マクロな疫学
AIDS発症はHICではPcPが最頻，LMICでは結核が最頻
ミクロな疫学
原則
- 異なる2クラスで異なる3剤によるcombination Txが必須
- 生涯治療
Combination
- NRTI - Nucleoside reverse transcriptase inhibitor
- NNRTI - Non-Nucleoside reverse transcriptase inhibitor
- PI - Protease inhibitor
- INI - Integrase inhibitor
NRTI + NRTI + {NNRTI or INI or PI}
scheme
| NRTI Nucleoside Reverse Transcriptase Inhibitor
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Tenofovir
TDF
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- Once daily
- well tolerated
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- Renal toxicity (tubular damage)
- Fanconi syndrome
- hypophosphataemia
- glucosuria
- proteinuria
- Osteoporosis
Less side effects in TAF
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Tenofovir alafenamide fumarate
TAF
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Lamivudine
3TC
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- backbone for all regimens
- well tolerated
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Emtricitabine
FTC
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Zidovudine
AZT
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- Twice daily
- well tolerated
- the world-first anti-HIV
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- macrocytic anemia
- lipodystrophy
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NRTIs
- Nucleoside analogue 競合的にNRTを阻害する
- Tenofovir TDF 最重要
- Once daily
- hep Bにも有効
- 腎毒性；尿細管障害
- 骨塩減少
- Tenofovir alafenamide fumarate TAF；新しいプロドラッグ
- Zidovudine AZT
- 最初のARV in 1987
- 骨髄抑制；大球性貧血
- Twice daily
- Lamivudine 3TC /Emtricitabine FTC
- Lamivudine 3TC
- すべてのレジメンでbackbone
- high tolerance
- hep Bにも有効
- 耐性閾値が低い
- Emtricitabnine FTC
- Abacavir ABC
- 他薬intolerance時の代替
- HLA-B5701陽性者でのfebrile hypersensitivity
NNRTIs
- Efavirenz EFV
- Nevirapine NVP
- Efavirenz EFV
- NNRTIの1st choice
- little interaction with Tb drugs
- dizzyness, insomnia, nightmare, depression, psychoses
- rash
- gynecomastia; 6% in Africa
- Nevirapine NVP
- あまり使われなくなった
- Rash→Stevens-Johnson
- 肝毒性
- HIV-2に無効
- RifampicinがNVP濃度を下げる
INIs
- Dolutegravir DTG
- Raltegravir RAL
- very well tolerated
- rapid viral suppression
- lesser drug interaction
- high threshold resistance
- Doltegravir DTG
- 1st line としてEFVに取って代わった
- once daily
- no food interaction
- neural tube defectがわずかに増加する；妊娠可能女性では十分な説明と同意
PIs
- 2nd line
- 下痢
- dyslipidemia, 耐糖能異常
- lipodystrophy syndrome
- CYP3A4阻害
- boosting PIs；PIをごく少量の他のPI ritonavirと併用
- -rを付す
- Lopinavir-Ritonavir LPV-r
- Atazanavir ATV-r
WHO 1st line
- TDF+3TC+DTG
- TDF+3TC+EFV
WHO 2nd line
- NRTI+NRTI+INI
- NRTI+NRTI+PI
CPT
Co-trimoxazole preventive therapy
Immune reconstitution inflammatory syndrome
- importance to monitor IRIS
- CD4 count が低い状態で日和見感染を開始するときはARTは最低限1ヶ月空けてから
