Internal Medicine

0521779407-09 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:13

Human Immunodeficiency Virus Type 1 (HIV-1) 733

origin), asymptomatic chronic infection with severe immunosup-

pression or high viral loads

■General indications during asymptomatic chronic infection in-

clude:

➣IAS:

CD4 <350: recommend

CD4 350–500: consider if VL <5000, recommend in all other

cases

CD4 >500: defer if VL <5000, consider if VL 5000–3000, recom-

mend if VL >30,000

➣DHHS:

CD4 <350: recommend (some controversy for CD4=200–350)

CD4 >350: recommend if VL>30,000

Treatment Options

■3 major drug classes:

➣Nucleotide reverse transcriptase inhibitors (NRTIs) – AZT, 3TC,

d4T, ddI, ddC,abacavir, tenofovir, FTC

➣Non-Nucleotide reverse transcriptase inhibitors (NNRTIs) –

efavirenz, nevirapine, delavirdine

➣Protease inhibitors (PIs) – indinavir, ritonvir, nelfinavir, saqui-

navir, amprenavir, fosamprenavirlopinavir-ritonavir, atazanavir,

tipranavir

Entry inhibitors – enfuvirtide

■Recommended: PI+2NRTIs, NNRTI+2NRTIs, or 2PIs+2NRTIs

■Alternatives: 3NRTIs (3TC+AZT+ABC), PI+NNRTI+NRTI, low

dose ritonavir+PI (crixivan, amprenavir, lopinavir) as a PI compo-

nent of a regiment

■Avoid: d4T+AZT, ddC+3TC, ddC+d4T, ddC+ddI

Fixed combination drugs (NRTIs) available and decrease pill burden

Side Effects & Contraindications

■NRTIs: bone marrow suppression, subjective complaints, GI intol-

erance, headache, insomnia, asthenia, pancreatitis, peripheral neu-

ropathy, abacavir hypersensitivity

■NNRTIs: rash; nevirapine liver disease in settings of hepatitis;

efavirenz associated disconnectedness, intense dreams, and terato-

genicity

■PIs: GI intolerance, nephrolithiasis or nephrotoxicity, diarrhea,

drug interactions, lipodystrophy (fat redistribution, hypertriglyc-

eridemia, insulin resistance)