(TH) Hiv 2017 PDF

2560
Thailand National Guidelines on

HIV/AIDS
Treatment and Prevention 2017
3
2560
Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017
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6
7

(Introduction) 29
2 33
(HIV Laboratory for Diagnostic and Monitoring)
2.1 35
(HIV Testing and Counselling; HTC)
2.2 39
2.2.1 (HIV viral testing) 39
2.2.2 40
2.3 55

2.3.1 CD4 (CD4 count) 55
2.3.2 (HIV viral load) 56
2.3.3 58
(HIV drug resistance testing)
2.4 61
2.5 (false positive) anti-HIV 64
2.6 65
2.6.1 65
2.6.2 66
3 (Management of HIV-Infected Adult) 67

3.1 69
3.2 74
3.3 74

3.4 77
3.4.1 77

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3.4.2 78
(Multi-class antiretroviral treatment failure)
3.5 80
3.6 81
3.7 (Drug-drug interaction) 83
3.8 110
3.9 115
3.10 116

3.11 121

3.12 134
()
3.13 137
(Adherence to antiretroviral therapy)
3.14 Immune reconstitution inflammatory syndrome (IRIS) 137
3.15 141
3.15.1 141
(Acute HIV infection)
6 (Recent HIV infection)
3.15.2 144
3.15.3 155
3.15.4 158

3.15.5 161
3.15.6 164
3.15.7 165
3.15.8 166
3.16 173
8
9
4 177
(Management of HIV-Infected Children and Adolescent)
4.1 181
4.1.1 181
4.1.2 182
4.2 (Early infant diagnosis) 191
4.3 197
(ARV therapy in nave HIV-infected children)
4.3.1 198
4.3.2 201
4.3.3 203
(antitretroviral nave)
4.3.4 205
3

4.3.5 206

(antiretroviral therapy in children with opportunistic infection)
4.4 210
4.4.1 210
4.4.2 211
4.4.3 212

4.5 213

4.6 214
(Immune Reconstitution Inflammatory Syndrome: IRIS)


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4.7 218
4.7.1 > 3 LPV/r 218
4.7.2 218
4.7.3 218
4.8 219
(diagnosis of treatment failure in HIV-infected children)
4.9 221
4.10 HIV genotyping 223
4.10.1 225
2NRTIs + 1NNRTIs
4.10.2 226
2NRTIs + PI
4.10.3 3 NRTIs, NNRTIs 227
PIs (salvage regimen)
4.10.4 229
4.11 230

4.12 232
4.13 234
4.14 235
(adherence to antiretroviral treatment in children)
4.15 238
4.16 (Transition to adult clinic) 239
10
11
5 243
(Prevention of Mother-to-Child HIV Transmission)
5.1 248
5.1.1 249
5.1.2 252
5.2 255

5.3 260
5.3.1 262
5.3.2 264
5.3.3 271
5.3.4 271

5.3.5 274
5.4 282
5.5 285
5.5.1 285
5.5.2 285
5.6 287
5.7 287
5.7.1 287
5.7.2 289
5.8 290
(Early infant diagnosis EID)

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6 293
(Opportunistic Infections: Prophylaxis and Treatment)
6.1 (Tuberculosis) 293
6.2 313
6.2.1 Pneumocystis pneumonia (PCP) 314
6.2.2 Cryptococcosis 318
6.2.3 Candidiasis 321
6.2.4 Toxoplasmic encephalitis 324
6.2.5 Penicilliosis histoplasmosis 327
6.2.6 Cytomegalovirus (CMV) infection 331
6.2.7 Mycobacterium avium complex (MAC) infection 334
7 (HIV Prevention) 343

7.1 344
(Antiretroviral-based HIV prevention)
7.1.1 (Treatment as Prevention: TasP) 344
7.1.2 346
(Pre-Exposure Prophylaxis: PrEP)
7.1.3 353
(Post-Exposure Prophylaxis: PEP)
7.2 (Male circumcision) 364
7.3 369
7.4 374
7.5 376
8 379
(Service delivery guidance)
8.1 (Reach & Recruit) 381
8.2 (Test) 392
8.3 (Treat) 400
12
13
8.4 (Retain) 406

8.5 422
8.6 430

437
439
(Dose and Route of HIV medication in Adults)
CDC Classification 2014 449
451
(WHO Classification System for HIV-Infected Children)
454
(Dose and Route of HIV Medication in Pediatrics)
464
creatinine clearance 475
476
480
481
482
rapid desensitization TMP-SMX 484

485
509
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2.1 40

2.2 41

99.5 99.0
2.3 61
2.4 63
2.5 64

3.1 69

3.2 70
3.3 72
3.4 75
3.5 75
3.6 virological failure 77
3.7 79
3.8 79

3.9 80
3.10 83
3.11 85
6
3.12 88
14
15
3.13 NNRTIs, RAL and PIs 107

3.14 110
3.15 115
3.16 117

3.17 120

3.18 122

3.19 136
3.20 Immune reconstitution 138
inflammatory syndrome IRIS
3.21 IRIS 139
3.22 IRIS 140
3.23 acute HIV infection 143
3.24 HIV/HBV 144
co-infection HBsAg 6
3.25 145

3.26 anti-HCV 147
3.27 HIV/HCV co-infection 149
3.28 DAA 150
3.29 152
pegylated interferon
3.30 153
3.31 154
3.32 156

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3.33 164
3.34 PIs methadone 165
3.35 TDF 167

3.36 174
4.1 183

.. 2559
4.2 1-6 190

4.3 7-18 190

4.4 195

4.5 202
.. 2559
4.6 203

4.7 1 204

4.8 213
4.9 227
4.10 231

CD4 < 15
16
17
5.1 249

5.2 254

5.3 262

5.4 HAART 263

5.5 265

5.6 280

5.7 282

5.8 283
HAART
5.9 100 g OGTT 284
5.10 290

6.1 297
6.2 298
6.3 299
6.4 303
6.5 304
6
6.6 304
rifampicin

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6.7 IPT 308

6.8 309
6.9 337
6.10 CD4 primary secondary prophylaxis 341

6.11 CD4 primary secondary prophylaxis 342

7.1 PrEP 347

adherence
7.2 PrEP 348
7.3 PrEP PrEP 349
7.4 PrEP 351
7.5 PrEP PrEP 352
7.6 HIV oPEP 358
HIV oPEP
7.7 HIV oPEP* HIV nPEP 359
7.8 360

7.9 HIV nPEP 362
7.10 nPEP 363
nPEP
7.11 367

7.12 368

7.13 376
18
19
8.1 415
8.2 418

8.3 431

1 437
2 439
3 449
CD4
4 450
5 454
6 rapid desensitization TMP-SMX 484


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2.1 36
2.2 43
24
2.3 52
24
2.4 60
3.1 135
3.2 anti-HCV 148
3.3 TDF 169
HIV
4.1 IRIS 216

4.2 222
5.1 258

5.2 259

5.3 279

6.1 310
(treatment latent tuberculous infection isoniazid preventive therapy)
6.2 312
20
21
7.1 357

7.2 (GC) (CT) 370
.. 2553-2557
7.3 373
8.1 380
8.2 387
8.3 390
8.4 407
8.5 3x4 426

8.6 429

8.7 433


23
/r Ritonavir boosted
3TC Lamivudine
ABC Abacavir
ATV Atazanavir
AZT Zidovudine
CCBs Calcium channel blockers
COBI Cobicistat
d4T Stavudine
DCCBs Dihydropyridine calcium channel blockers
ddl Didanosine
DMPA Depot medroxyprogesterone acetate
DRV Darunavir
DTG Dolutegravir
E Ethambutol
EE Ethinyl estradiol
ENG Etonogestrel
EFV Efavirenz
ETR Etravirine
EVG Elvitegravir
FTC Emtricitabine
HRAs H2-receptor antagonists
IDV Indinavir

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LNG Levonorgestrel
INH, H, I Isoniazid
LPV/r Lopinavir/ritonavir
MVC Maraviroc
NET Norethindrone
NFV Nelfinavir
NGM Norgestimate
NRTI Nucleoside reverse transcriptase inhibitor
NSAIDs Nonsteroidal anti-inflammatory drugs
NVP Nevirapine
PAS Para-aminosalicylic acid
PI Protease inhibitor
PPIs Proton pump inhibitors
PZA, Z Pyrazinamide
R Rifampicin
RAL Raltegravir
RPV Rilpivirine
RTV Ritonavir
SQV Saquinavir
TCAs Tricyclic antidepressants
TDF Tenofovir
TMP Trimethoprim
TMP-SMX Trimethoprim/sulfamethoxazole
24
25
BCG Bacillus Calmette-Gurin

DT/dT Diphtherias, tetanus vaccine
DTaP/Tdap Diphtherias, tetanus, acellular pertussis vaccine
DTP Diphtherias, tetanus, pertussis vaccine
DTwP Diphtheria, tetanus, whole cell pertussis vaccine
HAV Hepatitis A vaccine
HBV Hepatitis B vaccine
Hib Haemophilus influenza type B vaccine
HPV Human papillomavirus vaccine
IPV Injection polio vaccine
JE Japanese encephalitis vaccine
MMR Measles, mumps, rubella vaccine
OPV Oral polio vaccine
PCV Pneumococcal conjugate vaccine
PPSV-23 23-valent pneumococcal polysaccharide vaccine
PRP-T Polyribose ribital phosphate-tetanus toxoid
Td Tetanus and diphtheria toxoid
TT Tetanus toxoid
VZV Varicella-zoster virus vaccine

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AFB Acid-fast bacilli
AHI Acute HIV infection
ALT Alanine aminotransferase
ARS Acute retroviral syndrome
AST Aspartate aminotransferase
AUC Area under the curve
BMD Bone mineral density
BMI Body mass index
CBC Complete blood count
CD4 Cluster of Differentiation
CITC Client-initiated testing and counseling
CMV Cytomegalovirus
CrCl Creatinine clearance
CT Chlamydia trachomatis
CXR Chest x-ray
DAA Direct Acting antivirals
DOT Directly observed therapy
DSC Disease specific certification
DXA Dual energy x-ray absorptionmetry
EBV Ebstein-Barr virus
EID Early infant diagnosis
EM Erythema multiforme
EWI Early warning indicators
FBS Fasting blood sugar
FDA Food and Drug Administration
GCT Glucose challenge test
26
27
HAART Highly active antiretroviral therapy

HAV Hepatitis A virus
HBV Hepatitis B virus
Hct Hematocrit
HCT HIV counseling and testing
HCV Hepatitis C virus
HDL High-density lipoprotein
HHV Human herpes virus
HPV Human papillomavirus
IGRA Interferon gamma release assay
INR International normalised ratio
IPT Isoniazid preventive therapy
IRIS Immune reconstitution inflammatory syndrome
IRS Immune restoration syndrome
IUD Intrauterine device
IUI Intrauterine insemination
IVF In vitro fertilization
LDL Low-density lipoprotein
MAC Mycobacterium avium complex
MEMS Medication events monitoring system
MMT Methadone maintenance treatment
NAT Nucleic acid testing
NTM Nontuberculous mycobacteria
OGTT Oral glucose tolerance test
OI Opportunistic infection
PCP Pneumocystis carinii pneumonia

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PCR Polymerase chain reaction
PDCA Plan do check act
PEP Post-Exposure Prophylaxis
PITC Provider-initiated testing and counseling
PML Progressive multifocol leukoencephalopathy
PMTCT Prevention of mother-to-child transmission
PrEP Pre-Exposure Prophylaxis
PwP Prevention with positives
RPR Rapid plasma reagin
SDR Same day result
SJS Stevens Jonhson syndrome
TAMs Thymidine analog mutations
TasP Treatment as Prevention
TB Tuberculosis
TEN Major/Toxic epidermal necrolysis
TG Triglyceride
TLTI Treatment latent tuberculous infection
TST Tuberculin skin test
UIC Unified identification code
UNAIDS
UP Universal precaution
VCT Voluntary counseling and testing
VDRL Venereal disease research laboratory test
VL Viral load
WHO World Health Organization
.
28
Introduction
29
36.7
17 15
1.8 1.5
Sub-Saharan Africa .. 2558
2.1 1.1
15 1.5 1.1
35
.. 2543 (Millennium Development
Goal; MDG) 43 .. 2546

32 .. 2547
(Latent TB)
(Sustainable Development Goals; SDG)
SDG 3
3.3
.. 2573

(AIDS epidemic model Spectrum) .. 2559 423,778
1.1 15-49
179,590 6,304
1,821 15 78
3,180
15 3,221

2560
.. 2558
284,434 65

.. 2543 2553
65 .. 2553
30
.. 2557

(Treatment
as prevention)
(Same
Day Result HIV Testing)
CD4 2558 32,926
2557 27,884 CD4
2556, 2557 2558 125,
129 196 cells/mm3
.. 2556 2.3
2.1 .. 2557 1.9 .. 2558
2559
(Elimination of Mother to Child Transmission on HIV and Syphilis)

30
Introduction
31
(Pre-Exposure Prophylaxis)
Tenofovir Emtricitabine

28 .. 2557 .. 2573
1,000

2559

.. 2573 .. 2563
500,000 500,000

90

90
90 1,000 copies/mm3
90-90-90
.. 2563 30
75

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/
.. 2560

32
HIV Laboratory for Diagnosis and Monitoring
33
2

(HIV Laboratory for Diagnostic and Monitoring)

(Verbal consent)
3 rapid test 3

(inconclusive) 2 / 1
1

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24

HIV DNA PCR 7
CD4 CD4

VL 1
VL > 1,000 copies/mL

.. 2573

.. 2563 3 90
90
90
RRTTR (Reach-Recruit-Test-Treat-Retain)
.. 2558-2562

90
34
35
2.1
(HIV Testing and Counselling; HTC)

(Verbal
consent)
(pre-test/post-test
counselling) 2.1
(group counselling)

(individual counselling)
2
(client-initiated testing
and counselling; CITC) (provider-initiated testing
and counselling; PITC) PITC
(WHO) (UNAIDS)


2560
2.1
CITC PITC

(Pre-test counseling)

PrEP

(ongoing counseling)
36
37
(Same day result)

rapid test
(machine based)
3
1-2

2560
1)
2)
- - -
3)
4)
5)
6)
7)
8)
9)
10)
38
39
2.2
2.2.1 (HIV viral testing)

p24 antigen

24

1

(qualitative assay)1 NAT (nucleic acid amplification testing)
RNA proviral DNA

p24 Antigen
p24

Qualitative
NAT

1
(Positive or Negative)
2560
2.2.2

Enzyme-linked immunosorbent assay : ELISA,
agglutination assay, immonochromatography dot immunoassay

.. 2551
.. 2552

(sensitivity) (specificity)
2.1
2.1

1 p24 antigen 100 99.5
2 100 99.5
3 anti-HIV 99.5 99.0
: 14
.. 2552
40
41
2.2.2.1

(predictive value) (positive predictive value: PPV)
(negative predictive value: NPV) PPV NPV

2.2
.. 2558 0.82
PPV NPV 99.99

3 UNAIDS WHO
3 2.2
2.2
99.5
99.0
Prevalence %PPV: 1 test %PPV: 2 tests %PPV: 3 tests %NPV
0.05 14.292 83.200 99.99460 100.00
0.5 62.594 99.821 99.99946 99.999
0.82 73.356 99.891 99.99967 99.999
2.0 87.173 99.956 99.99987 99.998
5.0 94.602 99.983 99.99995 99.995
10.0 97.368 99.992 99.9998 99.989

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2.2.2.2

3

3

3 2 3

(machine based assay) rapid test
simple test 1 2
3
rapid test

rapid test

2.2.2.3
24
24
3 UNAIDS WHO 2.2
42
43
2.2
24
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) (anti-HIV positive)(2)

2560

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

(4)
2 / 3
(3)
qualitative NAT
neutralization p24 assay window period
(Anti-HIV)

1) (anti-HIV negative)
(non-reactive)
2) (anti-HIV positive) 3
(reactive)
3) (inconclusive) 3

2 / 1

44
45
2
(human error)

1
2
CD4 /
(retesting)

3
1.

1.1
/
1.2 (discordant couple)
1.3 window period
1.4
1

1.5

2560
1.6
1.7
1.8 (PEP)
(PrEP)
1.9
1

2.

2 / 1
2.1 (seroconversion)

2.2 (fasle positive)

3.

3.1

OPD card
3.2

3.3
CD4 CD4 > 500 cell/mm3
5

46
47
2.2.2.4
24

24
12 95

18
18-24

12 < 24
24 12

30 1
50 2
PCP

DNA PCR
2 2.3

2560
DNA PCR
DNA PCR
24
2
(1) (dried blood spot; DBS)
EDTA

.

(DBS)

(2)
EDTA ACD 0.5-2.0 mL

48
49
-
.
-
12

DNA PCR
( 2.3)
1. PCR 7
2.3

2. PCR 1

PCR
3.
PCR ( 4-6

4 5)
4. PCR 1 PCR
(standard risk)
PCR 2 2-4 (high risk)
PCR 2 2 4
. 2

2.3

2560
. 2
2 4 PCR

4
2.3
24

12-24
1. 12-24

.

.
18
5-10
18

24
PCR
2.
(HIV Ag/Ab)
18
PCR
HIV Ag/Ab
18
24
50
51

1. (Definitive exclusion of HIV infection)

24
. PCR 2
2 2
4

. 6
2 PCR

. PCR 1 4
1 6

CD4
2. (Presumptive exclusion of HIV infection)

. PCR 2
2
. PCR 1
2
4
PCR
. 6 1

PCR
CD4

52
2.3 24
24 (1)
> 1 < 12 12-24
HIV DNA PCR HIV DNA PCR (2) Anti-HIV(8)

0-7 (3) 4

(Positive) (Negative) (Positive) (Negative) (Positive)(9) (Negative)

DNA PCR DNA PCR DNA PCR Anti-HIV
2 18

(Positive) (Negative) (positive) (negative) (Negative) (Positive) (Positive)(10) (Negative)(11)
2560
Anti-HIV

(4) (5)
24

DNA PCR DNA PCR
4 (Positive) (Negative)

(12)
(Positive) (Negative) (Negative) (Positive) (Anti-HIV Positive) (Anti-HIV Negative)
(6) (7) (6)

(1)
24 DNA PCR

(2) NAT (nucleic acid amplification testing)

(3) DNA PCR 0-7 4
(4) 4 VL
50 copies/mL
(5)
(6) DNA PCR 24

(7) 24

(8) 24
(9) 12-24 Anti-HIV HIV DNA PCR PCR

(10) 3 3
2
(11) PCR 2
(12) 6

53
2560

5

proviral DNA DNA PCR HIV RNA
HIV RNA HIV RNA (qualitative
HIV RNA)
(copies/mL)
(quantitative HIV RNA)

HIV RNA (qualitative HIV RNA)

(in-house)

54
55
2.3

2.3.1 CD4 (CD4 count)

CD4

CD4 CD4

CD4
CD4 2
Flow cytometry Flow cytometry
CD4 point-of-care
point-of-care
Flow cytometry

IQC EQA
CD4
CD4
CD4 350
cells/mm3 CD4 2
CD4 > 350 cells/mm3 CD4
VL 50 copies/mL
VL < 50 copies/mL 1 CD4
VL < 50 copies/mL
2 CD4

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(%CD4) CD4 (absolute CD4)

NRBC (nucleated RBC) CD4
%CD4
CD4
5 CD4
EDTA
6

25C
CD4
CD4

steroid
CD4

2.3.2 (HIV viral load)

viral load (VL) RNA

real time nucleic acid amplification

CD4, VL
56
57
Viral load
VL
2
1

6 12

1
VL copies/mL ( IU/mL) Log10
equivalence
EDTA ACD

6

/
VL
1
VL > 1,000 copies/mL ( 2.4)
VL

Viral load

10
VL


2560
2.3.3 (HIV drug resistance testing)

genotype

(in-house)

CD4, VL

4
VL
VL > 1,000 copies/mL (
2.4)
VL
EDTA ACD

58
59
6

/

2.5

2560
2.4
Viral load 6 1
viral load (1)
viral load < 1,000 copies/mL viral load > 1,000 copies/mL

drug resistance(2)

(1)
VL EDTA 6 - 9 mL
VL -20 -70C
(2)
VL drug
resistance
60
61
2.4
CD4 VL

ISO15189
CD4 VL

2.3
CD4 dual platform
(CBC analysis machine)
2.3

(IQC) (EQA)
IQC
HIV testing (machine based)
3 2 levels
IQC
HIV testing (simple test)
3 1 levels

IQC
HIV testing (rapid test)
3 1 level
1
IQC
CD4 count
6 1 level
IQC
Viral load testing
2 1 level
IQC
Drug resistance testing
2 1 level

2560
CD4, VL

US FDA
CE mark IVD
CD4 VL
(WHO prequalification of diagnostics program)

2

3
/

62
2.4

Anti-HIV testing EIA/CMIA/ECIA, Clotted blood 5 mL 2-8C
agglutination test, Serum or EDTA 1 mL 24 .
immunochromatography plasma
HIV testing(1) Nucleic acid amplification EDTA blood 2-3 mL 2-8C
testing (NAT) EDTA plasma 1 mL 24 .
Dried blood spot 1
CD4 count Flow cytometry POCT EDTA blood 2-3 mL (18-25C)
6 . ( 18-25C
)
Viral load testing Real time nucleic acid EDTA or ACD blood 6-9 mL 6 .
(HIV-1 RNA) amplification EDTA ACD 2 4-8C 24 .
Plasma 1.5 mL 6 .
PPT EDTA gel 6-9 mL ( 4C)

()
Drug resistance Genotype EDTA or ACD blood 6-9 mL 6 .
testing EDTA or ACD 2 4-8C 24 .
plasma 1.5 mL 6 .
( 4C)
(1)

, 12 ,
63

2560
2.5

Stanford
ViroSeq
(in-house)
(mutation) Susceptible / Potential
None
low level resistance
mutation Possible Low level resistance
resistance Intermediate resistance
mutation
Resistance High level resistance

( )
2.5 (false positive) anti-HIV
(false positive)

anti HIV
(antibody cross reactivity)

(mycobacteria)
(giardia) (cytomegalovirus; CMV)

64
65

(influenza vaccination)

(human leukocyte
antigen; HLA) 1

2.6
2.6.1
(first generation sequencer)
(Sanger sequencing)
800 (mutant virus)
(wild type virus)

(second generation sequencer) next generation
sequencer massively parallel sequencing

PCR 200-400
(Chip)
flow cell

(single mutation)

(sensitivity)
2560
2.6.2
(severe adverse drug reaction)
(Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN))

.

HLA-B*57:01 (drug
hypersensitivity) Abacavir
HLA-B*35:05
(single nucleotide polymorphism)
Nevirapine
HLA-B*40:01
(lipodystrophy) Stavudine
CYP2B6 Efavirenz
(Efavirenz-associated CNS symptoms)

(good compliance)
VL

66
Management of HIV-Infected Adult
67
3

(Management of HIV-Infected Adult)

CD4
CD4 > 500 cells/mm3 serious AIDS-related
serious non-AIDS CD4 350
cells/mm3 Kaposi sarcoma
malignant lymphoma
TDF/FTC TDF + 3TC

EFV RPV NNRTIs LPV/r ATV/r
ABC + 3TC AZT + 3TC
NVP INSTI RAL EVG/c DTG
VL < 50 copies/mL 2
CD4
EFV
EFV 600 ./ 400 ./ ( EFV 400 .
rifampicin) NNRTIs
RPV NVP
RPV VL VL > 500,000
copies/mL
VL RPV CD4 > 350
cells/mm3 VL < 50 copies/mL 6

2560
TDF CrCl < 60 ./

TDF eGFR
6 UA 1 high risk ,
,
NSAIDs UA 6
adherence (stable on ART)
3-6

2

(< 50 copies/mL) CD4

(AIDS-related illness)
(Non AIDS-related illness)
(adherence)
95 2
12 1 24
68
69
3.1

3.1-3.3
3.1

()

CD4

70
3.2

6 12 sexual dysfunction

2560

(current lifestyle) 6 12

EFV

1


1 1

drug adherence

71
72
3.3

CD4 CD4 350 cells/mm3 2 VL > 1,000 copies/mL
CD4 > 350 cells/mm3
VL 50 copies/mL CD4
VL < 50 copies/mL
2 CD4
6 12 VL 50 copies/mL
(VL)
( VL
3-6
) VL < 50 copies/mL
1
2560
HBsAg anti-HBs

Anti-HCV anti HCV: negative
active IDU ( ) CD4
< 100 cells/mm3 CD4
Syphilis (VDRL) MSM 6
3
ALT 3

Creatinine TDF ATV 6
50 < 45 .
1
Total cholesterol 1 1 < 35
Triglyceride 1 /
Fasting blood sugar < 35
2 /
35 2 /
Urinalysis TDF ATV Fanconi syndrome
50 TDF (tubular dysfunction)
< 45 . PIs TDF
NSAIDs 6 3.15.8
1
Chest X-ray
Drug resistance VL > 1,000 copies/mL
6
PrEP
Pap smear 1 1
Anal PAP 1 1
Serum cryptococcal Ag CD4 < 100 cells/mm3

73
2560
3.2
CD4 > 500 cells/mm3

serious AIDS-related serious non-AIDS
CD4 < 350 cells/mm3
Kaposi sarcoma malignant lymphoma
CD4 > 500 cells/mm3
VL

CD4

Adherence

3.3
3.4
NRTIs + NNRTIs TDF/FTC TDF + 3TC
EFV
74
75
3.4
NRTIs backbone NNRTIs

TDF/FTC
EFV RPV2 LPV/r
TDF + 3TC1
+

ABC + 3TC + NVP ATV/r
AZT + 3TC NNRTIs
INSTI4
RAL
EVG/c/TDF/FTC3
DTG
1

2
RPV-Rilpivirine 25 . 3.5
3
Elvitegravir/cobicistat/TDF/FTC 1

4

3.5

NRTIs ABC + 3TC AZT +
3TC
ABC
TDF VL < 100,000 copies/mL ( dolutegravir)

EFV 600 ./ 400 ./
EFV ( EFV 400 .
rifampicin)
NNRTIs RPV
RPV
VL VL > 500,000 copies/mL

VL
CD4 > 350 cells/mm3

RPV

RPV VL < 50 copies/mL
6 NNRTIs
2560

EFV adherence EFV
EFV
2
RPV VL > 500,000 copies/mL
PIs LPV/r ATV/r
NNRTIs 3

d4T VL d4T TDF ABC
< 50 copies/mL
integrase inhibitors
3.4 3 RAL DTG

DRV/r
2
NNRTIs
(EFV/NVP intolerance) rifampicin
VL VL < 50
copies/mL RPV PI
ABC HLA-B*5701
ABC
ABC
(hypersensitivity reaction) HLA-B*5701
HLA-B*5701

ABC 6
2 (1) (2) (3)

(4) (5)

creatine phosphokinase lymphopenia

ABC Child-Pugh Score of 7-12
76
77
3.4
3.4.1
3 (1) virological failure
(2) immunological failure (3) clinical failure
1 2
3

virological failure
: virological failure HIV RNA (VL) > 200
copies/mL 6
3.6 virological failure

virological failure
1. VL
adherence 1 VL
2. VL -
VL > 50-1,000 - 2-3
copies/mL
VL HIV drug resistance
>1,000 genotypic testing
copies/mL

adherence

3

1 VL
VL > 10 VL 10
VL adherence
3 VL VL > 1,000
< 50 copies/mL copies/mL

2560

(1) NNRTIs VL
> 1,000 copies/mL
(2) boosted-PIs
poor adherence
VL 50 copies/mL

LPV/r + AZT
1
VL

2-6
4
3.7 3.8

3.4.2
(Multi-class antiretroviral treatment failure)
VL < 50 copies/mL

3
3 2
VL 3
78
79
3.7
1.

