» Home » CAD » Infectious Disease » Sexually Transmitted Infections(STI) » Human Immunodeficiency Virus (HIV)
ADVERTISEMENT
ADVERTISEMENT
» Home » CAD » Infectious Disease » Sexually Transmitted Infections(STI) » Human Immunodeficiency Virus (HIV)
Background
Human Immunodeficiency Virus (HIV) is a virus that attacks the body’s immune system, specifically the CD4 cells, which help the body fight off infections. When HIV is left untreated, it can lead to acquired immunodeficiency syndrome (AIDS).
AIDS is a serious condition that debilitates the immune system and leaves the body vulnerable to life-threatening infections and cancers. HIV is primarily spread through sexual contact but can also be transmitted through blood transfusions, sharing needles, or from mother to child during pregnancy, childbirth, or breastfeeding.
Symptoms of HIV may include fever, sore throat, swollen lymph glands, and a rash, but many people infected with the virus may not have any symptoms. Many individuals are unaware they have the virus for several years after becoming infected. There is currently no cure for HIV.
Epidemiology
The epidemiology of HIV has changed significantly over the past few decades. Since the first cases of AIDS were reported in the early 1980s, the virus has become a global concern, with millions of people living with HIV. As of 2020, an estimated 38 million people worldwide were living with HIV, with most cases concentrated in sub-Saharan Africa.
In this region, HIV prevalence is highest among certain populations, such as men who have sex with men, individuals using injectable drugs, and sex workers. In addition, women are more likely to be infected with HIV than men in sub-Saharan Africa, due in part to biological factors such as increased susceptibility to HIV during unprotected sex but also because of social and economic factors such as lack of education and empowerment that can increase vulnerability to HIV.
In recent years, there has been progress in HIV prevention and treatment efforts, which has led to a decline in new HIV infections and deaths due to AIDS. ART (antiretroviral therapy) has been particularly effective in reducing the mortality rate of HIV-positive individuals and the risk of HIV transmission.
Anatomy
Pathophysiology
The pathophysiology of HIV is complex and not fully understood. After HIV enters the body, it attaches to and enters CD4+ T cells, a type of white blood cell that plays a vital role in the immune system. Once inside the cell, the virus uses an enzyme called reverse transcriptase to convert its genetic material (RNA) into DNA. This viral DNA then integrates into the DNA of the host cell. Once integrated, the viral DNA can remain latent or inactive for long periods.
However, at some point, the virus will reactivate and begin replicating, producing more viral copies that infect other CD4+ T cells. As the virus replicates, it attacks and kills CD4+ T cells, leading to a decline in the number of these cells in the body. This makes it harder for the body to fight off infections, which is why people with HIV are at increased risk of developing infections and cancers that would not normally be a threat to a person with a healthy immune system. As the number of CD4+ T cells decreases, the immune system becomes increasingly compromised.
This is measured by the CD4+ T-cell count, and when the count drops below a certain threshold level (typically below 200 cells/mm3), the person is said to have developed AIDS. In addition to the direct effects of HIV on the immune system, the virus can also indirectly harm the body by increasing inflammation and triggering the activation of other immune cells, such as macrophages and monocytes, which in turn can lead to chronic immune activation and inflammation, that is associated with increased risk of other diseases such as cardiovascular diseases and cancer.
Etiology
The etiology of HIV is related to the discovery of the virus itself. HIV is a virus from the genus Lentivirus, which belongs to the Retroviridae family. It was first identified in 1983 by two separate research teams, one led by Luc Montagnier at the Pasteur Institute in Paris and the other by Robert Gallo at the National Cancer Institute in the United States.
The origins of HIV can be traced back to non-human primates in Central and West Africa, where it is thought that the virus crossed over to humans through contact with an infected chimpanzee’s blood. It is believed that the virus may have crossed over to humans as early as the early 20th century and that it slowly spread within human populations before the first cases of AIDS were reported in the early 1980s.
HIV is primarily transmitted through sexual contact but can also be transmitted through blood transfusions, sharing needles, or from mother to child during pregnancy, childbirth, or breastfeeding. The most common method of infection is through vaginal or anal intercourse without using protection or through sharing needles or other equipment for injecting drugs. It is also important to note that there are different subtypes of HIV, known as clades or strains, with different geographic distributions.
Some subtypes may be more transmissible or more likely to cause disease progression than others. Risk factors for HIV infection include unprotected sexual contact with an HIV-positive individual, having multiple sexual partners, injection drug use, and man who has sex with other men. People with a high risk of exposure to the virus, such as healthcare workers, or people living in areas where HIV is common, are also at increased risk of infection.
Genetics
Prognostic Factors
The prognosis of HIV, or the likely outcome of the infection, has improved significantly in recent years due to advances in antiretroviral therapy (ART). With proper medical care and ART, people with HIV can live long and healthy lives, even with the virus. In the past, the progression of HIV to AIDS was a virtual death sentence, as there were no effective treatments available.
However, ART is highly effective in slowing the virus’s progression. The treatment of HIV is lifelong, and it is essential that people with HIV take ART, to maintain viral suppression and keep the virus under control. However, with proper treatment, people with HIV can expect to live long and healthy lives.
