (0.25 .)
11. (PCV)
2 3 2
12-15
PCV
PPSV23 2 PCV
2 PPSV23
1 5 14-59
PCV7 4
PCV13 1 PCV7
8
6-18 PCV13
1 dose PCV7 PPSV23

12. 3 0, 1-2, 6
9 26
11-12

13. 2, 4
( 6 pentavalent vaccine)

148

8

CD4
15

1
2
6

HBV vaccine1

HBV1

JE vaccine
()2

HBV2
JE1

HBV3

JE2

Measles vaccine3 MMR1

3
2
1

dT vaccine
> 7 4

10

1.
1
3 dose
()

CD4 15%
1 anti-HBs > 10 mIU/ml 2
anti-HBs

149

 anti-HBs < 10 mIU/mL

3 dose (
)
anti-HBs 10-100 mIU/mL 1
dose
CD4
anti-HBs > 100 mIU/mL

2.
2 dose 1
CD4
6
1
3. --
1 CD4
6 MMR

4. -- (DTwP, DTaP Tdap)
< 7 DTwP DTaP
7 dT Tdap

150

151

152
153

-
1

- window period
1
-

-
- CD4

CD4

32
same day test result

PMTCT

window period

( / )

(b)

(b)
Anti-HIV

Reactive(a)

(c)

Non Reactive(a)

window period

Negative

Positive

2 1
3

Negative

Positive

154

2
(a)

(rapid test)

(b)

rapid test

anti-HIV
rapid test

48

(c)



rapid test

155

1


Antepartum

Intrapartum

Newborn

Postpartum

( + )

1 HAART
( CD4@)
+

: TDF (300 mg) + 3TC (300 mg)

AZT* 300 mg
+ EFV (600 mg)
3 . 600
#

mg
: (AZT + 3TC) 1 + LPV/r (200/50)

2 12 .
: TDF (300 mg) + 3TC (300 mg)
+ LPV/r (200/50) 2
12 .

156

o LPV/r-based
HAART

o TDF + 3TC +
EFV
EFV TDF +
3TC 7-10

157

AZT (syr) 4 mg/kg

12 . 4
(
1 .
)

3
(

6
3
3)

Antepartum

Intrapartum

Newborn

Postpartum

( + )

2 HAART

VL < 50 copies/mL

+
AZT* 300 mg
3 . 600
mg

EFV

3 (No ANC)
2 .

158

AZT 300 mg
3 . 600
mg

AZT (syr) 4 mg/kg

12 . + 3TC
(syr) 2 mg/kg
12 .+ NVP (syr)
4 mg/kg 24
. 6

159

Antepartum

Intrapartum

2 . AZT 300 mg
3 . 600
mg +
NVP 1

(SD NVP)

Newborn

Postpartum

( + )

TDF + 3TC +
EFV

3
CD4 > 500 cell/mm

AZT + 3TC + LPV/r
4 (tail)
3

CD4 < 200 cells/mm3 TMP-SMX 2 24

.
#
LPV/r-based HAART 1)
NNRTI

AZT+SD NVP
2) CD4 > 500 cells/mm3
tail
regimen NNRTI

* AZT VL < 50 copies/mL

160

161

/ : CD4
< 500 cell/mm3,
,

162
163

TDF (300 mg 24 )

boosted atazanavir (ATV/r 300/100 mg )

LPV, EFV, NVP

AZT monotherapy AZT
NVP 200 mg 1 (SD NVP)

(HAART)
tail regimen Tail
regimen* NVP

4 tail
regimen AZT + 3TC + LPV/r 4

* Tail regimen: AZT + 3TC 7 AZT + SD NVP

EFV, LPV/r, NVP ATV/r

NVP CD4 count < 250 cell/mm3

CD4 > 250 cell/mm3 NVP

LPV/r EFV

LPV/r (200/50) 2 12

EFV (600 mg 24 )

EFV

LPV/r

TDF AZT (300 mg 12 )

AZT

2 HAART

164

AZT (10 mg/mL)*

()
4 mg/kg 12
18 . (1.8 mL )
16 . (1.6 mL )
14 . (1.4 mL )
12 . (1.2 mL )
10 . (1.0 mL )
8 . (0.8 mL )
9 . (0.9 mL )
8 . (0.8 mL )
7 . (0.7 mL )
6 . (0.6 mL )
5 . (0.5 mL )
4 . (0.4 mL )

2 mg/kg 12

3TC (10 mg/mL)

NVP (10 mg/mL)

