Sindromul de imunodefi cienta

1983: se definosteclinic SIDA si ss izolazaun retmvirus(Luc Montagnio

& 1984: se confirma retrovirusul ca agent etiologlc al SIDA (Robed Gallo) t ! t 1986: evolepidemi a inf HIV 1987: se aproba AZT in tratamsnlul inf HIV i995: perspedive de tratamsnl prin folosirea asocisrilor ARV (era l-lMRT.trighly adive sntirtroviral therapy)

E In prszent infectiB pandemica (>40 milinfsc{ati) * 198q primulcazraportaiinRomania -10.000cazurlRomania

!2010:

e Pandemla: dedansata din 1970 * Originea: Afic r 1980 raspandrea ps calelate contlnenls

x Sur6a: cimpanzei,gorile;virus adaptatla om

Epidemiologie
(hetaro,homo) ] Calesexuala r Cab parenleEla -expuners la sange / produss sg psrlnatala: }' Transmibro intrautrh, la nastsrs, Postnstal in tundiedetratamsnt .Risc:45%-10%
r HIV nu sa transmiie prin contacl obisnuit

3 Fccarefavorizeaza transmitersa: -marim6sinodlului -asociorea altor boli cu transmitere sexuala

Efologie. HIVesteLentivirus,fam Retroviridae I Trasaturi: persistents I r -virusuri

Fam Retrgviridae are 3 genuri: l.Lntiviridae 4> is nrv, 2.Oncoviridas (o(HTLVI -> | I \

'inf cronice pmgrgsivs cu latentalunga soldate

-rEPlicare in cel slst lmun t Do[ | I 'neurologico frooucrumon, reucemil, r

3.Spumaviridae d>

nepatogon

Structura HIV
-2 stEturilipidicesi -2 p'oisctiigli@pmtaic(gp):gp 12Ogp 4l E Matrice proteica: -potina p17

-p 24 (mk de replicare) -prct NC (p 9) nzime (RT + integraza)

r Nucleo-capsida formata din proteine:

E Genom:2 mol RNA

1. CELULELE INFECTATE HIV infecteaza> tiDuride clule GP 120 are afinltatepentrucelule e exprimape suprafatarec CO4

Cslullesusceptibile fata do infedja HIV: '1.La nivslulmu@aslorsi tegumenlglor 2. Sistem hmatopoistic 3. Sisiom Nervos 4. Alt tesuturi

2. REPUCAREA E Atasarea(fuziunea): gp 120 / rec CO4 si CCRS,CXCR4 r Patrundere in csl receptoaresi eliberarsds RNA * RNA ] ---* Rr.-----_ONAds h{u } povirus Integrat RNAviraleliberatvafunctiona

IntegEre

ri Transcriptiaprovirusului+ sa RNA m si viEl & Translaiis cu sinteza poteica r Ansamblarcavirionului r, Eliberarea din celula

ffi

r Replicarea HIV este dinamica (1d particulevirale/zi)

s Replicarea se face cu o rata ds mutatiif. inalta.

s Rezulta o populatie hetsmgena de tulpini virals.

c Sub presiunea drcgurilor antiviEle apar tulpini rezistente fata d acestea.

ACTIVAREARASPUNSULUIIMUN NU POATE ELIMINAHIV

r Menisme de'scapare' -fomarBa unui sloc de LT-CD4infectateinaints de apar,tiaraspunsului specificantiviEl

-prindereaHIV in Bteaua de celuls dendritice

-vadabilltalea geneti HIV

F o

&

t& Is t@ e lw & i ,00 m 16 t 4 e

k(&!rrdE Hd!'tww eqH..i

T a

e
F I

consecintleinf Hlv F lrfectia HIV netratalawotueaza pe parcursula 8-12 ani in mai multe etape: r Incubatie: 24 sapt. (l-12) D Infedia primara-2 sapt r Infedia cfonicaasimptomatica-1oani tr Infedie HIV simptomalica 9 SIDA constituit- 2 ani (stadiullinal, in care se manfiestairf oportuniste, neoplaiile, manif spcifice)

