AIDS (Acquired Immunodeficiency Syndrome) — MBBS / MD स्तर का Clinical & Therapeutic Guide
यह विस्तृत गाइड AIDS/HIV-related disease के MBBS/MD-स्तर के clinical management के लिए है — definition से लेकर latest guideline-based ART/OI dosing, monitoring, और prevention तक।
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Definition — AIDS vs HIV
HIV (Human Immunodeficiency Virus) एक retrovirus है जो CD4+ T-lymphocytes को infect करता है। AIDS (Acquired Immunodeficiency Syndrome) HIV infection का advanced clinical stage है — आमतौर पर diagnosis तब होता है जब CD4 count <200 cells/mm³ या AIDS-defining illnesses मौजूद हों (PCP, cryptococcal meningitis, esophageal candidiasis, Kaposi sarcoma, certain lymphomas, extrapulmonary TB आदि)।
Clinical point: HIV-positive होना और AIDS अलग диагностिक अवधारणाएँ हैं — पर management दोनों में ART और complications के अनुसार tailored होती है।
Cause & Transmission
Cause: मुख्यतः HIV-1 (विशेषकर worldwide) और कुछ क्षेत्रों में HIV-2। वायरस RNA-based enveloped retrovirus है जो host DNA में integrate हो जाता है और lifelong persistence बनाता है।
Transmission routes: unprotected sexual contact, contaminated blood/blood products, shared needles (IDU), vertical transmission (in utero, intrapartum, breastfeeding), occupational exposure (needle-stick). Prevention strategies (condoms, safe transfusion, harm reduction, PMTCT) reduce transmission risk।
Public health: test & treat approach, PrEP for high-risk groups, and universal precautions remain cornerstones of HIV prevention. 0
Pathogenesis — molecular & immunologic detail
Entry & co-receptors
Viral gp120 binds CD4 and co-receptors CCR5 (early, macrophage-tropic) या CXCR4 (later, T-cell tropic). gp41 mediates fusion and entry।
Reverse transcription & integration
Viral RNA → cDNA by reverse transcriptase (error-prone) → integrase integrates provirus into host genome → latent reservoirs in memory CD4 cells और lymphoid tissue। यह high mutation rate और resistance का कारण बनता है।
Immune damage
CD4 depletion occurs via direct cytopathic effects, CD8+ mediated killing, apoptosis and chronic immune activation. Gut mucosal barrier breakdown → microbial translocation → systemic immune activation accelerates progression।
Reservoirs & cure barriers
Latent integrated provirus in resting memory CD4 cells and sanctuary sites (CNS, lymph nodes) is main barrier to cure।
Clinical course & Staging
Typical stages: Acute (seroconversion) → high viremia, mono-like illness; Chronic clinical latency → variable symptoms; Advanced disease / AIDS → opportunistic infections, malignancies, wasting। Early diagnosis and immediate ART markedly reduce progression to AIDS and transmission. 1
Symptoms & Red flags
Acute: fever, sore throat, lymphadenopathy, rash, myalgia, headache — lasts 1–4 weeks in many patients.
Chronic: asymptomatic or nonspecific symptoms (fatigue, weight loss, recurrent minor infections).
AIDS / advanced: prolonged fever, weight loss, chronic diarrhea, persistent oral/esophageal candidiasis, OIs (PCP, cryptococcus, CMV), Kaposi sarcoma, CNS infections (toxoplasma), severe bacterial infections।
Red flags: severe dyspnea/hypoxia, acute focal neurodeficit, sudden visual loss, high-grade fever with sepsis features — seek urgent care।
Diagnosis & Laboratory Workup
Screening & confirmation
4th generation Ag/Ab assays (p24 + antibody) are recommended for screening; confirmatory supplemental antibody differentiation assays and NAT (HIV RNA) used for discordant/early infections. If exposure recent and initial test negative, repeat testing per window period or use NAT. 2
Baseline investigations (if HIV positive)
- CD4 count
- HIV RNA (viral load)
- CBC, LFT, RFT
- HBsAg, anti-HCV
- Pregnancy test (if applicable)
- TB screen (symptom screen, chest X-ray, sputum/NAAT as indicated)
- Baseline genotypic resistance testing where available
Interpretation — key thresholds
CD4: >500 normal; 200–500 intermediate risk; <200 high risk for PCP; <100 risk cryptococcus/toxo; <50 risk CMV/MAC. Viral load: goal—undetectable on ART; persistent VL >200 copies/mL despite adherence suggests virologic failure and need for resistance testing. 3
Antiretroviral Therapy (ART) — Principles & Adult Dosing
Goal: durable viral suppression, immune recovery, reduce morbidity/mortality and prevent transmission. Start ART as soon as possible after diagnosis (rapid ART / same-day initiation when feasible). Preferred regimens evolve with evidence; currently INSTI (dolutegravir/bictegravir)-based regimens are widely recommended as first-line due to high barrier to resistance and tolerability. 4
Principles of selection
- Use combination of ≥3 active drugs (usually 2 NRTIs + 1 INSTI/NNRTI/PI).