Clinical History
Physical Examination
Age group
Associated comorbidity
Associated activity
Acuity of presentation
Differential Diagnoses
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
by Stage
by Modality
Chemotherapy
Radiation Therapy
Surgical Interventions
Hormone Therapy
Immunotherapy
Hyperthermia
Photodynamic Therapy
Stem Cell Transplant
Targeted Therapy
Palliative Care
Medication
500
mg
Orally
twice a day
600
mg
Orally
once a day
in combination with tenofovir and lamivudine
Discontinue therapy immediately, if moderate to severe hepatic impairment is noticed
Note: Not recommended to use in combination with abacavir and lamivudine, especially for patients receiving pre-antiretroviral therapy
For <60 kg:
125
mg
Solution
oral
twice a day
or 250 mg oral solution once a day
>60 kg: 200 mg oral solution twice a day or 400 mg oral solution once a day
25 kg to 60 kg: 250 mg oral capsule once daily
500
mg
Capsule
Orally
twice a day
in combination with ritonavir (200 mg)
1250
mg
Orally
every 12 hrs a day
or 750 mg orally every 8 hours a day
Indicated for the treatment of HIV-1 infection in patients in combination with other antiretrovirals
100mg orally every day
Indicated for HIV-associated Wasting or Cachexia:
Serostim: 0.1 mg/kg/day subcutaneously (SC) at bedtime increase up to 6 mg/day
Administer 0.1 mg/kg subcutaneously (SC) every other day if the patient is at risk of adverse effects
Alternatively:
Weight >55 kg: 6 mg/day subcutaneously (SC)
Weight 45-55 kg: 5 mg/day subcutaneously (SC)
Weight 35-45 kg: 4 mg/day subcutaneously (SC)
Weight <35 kg: 0.1 mg/kg/day subcutaneously (SC)
HIV Adipose Tissue Redistribution Syndrome
(Off-label)
Serostim: 4 mg/day subcutaneously (SC) at bedtime for 12 weeks; for maintenance following by 2-4 mg every other day for 12-24 weeks
2 recommended dosage regimens:
Dose option 1
Initiation:
Day 1: 927 mg Subcutaneous (SC) (2 x 1.5 mL) and 600 mg orally (2 x 300 mg)
Day 2: 600 mg orally (2 x 300 mg)
Maintenance:
Every six months (26 weeks), plus or minus two weeks: 927 mg Subcutaneous (SC) (2 x 1.5 mL)
Dose option 2
Initiation:
Day 1-2: 600 mg orally (2 x 300 mg) daily
Day 8: 300 mg orally (1 x 300 mg)
Day 15: 927 mg Subcutaneous (SC)
Maintenance:
Every six months (26 weeks), plus or minus two weeks: 927 mg Subcutaneous (SC)
(400/600) mg each drug once a month intramuscularly as two separate injections
Indicated in combination with other antiretroviral (ATV) medications for treating HIV-1 infection:
600mg orally twice a day
300 mg oral tablet twice a day
Or
600 mg oral tablet once a day
Note: used in combination with other antiretroviral agents
elvitegravir/cobicistat/emtricitabine/tenofovir DF
Take one tablet orally once daily with a meal
emtricitabine, rilpivirine, tenofovir DF
one tablet (200mg emtricitabine /25mg rilpivirine /300mg tenofovir DF) orally daily with a meal
Dose Adjustments
Dose Modifications
rifabutin Coadministration
Add one tablet of 25mg rilpivirine with Complera for this duration of coadministration with rifabutin
Hepatic impairment
Mild-moderate (Child-Pugh score class A or B): dose adjustment is not required
Severe (Child-Pugh score class C): Not known
Renal impairment
Mild (CrCl above 50 mL/min): dose adjustment is not required
Moderate-severe (CrCl below 50 mL/min): usually not recommended
dapivirine intravaginal (FDA Approval Pending)
Monthly once vaginal ring but FDA approval pending for prevention of human immune virus infection
Take 1 tablet orally two times a day
Dosage Modifications
Renal impairment
Moderate-to-severe: avoid use
Hepatic impairment
Mild-to-moderate: dose modification not required
Decompensated liver disease: Safety and efficacy not determined
Severe: study not performed
Indicated for HIV-1 Infection
This medication is recommended to be used along with other antiretroviral drugs for both treatment-experienced and naive patients who do not have darunavir resistance-associated mutations.
1 tablet of 800mg darunavir /150mg cobicistat orally one time a day with food.
If a patient has HIV RNA >100,000 copies/mL and a CD4 count <200 cells/mm3, they should not take raltegravir with darunavir and ritonavir. They should also avoid using raltegravir when used with abacavir and lamivudine.
Patients new to treatment:
Administer 400mg of Isentress tablets orally twice a day.
Note: Patients who first took raltegravir 400 mg twice a day and were virologically suppressed may change to taking Isentress HD once daily
Administer 1.2g daily once or 600mg Isentress HD twice daily
Note: Once-daily dose is not advised during pregnancy.
Patients with a prior medical history
Administer 400mg of Isentress tablets orally twice a day.
Non-occupational post-exposure prevention for HIV-1
Administer 400 mg twice daily for 28 days along with other antiretroviral medications. Begin treatment within 72 hours after exposure.
Occupational HIV-1 postexposure prophylaxis
Dosage modification for concurrent therapy: Serious medication interactions exist, necessitating dose/frequency modification or avoidance.
400mg of lopinavir /100mg of ritonavir orally every 2 times a day, OR
800 mg of lopinavir /200 mg of ritonavir orally every day in patients with less than 3 lopinavir resistance-associated substitutions
Coadministration with nevirapine, efavirenz, nelfinavir or fosamprenavir
500 mg of lopinavir /125 mg of ritonavir orally every 2 times a day (i.e., 2 times of 200 mg of lopinavir /50 mg of ritonavir + 100 mg of lopinavir /25 mg of ritonavir), OR capsules/oral solution: 533 mg of lopinavir /133 mg of ritonavir orally every 2 times a day (i.e., approximately 6.5 mL every 2 times a day)
Dose Adjustments
Dose Modifications
Dose adjustments during pregnancy and postpartum period
In pregnant patients who have not taken substitutions of lopinavir-associated resistance, administer 400mg of lopinavir/100 mg of ritonavir twice daily; there is not enough data to recommend dosage for pregnant patients who have documented lopinavir-associated resistance substitutions; dosage adjustment is not required for patients during the postpartum period
<16 years: Safety and efficacy are not established
>16 years: Administer 1000mg along with 100mg of ritonavir twice a day
There is no need for extra ritonavir in individuals receiving 100 mg twice daily of ritonavir as a component of their ART treatment.
Patients with no prior treatment
Initial dose-Administer 500mg orally twice a day along with 100mg of ritonavir twice a day for 7 days, then can increase the dose to 1000mg/100mg orally twice a day.
Investigation involving kids who have received therapy
≥2 years, ≥40 kg: Administer 50 mg/kg and 100mg of ritonavir orally twice daily.
≥2 years, 5 to <15 kg: Administer 50 mg/kg and 3mg of ritonavir orally twice daily.
≥2 years, 15 to 40 kg: Administer 50 mg/kg and 2.5mg of ritonavir orally twice daily.