INFECTIAPRIMARA (simptomatica la 40-90% din bolnavi) tr Febra,aslenie +: 1. Manifculanats 2, Ml seronsgativa 3. Meningooncefalita.(paElizii de nv +r- @ma) cran|nt, 4. Hepatocitoliza

+ Ex nespecifice: hemograma, modif in fc de manifestare Ex specifice: Agp24 RNA HIV Ac HIV (ELISA),confirmarc Westem Blot

hportants diagnosticului infectisi primare

1. 2. 3.

lmpiedica raspindirea bolii precocs Asigura traiamenl predictiva privind Valoare evolutia ulterioara

INFECTIA CRONICA ASTMPTOMATICA

G Dureaza-iO ani |n functiede rsactiasistemuluiimunologicpute$ avea: -pacientiprcgresoritipici (70%Fto anl -pacientimpid progresivi(10_20016)_5 anl -pacientilent progresori(5-10%)_15 ani -Pacienti foartelent progresori-1 06

LIMFADENOPATIA GENERALIZATA PERSISTENTA

e Adenopatii care cuprind>2 localizari extrainghinaledureaza3 luni si au un caraclor aparent benign

x Simptomeconstitutionale: -febra,diareeprelungita, scadsrc ponderala

e Uneleinfectiiasociate: -Herpes Zoster extins (VZV) -Candidoza -Angiomaloza bacilara (Bartonsils) -Leucoplakie paroasa(EBV) -Boalainflamatoriepelvina -Listerioza

SIDACONSTITUTT
I. MANIFESTARI GENERALE:fbra, <G, astenle II. MANIFESTARI ORGANICE: A).Legatede infectiaHIV B) Infedii cu oportunisti C) Nsoplazii . Manibstad pulmonale: pnEumonii/ limfoame, s. Kaposi 3 Manifestai digestive: infeclii ale cav bucale si ale tract. Dig. / limfoame, s. Kaposi B Manifestai genitourtna 1 Manif"-sladnourolog,?r: meningite, encefalite, neuropatii infectioase/ lirnfom, sarcom Kaposi

Cauze infectioass (S.pn, |r Bacierii H infi,S. aureus, BGN): pneumonii fecidivante r Mtbc TB cu evolclasica CD4>200: <200: manif extraresp . CD4 r Mynetbc(MAc) (PCP) r Fungi: P.iirovecii r Virusuri (pneum : CMV interst), EBV(Pn -(LlP)cu hiperplazie intertitiala limfoida (epit. limfoida difuu septuri) bmnsic,

Pulmonare Manifestari Diagnostic

* Plamanul: organulcel mai frecvntaf6c{at c In stadiile incipientB manifestari curx dasic6, ulterior necaEcterislica

Dg necasita: l ! Ex sputa ( color"atiipt bac'tarii,my, tungl si P. jirovsdl) (LBA si biopsie) Bronhoscopia

s Rx +/- CT toracic x HsmoqJltura ! Statusimunologic(CD4)

Manlfestari Digestive Etiologie

j

Virusurl: -HSV (GV bula, Ect), -CMV (esofag,colon), -EBV (lsucoplakie) .HIV -v. hepatics Bacistii: salrn/schigella Fungi: Candida (sofag lS) Polozoare: Cryptosporidium (mron)

x
Noplasm6: -s. Kaposi(lez oEle, alte lsz digestive) -limfomnonhodk(lez hep) Postmedicamentos: -pancreatita(ddl, cTx) -t|epauta(antiTB,lP, mamlids)

Manifestari Dlgestive

$ Frecvente, precoce{din primelestadii):diaree Diaonosticul nsceslta: r ixcoprcpaezitologic

n Hsmodtturi I Cooroculturi s Endoscopiecubiopsio

H> -

ctipto"po'idiut, |.o Microsporidium, { . Giardia E mycobactsrii,bactedi ri CMV,my,fungi,paraziti

