ACQUIRED IMMUNODEFICIENCY

SYNDROME (AIDS)
ANUNYA ITU DIGUNAKAN SEMBARANGAN

Etiology:
Human Immunodeficiency Virus
(HIV) Infection
 Clinical findings (1)
• Systemic complaints/ Symptoms
– Many individuals with HIV infection remain
asymptomatic for years without antiretroviral therapy
(ART/ARV)  approximate 10 years between
exposure of HIV and developmen of AIDS
– A combination of complains base on opportunistic
infections
• Fever  persistent fever
• Night sweats
• Weight loss
• Anorexia nausea  vomiting
• Diarrhea
 Clinical findings (2)
• Signs
– Physical examination may be entirely normal
– Abnormal findings range from completely
nonspesific to highly spesific for HIV infection
• Hairy leukoplakia of the tongue
• Disseminated Kaposi’s sarcoma
• Cutaneous bacillary angiomatosis
• Oral candidiasis
– Opportunistic infections
Wasting syndrome
Oral Hairy Leukoplakia
Bacillary Angiomatous
 Clinical findings (3)
– 1. Sinopulmonary disease
• Pneumocystic carinii pneumonia
• Other infectious pulmonary diseases/ KP
• Noninfectious pulmonary diseases  Kaposi’s
sarcoma
• Sinusitis
– 2. Central nervous system disease …
 Clinical findings (4)

– 2. Central nervous system disease

• Toxoplasmosis
• Central nervous system lymphoma
• AIDS dementia complex
• Cryptococcal meningitis
• HIV myelopathy
• Progressive multifocal leukoencephalopathy (PML)
 Clinical findings (5)

– 3. Peripheral nervous system

– 4. Rheumatologic manifestation
– 5. Myopathy
– 6. Retinitis
– 7. Oral lesions
– 8. Gastrointestinal manifestations …
 Clinical findings (6)
– 8. Gastrointestinal manifestations …
• Oral candidiasis
• Candidal esophagitis
• Hepatic disease  neoplasma & infection
• Biliary disease  cholecystitis
• Enterocolitis  diare
– 9. Endocrinologic manifestation 
hypogonadism
– 10. Skin manifestations …
INFEKSI OPORTUNISTIK
 Clinical findings (7)

– 10. Skin manifestations …

• Herpes simplex infections
• Herpes zozter
• Molluscum contagiosum
• Staphylococcus infections
• Bacillary angiomatosis
• Fungal rashes
• Seborreic dermatitis
• Xerosis
• Psoriasis
• PPE (Pruritic Papular Eruption)
– 11. HIV-related malignancies …
 Clinical findings (8)

– 11. HIV-related malignancies …

• Kaposi’s sarcoma
• Non-Hodgkin’s lymphoma
• Anal dysplasia & squamous cell carcinoma
• Cervical dysplasia & neoplasia
– 12. Gynecologic manifestations
– 13. Inflammatory reactions (immune
reconstitution syndrome = IRIS)
 Treatment
There are 5 catagories:
A. Supportive therapy
B. Opportunistic infections & malignancies
C. Prophylaxis of opportunistic infections
D. Antiretroviral treatment (ARV/ART)
E. Hematopoietic stimulating factors recormon?
 A. Supportive therapy
1. Sympthomatic
2. Fluid and electrolite
3. Anti depressant
 B. Therapy for Opportunistic infections &
malignancies (1)
INFECTION OR TREATMENT
MALIGNANCY
Pneumocystic infection
(PCP)

Mycobactrium avium Clarithromycin + ethambutol

complex infection (MAC) Rifabutin
Toxoplasmosis Pyrimethamin + sulfadiazine + folic acid 
Pyrimethamin + klindamisin + folic acid
Lymphoma Combination chemotherapy
Cryptococcus meningitis Amphotricin B
Fluconazole
 B. Therapy for Opportunistic infections &
malignancies (2)
INFECTION OR MALIGNANCY TREATMENT
Cytomegalovirus (CMV) infection - Valgaciclovir Valcyte 1x1 tab let (450
mg)
- Ganciclovir Cymevene IV  5 mg/kg
2x sehari
- Foscamet
Candidiasis: esophageal, vaginal Fluconazole
Herpes simplex infection - Acyclovir
- Famciclovir
- Valacyclovir
- Foscamet
Herpes zoster - Acyclovir - Famciclovir
- Falaciclovir - Foscamet
Kaposi’s sarcoma: - Observasion, intralesional vimblastine
- Cutaneous - Systemic chemotherapy
- Extensive/aggressive cutaneous - Combination chemotherapy
disease
 C. Prophylaxis of opportunistic infections
OI Primary prophylaxix Secondary prophylaxix
Pneumocystis carinii Cotrimoxazole, pentamidin,
dapson, atovaquone
Kaposis’s sarcoma
Oesophagyal Fluconazole, Itraconazole,
candidiasis Voriconazole
Mycobacterium Azithromycin, Azithromycin, Clariromycin,
avium complex (MAC) Clariromycin, Rifabutin minus Rifabutin
Mycobacterium Isoniazid for 9-12 months
tuberculosis or rifabutin+ pyrazinamide ???
for 2 months
Toxoplasmosis Cotrimoxazole, Dapsone 50 Sulfasiazine 2 g +
mg+ pyrimethamine 50-100 pyrimethamine 25 mg or
mg clindamycin 1.2 g+
pyrimethamine 25 mg
Cryptococcosis Fluconazole 100-200 mg Fluconazole 200-400 mg
Cryptosporidiosis Clarithromycin, rifabutin
Cytomegalovirus Convenience, gansciclovir
Microsporidiosis Albendazole
 MANAGEMENT OF OPPORTUNISTIC INFECTIONS (1)
OI MANAGEMENT
Pneumocystis carinii Cotrimoxazole, dose is depend on the
degree of severity of diseases,
pentamidine, clindamycin + primaquine

