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HIV Treatment Singapore | Shim Clinic

HIV Treatment Singapore. Human immunodeficiency virus (HIV) is treated with a combination of medications taken daily, to suppress the virus from multiplying, called antiretroviral therapy (ART). ART cannot cure HIV, but allows people living with HIV (PLWH) to live longer and healthier.

There are 3 types of HIV treatment:

Classes of HIV medication:

Entry inhibitors Tradename Dose Freq. FDA Approval
CCR5 inhibitor
maraviroc (MVC) Selzentry 600mg bd 2007 Aug
Fusion inhibitor
enfuvirtide (T-20) Fuzeon 90mg bd 2003 Mar

 

 

  Trade name Dose Freq. FDA App.
NRTI / pyrimidine / thymidine
azidothymidine (AZT) / zidovudine (ZDV) Retrovir 300mg bd 1987 Mar 300mg 250mg
stavudine (d4T) Zerit 40mg bd 1994 Jun 30mg / 40mg
NRTI / pyrimidine / cytidine
lamivudine (3TC) Epivir 300mg od 1995 Nov 150mg 300mg 150mg 150mg
emtricitabine (FTC) Emtriva 200mg od 2003 Jul 200mg 200mg 200mg 200mg 200mg
NRTI / purine / adenosine
didanosine (ddI) Videx 400mg od 1991 Oct
tenofovir disoproxil (TDF) Viread 300mg od 2001 Oct 300mg 300mg 300mg
tenofovir alafenamide (TAF) 10mg 25mg
NRTI / purine / guanosine
abacavir (ABC) Ziagen 300mg bd 1998 Dec 300mg 600mg
NRTI combinations:       Truvada     Combivir (ZDV/3TC) Epzicom
Kivexa
  Descovy    
Frequency: od bd od od
FDA Approval: 2004 Aug 1997 Sep 2004 Aug 2016 Apr
NNRTIs
nevirapine (NVP) Viramune 200mg bd 1996 Jun 200mg 200mg
delavirdine (DLV) Rescriptor 400mg tds 1997 Apr
efavirenz (EFV) Sustiva 600mg od 1998 Sep 600mg
etravirine (ETR) Intelence 200mg bd 2008 Jan
rilpivirine (RPV) Edurant 25mg od 2011 May 25mg 25mg
Integrase inhibitors
raltegravir (RAL) Isentress 400mg bd 2007 Oct
dolutegravir (DTG) Tivicay 50mg od 2013 Aug 50mg
elvitegravir (EVG) Vitekta 150mg od 2014 Sep 150mg 150mg
Pharmacokinetic enhancer
cobicistat (COBI) Tybost 150mg od 2014 Sep 150mg 150mg
Complete regimens:       Atripla Complera Stribild (QUAD) Trizivir Triumeq Genvoya Odefsey Z250 S30 / S40
Frequency: od od od bd od od od bd bd
FDA Approval: 2006 Jul 2011 Aug 2012 Aug 2000 Nov 2014 Aug 2015 Nov 2016 Mar

 

 

 

Tradename Dose Freq. FDA Approval
PIs (protease inhibitors)
saquinavir (SQV) Invirase 1,000mg bd 1995 Dec
ritonavir (RTV) Norvir 600mg bd 1996 Mar 50mg
indinavir (IDV) Crixivan 800mg tds 1996 Mar
nelfinavir (NFV) Viracept 1,250mg bd 1997 Mar
lopinavir (LPV) 2000 Sep 200mg
atazanavir (ATV) Reyataz 300mg od 2003 Jun 300mg
fosamprenavir (FPV) Lexiva 1,400mg bd 2003 Oct
tipranavir (TPV) Aptivus 500mg bd 2005 Jun
darunavir (DRV) Prezista 800mg od 2006 Jun 800mg
Pharmacokinetic enhancer
cobicistat (COBI) Tybost 150mg od 2014 Sep 150mg 150mg
Boosted PIs:         Kaletra (LPV/r) Evotaz Prezcobix
Frequency: bd od od
FDA Approval: 2000 Sep 2015 Jan 2015 Jan

 

 

References

 


 

TREATMENT

Each HIV-infected patient entering into care should have a complete medical history, physical examination, and laboratory evaluation and should be counselled regarding the implications of HIV infection. The goals of the initial evaluation are to confirm the presence of HIV infection, obtain appropriate baseline historical and laboratory data, ensure patient understanding about HIV infection and its transmission, and initiate care as recommended by established guidelines. Baseline information can then be used to define management goals and plans.