Cav bucala

& Leziunile sunt nedureroasg D Loucoplakie (EBV) G Ulceratiibucale (CMV, HSV, sifilis,limfom) * Limfomnonhodkinian (nodulsau masa tumoralape palat -s pot ulcera) D SarcomK(papule, noduli rosii, nedurerosi) e Boala periodontiala(anaerobl)

t-=''.g,;-_-]
r Clinic: volulie cloni recidivanta distagie, dureri retrostemalo e iiiijtogie infctioass: {andida 80% -CMV E Dg endoscopic, biopsie

r---'*ffi--l
3 Clinic: -evolutiocrcni recidivanta diare ] Etiologieinfectloasa: HIV (entaopatia HIV) + -bactedi (Salr/Schig) -virusuri(CMV,HSV) -tungi, protozoare . r si PostmediGmentos(lP) Dg: excopmparazitologic cu @proeltuE, hem@ , endoscopie biopsie

CAUZE: r lnfadioase: Virale:HBV, HCV, CMV E Medicamentoase: antifB, ddl ?: Neoplazice (limfoame, sarcom K)

Entitati: E Colecislitaacalculoasa G Colecistitecu BGN & Colangita sclercanta ; Stenozapapilara(funglsau int cMV)

B Pancreatite: {edicamentoass

Manifestarl Genltourinare

Nefrcpatie: -Htv -complue imuns -postmedicamentos: CTX, indinavir,pentamidina

* Boala inflamatorie pelvina " Candidozavaginala

Manifestari Neurologice -trasaturi-

1. 2. 3. 4.

Apar pE@ce si pe parcurs O manifestare are > cauze Lez perifericepre@d leziunileintEcerebrale Afectarsla multiDle nivelesi simultan

Etiologia manifestarilorneurologice A. Cauze infectioase

r. HIV: -meningita aseptica nfalita acuta -complexdementialAIDS -mielopatie vacuolara -mielita -PN senz -PRN

Infecliioportunists

-Virale:LMP, PR progresiva, mononevrita multiplex -Bacteriene: NTB, neurosif ilis -Fungice:criptococoza -Parazitara: toxoplasmoza a n ultif06l a "LMP=teu@en@fa!o pati Wgresiva,'PRN-Falindiculonevrita ' PN =Fpl inevrita,'NTB=neurcTB

e Neoplazii: limfomprimar,sarcomKaposi & Postmedicamentos :ddl.ddc, d4T

Manifestari neurologice

Diagnostidl nEcssita: ] Ex obiediv : -stalus mental, psihic, @nslienta, memorie, @nentEre {rsrvi cranieni +flxe -x motilitatii si al sensibilitatii r, Eplorari speiale: RMN LCR (dstgrminari moleculars, Eg/ac), EU EMG

Manifestari precoce r Encefalita acuta (nodulisubcorticali cu celulemultinucleate) * Meningitsaseptica ] ; PN prifsrico EnGfalopatia (lez g. bazali)

Manifsstari tardive E Leucoencefalita (dementaAIDS, LMP) B Mielita(vacuolara, e @lule multinucleate) I Meningitacu oportunisti

ti PN perfferice (diverse formg) si craniene (mononevrita multiplex) * Neuropalie vegetativa r Neoplazii

r. Postmedicamentos

Manifestari nsurologics Entltaticlinlcs

Clinic psihomotorii 3 Disfunclii usoare , tulb de comportament dementa,$ incontinenta Paraple9i6 }! LCR : pleiodtozacu MN, ag p24, 82 microglob

AP: ] LE subcorlicala cu cel multinuclsate, vadolizai, -se asociaza cu Miglita vacuolara in timD atrofie corticala;

Lucoencafalita multifocala (LMP) Prcgresiva Toxoplasmoza @Ebrala s Etiol:virusJo (papovav) -Evol progresiva -Cliniq afsbril, @nstiant, semns de focar,dementa -Diagnostic RMN (lezla jonctiuns),PCR In LCR BC * Etiol:Tgondil -EvolEpida 4liniq afebril,semne de tor -Diagnosuc: CT, RMN: abcess cu localizare in cortex sau nc bazall Semlogiopozitiva

tr Mningitacucriptococus evol cronica cu LCR clar, limfocitar, glicorahie < Diagnostic:frotiu si culturiLCR, ag. Criptocin LCR, ser ! Neurosmlis : {ln cronica cu dementa, {suoPatii traniene, -mielopaue, -LCRq pleiocitoza, -serol +

r MeningoencefalitaTB -evol cmnica cu LCR clar,limfocitar, glicorahie < ,sau modi,icari minine -insotita de TB pulmonara frotiu,elturi LCR, Diagnostic: hemoc