4 mg/kg
(simplified dosing)
18 . (1.8 mL )
16 . (1.6 mL )
14 . (1.4 mL )
12 . (1.2 mL )
10 . (1.0 mL )
8 . (0.8 mL )

* 30-35 : AZT 2 mg/kg 12 . 8 . 2

* < 30 : AZT 2 mg/kg 12 . 8 . 4

4000 - 4499
3500 - 3999
3000 - 3499
2500 - 2999
2000 - 2499
1500 - 1999

(g)

1. HAART

VL
AZT
AZT
wild type AZT
2. NVP
HAART
AZT TDF + 3TC + LPV/r
CD4
NVP
3. acute HIV
infection
HAART


50 copies/mL

4.

165

1
VL < 50copies/mL

1 VL
()

GA < 36
GA > 36
anti-HIV GA
32-34 anti HIV

(4th gen) (
6

3rd gen)

2
()

GA 32-34

(> 32 )

window
period
no ANC

window period

HIV DNA RNA (qualitative) PCR

166

167

168
169

2.5 upper limit 2.5 upper limit
NVP
NVP EFV
LPV/r

ALT

TDF 3 6

creatinine clearance < 50 creatinine clearance < 50
mL/min TDF
mL/min TDF
AZT

AZT 4-8
Hb < 8 g/dL Hct < 24%
AZT TDF

36 *
4

Creatinine

Hb < 8 g/dL Hct < 24%
AZT TDF

CBC

Viral load

CD4 count

4 HAART

HAART

170
171

LPV/r LPV/r 24-28

LPV/r 4
blood sugar 140
blood sugar
mg/dL 100 g OGTT***
140 mg/dL 100 g OGTT

VL < 1,000 copies/mL VL 36

4
VL >1,000 copies/ml VL > 50 copies/ml 3
AZT/3TC/NVP 6
** 50 g GCT (glucose challenge test) glucose 50 g 50%
glucose 100 mL blood glucose glucose 1
*** 100 g OGTT (oral glucose tolerance test) 8
fasting blood glucose glucose 100 g
blood glucose 1, 2 3 glucose

* HAART 8-12

50 g GCT**

urine sugar
LPV/r EFV

Urine sugar

(artificial rupture of membranes)
4

38
(elective

caesarean

section)

38

VL 36
4 .
> 1,000 copies/mL


4
VL
172

(emergency

caesarean

section)

1. methergin
ergotamines
protease inhibitor EFV protease inhibitor
potent CYP3A4 enzyme inhibitors
ergotamines
vasoconstriction EFV
CYP3A4 enzyme inhibitors inducer
methergin

2. AZT 600 mg
( NVP 200 mg )
4
(prophylactic antibiotic)
ampicillin cefazolin
173

1 3

18

TMP-SMX prophylaxis ( TMP 150 mg/m2/day

SMX 750 mg/m2/day) 3
4-6
PCR
1
( :
)


AZT + 3TC + LPV/r
AZT + 3TC + NVP
NVP LPV/r
( :
)
174

*@

(standard HIV DNA PCR

2 1
risk)
2-4

#
(HAART)

> 4
AZT

4

50 copies/mL
(high risk) HIV DNA PCR

3 1, 2 4
3
4

(AZT + 3TC + NVP)

3
> 50 copies/mL

6

*
(dried blood spot)
(

175

 )


HIV DNA PCR 1-2
DNA PCR

@

anti-HIV 18
( :

)
#
1
HIV DNA PCR
2

176

177

6-9
12
directly observed therapy

3
CD4 50 cells/mm
2

3
CD4 > 50 cells/mm
2
2-8
rifampicin

rifampicin
EFV EFV
NVP RAL
PI
rifampicin
178

179

co-trimoxazole Pneumocystis
pneumonia (PCP)


CD4 < 200 cells/mm3 %CD4 < 14
oropharyngeal candidiasis AIDS-defining
illness () PCP
primary prophylaxis
cryptococcosis, penicilliosis, histoplasmosis
Mycobacterium avium complex (MAC)

CD4 (
prophylaxis)

180

Tuberculosis Drug susceptible

2 HRZE/4-7IR
Isoniazid 5-8 mg/kg
(300 mg) PO
Rifampicin 10 mg/kg
(450-600 mg) PO
Ethambutol 15-20 mg/kg
(800-1,200 mg)
PO
Pyrazinamide 20-30 mg/kg
(1,000-2,000 mg)
PO

