Question

medical management of HIV?

Answer 1

HIV

• It is an RNA virus belong to the family Retroviredae.
• Human Immunodeficiency Virus comprises of two viruses HIV1 and HIV2.
• It causes Acquired Immune Deficiency Syndrome.(AIDS)

MODE OF TRANSMISSION

•Unprotected sexual contact with an infected partner

•Exposure of broken skin or wound to infected blood or body fluids

•Transfusion with HIV-infected blood

•Injection with contaminated objects

•Mother to child during pregnancy, birth or breastfeeding

Medical Mangemnt Of HIV

1.Antiretroviral therapy

Goals of therapy

• Improve quality of life
• Reduce HIV-related morbidity and mortality
• Restore and/or preserve immunologic function
• Maximally and durably suppress HIV viral load
• Prevent HIV transmission

Factors to be considered before taking antiretro viral therapy

• Confirm HIV results
• Complete History collection and PE
• CBC, chemistry profile
• CD4 cell count
• Plasma HIV RNA measurement
• Consider resistance testing
• Assess “readiness” for treatment and adherence
• Additional Tests like, RPR or VDRL , PPD , Chest X ray , Hepatitis A,B,C serology , Toxoplasma IgG , Fasting glucose and lipids , Gynecologic tests with pap smear , Testing for chlamydia and gonorrhea , Ophthalmology check up (CD4+ T cell count <100 cells/µL) also should be performed prior.

Guidelines for when to start ART

• Potent ART may improve and preserve immunefunction in most patients with virologic suppression, regardless of baseline CD4 count
• ART indicated for all with low CD4 count or symptoms
• Earlier ART may result in better immunologic responsesand better clinical outcomes

1. Reduction in AIDS- and non-AIDS-associated morbidity and mortality
2. Reduction in HIV-associated inflammation and associated complications
3. Reduction in HIV transmission

• Recommended ARV combinations are considered to bedurable and tolerable
• Exact CD4 count at which to initiate therapy not known, but evidence points to starting at higher counts
• Current recommendation: ART for all patients with CD4 <500 cells/µL
• For patients with CD4 >500 cells/µL, 50% of the panel recommend ART, 50% consider ART to be optional

Mechanism of action of anti retro viral agents

1. Entry Inhibitors:

- Prevent HIV from entering healthy T cells in the body

- enfuvirtide(Fuzeon)

2.Reverse Transcriptase Inhibitors

i. Nucleoside reverse transcriptase inhibitors

 (NsRTIs)Incorporate into viral DNA terminating its construction E.g. Lamivudine - Abacavir

ii. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI’s)

 Action is similar to NRTI’s; bind directly to reverse transcriptase , E.g. Nevirapine

3. Reverse Transcriptase Inhibitors

iii. Nucleotide Reverse Transctriptase Inhibitors (NtRTI’s) , E.g. Tenofovir

4. Protease Inhibitors (PI’s)

• Prevent assembly & release of new virus particles , E.g Ritonavir - Saquinavir

5.  Integrase inhibitors

 work by disabling a protein called integrase, which HIV uses to insert its genetic material into CD4 T cells. , E.g raltegravir

Antiretroviral Agents Regimen

All recommended regimens for initial treatment contain an NNRTI, a ritonavir-boosted PI, or an INSTI in combination with tenofovir (NtRTI) and emtricitabine (NRTI).

The preferred agents are as follows:

1. NRTI/NtRTI combination: Tenofovir and emtricitabine

2. PIs: Atazanavir/ritonavir

3. NNRTI: Efavirenz

4. INSTI: Raltegravir

Evaluation of treatment

 Criteria

• HIV RNA (viral load) in blood
• Count of T cells
• Appropriate clinical response

 Treatment Failure

• viral load with low T-cell count
• Clinical deterioration
• New opportunistic infections

ARV treatment in pregnant women

•Follow the treatment guidelines as for non-pregnant adults except that EFV should not be given in the first trimester

•First-line regimens:

-ZDV + 3TC + NVP

-d4T + 3TC + NVP

•Consider delaying initiating ARV treatment until after the first trimester, although for severely ill women the benefits of initiating treatment early clearly outweigh the potential risks

ARV treatment in Infants

•ZDV for one week or

•single-dose NVP or

•single-dose NVP plus ZDV for one week

TREATMENT FOR HIV ASSOCIATED GINGIVITIS (HIV-G) AND HIV ASSOCIATED PERIODONTITIS (HIV-P)

• Gingival and periodontal diseases (NUG&NUP) - first sign of HIV infection.
• Gingivitis in HIV infected children appears as an intensely erythematous band that extends 2 to 3 mm apically from the free marginal and attached gingiva.
• Treatment
• Aggressive curettage , Peridex (0.12 %chlorhexidine digluconate) rinses 3 times daily , Antibiotic treatment
• In cae of periodntitis , Drugs like Zidovudine can be given but usually used.
• For oral ulcers,
• Fluconamide ointment (0.5%) , Orabase 3-6 times/day , Dexamethasone 0.5 mg/ml are used as modalities of tratment

PREVENTION OF HIV

• The various approaches are:

 If a pregnant lady on testing proves that the foetus is also HIV positive, she should be allowed to medically terminate pregnancy

• Blood and blood products to be screened for any contamination
• Needles should not be re-used
• Educating & creating awareness among the population
• Safe sex

 In dentistry there is a little scope of HIV transmission but precautions should be taken like:

1. Proper medical history of the patient

2. Proper sterilization

3. Barrier techniques like: i. Eye protection in terms of eye glasses ii. Mouth mask iii. Disposable needles iv. Gloves (double) v. Change of clothes