The following laboratory tests performed during initial patient visits can be used to stage HIV disease and to assist in the selection of antiretroviral (ARV) drug regimens:

  • HIV antibody testing
  • CD4 T-cell count
  • Plasma HIV RNA (viral load)
  • FBC, LFTS, renal function tests, thyroid function tests
  • Urinalysis
  • Serologies for hepatitis A, B, and C viruses
  • Syphilis serology
  • Toxoplasma and CMV antibody tests
  • Fasting blood glucose and serum lipids
  • CXR
  • Genotypic resistance testing at entry into care, regardless of whether ART will be initiated immediately

Newly diagnosed HIV-infected persons should receive psychosocial evaluation including ascertainment of behavioral factors indicating risk for transmitting HIV. They may require referral for specific behavioural intervention (e.g; a substance abuse program), mental health disorders (e.g; depression), or emotional distress. They might require assistance with securing and maintaining employment and housing as well as medical insurance status and adequacy of coverage. Women should be counselled or appropriately referred regarding reproductive choices and contraceptive options.

Starting ART

More than 20 approved ARV drugs in 6 mechanistic classes are available to design combination regimens. These 6 classes include the nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), fusion inhibitors (FIs), CCR5 antagonists, and integrase strand transfer inhibitors (INSTIs).

A combination ART regimen generally consists of two NRTIs + one active drug from one of the following classes: NNRTI, PI (generally boosted with RTV), INSTI, or a CCR5 antagonist. Selection of a regimen should be individualized based on virologic efficacy, toxicity, pill burden, dosing frequency, drug-drug interaction potential, resistance testing results, and the patient’s comorbid conditions.

Regimen A B C
Preferred Efavirenz* Tenofovir*^
Abacavir**
Lamivudine+**
Emtricitabine*^
Alternative Lopinavir/r
Fosamprenavir/r
Atazanavir/r
Saquinavir/r
Didanosine
Zidovudine+
Specific groups Nevirapine^^
Atazanavir++

Choose one drug from columns A, B and C.
* Coformulated as Atripla (licensed for virologically suppressed patients only).
^ Coformulated as Truvada.
+ Coformulated as Combivir
** Coformulated as Kivexa
^^ Only when CD4<250 cells/μL in female patients and <400 cells/μL in male patients
++ Where there are established cardiovascular disease risk factors and a PI is required.

Initiating Antiretroviral Therapy in Treatment-Naive Patients

There have been recent changes to recommendations on initiation of ART in treatment-naive patients. This is due to increasing evidence showing the harmful impact of ongoing HIV replication on AIDS and non-AIDS disease progression. In addition, the updated recommendations reflect emerging data showing the benefit of effective ART in preventing secondary transmission of HIV. The following recommendations have been accessed from: http://www.aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf . as of September 2012.

ART is recommended for all HIV-infected individuals. The strength of this recommendation varies on the basis of pretreatment CD4 cell count:

  • CD4 count <350 cells/mm3 [A]
  • CD4 count 350 to 500 cells/mm3 [AII]
  • CD4 count >500 cells/mm3 [BIII]

Regardless of CD4 count, initiation of ART is strongly recommended for individuals with the following conditions:

  • Pregnancy [AI]
  • History of an AIDS-defining illness [AI]
  • HIV-associated nephropathy (HIVAN) [AI]
  • HIV/hepatitis B virus (HBV) coinfection [AI]

Please refer to the latest treatment guidelines before initiating treatment.

Proper management of HIV infection requires medical therapy, which for many patients should be coupled with behavioural and psychosocial services. Comprehensive HIV treatment services are available at infectious disease clinics, and patients should be referred there upon diagnosis of HIV infection.

 



Sexual risk (of HIV/STD/pregnancy), and what you can do before and after exposure.

Timeline HIV STD Pregnancy
Before exposure
Abstain from sex, Be faithful, or Condom use
Circumcision (males only)
Contraception
(females only)
HIV PrEP (pre-exposure prophylaxis)
– Stop HIV infection before exposure
STD vaccine:
Hepatitis vaccine
HPV vaccine
STD / HIV exposure
Unsafe sex / unprotected sex:
No condom / Condom broke / Condom slip
0-72 hours HIV PEP (post-exposure prophylaxis)
– Stop HIV infection after exposure
STD testing *
Screening test
– to look for asymptomatic infections
– from previous exposures
Emergency contraception
with the
morning-after pill
(females only)
2 weeks HIV DNA Test
1 month HIV 4th Generation Test
SD Bioline HIV Ag/Ab Combo
– Fingerprick blood sampling.
20 minutes to results
3 months HIV 3rd Generation Test
OraQuick® HIV-1/2 Antibody
– Oral fluid or
– Fingerprick blood sampling.
20 minutes to results
STD testing *
– Full & comprehensive
diagnostic test
– to look for current infections
Watch for HIV Symptoms STD Symptoms
If infected HIV Treatment STD Treatment Abortion

* Males: Do not urinate for at least 4 hours before arriving.
* Females: testing is more accurate when you are not menstruating.