- Consider comorbidities (renal, hepatic), drug interactions (TB drugs), pregnancy, formulary availability.
- Baseline resistance testing where possible to guide regimen choice.
Table: Common first-line adult regimens (examples) — typical dosing
| Regimen | Typical adult dosing | Notes |
|---|---|---|
| TDF + 3TC (or FTC) + DTG (TLD) | TDF 300 mg once daily + Lamivudine (3TC) 300 mg once daily (or Emtricitabine 200 mg once daily) + Dolutegravir 50 mg once daily | Preferred in many national programs; check baseline renal function (eGFR) for TDF; monitor LFT/RFT. 5 |
| Bictegravir/TAF/FTC (single tablet) | One tablet once daily (product specific) | Alternative first-line where available; TAF has better renal/bone safety vs TDF but check CrCl limits. 6 |
| TDF + 3TC + Efavirenz 400 mg | TDF 300 mg + 3TC 300 mg once daily + Efavirenz 400 mg once daily (bedtime) | Use where INSTI not available; monitor neuropsychiatric effects. 7 |
Special note — TB co-treatment (rifampicin interaction)
Rifampicin induces several ARV pathways. Current practical guidance: when rifampicin is co-administered with dolutegravir, increase DTG to 50 mg twice daily while on rifampicin (monitor). Coordination between TB and HIV teams is essential. 8
Virologic failure & switching
Persistently elevated VL despite adherence → resistance testing (genotypic) and switch to evidence-based second/third line regimens (PI-based or INSTI-based depending on resistance profile). Specialist input recommended. 9
Opportunistic Infections (OI) — Prophylaxis & Treatment (Adult dosing)
OI management is crucial in AIDS. नीचे सामान्य OIs के diagnostic & treatment summaries दिए गए हैं — अस्पताल में monitor और toxicities के लिए labs आवश्यक होते हैं।
PCP (Pneumocystis jirovecii pneumonia)
Prophylaxis: TMP-SMX DS (800/160) 1 tablet once daily — start if CD4 <200 cells/mm³ and continue until CD4 >200 for ≥3 months on ART.
Treatment (moderate–severe): TMP-SMX at dose equivalent to trimethoprim 15–20 mg/kg/day (SMX 75–100 mg/kg/day) divided in 3–4 doses IV or PO, for 21 days; add adjunctive corticosteroids if PaO₂ <70 mmHg or significant A–a gradient. Monitor renal function, electrolytes, and cytopenias. 10
Cryptococcal meningitis
WHO recommends a simplified induction regimen using a single high-dose liposomal amphotericin B (10 mg/kg) plus flucytosine and fluconazole in resource-appropriate settings (AMBITION regimen) — this reduces toxicity and monitoring demands compared to prolonged amphotericin deoxycholate regimens. Follow with consolidation and maintenance fluconazole per protocol. Monitor renal function, electrolytes, CBC. 11
CMV disease (retinitis)
Induction valganciclovir 900 mg PO twice daily for 14–21 days → maintenance 900 mg once daily; consider IV ganciclovir if severe; intravitreal therapy for vision-threatening lesions. Monitor neutropenia and renal function.
Tuberculosis (HIV co-infection)
Standard anti-TB (HRZE) per weight. Timing of ART initiation during TB treatment depends on CD4 and clinical condition; coordinate care and manage interactions (rifampicin effect on ARVs). 12
Esophageal/oropharyngeal candidiasis
Fluconazole 100–200 mg PO once daily for 14–21 days (adjust per response); IV for severe cases or inability to swallow.
PEP & PrEP — Adult dosing & practical steps
PEP (Post-Exposure Prophylaxis)
PEP is an emergency 28-day course and should be started as soon as possible, ideally within 2 hours and no later than 72 hours after exposure. Preferred adult regimen: TDF 300 mg + FTC 200 mg (or 3TC 300 mg) once daily + dolutegravir 50 mg once daily (or bictegravir/TAF/FTC single tablet where available). Provide baseline HIV testing and follow-up per protocol. 13
PrEP (Pre-Exposure Prophylaxis)
Daily oral TDF/FTC (TDF 300 mg + FTC 200 mg) once daily for HIV-negative adults at substantial ongoing risk; baseline HIV testing and renal monitoring required. Newer options (TAF/FTC; long-acting cabotegravir injection) may be used per approvals and availability. 14
Supportive medicines & symptom control (adult dosing)
| Symptom | Typical adult dosing | Notes |
|---|---|---|
| Fever / pain | Paracetamol 500–1000 mg PO every 4–6 h PRN (max 3–4 g/day) | Avoid NSAIDs in severe renal dysfunction or bleeding risk. |
| Nausea / vomiting | Ondansetron 4–8 mg PO/IV q8h PRN; Metoclopramide 10 mg PO/IV q6–8h | Check QT and extrapyramidal risks. |
| Anemia (IDA) | Oral elemental iron 60–120 mg/day or IV iron if severe/malabsorption | Confirm iron deficiency via ferritin/TSAT prior to therapy if possible. |
| Electrolyte correction (cryptococcal/amphotericin) | IV potassium and magnesium replacement guided by labs | Monitor renal function frequently with amphotericin therapy. |
Nutrition — Recommended & Foods to avoid
Nutrition goals: maintain/restore lean body mass, correct lab-documented micronutrient deficiencies, manage malabsorption and support immune recovery. Tailor to cultural context and availability.