D. Meningoencefalltacu mycobactrii neTB s Tuberculomcersbral

n LimfomprimarSNC

Evol lenta (r detici0 tulburaride personalitats Pacientconslient,

Diagnostic : -CT cerbral (leziuni localizats in SA poriventricular) -BC

Trebuis difersntiat do toxoplasmoza

Manifeslari als SN oeriferic

I

-PoIineu,o pat ia di stala senzitiva: Cl: tulburaride snsibilitate distal, simalric, la nivelul xttemitatilor +'teurc patie vege taliva: Cl: hTA posturala,aritmiisi moarte subita -PRN: Ct tulburarid sb si motilitate

PRptwresivd -Cl; miastenie, tulb sfincterieno, hiposlezie, paraparsza flasca, n abolits LCR: ctl PMN, DNA CMV+ EMG -modifiri Mononevrlta multlplax l: tulbuEri de Sb la nivelulnv traniani si prifsrlcl:

Alte manifestari in inleciia HIV s MiopaliHIV: Clinic astniesi mialgii Diagnostic: EMG,CPK Biopsie musqjars AZT poale conlribui la miopatis

3 Manifstari reumatice :artdta HIV (oligoartrita persistsnta ducrcasa)

Manifestari dermatclogice

papule a Maculo, (trunsii, palmoplantar) e PaPule l Vezicul e Ulceratil B Vrud r Alsrgodomii I Tumora (macula, papula, vasculara nodul) - Angiomatoza bacilara

Manifestari oftalmologice

e Keratita: HSV,HZV e Corioretinita: MV: Corioretinita unilatapoi bilat cu orbire;dg FO -Toxoplasma

SIDA infectii oportunistesi neoplazii

Manifestariclinice, diagnostic,tratament

i I Celemai frecventeinfec{iioportunistein infectia HIV I

r. virusuri

*{'
-l E -a -

lxFo^r-

;5"T,#i:?:";J,,::laririce,papovav,
{o a. on, ,. aureus,H. infl, K pneum,ps. aeruginoss * Satmonella.rschigeila,Campylobac Spn,BGN,T.pafiidum r Bartonella

T*:^"1",1 _ {ntrespiratorii -infdigestive -infneurologice -infcutanate B Mycobacterii E Fungt x Protozoare -

3 p.jirovecii,Candida,Criptococcus. Htstoptasma, Coccidioides, Blastomyces t n Toxoplasma, Criptosporidium, Micmspoddium, lsospora I [

INFECTIIVIRALE OPORTUNISTE

Infectia cu CMV
* Roactivar x FcrissCD4<100 & Clinic c Tratamnt: {anciclovir ivl inlraoculer (anatogguanosina,inhibasinteza DNA) -cidofovir iv, -foscamet iv intraocular ; u G ; ] Corior6tinila Pn interstitiala; Esofaglta cu ulceratii; Enterocoliia Neurologic: PR progresiva Mononevrmultiplex dg: RMN, DNA-CMYn LCR

lnfectiacu herpessimplex
B Raadivarsa inf latsnte *, Fcrisc:CtX<100 x Clinic f ! I | .{ | ; | " Lez mucocutanatspclungite (utceratii, necroza;ionce iezlune ulcaratatrebuiesuspectataHSV; dg colTzank, cultura,PCR Esofagitai dg endoscopic Encetaltta; og cT, PcR / LcR