Second line drug

Streptomycin 15 mg/kg ( 1,000 mg) IM
Kanamycin 15 mg/kg ( 1,000 mg) IM
Amikacin 15 mg/kg ( 1,000 mg) IM
Ethionamide 15 mg/kg (500-750 mg/day) PO 2-3
Cycloserine 10 mg/kg (500-750 mg/day) PO 2-3
4-aminosalicylic acid (PAS) 200 mg/kg (8,000-12,000 mg/day) PO 2
Ofloxacin 600-800 mg/day PO
Levofloxacin 500-750 mg/day PO
Moxifloxacin 400 mg/day PO
( .. 2555
)

181

182
183

Itraconazole 400 mg/day PO

8-10

Consolidation phase:
Fluconazole 400-800 mg/day
PO 8-10

Candidiasis

Oropharyngeal Clotrimazole oral troches 10 mg Nystatin oral solution 500,000

candidiasis
4-5 7-14 5
Fluconazole 100 mg/day Po
7-14
7-14
Itraconazole capsule 100
mg/day PO 7-14
Itraconazole oral solution 100
mg/day PO 7-14
Amphotericin B 0.3-0.5
mg/kg/day IV 7-14

Trimethoprim-sulfamethoxazole Clindamycin 600 mg IV 6 TMP -SMX

Dapsone 100
(TMP-SMX) TMP 15-20 . 900 mg IV 8 . (80-400 mg mg PO
mg/kg/day SMX 75-100
300 mg PO 6 .
single strength,

mg/kg/day 3-4
450 mg PO 8 . + SS Tablet) PO 2 Atovaquone
21
Primaquine 30 mg PO
1,500 mg PO
21

Pentamidine isethionate 3-4

mg/kg IV 21
Cryptococcosis Induction phase:
Fluconazole
Itraconazole 200
(cryptococcal Amphotericin B 0.7-1.0 mg/kg/ Fluconazole 1,200 mg/day IV 200-400 mg PO mg PO
meningitis day IV + fluconazole 800 mg/day PO 14

disseminated)
IV PO 14
Amphotericin B 1.0 mg/kg/day
IV 14

Pneumocystis
pneumonia
(PCP)

184
185

Fluconazole 200 mg/day Po

14-21

Esophageal
candidiasis

Toxoplasmosis Pyrimethamine 200 mg

TMP-SMX (TMP 5-10 mg/kg/day) Pyrimethamine Pyrimethamine
PO 1 50 mg/day IV or PO 2 6 25-50 mg/day
25-50 mg/day
(. 60 kg) 75 mg/day
PO + PO +
(. > 60 kg) PO + Pyrimethamine sulfadiazine
clindamycin 600
sulfadiazine 1,000 mg
+ clindamycin 600 mg
500-1,000 mg
mg PO 8 .
(. 60 kg) 1,500 mg
IV PO 6
PO 4
+ folinic acid
(. > 60 kg) PO 4 Pyrimethamine
+ folinic acid
10-25 mg/day
+ folinic acid 10-25 mg/day
+ azithromycin
10-25 mg/day
PO
PO 6
1,000-1,250 mg/day
PO
TMP-SMX SS

PO
tablet 2 PO

Itraconazole capsule 400 mg/day

2 14-21
Itraconazole oral solution 400
mg/day 2
14-21
Amphotericin B 0.3-0.5
mg/kg/day IV 14-21
Cervicovaginal Clotrimazole vaginal cream
Miconazole cream 5 mg/day
candidiasis
5 mg/day Clotrimazole
miconazole vaginal
vaginal suppository tablet 100 suppository tablet 100 mg
mg 3-7 7

Itraconazole capsule 200

Fluconazole 200 mg Po mg/day PO 3
Itraconazole oral solution 200
mg/day PO 3

186
187

MAC

CMV

Ganciclovir 5
mg/kg IV

Ganciclovir
intravitreous
2,000 g 1
2-4

Ganciclovir 5 mg/kg 12 . Ganciclovir intravitreous 2,000 Valganciclovir

IV 2-3
g/dose 1
900 mg
Valganciclovir 900 mg PO
PO
2 2-3 Ganciclovir implant 4.5
mg
6-8
( retinitis)
Clarithromycin 500 mg PO
Azithromycin 500 mg PO
2 + ethambutol 15
+ ethambutol 15 mg/
mg/kg/day
kg/day

Itraconazole 200 mg PO
Itraconazole 200 Fluconazole 400
3 3
mg PO
mg PO
200 mg 2

14
Amphotericin B
0.6-0.7
Consolidation phase
mg/kg/day
Itraconazole 200 mg PO Amphotericin B 0.4-0.5
IV
2 10-12
mg/kg/day IV
10-12
Fluconazole 800 mg PO
10-12