2. 3
integrase inhibitor

3.
1) Integrase inhibitors: RAL, DTG
2) Protease inhibitors: DRV ()
3) NNRTIs: ETR ()
3.8

Mutation

NNRTIs + NNRTIs-associated mutation AZT TDF
NRTIs (EFV, NVP) M184I/V + 3TC (FTC) + boosted PIs boosted PIs
NRTIs mutation + INSTI (RAL DTG)
RPV TDF AZT
E138K M184I/V NRTIs + 3TC (FTC) + boosted PIs boosted PIs
mutation + INSTI (RAL DTG)
Boosted- M184I/V PIs adherence / drug interaction
PIs + NRTIs resistance mutation adherence

adherence
M184I/V + NRTIs mutation AZT TDF
PI resistance + 3TC (FTC) + boosted PI
mutation TDF AZT
+ 3TC (FTC) + boosted PI

2560
Mutation

Boosted- M184I/V + PIs resistance genotypic
PIs + NRTIs mutation resistance
()

INSTI- M184I/V INSTI resistance Boosted PIs + NRTIs (
based + mutation )
NRTIs Boosted PIs + DTG genotypic
resistance

PI-based regimen
rifampicin ( 6 )
rifampicin lopinavir double-dose LPV/r (800/200)
12 .

TDF + 3TC (FTC)

3.5
3.9

1 NRTIs + 1 NNRTIs
1 NRTIs + 1 PIs boosted
RTV
1 NRTIs + RAL 2 NRTIs
Triple NRTIs combinations
TDF + 3TC + ABC
2 NNRTIs combination
80
81

d4T + AZT Pharmacologic antagonism
FTC + 3TC resistance profile
TDF + ddI ddI
d4T + ddI peripheral neuropathy, pancreatitis,
hyperlactatemia lactic acidosis
2
ATV + IDV hyperbilirubinemia

NRTIs
2

NVP
CD4 > 400 cells/mm3
CD4 > 250
cells/mm3
d4T
VL < 50 copies/mL

3.6

12

TDF/FTC 3TC EFV RPV
3.10 AZT d4T TDF VL < 50 copies/mL
HBV (HBsAg)
EFV

2560

1-2 RPV
proton pump inhibitor

()

12

82
83
3.10

EFV EFV
NVP NVP 400 . 24 . RPV 25 .
RPV 25 .

1

LPV/r LPV/r 2 12 . 4 24 .
ATV/r 1
TDF TDF
AZT d4T TDF 24 .
VL < 50 copies/mL TDF
3TC 3TC (150 .) 1 12 . 300 . 24 .
TDF/FTC 1 1
3.7 (Drug-drug interaction)
NNRTIs PIs
cytochrome P450 (CYP450) CYP3A4 isoenzyme


2560

PIs
CYP450 p-glycoprotein NRTIs
CYP450 ddI
hydroxyurea, ribavirin TDF
3
1) CYP inducer CYP inducer CYP450
CYP450
rifampicin CYP inducer NNRTIs
PIs rifampicin
EFV
PIs
2) CYP inhibitor CYP inhibitor CYP450
CYP450
RTV CYP inhibitor PIs
PIs
boosted PIs
3) CYP inducer CYP inhibitor EFV NVP
(substrate) CYP450 CYP inducer
84
3.11 6
//
1) Ergotism Ergot CYP450 CYP inhibitor Ergot
clarithromycin, ketoconazole, NNRTIs EFV PIs RTV
(peripheral vascular vasoconstriction)
(ischemia)
/
() (cyanosis) (gangrene)
(vasodilator drug) prostaglandin analogue
PIs, EFV EVG/c Ergot derivative ergotamine

2) Torsades de PIs ATV QT prolong

Pointes (ventricular arrhythmia) QT prolong

CYP inhibitor RTV QT prolong
terfenadine, astemizole, cisapride pimozide calcium channel bolckers diltiazem
flecainide, propafenone, amiodarone, quinidine

85
86
//
3) Rhabdomyolysis

fibrate statins

2 statins
pravastatin rosuvastatin fibrate derivative fenofibrate gemfibrozil
4) Symptomatic CYP inhibitor RTV
hypotension dihydropyridine calcium channel blockers -blockers
sidenafil
2560
CYP inhibitor RTV Cobicistat dihydropyridine

calcium channel blockers felodipine, nifedipine, amlodipine -blockers

sidenafil boosted PIs LPV/r sidenafil 11

sidenafil 25 . 48 .
sidenafil nitrate

//
sidenafil EVG/c
pulmonary hypertension EVG/c
erectile dysfunction
25 . 48 .

5) Excessive benzodiazepines
sedative
benzodiazepines
benzodiazepines midazolam, triazolam, alprazolam diazepam
lorazepam CYP450
6) Cushings RTV Cobicistat CYP inhibitor CYP450

syndrome
Cushings syndrome (adrenal insufficiency)
RTV Cobicistat fluticasone
: EVG/Cobicistat/TDF/FTC Cobicistat CYP inhibitor RTV RTV

87
88
3.12

ergotamine
Ergotamine group PIs, EFV Ergot boosted PIs Ergot PI EFV
(dihydroergotamine, severe vasoconstriction gangrene
ergotamine) methergin EVG/c EVG COBI Ergot Ergot EVG/c
(methylergonovine)

Antacids ATV, ATV/r antacid ATV ATV 2 . 1-2 .
antacid buffered medications
RPV antacid RPV antacid 2 . 4 .
RPV
2560
RAL Al-Mg Hydroxide Antacid:
RAL Al-Mg hydroxide antacids

RAL Cmin 54% to 63%
CaCO3 Antacid: RAL CaCO3
RAL Cmin
32% Antacid
EVG/c EVG AUC 40% to 50% EVG/c/TDF/FTC antacid 2 .
antacid
EVG AUC 15% to 20% 2 .
4 .
EVG/c

H2-receptor ATV HRAs ATV boosted ATV / HRAs
antagonists (HRAs) 10 .
RPV HRAs RPV HRAs 12 . 4 . RPV
Proton-pump ATV PPIs ATV ATV PIs ,
inhibitors (PPIs) PIs PPIs 12 . ATV
boosted ATV PPI
omeprazole 20 .
RPV PPIs RPV 40% RPV
RPV AUC 40%, Cmax 33%
Cisapride EVG/COBI/TDF/FTC cisapride serious life-threatening events
EFV
Antifungals
Fluconazole EFV
ETR ETR AUC 86%

NVP NVP AUC 110%
NVP
Itraconazole EFV Itraconazole OH-itraconazole AUC,
Cmax Cmin 35-44% itraconazole itraconazole
ETR Itraconazole itraconazole
ETR itraconazole
NVP Itraconazole itraconazole NVP

89
NVP
90

Itraconazole () EVG/c itraconazole itraconazole
EVG/c itraconazole (> 200 ./)
itraconazole
Ketoconazole EFV Ketoconazole
ETR Ketoconazole ketoconazole
ETR
NVP Ketoconazole AUC 72%
NVP 15-30%
EVG/c Elvitegravir AUC: 48%; ketoconazole > 200
Cmin: 67% ./
2560
Posaconazole EFV Posaconazole: AUC 50%
ETR ETR
EVG/c Posaconazole posaconazole
EVG/c
Voriconazole EFV Voriconazole: AUC 77% voriconazole 400 .
EFV: AUC 44% 12 . EFV 300 . 24 .
ETR Voriconazole 14% voriconazole
ETR AUC 36% voriconazole

Voriconazole () NVP Voriconazole voriconazole
NVP
RPV Voriconazole
RPV voriconazole
EVG/c Voriconazole / voriconazole
EVG/c voriconazole
(anticonvulsants)
Carbamazepine, EFV Carbamazepine + EFV: EFV
phenobarbital, Carbamazepine AUC 27%
phenytoin EFV AUC 36%
Phenytoin + EFV: EFV
phenytoin
ETR Anticonvulsant ETR
RPV RPV
NVP Anticonvulsant NVP NVP
EVG/c carbamazepine AUC 43%
EVG AUC 69% and Cmin > 99%
COBI expected

91
92

Oxcarbazepine RPV RPV
EVG/c ;
EVG/c
Antimycobacterials
Clarithromycin (Clar) EFV Clar AUC 39%
Azithromycin ( MAC)
ETR Clar AUC 39% azithromycin ( MAC)
ETR AUC 42%
NVP Clar AUC 31%
2560
azithromycin ( MAC)
RPV RPV azithromycin ( MAC)

ATV/r Clar AUC 94% QT prolong clarithromycin 50%
azithromycin
DRV/r, LPV/r Clar AUC 57% clarithromycin
azithromycin
CrCl 30-60 ./ clarithromycin 50%
CrCl < 30 ./ clarithromycin 75%

Clarithromycin (Clar) EVG/c Clar CrCl 50-60 ./:
() COBI clarithromycin 50%.
CrCl < 50 ./:
EVG/c
Rifabutin EFV Rifabutin 38% Rifabutin 450-600 ./ EFV PIs
ETR Rifabutin metabolite AUC 17% Rifabutin 300 ./ ETR boosted PIs
ETR AUC 37% boosted PIs rifabutin
NVP Rifabutin AUC 17% metabolite rifabutin
AUC 24%, NVP Cmin 16%
RPV RPV AUC 46% RPV 50 .
EVG/c Rifabutin 150 . EVG/c
Rifabutin 300 .
:
rifabutin AUC
25-O-desacetyl-rifabutin AUC 625%
EVG AUC 21%, Cmin 67%
Rifampicin EFV EFV AUC 26% EFV 600 ./ EFV
ETR ETR
RPV RPV 80%

93
94

Rifampicin () NVP NVP 20-58% NVP 400 ./ EFV lead-in
EVG/c Rifampicin EVG COBI
RAL RAL 400 .: RAL 400 . 12 .
RAL AUC 40%, Cmin 61%
RAL 400 . 12 .,
rifampicin RAL 800 . 12 .
RAL AUC 27%, Cmin 53%
Benzodiazepines
Alprazolam ETR, EFV, NVP, RPV alprazolam
PIs PIs benzodiazepine
2560
Diazepam ETR diazepam diazepam
PIs PIs diazepam benzodiazepine

EVG/c midazolam benzodiazepine
Lorazepam EFV Lorazepam: Cmax 16%,
AUC
Midazolam PIs EFV midazolam

EVG/c midazolam
midazolam
Triazolam PIs, EFV EVG/c Triazolam

Antidepressants
Sertraline DRV/r, EFV Sertraline 39% sertraline
EVG/c Sertraline Sertraline

Trazodone PIs, EVG/c Trazodone trazodone

Tricyclic antidepressants PIs TCAs TCAs
(TCAs) (Amitriptyline,
Desipramine, Doxepin EVG/c Desipramine AUC 65% trazodone
Imipramine, Nortriptyline)
(alpha-adrenergic blockers 5-alpha-reductase inhibitors)
Tamsulosin PIs Tamsulosin tamsulosin dose

Finasteride PIs Finasteride finasteride

Amiodarone PIs Amiodarone
EVG/c antiarrhythmics possible digoxin Cmax
41% and AUC no significant change

95
96

Diltiazem PIs Diltiazem diltiazem 50% ATV RTV
EVG/c Diltiazem
EFV Diltiazem AUC 69% diltiazem
NVP Diltiazem diltiazem
Dihydropyridine calcium EFV, NVP DCCBs CCBs
channel blockers (DCCBs) DCCBs DCCBs
PIs
pulmonary arterial hypertention
Bosentan PIs bosentan bosentan unboosted ATV
2560
PI ( unboosted ATV) > 10
bosentan 62.5 .
PI ( unboosted ATV) bosentan
bosentan 36 . PI
PI 10 62.5 .
EVG/c Bosentan EVG/c 10 :
bosentan 62.5 .

Bosentan () EVG/c Bosentan bosentan EVG/c:
bosentan 36 . EVG/c
EVG/c 10
bosentan 62.5 .

Sildenafil PIs Sildenafil sidelnafil 25 . 25 .
+ DRV/r sildenafil boosted PIs
sidelnafil 100 . DRV/r
RPV Sildenafil
ETR Sildenafil 57% ETR
EVG/c Sildenafil pulmonary hypertension EVG/c
priapism erectile dysfunction 25 .

48 .
(corticosteroids)
Dexamethasone PIs, NVP, EFV, ETR, Dexamethasone PIs, NVP, EFV, RPV,
(systemic) RPV ETR, RPV dexamethasone
EVG/c EVG/c dexamethasone
VL
corticosteroid

97
98

Fluticasone, budesonide RTV boosted Fluticasone budesonide
(inhaled intranasal) PIs, EVG/c
Herbal products
St.Johns Wort EFV, ETR, NVP, RPV NNRTIs
Hormonal contraceptives
Ethinyl estradiol (EE), ETR EE AUC 22%
progestin, Norethindrone
norgestimate, NVP EE AUC 29% Cmin 58%
norethindrone Norethindrone AUC 18%

Depot medroxyprogesterone acetate
2560
Levonogestrel (implant) AUC 30%

EFV EE AUC ,
Levonogestrel (oral) AUC 64%,
Norelgestromin AUC 64%, levonogestrel, norelgestromin, etonogestrel
Etonogestrel (implant) AUC 63%
Levonogestrel (implant) AUC 48%
RPV EE 14%
Norethindrone: no significant effect

Ethinyl estradiol (EE), ATV/r EE 19% Cmin 37% EE 35 g
progestin, Norgestimate 85% progestin
norgestimate, Norethidone AUC 51% Cmin norgestimate norethindrone
norethindrone 67%
DRV/r EE AUC 44%
() Norethindrone AUC 14%
LPV/r EE 42%
Norethindrone AUC 17%
EVG/c Norgestimate AUC, Cmax, and Cmin progestin (norgestimate)
> 2 /
Ethinyl estradiol AUC 25%
Cmin 44%
HMG-CoA reductase inhibitors

Atorvastatin EFV, ETR, NVP Atorvastatin AUC 32-43% atorvastatin
EFV, ETR
RPV Atorvastatin AUC
Atorvastatin metabolites
ATV/r Atorvastatin atorvastatin

LPV/r Atorvastatin 488%
99
100

Atorvastatin () DRV/r Atorvastatin atorvastatin
DRV/r + atorvastatin 10 . atorvastatin 20 ./
atorvastatin atorvastatin
40 .)
EVG/r Atorvastatin atorvastatin
Fluvastatin ETR Fluvastatin fluvastatin
Lovastatin, simvastatin EFV Simvastatin AUC 68% simvastatin

ETR, NVP Lovastatin simvastatin lovastatin
Simvastatin
2560
EVG/c Simvastatin simvastatin
myopathy rhabdomyolysis
Pravastatin, EFV Pravastatin AUC 44% pravastatin rosuvastatin
Rosuvastatin Rosuvastatin
ETR
EVG/c Pravastatin
Rosuvastatin AUC 38% and Cmax rosuvastatin
89%

Pitavastatin EFV Pitavastatin AUC 11%, Cmax 20%
ETR, NVP, RPV
All PIs ATV Pitavastatin AUC 31%,
Cmax 60%
LPV/r Pitavastatin AUC 20%
DRV/r Pitavastatin
Oral anticoagulant
Warfarin EFV, NVP Warfarin INR warfarin
ETR Warfarin INR warfarin
All PIs Warfarin INR warfarin
EVG/c Warfarin INR warfarin

Clopidogrel ETR clopidogrel

Salmeterol, long-acting EVG/c Salmeterol salmeterol
2 adrenergic receptor

agonist (LABA)
101
102

Colchicine EVG/c Colchicine
:
Colchicine 0.6 . , 0.3 . 1 .
colchicine 3

colchicine 0.6 . 2
colchicine 0.3 .
colchicine 0.6 .
2560
colchicine 0.3 .

Metformin DTG DTG 50 . metformin 1,000 ./
metformin 500 . 2 : / DTG metformin,
Metformin AUC 79%, Cmax 66% metformin
DTG 50 . 2 metformin GI
500 . 2 :
Metformin AUC 2.4 , Cmax 2

Opioid antagonist
Methadone Boosted PIs R-methadone (active form methadone withdrawal
methadone) methadone
LPV/r methadone 26-53%
ATV/r, DRV/r methadone
( methadone 16-18%)
EFV, NVP methadone 41-52% methadone withdrawal
methadone
ETR methadone
RPV R-methadone AUC 16% methadone
AZT AZT 29-43% AZT

EVG/c, RAL, DTG methadone
(Hepatitis C Direct-Acting Antiviral Agents)
Sofosbuvir/Ledipasvir EFV Ledipasvir AUC, Cmin, Cmax 34%
Sofosbuvir
ETR,NVP,RPV Sofosbuvir Ledipasvir


103
104

Sofosbuvir/Ledipasvir ATV/r Ledipasvir AUC 113% TDF toxicity
() Sofosbuvir boosted PIs
ATV AUC 33%
DRV/r, LPV/r, SQV/r
DTG, RAL, EVG/c DTG,RAL
TAF
TDF Ledipasvir TDF AUC 40-98% TDF toxicity
TDF+ RPV EFV boosted PIs
TDF boosted PIs TDF/FTC/Elvitegravir/cobi
Daclatasvir ATV/r Daclatasvir daclatasvir 30 ./
2560
DRV/r, LPV/r, Daclatasvir
unboosted ATV
EFV,ETR,NVP Cmin Daclatasvir 17% Daclatasvir 90 ./
Daclatasvir 120 . + EFV 600 .
RPV
DTG Daclatasvir
EGV/c Daclatasvir Daclatasvir 30 ./
RAL

Dasabuvir + Paritaprevir/ ATV ATV ATV 300 . Dasabuvir +
Ombitasvir/RTV Paritaprevir/Ombitasvir/RTV RTV
DRV DRV Cmin 43-48%
LPV/r Paritaprevir AUC 117%
EFV
ETR,NVP Dasabuvir,Paritaprevir/
Ombitasvir
RPV RPV AUC 150-225% QT prolong
DTG
EVG/c
RAL RAL AUC 134%

Elbasvir/grazoprevir ATV/r Elbasvir AUC 4.8
Grazoprevir AUC 10.6
Elbasvir ATV ALT elevation
Grazoprevir ATV 43% grazoprevir
DRV/r Elbasvir AUC 66%
Grazoprevir AUC 7.5

DRV
105
106

Elbasvir/grazoprevir LPV/r Elbasvir AUC 3.7
() Grazoprevir AUC 12.9
LPV
RPV Elbasvir, grazoprevir RPV

ETR, NVP Elbasvir, grazoprevir
EFV Elbasvir AUC 54 %
Grazoprevir AUC 83%
EFV
DTG Elbasvir, grazoprevir DTG

2560
EVG/c Elbasvir, grazoprevir
RAL Elbasvir, grazoprevir

elbasvir RAL
Grazoprevir RAL 43%
: AUC = aera under the curve
Cmax = maximum plasma concentration
Cmin = minimum plasma concentration
CrCl = creatinine clearance
3.13 NNRTIs, RAL and PIs
EFV ETR NVP RPV RAL
ATV Unboosted ATV: Unboosted ATV: ATV RPV Unboosted ATV:
ATV AUC 74% ETR: AUC 50% RAL AUC 72%
EFV
Cmin 58%
ATV: AUC 17%
Cmin 47%
Boosted ATV: ATV Boosted ATV: Boosted ATV: RPV Boosted ATV:
unboosted ATV ETR: AUC, Cmax, ATV: AUC 42% RAL AUC 41%
EFV Cmin ~ 30% Cmin 72%
ATV: AUC NVP: AUC 25%
Cmin 18%
ATV EFV ATV ETR NVP ATV

RTV ATV/RTV 300/100 ATV/r
.
DRV Boosted DRV: Boosted DRV: Boosted DRV: RPV AUC 130% Boosted DRV:
DRV AUC 13%, DRV: DRV: AUC 24% Cmin 178% RAL: AUC 29%
Cmin 31% NVP: AUC 27% DRV Cmin 38%
EFV: AUC 21% ETR: AUC 37%, Cmin 47%
Cmin 49%

107
108
EFV ETR NVP RPV RAL
DRV
() DRV/r 600/100 . DRV/r 600/100 . + DRV/r 600/100 . + DRV/r 600/100 . +
12 . + EFV 600 . ETR 200 . 12 . NVP 200 . 12 . RAL 400 . 12 .
24 .
EFV - ETR NVP RAL AUC 36%

EFV AUC 22%
-
ETR ETR - ETR ETR Cmin 17%
RAL Cmin 34%
2560
LPV/r LPV/r 500/125 . ETR 30-45% LPV AUC 27% RPV AUC 52% RAL
12 . + EFV 600 .: LPV 13-20% Cmin 51% Cmin 74% LPV/r
LPV LPV/r LPV/r
400/100 . 12 .
EFV
LPV/r 500/125 . LPV/r 500/125 . +
12 . + EFV 600 . NVP 200 . 12 .
24 .
EFV ETR NVP RPV RAL
NVP NVP ETR -

EFV AUC 22%
-
RAL RAL AUC 36% ETR Cmin 17% -
RAL Cmin 34%
-
* LPV 7.3 ./ (LPV 1-4 ./) EFV, NVP LPV/r
LPV/r + EFV

109
2560
3.8

3.14
3.14

anti-HBc, anti-HBs HBsAg
(hepatitis B)
HBsAg HBV Vaccine
anti HCV CD4 > 100 cells/mm3
(hepatitis C) ( CD4 )

-

2 neurosyphilis

1 MSM,
( 2-4
) Lumbar puncture failure to treatment,
ocular Syphilis tertiary
Syphilis CSF RPR neurosyphilis
110
111

CXR
CXR 14

2
*
1. (unexplained)
2. 1
3. 5 1
4. > 3 1
CXR AFB

* 2

CMV retinitis indirect ophthalmoscope
CD4 < 100 cells/mm3

serum cryptococcal Ag CD4 < 100
cells/mm3
Cryptococcus Ag positive LP
meningitis ( stiff neck + ve)
cryptococcus menigitis

2560

Anti HIV +
CD4 < 100 cells/mm3
()
Negative
serum cryptococcal
antigen + *
Positive
lumbar
puncture**

uconazole 800 . 2 CSF WBC, sugar ,

400 . 8 cryptococcal Ag +
amphotericin B 0.7-1 ././

+ uconazole 800 . 2
2 uconazole 400-800 .
8-10
10
uconazole 200 .

1 CD4 > 100 4-6 ***
cells/mm3 3
* primary prophylaxis
primary prophylaxis

** CT brain lumbar
puncture
112
113

( )
() LP cryptococcemia
fluconazole LP
cryptomeningitis IRIS
/ crypto-
coccal menigitis CSF cryptococcal
antigen serum cryptococcal Ag
cryptococcal meningitis (
serum antigen meningitis
disseminated disease serum antigen
CSF ) secondary prophylaxis
fluconazole 200 . CD4 > 100 cells/mm3 3

serum cryptococcal Ag
primary prophylaxis

cryptococcal capsular polysaccharide antigen serum
CSF latex agglutination (LA) enzyme immunoassay (EIA)
overall sensitivity 93-100% specificity 93-98% test
false positive (0-0.4%)
serum CSF
: cryptococcal antigen
rheumatoid factor ( LA serum specimen
CSF), non-specific protein CSF
autoimmune diseases, malignancy CNS involvement /
lymphoma/leukemia, ,
Trichosporon spp. false positive test titer 1:8

MSM transgender (TG)

Q2
Q9


2560

Q2 Q9
()

RPV, NVP
EFV

6

pap smear
1 CD4

controversial standard protocol

MSM digital anorectal
examination anal pap 1-3
anoscopy

114
115
3.9

VL CD4 VL
CD4
3.15

adherence (stable
on ART) VL < 50 copies/mL 1
3-6
6
VL < 50 copies/mL
VL > 50 copies/mL > 200 copies/mL

VL 50-200 copies/mL

VL 3
VL 6 VL < 50
copies/mL 1

2-4 VL


2560

CD4 CD4

CD4 < 350 cells/mm3 2
CD4 350 cells/mm3
VL > 50 copies/mL
VL < 50 copies/mL
2 CD4
3.10
2 NRTIs
AZT ddI NNRTIs PIs

CrCl
Child-Pugh score
3.16 3.17
116
3.16
eGFR CrCl (./)(1)
Hemodialysis
50 30-49 10-29 < 10
NRTIs
50-25 .
3TC 300 . 24 . 150 . 12 . 150 . 24 . 100 . 24 .(2) 50-25 . 24 .(2)
24 .(2) AD(3)
300 . 300 .
TDF(4) 300 . 24 . 300 . 48 .
2 7 AD(3)
AZT 200-300 . 12 . 100 . 8 . 300 . 24 .
15 .
d4T 30 . 12 . 30 . 12 . 15 . 12 . 15 . 24 . 15 . 24 .
24 . AD(3)
ddI(5) > 60 . 400 . 24 . 200 . 24 . 150 . 24 . 100 ./24 .

< 60 . 250 . 24 . 125 . 24 . 100 . 24 . 75 ./24 .
ABC 300 . 12 . 600 . 24 .
TDF/FTC 1 24 . 48 .
NNRTIs
EFV 600 . 24 .
NVP 200 . 12 .

