HAART

ART with reference to Indian cenario

1. HAART-The Heart of HIV Management.

2. Goals of ARV therapy

3. Government of India launched the free ART programme on 1st April 2004 The Clinical goals of ART are : • To improve quality of life, • To reduce HIV-related morbidity and mortality, • To provide maximal and durable suppression of viral load. • To restore and/or preserve immune function.

4. Currently available drugs for the treatment of HIV infection as part of a combination regimen fall into four categories:- Those that inhibit the viral reverse transcriptase enzyme ( nucleoside and nucleotide reverse transcriptase inhibitors; non-nucleoside reverse transcriptase inhibitors ) Those that inhibit the viral protease enzyme ( protease inhibitors ) Those that inhibit the viral integrase enzyme( integrase inhibitors ) those that interfere with viral entry ( fusion inhibitors; CCR5 antagonists)

5. Classes of drugs available HIV 2(West Africa) is resistant to NNRTI HIV 1 infection(M/C in the world) doesn’t protect from HIV 2 infection

6. When to start ART in Adults and Adolescents

7. Managing OIs before starting ART

8. Currently, the national programme provides the following drugs/ combinations for first-line regimens. ( i ) Zidovudine (300 mg) + Lamivudine (150 mg) (ii) Tenofovir (300mg) + Lamivudine (150 mg) (iii) Zidovudine (300 mg) + Lamivudine (150 mg) + Nevirapine (200 mg) (iv) Efavirenz (600 mg) (v) Nevirapine (200 mg) Fixed-dose combinations (FDCs) are preferred because they are easy to use, have distribution advantages(procurement and stock management), improve adherence to treatment and thus reduce the chances of development of drug resistance. The current national experience shows that bid (twice a day) regimens of FDCs are well tolerated and complied with.

9. Principles for selecting the first-line regimen 1. Choose 3TC ( Lamivudine ) in all regimens 2. Choose one NRTI to combine with 3TC ( AZTorTDF ) 3. Choose one NNRTI ( NVPorEFV

10. Revised NACO ART Regimen

11. Routine Monitoring of Patients on ART

12. ART in Pregnant Women, PPTCT Single dose Nevirapine ( Sd NVP) is being given as prophylaxis to ANCs at the onset of labour pains/delivery and Syp NVP to the baby soon after birth. The recommended regimen for the HIV infected pregnant woman is TDF+3TC+EFV (FDC, single pill, once daily). The baby is also given Syp . Nevirapine for 6 weeks birth.

13. Immune reconstitution inflammatory syndrome: This is a spectrum of clinical signs and symptoms resulting from the body’s ability to mount an inflammatory response associated with immune recovery. Antiretroviral therapy partially restores immune defects caused by chronic HIV infection, including the restoration of protective pathogen-specific immune responses. The protective response sometimes causes (atypical) inflammatory manifestations to concurrent infective or non-infective conditions, e.g. TB, MAC or CMV. Clinically, IRIS manifests itself as the occurrence or worsening of clinical and/or laboratory parameters, despite a favourable CD4 count (and viral load). The temporal association between the commencement of HAART (or change from a previously failing regimen) and the development of an unusual clinical phenomenon often provides a strong clue to the diagnosis of IRIS.

14. Nonnucleoside reverse transcriptase inhibitors are quite selective for the HIV-1 reverse transcriptase, the nucleoside and nucleotide analogues inhibit a variety of DNA polymerases in addition to those of the HIV-1 reverse transcriptase. For this reason, serious side effects are more varied with the nucleoside analogues and include mitochondrial damage that can lead to hepatic steatosis and lactic acidosis as well as peripheral neuropathy and pancreatitis.

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