Penicilliosis/ Induction phase

Histoplasmosis Amphotericin B
0.6-0.7 mg/kg/day IV

188

Quinolones:
ciprofloxacin 500-750 mg
PO 2
levofloxacin 500 mg
PO
moxifloxacin 400 mg
PO
amikacin 15 mg/kg IV IM

189

190
191

(secondary prophylaxis)

Rifampin 10-20 mg/kg/dose ( 600 mg)

2 6-9

miliary 12
PI continuation phase
rifampicin quinolones pyrazinamide
ethambutol 12-18
prednisolone 2 mg/kg/day ( 60 mg) 4-6
miliary
endobronchial TB
Drug-resistant TB ()
3-6
18-24

Tuberculosis Drug-susceptible TB
Second-line drug
Intensive phase
Amikacin 15 mg/kg/dose ( 1,000 mg)
INH 10-15 mg/kg/dose ( 300 mg)


Kanamycin 15 mg/kg/dose ( 1,000 mg)
Rifampicin 10-20 mg/kg/dose ( 600 mg)


Ofloxacin 15-20 mg/kg/dose ( 800 mg)
Pyrazinamide 30-40 mg/kg/dose ( 2,000 mg)
Levofloxacin 7.5-10 mg/kg/dose

( 750 mg)
Ethambutol 15-20 mg/kg/dose ( 1,000 mg)
Ethionamide 15-20 mg/kg/day ( 1,000 mg)

2-3
PI
Cycloserine 10-20 mg/kg/day ( 1,000 mg)
rifampicin quinolones aminoglycoside
1-2
Continuation phase
Para-aminosalicylic acid 200-300 mg/ kg/day
INH 10-15 mg/kg/dose ( 300 mg)
( 10 g) 3-4

192
193

PCP

(secondary prophylaxis)

(secondary prophylaxis)

corticosteroids
PaO2 70 mmHg room air alveolar- arterial (A-a) gradient 35 mmHg
72 prednisone 1 mg/kg/dose 2 1-5
0.51 mg/kg/dose 2 6-10 0.5 mg/kg/dose
11-21 methylprednisolone 1 mg/kg/dose 6
1-7 1 mg/kg/dose 2 8-9 0.5 mg/kg/dose
2 10-11 1 mg/kg/dose
1216
TMP-SMX rapid desensitization

TMP 5 mg/kg Dapsone

TMP-SMX TMP 15-20 Pentamidine isethionate 4
150
2 mg/kg
mg/kg/day SMX 75-100
mg/kg/day
2
mg/m /day

mg/kg/day
60-90
SMX

750 mg/m2/day ( 100 mg)

dapsone 2
mg/kg/day
( TMP 320 4 mg/kg

mg SMX

1 . atovaquone 30-40
1,600 mg)

4 21 mg/kg/day
1-2
1-2
( 200 mg)

3
21

secondary prophylaxis

194
195

(secondary prophylaxis)

Fluconazole
Itraconazole
6 mg/kg
5 mg/kg
( 200 mg) ( 200 mg)

(secondary prophylaxis)

Candidiasis
Oropharyngeal Clotrimazole troches 10 mg Itraconazole ( Fluconazole 3-6 Itraconazole
candidiasis
4-5 Nystatin 46 ) 2.5
mg/kg (
5 mg/kg
mL 4-5
mg/kg/dose 200 mg)
( 200 mg)
fluconazole 612 mg/kg/dose 2 ketoconazole 5-10
( 400 mg)
mg/kg/day


7-14
1-2

Esophageal Fluconazole 6-12 mg/kg/dose Amphotericin B 0.3 0.7

candidiasis
( 600 mg)
mg/kg/dose
itraconazole 2.5
mg/kg/dose 2
3

Cryptococcosis
Localized
Fluconazole 12 mg/kg/dose 6-12
disease,
mg/kg/dose ( 600 mg)
isolated

pulmonary

disease
CNS disease, Induction therapy:
Disseminated Amphotericin B 1-1.5 mg/kg/dose
fluconazole 12 mg/kg/dose
10-12 mg/kg/dose ( 800 mg)
14
Consolidation therapy
Fluconazole 12 mg/kg/dose 10-12
mg/kg/dose ( 800 mg)
8
secondary prophylaxis

196
197

(secondary prophylaxis)

