HIV/AIDS & Antiretroviral Therapy (ART) Management
HIV management in India is led by NACP through 700+ free ART centres serving 17 lakh PLHIV. The TLD regimen (Tenofovir + Lamivudine + Dolutegravir) is now first-line since 2020. With lifelong ART, life expectancy approaches normal — HIV is now a manageable chronic disease, not a death sentence.
HIV is a retrovirus (HIV-1 and HIV-2) that infects and destroys CD4+ T-lymphocytes, leading to progressive immunodeficiency. Transmission: sexual (vaginal, anal, oral), blood-borne (contaminated needles, transfusion, needle-stick), vertical (mother-to-child during pregnancy, delivery, breastfeeding). Incubation: 2-4 weeks to seroconversion illness; 8-10 years from infection to AIDS without treatment.
WHO Clinical Staging (4 stages):
- Stage 1 (Asymptomatic): Persistent generalised lymphadenopathy may be present
- Stage 2 (Mild): Weight loss < 10%, minor mucocutaneous manifestations (seborrhoeic dermatitis, fungal nail infections, recurrent oral ulcerations), herpes zoster, recurrent RTI
- Stage 3 (Advanced): Weight loss > 10%, unexplained chronic diarrhoea > 1 month, unexplained chronic fever, oral candidiasis, oral hairy leukoplakia, pulmonary TB, severe bacterial infections
- Stage 4 (AIDS): HIV wasting syndrome, Pneumocystis pneumonia, recurrent severe bacterial pneumonia, chronic herpes simplex, oesophageal candidiasis, extrapulmonary TB, Kaposi sarcoma, CMV disease, cerebral toxoplasmosis, HIV encephalopathy, disseminated non-tuberculous mycobacteria, cryptococcal meningitis
HIV testing (NACP 3-test algorithm): Three different rapid tests used in sequence. Sample reported positive only if all three reactive. Discordant result = repeat in 2 weeks or use NAAT. Voluntary, confidential, with pre- and post-test counselling.
CD4 count: Measures immune function. Normal 500-1500 cells/µL. ART initiation thresholds (current NACP): Start ART in ALL HIV-positive individuals regardless of CD4 count ('Test and Treat' since 2016). CD4 still useful for monitoring: severe immunosuppression if CD4 < 200, requires OI prophylaxis.
Viral load (HIV RNA): Gold standard for treatment monitoring. Target: undetectable (< 50 copies/mL or < 1000 copies/mL by NACP assay). Check at 6 months after ART initiation, then annually. If viral load detectable, assess adherence, drug interactions, resistance.
First-line (NACP 2020 onwards): TLD — Tenofovir 300 mg + Lamivudine 300 mg + Dolutegravir 50 mg, single tablet once daily. Dolutegravir preferred over Efavirenz due to higher viral suppression, higher genetic barrier to resistance, better tolerance. Replaced TLE (Tenofovir + Lamivudine + Efavirenz) which was the older first-line.
Second-line (after first-line failure): Boosted Atazanavir (ATV/r) or Lopinavir/ritonavir (LPV/r) + 2 NRTIs selected on basis of resistance testing.
Third-line: Darunavir/ritonavir + Etravirine + Dolutegravir or Raltegravir. Available only at select centres.
Pregnancy (PPTCT Option B+): Lifelong TLD regardless of CD4. Continue throughout pregnancy, delivery, breastfeeding. Baby receives Nevirapine prophylaxis for 6-12 weeks.
When to switch regimen: Virological failure (VL > 1000 copies/mL after 6 months of ART, confirmed on repeat), drug toxicity, new drug interaction, pregnancy.
ART side effects: Tenofovir — renal toxicity, bone density loss. Lamivudine — minimal. Dolutegravir — insomnia, weight gain, neuropsychiatric symptoms. Efavirenz — vivid dreams, depression, rash. ATV — hyperbilirubinaemia (jaundice).
Cotrimoxazole prophylaxis (Bactrim DS — 1 tablet OD): For all PLHIV with CD4 < 200 (or stage 4 disease, or pregnant women regardless of CD4). Protects against Pneumocystis pneumonia, Toxoplasma encephalitis, bacterial infections. Continue until CD4 > 200 for 6 months on ART.
TB screening: Every PLHIV at every visit — symptom screen (cough, fever, night sweats, weight loss). If positive, evaluate for TB. If active TB ruled out, start TB Preventive Treatment (TPT) — 3HP (Rifapentine + Isoniazid weekly x 3 months) or 6H (Isoniazid daily x 6 months).
Common OIs and treatment:
- Oral candidiasis: Fluconazole 100 mg OD x 7-14 days
- Oesophageal candidiasis: Fluconazole 200 mg OD x 14-21 days
- Pneumocystis pneumonia: Cotrimoxazole 15 mg/kg/day (TMP component) x 21 days + steroid if severe (PaO2 < 70)
- Cryptococcal meningitis: Amphotericin B 0.7-1 mg/kg/day x 2 weeks + Flucytosine, then Fluconazole 400 mg OD x 8 weeks, then 200 mg OD lifelong (until immune restoration)
- Cerebral toxoplasmosis: Sulphadiazine + Pyrimethamine + Leucovorin x 6 weeks
- CMV retinitis: Ganciclovir IV or Valganciclovir oral
Immune Reconstitution Inflammatory Syndrome (IRIS): Paradoxical worsening of OI symptoms after ART initiation due to recovering immune system. Common in TB-IRIS (within 2-8 weeks of ART). Mild IRIS — NSAIDs, continue ART. Severe IRIS — short course steroids (Prednisolone 0.5-1 mg/kg).
HIV is now a chronic manageable disease with ART. For UPSC CMS aspirants, WHO staging, TLD regimen, PPTCT Option B+, OI prophylaxis, and IRIS are highly testable topics.