<2 years: Safety and efficacy not established
1
Tablet (600 mg/300 mg lamivudine)
Orally
every day
emtricitabine/tenofovir DF /efavirenz
Indicated for HIV Infection
One tablet of 200 mg of emtricitabine/600 mg of efavirenz/300 mg of tenofovir DF orally every day on an empty stomach (recommended every night)
efavirenz/lamivudine/tenofovir DF
Indicated for HIV Infection
One tablet of 400 mg of efavirenz/300 mg of tenofovir DF/300 mg of lamivudine orally every night
Or
One tablet of 600 mg of efavirenz/300 mg of tenofovir DF/300 mg of lamivudine orally every night
Note: Not recommended to use in combination with abacavir and lamivudine, especially for patients receiving pre-antiretroviral therapy
Not recommended for <3 months infants
Oral Dose instructions based on weight:
10 kg to <15 kg: 200 mg/day orally
15 kg to <20 kg: 250 mg/day orally
20 kg to <25 kg: 300 mg/day orally
25 kg to 32.5 kg: 350 mg/day orally
32.5 to <40 kg: 400 mg/day orally
>40 kg: 600 mg/day orally
Discontinue therapy immediately, if moderate to severe hepatic impairment noticed
Children >2 years:
14
mg/kg
in combination with 6 mg/kg ritonavir twice a day (NMT 500 mg)
Age: 2-13 years
45-55 mg/kg orally every 12 hours a day or 25-35 mg/kg orally every 8 hours a day
Adolescents:
1250 mg orally every 12 hours a day or 750 mg orally every 8 hours a day
(400/600) mg each drug once a month intramuscularly as two separate injections
Infants >3 years to adolescents:
Dose instructions based on weight:
14 to <20kg: 150 mg orally twice daily
20 to <25 kg: 150 mg orally in the morning and 300 mg orally in the evening
>25 kg 300 mg orally every 12 hours
elvitegravir/cobicistat/emtricitabine/tenofovir DF
Age 12 years or older, with a minimum weight of 35 kg: Take one tablet orally once daily with a meal
emtricitabine, rilpivirine, tenofovir DF
Below 12 yrs: Safety & efficacy were not established
Above 12 yrs and above 35 kgs: 1 one tablet (200mg emtricitabine /25mg rilpivirine /300mg tenofovir DF) orally daily with a meal
Dose Adjustments
Dose Modifications
rifabutin Coadministration
Add one tablet of 25mg rilpivirine with Complera for this duration of coadministration with rifabutin
Hepatic impairment
Mild-moderate (Child-Pugh score class A or B): dose adjustment is not required
Severe (Child-Pugh score class C): Not known
Renal impairment
Mild (CrCl above 50 mL/min): dose adjustment is not required
Moderate-severe (CrCl below 50 mL/min): usually not recommended
emtricitabine, rilpivirine, tenofovir DF
Below 12 yrs: Safety & efficacy were not established
Above 12 yrs and above 35 kgs: 1 one tablet (200mg emtricitabine /25mg rilpivirine /300mg tenofovir DF) orally daily with a meal
Dose Adjustments
Dose Modifications
rifabutin Coadministration
Add one tablet of 25mg rilpivirine with Complera for this duration of coadministration with rifabutin
Hepatic impairment
Mild-moderate (Child-Pugh score class A or B): dose adjustment is not required
Severe (Child-Pugh score class C): Not known
Renal impairment
Mild (CrCl above 50 mL/min): dose adjustment is not required
Moderate-severe (CrCl below 50 mL/min): usually not recommended
<6 years: Safety and efficacy not determined
≥6 years and weight more than and equal to 30 kg: take 1 tablet orally two times a day
Dosage Modifications
Renal impairment
moderate-to-severe: avoid use
Hepatic impairment
Mild-to-moderate: dose modification not required
Decompensated liver disease: Safety and efficacy not determined
Severe: study not performed
Indicated for HIV-1 Infection
This medication is prescribed in combination with other antiretroviral drugs for HIV treatment in patients who weigh at least or more than 40 kg, are treatment-naive or experienced, and do not have darunavir resistance-associated substitutions.
1 tablet of 800mg darunavir /150mg cobicistat orally one time a day with food.
Oral suspension (10 mg/mL):
Infants and Children weighing <20 kg:
Administer 6 mg/kg/dose orally twice a day. Do not exceed 100 mg/dose
Fixed dosing:
3 to <4 kg: Administer 25 mg orally twice a day.
4 to <6 kg: Administer 30 mg orally twice a day.
6 to <8 kg: Administer 40 mg orally twice a day.
8 to <11 kg: Administer 60 mg orally twice a day.
11 to <14 kg: Administer 80 mg orally twice a day.
14 to <20 kg: Administer 100 mg orally twice a day.
Chewable tablets
Children, Adolescents, and Infants weighing ≥3 kg:
Administer 6 mg/kg/dose orally twice a day. Do not exceed 300 mg/dose.
3 to <6 kg: Administer 25 mg orally twice a day.
6 to <10 kg: Administer 50 mg orally twice a day.
10 to <14 kg: Administer 75 mg orally twice a day.
14 to <20 kg: Administer 100 mg orally twice a day.
20 to <28 kg: Administer 150 mg orally twice a day.
28 to <40 kg: Administer 200 mg orally twice a day.
≥40 kg: Administer 300 mg orally twice a day.
Film-coated tablets
Isentress: Children and Adolescents ≥25 kg: Administer 400 mg orally twice daily.
Isentress HD: Children and Adolescents ≥40 kg:
Administer 1200 mg orally once a day.
Treatment-naive individuals should follow a different regimen than those who have been virologically suppressed by raltegravir 400 mg twice daily.
Non-occupational post-exposure prevention for HIV-1
Children <2 years and Infants:
Administer 6mg/kg/dose twice a day orally
Children >2 years:
11 to <14 kg: Administer 75 mg twice a day.
14 to <20 kg: Administer 100 mg twice a day.
20 to <28 kg: Administer 150 mg twice a day.
28 to <40 kg: Administer 200 mg twice a day.
≥40 kg: Administer 300 mg twice a day.
Film-coated tablets
Isentress: Children > 6 years weighing ≥25 kg: Administer 400 mg orally twice a day.