Kaposis’s sarcoma ART will lead to quiescence of KS

Oesophagyal candidiasis Fluconazole 100-200 mg/daily;
itraconazole 200 mg; amphotericine B
(0.3-0.5 mg/kg/daily; voriconazole 2 x
200 mg
Mycobacterium avium complex Clarithromycin 2 x 500 mg/daily;
(MAC) etambuthol 15 mg/kg/day ± rifabutin 300
mg/daily; azithromycin 450 mg/daily;
ciprofloxacin
Mycobacterium tuberculosis Rifampicin/rifabutin+isoniazid+pyrazina
mide+ethambutol (with pyridoxin) for 9-
12 months
 MANAGEMENT OF OPPORTUNISTIC INFECTIONS (2)

Toxoplasmosis Sulfadiazin 4-6 g/day or clindamycin 4x600

mg/day + pyrimethamine 100-200 mg  50-75
mg/daily
Cryptococcosis Amphotericine B (0.5-0.8 mg/kg/day ±
flucytosine 14 days  fluconazole 400 mg/ daily
for 8-10 weeks
Cryptosporidiosis There is no therapeutic agent

Cytomegalovirus Valganciclovir, iv ganciclovir, foscarnet,

cidofovir
Microsporidiosis Albendazole 2 x 400 mg
 Natural History HIV

Viral Load

Window period
Source of Infection uninfectious
All blood product tears
Vaginal discharge feces
Semen  man urine
Pericardial fluid saliva
Pleural fluid nose secrettion
Cerebrospinal fluid sputum
Amnion fluid  birth vomit
Peritoneal fluid sweat
Sinovial fluid Clothes CAKAR
Breast-feed kitchenware
 D. Antiretroviral treatment

ANTIRETROVIRAL(ARV) DRUGS
1. Nucleoside reverse transcriptase inhibitors
(NRTI)
2. Nonnucleoside reverse transcriptase
inhibitors (NNRTIs)
3. Nucleotide reverse transcriptase inhibitors
4. Protease inhibitors (PIs)
5. Entry inhibitor
 1. Nucleoside reverse transcriptase inhibitors
(NRTI)
DRUGS DOSE SIDE EFFECTS

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

,headache,insomnia,myopathy
Didanosine (ddI) 400 mg/daily PN, pancreatitis, dry mouth,
hepatitis
Zalcitabine (ddC) 3 x 0375-0.75 PN, aphthous ulcers, hepatitis,
mg/daily pancreatitis
Stavudine (d4T) 2 x 40 mg/daily PN, hepatitis, pancreatitis

Lamivudine 2 x 150 mg Rash, PN

(3TC)
Emtricitabine 1 x 300 mg/daily Skin discoloration /soles (mild)

Abacavir (ABC) 2 x 300 mg/daily Rash, fever if occur may be fatal

PN: pheripheral neuropathy

 2. Nonnucleoside reverse transcriptase
inhibitors (NNRTIs)
DRUGS DOSE SIDE EFFECTS
Nevirapine 200 mg/daily for 2 Rash
(Viramune) weeks, then 2 x
200 mg/daily

Delavirdine 3 x 400 mg/daily Rash ???

