1
Approach to Infectious Diseases and their prevention
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2
Antibiotic stewardship practices
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3Community-Acquired Infections
4
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Health Care?Associated Infections
5
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Gram-Positive Bacteria (part-1)6
Gram-Positive Bacteria (part-2)
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7
Gram-Negative Bacteria (part-1)
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8Gram-Negative Bacteria (part-2)
9
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Spirochetal Diseases
10
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Diseases Caused by Atypical/Miscel aneous Bacterial Infections11
Revision-cum-exam on bacteria (Must to know type)
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12
Infections Due to DNA Viruses
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113
Infections Due to RNA Viruses (part 1)
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14
Infections Due to RNA Viruses (part 2)
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15HIV/AIDS ? part 1
16
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HIV/AIDS ? part 2
17
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Fungal Infections18
Parasitic Infections (part 1)
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19
Parasitic Infections (part 2)
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20Revision-cum-exam on Virus, Fungal, and Parasite (Must to know type)
Clinical Manifestations
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The center for disease control (CDC) has classified the
clinical course of HIV infection under various groups.
1. Acute HIV infection
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2. Asymptomatic or Latent infection3. Persistent generalized lymphadenopathy (PGL)
4. AIDS related complex
5. Full blown AIDS (Last stage)
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WHO clinical staging of HIV/AIDS for adults & adolescents 2010
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Clinical Stage 1Clinical stage 43
Asymptomatic
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HIV wasting syndrome Pneumocystis pneumonia
Persistent generalized lumphadenopathy
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Recurrent severe bacterial pneumoniaClinical Stage 2
Chronic herpes simplex infection (orolabial, genital or anorectal of more than one month's
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Unexplained moderate weight loss (<10% of presumed or measured body weight)' Recurrent dura- tion or visceral at any site)
respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis) Herpes zoster
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Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs) ExtrapulmonaryAngular Cheilitis Recurrent oral ulceration Papular pruritic eruptions Seborrhoeic dermatitis tuberculosis
Fungal nail infections
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Kaposi sarcoma
Cytomegalovirus infection (retinitis or infection of other organs) Central nervous system
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toxoplasmosisHIV encephalopathy
Extrapulmonary cryptococcosis including menigitis
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Disseminated mycosis (extrapulmonary histoplasmosis, coccidiomycosis) Recurrent
septicaemia (including non-typhoidal salmonela)
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Clinical Stage 3Lymphoma (cerebral or B cell non Hodgkin) Invasive cervical carcinoma
Unexplained 2 servere weight loss (>10% of presumed or measured body weight)
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Atypical disseminated leishmaniasis
Unexplained chronic diarrhoea for longer than one onth
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Symptomatic HIV-associated nephropathy or symptomatic HIV ? associated cardiomyopathyUnexplained persistent fever (above 37.5OC intermittent or constant for longer than one month)
Persistent oral candidiais
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Oral hairy leukoplakia Pulmonary tuberculosis
Severe bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or joint infection,
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meningitis, bacteraemia)Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
1 Assessment of body weight in pregnant women needs to consider expected weight gain of pregnancy. 2
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Unexplained anaemia (<8 g/dl), neutropenia (<0.5 x 109/litre) and or chronic
Unexplained refers to where the condition is not explained by other conditions.
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thrombocytopenia (<50 x 109/litre3)3 Some additional specific conditions can also be included in regional classifications (e.g. reactivation of
American trypanosomiasis (meningoencephalitis and / or myocarditis) in Americas region, Penicillionsis in
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Aisa)
Acute HIV infection (window period or phase of Sero conversion)
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-50?70% experience this, 3?6 weeks after primary infectionAsymptomatic or Latent infection
? Clinical latency may last from a few months to more than 10 years.
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? During this period, the virus continues to multiply actively andinfects and kills the cells of the immune system.
Persistent generalized lymphadenopathy (PGL)
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? This has been defined by presence of enlarged lymph nodes, at
least I cm in diameter, in two or more non contiguous extra
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inguinal sites, that persist for at least three months, in the absenceof any current illness or medication that may cause
lymphadenopathy.
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AIDS related complex / Ful blown AIDS
? A diagnosis of AIDS is made in individuals age 6 years
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and older with HIV infection and a CD4+ T cell count<200/L and in anyone with HIV infection who
develops one of the HIV-associated diseases.