G Tratsmenl: -aciclovF -tuF rzistents: foscamet -cidofovir local

Infec{iicu HerpesZostervirus
3 Rsactivara B fndicatorde infectlgl

-ncrnr" +

l:r fi"#:::iffi,","," mningita, Dissminar"d

I
L encfalita 1:"

r Tratament: aciclovflv ,dozemari(49/zi)

progresiva (LMP) Leuconcefalopatia multi-focala

* Etiol virus JC (DNA, papovav), cale dig?, frecv. 58%, reaciivare, corelat (rI no colon, adm dB ac monodonali n Demielinizars s Clinlc : deficit motor focal car pogresaza rapid (4 luni), dsmenla, orbitE } Dg: BC,PCR/LCR, RMN

INFECTIi BACTERIENE OPORTUNISTE

Infediile bactadane sunt cele mai frecvente omolicalii

TRASATURI r Apar si la nivele mari de CD4 ; Favorizatad: -det6d de imunitatecel (infectiicu patogEniintra@lulari) dsfsct de im. umorala(S pn, S.sucus, H.infl,piocianic) {utmpnig {eficit Complemenl I 3 ; 3 Tratarnent antitiograma Profilaxi: va@inare la pacienti Co/t>200 ( H inn, S pn) lmunoterapie : lg iv la 2'l zllE Faclori de crBslelgranulocitara: GCSF la pacienticu PMN <1000/mm3

lnfedil baderiene

lnf cutanato . . Abcss,fiegmon Angiomatozabacilara-noduli eritematosi subculanati sau evol sistomica Dg :biopsie, ac Tratam: claritro

hteotii rcspintodi li Fcrisc: CD4 <200, lipsa va6inarii . . -Sinuzite -Pneumonii

3 TEtam (Cef lll) si prclilaxis lnf cligestive: nlerccolite cu Salmonella G Tratam (FQ) si Profilaxie

Candidoze
* 50% C albicans a Evol recurenta. frewenta rrErg ] Fc risc: CD4, igi6na, prcfilaio cu antb tr Clinic: precocs mu@ase, tardiv -glositra -keilitaangulara -esofagila orcziva -vaginita 3 Dg:diniq frotiu, cultura ; Tratament local : nystatin, clotrimazol -sistemic: fluconzol 200-400 mg/zi $ Protilaie (CD 4<200): nu@nazol100 mg/zi

Criptococoza
Fung ubicuitar, incapsulat Inf primara(inhslap) sau reactivara Fc tisq CD4<50 Clinic:meningosncefaliia cronica,uneorifara sdr maningeal,cu edem cerebral Dg LCR frotiu,ag, cultura,hemoc + Tratamenl:amfotericina apoi fluconaol xg saptamaniapoi profilaxie cu fluconazol200 mg/A toata viata

Poate irodue si pneumonie(hemoc+) Leziunicutanate- moluscum

c Coctidioidomicoza (C.immitis) ; Fung ubicuttar(sol) r: Infedieprimara sau reactivaro B FcrisecD4<2so x Clinic

r Fcrisc neutropenia, tratamantbcri corticoierapie, spctru larg . Clinic -aspergiloza pulmonara (6volc1linfarctpulm) . -aspergiloza osoasa, SN(invzie

vasculara-infarcl corebral) -pneumonis inter$ruah cronica r culturi Dg:froliu, {isemina ql nfalitg r Tratament: amfotericina B apoi 3 Dg:cultura,serologie profi laxiecu itmconazol * Tratamenl: amfotsricina B Varhnte:caspotungin, vori@nazol
apol

Pneumoniacu P jircvecii

Fc risq CD4<200 ' Pneumoniearipie subaeta (3* sapt) s Rx : pneumonie inteFtitiala bilat ePoi intersualveolar ._ B Dg: brcnhoscopie, coloratieAg (chisti),Weigert GEm (trofozoiti) F: TEtament CTX 20 mg/kg/zi T si CT x 2'1zil6

{ I f I I

Tus seaca,febra+/dispnee,hipoxemiesevera Aspecl de 'fagure de miere sau alte variante

Infectii cu mycobacterii

e Inf cu M. tbc accelereaa progresiainf HIV E Inf HIV prsdisPune ta reactivarea TE sau la aparitia TB acute e Fcderisc _ F -=\ e Tratament 6 luni (2+4)