Acquired
Pyrimethamine 2 mg/kg/dose ( 50 mg)
CNS ocular
3 1
systemic mg/kg/dose ( 25 mg)
toxoplasmosis sulfadiazine 25-50 mg/kg/dose ( 1-1.5
g/dose) 4 folinic acid
10-25 mg/day
6

dexamethasone CSF
protein ( > 1,000 mg/dL)
( pyrimethamine
CBC )

(secondary prophylaxis)

TMP 5 mg/kg
150
mg/m2/day
SMX 750
mg/m2/day (
TMP 320
mg SMX
1,600 mg)
1-2

Toxoplasmosis
Congenital Pyrimethamine 2 mg/kg/dose sulfadiazine
Sulfadiazine
Clindamycin
toxoplasmosis 2 clindamycin 5-7.5 85 -120 mg/kg/day 20-30 mg/kg/day

1 mg/kg/dose
mg/kg/dose ( 600
2-4 4
2-6 mg/dose)



4


1 mg/kg/dose 3
pyrimethamine folinic
pyrimethamine
pyrimethamine
sulfadiazine acid
1 mg/kg 15 1 mg/kg
50 mg/kg/dose TMP 5-10 mg/kg/day
mg/m2 ( 25
2 folinic acid SMX 25-50 mg/kg/day mg)
folinic
10 mg/day

acid 5 mg
pyrimethamine 2
folinic acid 5 mg
12

3
3

198
199

Amphotericin B 0.7
mg/kg/dose
2 (
)
itraconazole 10 mg/kg/day
2 10

(secondary prophylaxis)

Ganciclovir 5
mg/kg/dose

57

(secondary prophylaxis)

Itraconazole
Fluconazole 6
5 mg/kg
mg/kg
( 200 mg)

(MAC) (
severe
disseminated
disease)

2
ethambutol 15-25 mg/kg/dose
( 2,500 mg)

1

Mycobacterium Clarithromycin 7.5-15

Azithromycin 10-12

avium complex
mg/kg/dose ( 500 mg/dose) mg/kg/dose ( 500 mg)

clarithromycin

Disseminated Ganciclovir 5 mg/kg/dose

CMV or CMV 12 .
retinitis
2-3
5 mg/kg/dose
57
secondary prophylaxis

Cytomegalovirus
(CMV)
Congenital Ganciclovir 6 mg/kg/dose
CMV
12 .
6

Penicilliosis

200
201

(secondary prophylaxis)

CMV retinitis

Penicilliosis/
Histoplasmosis
MAC

CD4 200 cells/mm3 3

CD4 200 cells/mm3 6
secondary prophylaxis 1
CD4 100 cells/mm3 3
CD4 100 ( penicilliosis) 150
CD4 100 ( penicilliosis) 150
( histoplasmosis) cells/mm3 6 ( histoplasmosis) cells/mm3 6
CD4 100 cells/mm3 3 *
MAC 12
CD4 100 cells/mm3 6

CMV retinitis 3-6

CD4 100 cells/mm3 3-6

PCP
CD4 200 cells/mm3 3
Toxoplasmosis CD4 200 cells/mm3 3
Cryptococcosis CD4 100 cells/mm3 3 *

3 CD4

Disseminated
diseases
quinolone ciprofloxacin
10-15 mg/kg/dose ( 1,500
mg)
2
levofloxacin 500 mg

amikacin 15-30 mg/kg/dose
( 1,500 mg)

202
203

< 1 :
1-5 : CD4 500 cells/mm3 15%
3
6 : CD4 200 cells/mm3
3
6
< 1 :
1 - < 6 : CD4 15% 3
6 : CD4 200 cells/mm3
3
6

MAC

Penicilliosis/
Histoplasmosis

< 1 :
1 - < 6 : CD4 15% 6
6 : CD4 200 cells/mm3 6
6 TE

< 1:
1-5 : CD4 500 cells/mm3 15% 3
6 : CD4 200 cells/mm3 3
( primary prophylaxis)

6 CD4 100 cells/mm3 undetectable

viral load - 3
12

6 itraconazole 1
CD4 100 cells/mm3 penicilliosis ( 150 cells/mm3
histoplasmosis) 6
< 2 :
< 2 :
3
2-5 : CD4 200 cells/mm 3 2-5 : CD4 200 cells/mm3 6
> 6 : CD4 100 cells/mm3 3 > 6 : CD4 100 cells/mm3 6
6
6
MAC 1

