Gupta S B, Pujari S N, Joshi S R, Patel A K
Central Railway Headquarters Hospital, Mumbai.
J Assoc Physicians India. 2006 Jan;54:57-74.
With rational use of antiretroviral therapy (ART), human immunodeficiency virus (HIV) infection has been transformed into a chronic manageable illness like diabetes and hypertension. These guidelines provide information on state of art, evidence based approach for use of ART in Indian context. When to initiate ART? Antiretroviral therapy is indicated for all symptomatic HIV infected persons regardless of CD4 counts and plasma viral load (PVL) levels. In asymptomatic patients, ART should be offered when the CD4 counts < 200/mm3 and should be considered in patients with CD4 counts between 200-250/mm3. Therapy is not recommended for patients with CD4 count more than 350/ mm3. Involvement of patient in all treatment decisions and assessing readiness is critical before initiating ART. What to start with? A non-nucleoside reverse transcriptase inhibitor (NNRTI) based regimen is recommended for antiretroviral naïve patients. The choice between nevirapine and efavirenz is based on differences in adverse events profiles; cost and availability of convenient fixed dose combinations and need for concomitant use of rifampicin. A backbone of 2-nucleoside reverse transcriptase inhibitors (NRTIs) is combined with the NNRTI. Various combinations and ART strategies not to be used in clinical practice has been enlisted. How to follow up? Recommendations have been made for baseline evaluation and monitoring of patients on ART. These include guidelines on laboratory and clinical evaluation. A plasma viral load at 6 months after initiation of first-line ART is strongly recommended. Yearly estimation of lipid profile has been recommended. How to identify and manage ART failure? The guidelines recognize the issue of identifying ART failure late if only CD4 counts are used for monitoring. In the absence of resistance testing various second-line regimens have been enlisted. A boosted protease inhibitor based regimen is recommended in this situation to be combined with 2-NRTIs. Special situations Recommendations have been made for use of ART in HIV-TB, HIV-HBV, and HIV-HCV co-infected patients. In patients with active TB and a CD4 count < 200/mm3, initiation of ART is recommended as soon as the anti-TB treatment is tolerated. Efavirenz is the only ARV drug, which can be safely used with rifampicin. In pregnancy use of single dose nevirapine for reducing risk of mother to child transmission of HIV is not recommended, because of the risk of development of resistance. For post-exposure prophylaxis taking ART treatment history of the source patient is crucial in designing an effective regimen.
通过合理使用抗逆转录病毒疗法（ART），人类免疫缺陷病毒（HIV）感染已转变为一种如糖尿病和高血压般可慢性控制的疾病。这些指南提供了在印度背景下使用ART的最新技术和循证方法的信息。何时开始ART？所有有症状的HIV感染者无论CD4细胞计数和血浆病毒载量（PVL）水平如何均需进行抗逆转录病毒治疗。对于无症状患者，当CD4细胞计数<200/mm³时应开始ART，CD4细胞计数在200 - 250/mm³之间的患者应考虑使用。CD4细胞计数超过350/mm³的患者不建议进行治疗。在开始ART之前，让患者参与所有治疗决策并评估其准备情况至关重要。开始用什么药物？对于初治抗逆转录病毒治疗的患者，推荐使用基于非核苷类逆转录酶抑制剂（NNRTI）的治疗方案。奈韦拉平和依非韦伦之间的选择基于不良事件谱、成本、方便的固定剂量组合的可用性以及是否需要同时使用利福平的差异。两种核苷类逆转录酶抑制剂（NRTIs）组成的骨干药物与NNRTI联合使用。已列出临床实践中不应使用的各种组合和ART策略。如何进行随访？针对接受ART治疗的患者的基线评估和监测提出了建议。这些包括实验室和临床评估指南。强烈建议在开始一线ART治疗6个月后检测血浆病毒载量。建议每年评估血脂情况。如何识别和管理ART失败？指南认识到仅使用CD4细胞计数进行监测时识别ART失败较晚的问题。在没有耐药性检测的情况下，已列出各种二线治疗方案。在这种情况下，推荐使用基于增强型蛋白酶抑制剂的治疗方案并与两种NRTIs联合使用。特殊情况针对HIV - TB、HIV - HBV和HIV - HCV合并感染患者使用ART提出了建议。对于患有活动性结核病且CD4细胞计数<200/mm³的患者，一旦能耐受抗结核治疗，建议尽快开始ART。依非韦伦是唯一可与利福平安全联用的抗逆转录病毒药物。在妊娠期间，不建议使用单剂量奈韦拉平来降低HIV母婴传播风险，因为存在产生耐药性的风险。对于暴露后预防，在设计有效的治疗方案时，了解源患者的ART治疗史至关重要。