CD4>200: localizarpulm, tablouclasic r. CD 4 < 200: localizareextrapulm, bacteriemie. tablou radiologicnecara61. CD 4 <1OO; forme sistemice,dg bac{eriologic (scaun,sango, gang'ioni,maduva)

H lnf cu my. netb (MAC) eTratamenlclaritromicina, ciprofloxacina, rlfa, ETBi amikacina

Infectliparazitare

Toxoplasmoza E Reactivare (irf latenta SN. sau etina) = ::::: =B Clinic ncefalita -retinita (focala) s Tratamsnt pirimetamina+SDxlluna apoi prcfilaxie toata viata cu CTX ltbta

B CD4 <1u0,serotogte +, ttpsa profilaxiei

I Dg: LCR dil cu MN | r. RMN : abcese> (g baali, codimmedular,edem) I r proba terapeutica I lr BC

Llmfom nonhodkinlan (EBV) [i SarcomKap6t(HHV8] TEnsfo.mare maligna a cel spinoase endoteliale . Aspect-,nedurercs E Lo@lizari >: mlcmu! di& pulm E Dgr biopsie, endoscople I Tratament tFN 18 MU/zi +AZT CTagEreaza evolutial s Fc risc: CD4 <100, 3 Clinic:geneElizat, Dg: Cfcerebnl (lez s4 g bazali) giopsie

s Tratament chimloterapl9 cancer ceM@l Invazlv

Tratmentulantiretroviral (ARV)

G hpiedica infectareacelulolorsanatoaso s Nu actiongazaasupraclulelordejainfectatg s Nu aclioneazape provirusulintegrat,carc nu se replica si car se afla in CD4 neactivate (rszervoarc)

Clasifi caremedicamentelor ARV

r INHIBITORI DE REVERSTRANSCRIPTAZA(RT) -RT asigura ttansciptia RNA in DNA ptovinl carc va fi integnl in genom 3 tipuri: Inhibltori nudeozidicid6 RT (INRT) Inhibitod nudeolidici Inhibitori nonduclstidici de RT 0NNRT) * tNHtBtTORt DE PROTEAZA (tP) -pmteaza.Hlv asigun divajul poliptuteinei pPJcu's'or gag pol in prcteine mat mn; Erufta vtnont tmatun natntecuost r INHIBITORI DE INTMRE -3 tipuri:hhibitori de atasare(gp 120) Antagonistide coreceptori(CCR5) Inhibittri de fuiune

Inhibitori nucleozidici de RT INRT

r AzT (zidovudina)- 600 mg/, -indicatii:tratam,protilaxisexpunerii,matemofetala (trim ll,lll,sl la nn 6 spO -rc adverse:toxjc medular,miopatii,neuropatii G DDI (didanozina)-200 mg x 2ld -rc.advers:nauropatls,pancreatita, hematol. s DDC (zalcitabina){,75 mg x 3/zi -rc adv: neuropatie, hematologice - 40fttgx2lzj E d4T(stavudina) periferica { adverse:neuropatie -150 mgE F 3TC (lamivudina) -300m9 r ABA (abacavir) x2 -rc adverse:hipersensibilitate G 3TC +ABA (Combivir)

lnhibitori sau Analogi nucleozidici

prin mec Inhibitori compelruv (substral fals) cu bad O,C,G,A) Nudeozidica

Se sint'etizeaza DNA proviral nefunctional

Inhibitori nonnucleozidici ai RT
D- NVP(Nevirapina) 200m9x2 -rc adverse: fltanale s DLV(Delavirdina) 400mgx3 {c adverso:cutanate n EFV(Efavirenz ) 600mg/zi -rc adverse: psihice

G lnhibaRT necomoetitiv (lsgars de snzima) F Produc: -rezistenta incrucisaia, rapida, -rc aovors interactiuni medicamentoase

3 lP nu patrund in t_cR 3. Rezistenta incrucisata s lnteractiuni > medicamentoase (inhiba P450) s Produc lipodistrofie