117
118
eGFR CrCl (./)(1)
Hemodialysis
50 30-49 10-29 < 10
ETR 200 . 12 .
RPV 25 . 24 .
EFV/TDF/FTC 1 24 .
RPV/TDF/FTC 1 24 .
Protease inhibitor (PIs)
ATV 400 . 24 .
300/100 . 24 . Hemodialysis (HD)
: ATV/r 300/100 . 24 .
ATV ATV/r
2560
800/100 . 24 . (nave)
DRV
600/100 . 12 .
LPV/r 400/100 . 12 . HD
Integrase inhibitors
RAL 400 . 12 .
DTG 50 . 24 .
EVG/COBI/
150/150/300/200 . 24 . CrCl < 70 ./ CrCl < 50 ./
TDF/FTC
(1)
creatinine clearance:
: (140 - ) x (.) : (140 - ) x (.) x 0.85

72 x serum creatinine 72 x serum creatinine
(2)
150 . loading dose
(3)
AD:
(4)
CKD , TDF boosted PIs TDF
CrCl < 60 ./ 1 48 . tenofovir (GPO) 150 . 24 .
(5)
TDF

50 CrCl < 50 ./ TDF
TDF TDF + boosted PIs creatinine clearance (Cockcroft-Gault
Equation) < 60 ./ TDF 300 . TDF 150 . TDF
TDF
eGFR 30 ./

119
2560
3.17

Child-Pugh score
5-6 A 7-9 B 10 C
NRTIs
3TC
TDF
AZT
d4T
ddI
ABC 200 . 12 .
TDF/FTC
NNRTIs
EFV
NVP
ETR
RPV
EFV/TDF/FTC
RPV/TDF/FTC
PIs
ATV 300 . 24 .
RTV
boosting
DRV
LPV/r
Integrase inhibitor
RAL
EVG/COBI/

TDF/FTC
120
121
Child-Pugh score

1 2 3
Total bilirubin (./) <2 2-3 >3
(./) > 35 28-35 < 28
International normalized ratio (INR)
< 1.7 1.7-2.3 > 2.3

Prothrombin time
<4 4-6 >6
()

(ascites)

Encephalopathy* 1-2 3-4
: Encephalopathy
* 1:
2:
3: routable
4:
3.11
3
1) (life-threatening adverse effects)
2) (serious adverse effects)
3) (long-term adverse effects)
3.18

122
3.18
/
1) (life-threatening adverse effects)
Stevens-Johnson 2-3 NVP NVP 200 . 24
Syndrome (SJS) 2-3 CD4 > 250 cells/mm3 . 2
Toxic Epidermal Necrolysis cotrimoxazole
(TEN) 200 . 12 . supportive, cross reaction
skin eruption , , NNRTIs
NVP 0.3-1%, mucosal ulceration parenteral nutrition
DLV EFV 0.1%, ( )
ETR < 0.1% blister/bullae
2560
1-2 AZT, superinfection
ddI, ABC, IDV, LPV/r, epidermal detachment corticosteroids

ATV, DRV necrosis IVIG

fluid depletion, bacteria
or fungal superinfection,
multiorgan failure
NVP

/
1-3 CD4 NVP NVP NVP
18 (> 250 cells/mm3
NVP , > 400 cells/mm3 CD4 > 250 cells/mm3
hepatic necrosis ) CD4 > 400
Baseline AST cells/mm3
NVP 4% ALT
11% HBV /
3
CD4 > 250 cells/mm HCV NVP
( 0.9% NNRTIs
CD4 250 fulminant 2 supportive care EFV
3
cells/mm ) 6.3% hepatic failure NVP
CD4 > 400 encephalopathy

3
cells/mm ( AST ALT
2.3% CD4 50% 2
3
400 cells/mm ) 3TC
FTC TDF
DRESS syndrome

123
124
/
Lactic acidosis, hepatic NRTI d4T
steatosis +/- pancreatitis d4T ddI supportive care lactate
(severe mitochondrial nonspecific ddI, AZT IV fluid
toxicities) gastrointestinal syndrome acidosis IV
BMI lactate bicarbonate,
NRTIs d4T ddI hemodialysis/
d4T ddI hemofiltration, serum lactate
AZT ddI
0.85% hydroxyurea IV thiamine
50% ribavirin / riboflavin

2560

: lactate
Lactate ( > 5 mmol/L) NRTIs mitochondrial toxicities
Arterial pH ( < 7.0) ABC, TDF, 3TC, FTC
Serum CO2 serum lactate
Anion gap NRTI-sparing regimens
ALT, AST, prothrombin time, bilirubin , albumin boosted PIs + NNRTI LPVr + EFV (
amylase lipase LPV/r 500/125-600/150 . 12
Histology microvesicular . EFV 600 . 24 .)
macrovesicular steatosis
/
Lactic acidosis, rapidly d4T d4T
progressive ascending
neuromuscular weakness
supportive care

d4T ascending lactic
demyelinating acidosis
polyneuropathy

Guillain-Barr plasmapheresis, high
syndrome dose steroid, IVIG,
carnitine


:
Serum lactate, anion gap

Arterial pH, serum CO2
Creatine phosphokinase


125
126
/
Hypersensitivity reaction HLA-B*5701, ABC ABC ABC
(HSR) 9 90% HLA-DR7, HLA-DQ3 HLA-B*5701 HSR
6 HSR grade 3 screening ABC
ABC 4 ABC ABC 48 .
8% 600 . 24 . HSR
2-9% 300 .
12 . (5% supportive
2%) IV fluid HLA-B*5701
screening
2560
HSR ABC
ABC viral syndromes ABC

/
2) (serious adverse effects)
Skin rash 2-3 NVP NVP 200 . 24
. 2
NVP 14.8% diffuse antihistamine NVP
( 1.5%), EFV maculopapular rash EFV 18
26% ( grades 3-4 1%), AST, ALT
ABC < 5%
HSR, ATV 2.1%
( < 1%) bleb
TDF, mucous membrane NNRTI blisters, ,
LPV, AZT, 3TC involvement NNRTI mucous
membrane involvement

3
Bone marrow suppression 2-3 Advanced HIV AZT AZT NRTI
AZT G-CSF
AZT neutropenia
1.1-4.0% neutropenia erythropoietin
neutropenia 1.8-8.0%

CBC

anemia
3-6 (
neutropenia cotrimoxazole, ribavirin, folic acid supplement

ganciclovir )
127
128
/
Hepatotoxicity, clinical NNRTIs 60% HBV/HCV NVP hepatotoxicity
hepatitis or symptomatic 12 HBV
serum transaminase AST, ALT 3TC, FTC, TDF
elevation 2 4
1
50% NVP-associated hepatic 3
NNRTIs, PIs, NRTIs NVP hepatitis events 3-6 AST, ALT
CD4 > 250 cells/mm3
NRTIs d4T, CD4 > 400 AST, ALT ALT > 5-10
ddI, AZT cells/mm3 3-4
AST, ALT

3TC, FTC, TDF
2560
HBV

PIs

/
Nephrolithiasis, 1.5- IV fluid
urolithiasis, crystalluria nephrolithiasis 2
/
IDV 12.4% pyuria, hematuria, crystalluria peak IDV urinalysis serum
(4.7-34.4%) creatinine IDV creatinine 3-6 IDV
ATV, EFV
Nephrotoxicity TDF

TDF ATV serum creatinine,
nephrogenic diabetes insipidus
urinalysis, serum potassium

Fanconi syndrome phosphorus supportive care
: CD4 electrolytes
TDF: Cr , proteinuria, glycosuria,
hypokalemia, hypophosphatemia,
non-anion gap, metabolic acidosis

129
130
/
Pancreatitis intracellular ddI
/ serum ddI
ddI 1-7% pancreatitis
ddI d4T pancreatitis ddI pancreatitis
ribavirin hydroxyurea Amylase lipase d4T, ribavirin, hydroxyurea bowel rest, IV hydration,
3TC, ddI pain control, parenteral
d4T TDF hypertriglyceridemia TDF nutrition
ddI d4T,
hydroxyurea, ribavirin amylase lipase
2560

ddI TDF
ddI
hypertriglyceridemia
Bleeding episodes 2-3 PIs NNRTI Factor VIII
increase in hemophiliac hemophilia regimen
patients
PIs
/
3) (long-term adverse effects)
Lipodystrophy baseline BMI LPV/r
lipoatrophy ATV/r
Lipohypertrophy Lipohypertrophy injectable poly-L-lactic visceral fat
PI acid
NNRTI-based regimens
lipohypertrophy
d4T AZT (dorsocervical lipohypertrophy recombinant human
fat pad buffalo growth hormone
Lipoatrophy hump) GH-releasing hormone
NRTIs d4T Lipoatrophy restorative analogue
AZT,
ddI TDF,
ABC
Hyperlipidemia PIs NNRTIs cardiac risk
factors

PIs ( PIs LDL, TC
d4T lifestyle
unboosted ATV) 47- TG - PIs: RTV-boosted PIs fasting lipid profile modifications
75% HDL ATV, ATV/r 3-6 simvastatin
NRTIs NNRTIs DRV, LPV, SQV LDL, atorvastatin
PIs > NNRTIs boosting RTV TG
EFV > NVP d4T TG, LDL TC rhabdomyolysis
d4T > AZT > ABC > EFV, NVP LDL, TC,
TDF TG HDL EFV


NVP
131
132
/
Insulin resistance/diabetes hyperglycemia
mellitus

polyuria, polydipsia, FBS

d4T, AZT PIs polyphagia, fatigue 1-3 d4T, AZT
3-5% 3-6
NNRTIs

metformin,
glitazones, sulfonylurea
insulin
Peripheral neuropathy peripheral
neuropathy
ddI 12-34%, d4T advanced HIV
2560
52% neuropathy disease

monotherapy d4T ddI gabapentin,

tricyclic antidepressants,
painful neuropathy intracellular activities lamotrigine,
ddI oxycarbamazepine,
TDF, hydroxyurea, topiramate, tramadol,
ribavirin narcotic analgesics,
capsaicin cream, topical
lidocaine

/
Osteonecrosis Advanced AIDS Conservative management:
periarticular pain steroids steroid
old PIs
Surgical intervention:
HIV Early stages core decompression /
symptomatic hyperlipidemia 15% bone head bone grafting
osteonecrosis 0.08-1.33% 85% femoral head MRI 3-6 Severe debilitating disease total joint
asymptomatic 1 arthroplasty
osteonecrosis 4% 6 1
MRI
Cardiovascular effects, cardiac risk
including myocardial CVD factors hyperlipidemia, hypertension, insulin resistance/
infarction (MI), coronary diabetes mellitus
cerebrovascular accidents artery disease cardiac risk factors
(CVA) cerebrovascular coronary artery lifestyle modifications

accidents disease
premature hyperlipidemia
PIs MI CVA coronary artery disease hyperglycemia cardiovascular effects NNRTIs
ABC MI lifestyle modification ATV-based regimen d4T
ddI MI
observational studies
RCT
MI 0.3-0.6%

CVA 0.1%
133
2560
3.12 ()

PIs 1.7-2.3

National Cholesterol Education Program,
Adult Treatment Panel III (NCEP ATP III)
10 Framingham
LDL 3.1

10 10
LDL-C 80
./

(lifestyle modification)

primary secondary
coronary prevention statin
LDL
3.1 LDL
134
3.1
10 1

10 20%2

SBP > 140 mmHg 2

DBP > 90 mmHg
10 10%

HbA1C < 6.5-7.0% 3 (mg/dL)

4
SBP < 130 mmHg SBP < 140 mmHg 155 190
DBP < 80 mmHg DBP < 90 mmHg LDL 80 115

135
2560
:
1. 10
10 Framingham www.cphiv.dk/tools.aspx
2.
. Boosted PIs RPV, NVP, RAL Boosted PIs

. d4T, AZT TDF ABC
3.
LDL
> 400 ./ LDL [ LDL =
TC - HDL - (TG/5)] LDL 30 ./
4.

> 1,000 ./

3.19

PI
NNRTI
Statin Atorvastatin 10-80 ./ 1 2
( 40 ./)
Fluvastatin 20-80 ./ 2 2
Pravastatin 20-80 ./ 2,3 2
Rosuvastatin 5-40 ./ 1 1
( 20 ./)

Simvastatin 10-40 ./ 2
Pitavastatin 1-4 ./

Cholesterol Ezetimide 10 ./
uptake
:
1. statin statin

2. statin statin statin

136
137
3. DRV/r pravastatin
pravastatin metabolism CYP450
. atorvastatin
atorvastatin 10-20 ./ pitavastatin
statin
pravastatin
3.13
(Adherence to antiretroviral therapy)

adherence

adherence
adherence
1 adherence

adherence

3.14 Immune reconstitution inflammatory syndrome (IRIS)
IRIS


2560
3.20 Immune reconstitution

inflammatory syndrome IRIS
Definition
IRIS

IRIS 2
Unmasking IRIS
3-6
Paradoxical IRIS

mycobacteria (TB MAC) cryptococcus
3-6
CD4 50-100 cells/mm3

CD4
IRIS (Graves disease)

IRIS

IRIS IRIS

paradoxical IRIS
NSAIDs short course corticosteroids
IRIS

systemic corticosteroids
138
139
3.21 IRIS

Tuberculosis paradoxical reaction
38.5oC, , ,
cutaneous lesions, ascites, CXR worsening, tuberculoma, inflammatory
bowel perforation, serositis, psoas abscess
MAC Localized lymphadenitis, necrotizing subcutaneous nodules,
atypical mycobacteria endobronchial tumors, small bowel involvement, paravertebral
abscesses, osteomyelitis, arthritis, focal brain lesion, ileitis
CMV CMV retinitis CD4 , immune recovery vitreitis,
immune recovery uveitis, CMV pneumonitis
, pseudotumoral colitis,
adenitis, encephalitis, cutaneous ulceration
Hepatitis (B,C)
Parvovirus B19 Encephalitis, worsening anemia
Herpes simplex Erosive herpes simplex encephalitis
Varicella zoster virus Acute retinal necrosis ,

Kaposi's sarcoma (KS) Worsening KS lesion with inflammation and edema
PML Inflammatory PML variant
BK virus Hemorrhagic cystitis
Cryptococcus Recurrent meningitis , pulmonary cryptococcosis,
cutaneous cryptococcosis (recurrent abscesses), necrotizing mediastinal
cervical lymphadenitis, intracranial cryptococcoma, intramedullary
abscess, necrotizing pneumonitis
PCP Pneumonitis (patchy aveolar or reticulonodular infiltrates)
Skin yeasts Folliculitis
Sarcoidosis Worsening of sarcoidosis, pulmonary infiltrates, erythrema nodosum,
lymphadenopathy, interstitial nephritis
Toxoplasmosis Encephalitis
Leishmaniasis Vitreitis, uveitis, post-kala-azar dermal leishmaniasis

2560

Bartonella henselae Granulomatous splenitis
Leprosy Leprosy cutaneous lesions
Microsporidia Keratoconjunctivitis
Chlamydia trachomatis Reiters syndrome
Non infectious etiology Grave diseases, SLE, vasculitis, relapsing Guillain-Barres syndrome,
rheumatoid arthritis, polymyositis, alopecia universalis, cerebral
vasculitis, hyperergic reaction ( ),
pre-eclampsia, multiple eruptive dermatofibromas, eruptive cheilitis,
Peyronies disease
3.22 IRIS
Paradoxical IRIS
IRIS
1.

2. 1

1

Unmasking IRIS
IRIS
1.

2.

140
141
Unmasking IRIS ()
3.

3

3.15
3.15.1 (Acute HIV infection)

Early HIV infection

6
(Acute HIV infection acute

retroviral syndrome)

anti-HIV inconclusive qualitative HIV
RNA p24Ag
sero conversion 6
6
anti-HIV positive

2560
early HIV infection

40-90
acute retroviral syndrome

VL
( > 100,000 copies/mL)

anti-HIV negative
positive 6

NAT anti-HIV
window period anti-HIV ( 4
window period 3 )
VL > 100,000 copies/mL p24Ag
/ anti-HIV inconclusive (negative or weakly
positive ELISA)
early HIV infection

early HIV infection

142
143
early HIV infection

5
3.23 acute HIV infection

96
74
70
(erythematous maculopapular rash) 70

54
32
32
27
14
13
(thrush) 12
( aseptic meningitis, peripheral neuropathy, facial 12
palsy, Guillain-Barre's syndrome, brachial neuritis cognitive impairment)

2560
3.15.2

> 40 30-50

1-4

HIV/HBV co-infection
TDF, FTC 3TC

3.24 3.25
3.24 HIV/HBV co-infection

HBsAg 6

liver function test, HBeAg
HBV HBV DNA
ultrasound liver

HBV

HAV
HAV IgG
HIV/HBV
co-infection 3.25
144
145
3.25
/
HIV Backbone: TDF/FTC TDF + 3TC
3TC FTC TDF
HBV
FTC, 3TC hepatic
TDF flare
entecavir ( 3TC
entecavir 1 ./) hepatic flare
HIV FTC, 3TC TDF, 3TC
TDF FTC
TDF FTC 3TC d4T
TDF AZT TDF HIV RNA < 50 copies/mL

HIV/HBV HIV/HBV TDF/FTC TDF + 3TC
tenofovir HBsAg HBsAg
CrCl < 30 ./ 10-20 HIV/HBV
tenofovir HBsAg tenofovir
HBsAg HBV DNA < 2,000 IU/mL
entecavir HBV DNA
TDF/FTC TDF/3TC > 3
HBV TDF
HBV 3TC HBV
boosted PI + 3TC
TDF abacavir
HIV LPV/r + 3TC ARV
nave (GARDEL study) ARV experience HIV
RNA < 50 copies/mL (OLE study) ATV/r + 3TC
ARV experience HIV RNA < 50 copies/mL (SALT
study)
AZT d4T VL < 50 copies/mL
TDF

2560
/
1. FTC, 3TC TDF eGFR
3.16
2. TDF entecavir entecavir

HBV 3TC
CrCl > 50 ./, entecavir 0.5 ./
CrCl 30 - < 50 ./, entecavir 0.25 ./ 0.5
. 48 .
< 30 ./, entecavir 0.15 ./ 0.5 .
CrCl
72 .
CrCl < 10 ./, hemodialysis, CAPD, entecavir 0.05
./ 0.5 . 7
HBV 3TC/decompensated liver disease
CrCl > 50 ./, entecavir 1 ./
CrCl 30 - < 50 ./, entecavir 0.5 ./ 1 .
48 .
< 30 ./, entecavir 0.3 ./ 1 . 72
CrCl
.
CrCl < 10 ./, hemodialysis, CAPD, entecavir 0.1 ./
1 . 7
3. TDF
ABC
4. HIV RNA <50 copies/mL
LPV/r + 3TC ATV/r + 3TC
> 40 > 50
liver ultrasound

HIV/HCV co-infection
3 45-50
pegyrated interferon/
ribavirin 1 30-35
pegyrated interferon/ribavirin

146
147
3-6

Direct acting antiviral (DAA)

(extrahepatic manifestation)

95 3
24-48
8-12 20-24
anti HCV 3.26-3.31
3.26 anti-HCV

anti-HCV
HCV RNA
anti-HCV
HCV RNA
spontaneous clearance
HCV RNA
liver fibrosis
(LFT) APRI, FIB-4
ultrasound /
(liver stiffness) transient elastography

HBsAg, anti-HBc HAV Ab

(HCV genotype)

2560

acute
anti-HCV HCV HCV RNA

HCV RNA
CD4 HCV RNA 6
< 100 cells/mm3 3.2
(crystal metamphetamine) spontaneous
clearance
HCV RNA

anti-HCV
CD4 100 cells/mm3
3.2 anti-HCV
Anti HCV Ab
positive
HCV RNA
Positive: EASL 2015

active HCV negative
infection HCV RNA
3

Further Refer for Spontaneous
HCV
evaluation treatment clearance
Genotype
Fibroscan/APRI/Fib-4
EASL: European Association for the Study of the Liver

APRI: AST to Platelet Ratio Index
Fib: Fibroscan
148
149
3.27 HIV/HCV co-infection

12
24 genotype 3
ribavirin
HIV/HCV co-infection
HIV RNA < 50 copies/ml

AST ALT 1
3
AST ALT

> 5 upper limit laboratory
reference range

HAV HBV

ALT 10 upper limit

ALT 5 upper limit

d4T, ddI, AZT HIV/HCV co-infection
ribavirin
AZT, d4T, ddI
HBsAg anti-HBs CD4 350
cells/mm3 HIV RNA < 50 copies/mL
CD4 < 350 cells/mm3
ultrasound liver 6-12
fibroscan > 14kPa
APRI > 1.5 FIB-4 > 3.25
DAA NS5A inhibitor, HCV
PIs inhibitor
efavirenz DAA
daclatasvir, elbasvir/ grazoprevir, sofosbuvir/velpatasvir
HCV

2560

MSM IDU

(reinfection) 30-40

3.28 DAA

Sofosbuvir HCV NS5B inhibitor nucleotide metabolize cytochrome
polymerase inhibitors P450 enzyme p-
glycoprotein transporter

Ledipasvir HCV NS5A inhibitor TDF TDF
sofosbuvir + TDF
ledipasvir boosted PIs tenofovir
sofosbuvir/ledipasvir toxicity
400/90 ./ (1 1 )
CrCl < 30 ./
HCV genotype 1, 2, 4,
5, 6 3
60-70%
Dasabuvir
ombitasvir (NS5B inhibitor)
(NS5A inhibitor), Paritaprevir substrate CYP3A4
paritaprevir inhibitor CYP3A4 enzymes ATV RTV
(HCV PI)/RTV dasabuvir metabolized
CYP2C8 enzymes
ombitasvir,paritaprevir,dasabuvir
UGT1A1
substrates P-gp
150
151

Daclatasvir HCV NS5A inhibitor p-glycoprotein transporter
sofosbuvir
EFV, ETR, NVP
12
24 daclatasvir daclatasvir
90 ./
ribavirin ATV/r
daclatasvir daclatasvir daclatasvir
60 . (1 1 ) 30 ./
HIV/HCV

HCV
EFV RPV
ATV/r LPV/r
(ATV/r)
daclatasvir 30 ./
Elbasvir genotype 1, 4 p-glycoprotein
(NS5A inhibitor)/ 1 transporter
grazoprevir
(HCV PI) EFV

Sofosbuvir NS5B inhibitor/ p-glycoprotein
Sofosbuvir/ velpatasvir NS5A inhibitor transporter
velpatasvir genotype
1 EFV
tenofovir
tenofovir toxicity
CrCl < 30 ./

2559 pegylated
interferon, ribavirin, sofosbuvir, daclatasvir pegylated interferon,
ribavirin 2559 pegylated interferon/ribavirin + sofosbuvir 12
Daclatasvir + sofosbuvir 3 sofosbuvir/ledipasvir
3

2560
3.29 pegylated
interferon
*
18 (decompensated cirrhosis)

> 6
HCV RNA 5,000 interferon ribavirin
IU/mL
3
HIV RNA < 50 copies/mL

* - pegylated interferon/ribavirin

- AZT, d4T ddI
ribavirin
152
3.30

DCV/SOF LDV/SOF SOF/RBV DCV/SOF DCV/SOF/RBV LDV/SOF LDV/SOF/RBV SOF/RBV
Genotype 1 12 12 * 24 12 24 12 **
Genotype 2 12 16
Genotype 3# 12 24 24
Genotype 4 12 12 24 12 24 12
Genotype 5 12 24 12
Genotype 6 12 24 12


* 8 nave, HCV RNA < 6 million/IU/mL, no cirrhosis
** < 75 x 103 IU/uL, RBV 24
# AASLD/IDSA guideline July 2016: SOF/DCV SOF/VEL 12 HCV genotype 3, non cirrhosis SOF/VEL SOF/DCV+/-
RBV 24 HCV genotype 3, compensated cirrhosis SOF/VEL SOF/DCV+RBV (low dose) 12 HCV genotype 3,
compensated cirrhosis
: DCV/SOF-Daclatasvir/Sofosbuvir, SOF/VEL-Sofosbuvir/Velpatasvir, LDV/SOF-Ledipasvir/Sofosbuvir, SOF/RBV-Sofosbuvir//Ribavirin

153
154
3.31

Simeprevir/ DCV/SOF Ombitasvir/ Ombitasvir/ SOF/RBV DCV/SQF Simeprevir/ Simeprevir/ Ombitasvir/ SOF/Peg
SOF Paritaprevir/ Paritaprevir/ SOF SOF/RBV Paritaprevir/ IFN/RBV
RTV/ RTV/ RTV/
dasabuvir dasabuvir dasabuvir
Genotype 1 12 a 12 b 24 a 12 a 24 b
Genotype 2 12 12 12
Genotype 3 12
2560
Genotype 4 12 12 24 12 a 24
Genotype 5 12 12
Genotype 6 12 12
a. genotype 1a Q80K Sim/SOF
b. genotype 1a: Ombitasvir/Paritaprevir/RTV/dasabuvir ribavirin
genotype 1b: Ombitasvir/Paritaprevir/RTV/dasabuvir
155
3.15.3

50

1.

(
CD4)

2. (pharmacokinetic)
> 40 glomerular
filtration rate 1 .

CrCl Child-Pugh class

3.

albumin
CYP450

2560

AZT
TDF PIs
4.

3.32
3.32

d4T, ddI AZT

NVP, EFV boosted ATV/r DRV/r
PIs
ABC, ddI, LPV/r

TDF TDF
ATV
ATV

NVP
boosted PIs, d4T ddI
d4T
ddI non-cirrhotic
portal hypertension
156
157

TDF
ATV/r EFV

EFV EFV

Cognitive impairment

5.