In children and teenagers, do not use a once-daily dosage (administered every 12 hours)
less than 2 weeks: Safety and efficacy have not been established
2 weeks to 6 months
oral solution: 300 mg of lopinavir /75 mg of ritonavir (LPV/r) per m² or 16 mg of lopinavir /4 mg ritonavir LPV/r per kg orally every 2 times a day
In infants aged below 6 months, do not administer efavirenz, fosamprenavir, nevirapine, or nelfinavir
Use of 300 mg of lopinavir /75 mg of ritonavir (LPV/r) per m² in infants aged below 6 months LPV trough levels were lower in children than in adults; LPV dose was evaluated and adjusted for the growth at regular intervals
Oral solution: 6 months to 18 years (not receiving the concomitant nevirapine, efavirenz, nelfinavir, or fosamprenavir)
230 mg of lopinavir /57.5 mg of ritonavir /m² per dose orally every 2 times a day, should not exceed more than 400 mg/dose of lopinavir, OR weight-based on dosing listed below
7 to less than 15 kg: 12 mg/kg/dose orally every 2 times a day based on the lopinavir component
15 to 40 kg: 10 mg/kg/dose orally every 2 times a day based on the lopinavir component; should not exceed more than 400 mg of lopinavir /100 mg of ritonavir orally every 2 times a day
Above 40 kg: As adults; 400 mg of lopinavir /100 mg orally every 2 times a day
Oral tablets: 6 months to 18 years (not receiving the concomitant nevirapine, efavirenz, nelfinavir, or fosamprenavir)
Above 15 to 25 kg or above 0.6- below 0.9 m²: 200 mg of lopinavir /50 mg of ritonavir (two 100 mg of lopinavir /25 mg of ritonavir -tab) orally every 2 times a day
Above 25 to 35 kg or above 0.9- below 1.4 m²: 300 mg of lopinavir /75 mg of ritonavir (three 100 mg of lopinavir /25 mg of ritonavir -tab) orally every 2 times a day
Above 35 kg or above 1.4 m²: 400 mg of lopinavir /100 mg of ritonavir orally every 2 times a day
6 months to 18 years (coadministered with nevirapine, efavirenz, nelfinavir, or fosamprenavir)
300 mg of lopinavir /75 mg of ritonavir (LPV/r)/m²/dose orally 2 times a day, should not exceed more than 400 mg/dose of lopinavir
FDA-approved dosage: 500 mg of lopinavir /125 mg of ritonavir LPV/r orally 2 times a day, administer as the combination of 2 tablets of 200mg of lopinavir /50 mg of ritonavir LPV/r and 1 tablet of 100 mg of lopinavir /25 mg of ritonavir LPV/r
Most NIH Panel members recommend 600 mg of lopinavir /150 mg of ritonavir LPV/r orally 2 times a day (i.e., 3 tablets of 200 mg of lopinavir /50 mg of ritonavir for ease of administration)
Determine whether the child can take the pill whole
weight <25 kg: not safe
weight >25 kg: 1 tablet orally every day
Determine whether the child can take the pill whole
weight <25 kg: not safe
weight >25 kg: 1 tablet orally every day
emtricitabine/tenofovir DF /efavirenz
Indicated for HIV Infection
Age >12 years and body weight >40 kg
One tablet of 200 mg of emtricitabine/600 mg of efavirenz/300 mg of tenofovir DF orally every day on an empty stomach
Age <12 years
Safety and efficacy not established
efavirenz/lamivudine/tenofovir DF
Indicated for HIV Infection
Symfi:
Body weight >40 kg: One tablet of 600 mg of efavirenz /300 mg of lamivudine /300 mg of tenofovir DF orally every night
Body weight <40 kg: Safety and efficacy not established
Symfi Lo:
Body weight >40 kg: One tablet of 400 mg of efavirenz /300 mg of tenofovir DF/300 mg of lamivudine orally every night
Body weight <40 kg: Safety and efficacy not established
Future Trends
References
https://www.ncbi.nlm.nih.gov/books/NBK534860/
ADVERTISEMENT
» Home » CAD » Infectious Disease » Sexually Transmitted Infections(STI) » Human Immunodeficiency Virus (HIV)
Human Immunodeficiency Virus (HIV) is a virus that attacks the body’s immune system, specifically the CD4 cells, which help the body fight off infections. When HIV is left untreated, it can lead to acquired immunodeficiency syndrome (AIDS).
AIDS is a serious condition that debilitates the immune system and leaves the body vulnerable to life-threatening infections and cancers. HIV is primarily spread through sexual contact but can also be transmitted through blood transfusions, sharing needles, or from mother to child during pregnancy, childbirth, or breastfeeding.
Symptoms of HIV may include fever, sore throat, swollen lymph glands, and a rash, but many people infected with the virus may not have any symptoms. Many individuals are unaware they have the virus for several years after becoming infected. There is currently no cure for HIV.
The epidemiology of HIV has changed significantly over the past few decades. Since the first cases of AIDS were reported in the early 1980s, the virus has become a global concern, with millions of people living with HIV. As of 2020, an estimated 38 million people worldwide were living with HIV, with most cases concentrated in sub-Saharan Africa.
In this region, HIV prevalence is highest among certain populations, such as men who have sex with men, individuals using injectable drugs, and sex workers. In addition, women are more likely to be infected with HIV than men in sub-Saharan Africa, due in part to biological factors such as increased susceptibility to HIV during unprotected sex but also because of social and economic factors such as lack of education and empowerment that can increase vulnerability to HIV.
In recent years, there has been progress in HIV prevention and treatment efforts, which has led to a decline in new HIV infections and deaths due to AIDS. ART (antiretroviral therapy) has been particularly effective in reducing the mortality rate of HIV-positive individuals and the risk of HIV transmission.
The pathophysiology of HIV is complex and not fully understood. After HIV enters the body, it attaches to and enters CD4+ T cells, a type of white blood cell that plays a vital role in the immune system. Once inside the cell, the virus uses an enzyme called reverse transcriptase to convert its genetic material (RNA) into DNA. This viral DNA then integrates into the DNA of the host cell. Once integrated, the viral DNA can remain latent or inactive for long periods.
However, at some point, the virus will reactivate and begin replicating, producing more viral copies that infect other CD4+ T cells. As the virus replicates, it attacks and kills CD4+ T cells, leading to a decline in the number of these cells in the body. This makes it harder for the body to fight off infections, which is why people with HIV are at increased risk of developing infections and cancers that would not normally be a threat to a person with a healthy immune system. As the number of CD4+ T cells decreases, the immune system becomes increasingly compromised.
