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2023年9月14日 (木) 15:04時点における版

11,807 バイト追加 、 2023年9月14日 (木) 15:04
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==疫学==
===マクロな疫学===
#≧4 doses/week - anal sex
====dailyPrEP====
*1 tablet/day
*effective for anal sex 1 day after of commencement
*effective for vaginal sex 7 days after of commencement
====event-basedPrEP====
*2 tabltes at 2-24 hours before anal sex + 1 tablet 24-48 hours after the sex
*not effective against vaginal sex
====4 doses/week====
====how to stop====
*have to continue for a certain duration after the last sex
*
*
====monitoring====
*test renal function every 3 mo
**annually for eGFR>90 or <40y/o
*offer STIs screening
====contraindicationof PrEP====
*Renal dysfunction; eGFR<60
*Osteoprorosis
*event-based dosing is option for contraindicated people
====clincal trialtrials of PrEP====
*PROUD study
**86% reduction of HIV
*IMPACT study
 
===Prevention of Mother to Child transmission (PMTCT)===
*Primary prevention in women of childbearing age
*Voluntary counseling and testing (VCT) provided in prenatal care
*ART for PMTCT
 
====WHO Consolidated Guidelines in 2021====
*[https://www.who.int/publications/i/item/9789240031593 Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. 16 July 2021]
**refer to 'Chapter 3.4 Infant prophylaxis' on pp.91 (134th as PDF)
*Mother
**Urgently commence ART for all HIV-infected pregnant and post-partum women irrespective of time or viral load
*All Infants
**Daily AZT+NVP from 0d to 6w
*Breastfed infants of high risk
**Additional AZT+NVP or NVP alone from 6w to 12w
*Breastfed infants of mother under ART
**Additional daily NVP from 6w to 12w
*Replacement fed infants of mother under ART
**Additional daily NVP from 6w to 10-12w
 
==WHO Clinical staging==
{{quote|content=[https://apps.who.int/iris/handle/10665/43699 WHO case definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-related disease in adults and children (2007)]
}}
 
{|class="wikitable"
|-
!style="width:4%"|Stage
!style="width:24%"|1<br>&asymp; CD4 500-
!style="width:24%"|2<br>&asymp; CD4 350-500
!style="width:24%"|3<br>&asymp; CD4 200-350
!style="width:24%"|4<br>&asymp; CD4 -200
|- style="vertical-align:top"
!Skin
|
|
*Herpes zoster
*Papular pruritic eruptions
*Seborrheic dermatitis
*Fungal nail infections
|
|
*Herpes simplex infection (oral, genital) > 1 month
*[[Talaromycosis|Talaromycosis]] (Asia only)
|- style="vertical-align:top"
!Oral<br>GI tract
|
|
*Angular cheilitis
*Oral ulcer, recurrent
|
*'''Oral''' candidiasis
*Oral hairy leukoplakia (EBV-associated)
*Acute necrotizing ulcerative stomatitis/gingivitis/periodontitis
*Diarrhea > 1 month, unexplained
|
*'''Esophageal''' candidiasis
*Cryptosporidiasis, chronic
*Isosporiasis, chronic
|- style="vertical-align:top"
!Respiratory
|
|
*URIs, recurrent
|
*Bacterial LRIs
*Pulmonary TB, '''pluribacillary'''
|
*Severe bacterial LRIs, recurrent
*Pulmonary TB, '''paucibacillary'''
*Pneumocystis pneumonia (PcP)
|- style="vertical-align:top"
!Neurological
|
|
|
|
*CNS toxoplamosis (Toxoplasmoma)
*HIV encephalopathy
*CNS cryptococcal infection (Cryptococcoma)
*Progressive multifocal leukoencephalopathy
|- style="vertical-align:top"
!Systemic
|
*Asymptomatic
*Acute HIV infection
*Lymphadenopathy, persistent
|
*Weight loss '''<10%''', unexplained
|
*Weight loss '''>10%''', unexplained
*Fever > 1 month, unexplained
*Sever bacterial infections (LRI, bone/joint infections, meningitis)
*Anemia < 8g/dL of Hb, unexplained
*Thrombocytopenia < 50<math>\times</math>10<math>^9</math>/L, unexplained
|
*HIV wasting syndrome
*Extrapulmonary TB
*Cytomegalovirus infection
*Non-typhoidal salmonellosis (NTS), recurrent
*[[Coccidioidomycosis|Coccidioidomycosis]] (America only)
*[[Histoplasmosis|Histoplasmosis]]
*Atypical disseminated leishmaniasis
*HIV-associated nephrophathy
*HIV-associated cardiomyopathy
|- style="vertical-align:top"
!Malignancy
|
|
|
|
*Kaposi's sarcoma
*Lymphoma
*Cervical carcinoma
*HIV-associated solid tumors
|}
==Treatment==
NRTI + NRTI + {NNRTI or INI or PI}
 