6.
2
2
2
5


2560

EFV
EFV
3.15.4

(MSM) (TG)
adherence
(retention)
MSM TG

/
/

MSM TG

3
6

(cardiovas-
cular disease)

TG

158
159

() erectile
dysfunction

(digital rectal examinations)

(
fosampinavir ampinavir
)
adherence

DMPA
3.12

TG


2560

/ /
MSM
TG

3

160
161
3.15.5

2
(AIDS-related malignancies)
Kaposi sarcoma Non-Hodgkins (Non-Hodgkins
lymphoma)
(primary central nervous system lymphoma)

2 (non-AIDS-related malignancies)


2560

(oncogenic virus) human
herpes virus (HHV) 8, Ebstein-Barr virus (EBV), human
papillomavirus

2 2

/

CD4 VL
CD4

CD4 200 cells/mm3
CD4 < 200 cells/mm3

162
163

()

/
CD4

(drug-
drug interaction)
protease inhibitors
taxanes, vinca alkaloids, etoposide
gefitinib

AZT

d4T ddI peripheral neuropathy


2560
3.15.6

3.33
3.33

VL 2-3

NNRTIs NNRTIs boosted PIs
(elective) 10-14

NNRTIs 7-10
NRTIs

PIs

164
165
3.15.7
methadone

HCV
methadone
adherence HIV/HCV
coinfection 3.15.2
methadone 3.34 1
3.34 PIs methadone

Boosted PIs
DRV/r R-methadone* 16% methadone
withdrawal
methadone
LPV/r methadone 26-53% methadone
withdrawal
methadone
ATV/r R-methadone* 16% methadone
withdrawal
methadone
Unboosted PIs
ATV
NNRTIs
EFV methadone 52% methadone
withdrawal
methadone

2560

NVP methadone 50% methadone
withdrawal
methadone
ETR
RPV
Integrase strand transfer inhibitors (INSTIs)
RAL
DTG
EVG/COBI
* R-methadone = active form methadone
3.15.8
TDF

proximal tubular dysfunction persistent proteinuria
[urine dipstick > 1 urine protein/creatinine (UP/C) > 30 mg/mmol],
glycosuria eGFR
phosphaturia
TDF
TDF (vi)
Fanconi syndrome TDF Assessment:
Tests for proximal renal tubulopathy/renal
Fanconi syndrome(iii)
Consider renal bone disease
hypophosphataemia :
25(OH) vitamin D, PTH, DXA
166
167
TDF (vi)
Proximal tubulopathy with any combination TDF :
of: Progressive decline in eGFR
1. Proteinuria: urine dipstick 1,
urine protein/creatinine (UP/C) Confirmed hypophosphataemia
> 30 mg/mmol, glycosuria
(i) Osteopenia/osteoporosis
2. Progressive decline in eGFR and eGFR urine phosphate leak
< 90 mL/min(ii) eGFR

3. Phosphaturia(iii): confirmed hypophospha-
taemia secondary
phosphate
(i) spot urine urine protein/creatinine (UP/C) total urinary protein

glomerular tubular urine dipstick albuminuria
glomerular disease tubular
(ii) For eGFR: CKD-EPI formula
(iii) Proximal Renal Tubulopathy (PRT)
3.35 TDF
HIV
glomerular function
tubular function eGFR 6 UA 1
eGFR HIV

> 60 ml/min/1.73 m2 Protease inhibitor, ,
proteinuria, ,
normoglycemic glucosuria
phosphaturia NSAIDs
eGFR, UA
phosphorus 6

2560
HIV
proteinuria / TDF
eGFR 60 ml/
min/1.73 m2 TDF
eGFR
eGFR
proteinuria
TDF
TDF

proteinuria

TDF

1 3

TDF

2 TDF
TDF eGFR
proximal dysfunction
dose TDF

eGFR / eGFR
proximal proximal dysfunction
dysfunction eGFR
Bone demineralization

TDF proximal tubular dysfunction
proteinuria, normoglycemic glucosuria phosphaturia
phosphorus
168
169
HIV
proteinuria normoglycemic
glucosuria phosphaturia fractional excretion
phosphorus proteinuria
normoglycemic glucosuria phosphorus presumptive
diagnosis TDF
proximal tubular dysfunction TDF
eGFR TDF
eGFR proximal
tubular dysfunction
3.3 TDF HIV
eGFR 60 cc/min proteinuria

1 3
6
eGFR Cr 6 UA
1 *
2
1 3
Cr (optional)
(optional)
eGFR proteinuria 1+
normoglycemic glycosuria
TDF TDF
1
TDF

2560
eGFR < 60 cc/min protein 1+
TDF

1-2
1-3 Cr
(optional)
eGFR
proteinuria normoglycemic
glycosuria TDF

(hemodialysis, HD), (peritoneal dialysis, PD)
(kidney transplantation, KT)

ESRD

170
171
(chronic kidney disease: CKD)

1. Screening/Detection proteinuria, urine
sediment BUN, Cr eGFR
2. Diagnosis/Treatment/Delayed Renal Progression

3. Counseling/
counseling

4.
(PD)
Tenckhoff PD elective
unplanned HD PD

(HD)
AV fistula

AV fistula
elective HD unplanned HD
AV fistula tunneled cuffed catheter AV graft


2560

(standard infection control)

1.
2.

3.
CDC

sterilization
4. ultrafiltrate
ultrafiltrate
ultrafiltrate

ultrafiltrate
:

(dialyzer)
(blood line)
(benzalkonium chloride)
heparin
172
173
Hemodialysis vascular access

arteriovenous graft (AVG)
arteriovenous fistula (AVF)
vascular access AVF
AVF AVG
(tunneled catheter)
(Renal transplant recipients)

3.16

CD4

CD4

3.36
(live-attenuated vaccine)
measles, mumps, varicella zoster yellow fever

2560
3.36

Hepatitis A 2 :
vaccine HAV (MSM)
(HAV) ( HBV/HCV) clotting factor
concentration HAV
serum HAV IgG
2 : 2 6-12
Hepatitis B 3 HBV HBsAg,
vaccine anti-HBs, anti-HBc
(HBV) 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
CD4 < 350 cells/mm3
Human 3 HPV 4 (quadrivalent)
papillomavirus 9-26
vaccine (HPV) 19-26 MSM
HPV
(anal cancer)

Influenza
1
nasal spray
Tetanus and 1 1 10
diphtheria Tetanus, diphtheria and pertussis (Tdap) Td
toxoid (Td) TT 1
Tetanus
Toxoid (TT)
23-valent 1 CD4 > 200 cells/mm3
pneumococcal 1 5
polysaccharide 65 65
vaccine PCV-13 PPSV-23
(PPSV-23) 1
174
175

13-valent 1 CD4 > 200 cells/mm3
pneumococcal
conjugate PPSV-23 PCV-13
vaccine 2
(PCV-13)
Rabie vaccine 5 2 rabies
neutralizing antibody
()
19-27 27-64 65
Influenza
Tetanus,diphtheria,pertussis (Td/TT/Tdap) 1 Td ( TT) 10
Td (or TT) Tdap 1
(Varicella)
(HPV) 3
(0, 2, 6 )
(HPV) 3
Measles, mumps, rubella (MMR)
PCV13 1 1 ( > 50 )
PPSV-23 1 1 1
Meningococcal*
(hepatitis A) 2
:
HAV
( HBV/
HCV) clotting factor concentration
HAV
serum HAV IgG
(hepatitis B) 3
HBV
HBsAg, anti-HBs, anti-HBc
2

(optional vaccine)
*
10
(meningitis belt)
(anatomic functional asplenia)

Management of HIV-Infected Children and Adolescent
177
4

(Management of HIV-Infected Children and Adolescent)

1. 18

2.

HIV DNA
PCR
HIV DNA PCR 4 , 1, 2
4
HIV DNA PCR 2
1 2-4
3. HIV DNA PCR
HIV DNA PCR HIV RNA
viral resistance

AZT + 3TC + LPV/r HIV DNA PCR
HIV DNA PCR

HIV DNA PCR

4. 18

2560
5.

< 1 1-< 5 5-15
WHO WHO
stage 3,4 stage 3,4

CD4 CD4 < 500 cells/mm3
1-3 CD4 < 25
CD4 < 1,000 cells/mm3
3-< 5 CD4
< 25 CD4 < 750
cells/mm3
6. 4.6

< 3 3-12 > 12
AZT ( ABC) + AZT ( ABC) + TDF + 3TC (FTC) +
(preferred regimens) 3TC + LPV/r 3TC + EFV EFV
AZT ( ABC) + AZT ( ABC) + AZT ( ABC) +
(alternative regimens) 3TC + NVP 3TC + NVP 3TC + EFV
TDF + 3TC (FTC) + TDF + 3TC (FTC) +
EFV ATV/r
TDF + 3TC (FTC) + TDF + 3TC (FTC) +
NVP RPV
7. 1

4.7
8. drug interaction
rifampin efavirenz
2-8
178
179
9.
CD4 6 > 5
plasma HIV Viral load < 50 copies/ml, CD4 > 500 cells/mm3
CD4
10.

4.7
11.
(Transition to adult clinic) 4.14
12.
CD4
< 12 1-5 6-12

CD4 count CD4 count CD4 count
CD4 CD4 CD4
1: 1,500 34 1,000 30 500 26
2: 750-1,499 26-33 500-999 22-29 200-499 14-25
3: < 750 < 26 < 500 < 22 < 200 < 14

2560

5,000
2557 2.1
100

18

( 2 2.1
)

180
181
4.1

PCP 4-6

Isoniazid

HIV DNA PCR

HIV DNA PCR

HIV DNA PCR 4 1, 2
4
HIV DNA PCR 2
1 2-4
4.1.1

5

2560
4.1.2

AZT
CBC 1

Pneumocystis
jiroveci (PCP)

1)
CD4 > 25
CD4 15
6
CD4 > 15
CD4
2)

immunoglobulin (TIG)
(RIG)

4.1
182
4.1
.. 2559

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

1 BCG
2 HBV1 (HBV2) DTwP- DTwP- DTwP-
HBV1 HBV2 HBV3
--3 DTwP DTwP DT
1 2
4 OPV1 OPV2 OPV3 OPV or OPV or
or or or IPV IPV
IPV IPV + IPV 1 2
--5 MMR1 MMR2

6 MBVJE1, JE2 MBVJE3
4

183
184

1 2 4 9 12
6 4-6 11-12
18 2-2
-- DTaP1 DTaP2 DTaP3 DTaP DTaP Tdap
( 4 DTaP, 7 ; Tdap)3 1 2
6 (Inactivated JE) Inactivated JE 3 JE4 (4-5
JE3)
7 (Hib: PRP-T, PRP-OMP) Hib1 Hib2 Hib3 Hib4
8 (HAV) HAV1, HAV2 6-12
9 (VZV) VZV1 VZV2
2560
10 (influenza) 6
11 PCV1 PCV2 PCV3 PCV4

(PCV PPSV23) 12-15 PPSV23 2 5

12 (HPV) HPV 3
9-26
(Rota)13 Rota 1 Rota 2 (Rota 3)

pentavalent
185
1.
1) BCG
BCG
BCG
2) 0.1 .
3)
4)
2.

1) 3 6
2) HBsAg 3 1-2
6 1
12 . 2 3 1 6
3) HBsAg ( HBeAg )
HBIG 0.5 . 12 . 1
HBIG
a. HBIG 2 1-2 3 6

b. HBIG 1 12 . 2
1 3 6
4) HBsAg HBIG
7
5) -
-- (DTP-HB) 2, 4, 6 HBsAg
HBIG 1
( 5 )
6) HBsAg HBsAg anti-HBs
9-18
3. --
1) (DTaP) (DTwP)
2) DTaP 2, 4, 6

3) 18 DTwP DTaP
4) 4-6 DTwP, DTaP Tdap
5) 11-12 Td Tdap Tdap 4-6
Td 10

2560
4.
1) IPV OPV IPV

2) OPV 5 IPV
1 4 trivalent OPV bivalent OPV
2559
3) 4
18
5. --
-- (clinical stage C
CD4 < 15) CD4 > 15
1) 9-12 2
2 12 2
4-6
2) 6
2 2 3
9 2 12 3 2
3) --
--- (MMRV)
1-12 MMRV 2-6
MMRV
12-23
MMR VZV MMRV MMR
1 VZV 3
6.
3 1 0, 1 , 1
1 3 4-5
(
6 CD4 > 15% 2 3-12
)
1) (Inactivated vaccine) 2 mouse-brain derived
vaccine (MBV) P3 vero
cell (JEVACTM) 3 9-18 4
1 MBV 3
4-5
186
187
2) (live JE) SA 14-14-2 2 2 CD-

JEVAXTM 9-12 2 3-12 Chimeric
JE (IMOJEVTM) 9-12 2 12-24 Live JE
12
live JE Inactivated JE
Inactivated JE live JE vaccine
Inactivated JE live-attenuated JE
1 2 3-24 ()
2-3 1 1
4 *
* Live JE 1 1

3) Live JE 1 Inactivated JE
1 12
7.
conjugate PRP-T 2
3 2, 4 6 1 12-18
2

PRP-T
2-6 0, 2, 4, Booster
7-11 0, 2, Booster
12-59
Booster 12-18 2
8.
1 2 6-12

9.
1 CD4 > 15 2
1 2 4-6 2 4
3 > 13
1

2560
10.
1) 6 18
< 2
2) < 9 1

3) < 3 0.25 0.5 . ()
4) 3 4
11.
10 (PCV10) 13 (PCV13) 3 2, 4
6 12-15 2
PCV PS-23
2 PCV 2 PS-23
1 5

2- 7 PCV 3 6-8 PCV 1 12-15
7- 12 PCV 2 6-8 PCV 1 12-15
12-23 PCV 2 6-8
2-5 PCV 10 2 PCV 13 1

2- 6 PCV13 2 8 PS-23 1
> 6-18 PCV13 1 PCV 8
: PCV = Pneumococcal conjugate vaccine, PS-23 = 23-Valent pneumococcal polysaccharide
vaccine PCV13
2 PS-23
PCV PS-23 1 5
PCV PS-23 PS-23
PS-23 PCV
12.

1) monovalent 2 2 4
2) pentavalent 3 2, 4 6
3) 6-15
8 4
188
189
4)
3
5)
6) severe combined immune deficiency (SCID)

13.

1) 2 2 (bivalent 16, 18) 4 (quadrivalent
6, 11, 16, 18)
2) 9-26 ( 11-12 ) 3
0, 1-2, 6
3)
4) > 26
5) 4 9-26
11-12 9-26
1)

2)

4.2 4.3
CD4 > 15 > 200 > 5
CD4 < 15
6
CD4 > 15
CD4
CD4
2560
4.2 1-6

1 0 DTP-HB1, OPV/IPV1, MMR
2 1 JE1
3 2 DTP-HB2, OPV/IPV2, JE2
4 4 DTP-HB3, OPV/IPV3
5 12 DTP-HB4, OPV/IPV4, JE3
4.3 7-18

1 0 dT1, OPV/IPV1, MMR
2 1 HBV1, JE1
3 2 dT2, JE2, OPV/IPV2, HBV2
4 7 HBV3
5 12 dT3, OPV/IPV3, JE3
( 6)
PCP
PCP 2-3
6 CD4 15 PCP
CD4
PCP Co-trimoxazole
(TMP-SMX) 150 mg/m2 TMP 1-2 3
TMP/SMX
46 PCP

190
191
12 > 12
CD4 < 15
15 TMP/SMX dapsone
2 ./. ( 100 .) 4 ./. ( 200 .)
desensitization TMP/SMX

PPD
skin test isoniazid 10 ././ (
300 .) 9
4.2 (Early infant diagnosis)

10-15

PCP

PCR (
2 5)
1. HIV DNA PCR
1.1 ( HIV RNA
> 50 copies/mL HIV RNA
< 12

2560
) HIV
DNA PCR 4 , 1 , 2 4

HIV DNA PCR
4-6

(AZT/3TC/NVP) (AZT/3TC/LPV/r)

( 4.7)
1.2 HIV DNA PCR
() HIV DNA PCR 2 1
2-4 HIV DNA PCR

HIV DNA PCR
(AZT/3TC/LPV/r) HIV DNA PCR

HIV DNA PCR

HIV DNA PCR

50-60 HIV DNA PCR
HIV DNA PCR

4-6 HIV DNA PCR 2 1
2-4 ( > 4
)
192
193

3 HIV DNA PCR
(dried blood spot)
whole blood
HIV DNA PCR 1 2
4
HIV DNA PCR
HIV DNA PCR

HIV DNA PCR HIV RNA
viral resistance
AZT + 3TC + LPV/r
HIV DNA PCR
HIV DNA PCR
HIV DNA PCR

2. HIV DNA
PCR
6
18
18 HIV antibody
6-18

2.1
18
antibody

2560
antigen (HIV Ag/Ab; 4th generation)

antibody
HIV
DNA PCR

HIV antibody 24

2.2
18
< 6

HIV antibody

HIV DNA PCR 2

194
4.4
HIV DNA PCR HIV Ab

1 2 4 18
-ve N/A N/A N/A N/A HIV PCR

-ve -ve -ve N/A N/A : HIV PCR
: 4
4
-ve -ve -ve -ve N/A :
18-24
:
24
-ve -ve -ve -ve +
: HIV DNA PCR

+ve +ve N/A N/A N/A
-ve +ve +ve N/A N/A

-ve -ve +ve/+ve N/A N/A
-ve -ve -ve +ve/+ve N/A HIV DNA PCR

195
196
HIV DNA PCR HIV Ab

1 2 4 18
+ve/+ve -ve

+ve/+ve +ve

+ve N/A
HIV antibody VL

2560
-ve 2 > 4 N/A

+ve/+ve
197
4.3
(ARV therapy in na ve HIV-infected children)

1

> 1
WHO stage 3, 4)
CD4
1-5 CD4 < 25 CD4 < 1,000 cells/mm3
3-< 5 CD4 < 25 CD4 < 750 cells/mm3
5-15 CD4 < 500 cells/mm3

CD4
CD4 6

< 3 : 2NRTIs + Boosted PI (LPV/r)
3 : 2NRTIs + NNRTIs
2 NRTIs
12 AZT/3TC ABC/3TC
> 12 TDF/3TC (FTC)
NNRTIs boosted PI
3 boosted PI LPV/r
> 3 NNRTIs EFV

(Adherence) boosted
PI Atazanavir/r

2560
4.3.1
1. (medical evaluation)
1.1) (co-infection) (opportunistic
infections) Immune
reconstitution inflammatory syndrome (IRIS)
CXR

PPD skin test
latent TB infection
HBs Ag
HBs Ag NRTIs
Tenofovir Lamivudine Emtricitabine
anti-HCV

cytomegalovirus (CMV)
CMV (CMV retinitis) < 5 CD4 5
CD4 < 50 cells/mm3 6

floater
198
199

1.2) CD4
2

Co-Trimoxazole

Adherence Co-Trimoxazole

1.3)

NNRTIs

1.4)

CBC, differential count
CD4 CD4
CD4

ALT, AST
Tenofovir (TDF) urine analysis
glycosuria, proteinuria BUN, creatinine
estimated GFR (eGFR)

2560
urine pregnancy test

Plasma HIV Viral load (VL)

(genotype) Protease inhibitors
NNRTIs
PI
3 HIV RNA
< 50 copies/mL LPV/r EFV
genotype
NNRTIs
plasma
Dried blood spot
2. (ARV counseling)
2.1)

2.2) ( 6 )

2.3)

200
201
2.4)

2.5) (adherence
counseling) 4.14
4.3.2

1. CD4 < 1
10-15
1
CD4
> 1
CD4

CD4 1-5 CD4 > 25
5-15 CD4 > 500 cells/mm3
CD4 6
CD4
2.
2
2.1 CDC surveillance classification system .. 2537
category N, A, B C .. 2557
HIV infection stage 1,2,3 stage 1, 2
CD4 stage 3

2560
AIDS CD4
CDC stage 3
2.2 WHO staging system .. 2549 WHO stage 1, 2, 3
4 WHO stage 3 4
WHO stage 1, 2 7
20 WHO stage 3 4

3. (Behavioral- risk HIV-infected
adolescents)

(Treatment as Prevention)
adherence
4.5 .. 2559

< 1 1 - < 5 5 -15
WHO stage 3, 4 WHO stage 3, 4

CD4 CD4 < 500 cells/mm3
1-3 CD4 < 25
CD4 < 1,000 cells/mm3

3-< 5 CD4 < 25
CD4 < 750 cells/mm3

WHO stage
1
WHO stage 1, 2 CD4
CD4 6
202
203
4.3.3

(antitretroviral na ve)
4.6
4.6

< 3 3-12 > 12
AZT1 ( ABC2) + 3TC AZT1 ( ABC2) + 3TC TDF5+ 3TC (FTC) + EFV
(preferred + LPV/r3 + EFV
regimens)
AZT1 ( ABC2) + 3TC AZT1 ( ABC2) + 3TC AZT1 ( ABC2) + 3TC
(alternative + NVP4 + NVP4 + EFV
regimens)
TDF5 + 3TC (FTC) + EFV TDF5 + 3TC (FTC) + ATV/r6
TDF5 + 3TC (FTC) + NVP4 TDF5 + 3TC (FTC) + RPV7
1
(Hb < 8-9 g/dL) stavudine (d4T) 6
AZT
2
Abacavir (ABC) hypersensitivity ()
HLA-B*5701 HLA-B*5701
4.0
HLA-B*5701
6

3
Lopinavir/ritonavir (LPV/r) 14 42
post conceptional age Lopinavir propylene glycol

4
NVP AZT + 3TC + NVP (GPO-VIR Z250)
lead-in 2
2
5
Tenofovir (TDF) 2

35 tenofovir/
emtricitabine (TDF/FTC) TDF + 3TC
6
Atazanavir/r boosted PI
Efavirenz
NNRTIs NNRTIs

2560
7
Rilpivirine (RPV) NNRTIs
EFV EFV VL >100,000 copies/mL
HIV RNA Rilpvirine HIV RNA
CD4 > 350 cells/mm3
> 12 > 35

4.7 1
AZT 3TC LPV NVP *
(10 mg/mL) (10 mg/mL) (80 mg/mL) (10 mg/mL)
(kg) 180-240 mg/m2 4 mg/kg 300 mg/m2 200 mg/m2
12 . 12 . 12 . 12 .
> 3-4 . 4 mL 1.5 mL 1 mL 5 mL
> 4-5 . 5 mL 2 mL 1 mL 5 mL
> 5-6 . 6 mL 2.5 mL 1.2 mL 6 mL
> 6-7 . 7 mL 3 mL 1.4 mL 7 mL
> 7-9 . 8 mL 3.5 mL 1.6 mL 9 mL
> 9-11 . 9 mL 5 mL 1.6 mL 10 mL
12-15 . 12 mL 5 mL 1.8 mL 12 mL

* (
5.7)
* LPV/r NVP
*
(Body Surface Area) = () x ()
3600
204
205
4.3.4
3

3 AZT/3TC/NVP 6
HIV DNA PCR 1
HIV DNA PCR plasma
HIV RNA HIV viral resistance
AZT/3TC/LPV/r HIV
DNA PCR AZT 3TC
4.7 HIV DNA PCR

HIV DNA PCR 1
6
HIV DNA PCR 2 2
4 HIV DNA PCR 3
HIV DNA PCR
AZT/3TC/LPV/r
( 4.8)

2560
4.3.5
(antiretroviral therapy in children with opportunistic infection)
drug interaction
rifampin efavirenz, nevirapine ritonavir
boosted PI Efavirenz

2-8 boosted PI
rifampin
quinolone aminoglycoside rifampin

2-8 Immune reconstitution inflammatory
syndrome (IRS) CD4 CD4

Cryptococcus Cytomegalovirus (CMV) IRIS
CD4
Crytococcus antigen

(drug interaction)
IRIS
CD4
CD4 IRIS
19 4
2
tuberculosis (TB), Non tuberculous Mycobacterium (NTM) Mycobacterium
avuim intracellularae complex (MAC), Pneumocystis jiroveci (PCP), cryptococcosis,
cytomegalovirus (CMV) cryptosporidiosis,
206
207
microsporidiosis, JC virus

2-8
CD4 /

2-4
4-8
> 5 CD4
( 6)
< 5
CD4 5 CD4 < 50 cells/mm3
5
floater
IRIS CMV

CD4
2-8

Adherence

rifampicin
NNRTIs PIs
EFV, NVP ritonavir-boosted PIs

2560

1)
2
CD4
2-4 CD4
8 2
2)
3 2 NRTIs NVP
3 2NRTIs + EFV
ritonavir boosted PIs
rifampicin
CD4 (<15%)
rifampicin quinolones
aminoglycoside PIs
CD4
rifampicin 2
maintenance rifampicin PIs
PIs rifampicin 2 (
rifampicin )

NNRTIs
NVP

PIs ( NNRTIs)
CD4 (>15%) PIs
PIs rifampicin 2
208
209
PIs maintenance
aminoglycoside CD4 (<15%)
rifampicin PIs

3.3
(immune tolerance)
tenofovir (TDF), lamivudine (3TC)
3TC
3TC 20
TDF 3TC (FTC)
TDF > 2
3TC
TDF TDF

TDF 3TC (FTC)
(hepatic flare)


2560
4.4

Plasma HIV Viral load

6 6-12
CD4
6
> 5 plasma HIV Viral load < 50 copies/mL,
CD4 > 500 cells/mm3
CD4
4.4.1
2-3
2-3
1) (new clinical events)
IRIS
2) (secondary
sex characteristics)
3) (neurodevelopment)
2
210
211
4.4.2
1) (safety monitoring)
1.1) CBC 6 AZT
3 WBC
1.2) Chemistry liver enzymes (ALT), lipid profiles (cholesterol
triglycerides), serum creatinine fasting blood sugar 6
NVP ALT 2-4
1.3) Urine analysis 6 TDF
2) (immunological virological monitoring)
2.1) CD4 CD4 6
> 5 < 50 copies/mL,
CD4 > 500 cells/mm3
CD4
2.2) plasma HIV viral load
6
viral load 6 1
virological failure
CD4

2.3) HIV genotypic drug resistance mutations
4
VL > 1,000 copies/mL genotype

wild type
4


2560
4.4.3

1)

2)

3) (adherence
assessment)
3

212
213
4.5

4.8

4.8

/ efavirenz, raltegravir, atazanavir
(neuropathy) didanosine, stavudine, zidovudine
zidovudine
zidovudine, protease inhibitors
lopinavir, didanosine
(Hyperbilirubinemia) indinavir atazanavir
nevirapine didanosine
didanosine, stavudine raltegravir
tenofovir atazanavir
(Osteopenia) Protease inhibitors, tenofovir stavudine
Steven Johnson syndrome* nevirapine
nevirapine,efavirenz
(hypersensitivity)* abacavir, nevirapine
(lipohypertrophy) Protease inhibitors, efavirenz
(lipoatrophy) stavudine, zidovudine,didanosine,
Protease inhibitors, stavudine, efavirenz
ritonavir-boosted lopinavir, stavudine, didanosine,
(Glucose intolerance) zidovudine
Lactic acidosis* didanosine, stavudine
zidovudine
PENTA guideline 2015
*

2560
4.6 (Immune Reconstitution

Inflammatory Syndrome: IRIS)
IRIS CD4
viral load

6
2-12
Nontuberculous Mycobacteria,
herpes simplex, Cryptococcus, Mycobacterium tuberculosis
cytomegaloviurs
IRIS 2 paradoxical (worsening) type
unmasking type paradoxical type

unmasking type

IRIS

NSAIDs corticosteroid

Immune Restoration Syndrome (IRS) Immune Reconstitution Inflammatory

Syndrome (IRIS)
CD4
viral load

214
215
Immune Reconstitution Inflammatory Syndrome

(IRIS)
(typical manifestation) herpes zoster, mucocutaneous herpes simplex
(atypical
manifestation) Nontuberculous Mycobacteria herpes simplex
cytomegalovirus meningoencephalitis
(
CD4 = 5) Immune Reconstitution Inflammatory Syndrome (IRIS)
19 1-6 ( 2-12
) Mycobacterium tuberculosis, Nontuberculous
Mycobacteria ( Mycobacterium bovis BCG strain ), herpes simplex
cryptococcus acute respiratory distress syndrome
( nontuberculous Mycobacteria), herpes simplex, meningoencephalitis
Immune Reconstitution Inflammatory Syndrome (IRIS)
CD4 15 viral
load