This is measured by the CD4+ T-cell count, and when the count drops below a certain threshold level (typically below 200 cells/mm3), the person is said to have developed AIDS. In addition to the direct effects of HIV on the immune system, the virus can also indirectly harm the body by increasing inflammation and triggering the activation of other immune cells, such as macrophages and monocytes, which in turn can lead to chronic immune activation and inflammation, that is associated with increased risk of other diseases such as cardiovascular diseases and cancer.
The etiology of HIV is related to the discovery of the virus itself. HIV is a virus from the genus Lentivirus, which belongs to the Retroviridae family. It was first identified in 1983 by two separate research teams, one led by Luc Montagnier at the Pasteur Institute in Paris and the other by Robert Gallo at the National Cancer Institute in the United States.
The origins of HIV can be traced back to non-human primates in Central and West Africa, where it is thought that the virus crossed over to humans through contact with an infected chimpanzee’s blood. It is believed that the virus may have crossed over to humans as early as the early 20th century and that it slowly spread within human populations before the first cases of AIDS were reported in the early 1980s.
HIV is primarily transmitted through sexual contact but can also be transmitted through blood transfusions, sharing needles, or from mother to child during pregnancy, childbirth, or breastfeeding. The most common method of infection is through vaginal or anal intercourse without using protection or through sharing needles or other equipment for injecting drugs. It is also important to note that there are different subtypes of HIV, known as clades or strains, with different geographic distributions.
Some subtypes may be more transmissible or more likely to cause disease progression than others. Risk factors for HIV infection include unprotected sexual contact with an HIV-positive individual, having multiple sexual partners, injection drug use, and man who has sex with other men. People with a high risk of exposure to the virus, such as healthcare workers, or people living in areas where HIV is common, are also at increased risk of infection.
The prognosis of HIV, or the likely outcome of the infection, has improved significantly in recent years due to advances in antiretroviral therapy (ART). With proper medical care and ART, people with HIV can live long and healthy lives, even with the virus. In the past, the progression of HIV to AIDS was a virtual death sentence, as there were no effective treatments available.
However, ART is highly effective in slowing the virus’s progression. The treatment of HIV is lifelong, and it is essential that people with HIV take ART, to maintain viral suppression and keep the virus under control. However, with proper treatment, people with HIV can expect to live long and healthy lives.
500
mg
Orally
twice a day
600
mg
Orally
once a day
in combination with tenofovir and lamivudine
Discontinue therapy immediately, if moderate to severe hepatic impairment is noticed
Note: Not recommended to use in combination with abacavir and lamivudine, especially for patients receiving pre-antiretroviral therapy
For <60 kg:
125
mg
Solution
oral
twice a day
or 250 mg oral solution once a day
>60 kg: 200 mg oral solution twice a day or 400 mg oral solution once a day
25 kg to 60 kg: 250 mg oral capsule once daily
500
mg
Capsule
Orally
twice a day
in combination with ritonavir (200 mg)
1250
mg
Orally
every 12 hrs a day
or 750 mg orally every 8 hours a day
Indicated for the treatment of HIV-1 infection in patients in combination with other antiretrovirals
100mg orally every day
Indicated for HIV-associated Wasting or Cachexia:
Serostim: 0.1 mg/kg/day subcutaneously (SC) at bedtime increase up to 6 mg/day
Administer 0.1 mg/kg subcutaneously (SC) every other day if the patient is at risk of adverse effects
Alternatively:
Weight >55 kg: 6 mg/day subcutaneously (SC)
Weight 45-55 kg: 5 mg/day subcutaneously (SC)
Weight 35-45 kg: 4 mg/day subcutaneously (SC)
Weight <35 kg: 0.1 mg/kg/day subcutaneously (SC)
HIV Adipose Tissue Redistribution Syndrome
(Off-label)
Serostim: 4 mg/day subcutaneously (SC) at bedtime for 12 weeks; for maintenance following by 2-4 mg every other day for 12-24 weeks
2 recommended dosage regimens:
Dose option 1
Initiation:
Day 1: 927 mg Subcutaneous (SC) (2 x 1.5 mL) and 600 mg orally (2 x 300 mg)
Day 2: 600 mg orally (2 x 300 mg)
Maintenance:
Every six months (26 weeks), plus or minus two weeks: 927 mg Subcutaneous (SC) (2 x 1.5 mL)
Dose option 2
Initiation:
Day 1-2: 600 mg orally (2 x 300 mg) daily
Day 8: 300 mg orally (1 x 300 mg)
Day 15: 927 mg Subcutaneous (SC)
Maintenance:
Every six months (26 weeks), plus or minus two weeks: 927 mg Subcutaneous (SC)
(400/600) mg each drug once a month intramuscularly as two separate injections
Indicated in combination with other antiretroviral (ATV) medications for treating HIV-1 infection:
600mg orally twice a day
300 mg oral tablet twice a day
Or
600 mg oral tablet once a day
Note: used in combination with other antiretroviral agents
elvitegravir/cobicistat/emtricitabine/tenofovir DF
Take one tablet orally once daily with a meal
emtricitabine, rilpivirine, tenofovir DF
one tablet (200mg emtricitabine /25mg rilpivirine /300mg tenofovir DF) orally daily with a meal
Dose Adjustments
Dose Modifications
rifabutin Coadministration
Add one tablet of 25mg rilpivirine with Complera for this duration of coadministration with rifabutin
Hepatic impairment
Mild-moderate (Child-Pugh score class A or B): dose adjustment is not required
Severe (Child-Pugh score class C): Not known
Renal impairment
Mild (CrCl above 50 mL/min): dose adjustment is not required
Moderate-severe (CrCl below 50 mL/min): usually not recommended
dapivirine intravaginal (FDA Approval Pending)
Monthly once vaginal ring but FDA approval pending for prevention of human immune virus infection
Take 1 tablet orally two times a day
Dosage Modifications
Renal impairment
Moderate-to-severe: avoid use
Hepatic impairment
Mild-to-moderate: dose modification not required
Decompensated liver disease: Safety and efficacy not determined
Severe: study not performed
Indicated for HIV-1 Infection
This medication is recommended to be used along with other antiretroviral drugs for both treatment-experienced and naive patients who do not have darunavir resistance-associated mutations.
1 tablet of 800mg darunavir /150mg cobicistat orally one time a day with food.
If a patient has HIV RNA >100,000 copies/mL and a CD4 count <200 cells/mm3, they should not take raltegravir with darunavir and ritonavir. They should also avoid using raltegravir when used with abacavir and lamivudine.
