Continued...

Aims of ARVT:

The main objectives of ARVT are to improve immunity, decrease opportunistic infections, slow disease progression, prolong the survival, improve growth & development, improve neurological development & improve quality of life till death.

When to start ARVT:The indications for starting ARVT are:

1. All infants < 1 year who are confirmed to be infected should be put on ARVT irrespective of their clinical, immunological or virological status.
2. Above 1 yr., ARVT is started for all those who are symptomatic (clinical stages A, B, C) or when they are immunodeficient based on the CD4+ count or % for the age. (Stage II or III).
3. For those who are above 1 yr. & are neither clinically symptomatic (stage N) nor immunodeficient (stage I), there are two choices. One choice is to offer ARVT to all such patients. This amounts to giving ARVT to all children once diagnosed irrespective of age, clinical stage or immune status. This is for better immune preservation by suppressing viral replication much earlier. The second choice is to wait till CD4+ count starts declining rapidly to touch stage II or when the viral load exceeds 100,000 copies / ml or when the viral load rises by more than 0.7 log in 1-2 yr. old child or by 0.5 log in >2yrs. old child.

Which drugs to start:

Monotherapy is not used at all as it does not decrease the viral load significantly. This lead to development of resistance in short time. The only exception is use of single drugs like AZT & of late, nevirapine for prevention of vertical transmission. Only combination therapy is recommended as life long treatment.

Strongly recommended protocols:

These protocols have been shown to reduce viral load consistently to a very low level or even undetectable levels. These protocols include 2 NRTI & 1 protease inhibitor or 1NRTI, efavirenz & 1 protease inhibitor. The chances of development of resistance are low & these protocols are very effective clinically, immunologically & virologically.

Recommended alternate protocols:

These protocols have been shown to reduce viral load but not as consistently or for desired duration as the previous protocols. This could lead to development of resistance. These protocols induce 2 NRTI and nevirapine or 2 NRTI + abacavir. Abacavir is a toxic drug & has potentially fatal side effects in some of the recipients.

Recommended in special circumstances:

These protocols have limited benefits, inconsistent data on viral response & include use of only 2NRTI drugs.

Not recommended:

Certain drugs are not recommended either due to overlapping side effect, interference or due to undesirable efficacy on viral load. These include monotherapy, d4T+AZT, ddc+ddi, ddc+3TC, ddc+d4T.

When to change therapy:

1. Failure or suboptimal response or failure to sustain response with relapses. This will be detected on the basis of clinical, immunological or virological status
2. Toxicity or intolerance to drugs used.
3. Availability of better, newer drugs.

Contact with HIV patients:

HIV infection does not spread by hugging, touching, shaking hands with HIV infected patients nor by being together in house, using same towel, toiletries, bath room, toilet etc. Avoid using common toothbrushes, tongue cleaners, shaving razors etc. Avoid deep kissing and mouth to mouth resuscitation. Wear gloves while taking care of open wounds or discharges.

IV drug abuse:

Avoid sharing needles & unprotected sex. One can boil the needles thoroughly or use disposable needles.

Others: Avoid as far as possible tattooing, ear cleaning, ear piercing, pedicure etc. where sharp needles or instruments are used unless the needles or the instruments are properly boiled or sterilized. For injections either use disposable needles or use properly sterilized needles by boiling or autoclaving. Instruments, which cannot be boiled or heated, should be sterilized chemically. Common bleach solution can be used to disinfect blood spill or secretions of patients. The disposable items should be put in freshly prepared hypochlorite solution and disposed in a paper bag for incineration. The hypochlorite solution should be changed 6-8 hourly. Sharp disposables should be kept in a separate bag & labeled as "sharp" to avoid accidental injury to those who are taking care of the disposables.

Universal precautions:

These are general guidelines to be followed by medical personnel while taking care of any patients, thinking that every patient can be potentially infected with HIV, HBV, HCV etc. It includes:

1. Use of protective measures like gloves, gown, goggles etc
2. Thorough hand washing before & after touching the patient or doing a procedure on any patient.
3. Use of hypochlorite solution (freshly prepared) to take care of blood spills, disinfecting disposables, infective material or needles.
   Proper sterilization of instruments.
4. Disposal of disposables with sharps put in separate bags for proper incineration.
5. Avoid mouth to mouth resuscitation method. If inevitable use barrier mask.
6. Always report occupational exposure, needle stick injury or exposure to infective material to local health authority & take appropriate post-exposure prophylaxis as applicable & advised.