IRIS 4.1

4.1 IRIS
216

(clinical events)
(1)

CD4 IRIS paradoxical
/ viral load (worsening) (5, 7)
(2) (3)
2560
(OI) IRIS unmasking

(4) (6, 7)
(common childhood illness)

217
(1) (clinical events):

herpes zoster,
mucocutaneous herpes simplex
nontuberculous Mycobacteria,
herpes simplex cytomegalovirus meningoencephalitis
(2) : CD4 ( > 5
2 7 ) / viral load
(>2 log10 < 50 copies/mm3)
(3) Paradoxical (worsening) type: IRIS
IRIS cryptococcal meningitis IRIS

(4) Unmasking type: IRIS

nontuberculous Mycobacteria
human herpes virus

(5) :
cryptococcal
associated IRIS

(6) :
mycobacterium tuberculous nontuberculous

(7) : corticosteroid
prednisolone (1-2 ././) 1-4
NSAIDS

2560
4.7

( )
HIV RNA < 50 copies/mL

4.7.1 > 3 LPV/r

12 HIV RNA < 50 copies/mL
LPV/r EFV
LPV/r
EFV 3-6 HIV RNA

4.7.2
2 NRTIs AZT/3TC TDF/3TC
NNRTIs Efavirenz (EFV) Rilpivirine
(RPV) boosted PI Atazanavir/ritonavir LPV/r

Lopinavir ritonavir
4.7.3
LPV/r
ATV/r
d4T AZT
(lipodystrophy) TDF ABC
218
219
4.8
(diagnosis of treatment failure in HIV-infected children)
virological failure
plasma HIV Viral load

CD4
virologic failure
CD4

1-2 single dose
NVP
NNRTIs
3 1) virological failure 2) immunological
failure 3) clinical failure
viral load CD4
virological failure immunological failure
clinical failure viral load CD4
CD4
plasma HIV RNA

2560
1. Virological failure 2
1.1
viral load > 200 copies/mL
6
viral load > 50 copies/mL
12
1.2 viral load (viral rebound)
virological failure plasma viral load > 1,000 copies/mL
viral load 50-1,000 copies/mL
viral load
1-3 viral load > 50 copies/mL
virological failure
** NNRTIs plasma HIV viral load > 1000
copies/mL resistance
mutation HIV drug resistance
** boosted PI plasma HIV viral load > 1000
copies/mL resistance mutation 4-6

2. Immunological failure
virological failure CD4
CD4

( 6)
3. Clinical failure
3.1 brain growth,
cognitive function motor function
220
221
3.2

3.3 AIDS defining condition
4.9

second-line
AZT + 3TC TDF 3TC (FTC)
TDF + 3TC (FTC) AZT 3TC
NVP EFV LPV/r
LPV/r DRV/r
3 NRTIs, NNRTIs, PI
boosted darunavir, etravirine,
raltegravir

4.2

2560
4.2
adherence

CD4 < 200 cells/mm3
1
CD4 plasma HIV VL

adherence

adherence

HIV genotyping VL > 1,000 copies/mL
genotyping

222
223
4.10 HIV genotyping
1) HIV genotyping plasma viral load

> 1,000 copies/mL
4 4 (
)
2) NRTIs 3TC (FTC)
(mutation) NRTIs

Thymidine Analog Mutations (TAMs) TAMs < 4
NRTIs NRTIs
TAMs 4 NRTIs
TDF ABC
multi-NRTI mutations 69 insertion NRTIs
multi-NRTI mutations Q151M complex NRTIs
TDF
K65R TDF
AZT TDF K65R
3) 3TC
NRTIs M184V
M184I 3TC 3TC
M184V
(less viral fitness)
1-2 3TC Thymidine analog AZT
TAMs

2560
4) NNRTIs NVP EFV RPV

(major
mutation) cross resistance
NVP EFV
etravirine (ETR) NNRTIs

ETR mutation score
Update of the IAS-USA Drug Resistance Mutations
group
5) PIs ritonavir boosted PIs
5
LPV/r ATV/r DRV/r
6) HIV genotyping 2
mutations
no evidence of resistance, possible resistance resistance
genotyping

NRTIs PIs possible resistance resistance
3TC (FTC)
3-4

224
225
4.10.1
2NRTIs + 1NNRTIs
2NRTIs + 1NNRTIs (NVP
EFV)
1. 2NRTIs resistance testing
4.9
AZT TDF 3TC
( 3TC )
TDF + AZT AZT TDF K65R
AZT 2 TDF + ABC
ABC TDF
K65R ABC + 3TC

TDF ABC AZT 3TC
ABC + 3TC ABC
2NRTIs AZT + d4T TDF + ddI
d4T + ddI
ddI
()
d4T
lipodystrophy
2. boosted PI
LPV/r boosted PI RTV

ATV/r
ATV > 3
Atazanavir
200 . 300 . 20

2560
DRV/r salvage regimen PI

LPV/r ATV/r DRV/r
4.10.2 2NRTIs + PI
2 NRTIs + LPV/r virological
failure
1. 2NRTIs resistance testing
4.10.1 4.9
AZT + 3TC TDF ABC + 3TC
TDF ABC + AZT
ABC + 3TC TDF + AZT
TDF + 3TC (FTC) K65R
AZT + 3TC
TDF + 3TC (FTC) AZT + 3TC

2. 2NRTIs
NNRTIs 2NRTIs
NNRTIs EFV
NVP NRTIs
NNRTIs NRTIs
NRTIs
3TC TAMs TDF ABC
2NRTIs
NNRTIs DRV/r
2NRTIs
226
227
4.9

(first-line regimen) (second-line regimen)
AZT + 3TC + NVP EFV TDF + 3TC (FTC) + LPV/r1 ATV/r
TDF ABC + 3TC + NVP EFV AZT + 3TC + LPV/r2 ATV/r
AZT + 3TC + LPV/r NNRTIs:
TDF + 3TC (FTC)5 + EFV 3
NNRTIs:
TDF + 3TC (FTC)5 + DRV/r 3
ABC + 3TC + LPV/r NNRTIs:
TDF + AZT+ EFV 4
NNRTIs:
TDF+ AZT + DRV/r
1
TDF + AZT ABC + 3TC TDF + ABC
2
ABC + 3TC ABC
3
TDF ABC + AZT
4
TDF + 3TC (FTC) AZT + 3TC K65R
5
35 tenofovir/
emtricitabine (TDF/FTC) TDF + 3TC
4.10.3 3 NRTIs, NNRTIs PIs

(salvage regimen)
3
2
viral load < 50 copies/mL
genotypic resistance testing

adherence
(salvage regimen)

2560
NRTIs 1 genotyping NRTIs

mutations 3NRTIs
AZT/3TC ABC/3TC TDF
boosted PI DRV/r
NRTIs PI mutation
integrase inhibitor raltegravir
(RAL), dolutegravir (DTG) CCR5 inhibitor maraviroc (MVC)
NNRTI etravirine (ETR)
salvage regimen
Boosted darunavir (DRV/r) 3 RTV
boosted 50 . 60 . RTV
RTV boosted 100 .
DRV resistant mutation
Etravirine (ETR) 6 ETR boosted
PIs ETR 2NRTIs NNRTIs

Raltegravir (RAL) 4
3-20
2-12 12
2 RAL
(low resistance threshold)
( active drug )
Integrase inhibitors Elvitegravir (EVG)
Dolutegravir (DTG) EVG boost
RTV cobicistat RAL

DTG
RAL EVG
228
229
Maraviroc (MVC) 16
CCR5 receptor (R5 virus) tropism
50-70
R5 MVC drug interaction
MVC
EFV, ETR PIs

CD4
NNRTIs
NNRTIs ETR
CD4 3TC
mutation CD4
NRTIs CD4
NNRTIs PI NRTIs AZT + 3TC
CD4
4.10.4
1) 1 3
adherence
PIs metabolic 2-3
lipid profile blood sugar 1-2
TDF urinalysis Creatinine 6
CrCl < 50 ./ TDF TDF

2) CD4 3-6
viral load 6 6
viral

2560
load 6 > 50 copies/mL adherence

viral load 3-6 viral
load
4.11

CD4 < 15
,
, -- --

CD4 (immune recovery)
> 25 > 350 cells/mm3 ( > 5 ) 6
CD4 > 15 viral load < 50 copies/mL > 1

lymphoid tissue

(primary
immune response)
memory cell

CD4 (CD4 nadir) < 15
230
231
(revaccination)
CD4 < 15
CD4 (immune
recovery) > 25 > 350 cells/mm3 ( > 5 ) 6
CD4 > 15 viral load < 50 copies/mL 1
CD4 > 15
4.10
CD4 < 15
1 2 6

HBV vaccine1 HBV1 HBV2 HBV3 3
JE vaccine ( ) 2 JE1 JE2 2
MMR vaccine3 MMR1 1
dT vaccine 7 4 10
1.
1
3 ()
CD4 15
1 antiHBs Ab > 10 mIU/ml
2 anti-HBs Ab

anti-HBs Ab
< 10 mIU/mL 3 (
)

2560
anti-HBs Ab
10-100 mIU/mL 1
CD4
100 mIU/mL
2.
2 1 CD4
6 1
3. -- 1 CD4
6 MMR

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

4.12

4
1)
2)
3)
4)

232
233
1)

2)

3)

/
4)

5)


2560
4.13

7

10

www.cqihiv.com
234
235
4.14
(adherence to antiretroviral treatment in children)

Adherence

Adherence
7

Adherence

Adherence
3 Viral load

4
.
.
.
.

(adherence)
95


2560
adherence

adherence
adherence
4
1 :

2 :
1-2

Cotrimoxazole
(Bactrim) 2-4
3 :

(fixed dose combination)

236
237

4 :
4.1 ( 7 )

4.2

4.3 :
adherence
(
Visual analog scale )
viral load


2560
4.15

(5Ds)
D1-Disclosure

1)
> 7

2)

3)
4)
D2-Depression self esteem
13

D3-Drug :

D4-Dangers :
( 9-12 )

238
239

12-14

D5-Daily activity :

(life goals)

www.
cqihiv.com
4.16 (Transition to adult clinic)

3
1
1.1

1.2 (Holistic care)

CD4 Viral Load


2560

1.3
1

1-2

1.3.1

1.3.2

240
241
2
2.1

2.2

3
1

2560
242
Prevention of Mother-to-Child HIV Transmission
243
5

(Prevention of Mother-to-Child HIV Transmission)

1. .. 2558

2. 2
28-32

3.

4.

5. VL 34-36
4
VL
6.
12
VL 50 copies/mL

2560
(standard risk)
VL 50 copies/mL VL
HAART > 12
(high risk)
VL > 50 copies/mL VL
HAART HAART < 12

7.
NNRTIs : AZT + 3TC + LPV/r TDF +
3TC (FTC) + LPV/r

1

HIV VL > 50 copies/mL
HIV VL
AZT + single dose NVP
NNRTI-based HAART
NNRTI
8.
9. 32
raltegravir (400 .)
HAART 32

12 VL > 1,000 copies/mL
32 raltegravir

raltegravir
244
245
10. HIV PCR dried blood spot ( 0-7 )

: 2 1 2-4
: 4 , 1, 2 4
11. HIV PCR 1 25
12.

13.

anti-HIV 28-32 6

window period

72 :
(HIV non-occupational Post-
Exposure Prophylaxis: HIV nPEP) 4
AZT TDF + 3TC (FTC) + LPV/r
EFV nPEP

2560
< 36
> 72 4 : anti-HIV
( 4th generation) 2
28-32

(Pre-Exposure Prophylaxis PrEP)
36
> 72 4 :

window period (4
)
window period

PrEP

246
247

25-40
.. 2543

.. 2558
0.6 0.8 .. 2551
PCR
3.8
.. 2551 2.0 .. 2557 1.6 .. 2558
PCR
PCR 4.6
.. 2551 2.0 .. 2557 1.9 ..
2558
( 2)
.. 2558
1 .. 2563
.. 2558
1)
19
8 2)

3)
HAART
HAART

2560
12 < 50
copies/mL 1 4)
10

.. 2558 42

0.2
1,500

5.1
Key messages

(dual protection)
CD4 VL

EFV, LPV/r
EE 30

VL < 50 copies/mL CD4 > 350 cells/mm3

248
249
5.1.1

( 5.1)

VL < 50 copies/mL
5.1

1.
2.
3. VL < 50 copies/mL

1.
2.


2560

1.
2. VL < 50
copies/mL

(3-5 .)
30

14
( 0.5-1
)

LH
LH
24-36

(intrauterine insemination,
IUI)
(ultrasound)
250
251

IUI
> 3-6 (in vitro fertilization,
IVF) (intracytoplasmic sperm
injection)
(sperm washing)
IUI IVF
HIV
HIV (seminal fluid)

3
(timed natural conception)

VL < 50 copies/mL

6

TDF/FTC 1 24

4

4

2560
5.1.2
WHO (spermicides)

(intrauterine device, IUD)

(copper IUD, Cu-IUD) (levonorgestrel IUD,
LNG-IUD)

2 Jadelle LNG 2 5
Implanon etonogestrel (ENG) 1 3
252
253
Implanon 24
depot medroxyprogesterone
acetate (DMPA) 150 . 3
DMPA
DMPA

NNRTIs PIs CD4
VL DMPA

ethinyl estradiol (EE) LNG,
norethindrone (NET), norgestimate (NGM)
EE
30-35 EE < 30 (ultra low dose)

2560
5.2

PIs
ATV - EE , NET
ATV/r - EE , NET , NGM
DRV/r EE , NET
LPV/r - EE , NET
RTV - EE , NET
NNRTIs
EFV EE , NGM , LNG
ETR EE , NET
NVP EE , NET
RPV - EE , NET
RAL - EE
EVG - EE , NGM
30
EE: ethinyl estradiol, NET: norethindrone, LNG: levonorgestrel, NGM: norgestimate
EFV ritonavir-boosted PIs

5.2
EE 30

254
255
5.2
Key messages

2
28-32

1.

2.

3.


2560

5.1

5.2

4.

: Hct/CBC, syphilis testing, HBsAg, blood gr, Rh,
anti-HIV, thalassemia screening ultrasound
anti-HIV, syphilis testing (
), thalassemia screening (
thalassemia)
5. (
)

256
257
6.
CD4 6
VL 34-36
4 VL

(anti-HCV) 3


258
5.1

( / )

PMTCT
window
2560

period
5.3.5 CD4

- window period 1 2
- - -
PrEP
- -
- 1 - CD4

28-32
(same day test result)
28
259
5.2

(b) (b)
anti-HIV
reactive(a) non reactive(a) negative positive

5.6
window period 2 5.6
5.7
1

(c)
positive negative

2560
5.2
(a)
(rapid test)

(b)
rapid test
anti-HIV
rapid test

(c)

rapid test

anti HIV,
syphilis screening test HBsAg
5.3
Key messages

: CD4

TDF + 3TC (FTC) + EFV
260
261
NNRTIs
: AZT + 3TC + LPV/r TDF + 3TC (FTC) + LPV/r
HIV genotype RT gene

32
12
VL 32 > 1,000 copies/mL
Raltegravir 400 . 12 . HAART
raltegravir 2-4

: AZT 4
: AZT + 3TC + NVP 6
(
)

CD4


2560
5.3.1
1
5.3
5.3

( CD4 count)
* $:
TDF/FTC + EFV
TDF + 3TC + EFV
# $:
TDF/FTC + LPV/r
TDF + 3TC + LPV/r
AZT + 3TC + LPV/r

* TDF/FTC + EFV TDF + 3TC + EFV
CD4 ( TDF 300 . 24 . + 3TC 300 .
+ EFV 600 . 24 .)
$
32
raltegravir (400 .) - HAART
raltegravir
raltegravir
#
primary drug resistance 8-10

1
-
HIV VL > 50 copies/mL HIV VL
- AZT + single dose NVP NNRTIs-based
HAART NNRTIs

TDF/FTC ( TDF + 3TC)
+ LPV/r AZT + 3TC + LPV/r (TDF 300 . 24 .; AZT 200-300 .
12 .; 3TC 150 . 12 .; AZT + 3TC (300 + 150) 12 .; LPV/r (200/50) 2
12 .) () HIV genotype (RT gene)
( )
NNRTI (NNRTI)
RT genotype
262
263
5.4 HAART

AZT TDF (300 . 24 .)
TDF AZT (300 . 12 .)
LPV/r EFV (600 . 24 .)
EFV LPV/r (200/50) 2 12 .
LPV/r EFV NVP CD4 count < 250 cells/mm3
CD4 > 250 cells/mm3
NVP
LPV, EFV, NVP boosted atazanavir (ATV/r 300/100 . )
EFV, LPV/r, NVP ATV/r HAART

AZT monotherapy AZT
NVP 200 . 1 (SD NVP)

(HAART)
tail regimen
tail regimen*
NVP
* tail regimen: AZT + 3TC TDF/FTC 14
AZT + SD NVP
VL (< 50 copies/mL)

VL 1,000 copies/mL
6
EFV
neural tube defect
2560
( 6 )

ultrasound 18-20

12
32
> 1,000 copies/mL
raltegravir (400 .)
- HAART

raltegravir
5.3.2

AZT 300 . 3 . AZT 600 .
AZT
AZT
AZT 600 . 4
AZT VL < 50 copies/mL

3 NVP
NNRTIs
AZT monotherapy NVP 200 .
1
ergot methergine ( oxytocin )
LPV/r EFV severe vasoconstriction
264
5.5
FDA

pregnancy

category*
NRTIs
AZT C CBC

Hb < 8 g/dL Hct
< 24% AZT
TDF
3TC C
3TC

TDF B

NRTIs
TDF


265
266
FDA

pregnancy

category*
FTC B
FTC
d4T C
lactic acidosis ( NRTIs
ddI
d4T/ddI
)
ddl B
2560
NRTIs

lactic acidosis (
d4T
d4T/ddI
)
FDA

pregnancy

category*
NNRTIs
NVP B ( CD4 > 250
) antihistamine cells/mm3
( chlorpheniramine,
hydroxyzine topical
/ steroid 0.1% TA cream/
) lotion ALT
LPV/r
ALT > 2.5
upper limit
LPV/r
EFV D
EFV
NVP

2-4 EFV neural tube
defect 6
2 .

EFV
ergot methergine

267

268
FDA

pregnancy

category*
RPV B 20-30
RPV

Pls
2560
LPV/r C urine sugar 50 g glucose challenge

test
2-4

glucose challenge
test ergot methergine

FDA

pregnancy

category*
ATV B indirect ATV
bilirubin ATV/r 300/100 .
TDF
hyperbilirubinemia
ATV

DRV C RTV boosted
800/100 . 12

Integrase inhibitor
RAL C , ,
, , (AST, ALT)


269
270
FDA

pregnancy

category*
Dolutegra B - -
vir (DTG) PK

* Food and Drug Administration (FDA) pregnancy category:

2560
A (
2 3)
B
C

D

X
271
5.3.3

PIs

NNRTIs ()

3

: 3
NNRTIs
NNRTIs NRTIs AZT TDF 3TC (FTC)
14
5.3.4

Key messages

VL 34-36 > 50 copies/
mL VL
HAART < 12

(seroconversion)


2560
AZT 600 .
2 . NVP 200 .
2 NVP
NVP 200 .
(HAART)

(VL > 1000 copies/mL) 38 AZT
NVP 4

PMTCT AZT + 3TC + NVP 6

25-40 5.2

4

AZT 300 . NVP 200 .
AZT 300 . 3 AZT 600 .
2 NVP
NVP

272
273
(standard risk)
VL 50 copies/mL VL HAART
12 AZT 4 ././ 12 .
4 NVP (
5.7)
(high risk)
VL > 50 copies/mL VL HAART
HAART 12
3 AZT 4 ./. 12 .
3TC 2 ./. 12 . NVP 4 ./. 24 . 6
LPV/r < 14
< 14 (expected date of
confinement, EDC)
LPV/r
< 14
PCR 1
NVP LPV/r
AZT 3TC ( 4.6 4)
LPV/r AZT + 3TC + NVP
( 4.6 4) DNA PCR
HIV genotype (viral resistance dried
blood spot )
4
2

2560
DNA PCR

48
> 48

5.7
5.3.5
1. HAART
VL
AZT AZT
wild type AZT
2. NVP
HAART AZT TDF + 3TC (FTC)
+ LPV/r CD4 NVP
3.

3
acute retroviral syndrome (ARS)

3.1

VL < 200 copies/mL
3
274
275
anti-HIV 28-32
6

3.2 (
1 window period
VL 200 copies/mL) ( )

3.2.1)
72
(HIV non-occupational
Post- Exposure Prophylaxis: HIV nPEP) 7
HIV nPEP
( 1-2 ) 72 .
4
AZT TDF + 3TC (FTC) + LPV/r EFV
nPEP
3.2.2) < 36
> 72 4
anti-HIV ( 4th generation)
2
28-32

(Pre-Exposure Prophylaxis PrEP)

2560

TDF/FTC
75
(Partners PrEP) TDF
67 (Partners PrEP)

PrEP
7
3.2.3) 36
> 72 4

window period (4 )

window period

PrEP
PrEP
PrEP
PrEP

5.3
3.2 HIV DNA RNA PCR

276
277
4.

5. anti-HIV inconclusive ()
ARS
2

ARS 3 ()
6. AHI (Acute HIV infection)
HAART

VL < 50 copies/mL

AHI 4-6
AHI 60-90
(ARS) 2-3

10 AHI

AHI
window period
inconclusive AHI
-
(4th generation immunoassay) window period 15-20

2560
rapid test window period 20-35

(nucleic acid test, NAT)
window period 10-15
2 ARS
AHI AHI
HIV IgG IgM inconclusive ( rapid test)
HIV antigen NAT
4-6 ARS
genotyping AHI

AHI (< 12 )

cesarean section
3

278
279
5.3

3

#
1
VL < 200 copies/mL VL VL
anti-HIV 72 3 -1
28-32
6 nPEP* 4 wks
< 36 36
anti HIV

nPEP anti
HIV (4th gen)
(
3rd gen)
2
window period
PrEP**
28-32
()

window period
(4 )
* HIV non-occupational Post-Exposure Prophylaxis

(nPEP) ( 1-2
PrEP**
) 72 .

4
HAART PrEP**
TDF + 3TC + LPV/r EFV

** Pre-Exposure Prophylaxis (PrEP)

TDF/FTC

75
window
(Partners PrEP)
period (4 )

PrEP ( 7)

PrEP**
#
HIV DNA RNA (Qualitative)


280
5.6
Antepartum Intrapartum Postpartum6 Newborn ( + )
1 HAART ( CD41)4
+ AZT3 AZT Syrup 4 ./. 12 .
TDF/FTC/EFV (300/200/600 .) 300 . 3 . 4 ( 1 .
1 600 . )
TDF (300 .) + 3TC (300 .) + 5.7 (
EFV (600 .)
2
- (AZT + 3TC) 1 + LPV/r (200/50 5.7
.) 2 12 . 3
- TDF (300 .) + 3TC (300 .) 3)
2560
TDF/FTC (300/200 .)
+ LPV/r (200/50 .) 2
12 .
2 HAART 4
VL < 50 copies/mL + AZT3 1
EFV 300 . 3 .
600 .

Antepartum Intrapartum Postpartum6 Newborn ( + )
3 (no ANC)
2 . AZT 600 . AZT (syr) 4 ./. 12 . +
3TC (syr) 2 ./. 12 .+
NVP (syr) 4 ./. 24 .
6 5
5.7
2 . AZT 300 . 3 . TDF/FTC/EFV TDF + 3TC + EFV
600 .
+ NVP 200 . 1

(SD NVP)
1. CD4 < 200 cells/mm3 TMP-SMX (80/400 .) 2 24 . double strength TMP-SMX (160/800 .) 1 24 .
2. LPV/r-based HAART 1) HIV VL
> 50 copies/mL HIV VL 2) AZT + single dose NVP NNRTIs-based HAART
NNRTIs
3. AZT VL < 50 copies/mL AZT

4. 32 12 VL
> 1,000 32 Raltegravir 400 . 12 .
5. LPV/r 14 14

6.
- LVP/r-based HAART

281
- TDF/FTC/EFV TDF + 3TC + EFV EFV TDF/FTC TDF + 3TC 14

2560
5.7

AZT (10 ./.)* 3TC (10 ./.) NVP (10 ./.)

(.) () 4 ./. 2 ./. 12 4 ./.
12 (simplified dosing)
4000-4499 18 . (1.8 . ) 9 . (0.9 . ) 18 . (1.8 . )
3500-3999 16 . (1.6 . ) 8 . (0.8 . ) 16 . (1.6 . )
3000-3499 14 . (1.4 . ) 7 . (0.7 . ) 14 . (1.4 . )
2500-2999 12 . (1.2 . ) 6 . (0.6 . ) 12 . (1.2 . )
2000-2499 10 . (1.0 . ) 5 . (0.5 . ) 10 . (1.0 . )
1500-1999 8 . (0.8 . ) 4 . (0.4 . ) 8 . (0.8 . )
* 30-35 : AZT 2 ./. 12
8 2
* < 30 : AZT 2 ./. 12
8 4
5.4
CD4 < 200 cells/mm3

PCP TMP-SMX (80/400 .) 2 24 . double strength
TMP-SMX (160/800 .) 1 24 . TMP-SMX

2 TMP-SMX
folic acid 1 1
CD4 < 100 cells/mm3
cryptococcal meningitis fluconazole

6
282
283
HAART
5.8
HAART

CD4 count 6
Viral load - 34-36 *
4
CBC AZT 4-8
Hb < 8 g/dL Hct < 24% Hb < 8 g/dL Hct < 24%
AZT TDF AZT TDF
Creatinine TDF 3 6
creatinine clearance
< 60 mL/min TDF creatinine clearance
< 50 mL/min TDF
AZT
ALT
2.5 upper 6
limit NVP 2.5 upper
limit NVP
EFV LPV/r
Urine sugar
urine sugar
LPV/r
EFV
TDF UA 6
urine protein
50 g GCT LPV/r LPV/r
24-28 LPV/r
blood sugar 4
140 mg/dL 100 g OGTT blood sugar 140 mg/dL
100 g OGTT


2560
* HAART 8-12
VL < 1,000 copies/mL VL 34-36

4 VL
1,000 copies/mL VL > 50 copies/mL
3 AZT/3TC/NVP 6

50 g GCT (glucose challenge test) glucose 50
50% glucose 100 . blood glucose glucose 1
100 g OGTT (oral glucose tolerance test)
8 fasting blood glucose glucose
100 blood glucose 1, 2 3 glucose

5.9 100 g OGTT

blood glucose (mg/dL)
Fasting blood glucose 105
1 . glucose 190
2 . glucose 165
3 . glucose 145
OGTT
1) glucose 1

OGTT 4

2) glucose 2

284
285
5.5
5.5.1

(artificial rupture of membranes)
oxytocin
4

scalp electrode forceps extraction vacuum
extraction / (episiotomy)

5.5.2
5.5.2.1 (elective caesarean section)

latent phase of labor
4 .