Patients new to treatment:
Administer 400mg of Isentress tablets orally twice a day.
Note: Patients who first took raltegravir 400 mg twice a day and were virologically suppressed may change to taking Isentress HD once daily
Administer 1.2g daily once or 600mg Isentress HD twice daily
Note: Once-daily dose is not advised during pregnancy.
Patients with a prior medical history
Administer 400mg of Isentress tablets orally twice a day.
Non-occupational post-exposure prevention for HIV-1
Administer 400 mg twice daily for 28 days along with other antiretroviral medications. Begin treatment within 72 hours after exposure.
Occupational HIV-1 postexposure prophylaxis
Dosage modification for concurrent therapy: Serious medication interactions exist, necessitating dose/frequency modification or avoidance.
400mg of lopinavir /100mg of ritonavir orally every 2 times a day, OR
800 mg of lopinavir /200 mg of ritonavir orally every day in patients with less than 3 lopinavir resistance-associated substitutions
Coadministration with nevirapine, efavirenz, nelfinavir or fosamprenavir
500 mg of lopinavir /125 mg of ritonavir orally every 2 times a day (i.e., 2 times of 200 mg of lopinavir /50 mg of ritonavir + 100 mg of lopinavir /25 mg of ritonavir), OR capsules/oral solution: 533 mg of lopinavir /133 mg of ritonavir orally every 2 times a day (i.e., approximately 6.5 mL every 2 times a day)
Dose Adjustments
Dose Modifications
Dose adjustments during pregnancy and postpartum period
In pregnant patients who have not taken substitutions of lopinavir-associated resistance, administer 400mg of lopinavir/100 mg of ritonavir twice daily; there is not enough data to recommend dosage for pregnant patients who have documented lopinavir-associated resistance substitutions; dosage adjustment is not required for patients during the postpartum period
<16 years: Safety and efficacy are not established
>16 years: Administer 1000mg along with 100mg of ritonavir twice a day
There is no need for extra ritonavir in individuals receiving 100 mg twice daily of ritonavir as a component of their ART treatment.
Patients with no prior treatment
Initial dose-Administer 500mg orally twice a day along with 100mg of ritonavir twice a day for 7 days, then can increase the dose to 1000mg/100mg orally twice a day.
Investigation involving kids who have received therapy
≥2 years, ≥40 kg: Administer 50 mg/kg and 100mg of ritonavir orally twice daily.
≥2 years, 5 to <15 kg: Administer 50 mg/kg and 3mg of ritonavir orally twice daily.
≥2 years, 15 to 40 kg: Administer 50 mg/kg and 2.5mg of ritonavir orally twice daily.
<2 years: Safety and efficacy not established
1
Tablet (600 mg/300 mg lamivudine)
Orally
every day
emtricitabine/tenofovir DF /efavirenz
Indicated for HIV Infection
One tablet of 200 mg of emtricitabine/600 mg of efavirenz/300 mg of tenofovir DF orally every day on an empty stomach (recommended every night)
efavirenz/lamivudine/tenofovir DF
Indicated for HIV Infection
One tablet of 400 mg of efavirenz/300 mg of tenofovir DF/300 mg of lamivudine orally every night
Or
One tablet of 600 mg of efavirenz/300 mg of tenofovir DF/300 mg of lamivudine orally every night
Note: Not recommended to use in combination with abacavir and lamivudine, especially for patients receiving pre-antiretroviral therapy
Not recommended for <3 months infants
Oral Dose instructions based on weight:
10 kg to <15 kg: 200 mg/day orally
15 kg to <20 kg: 250 mg/day orally
20 kg to <25 kg: 300 mg/day orally
25 kg to 32.5 kg: 350 mg/day orally
32.5 to <40 kg: 400 mg/day orally
>40 kg: 600 mg/day orally
Discontinue therapy immediately, if moderate to severe hepatic impairment noticed
Children >2 years:
14
mg/kg
in combination with 6 mg/kg ritonavir twice a day (NMT 500 mg)
Age: 2-13 years
45-55 mg/kg orally every 12 hours a day or 25-35 mg/kg orally every 8 hours a day
Adolescents:
1250 mg orally every 12 hours a day or 750 mg orally every 8 hours a day
(400/600) mg each drug once a month intramuscularly as two separate injections
Infants >3 years to adolescents:
Dose instructions based on weight:
14 to <20kg: 150 mg orally twice daily
20 to <25 kg: 150 mg orally in the morning and 300 mg orally in the evening
>25 kg 300 mg orally every 12 hours
elvitegravir/cobicistat/emtricitabine/tenofovir DF
Age 12 years or older, with a minimum weight of 35 kg: Take one tablet orally once daily with a meal
emtricitabine, rilpivirine, tenofovir DF
Below 12 yrs: Safety & efficacy were not established
Above 12 yrs and above 35 kgs: 1 one tablet (200mg emtricitabine /25mg rilpivirine /300mg tenofovir DF) orally daily with a meal
Dose Adjustments
Dose Modifications
rifabutin Coadministration
Add one tablet of 25mg rilpivirine with Complera for this duration of coadministration with rifabutin
Hepatic impairment
Mild-moderate (Child-Pugh score class A or B): dose adjustment is not required
Severe (Child-Pugh score class C): Not known
Renal impairment
Mild (CrCl above 50 mL/min): dose adjustment is not required
Moderate-severe (CrCl below 50 mL/min): usually not recommended
emtricitabine, rilpivirine, tenofovir DF
Below 12 yrs: Safety & efficacy were not established
Above 12 yrs and above 35 kgs: 1 one tablet (200mg emtricitabine /25mg rilpivirine /300mg tenofovir DF) orally daily with a meal
Dose Adjustments
Dose Modifications
rifabutin Coadministration
Add one tablet of 25mg rilpivirine with Complera for this duration of coadministration with rifabutin
Hepatic impairment
Mild-moderate (Child-Pugh score class A or B): dose adjustment is not required
Severe (Child-Pugh score class C): Not known
Renal impairment
Mild (CrCl above 50 mL/min): dose adjustment is not required
Moderate-severe (CrCl below 50 mL/min): usually not recommended
<6 years: Safety and efficacy not determined
≥6 years and weight more than and equal to 30 kg: take 1 tablet orally two times a day
Dosage Modifications
Renal impairment
moderate-to-severe: avoid use
Hepatic impairment
Mild-to-moderate: dose modification not required
Decompensated liver disease: Safety and efficacy not determined
Severe: study not performed
Indicated for HIV-1 Infection
This medication is prescribed in combination with other antiretroviral drugs for HIV treatment in patients who weigh at least or more than 40 kg, are treatment-naive or experienced, and do not have darunavir resistance-associated substitutions.