E IDV (lndinavir)400 mgx3 -rc advlitiaza renala,hepatice,digestive h NLF (Nsltinavlr)-1250 mg 12 -rc adv:digestivo s SQV (Saquinavir)L1200m9x3 r APV (Amprenavir)' {c adv:cutanate, dig r RTV (Ritonavir)' a LoDinavir/ritonavir (Kaletra) r Azv(Atazanavir) -nu producedislipidemi

lnhibitori de intrare Inj,HlVl T 20=Enfuvirtid=Fuzeon, 1. Inhibitor de fuziune:= . Terapie de salvare . Reactii adverse locale si alergice 2. BlocantCCR5= Maraviroc

(ARV) Scopul antiretroviral tratamentului 1. Supresia maxima virusologica 2. Refacerea imunologica 3. Stabilizarea clinica

c Oi@ tntament ARV poate selediona mutatii carc sunt asociate cu scadeaa efedului si duc la apanlia de tulpini rczistente e Tulpinile au in genenl rezistenta incrucisata

Recomandaride tratament ARV k Infectia primara HIV ., ./ lnfectia HIV ,/ x, Optional -dacacD4<350/mm3 ,t urata scaderii e rapida) -daca RNA HtV <5o.ooo dml

asimptomaticduftrff;f*""ierapida)

-dacaCD4<200/ mm3si -RNAHIV>50.000 cr'ml s Infectie simptomatica

Scheme de asocieri

x 2INRT+1 standard D 2INRT+lINNRT n 2lP+2INRT F 3 INRT (salveaza lP si INNRT pentru tratiamente ulterioare g' 1IP +1 INNRT+ 1 INRT

Asocierea INRT Clasa reprezentanti m A. s: B. S C. AZT,d4T dd0,3TC ABA

$ Nu se asociaza2 analogi dinaceeasi clasa(reactii adveBe, antagonism)

Factorii careinfl uenteaza eficienta teraoeutica pacientului ri Aderentia la tratament n Nivel CD4>200 > e NivelHIVRNAmoderat e. Rapiditatea raspunsului virusologic : - la 3luniRNAHIV<400c/ml - si la 6luniRNAHIV< 50 c/ml

Modificarea schemei F lnlocuirea unuiARVin cazulreactiilor adverse s lntensificarea (adaugarea 1-2 ARv-rezultate schemei partiale) E Schimbarea in cazulesecului schemei in intregime virusologic

Pofilaxiaprimara oportuniste a infectiilor x, cD4 > 500 e cD4 <200 c CD4<100 e cD4 <75 F cD4 <50 _> @ eVaccin:pneumococ, gripa, hepB, HINdacaidr PPD+ e PCP: CTxzilnic

@>
@ -

(seropozitiv): E"#?Ifi.,if.

E MAC :claritromicinazilnic r RetinitaCMV:ganciclovir oral

Profilaxie secundara a infectiilor oportuniste

x: PCP c Encefalitacu T gondii 3 Inf diseminaia cu MAC D Infectieviscerala cu CMV x Inf Criptococcus ] Candidoza mucocutanata recurenta s Bacteriemiec1r Salmonela

s CTX480mgp/zi 4. SDZ4glzi+primetamina 50 mg/zi e Claritromicina 1glzi+ciproflox 1glzi s Ganciclovir 3g/zipo e Fluconazol 200mg/zi x' Fluconazol 200mg/zi E Ciprofloxacin 1g/zicateva luni

& Niciunul pentru HIV dindrogurile utilizate a tratainfectia nu poate eradica infectia s Tratamentul actual: -scade incarcatura viralasi -intiziedeclinul imunologic, -protejeaza celuleleneinfectate de infectie,

& Darnu au niciun efectantiviral asupra celulelor deja infectate

* Dezvoltarea unuivaccineficient esteobstructionata de urmatoarele: r Incompleta intelegere a procesului imunologic in infectia HIV r Lipsa unuimodel de studiu(animal ) pentru imunologice . experimentele n Restrictionari etice privindexperimentiarea umanaa vaccinurilor elaborate genetica (> SUBTIPURI) E Variabilihtea E Mutatii (Ac) neasteptate

s 2 tipuridevaccinuri: c Vaccin de preventie a infectiei s Vaccin imunla persoane decrestere a raspunsului infectate