38
1. 38 VL 34-36
1,000 copies/mL
2.
4 VL
2560
3.
4.

> 3,500
4
(oligohydramnios)
scalp electrode, forceps extraction, vacuum extraction
prolonged rupture of membranes
5.5.2.2 (emergency caesarean section)

(postpartum
morbidity)
AZT 600 . ( NVP
200 . ) 4
(prophylactic antibiotic)
ampicillin cefazolin
methergin
ergotamines PIs
EFV potent CYP3A4 enzyme inhibitors
ergotamines
(vasoconstriction)
286
287
5.6

hypothermia

5.6
vitamin K BCG HBV
5.7
5.7.1
1)

4-6 pap smear
( 1 )

CD4 6

2560
2)

3)

3.1)
3.2)

2
4)

5)
5.1
288
289
5.7.2
5.6 5.7

18

AZT (CBC)

7-10 g/L 21-30%
2
< 7 g/L < 21%

AZT 20-30
1 AZT
AZT

4.8
TMP-SMX prophylaxis ( TMP 150 mg/m2/day SMX 750 mg/m2/day)
3 4-6
PCR > 6
1
CD4 < 15%

2560
5.8
(Early infant diagnosis EID)
DNA PCR
( 2 4)
5.10
*
(standard risk) HIV DNA PCR 2 1
2-4
50 copies/mL
VL AZT 4

(HAART) >12

(high risk) HIV DNA PCR 4 * 1,
> 50 2 4
copies/mL 3 (AZT + 3TC +
VL NVP) 6
12 1
3
NVP
LPV/r ( 4)

* HIV PCR
(DBS) (

)

anti-HIV 18
( 2 4)
1 HIV DNA
PCR 2

290
291
HIV drug resistance

dried blood spot
LPV/r-based HAART
NNRTIs-based HAART

Opportunistic Infections: Prophylaxis and Treatment
293
6

(Opportunistic Infections: Prophylaxis and Treatment)
6.1 (Tuberculosis)

6

2 9
12
Directly Observed Treatment

CD4
CD4 < 50 cells/mm3 2 4
CD4 50 cells/mm3
2 4
2 8


2560
rifampicin efavirenz
efavirenz nevirapine raltegravir dolutegravir

protease inhibitor
rifampicin
Isoniazid Preventive Therapy

CD4 < 200 cells/mm3

rifampicin
paradoxical reaction immune reconstitution inflammatory
syndrome (IRIS)

294
295
(

.. 2556)
AFB
AFB
2

acid fast bacilli (AFB)
nontuberculous mycobacteria
(NTM)

needle aspiration
tissue biopsy
pancytopenia bone marrow aspiration

(cerebrospinal fluid)

> 14

AFB

NTM


2560

polymerase chain reaction (PCR) real-time PCR
(molecular NTM
method)

3

(primary infec-
tion)

(Tuberculin
skin test TST)
indetermine
interferon gamma
release assay
(IGRA)
296
297
()
TST IGRA

IGRA
6

6.1-6.2
6.1
6

9

2
12
2 4 isoniazid, rifampicin,
ethambutol pyrazinamide
4-7 isoniazid rifampicin
2 4-7

2560
6.2

Isoniazid* 5-8 ./. (300 .)
Rifampicin (R) 10 ./. (450-600 .)
Ethambutol (E) 15-20 ./. (800-1,200 .)
Pyrazinamide (Z) 20-25 ./. (1,000-2,000 .)
* pyridoxine 25-50 . isoniazid
(multi-drug resistant TB)

isoniazid rifampicin 3-4 1

(

.. 2556)

Streptomycin (S) 15 ./. ( 1,000 .)
Kanamycin 15 ./. ( 1,000 .)
Amikacin 15 ./. ( 1,000 .)
Ethionamide 15 ./. (500-750 ./) 2-3
Cycloserine 10 ./. (500-750 ./) 2-3
4-aminosalicylic acid (PAS) 200 ./. (8,000-12,000 ./) 2
Levofloxacin 500-750 ./
Moxifloxacin 400 ./
: levofloxacin ofloxacin

(meningitis)
(pericarditis) prednisolone 1 ././
3 3
298
299

6-9
.. 2557
(http://www.pidst.net/A367.html)
2 (intensive phase) 4 isoniazid, rifampicin, pyrazi-
namide ethambutol
4-7 (continuation phase) isoniazid rifampicin isoniazid
rifampicin pyrazinamide
ethambutol
isoniazid rifampicin
miliary 10
12
prednisolone 1-2 ./ 4-6
miliary
endobronchial TB
6.3

Isoniazid 10-15 ./. ( 300 .)
Rifampicin 10-20 ./. ( 600 .)
Pyrazinamide 30-40 ./. ( 2,000 .)
Ethambutol 15-20 ./. ( 1,200 .)

3-4 2 (bactericidal)


2560

Amikacin 15-20 ./. ( 1,000 .)
Kanamicin 15-30 ./. ( 1,000 .)
Ethionamide 15-20 ./. ( 1,000 .) 2-3
Capreomycin 15-30 ./. ( 1,000 .)
Cycloserine 10-20 ./. ( 1,000 .) 2
Levofloxacin (Lfx) < 5 20 ././ 2
5 10 ././ ( 1 )
Moxifloxacin (Mfx) 7.5-10 ././ ( 400 .)
Ofloxacin (Ofx) 15-20 ././ ( 800 .)

streptomycin, kanamycin, amikacin
ethionamide quinolones, cycloserine PAS
(

.. 2556)

(intensive phase)
2 2
isoniazid rifampicin
DOT
300
301
(

.. 2556)

isoniazid rifampicin ethambutol
pyrazinamide 3-5

isoniazid, rifampicin pyrazinamide
alkaline phosphatase bilirubin
transaminase enzyme rifampicin
AST ALT > 5 > 3
isoniazid, rifampicin pyrazinamide ethambutol,
quinolones, streptomycin
AST ALT < 2 total bilirubin
< 1.5 isoniazid,
rifampicin pyrazinamide
1

2560

ALT > 3

2 2SIRE/7IR, 9IRE, 9RZE
1 2SIE/16IE, 24-18IE +
quiniolone

ethambutol metabolites pyrazinamide
creatinine clearance < 30 /

3
streptomycin

hemodialysis

Rifampicin
CYP450 efflux multi-drug transporter P-
glycoprotein non-nucleoside reverse transcriptase
inhibitors (NNRTIs) protease inhibitors
NNRTIs efavirenz nevirapine

protease inhibitor
1. protease inhibitor NNRTIs ( efavirenz
nevirapine) integrase inhibitor ( raltegravir)

302
303
2. NNRTIs integrase inhibitor

2IEZ + quinolone/10-16IE + quinolone
streptomycin 2 quinolone

CD4
6.4
6.4
CD4
< 50 cells/mm3 2 4
50 cells/mm3 * 2
4
2
8
*

2
rifampicin

rifampicin
1. Efavirenz 600 ./
2. Nevirapine 200 . 2 lead-in
3. Raltegravir 400 . 2
4. Dolutegravir (DTG) 50 . 2
2560

2-8
IRIS CD4
CD4
6
6 6.5
6.5
6
CD4
CD4 < 15% 2
CD4 15% * 2
2-8

*
2
6.6
rifampicin
NNRTIs efavirenz
efavirenz nevirapine (Lead-in) Integrase
inhibitor raltegravir dolutegravir

NNRTIs
PIs CD4 < 15% aminoglycoside
PIs

rifampicin 2
CD4 15% maintenance
304
305
rifampicin quinolone
IZ IE +
quinolone 10-16
PIs
rifampicin 2 (
rifampicin )
NRTIs 3 zidovudine (AZT)
stavudine (d4T) + lamivudine (3TC) + abacavir (ABC)
rifampicin

NNRTIs PIs

NNRTIs PIs VL 100,000
copies/mL
(immune reconstitution inflammatory syndrome: IRIS)

TB IRIS TB
paradoxical IRIS

unmasking TB IRIS

TB paradoxical Paradoxical TB-IRIS
IRIS 8 43

CD4


2560
TB paradoxical IRIS

2

12
radiculomyelitis
(serositis)

3

2-4

IRIS

IRIS

306
307

TB paradoxical IRIS (non-steroidal
drugs systemic corticosteroids)
IRIS
prednisolone 1 ././ 2
4-8
Unmasking TB IRIS

(latent TB infection)

10
10

isoniazid 9

5 .

isoniazid
6-9
isoniazid preventive therapy (IPT) TLTI (treatment latent
tuberculous infection)
2560
tuberculin

48-72
(anergic)
randomized controlled trials
meta-analysis IPT

IPT
IPT

6.7 IPT

(TST) INH
(induration < 5 )
TST (induration 5 ) INH

IPT

1

308
309
IPT 9

IPT
:

(LTBI)
IPT active hepatitis (acute or chronic)
symptoms of peripheral neuropathy
INH
6.8
Isoniazid 300 . 9
pyridoxine 25-50 .
Isonazid 10 ./. ( 300 .)
9
2
(pyrazinamide + rifampicin)
Rifampicin 10 ./. ( 600 .)
isoniazid 4
IPT
6 2


2560
6.1
(treatment latent tuberculous infection isoniazid preventive therapy)
TST

(induration 5 .) (induration < 5 .)
IPT 9 IPT

CD4

310
311

1. (unexplained)*
2. 1
3. 5 1
4. > 3 1
2
* 2

1. ( 2 )
2. 1
3. ( 6.2)
4.
1

(LTBI)
isoniazid 9


2560
6.2

4
1 4
- 1
- ( 2 )
- *
-
IPT *** **

* (
3 z-score) ( 2 z-score)
(> 5)
(Strong recommendations, low quality of evidence)
** ,
contact investigation
*** INH preventive therapy (IPT)

312
313
6.2
co-trimoxazole Pneumocystis pneumonia (PCP)

CD4 < 200 cells/mm3
co-trimoxazole
2-4
primary prophylaxis cryptococcosis, penicilliosis,
histoplasmosis
(optional)
CD4
( prophylaxis)

(primary and
secondary prophylaxis)


2560
6.2.1 Pneumocystis pneumonia (PCP)
PCP
Pneumocystis jirovecii

PCP 3-6

1 CD4
P. jirovecii
30-65

A. Primary prophylaxis

CD4 < 200 cells/mm3 CD4 < 14
oropharyngeal candidiasis AIDS-defining illness ()

PCP PCP 4-6
CD4 PCP

12
CD4 CD4 15% CD4 500 cells/mm3
1-5 CD4 < 200 cells/mm3 6
CD4 clinical CDC category C
314
315

co-trimoxazole (TMP-SMX) single-
strength (SS) (TMP 80 .-SMX 400 .) 1-2
2 toxoplasmosis

TMP 5 ./. 150 ././ SMX 750
././ ( TMP 320 . SMX 1,600 .) 1-2
3
co-trimoxazole
1 dapsone 2 ./. ( 100 .)
4 ./. ( 200 .) ( dapsone
atovaquone 1-3 2
30 ./. 4-24 45 ./.
12 1,500 . )
clindamycin primaquine

PCP

CD4 > 200 cells/mm3 3
primary prophylaxis CD4 < 200 cells/mm3

primary prophylaxis
6 CD4 3
1-5 CD4 > 15% > 500 cells/
mm3 6 CD4 15% > 200 cells/mm3
1 1 CD4


2560
CD4 < 200 cells/mm3 VL 1 CD4 100-200

cells/mm3
B. Treatment

Co-trimoxazole TMP 15-20 ././ SMX 75-100././

1 . 3-4
21

co-trimoxazole

(desensitization)
70

Clindamycin 600 . 6 . 900 .
8 . 300 . 6 . 450 . 8 .
primaquine 30 . 21
Pentamidine 3-4 ./. 1 .
PaO2 70 . alveolar-arterial (A-a) gradient
35 . prednisolone (
72 . ) 40 . 2
5 40 . 5 20 .
11 methylprednisolone prednisolone 1 ./.
12 . 1-5 0.5 ./. 12 . 6-10
0.5 ./. 21
316
317

1)
PCP
co-trimoxazole kernicterus
bilirubin
2)
PCP
co-trimoxazole co-trimoxazole

50
co-trimoxazole 5-7 pentamidine
isethionate 4 ././ 60-90
dapsone 2 ././ atovaquone 30-40 ././
2 21 co-trimoxazole
rapid desensitization desensitization

C. Secondary prophylaxis

PCP

primary prophylaxis

CD4 < 200 cells/mm3

PCP CD4 > 200 cells/mm3 secondary
prophylaxis CD4

2560
primary prophylaxis
1
PCP PCP CD4
6.2.2 Cryptococcosis
Cryptococcosis Cryptococcus neoformans

3
PCP

cryptococcal antigen CD4 < 100 cells/mm3
cryptococcal antigen cryptococcus


fluconazole
primary prophylaxis
(optional)
primary prophylaxis
(optional)
CD4 < 100 cells/mm3
C. neoformans
cryptococcal antigen ()

Fluconazole 400 .
318
319


B. Treatment
Induction phase: 2

Amphotericin B 0.7-1.0 ././ fluconazole
800 ./
(meningitis)

Amphotericin B 1.0 ././
fluconazole

Fluconazole 1,200 ./

amphotericin B
Consolidation phase: 8-10

Fluconazole 400-800 ./

Itraconazole 400 . 2
cryptococcal antigen
(cryptococcal anti-
genemia) consolidation phase

2560

1)
fluconazole itraconazole teratogenic effect
2 amphotericin
B
2)
amphotericin B 0.7-1.0 ./.
14 fluconazole 12 ./. 6-12 ./
./ 8
fluconazole 12 ./.
6-12 ./. ( 600 .)
fluconazole 5-6 ./. 8

cryptococcosis induction
consolidation secondary prophylaxis

fluconazole 200-400 ./
fluconazole 6 ./. ( 200 .)

itraconazole 200 ./
itraconazole 5 ./. ( 200 .)

cryptococcosis
cryptococcosis 1
320
321
CD4 100 cells/mm3

3 VL CD4
100 cells/mm3

> 6
6

6.2.3 Candidiasis
Candidiasis mucocutaneouscandidiasis
oropharyngeal candidiasis, cervicovaginal candidiasis, esophageal candidiasis
diaper dermatitis invasive candidiasis

oropharyngeal candidiasis CD4 < 100
cells/mm3, VL , WBC < 500 cells/mm3 esophageal candidiasis
herpes simplex virus CMV

B. Treatment
1. Oropharyngeal candidiasis

Clotrimazole oral troches 10 . 4-5 7-14
Fluconazole 100 . 7-14

Nystatin oral solution 500,000 5
7-14

2560
Itraconazole capsule 100 . 7-14

Itraconazole oral solution 100 . 7-14
Amphotericin B 0.3-0.5 ././ 7-14
2. Esophageal candidiasis

Fluconazole 200 . 14-21

Itraconazole capsule 200 . 2 14-21
Itraconazole oral solution 200 . 2 14-21
AmphotericinB 0.3-0.5 ././ 14-21
3. Cervicovaginal candidiasis

Clotrimazole vaginal cream 5 gm/ clotrimazole vaginal suppository
tablet 100 . 3-7
Fluconazole 200 .

Miconazole cream 5 gm/ miconazole vaginal suppository tablet
100 . 7
Itraconazole capsule 200 . 3
Itraconazole oral solution200 . 3

1)
fluconazole itraconazole
teratogenic effect amphotericin B
2)
Orpharyngeal candidiasis
clotrimazole troches oral polyenes ( nystatin) fluconazole
322
323
3-6 ./. itraconazole () 2.5

././ 2 7-14 ketoconazole 5-10 ././
1-2 14 ( ketoconazole
)
Esophageal candidiasis fluconazole 6 ./.
3-6 ./. 14-21 itraconazole
2.5 ./. 2 5 ./. 14-21
amphotericin B 0.3-0.5 ./.
7

/

fluconazole 100-200 . itraconazole 100-200
.
fluconazole 3-6 ./. ( 200 .) itraconazole
5 ./. ( 200 .)

CD4 > 200 cells/mm3
6 CD4 >15% 6

2560
6.2.4 Toxoplasmic encephalitis
Toxoplasmic encephalitis Toxoplasma gondii

CD4
congenital toxoplasmosis
retinitis, neurologic impairment
hydrocephalus, intracranial calcification,
bone marrow suppression

CD4 < 100 cells/mm3
IgG antibody toxoplasma
6 CD4
< 15% 6 CD4 < 100 cells/mm3

co-trimoxazole SS 2
co-trimoxazole TMP-SMX 150/750 ././ 6/30
././ 1 2 3

co-trimoxazole (80/400) tablet 1 2 3
Dapsone 50 ./ pyrimethamine 50 ./ folinic
acid (leucovorin) 25 ./
324
325
Dapsone 200 . pyrimethamine 75./ folinic

acid 25 ./
co-trimoxazole primary prophylaxis PCP
toxoplasmosis dapsone

CD4 < 100-200 cells/mm3

6 CD4 > 200 cells/mm3
3 1-5 CD4 15% 3
1
B. Treatment

Co-trimoxazole TMP 5-10 ././ SMX 25-50 ./
./ 2
Pyrimethamine 200 . 1 50 ./ ( 60 .)
75 ./ ( > 60 .) sulfadiazine 1,000 . (
60 .) 1,500 . ( > 60 .) 4 folinic
acid 10-25 ./ 6

Pyrimethamine clindamycin 600 . 6 .
Pyrimethamine azithromycin 1,000-1,250 ./

1)

hyperbilirubinemia kernicterus

2560
2)
Congenital toxoplasmosis pyrimethamine 2 ././ 2
1 ././ 2-6 1 ./. 3
sulfadiazine 50 ./. 2 folinic acid 12
toxoplasmosis

acquired CNS ocular systemic toxoplasmosis pyrimethamine
2 /./ 3 1 ././ folinic acid 10-25 ./
sulfadiazine 25-50 ./. 4 6

sulfadiazine clindamycin 5-7.5 ./. 4 (
600 ./ ) pyrimethamine folinic acid dexamethasone
( > 1,000 ./)

pyrimethamine CBC


toxoplasma

pyrimethamine 25-50 ./ sulfadiazine 500-1,000
. 4 folinic acid 10-25 ./
sulfadiazine 85-120 ././ 2-4
pyrimethamine 1 ./. 15 ./. ( 25 .)
folinic acid 5 . 3
326
327

pyrimethamine 25-50 ./ clindamycin 600 .
8 . folinic acid 10-25 ./ co-trimoxazole SS 2

clindamycin 20-30 ././ 4
pyrimethamine 1 ./. folinic acid 5 . 3

CD4 > 200 cells/mm3 6 CD4
< 200 cells/mm3
6 CD4 > 200 cells/mm3 > 15%
1-5 CD4 15% ( CD4 > 500 cells/mm3)
3 6
1
6.2.5 Penicilliosis histoplasmosis
Penicilliosis histoplasmosis
CD4 < 100 ( penicilliosis) 150 ( histoplasmosis) cells/mm3
penicilliosis papulonecrotic
skin lesions histoplasmosis

Wright stain
histoplasmosis penicilliosis

65 penicilliosis

2560
penicilliosis histoplasmosis
cryptococcosis
cryptococcosis
primary prophylaxis 2
(optional)

CD4 < 100 cells/mm3 ( penicilliosis) 150 cells/mm3
( histoplasmosis)

itraconazole 200 .
itraconazole 5 ./.
itraconazole histoplasmosis penicilliosis
fluconazole cryptococcosis

CD4 > 100 cells/mm3 ( penicilliosis)
150 cells/mm3 ( histoplasmosis) 6
CD4
B. Treatment
Induction phase

Amphotericin B 0.6-0.7 ././ 7-14
328
329

Itraconazole 200 . 3 3 200 .
2 14
Consolidation phase

Itraconazole 200 . 2 10-12

Amphotericin B 0.4-0.5 ././ 10-12

Fluconazole 800 .

1)
itraconazole
itraconazole teratogenic effect amphotericin
B
2)
2.1) Histoplasmosis itraconazole 6-8 ././ 3-12

amphotericin B 1 ./. 4-6
itraconazole 5 ./.
2.2) Penicilliosis amphotericin B 0.7 ./. 2
itraconazole 10 ././ 2 10
amphotericin B
2

2560

penicilliosis histoplasmosis

Itraconazole 200 . itraconazole 5 ./.

Fluconazole 400 .
Amphotericin B 0.6-0.7 ./.
malabsorption

CD4 > 100 cells/mm3 ( penicilliosis) 150
cells/mm3 (histoplasmosis) 6
CD4
6 CD4 > 100 cells/mm3
( penicilliosis) >150 cells/mm3 ( histoplasmosis)
1-5 CD4 15% itraconazole
1 6
330
331
6.2.6 Cytomegalovirus (CMV) infection
CMV CD4
50 cells/mm3

CMV

1
(congenital infection)

congenital CMV
microcephaly, intracranial calcification, bone marrow
suppression

CMV retinitis
CD4 50 cells/mm3

fundus
screening CMV retinitis 4-6
5
CD4 5% CD4 < 50 cells/mm3
6 floater

CMV IRIS

2560

CD4
100 cells/mm3
B. Treatment

Ganciclovir 5 ./. 12 . 2-3

3-6
Valganciclovir 900 . 2 2-3

Ganciclovir intravitreous 2,000 / 1

Ganciclovir implant 4.5 .
vitreous 6-8
ganciclovir retinitis
CMV
CD4
CMV
CMV
ganciclovir
CD4 VL

1)

332
333
2)
CMV CMV retinitis ganciclovir
5 ./. 12 . 2-3 congenital CMV
infection ganciclovir 6 secondary
prophylaxis

CMV retinitis

Valganciclovir 900 .

Ganciclovir 5 ./.
Ganciclovir intravitreous 2,000 1 2-4
( )

retinitis
CMV retinitis 3-6
CD4 > 100 cells/mm3 3-6
CD4 < 100 cells/mm3
6 CD4 > 100 cells/mm3 1-5
CD4 15% CD4 500 cells/mm3 6
6
3-6

2560
6.2.7 Mycobacterium avium complex (MAC) infection
MAC nontuberculous mycobacterium

CD4
50 cells/mm3
MAC
mycobacteria
MAC

clarithromycin azithromycin
CD4 < 50 cells/mm3 2 MAC clarithromycin
MAC

MAC
primary prophylaxis
MAC (optional)

CD4 < 50 cells/mm3

6 CD4 < 50 cells/mm3
2-5 CD4 < 75 cells/mm3
1-2 CD4 < 500 cells/mm3
1 CD4 < 750 cells/mm3
334
335

clarithromycin 500 . 2 azithromycin
1,000-1,250 .
clarithromycin 7.5 ./. 2 azithromycin
20 ./. ( 1,250 .) 5 ./. (
250 .)

CD4 > 100 cells/mm3
3 CD4 < 50 cells/
mm3
6 CD4 > 100 cells/mm3 2-5 CD4
200 cells/mm3 3
Treatment

Clarithromycin 500 . 2 ethambutol 15 ././

Azithromycin 500 . ethambutol 15 ././
( 4-8
) quinolones
(ciprofloxacin 500-750 . 2 levofloxacin 500 .
moxifloxacin 400 . ) amikacin 15 ./.

1)
clarithromycin
azithromycin
2)
clarithromycin 7.5-15 ./. ( 500 .)

2560
2 azithromycin 10-12 ./. ( 500 .)

ethambutol 15-25 ./. ( 2,500 .)
1
quinolone ciprofloxacin 10-15 ./.
( 1,500 .) 2 levofloxacin 500 .
aminoglycoside amikacin 15-30 ./. (1,500
.)
: clarithromycin CYP3A4
CYP3A4
PIs clarithromycin
rifampin, ergot alkaloids, carbamazepine, cisapride azithromycin
rifampicin
B. Secondary prophylaxis

disseminated MAC

MAC 12
MAC CD4

CD4 >100 cells/mm3 6
CD4 < 100 cells/mm3
6 CD4 > 100 cells/mm3 2-5
CD4 200 cells/mm3 6 6
MAC 1
2
336
6.9
Secondary prophylaxis

Tuberculosis 2 HRZE/4-7IR
Isoniazid 5-8 ./. (300 .)

Rifampicin 10 ./. (450-600 .)

Ethambutol 15-20 ./.
(800-1,200 .)
Pyrazinamide 20-25 ./.
(1,000-2,000 .)
Pyraidoxine 20-30 ./.
(1,000-2,000 .)
Pneumocystis Co-trimoxazole TMP 15-20 Clindamycin 600 . Co-trimoxazole Dapsone 100 .
pneumonia (PCP) ././ SMX 75-100 ./ 6 . 900 . (80-400 . or

./ 3-4 21 8 . 300 . single strength, SS)
6 . 450 . 8 . + 2
Primaquine 30 .
21
Pentamidine 3-4 ./.

21
337
338

Cryptococcosis Induction phase: Fluconazole 200
Amphotericin B 0.7-1.0 ././ Fluconazole 1,200 ./
14
.
+ fluconazole 800 12
./ 14
Amphotericin B 1.0 ././
14
Consolidation phase
Fluconazole 400-800 ./ Itraconazole 400 ./ 8-10
8-10
Toxoplasmosis
2560
Co-trimoxazole (TMP 5-10 ././ Pyrimethamine + Pyrimethamine 25-50 Pyrimethamine 25-50

) Clindamycin 600 . 6 ./ + Sulfadiazine ./ + Clindamycin
2 6 Pyrimethamine + 500-1,000 . 600 . 8 . +

Pyrimethamine 200 . 1 Azithromycin 1,000-1,250 ./ 4 + folinic folinic acid
50 ./ (. 60 .) 75 acid 10-25 ./ co-trimoxazole SS
./ (. > 60 .) + Sulfadiazine 2
1,000 . (. 60 .) 1,500
. (. > 60 .) 4 +
folinic acid 10-25 ./
6

Penicilliosis/ Induction phase Itraconazole 200 Fluconazole 400
Histoplasmosis Amphotericin B 0.6-0.7 ././ Itraconazole 200 . 3 . .
3 200 . Amphotericin B
2 14 0.6-0.7 ././
Consolidation phase
Itraconazole 200 . 2 Amphotericin B 0.4-0.5 ././
10-12 10-12

Fluconazole 800 .
10-12
CMV Ganciclovir 5 ./. 12 . Ganciclovir intravitreous 2,000 Valganciclovir 900 Ganciclovir 5 ./
2-3 / 1 . .
Valganciclovir 900 . 2
2-3 Ganciclovir implant 6-8 Ganciclovir intravitreous
2,000
1 2-4

339
340

MAC Clarithromycin 500 . 2 Azithromycin 500 . +
+ Ethambutol 15 ././ Ethambutol 15 ././
1 1

Quinolones:
ciprofloxacin 500-750 . 2
2560

levofloxacin 500 .
moxifloxacin 400 .
Amikacin 15 ./.