1 tablet of 800mg darunavir /150mg cobicistat orally one time a day with food.
Oral suspension (10 mg/mL):
Infants and Children weighing <20 kg:
Administer 6 mg/kg/dose orally twice a day. Do not exceed 100 mg/dose
Fixed dosing:
3 to <4 kg: Administer 25 mg orally twice a day.
4 to <6 kg: Administer 30 mg orally twice a day.
6 to <8 kg: Administer 40 mg orally twice a day.
8 to <11 kg: Administer 60 mg orally twice a day.
11 to <14 kg: Administer 80 mg orally twice a day.
14 to <20 kg: Administer 100 mg orally twice a day.
Chewable tablets
Children, Adolescents, and Infants weighing ≥3 kg:
Administer 6 mg/kg/dose orally twice a day. Do not exceed 300 mg/dose.
3 to <6 kg: Administer 25 mg orally twice a day.
6 to <10 kg: Administer 50 mg orally twice a day.
10 to <14 kg: Administer 75 mg orally twice a day.
14 to <20 kg: Administer 100 mg orally twice a day.
20 to <28 kg: Administer 150 mg orally twice a day.
28 to <40 kg: Administer 200 mg orally twice a day.
≥40 kg: Administer 300 mg orally twice a day.
Film-coated tablets
Isentress: Children and Adolescents ≥25 kg: Administer 400 mg orally twice daily.
Isentress HD: Children and Adolescents ≥40 kg:
Administer 1200 mg orally once a day.
Treatment-naive individuals should follow a different regimen than those who have been virologically suppressed by raltegravir 400 mg twice daily.
Non-occupational post-exposure prevention for HIV-1
Children <2 years and Infants:
Administer 6mg/kg/dose twice a day orally
Children >2 years:
11 to <14 kg: Administer 75 mg twice a day.
14 to <20 kg: Administer 100 mg twice a day.
20 to <28 kg: Administer 150 mg twice a day.
28 to <40 kg: Administer 200 mg twice a day.
≥40 kg: Administer 300 mg twice a day.
Film-coated tablets
Isentress: Children > 6 years weighing ≥25 kg: Administer 400 mg orally twice a day.
In children and teenagers, do not use a once-daily dosage (administered every 12 hours)
less than 2 weeks: Safety and efficacy have not been established
2 weeks to 6 months
oral solution: 300 mg of lopinavir /75 mg of ritonavir (LPV/r) per m² or 16 mg of lopinavir /4 mg ritonavir LPV/r per kg orally every 2 times a day
In infants aged below 6 months, do not administer efavirenz, fosamprenavir, nevirapine, or nelfinavir
Use of 300 mg of lopinavir /75 mg of ritonavir (LPV/r) per m² in infants aged below 6 months LPV trough levels were lower in children than in adults; LPV dose was evaluated and adjusted for the growth at regular intervals
Oral solution: 6 months to 18 years (not receiving the concomitant nevirapine, efavirenz, nelfinavir, or fosamprenavir)
230 mg of lopinavir /57.5 mg of ritonavir /m² per dose orally every 2 times a day, should not exceed more than 400 mg/dose of lopinavir, OR weight-based on dosing listed below
7 to less than 15 kg: 12 mg/kg/dose orally every 2 times a day based on the lopinavir component
15 to 40 kg: 10 mg/kg/dose orally every 2 times a day based on the lopinavir component; should not exceed more than 400 mg of lopinavir /100 mg of ritonavir orally every 2 times a day
Above 40 kg: As adults; 400 mg of lopinavir /100 mg orally every 2 times a day
Oral tablets: 6 months to 18 years (not receiving the concomitant nevirapine, efavirenz, nelfinavir, or fosamprenavir)
Above 15 to 25 kg or above 0.6- below 0.9 m²: 200 mg of lopinavir /50 mg of ritonavir (two 100 mg of lopinavir /25 mg of ritonavir -tab) orally every 2 times a day
Above 25 to 35 kg or above 0.9- below 1.4 m²: 300 mg of lopinavir /75 mg of ritonavir (three 100 mg of lopinavir /25 mg of ritonavir -tab) orally every 2 times a day
Above 35 kg or above 1.4 m²: 400 mg of lopinavir /100 mg of ritonavir orally every 2 times a day
6 months to 18 years (coadministered with nevirapine, efavirenz, nelfinavir, or fosamprenavir)
300 mg of lopinavir /75 mg of ritonavir (LPV/r)/m²/dose orally 2 times a day, should not exceed more than 400 mg/dose of lopinavir
FDA-approved dosage: 500 mg of lopinavir /125 mg of ritonavir LPV/r orally 2 times a day, administer as the combination of 2 tablets of 200mg of lopinavir /50 mg of ritonavir LPV/r and 1 tablet of 100 mg of lopinavir /25 mg of ritonavir LPV/r
Most NIH Panel members recommend 600 mg of lopinavir /150 mg of ritonavir LPV/r orally 2 times a day (i.e., 3 tablets of 200 mg of lopinavir /50 mg of ritonavir for ease of administration)
Determine whether the child can take the pill whole
weight <25 kg: not safe
weight >25 kg: 1 tablet orally every day
Determine whether the child can take the pill whole
weight <25 kg: not safe
weight >25 kg: 1 tablet orally every day
emtricitabine/tenofovir DF /efavirenz
Indicated for HIV Infection
Age >12 years and body weight >40 kg
One tablet of 200 mg of emtricitabine/600 mg of efavirenz/300 mg of tenofovir DF orally every day on an empty stomach
Age <12 years
Safety and efficacy not established
efavirenz/lamivudine/tenofovir DF
Indicated for HIV Infection
Symfi:
Body weight >40 kg: One tablet of 600 mg of efavirenz /300 mg of lamivudine /300 mg of tenofovir DF orally every night
Body weight <40 kg: Safety and efficacy not established
Symfi Lo:
Body weight >40 kg: One tablet of 400 mg of efavirenz /300 mg of tenofovir DF/300 mg of lamivudine orally every night
Body weight <40 kg: Safety and efficacy not established
https://www.ncbi.nlm.nih.gov/books/NBK534860/
Human Immunodeficiency Virus (HIV) is a virus that attacks the body’s immune system, specifically the CD4 cells, which help the body fight off infections. When HIV is left untreated, it can lead to acquired immunodeficiency syndrome (AIDS).