===scheme===
{|class="wikitable" style="width:1200px"
|-
!colspan="4"|
NRTI<br>Nucleoside Reverse Transcriptase Inhibitor
|-
!style="width:25%"|
Tenofovir<br>TDF
|style="width:25%"|
*Once daily
*well tolerated
|style="width:25%" rowspan="2"|
*effective for Hep B
|style="width:25%" rowspan="2"|
*Renal toxicity (tubular damage)
**Fanconi syndrome
**hypophosphataemia
**glucosuria
**proteinuria
*Osteoporosis
|-
!Tenofovir alafenamide fumarate<br>TAF
|
*prodrug of tenofovir
*less side effects than TAF
|-
!Lamivudine<br>3TC
|rowspan="2"|
*backbone for all regimens
*well tolerated
*3TC and FTC have almost the same molecular structures
|rowspan="2"|
*effective for Hep B
|rowspan="2"|
|-
!Emtricitabine<br>FTC
|-
!Zidovudine<br>AZT
|
*Twice daily
*well tolerated
*the world-first anti-HIV
|
|
*macrocytic anemia
*lipodystrophy
|-
!Abacavir<br>ABC
|
*in case of failure/intolerance of other NRTIs
|
|
*febrile hypersensitivity with HLA-B5701
**Caucasians need HLA-testing before treament
|}
 
<div style="float:left; padding-right:1em;">
{|class="wikitable" style="width:400px"
|-
!colspan="3"|
NNRTI<br>Non-Nucleoside Reverse Transcriptase Inhibitor
|-
!style="width:33.3%"|
Efavirenz<br>EFV
|style="width:33.3%|
*1st choice in NNTRIs
|style="width:33.3%|
*neuropsychiatric side effects
**dizzyness, insomnia, nightmares, depression, psychoses
*rash
*gynecomastia 5-6% in Africa
|-
!Nevirapine<br>NVP
|
*not effective against HIV-2
|
*rash to Stevens Johnson syndrome
*hepatic toxicity
*interact with rifampicin
**never use in HIV-TB
|}
</div>
 
<div style="float:left; padding-right:1em;">
{|class="wikitable" style="width:400px"
|-
!colspan="3"|
INI<br>Integrase Inhibitor
|-
!style="width:33.3%"|
Dolutegravir<br>DTG
|style="width:33.3%"|
*well tolerated
|style="width:33.3%"|
*insomnia
*dizzyness
*paresthesia
*weight gain
|-
!Raltegravir<br>RAL
|
|
|}
</div>
 
<div style="float:left; padding-right:1em;">
{|class="wikitable" style="width:400px"
|-
!colspan="3"|
PI<br>Protease Inhibitor
|-
!style="width:33.3%"|
Lopinavir-Ritonavir<br>LPV-r
|style="width:33.3%"|
*Twice daily
|style="width:33.3%"|
*diarrhea
*metaboilc disturbance
**dyslipidemia
**impaired glucose tolerance
**lipodystrophy
*CYP3A4 interactions
|-
!Atazanavir<br>ATV-r
|
*Once daily
|
*hyperbilirubinemia, jaundice
*interact with rifampicin
|}
</div>
 
<div style="clear:both;"></div>
 
===WHO Guideline 2019===
*[https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hiv/treatment/monitoring-toxicity-of-antiretrovirals WHO reference page is here]
 