341
6.10 CD4 primary secondary prophylaxis

Opportunistic
Primary prophylaxis Secondary prophylaxis
infections
PCP CD4 > 200 cells/mm3 3 CD4 > 200 cells/mm3 3

CD4 100-200 cells/mm3 VL
1
Toxoplasmosis CD4 > 200 cells/mm3 3 CD4 > 200 cells/mm3 6
Cryptococcosis CD4 > 100 cells/mm3 3 secondary prophylaxis
1 CD4 100 cells/mm3
3
Penicilliosis/ CD4 >100-150 cells/mm3 6 CD4 > 100 ( penicilliosis)
Histoplasmosis * > 150 ( histoplasmosis) cells/mm3
6
MAC CD4 >100 cells/mm3 3 * MAC 12
CD4
> 100 cells/mm3 6
CMV retinitis Not applicable CMV retinitis
3-6 CD4 > 100 cells/mm3
3-6
* primary prophylaxis

2560
6.11 CD4 primary secondary prophylaxis

Opportunistic
Primary prophylaxis Secondary prophylaxis
infections
PCP < 1 : < 1:
1-5 : CD4 500 cells/mm3 15% 1-5 : CD4 500 cells/mm3 15%
3 3
6 : CD4 > 200 cells/mm3 15% 6 : CD4 > 200 cells/mm3 15%
3 3
Toxoplasmosis < 1 : < 1 :
1-5 : CD4 15% 3 1-5 : CD4 500 cells/mm3 15%
6 : CD4 > 200 cells/mm3 > 15% 3
3 6 : CD4 > 200 cells/mm3 15%
3
Cryptococcosis Not applicable 6 CD4 > 200 cells/mm3
6
6
Penicilliosis/ Not applicable 6 itraconazole
Histoplasmosis 1 CD4 > 100 cells/mm3
( penicilliosis) > 150 cells/mm3
( histoplasmosis) 6
MAC < 2 : < 2 :
2-5 : CD4 200 cells/mm 2-5 : CD4 200 cells/mm3
3
3 6
> 6 : CD4 100 cells/mm > 6 : CD4 100 cells/mm3
3
3 6
MAC
1
CMV Not applicable < 1 :
1-5 : CD4 500 cells/mm3 15%
6
6 : CD4 > 100 cells/mm3 6

342
HIV Prevention
343
7

(HIV Prevention)

(comprehensive HIV prevention package)
PrEP 7.2-7.5
PrEP
PEP
TDF + 3TC TDF/FTC
RPV 25 .
ATV/r 300/100 .
LPV/r 400/100 . 12 . 800/200 .

DRV/r 800/100 .
TDF + 3TC TDF/FTC
RAL 400 . 12 .
DTG 50 .
EFV 600 .
(source)
oPEP nPEP
6
0, 1 3 anti-HCV 3
delayed HIV seroconversion

7.3

2560
7.1
(Antiretroviral-based HIV prevention)
7.1.1 (Treatment as Prevention: TasP)

Asian Epidemic Model .. 2555 2559
43,040 41

11 10
(Mathematical model)
90

CD4
2 3 ( 8,000
2,600 ) .. 2559
.. 2555 2559
(TasP)
1)

2)

2
CD4
344
HIV Prevention
345

(Strategic Timing of AntiRetroviral Treatment : START)

CD4 > 500 cells/mm3
CD4 500 cells/mm3

.. 2558 CD4

.. 2557
TasP

50 250,000

20

CD4 50 CD4 < 100 cells/mm3
(
)

TasP

2560

TasP

7.1.2 (Pre-Exposure Prophylaxis: PrEP)

(PrEP)
TDF/FTC
44 (iPrEx) 63
(TDF2) 75 (Partners PrEP)
TDF 67 (Partners
PrEP) 49 (Bangkok TDF Study)
PrEP ( 7.1)
92
.. 2557
2 1) IPERGAY
PrEP
TDF/FTC 2
2-24 1 24
48 86
IPERGAY

346
HIV Prevention
347

PrEP
2) PROUD
FTC/TDF 1 PrEP
PrEP 86
PrEP
2 PrEP
7.1 PrEP
adherence

Adherence
PrEP

adherence
IPERGAY MSM TDF/FTC 86% - -
PROUD MSM TDF/FTC 86% - -
Partners PrEP Serodiscordant TDF/FTC 75% 81% 90%
heterosexual couples TDF 67% 86%
TDF2 Heterosexual men TDF/FTC 63% 79% 78%
and women
iPrEX MSM TDF/FTC 44% 51% 92%
Bangkok TDF People who inject TDF 49% 84% 74%
drugs
FEM-PrEP Women TDF/FTC 6% 35-38% No protection
VOICE Women TDF/FTC -4% < 30% No protection
TDF -49% No protection

2560

PrEP

PrEP
PrEP
600-2,000
PrEP
( 7.2)
7.2 PrEP
PrEP
PrEP

Post-Exposure Prophylaxis (PEP)

3

6
PrEP 18
/

adherence

PrEP

348
HIV Prevention
349
7.3 PrEP PrEP

PrEP:
NAT

creatinine calculated creatinine clearance 60
creatinine clearance (Cockroft-Gault formula)

HBs Ag anti-HBs
HBs Ag negative (
)
anti-HBs negative (
)
HBs Ag negative anti-
HBs positive

HBs Ag positive ( PrEP HBs Ag
)1 6
(HBs Ag negative)
> 95%
HBs Ag positive 6
TDF/FTC PrEP

PrEP
PrEP
ALT 6 PrEP
PrEP
4

ALT TDF (
TDF/FTC )
AST to Platelet Ratio Index
(APRI) score2 APRI score > 1
PrEP TDF ( TDF/FTC )3

2560
PrEP:
Urine PrEP
pregnancy test (
PrEP) PrEP
1 4

PrEP

1
PrEP PrEP
/
(fibrosis)
PrEP
PrEP
PrEP

2
APRI score = [AST (IU/L)/upper limit of normal (IU/L)]/platelet(109/L) x 100
3
> 40 > 50
alpha-fetoprotein (AFP)
6-12 .. 2559

350
HIV Prevention
351
7.4 PrEP
TDF/FTC 300/200 . 1
PrEP
3
PrEP

7
PrEP

Methadone Maintenance Treatment (MMT)
PrEP
PrEP PrEP

PrEP 4

( window period)
PrEP

PrEP

(active)
PrEP
PrEP


2560
PrEP ()
PrEP

PrEP

2 PrEP
PrEP
TDF
(
1 200 1%)
7.5 PrEP PrEP

PrEP PrEP

1 3 6 9 12 PrEP

3
Creatinine creatinine
CrCl
6

(HBsAg)

HBsAg-negative

STI
6
( )

1 10
3-4
352
HIV Prevention
353
PrEP PrEP

Cr 1 200

PrEP

*

(acute HIV infection)

acute HIV infection anti-HIV
PrEP
nucleic acid
testing HIV RNA
PrEP (
PrEP )

controversy
PrEP
PrEP
( PrEP )
Seroconversion PrEP

7.1.3 (Post-Exposure Prophylaxis: PEP)

PEP 2

HIV occupational PEP (HIV oPEP)

( ) ( )

2560
HIV
non-occupational PEP (nPEP)

7.1.3.1
(HIV occupational Post-Exposure Prophylaxis: HIV oPEP)

(occupational exposures)

(percutaneous injury)

(contact of mucous membrane)

(contact of non-intact skin)
(dermatitis)

354
HIV Prevention
355

0.3 ( 95
0.2-0.5) 0.09 ( 95
0.006-0.5) 0.09

HIV oPEP 7.1
HIV oPEP 7.6 HIV oPEP
( 1-2 ) 72
* 4

HIV oPEP
(source)
VL
()
VL detectable VL NNRTI-
based regimen TDF/FTC TDF + 3TC + boosted PI
source PI-based regimen NNRTI resistance
TDF/FTC TDF + 3TC + RAL DRV/r
Dolutegravir ( 7.7)
undetectable VL
7.7
* 72

HIV oPEP

2560
HIV oPEP
7.6
(Standard precautions)

72
1 3

6
delayed HIV seroconversion

/

HIV
oPEP CBC, Cr SGPT
/
356
HIV Prevention
357
7.1

0.9% NSS
0.9% NSS

70%
alcohol betadine
solution
5% Chlorhexidine gluconate

anti-HIV
24 . source anti-HIV
source

source Source Source

anti-HIV -ve HIV anti-HIV +ve
source

HIV
Source
oPEP oPEP
HIV

7.7
HIV

2560
7.6 HIV oPEP

HIV oPEP

Source
1
Baseline 1 3 6

Anti-HIV 3 2
(same-day result)2
CBC, Cr, SGPT - 4 - - -
HIV PCR or VL - - 3 - - -
HBsAg 5 - - 6
Anti-HBs - 7 - - - -
Anti-HCV - - - 6
1
(source)
HIV oPEP
HIV oPEP
2
anti HCV
6 delayed
HIV seroconversion
3
HIV PCR VL
/
4

5
(acute)
6
6 /
7

358
HIV Prevention
359
7.7 HIV oPEP* HIV nPEP

**
TDF 300 . + 3TC 300 . + RPV 25 . boosted PI ATV/r
LPV/r
TDF 300 ./FTC 200 . ATV/r 300/100 ergotamine cafergot
.
LPV/r 400/100
. 12 .
800/200 RPV
.
DRV/r 800/100 ( 533 )
.
TDF 300 . + 3TC 300 . + RAL 400 . EFV
12 . ergotamine cafergot
TDF 300 ./FTC 200 . DTG 50 .

EFV 600 .

AZT 300 . 12 . TDF
CrCl < 60 ./

*
3
**

7.1.3.2
(HIV non-occupational Post-Exposure Prophylaxis: HIV nPEP)

/

7.8
2560
7.8

10,000

63
23

138
8
11
4
*
*

8-12

cervical ectopy

360
HIV Prevention
361
10,000
*

*

- HIV nPEP 7.9
- HIV nPEP HIV nPEP
7.10 HIV oPEP

HIV nPEP
( 1-2 ) 72 *
4 HIV oPEP
- HIV nPEP
HIV oPEP 7.7
- HIV nPEP
1-3 HIV nPEP
1 PrEP
- HIV nPEP
72 anti-HIV
1 3

/

HIV nPEP CBC, Cr SGPT
/
* 72

HIV nPEP
2560
7.9 HIV nPEP

nPEP
1.
nPEP

/

2.
1
nPEP

nPEP
2.1
2.2

2.3
2.4

3. (
nPEP
)

(

)

362
HIV Prevention
363
7.10 nPEP nPEP

1

Baseline 1 3 6

Anti-HIV (same-day result)2 3 2
CBC, Cr, SGPT 4 - - -
HIV PCR or VL - 3 - - -
HBs Ag 5 - - 6
Anti-HBs 7 - - - -
Anti-HCV - - - 6
VDRL or RPR - 8 - - 9
Pregnancy test - 10 - -
(for child-bearing age female)9
1
VDRL RPR
()
nPEP
nPEP
2
anti HCV
6 delayed HIV
seroconversion
3
HIV PCR or VL

4

5

6
6 /
7

8

VDRL RPR
9
6
10


2560
7.2 (Male circumcision)

.. 2539

Randomized controlled
trials 3

3
.. 2548-2550

51-60 .. 2550

58 6

(Herd
immunity)

1) (Langerhans
cells), CD4+, macrophage
364
HIV Prevention
365

2)
(keratin)
(micro injuries)
3)

4)

(keratinization)
(glans)

9.1
(balanitis)
(posthitis) HSV-2
(HR 0.72; 95% CI, 0.56-0.92) high-risk human papillomavirus (HPV) (RR 0.65;
95% CI, 0.46-0.90 RR 0.67; 95% CI, 0.51-0.89)
HPV (RR, 1.39; 95% CI, 1.17-1.64)
(chancroid)

2560

HPV

(phimosis)

1 3

3

Shang Ring
2

Shang
Ring
366
HIV Prevention
367
7.11

(

)

1


2560

/

"risk compensation"

1

American Academy of Pediatrics
.. 2555

American College
of Obstetricians and Gynecologists
7.12

risk compensation

368
HIV Prevention
369
7.3

2-5
3-11

(cost effectiveness strategy)

2556-2558 /
5.35 15.1

5.33 2

50-70 70-80 85-90

Test and Treat


2560

.. 2555
Urine PCR
(polymerase chain reaction) Chlamydia trachomatis (CT)
6.6 Neisseria gonorrhoeae (NG) 2.9 CT
NG 11.4 16.1
(venue-base female sex worker)
NG CT .. 2553, 2555
2557 ( 7.2)

()
( )
( .. 2558)
7.2 (GC) (CT)

.. 2553-2557
25 HIV GC. CT
20.0
20
17.7
15
11.1
10 9.2
7.27
5 4.9 4.2
3.38 2.7 2.4 2.7
2.17 1.9 2.4 1.6
1.07 0.98 1.1
0

2553 2555 2557
370
HIV Prevention
371
1.
()

2.

()

(
download a idssti.ddc,moph,go.th

2560
17
(STIQUAL program)
3,405
41.0
1

15.4

NAT

anti-HIV
7.3
372
7.3

3 1 ; ;
; RPR/VDRL titer visit
/ /
RPR/VDRL titer 4 RPR/VDRL titer 4
3
RPR/VDRL
Anti-HIV(1) 3 1
6 2
HIV Prevention
,
HIV positive HIV negative

Benzathine penicillin G
2.4
Neurosyphilis 3
Aqueous crystalline penicillin G

12-24 / 2-4
4 14

(1)
373
anti-HIV
2560
7.4

.. 2531

(ISO) .. 2533
3 49 52 54
0.05-0.08

( 87)
HSV-2 ( 92)
chlamydia ( 26) gonorrhea
( 62) trichomonas
HPV
HPV
98 88
15
(polyurethane)
7
5.5

(polyurethane)
(latex)

374
HIV Prevention
375

15-24 8.8
80
2.3 89.2
21.5
33 0.8
78.8

aidsstithai.org/female

2560
7.5

.. 2558
1.9-2.2
80 (The Thai
working group) .. 2558
7,324 11
.. 2532 2557
19

(Harm reduction)

7.13

1. (Outreach programme)

2.

376
HIV Prevention
377

3.

4.
5.

6.

7.

8.

9.

10.


Service delivery guidance
379
8

(Service delivery guidance)

Treatment cascade

NAP plus Treatment
cascade

viral load
1 viral load < 50 copies/mL
8.1

380
8.1

Cascade of HIV care and treatment services and key indicators
0% 25% 50% 75% 100%

Estimated alive PLHA 459,509 Recruit
15%
Registered to care 388,633* #-% HIV test, # HIV+ diagnosis
% HIV+ referred to care Test
38% #-% ART-eligible not on ART
Started ART 286,214 % CD4 <200/median CD4 at ART initiation Treat
50% % retained to ART at 12, 24, 36 & 60 m

Retained to ART 227,779 #-% lost to FU
#-% deaths
62% Retain
VL annual testing 175,304 % VL screening during the past 12 m
2560
66% % of PLHA with VL suppression

VL suppressed 155,221 % of PLHA with VL failure
% switched to higher-class ART regimen
0 150,000 300,000 450,000

-
-

/ . .. 2558
381
Reach - Recruit - Test - Treat - Retain

- -
- -
4

NAP plus website
.
Reach - Recruit - Test - Treat - Retain

8.1 (Reach & Recruit)
HIV
1. ()
(STI)
( PWID)
2. ()

2560
3. ()
/ (
PWID)
(Reach)
1.
4
1.1 (STI)
(PWID)
1.2
PWID
1.3

1.4 Unique Identifying Code (UIC)
(Recruit)
1.
(pre-test counseling)
(mobile clinic)
382
383
Reach Recruit

Recruit Reach
1. Outreach worker
2.

(Peer)

()
Drop in center (Mobile clinic)

1. ( MSM TG MSW FSW PWID Migrant
)
2.

2560
3.

2 (Mobile clinic)

1. Mobile clinic
2. HCT SDR

(Mobile clinic)
3. Mobile
clinic

HCT SDR

drop-in center
Mobile clinic
384
385
3 (Network building in community)
1.
drop-in center ..
2.

drop-in center ..

..
Telemedicine Skype

2560
4

1.
2.
( outreach worker website /
)

Path2Health
www.adamslove.org

5

1.

386
387
2.

3 8.2
8.2

2560
6

1.
2.
3. ()
HCT SDR

4. UIC (Unique
Identifying Code)

/

8.3

1.

2.

388
389
3.

4.

5.


2560
8.3
390
391
1.

2.

3.

4.

5.
/

6. /


2560
8.2 (Test)

1. HCT
()
(
)
2.

3.

4.

5. ()

392
393
1
(Same day result HIV testing; SDR)
1. ( .. Drop-in center)
2.
( .. Drop-in center)
3. Mobile clinic

.. Mobile clinic
(Community based HIV testing)
(Concentrated
epidemic)
1) (Facility-based HIV Counseling

and Testing; HCT)
(Client-Initiated Testing
and Counseling; CITC) (Provider-Initiated
Testing and Counseling; PITC)

CD4 Drop-in center (DIC)


2560

99
(HIV Opt out testing) HCT
(Normalize HIV testing)

2) (Community-based HCT)

HCT

(KAP)

HCT

CD4

394
395

2
(1)

(2)

1.

2.

3.
4.

1.
2. -
-
3.
(
)
4.
5.


2560

(
)

1.
2.

3. CD4
4.
2

1.

2.

2
1)

396
397

2) -

8.1
6
3 (Friendly service)
1.
2.

5

1. 1

2


2560

2. 3

4

3. 5

6

hotline,
website, facebook
7

4. 8

398
399

5. 9

1.
8.1
6
1. (HIV Counseling handbook)

2.

3.

4.


2560
8.3 (Treat)

1.

2. 3

3. CD4 (
CD4 < 200 cells/mm3)
1 (Friendly service)

1.
2.

8.2 3

2

1.

2.
400
401
(Chronic and treatable disease)

(Holistic care)

9
35

1.
1.1

1.2 CD4 /

1.3 CD4
1.4 (HIV Viral load)
1.5 HIV Genotype

2560

2.
2.1

2.2 PCP (Pneumocystis jiroveci
pneumonia)

2.3

2.4
2.5 CMV retinitis CD4 < 100 cells/mm3
2.6

2.7

2.8 Pap Smear
VIA 1
3.
3.1

3.2

3.3 (HAART)

3.4

402
403

3.5
(Adherence)
3.6

4.
4.1

4.2 (Voluntary Counseling and
Testing)
(Provider-Initiated HIV Testing and Counseling, PITC)
4.3
5.
5.1
6.
6.1 (Prevention with Positives, PwP)
6.2
(PMTCT)
6.3
(PMTCT)
6.4

6.5

7.
7.1


2560

7.2

7.3 /

8.
8.1
9. ()
9.1
9.2
9.3

HIVQUAL 10
3 1) 2) /
3)

http://www.cqihiv.com/
(.)

1. ..
2554
404
405
3 CD4 Viral load, Genotype
1. CD4 3
2. viral load 1
3.
HIV resistance testing 4
2
NAP
1. CD4
2.
3.
3 4
NAP

2560
8.4 (Retain)
()
1.
(
)
2.
3. viral load < 50 copies/mL
4.
1 (Retention in care)

1.

2. 12

406
407

8.4
8.4

Re-Engagement
in Care

Loss to Follow up

Retention in Care
HIV Linkage ART ART Outcomes

Diagnosis to Care Receipt Adherence

5
1) (Individual/Intrapersonal factors)
(Predisposing)

(Enabling)

(Perceived need)

2) (Relationship/Interpersonal factors)


2560

3)

4) (Community factors)

5) (Policy and healthcare factors)

1. 2. 3. 5.
(Intrapersonal factors) (Interpersonal factors) (Community factors) (Policy and
healthcare factors)

1.1

/
1.2

4.
1.3

(Audit)
RRTTR
408
409

1)

Adherence
2)

Treatment Literacy

3)


2560
4)

5) (Case manager
Retention specialist)

Case management
Case manager

6)

3-5

31 18
2 Adherence

1.
2. 100%

410
411

Adherence 100%

Adherence

Adherence
Treatment
Literacy

Adherence stigma discrimination

CD4 < 200 cells/mm3

1
(fast track)
*
VL > 50 copies/mL
(VL < 50 copies/mL)
1 ()

3-6

2560
*

> 1 VL < 50 copies/mL

1.
(HIV/AIDS Treatment Literacy)

Treatment Literacy

(Treatment Literacy or TL)

7
1.
2.
3.
4.
5.
6.
7.
7
7
(Key message)

adherence
412
413
Treatment Literacy
1.
TL

(Key message)
2.

3.

1.
2.
3.
4.
5.

2560
3 (Task shifting and task sharing)

1. .. HCT

8.1
414
8.1
./.

on site

(mobile HCT) (coaching on-site)

./.
.
()
././.

routine lab
./.
(coaching on-site)

()

CD4 ( point of care CD4 .),

VL, DR
415
416
./.

Treatment Literacy

STI ( syndromic screening and treatment) STI
Pre-exposure Prophylaxis (PrEP) ( syndromic screening and treatment)

2560
./.
1. 1. / 1
./. VL suppression ( 50 copies/mL)
2.

3. HCT 2.

417
4
(Drug resistance monitoring & prevention)
1. 12
90 5
2. viral load 12
< 50 copies/mL 85
3. 12 viral load < 50
copies/mL 90
4.
5. drug resistance
2

(1)
(2)
(Early Warning
Indicators) (3)
8.2
(4) (5)

418
8.2
EWI *
VL Coverage VL < 50
VL Suppression/Failure VL > 1,000
ARV regimen
(
)
Drug stock out
2560
Lost follow-up

Poor adherence adherence

* case management /
. 8.6
419

(Visit adherence drug adherence)
viral load
HIV resistance testing

1.

2. World Health Organization global strategy for the surveillance and
monitoring of HIV drug resistance: an update. World Health Organization 2012,
ISBN 978 92 4 150476 8.
1.

2560

CD4

420
421
1. (Real life) /
International
HIV/AIDS Alliance (AIDS Net)
2. (Life-Skills Activities Manual
on HIV and AIDS)
1.

(
)

(PrEP- Pre-exposure Prophylaxis)
7
PEP (Post-exposure Prophylaxis)


2560
8.5

1.

1.

2.

/

2573

2 1)

2)

1)

2)
/
422
423
1.
2. 75

3x4 ( 8.5) 4
1)
2)
3) 4)

3
1.
1.1


2560
1.2

2.

2.1

2.2 Consultative meeting

2.3 ( 2-3 )

2.4
(
)
2.5
/
3.
3.1

424
425
3.2 consultative meeting

(1)

HA (2)


426
8.5 3x4

3x4
S&D

Consultative
meeting /
Case conference
S&D
(50% ) +
/ /

2560
Case conference
/
E-learning
/
3 4
1. 3.
1. 2. / 3. 2. ( 2 2-3) 4.

1. Laura Nyblade, Anne Stangl, Ellen Weiss and Kim Ashburn. Combating HIV stigma in health care settings: what works?. Journal
of the International AIDS Society 2009, 12:15 doi:10.1186/1758-2652-12-15.
2. UNAIDS. 2014. Reduction of HIV-related Stigma and Discrimination.
427
2
/
1.
( 8.6)
1.
2.

/

2560

3.
1)
2)
3)
Standard
Precaution
4.

5.
/
428
429
8.6

1.
2.
3.
/
4.
PDCA
...

1.
2.
3.

(

)

1. .
. :
, 2555. http://
www.thailandaids.org/main/index.php/2014-02-17-04-23-20

2560
8.6

1.

1.

2.

2
8.3 R-R-T-T-R

430
431
8.3

Surveillance
( )
Program data
() Surveillance
- REACH & RECRUIT
() () Program data
1. STI Surveillance
2.
3. STI /
( PWID)
- TEST
1. Program data
Surveillance
2.

3.

4.

5. ()

- TREAT
1. Program data

2. 3

3. CD4 (
CD4 200)

2560

- RETAIN
1. Program data
Estimation
2. 12

3.

4.

5. viral load < 50
copies/mL
3

(Effective Continuous
Quality Improvement)

(
)
8.7
432
433
8.7

Death
( ) ARV resistance
( )
-

Process, Outcomes, Impact
1.
( )
2.

3. .. 2558-2562

1
Ombitasvir/
Ombitasvir/
Ledipasvir/ paritaprevir/ Simeprevir Pegyltated
Daclatasvir paritaprevir/ Sofosbuvir Ribavirin
sofosbuvir Ritonavir/ (SMV) interferon
ritonavir
dasabuvir
Nucleoside reverse transcriptase inhibitors (NRTIs)
Appendix
Abacavir (ABC)
Emtricitabine (FTC)
Lamivudine (3TC)
Tenofovir (TDf)
Zidovudine (AZT) X X
HIV entry/integrase inhibitor
Dolutegravir (DTG)

437
438
Ombitasvir/
Ombitasvir/
Ledipasvir/ paritaprevir/ Simeprevir Pegyltated
Daclatasvir paritaprevir/ Sofosbuvir Ribavirin
sofosbuvir Ritonavir/ (SMV) interferon
ritonavir
dasabuvir
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Efavirenz (EFV) X X X
Nevirapine (NVP) X X X
2560
Potease inhibitor
Lopinavir X X X
Ritonavir X X X
: 2016 X

(Dose and Route of HIV medication in Adults)
2

() /
Nucleoside reverse transcriptase inhibitors (NRTIs)
Abacavir 300 . 12 . alcohol 1.5 ./ Hypersensitivity reaction (HSR) HLA-B*5701
(ABC) 300 . dehydrogenase 1226 . positive
Appendix
600 .
glucuronyl transferase HLA ABC

82%
HSR

ABC

439
440

() /
Didanosine Videx EC: 60 . 50% 1.5 ./
(ddI) 400 . > 20 . Peripheral neuropathy
125, 200, 250, TDF: Retinal changes, optic neuritis
400 . Lactic acidosis with hepatic steatosis +/- pancreatitis
250 . ()
< 60 .