Recommended
- High-quality proteins: eggs, fish, poultry, lean meat, paneer, legumes, soy.
- Energy-dense foods for wasting: nuts, nut butters, avocados, millets, whole grains.
- Micronutrient-rich fruits/vegetables: vitamin C (guava — Guava guide), vitamin A sources (carrot, sweet potato), zinc (pumpkin seeds, meat).
- Probiotics (yogurt) and gentle fiber if tolerated; rehydrate during diarrhea (ORS).
To avoid
- Raw/undercooked meats, seafood, and eggs in severely immunosuppressed patients.
- Unpasteurized dairy products.
- Excess alcohol and unregulated herbal supplements (drug interactions/toxicity risk).
Helpful resources on food & cardiac/organ specific diets (example: Heart Failure Diet) linked in footer for cross-reference. See also banana/anjeer pages for calorie & potassium references: Banana, Anjeer.
Monitoring, Follow-up & Resistance
- Viral load: baseline, ~3 months after ART start, then every 6–12 months once suppressed (local protocols may vary).
- CD4: baseline and until immune recovery; guide OI prophylaxis decisions.
- Routine labs: CBC, LFT, RFT as per regimen and comorbidities.
- Genotypic resistance testing at baseline where available and at virologic failure to guide regimen changes. 15
- Adherence counselling, side-effect management and simplified regimens to improve retention in care.
Special situations
Pregnancy & breastfeeding
Pregnant persons with HIV should receive ART — regimen selection follows pregnancy safety data and national PMTCT protocols. Early linkage to antenatal care, maternal ART, intrapartum management and infant prophylaxis/testing are essential. Breastfeeding guidance varies by setting and should follow national recommendations.
Pediatrics
Pediatric ART uses weight/age-based dosing and pediatric formulations; early infant diagnosis and prompt ART are life-saving — refer to pediatric HIV specialists.
TB co-treatment
Integrated TB/HIV care required. Adjust ART in presence of rifampicin (eg DTG dosing) and monitor closely. Timing of ART initiation during TB treatment depends on CD4 and clinical status. 16
Complications & Prognosis
With early diagnosis and sustained viral suppression on ART, prognosis is greatly improved and life expectancy approaches general population for many. Complications without ART or with advanced disease include severe OIs, malignancies, wasting, neurocognitive decline, and end-organ disease (renal, hepatic, cardiovascular). Long-term ART may have metabolic/renal/bone effects needing surveillance.
FAQ — स्पष्ट उत्तर
कब ART शुरू करें?
Test-and-treat: HIV diagnosis के बाद जल्दी से जल्दी ART शुरू करना चाहिए — same-day start possible when counseling and baseline labs arranged. 17
PEP कब तक दिया जाता है?
PEP एक 28-day ARV course है और ideally within 72 hours of exposure start किया जाना चाहिए; first dose immediate दिया जा सकता है जबकि baseline tests arrange हो रहे हों। 18
Cryptococcal meningitis का नया induction क्या है?
WHO ने simplified AMBITION regimen recommend की है—single high-dose liposomal amphotericin B with flucytosine and fluconazole for induction—to reduce toxicity और monitoring needs; local implementation protocols follow national policy. 19
Selected Guideline References (authoritative)
- Panel on Antiretroviral Guidelines for Adults and Adolescents — NIH / US DHHS: Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents. 20
- WHO — Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring. 21
- WHO — Guidelines for cryptococcal disease (AMBITION simplified regimen / single high-dose liposomal amphotericin B). 22
- CDC — PEP guidance & OI prevention/treatment resources. 23
- Clinical reviews: PCP treatment recommendations (StatPearls / NCBI) and AMBITION implementation reports. 24
नोट: दिशानिर्देश समय-समय पर अपडेट होते हैं—publish/last-updated dates की जाँच और राष्ट्रीय प्रोटोकॉल का पालन आवश्यक है।
Internal links (related posts on this site)
- Heart Failure Diet — Complete Guide & Menu (nutrition / fluid balance संदर्भ)
- Biotin Deficiency (हिंदी/English) (B-vitamin discussion)
- Epistaxis — Symptoms & Treatment (bleeding / coagulopathy संदर्भ)
- Onion (Allium cepa) — Benefits (phytonutrients / antioxidant context)
- Guava — 40 Benefits, Banana — Benefits (food / micronutrient references)
- Anjeer (Figs) — Benefits
- Digoxin — Complete Guide (drug interaction / cardiac support reference)
- Fever — Complete Guide (management of febrile patients)