Cryptococcosis

Toxoplasmosis

PCP

4 CD4

204

CMV

*** retinitis 3 - 6
relapse immune restoration uveitis

< 1 :
1-5 : CD4 15% 6
6 : CD4 100 cells/mm3 6
6

205

(Post-Exposure Prophylaxis PEP)

PEP 2
- Occupational PEP (oPEP)

( )
( )
( )

206

207

- Non-occupational PEP (nPEP)

body uids

body uids

70%
alcohol betadine
solution
5% chlorhexidinegluconate

body uids

0.9% NSS

0.9% NSS

anti-HIV
24 .

source anti-HIV
source

source
anti-HIV -ve

source
HIV
source

source
anti-HIV +ve

HIV

oPEP

208

body uids

source

HIV
body uids

HIV
209

oPEP

210
211

HIV-PCR or viral load

HBsAg
Anti-HBs
Anti-HCV
P

Baseline

- anti-HIV source known HIV+ve case

- source HCV infection delay seroconversion anti-HIV
12
- anti-HIV source oPEP
oPEP
2
anti-HIV HIV-PCR viral load acute HIV infection

3

4
acute hepatitis B infection
5
3 6 source HBV / HCV infection
6

1

Anti-HIV (rapid test)1

CBC, Cr, SGPT

Source

1 oPEP oPEP

212
213

HIV nPEP HIV

2.2

2.3
2.4

3. nPEP (
)

( lancet )

HIV nPEP HIV

1. nPEP

/

2. 1.
nPEP

HIV
nPEP

2.1 HIV HIV

> 1,500 copies/mL

2 nPEP

214
215

P
4
P
3
P
5
P
-

P
P
-

P
P
-

Baseline

P
-

P
9
P

P
-

P
-

identify source anti-HIV, VDRL RPR

anti-HIV source nPEP
nPEP
2
anti-HIV 12 source HCV infection delay seroconversion
3
anti-HIV HIV-PCR viral load acute HIV infection

4

5
acute hepatitis B infection
6
3 6 source HBV / HCV infection
7

8
VDRL RPR
9

1

Anti-HIV (rapid test)

CBC, Cr, SGPT
HIV-PCR or viral load
HBsAg
Anti-HBs
Anti-HCV
VDRL or RPR
Pregnancy test
(for child-bearing age female)

3 nPEP nPEP

216
217

Cr clearance < 60 mL/min

AZT 300 mg BID TDF A B

* 3
** source patient

drug-resistant HIV

EFV ergotamine cafergot

TDF 300 mg + 3TC 300 mg OD + Raltegravir 400mg BID

EFV 600 mg OD
TDF 300 mg + FTC 200 mg OD

TDF 300 mg + 3TC 300 mg OD + Rilpivirine 25 mg OD

boosted PI ATV/r LPV/r

/
ergotamine cafergot
TDF 300 mg + FTC 200 mg OD ATV/r 300/100 mg OD
/
LPV/r 400/100 mg BID

**

oPEP nPEP
source
source known HIV +ve case
source VL resistance
testing ()
source VL detectable VL
source NNRTI-based regimen TDF
+ 3TC FTC + boosted PI source PI-based
regimen NNRTI resistance
TDF + 3TC FTC + raltegravir ( 4)
source undetectable VL
source 4
4 oPEP* nPEP

oPEP nPEP



1-2 72
( 72

) 28

(Pre-Exposure Prophylaxis PrEP)

(Pre-Exposure
Prophylaxis PrEP)
44% 49%
62-75%

PrEP
92%
PrEP
PrEP


218

5
PrEP

PrEP

o Sero-negative partner serodiscordant couples
VL

o post-exposure prophylaxis

o
o
o
3
o

219

 6 PrEP
PrEP

anti-HIV
acute HIV infection
nucleic acid testing
anti-HIV

Cr Cr clearance
calculated Cr clearance
60 mL/min (Cockroft-Gault formula)
HBV
HBsAg anti-HBs
HBV

urine pregnancy test
PrEP

PrEP PrEP FTC/TDF

200/300mg 1
PrEP
3

PrEP

220

PrEP

Methadone Maintenance Treatment (MMT)
anti-HIV 2-3


Cr 3
6
urine pregnancy test

PrEP
PrEP

anti-HIV PrEP

PrEP
anti-HIV
active hepatitis B
PrEP hepatitis B

221


(Male circumcision)

51-60

HSV-2 HPV

222

o


Grams stain, Wet Smear nucleic acid
amplification test
o

223

224

225

226

227

228

229

230

231

232

233

234

235

236

237

238

239

240