====Adults and adolescents====
<div style="float:left; padding-right:1em;">
{|class="wikitable" style="width:400px; text-align:center"
|+1st line
|-
!colspan="3"|NRTI
|-
!colspan="3" style="background-color:gold"|Tenofovir<br>TDF
|-
|colspan="3"|Tenofovir alafenamide fumarate<br>TAF
|-
!colspan="3" style="background-color:gold"|Lamivudine<br>3TC
|-
|colspan="3"|Zidovudine<br>AZT
|-
|colspan="3"|Abacavir<br>ABC
|-
!style="width:33.3%"|NNRTI
!style="width:33.3%"|INI
!style="width:33.3%"|PI
|-
|Efavirenz<br>EFV
!style="background-color:gold"|Dolutegravir<br>DTG
|Lopinavir-Ritonavir<br>LPV-r
|-
|Nevirapine<br>NVP
|Raltegravir<br>RAL
|Atazanavir<br>ATV-r
|}
</div>
 
<div style="float:left; padding-right:1em;">
{|class="wikitable" style="width:400px; text-align:center"
|+Alternative 1st line
|-
!colspan="3"|NRTI
|-
!colspan="3" style="background-color:gold"|Tenofovir<br>TDF
|-
|colspan="3"|Tenofovir alafenamide fumarate<br>TAF
|-
!colspan="3" style="background-color:gold"|Lamivudine<br>3TC
|-
|colspan="3"|Zidovudine<br>AZT
|-
|colspan="3"|Abacavir<br>ABC
|-
!style="width:33.3%"|NNRTI
!style="width:33.3%"|INI
!style="width:33.3%"|PI
|-
!style="background-color:gold"|Efavirenz<br>EFV 400mg
|Dolutegravir<br>DTG
|Lopinavir-Ritonavir<br>LPV-r
|-
|Nevirapine<br>NVP
|Raltegravir<br>RAL
|Atazanavir<br>ATV-r
|}
</div>
 
<div style="float:left; padding-right:1em;">
{|class="wikitable" style="width:400px; text-align:center"
|+Special circumstances
|-
!colspan="3"|NRTI
|-
|colspan="3"|Tenofovir<br>TDF
|-
|colspan="3"|Tenofovir alafenamide fumarate<br>TAF
|-
|colspan="3"|Lamivudine<br>3TC
|-
|colspan="3"|Zidovudine<br>AZT
|-
|colspan="3"|Abacavir<br>ABC
|-
!style="width:33.3%"|NNRTI
!style="width:33.3%"|INI
!style="width:33.3%"|PI
|-
|Efavirenz<br>EFV
|Dolutegravir<br>DTG
|Lopinavir-Ritonavir<br>LPV-r
|-
|Nevirapine<br>NVP
|Raltegravir<br>RAL
|Atazanavir<br>ATV-r
|}
</div>
 
<div style="clear:both;"></div>
 
====Children====
<div style="float:left; padding-right:1em;">
{|class="wikitable" style="width:400px; text-align:center"
|+1st line
|-
!colspan="3"|NRTI
|-
|colspan="3"|Tenofovir<br>TDF
|-
|colspan="3"|Tenofovir alafenamide fumarate<br>TAF
|-
!colspan="3" style="background-color:khaki"|Lamivudine<br>3TC
|-
|colspan="3"|Zidovudine<br>AZT
|-
!colspan="3" style="background-color:khaki"|Abacavir<br>ABC
|-
!style="width:33.3%"|NNRTI
!style="width:33.3%"|INI
!style="width:33.3%"|PI
|-
|Efavirenz<br>EFV
!style="background-color:khaki"|Dolutegravir<br>DTG
|Lopinavir-Ritonavir<br>LPV-r
|-
|Nevirapine<br>NVP
|Raltegravir<br>RAL
|Atazanavir<br>ATV-r
|}
</div>
 
<div style="float:left; padding-right:1em;">
{|class="wikitable" style="width:400px; text-align:center"
|+Alternative 1st line
|-
!colspan="3"|NRTI
|-
|colspan="3"|Tenofovir<br>TDF
|-
|colspan="3"|Tenofovir alafenamide fumarate<br>TAF
|-
!colspan="3" style="background-color:khaki"|Lamivudine<br>3TC
|-
|colspan="3"|Zidovudine<br>AZT
|-
!colspan="3" style="background-color:khaki"|Abacavir<br>ABC
|-
!style="width:33.3%"|NNRTI
!style="width:33.3%"|INI
!style="width:33.3%"|PI
|-
|Efavirenz<br>EFV
|Dolutegravir<br>DTG
!style="background-color:khaki"|Lopinavir-Ritonavir<br>LPV-r
|-
|Nevirapine<br>NVP
|Raltegravir<br>RAL
|Atazanavir<br>ATV-r
|}
</div>
 