(Rescriptor)

Efavirenz (Sustiva) 600 mg/ daily Neurologic

disturbances
3. Nucleotide reverse transcriptase inhibitors

DRUG DOSE SIDE EFFECTS

Tenofovir (TDF) 1 x 300 mg/daily Gastrointestinal distress

 4. Protease inhibitors (PIs) VIR
DRUGS DOSE SIDE EFFECTS
Saquinavir hard gel 2 x 1000 mg+2x100 mg Rironavir Gastrointestinal
(Invirase) orallly /daily distress
Saquinavir soft gel 3 x 1200 mg/daily Gastrointestinal
(Fortovase) distress
Ritonavir (Norvir) 2 x 600 mg or 1-2 x 100 mg/dailt fot Gastrointestinal
boosting pther PIs distress, PN
Indinavir (Crixivan) 3 x 800 mg Kidney stones

Nelvinavir (Viracept) 3 x 750 mg/daly Diarrhea

Amprenavir (Agenerase) 2 x 1200 mg Gastrointeratinal,

rash
Fosamprenavir (Lexiva) 2 x 1400 mg or 1 x 1400 mg + Same as
ritonavir 1x 200 mg/daily amprenavir
Lopinavir/ ritonavir 400 mg/ 2 x 100 mg/daily Diarrhea
(Kaletra)
Atazanavir (Reyatas) 1 x 400 mg Hyperbilirubinemia
 5. Entry inhibitor
DRUGS DOSE SITE EFFECTS
Enfuvirtide 2 x 90 mg subcutaneous/ Injection site pain
(Fuzeon) daily & allergic reaction
 1st and 2nd line ARV Drugs

1st Line 2nd line

Start Substitute Switch Salvage

DUVIRAL

AZT, d4T, ddI,

3TC, NVP ABC,
EFV TDF PI/r
Frequently
Recommended as 2nd
Recommended 1st Line
line drugs, but also as
ARV Drugs Recommended as 2nd Line
alternative drugs in 1st
line regimens Drugs
30

25

20 No therapy Monotherapy

Dual therapy
15 0 2
1

10

Triple therapy
5 3

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
 1st LINE ARV FORMULARY

d4T NVP

X 3TC

AZT EFZ

1 2 3
 Switching to
second line drugs in Indonesia

LPV/r

TDF ddI

 10 x more expensive than first line

 Renal toxicity, metabolic complications
 More drug interactions
 Available drugs and dosage
ARV Drug PACK DOSAGE
Tenofovir 300 mg/tab 300 mg / day
(TDF)

Didanosine 100 mg/ tab 400 mg / day (250 mg / day if <60 kg)
(ddI) (250 mg / day if w TDF)

Lopinavir/rito 133.3/33.3 400 mg/100 mg /12 hrs , (533 mg/133

navir (LPV/r) mg/cap mg /12 hrs if combine w EFV or NVP)
 Time to Start ARV Therapy
Condition Treatment
CD4 < 200 Start anti TB therapy.
ARV after anti TB is tolerated (2-8 weeks)

CD4 200- Start anti TB therapy.

350 ARV after anti TB finished vs after tolerance

CD4 > 350 Start anti TB until finish

delayed ARV, CD4 monitor

There is no Start anti TB

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

Recommended regimen: AZT/d4T+3TC+EFV

WHO, 2003
 E. Hematopoietic stimulating factors

• Erythropoietin (Epoetin alfa):

– HIV infected patients with anemia
– Anemia secondary to zidovudine use 
trans?
• Human G-CSF (filgrastim) and granulocyte
– macrophage colony-stimulating factor
(GM-CSF [sargramostim]) to increase the
neutrophil counts of HIV-infected patients
 To slow AIDS wasting
– Fever control  antipyretic drugs
– Food supplementation with hight-caloric drinks
– Total parentral nutrition (NTN)
– Progestational agent: megestrol acetate
– Antiemetic agent: dromabinol  marjuana
– Growth hormone
– Anabolic steroid testosteron for 2-4 weeks
– Nausea  weight loss  metoclopramide,
dromabinol
– Antideppresant
 Prognosis
• With improvements in therapy, patients are living
longer after the diagnosis of AIDS. This has
resulted in dramatic decreases in AIDS deaths.
Despite new therapeutic options, people
continue to die from HIV infection.
• Depend on:
– The stage of HIV/AIDS (I, II, III, IV)
– The Adherence of ARV
– The number of CD4 count
 Myelomeningocele in efavirenz-
exposed newborn

Fundaro et al. AIDS 2002; 16:299–300

SJS  AZT/Zidovudin
Steven Johnson Syndrome (SJS)
SJS
Steven Johnson syndrome
Hypersensitivity reaction- severe
NEVIRAPINE
Hypersensitivity reaction- severe
NEVIRAPINE
Hypersensitivity reaction- severe
NEVIRAPINE
Lipodystrophy
d4T atau PI

Peripheral fat loss

Lipodystrophy
Fat accumulation
central obesity

d4T atau PI
Buffalo hump fat accumulation as part of
lipodystrophy
KUKU BERWARNA UNGU PASCA TERAPI ARV