AIDS is a serious condition that debilitates the immune system and leaves the body vulnerable to life-threatening infections and cancers. HIV is primarily spread through sexual contact but can also be transmitted through blood transfusions, sharing needles, or from mother to child during pregnancy, childbirth, or breastfeeding.
Symptoms of HIV may include fever, sore throat, swollen lymph glands, and a rash, but many people infected with the virus may not have any symptoms. Many individuals are unaware they have the virus for several years after becoming infected. There is currently no cure for HIV.
The epidemiology of HIV has changed significantly over the past few decades. Since the first cases of AIDS were reported in the early 1980s, the virus has become a global concern, with millions of people living with HIV. As of 2020, an estimated 38 million people worldwide were living with HIV, with most cases concentrated in sub-Saharan Africa.
In this region, HIV prevalence is highest among certain populations, such as men who have sex with men, individuals using injectable drugs, and sex workers. In addition, women are more likely to be infected with HIV than men in sub-Saharan Africa, due in part to biological factors such as increased susceptibility to HIV during unprotected sex but also because of social and economic factors such as lack of education and empowerment that can increase vulnerability to HIV.
In recent years, there has been progress in HIV prevention and treatment efforts, which has led to a decline in new HIV infections and deaths due to AIDS. ART (antiretroviral therapy) has been particularly effective in reducing the mortality rate of HIV-positive individuals and the risk of HIV transmission.
The pathophysiology of HIV is complex and not fully understood. After HIV enters the body, it attaches to and enters CD4+ T cells, a type of white blood cell that plays a vital role in the immune system. Once inside the cell, the virus uses an enzyme called reverse transcriptase to convert its genetic material (RNA) into DNA. This viral DNA then integrates into the DNA of the host cell. Once integrated, the viral DNA can remain latent or inactive for long periods.
However, at some point, the virus will reactivate and begin replicating, producing more viral copies that infect other CD4+ T cells. As the virus replicates, it attacks and kills CD4+ T cells, leading to a decline in the number of these cells in the body. This makes it harder for the body to fight off infections, which is why people with HIV are at increased risk of developing infections and cancers that would not normally be a threat to a person with a healthy immune system. As the number of CD4+ T cells decreases, the immune system becomes increasingly compromised.
This is measured by the CD4+ T-cell count, and when the count drops below a certain threshold level (typically below 200 cells/mm3), the person is said to have developed AIDS. In addition to the direct effects of HIV on the immune system, the virus can also indirectly harm the body by increasing inflammation and triggering the activation of other immune cells, such as macrophages and monocytes, which in turn can lead to chronic immune activation and inflammation, that is associated with increased risk of other diseases such as cardiovascular diseases and cancer.
The etiology of HIV is related to the discovery of the virus itself. HIV is a virus from the genus Lentivirus, which belongs to the Retroviridae family. It was first identified in 1983 by two separate research teams, one led by Luc Montagnier at the Pasteur Institute in Paris and the other by Robert Gallo at the National Cancer Institute in the United States.
The origins of HIV can be traced back to non-human primates in Central and West Africa, where it is thought that the virus crossed over to humans through contact with an infected chimpanzee’s blood. It is believed that the virus may have crossed over to humans as early as the early 20th century and that it slowly spread within human populations before the first cases of AIDS were reported in the early 1980s.
HIV is primarily transmitted through sexual contact but can also be transmitted through blood transfusions, sharing needles, or from mother to child during pregnancy, childbirth, or breastfeeding. The most common method of infection is through vaginal or anal intercourse without using protection or through sharing needles or other equipment for injecting drugs. It is also important to note that there are different subtypes of HIV, known as clades or strains, with different geographic distributions.
Some subtypes may be more transmissible or more likely to cause disease progression than others. Risk factors for HIV infection include unprotected sexual contact with an HIV-positive individual, having multiple sexual partners, injection drug use, and man who has sex with other men. People with a high risk of exposure to the virus, such as healthcare workers, or people living in areas where HIV is common, are also at increased risk of infection.
The prognosis of HIV, or the likely outcome of the infection, has improved significantly in recent years due to advances in antiretroviral therapy (ART). With proper medical care and ART, people with HIV can live long and healthy lives, even with the virus. In the past, the progression of HIV to AIDS was a virtual death sentence, as there were no effective treatments available.
However, ART is highly effective in slowing the virus’s progression. The treatment of HIV is lifelong, and it is essential that people with HIV take ART, to maintain viral suppression and keep the virus under control. However, with proper treatment, people with HIV can expect to live long and healthy lives.
https://www.ncbi.nlm.nih.gov/books/NBK534860/
Founded in 2014, medtigo is committed to providing high-quality, friendly physicians, transparent pricing, and a focus on building relationships and a lifestyle brand for medical professionals nationwide.
USA – BOSTON
60 Roberts Drive, Suite 313
North Adams, MA 01247
INDIA – PUNE
7, Shree Krishna, 2nd Floor, Opp Kiosk Koffee, Shirole Lane, Off FC Road, Pune 411004, Maharashtra
Founded in 2014, medtigo is committed to providing high-quality, friendly physicians, transparent pricing, and a focus on building relationships and a lifestyle brand for medical professionals nationwide.
MASSACHUSETTS – USA
60 Roberts Drive, Suite 313,
North Adams, MA 01247
MAHARASHTRA – INDIA
7, Shree Krishna, 2nd Floor,
Opp Kiosk Koffee,
Shirole Lane, Off FC Road,
Pune 411004, Maharashtra
Both our subscription plans include Free CME/CPD AMA PRA Category 1 credits.
On course completion, you will receive a full-sized presentation quality digital certificate.
A dynamic medical simulation platform designed to train healthcare professionals and students to effectively run code situations through an immersive hands-on experience in a live, interactive 3D environment.
When you have your licenses, certificates and CMEs in one place, it's easier to track your career growth. You can easily share these with hospitals as well, using your medtigo app.