<div style="float:left; padding-right:1em;">
{|class="wikitable" style="width:400px; text-align:center"
|+Special circumstances
|-
!colspan="3"|NRTI
|-
|colspan="3"|Tenofovir<br>TDF
|-
|colspan="3"|Tenofovir alafenamide fumarate<br>TAF
|-
|colspan="3"|Lamivudine<br>3TC
|-
|colspan="3"|Zidovudine<br>AZT
|-
|colspan="3"|Abacavir<br>ABC
|-
!style="width:33.3%"|NNRTI
!style="width:33.3%"|INI
!style="width:33.3%"|PI
|-
|Efavirenz<br>EFV
|Dolutegravir<br>DTG
|Lopinavir-Ritonavir<br>LPV-r
|-
|Nevirapine<br>NVP
|Raltegravir<br>RAL
|Atazanavir<br>ATV-r
|}
</div>
 
<div style="clear:both;"></div>
 
====Neonates====
<div style="float:left; padding-right:1em;">
{|class="wikitable" style="width:400px; text-align:center"
|+1st line
|-
!colspan="3"|NRTI
|-
|colspan="3"|Tenofovir<br>TDF
|-
|colspan="3"|Tenofovir alafenamide fumarate<br>TAF
|-
!colspan="3" style="background-color:yellow"|Lamivudine<br>3TC
|-
!colspan="3" style="background-color:yellow"|Zidovudine<br>AZT
|-
|colspan="3"|Abacavir<br>ABC
|-
!style="width:33.3%"|NNRTI
!style="width:33.3%"|INI
!style="width:33.3%"|PI
|-
|Efavirenz<br>EFV
|Dolutegravir<br>DTG
|Lopinavir-Ritonavir<br>LPV-r
|-
|Nevirapine<br>NVP
!style="background-color:yellow"|Raltegravir<br>RAL
|Atazanavir<br>ATV-r
|}
</div>
 
<div style="float:left; padding-right:1em;">
{|class="wikitable" style="width:400px; text-align:center"
|+Alternative 1st line
|-
!colspan="3"|NRTI
|-
|colspan="3"|Tenofovir<br>TDF
|-
|colspan="3"|Tenofovir alafenamide fumarate<br>TAF
|-
!colspan="3" style="background-color:yellow"|Lamivudine<br>3TC
|-
!colspan="3" style="background-color:yellow"|Zidovudine<br>AZT
|-
|colspan="3"|Abacavir<br>ABC
|-
!style="width:33.3%"|NNRTI
!style="width:33.3%"|INI
!style="width:33.3%"|PI
|-
|Efavirenz<br>EFV
|Dolutegravir<br>DTG
|Lopinavir-Ritonavir<br>LPV-r
|-
!style="background-color:yellow"|Nevirapine<br>NVP
|Raltegravir<br>RAL
|Atazanavir<br>ATV-r
|}
</div>
 
<div style="float:left; padding-right:1em;">
{|class="wikitable" style="width:400px; text-align:center"
|+Special circumstances
|-
!colspan="3"|NRTI
|-
|colspan="3"|Tenofovir<br>TDF
|-
|colspan="3"|Tenofovir alafenamide fumarate<br>TAF
|-
!colspan="3" style="background-color:yellow"|Lamivudine<br>3TC
|-
!colspan="3" style="background-color:yellow"|Zidovudine<br>AZT
|-
|colspan="3"|Abacavir<br>ABC
|-
!style="width:33.3%"|NNRTI
!style="width:33.3%"|INI
!style="width:33.3%"|PI
|-
|Efavirenz<br>EFV
|Dolutegravir<br>DTG
!style="background-color:yellow"|Lopinavir-Ritonavir<br>LPV-r
|-
|Nevirapine<br>NVP
|Raltegravir<br>RAL
|Atazanavir<br>ATV-r
|}
</div>
 
<div style="clear:both;"></div>
===NRTIs===
*治療効果判定にはviral load
*CD4 countは初診時には有用だがフォローアップには無用；viral loadが大事
 
==Additional materials of HIV==
{{quote
|content=[https://www.nature.com/collections/mghkkdjlgx Nature Materials in HIV research]
 
https://www.nature.com/collections/mghkkdjlgx
}}
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