250 . noncirrhotic portal hypertension;
TDF: esophageal varices
MI
200 .
2560
( Insulin resistance/
.
2 . )
Tenofovir 300 . 17 ./ , Fanconi syndrome, proximal tubulopathy
disoproxil 300 . > 60 . osteomalacia
fumarate TDF
(TDF) 3 HBV-coinfected

() /
Zidovudine 300 . 12 . GAZT 1.1 ./ macrocytic anemia
(ZDV) 100, 250 300 200 . 12 . GAZT 7 . neutropenia
.

Lactic acidosis/severe hepatomegaly with hepatic
steatosis ()
Appendix
Hyperlipidemia
Insulin resistance/
Lipoatrophy
Myopathy
Lamivudine 150 . 12 . 57 ./
(3TC) 150 300 . 300 . 1822 . HBV-coinfected 3TC
70%


441
442

() /
Emtricitabine 200 . 10 ./
(FTC) 200 . > 20 . Hyperpigmentation/skin discoloration
86%
HBV-coinfected FTC
Atripla Teevir:
FTC
FTC 200 . +EFV 600

. + TDF 300 .
2560
Complera:
FTC 200 . + RPV 25
. + TDF 300 .
Truvada Teno-EM:
FTC 200 . + TDF 300
.

() /
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Efavirenz 600 . 40-55 .
(EFV) 50 (europsychiatric symptoms)
200 . CYPs 2B6 3A4 Increased transaminase levels
600 CYP3A4
.
EFV with 1 ( cannabinoid benzodiazepine
TDF + FTC EFV 600 . + )
Teratogenic in non-human primates and potentially
Appendix
( 3TC) FTC 200 . +

TDF 300 . teratogenic in humans

EFV 600 . +
3TC 200 . +
TDF 300 .
Etravirine 25, 100, 200 . 12 . 41 . , Stevens-Johnson syndrome
(ETR) 200 . CYP3A4, 2C9, HSR
2C19
3A4 ; 2C9
2C19

443
444

() /
Nevirapine 200 . CYP450 2530 . , Stevens-Johnson syndrome
(NVP) 200 . 14 (lead-in period); 3A4 2B6 fatal hepatic

200 .
80% necrosis
12 . (glucuronidated - ARV-nave CD4 > 250
400 . metabolites, < 5% cells/mm3
400 . (Viramune XR) ); 10% - CD4 > 400 cells/mm3
NVP CD4

50%
2560
lead-in

7

lead-in

28

() /
Rilpivirine 25 . 25 . CYP3A4 substrate 50 .
(RPV) EFV
1
RPV + TDF RPV 25 . +
+ FTC TDF 300 . +
FTC 200 .
Protease inhibitors (PIs)
Atazanavir ATV 300 . + RTV 100 CYP3A4 inhibitor 7 . Indirect hyperbilirubinemia
(ATV) 200 300 . . substrate PR interval prolongation: first degree
Appendix
ATV 400 . symptomatic AV block

conduction defects
PR prolongation
TDF Hyperglycemia
Fat maldistribution
H2 antagonist PPIs Cholelithiasis
Nephrolithiasis
3.12 Renal insufficiency
Serum transaminase elevations
Hyperlipidemia RTV boosting


Creatinine ( COBI)
445
446

() /
Darunavir 75, RTV CYP3A4 inhibitor 15 . (10%): DRV sulfa
(DRV) 150, 300, 600, substrate ( Stevens-Johnson syndrome, toxic epidermal
800 . RTV necrolysis, acute generalized exanthematous
pustulosis erythrema multiforme
DRV 600 . + RTV 100
. 12 . RTV

Serum transaminase elevation

800 . ) Fat maldistribution
+ RTV 100 .
2560
Lopinavir LPV/r 400 ./100 . CYP3A4 inhibitor 5-6 . GI intolerance, , ,

Boosted LPV 200 . + 12 . substrate
(LPV/r) RTV 50 . LPV/r 800 ./200 . Asthenia
LPV 100 . + PI Hyperlipidemia ( hypertriglyceridemia)
RTV 25 . Serum transaminase elevation
Hyperglycemia
Insulin resistance/
3LPV-associated Fat maldistribution
mutation EFV,
NVP, Carbamazepine, PR interval prolongation
phenytoin QT interval prolongation torsades de
phenobarbital pointes

() /
Dolutegravir 50 UGT1A1 ~14 . HSR constitutional
(DTG) . INSTI mediated glucuronidation symptoms organ dysfunction ()
INSTI Mutations
INSTI CYP3A4
rifampicin EFV (,
50 . 12 . pre-existing psychiatric)

INSTI
Appendix

50 .

Elvitegravir 1 EVG: CYP3A, ~13 .
(EVG) UGT1A1/3
EVG 150 . + CrCl < 70 cobi: CYP3A, CYP2D6
cobi 150 . + mL/min (minor) bone mineral density
cobi/TDF/ TDF 300 . +
FTC FTC 200 . HBV-coinfected FTC
TDF
(,

pre-existing psychiatric)
447
448

() /
Raltegravir 400 . 12 . UGT1A1-mediated ~ 9 . Stevens-Johnson syndrome, HSR
(RAL) 400 . rifampicin glucuronidation toxic epidermal necrolysis

800 . 2 CPK
400 . rhabdomyolysis
12 . (,
pre-existing psychiatric)

CCR5 antagonist
Maraviroc Boosted CYP3A4 substrate 14-18 .

2560
(MVC) 150 300 . PI ( PI

MVC)
150 . 2
NRTIs, NVP Hepatotoxicity
300 . 2
EFV ETR Orthostatic hypotension
600 . 2

: cobi = cobicstat; CPK = creatine phosphokinase; CrCl =creatinine clearance; CYP = cytochrome P; HBV = hepatitis B virus; HSR = hypersensitivity
reaction; INSTI = integrase strand transfer inhibitor; UGT = uridine diphosphate gluconytransferase
Appendix
449

CDC Classification 2014
1.

CD4
CD4 lymphocytes
1
2
3 2
3
CD4
< 12 1-5 6-12
CD4 CD4 CD4
3 %CD4 3 %CD4 %CD4
(cell/mm ) (cell/mm ) (cell/mm3)
1 : 1,500 34 1,000 30 500 26
2 : 750-1,499 26-33 500-999 22-29 200-499 14-25
3 : < 750 < 26 < 500 < 22 < 200 < 14

2560
2. (AIDS-Defining Illnesses CDC Classification)

4
Candidiasis of bronchi, trachea, or lungs
Candidiasis, esophageal
Cervical cancer, invasive
Coccidioidomycosis, disseminated or extrapulmonary
Cryptococcosis, extrapulmonary
Cryptosporidiosis, chronic intestinal (>1 month)
Cytomegalovirus disease (other than liver, spleen, or nodes)
Cytomegalovirus retinitis (with loss of vision)
Encephalopathy, HIV-related
Herpes simplex: chronic ulcer(s) (>1 month); or bronchitis, pneumonitis,
or esophagitis
Histoplasmosis, disseminated or extrapulmonary
Isosporiasis, chronic intestinal (>1 month)
Kaposis sarcoma
Lymphoma, Burkitts (or equivalent term)
Lymphoma, immunoblastic (or equivalent)
Lymphoma, primary, of brain
Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary
Mycobacterium tuberculosis, any site (pulmonary or extrapulmonary)
Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
Pneumocystis pneumonia
Pneumonia, recurrent
Progressive multifocal leukoencephalopathy
Salmonella septicemia, recurrent
Toxoplasmosis of brain
Wasting syndrome due to HIV

Nocardiosis
Penicilliosis
Rhodococcosis
450
Appendix
451

(WHO Classification System for HIV-Infected Children)
1 (WHO clinical stage 1)

1.
2.

1. (unexplained persistent hepatosplenomegaly)
2. (papular pruritic eruptions)
3. (angular cheilitis)
4. linear gingival erythema
5.
6. (extensive wart virus infection)
7. (extensive molluscum contagiosum)
8.
9. (unexplained persistent parotid enlargement)
10.
11.
(

1.

2. 14
3. 37 C 1

2560
4. (persistent oral candidiasis) 6-8

5. (oral hairy leukoplakia)
6.
(acute necrotizing ulcerative gingivitis or periodontitis)
7.
8.
9.
10. lymphoid interstitial pneumonitis
11. (bronchiectasis)
12. ( 8 g/dL)
( 500 cells/L) ( 50,000 cells/L)


1.

2. Pneumocystis jiroveci (PCP)
3. empyema
(pyomyositis)
4. (herpes simplex) 1
5.
6. non-tuberculous Mycobacteria
7. candida
8. toxoplasmosis ( 1 )
9. cytomegalovirus
( 1 )
452
Appendix
453
10. cryptococcosis
11. (disseminated endemic mycosis) histoplasmosis
coccidiomycosis, Penicillosis ()
12. Cryptosporidium
Isospora
13. HIV encephalopathy
14. progressive multifocal leukoencephalopathy
15. HIV-associated cardiomyopathy
16. HIV-associated nephropathy
17. Kaposis sarcoma
18. lymphoma Z (B-cell non Hodgkin lymphoma)

454

(Dose and Route of HIV Medication in Pediatrics)
5

Nucleoside analogue reverse transcriptase inhibitor (NRTI)
Zidovudine (AZT) : 10 mg/mL 6 ():
( 60 mL) 180-240 mg/m2/dose 12 .
: 100 . ( 300 mg/dose)
: 300 . > 4 ():

2560
4-< 9 . 12 ./. 12 . (
9-30 . 9 ./. 12 . )
30 . 300 . 12 . d4T
AZT
(- 6 )
35 4 ./. 12 .
30-< 35 2 ./. 12 .
2 3 ./. 12 .
< 30 2 ./. 12 . 4
3 ./. 12 .

Lamivudine (3TC) : 10 mg/mL < 4 2 ./. 12 .
( 60 mL) 4 4 ./. 12 .
: 150, 300 . ( 150 mg/dose) ( 30 )
3 VL < 40 copies/
mL 8-10
./. ( 300 .)
CrCl < 50 mL/min

Appendix
Emtricitabine 100 mg/mL

(FTC) 200 . < 3 : 3 ./.
3 - 17 6 ./. ( 240 .)

> 3.3 . 200 .
Stavudine (d4T) : 1 mg/mL - 13 0.5 ./. 12 .
: 20, 30 . 14 1 ./. 12 . 30
( 30 mg/dose) AZT

455
456

Didanosine (ddI, : 25, 125, 200 . ddI tablet .
dedioxyinosine) 2 < 3 50 mg/m2 12 . 2 .
enteric-coated 3-8 100 mg/m2 12 .
(ddI-EC): 200, 250, > 8 90-150 mg/m2 12 .
400 . ( 200 mg/dose)
enteric coated
240 mg/m2 24 . ddI TDF
( 400 mg/dose) ddI
ddI-EC ( > 6 ) ddI
20-< 25 . 200 . 24 .
25-< 60 . 250 . 24 .
2560
60 . 400 . 24 .
Abacavir (ABC) : 20 mg/mL 8 ./. 12 . ( 300 mg/dose)
: 300 . 3
14-< 20 . 150 . 12 . 300 . 6

20-< 25 . 150 . , 300 . HLA-B* 5701
450 .
25 . 300 . 12 . 600 .

Tenofovir (TDF) : 300 . 2-< 12 8 ./. ddI
2 12 35 . 300 .
Lopinavir Atazanavir
14-< 20 .: 150 . Tenofovir
20-< 30 .: 225 . CrCl < 50 mL/
> 30 .: 300 . min

48 . CrCl 30-49 mL/
min 72-96 . CrCl 10-29
mL/min
Appendix

Nonnucleoside reverse transcriptase inhibitor (NNRTI)
Nevirapine (NVP) : 10 mg/mL < 1 6 ./. 12 . Rifampicin NVP
: 200 . ( Lead-in) 20-30% NVP
1 < 8 200 mg/m2 12 . 2-4
8 120-150 mg/m2 12 .
( 200 mg/dose)

(Lead-in) 14
24 .

12 .

14 EFV NVP
457
458

Nevirapine (NVP) NVP 12 . lead-in
() 6 Rifampicin
4 mg/kg/dose ( NVP lead-in 7-10 (
5) 14 ) Rifampicin
NVP
Efavirenz (EFV) : 50, 200 . > 3
: 600 . 3 10-< 15 . 200 .
( 15-< 20 . 250 . (
3-36 20-< 25 . 300 .
25-< 32.5 . 350 . 50%)

2560
) 32.5-< 40 . 400 .
40 . 600 .
400 .
< 40 .
Etravirine (ETR) : 100 . 16-< 20 . 100 . 12 .
6 20-< 25 . 125 . 12 . 1-2
25-< 30 . 150 . 12 .
30 . 200 . 12 . NNRTI ETR

Rilpivirine 25 . >12 > 12 25 .
VL < 100,000 copies/mL
VL < 50
copies/mL

Fixed dose combined pill of NRTI and NNRTI
AZT + 3TC : AZT 300 . + 30 . 1 12 .
(fixed dose 3TC 150 .
combination) 30-60 .
Appendix

AZT 200 mg/dose
GPO-VIR S30 d4T 30 . + 3TC 150 GPO-VIR S30 2-4
. + NVP 200 . NVP 160-200
mg/m2 12 .
(Lead-in) NVP
14 10-< 14 . 12 .
GPO-VIR d4T+ 3TC 14-25 . 12 .
14 1
GPO-VIR > 25 . 1 12 .

12 .
459
460

GPO-VIR Z250 AZT 250 . + 3TC GPO-VIR S30 2-4
150 . + NVP 200 NVP 160-200
. mg/m2 12 .
(Lead-in) NVP GPO-VIR S30
14 GPO-VIR NVP
Z250 AZT + 3TC AZT
Kivexa ABC 600 . + 3TC > 12 > 12 > 40 .:
300 . 1
Truvada Ricovir- TDF 300 . + FTC > 12 > 12 > 35 .:
EM Teno-EM 200 . 1
Atripla TDF 300 . + FTC > 12 > 12 > 40 .:

2560
200 . + EFV 600 . 1

Complera TDF 300 . + FTC 200 > 12 > 12 > 40 .:
. + Rilpivirine 25 . 1
Triumeq ABC 600 . + 3TC > 12 > 12 > 40 .:
300 . + Dolutegravir 1
50 .
Stribild TDF 300 . + FTC 200 > 12 > 12 > 40 .:
.+Elvitegravir150 . 1
+ Cobicistat 150 .

Protease inhibitor (PI)
Lopinavir + : LPV 80 mg/mL + 2 2 - 1
ritonavir (LPV/r) RTV 20 mg/mL LPV 300 mg/m2 + RTV 75 mg/m2 12 . (25 C) 2
: LPV 200 . + 1 - 18 :
RTV 50 ., LPV 100 LPV 230 mg/m2 + RTV 57.5 mg/m2 12
. + RTV 25 . . ( LPV 400 . + RTV 100 .) LPV/r 200/50 .
( LPV/r 1
15 .)
LPV 230 mg/m2 LPV/r LPV/r
Appendix
LPV/r VL < 50 copies/mL

15-25 . LPV/r 200/50 . 12 .
25-35 . LPV/r 300/75 . 12 . 25-35 .: LPV/r 200/50 . 12 .
35 . LPV/r 400/100 . 12 . 35-50 .: LPV/r 300/75 . 12 .
LPV/r > 50 .: LPV/r 400/100 . 12 .
2 LPV/r NVP EFV
LPV/r 300/75 mg/m2 12 .
Ritonavir (RTV) : > 1 PI
100 . < 15 . 3 ./. 12 .
: 80 mg/mL 15 . 2.5 ./. 12 .

461
462

Atazanavir (ATV) : 200, 300 . 6 asymptomatic
RTV indirect hyperbilirubinemia
20-< 40 . ATV 200 mg/r 100 .

40 . ATV 300 mg/r 100 . ATV 200 ./100 .
ATV Cobicistat
TDF ATV 300 ./Cobicistat 150
./TDF 300 .
Darunavir (DRV) : 300, 600 . 3 DRV

10 . 1
10 - < 11 .: DRV 350 . + RTV 64 .

2560
11 - < 12 .: DRV 385 . + RTV 64 .

12 - < 13 .: DRV 420 . + RTV 80 . 12 - < 15 .: DRV 300 . + RTV 50
13 - < 14 .: DRV 455 . + RTV 80 . 100 . 12 .
14 - < 15 .: DRV 490 . + RTV 80 . 15-30 .: DRV 450 . / RTV 100 .
15 - < 30 .: DRV 600 . + RTV 100 . + DRV 300 . / RTV 100 .
30 - < 40 .: DRV 675 . + RTV 100 . 30-40 .: DRV 450 . + RTV 100 .
40 . DRV 800 . + RTV 100 . 12 .
DRV resistant associated mutation
40 .: DRV 600 . + RTV 100 .
2 12 .
15 - < 30 . DRV 375 . + RTV 50 .
30 - < 40 . DRV 450 . + RTV 60 . 15-40 .: DRV 600 . + RTV 100 .

Darunavir (DRV) 40 . DRV 600 . + RTV 100 .
() > 40 .: DRV 900 . + RTV 100 .

Integrase inhibitor (II)
Raltegravir Chewable tablet 25, Chewable tablet 2-12 chewable tablet film
100 . coat tablet
Film-coated tablet 10 - < 14 . 75 . 2

400 . 14 - < 20 . 100 . 2
20 - < 28 . 150 . 2
28 - < 40 . 200 . 2
Appendix
40 . 300 . 2
> 12 25
. film-coated tablet 400 . 1
2
Dolutegravir 50 . 12 50 .
Efavirenz Rifampicin 50
> 40 . . 2
Elvitegravir : 85, 150 . 12
> 35 ATV/r LPV/r 85
. .
DRV/r 150 .

463
464

1)

LPV/r
1-6 < 2
LPV/r

< 42
2560
1-2
EFV 2-4 4 mcg/mL

absence

2) Mitochondrial dysfunction

Lactic acidosis 1-20 metabolic serum lactate
NRTIs acidosis routine serum IV fluid fluoride-oxalate
d4T, ddI (anion gap >16) lactate tube
serum lactate 4
> 5 mmol/L
NRTIs
TDF ABC

AZT 3TC
Pancreatitis serum ddI
Appendix
NRTIs amylase routine serum d4T

ddI, d4T lipase amylase serum amylase
3TC lipase

NRTIs AZT
ABC
Peripheral neuropathy NRTIs
d4T, ddI AZT ABC

d4T ddI
hyporeflexia

465
466
3)

Fat maldistribution lipohypertrophy waist-to-hip ratio
NRTIs / PIs (
d4T NNRTI )
PIs boosted PIs d4T
PIs d4T
(waist-

to-hip ratio z-
score)
3.5

http://
2560
(BMI) www.rihes.cmu.ac.th/Ped_
HIV/10-BMI-WHR_z_score/
index.html
lipoatrophy
/ d4T
AZT ABC
TDF
NRTIs
d4T ddI AZT

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
insulinresistance, fasting blood 6
diabetes sugar > 126
mg/dL 3 60
NRTIs random BS
Appendix
d4T, ddI, AZT > 200 mg/dL

PIs
LPV/r (ATV/r, DRV/r
) oral
glucose 10 impaired
challenge test OGTT
(OGTT)
Insulin resistance metformin
FBS 100-125
mg/dL

467
468
4) metabolic syndrome ()

Hyperlipidemia cholesterol, LDL fasting fasting Fibrate
cholesterol cholesterol, HDL, TG > 500 mg/dL
PIs atherosclerosis > 200 mg/dL LDL TG
fasting LDL 6 gemfibrozil 150-300 .
NNRTIs EFV TG > 130 mg/dL 6-12 TG 2
NVP pancreatitis fasting TG > 200 mg/dL Statin - Pravastatin
NRTIs > 200 mg/dL ARV ATV/r 8-13 20 .
d4T NNRTIs ()
2560
14-18 40 .
Fibrate
8-10 10 .
LDL > 190 mg/dL LDL 4
>160 mg/dL atorvastatin
> 6 10-20 .

statin
5)

liver enzyme ALT / AST /
(hepatotoxicity) () AST ALT NVP
ARV NVP
6 ALT
NVP AST > 5-10 fluconazole
NNRTIs NVP 10 upper normal limit
(NVP EFV) upper normal hepatitis A, B, C EBV
hypersensitivity limit 2-4 CMV
Appendix
NRTIs ALT
lactic acidosis AST 5-10
upper normal limit

6 lactic
acidosis
AZT, d4T, ddI
Indirect bilirubin
hyperbilirubinemia liver
ATV enzyme indirect
bilirubin

469
470
5) ()

/ /
AZT /
PIs

adherence
/
PIs
buffered ddI

2560
6)

Hb <7-8 g/dL AZT
AZT
MAC, TB
CBC 6
AZT
AZT d4T
heart failure CBC TDF
3
6
6
CBC: absolute CBC 6
neutrophil AZT
(neutropenia) count < 500 CBC MAC
AZT cells/mm3 3
absolute neutrophil (severe < 250 6
(< 250 cells/mm3) cells/mm3) 6

7) Allergic reaction/ Hypersensitivity

Appendix
maculo-papular
rash 2-4 2-8 antihistamine ABC hypersensitivity
2-3
(rechallenge)
systemic hypersensitivity
NVP ABC TMP- systemic
SMX,
systemic ()


471
472
7) Allergic reaction/ Hypersensitivity ()

Stevens Johnson
syndrome (SJS)/ TMP-SMX
erythema multiforme

(EM) major/toxic
epidermal necrolysis TMP-
(TEN) (blister/bulla) SMX
1-2 NVP
2560
NNRTIs systemic
NVP TMP-SMX, EFV
AZT, NVP
ddI, LPV/r, ATV 2

8)

Impaired renal function U/A, Cr. eGFR
eGFR < 60 mL/min/1.73 m2 6 Cr. Schwartz
Fanconi syndrome eGFR (
TDF , acute tubular aminoacid, )
IDV necrosis, interstitial nephritis, glucose uric
renal proximal renal tubulopathy, serum glucose TDF FEP = [(Urine
cortical atrophy nephrogenic DI, Cr. acidosis, phosphate/serum
acute renal , sodium potassium phosphate)/(urine
failure phosphate phosphate wasting creatinine/plasma
Appendix
phosphate creatinine)] x 100

urine fractional excretion of
phosphate
UA
UA hematuria microscopic
hematuria
IDV, ATV IDV
( ) Creatinine
6

473
474
9)

(osteopenia (peak bone mass)
osteoporosis)

(BMD /
z-score)

-1
TDF d4T Serum steroid medroxyprogesterone
PIs -2 Z-score Vitamin D
DXA (dual energy

2560
x-ray absorptiometry)

(bone
mineral density)

12
Appendix
475

creatinine clearance
creatinine clearance (CrCl) Schwartz formula:

CrCl or eGFR* (mL/min/1.73 m2) = k x height (cm) / serum creatinine
*eGFR = estimated GFR
Proportionality constant (k) for calculating

k Values
Pre-term babies (< 1 year) 0.33
Full-term infants (< 1 year) 0.45
Children (1-13 years) 0.55
Adolescent girls (> 13 years) 0.55
Adolescent boys (> 13 years) 0.70

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4-12

1.
1)
8 4
8-10 1
2)
3)
4)
5)
6)
2.

476
Appendix
477
5-10 2-3
5
2
8 1:2 ( 1 2 )
4-5 1:1 ( 1 1 )

3.
1)

2) 1-2 2-3
3-4 4
4-6 6-7 5
6 7-8 4
3)

4)


2560
5) 2

6)

4.
1)

2)

3)

4)

5) 2-3

6)

2
2 1 2

ORS
478
Appendix
479
5.

(month) (g) (mL/dose) (dose/day) (mL/day) (kg/month)
0 3,000 75 6 450 2
1 3,400 85 6 510 2.3
2 4,200 105 6 630 2.8
3 5,000 125 6 750 3.5
4 5,800 145 6 870 4
5 6,600 160 6 960 4.3
6 7,400 185 6 1,110 5
7 7,800 195 5 975 4.5
8 8,200 205 5 1,025 4.6
9 8,600 215 5 1,075 4.8
10 9,000 225 4 900 4
11 9,400 240 4 960 4.3
12 9,800 240 4 960 4.3

: ()
.. ;
1 = 30 mL; 1 4.5 g; 50 kg/
6.
450 1
450 () 1 ()

(
)

()

2560
1.
2.

3.
4.
5.

6.
KY-jelly

7.

480
Appendix
481
1.

2.

3.

4.

5.

2560
1.

(: )
2.

3.
4.
5.

482
Appendix
483
6.
7.

8.


2560

rapid desensitization TMP-SMX
rapid desensitization TMP-SMX

1.
anaphylaxis adrenaline
5 mL TMP 40 mg SMX 200 mg
2.
1 mL 9 mL ( A)
A 1 mL 9 mL ( B)
B 1 mL 9 mL ( C)
C 1 mL 9 mL ( D)
6 rapid desensitization TMP-SMX

TMP/SMX (mg) (mL)
D 0.004 / 0.02 5
1 C 0.04/0.2 5
2 B 0.4/2 5
3 A 4/20 5
4 40/200 5
5 160/800 20
484
Reference
485

2560
486
Reference
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.. 2551-2554. : .

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Thailand National Guidelines on

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

3 (Management of HIV-Infected Adult) 67

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

7 (HIV Prevention) 343

8.4 (Retain) 406

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

3.13 NNRTIs, RAL and PIs 107

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

6.7 IPT 308

7.1 PrEP 347

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

4.1 IRIS 216

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

BCG Bacillus Calmette-Gurin

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

HAART Highly active antiretroviral therapy

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

(Same day result)

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

2.2.1 (HIV viral testing)

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

A1+, A2 _ A1+, A2+

A1_, A2 _ A1+, A2 _ A1+, A2+

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

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

> 1 < 12 12-24

HIV DNA PCR HIV DNA PCR (2) Anti-HIV(8)

(6) (7) (6)

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

2.3.1 CD4 (CD4 count)

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

(%CD4) CD4 (absolute CD4)

2.3.2 (HIV viral load)

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

2.3.3 (HIV drug resistance testing)

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

viral load (1)

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

PPT EDTA gel 6-9 mL ( 4C)

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

2.5 (false positive) anti-HIV

TDF/FTC TDF + 3TC

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

TDF CrCl < 60 ./

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017

CD4 > 500 cells/mm3