HIV/AIDS Treatment and Care : Clinical protocols for the European ...

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12 HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION 4.1.1. Clinical and immunological considerations WHO recommends initiation of ART using clinical and immunological criteria as per Table 6. Table . Recommendations for initiating ART in PLHIV WHO clinical stage a CD4 cell count Recommendation 1 2
PATIENT EVALUATION AND ANTIRETROVIRAL TREATMENT FOR ADULTS AND ADOLESCENTS WHO does not recommend individual drug resistance testing prior to initiation of ART in settings where only one first-line regimen is provided in the public sector because any results will not influence ART. Instead, sentinel surveys that demonstrate resistance at population level above the threshold of 5% (36, 37) should be taken into consideration in adapting national recommendations for first-line ART. Refer to Annex 3 for additional information on resistance testing. Where resources permit, and the public sector provides more than one first-line regimen, then drug resistance testing at baseline may help determine the choice of optimal ART; cost and availability will likely limit the widespread use of this in many settings (38–40). 4.2. First-line HAART regimen It is recommended that two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) and one non-nucleoside reverse transcriptase inhibitor (NNRTI) be combined in the first-line HAART regimen. Table . Recommended first-line HAART ARV drug classes HAART regimens 2 NRTIs + 1 NNRTI a EFV is highlighted as the preferred NNRTI. (For recommended dosages, please refer to Annex 4.) ZDV + 3TC + (EFV a or NVP) or TDF + FTC + (EFV a or NVP) or ABC + 3TC + (EFV a or NVP) 4.2.1. Considerations for NRTI component • The “backbone” of first-line ART is a combination of two NRTIs. One should be lamivudine (3TC) or emtricitabine (FTC); FTC is considered an equivalent drug to 3TC in both efficacy and toxicity (41). The second is most often the thymidine analogue zidovudine (ZDV also known as AZT). A large body of data and provider experience is available for ZDV, as it was the first known ARV drug. • Stavudine (d4T) is another thymidine analogue. It is available in several fixed-dose combinations (FDCs), is cheaper than ZDV and consequently widely used in many countries. However, it has a poor toxicity profile and recent studies have shown a higher rate of long term side-effects with d4T (42–49). Many national and international recommendations are moving away from recommending it for initial therapy. It is increasingly being reserved as an alternative for ZDV (a within class substitution) when ZDV has to be substituted or changed for side effects or toxicity. The lower dose 30 mg is now recommended for all weights to reduce long-term toxicity. • Other possible non-thymidine analogues for first-line are tenofovir (TDF) or abacavir (ABC) in combination with 3TC or FTC. Recently, one study has shown a slight superiority of TDF/FTC over ZDV/3TC when used in combination with EFV (42), probably due to a lower rate of sideeffects in the TDF arm. Further studies are needed. It should be noted that ABC has a risk of dangerous hypersensitivity syndrome; and, TDF can cause renal damage, so pre-screening for renal function is usually recommended. • The advantage of TDF and ABC is their resistance profile, which potentially allows more NRTI combinations to support second-line protease inhibitors (PIs). The disadvantages are cost, avail- 13
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Page 5 and 6: iv Acknowledgements The editors wou
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management of opportunistic infecti
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palliative care for people living w
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III. Initial evaluation palliative
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IV. Treatment palliative care for p
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Type of pain or treatment Usual sta
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Type Symptoms Possible causes Disea
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References palliative care for peop
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VI. Suggested minimum data to be co
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Contents I. Policy and principles .
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I. Policy and principles HIV/AIDS T
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HIV/AIDS TREATMENT AND CARE FOR INJ
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Social factors are: • homelessnes
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Table 3. Interactions between ARV d
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Other medications Use Rifampicin (R
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Table 5. Interactions of illicit dr
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ANNEX 1 ASI6 C © 2004 University o
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• Cardiovascular Hypertension Tac
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Contents I. Epidemiology and natura
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ManageMent of Hepatitis C and HiV C
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Annex 3. Alcohol screening question
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3.2. Considerations regarding treat
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278 hiv/aids tReatment and caRe cLi
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I. Prevention strategies Prevention
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Prevention of HePatitis a, B, C and
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I. Policy issues Prevention of Hiv
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III. Initial evaluation Prevention
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Prevention of Hiv transmission from
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Annex 3. Rabies vaccines ..........
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I. Policy issues post-exposure prop
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post-exposure prophylaxis for hiv i
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VI. Suggested minimum data to be co
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History of antiretroviral treatment
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Test results: HBV: HCV: HIV: Post-t
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The World Health Organization (WHO)
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