ACQUIRED IMMUNODEFICIENCY

SYNDROME (AIDS)

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

2. Central nervous system disease

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

3. Peripheral nervous system

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

10. Skin manifestations

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

11. HIV-related malignancies

Kaposis sarcoma
Non-Hodgkins lymphoma
Anal dysplasia & squamous cell carcinoma
Cervical dysplasia & neoplasia
12. Gynecologic manifestations
13. Inflammatory reactions (immune
reconstitution syndrome = IRIS)
 Treatment
There are 4 catagories:
A. Opportunistic infections & malignancies
B. Antiretroviral treatment
C. Hematopoietic stimulating factors
D. Prophylaxis of opportunistic infections
E. Supportive therapy
 A. Therapy for Opportunistic infections &
malignancies (1)
INFECTION OR TREATMENT
MALIGNANCY
Pneumocystic infection Kotrimoxazole 14-21 days
(PCP) Pentamidine 14-21 days
Trimetoprim + dapsone 14-days
Primaquine + clindamycin 14-21 days
Atovaquone 14-21 days
Trimetrexate + leucovorin
Mycobactrium avium Clarithromycin + ethambutol
complex infection (MAC) Rifabutin
Toxoplasmosis Pyrimethamin + sulfadiazine + folic acid
Pyrimethamin + klindamisin + folic acid
Lymphoma Combination chemotherapy
Cryptococcus meningitis Amphotricin B
Fluconazole
 A. Therapy for Opportunistic infections &
malignancies (2)
INFECTION OR MALIGNANCY TREATMENT
Cytomegalovirus (CMV) infection -Valgaciclovir
- Ganciclovir
- Foscamet
Candidiasis: esophageal, vaginal Fluconazole
Herpes simplex infection - Acyclovir
- Famciclovir
- Valacyclovir
- Foscamet
Herpes zoster - Acyclovir
- Famciclovir
- Falaciclovir
- Foscamet
Kaposis sarcoma:
- Cutaneous - Observasion, intralesional vimblastine
- Extensive/aggressive cutaneous - Systemic chemotherapy
disease - Combination chemotherapy
- Visceral diseases
 B.. Antiretroviral treatment

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

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

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

Lamivudine (3TC) 2 x 150 mg Rash, PN

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

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

PN: pheripheral neuropathy

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

Delavirdine 3 x 400 mg/daily Rash

(Rescriptor)

Efavirenz (Sustiva) 600 mg/ daily Neurologic

disturbances
3. Nucleotide reverse transcriptase inhibitors

DRUG DOSE SIDE EFFECTS

Tenofovir 1 x 300 mg/daily Gastrointestinal distress

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

Nelvinavir (Viracept) 3 x 750 mg/daly Diarrhea

Amprenavir (Agenerase) 2 x 1200 mg Gastrointeratinal,

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

1st Line 2nd line

Start Substitute Switch Salvage

AZT, d4T, ddI,

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

Erythropoietin (Epoetin alfa):

HIV infected patients with anemia
Anemia secondary to zidovudine use trans?
Human G-CSF (filgrastim) and granulocyte
macrophage colony-stimulating factor
(GM-CSF [sargramostim]) to increase the
neutrophil counts of HIV-infected patients
 D. Prophylaxis of opportunistic infections
OI Primary prophylaxix Secondary prophylaxix
Pneumocystis carinii Cotrimoxazole, pentamidin,
dapson, atovaquone
Kaposiss sarcoma
Oesophagyal Fluconazole, Itraconazole,
candidiasis Voriconazole
Mycobacterium avium Azithromycin, Clariromycin, Azithromycin, Clariromycin,
complex (MAC) Rifabutin minus Rifabutin
Mycobacterium Isoniazid for 9-12 months
tuberculosis or rifabutin+ pyrazinamide
for 2 months
Toxoplasmosis Cotrimoxazole, Dapsone 50 Sulfasiazine 2 g +
mg+ pyrimethamine 50-100 pyrimethamine 25 mg or
mg clindamycin 1.2 g+
pyrimethamine 25 mg
Cryptococcosis Fluconazole 100-200 mg Fluconazole 200-400 mg
Cryptosporidiosis Clarithromycin, rifabutin
Cytomegalovirus Convenience, gansciclovir
Microsporidiosis Albendazole
 MANAGEMENT OF OPPORTUNISTIC INFECTIONS (1)
OI MANAGEMENT
Pneumocystis carinii Cotrimoxazole, dose is depend on the
degree of severity of diseases,
pentamidine, clindamycin + primaquine

Kaposiss sarcoma ART will lead to quiescence of KS

Oesophagyal candidiasis Fluconazole 100-200 mg/daily;
itraconazole 200 mg; amphotericine B
(0.3-0.5 mg/kg/daily; voriconazole 2 x
200 mg

Mycobacterium avium complex Clarithromycin 2 x 500 mg/daily;

(MAC) etambuthol 15 mg/kg/day rifabutin 300
mg/daily; azithromycin 450 mg/daily;
ciprofloxacin

Mycobacterium tuberculosis Rifampicin/rifabutin+isoniazid+pyrazina

mide+ethambutol (with pyridoxin) for 9-
12 months
 MANAGEMENT OF OPPORTUNISTIC INFECTIONS (2)

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

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

Cytomegalovirus Valganciclovir, iv ganciclovir, foscarnet,

cidofovir
Microsporidiosis Albendazole 2 x 400 mg
 E. Supportive therapy
1. Sympthomatic
2. Fluid and electrolite
3. Anti depressant
 To slow AIDS wasting
Fever control antipyretic drugs
Food supplementation with hight-caloric drinks
Total parentral nutrition (NTN)
Progestational agent: megestrol acetate
Antiemetic agent: dromabinol marjuana
Growth hormone
Anabolic steroid testosteron for 2-4 weeks
Nausea weight loss metoclopramide,
dromabinol
Antideppresant
 Prognosis
With improvements in therapy, patients are living
longer after the diagnosis of AIDS. This has
resulted in dramatic decreases in AIDS deaths.
Despite new therapeutic options, people
continue to die from HIV infection.
Depend on:
The stage of HIV/AIDS (I, II, III, IV)
The Adherence of ARV
The number of CD4 count
 Myelomeningocele in efavirenz-
exposed newborn

Fundaro et al. AIDS 2002; 16:299300

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

Peripheral fat loss

Lipodystrophy
Fat accumulation
central obesity

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