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? While AIDS-related illnesses are the leading cause of
death in patients with HIV infection (<50% of deaths)
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Non-AIDS-defining malignancies, liver disease, andcardiovascular disease each account for 10?15% of
deaths
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Manifestations in AIDSTreatment of HIV/AIDS as per NACO/ART Centre
Clinical Assessment
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At the beginning of HIV care and prior to starting ART:1. Determine the clinical stage of HIV infection
2. Identify history of past illnesses (especially those
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related to HIV)
3. Identify current HIV-related illnesses that require
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treatment4. Determine the need for ART and OI prophylaxis
5. Identify coexisting medical conditions and
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treatments that may influence the choice of therapy
Medical History
HIV Testing
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HIV risks (can have multiple factors)
Pregnancy and contraception history Vaccination history
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? Ever tested for HIV in the past?? Unprotected sexual contact
? Previous pregnancies and
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? BCG
? Date and place of first HIV test
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? Injection drug useterminations
? Hepatitis A vaccine
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? Reason for the test
? Men having sex with men
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? Children and HIV status of children ? Hepatitis B vaccine? Documentation of the result
? Occupational exposure
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(living and dead)
? Date of last negative HIV test result ? Perinatal transmission
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? Exposure to ARVs during pregnancy? Previous CD4 cell counts (if available) ? Recipient of blood products
? Drugs and duration of ART
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? Previous viral load (if available)
? Unknown
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? Contraception used? Partner's HIV status being positive
? Last menstrual period
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System Review
Past history of HIV related ilnesses
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? Unexplained weight loss? Oral candidiasis or candida oesophagitis Medication
Alergies
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? Swollen lymph nodes
? Persistent diarrhoea
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? Past use of drugs and reasons for? Known allergies to drugs or other
? Night sweats and fever
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? Tuberculosis
taking them
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substances or materials? Unusual headaches or poor
? Varicela zoster (Shingles)
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? Current use of drugs and reasons for
concentration
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? Oral hairy leukoplakiataking them
? Changes in appetite
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? Pneumocystis juroveci pneumonia (PCP) ? Current use of traditional / herbal
? Skin rashes
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? Recurrent bacterial pneumoniaremedies
? Sores or white spots in mouth
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? Cyptococcal meningitis
? Opioid substitution therapy (OST)
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? Painful swal owing? Toxoplasmosis
ART history
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Psychosocial history
? Chest pain, cough or shortness or
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? Kaposi sarcoma? Current and past exposure to ARVs
? Family history, e.g. other immediate
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breath
? Disseminated Mycobacteriumvium
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? ARV use during pregnancy of PMTCTfamily members with known HIV
? Stomach pain, vomiting or diarrhea
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complex Cytomegalovirus (CMV) infection ? Which drugs taken and for how long
infection
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? Numbness or tingling in hand or feet ? Invasive cervical cancer? Social history e.g. maritial status,
? Muscular weakness and changes in
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education, occupation, source of income.
vision
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Tuberculosis historySexualy transmit ed infections (STIs) Substance use
Functional status
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? Last chest X-ray
? Genital ulcer or other lesion
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? Understanding of and readiness to ? Financial and family support status? History of past TB
? Genital discharge (abnormal vaginal
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commence ART
? Disclosure status, readiness to disclose
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? Treatment given (drugs and duration)discharge in women)
? Partner's ART history (if HIV-positive) ? Availability of care and treatment
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? History of exposure to TB
? Lower abdominal pain
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supporterGynaecological history
General medical history
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? Alcohol, stimulant, opiate and other ? Able to work, go to school, do
? Last PAP smear
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? Any other past medical condition, suchdrug use
housework
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? Menstrual irregularities
as diabetes, hypertension, coronary
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? Smoking history? Ambulatory but not able to work
? Pelvic pain or discharge
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artery disease, hepatitis B, heptatis C,
? Bed ridden
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hyperlipidaemia? Amount of day-to-day care needed
? Mental health issues, e.g. depression
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Physical examination
Record vital signs, body weight, height and body mass index (BMI), temperature,
blood pressure, pulse rate, respiratory rate
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Appearance ? Unexplained moderate or severe weight loss, HIV wastingMouth
? Look for signs suggestive of HIV infection including white plaques
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? Rapid weight loss in suggestive of active Ol, especialy if associated
on tongue, cheeks and roof of mouth (oral candida), white stripped
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with feverlesions on the side of the tongue (OHL) and craking at the corners
? Gradual weight loss (not caused by malnutrition or other obvious
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of the mouth (angular cheilitis)
ilness) is suggestive of HIV infection
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? Difficulty in swal owing is commonly caused by oesophageal? "Track marks" and soft tissue infections which are common among IDUs
candida
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Consider
? Malaria, tuberculosis, syphilis, gastrointestinal infections, bacterial Chest
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? The most common problems will be PCP and TBconditions
pneumonia, pelvic inflammatory disease, viral hepatitis
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? Signs and symptoms are cough, shortness of breath, haemoptysis,
other than HIV
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weight loss, fever, congestion or consolidation? Perform a chest X-ray, if symptomatic
Skin
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? Look for signs of HIV-related and other skin problems. These
Abdomen
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? Hepatosplenomegaly, masses and local tendernessinclude diffuse dry skin, typical lesions of PPE, especialy on the
? Jaundice may indicative viral hepatitis
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legs, seborrhoetic dermatitis on face and scalp
Ano-genital ? Herpes simplex and other genital sores / lesions, vaginal or penile
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? Look for herpes simplex and herpes zoster or scarring of previousdischarge
herpes zoster (especially multi-dermatome)
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? Perform PAP smear, if possible
Neurologic ? Focus on visual fields and the signs of neuropathy (bilateral
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Lymph nodes ? Start with posterior cervical nodesal
peripheral or localized mono-neuropathies)
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?
? Assess focal neurological deficit
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PGL (persistent glandular lymphadenopathy) typical y presents as examinationmultiple bilateral, soft, non-tender, mobile cervical nodes, Similar
nodes may be found in the armpits and groins
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? Tuberculous lymph nodes typical y present as unilateral, painful,
hard enlarging nodes, with constitutional symptoms such as fever,
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night sweats and weight lossNote : During each consultation, patient is to be clinically screened for TB (history and physical
examination)
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Laboratory Monitoring for patients at ART centresEssential tests
Additional tests
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? Haemogram/CBC,
For all patients to be started on ART (as per
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? Urine for routine and microscopicthe physician's
examination,
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decision depending on clinical presentation)
? fasting blood sugar,
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? USG abdomen,? blood urea,
? sputum for AFB,
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? ALT (SGPT),
? CSF analysis etc.
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? VDRL,Ef orts to be made to fast track these
? Serum creatinine (when considering TDF) investigations so that ART initiation is not
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? CD4 count,
delayed.
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? X-ray Chest PA view.? Pregnancy test (if required)
PAP smear & Fundus examination also to be
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? Symptoms and signs directed
done but ART initiation not to be delayed
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investigations for ruling out Ols.for these tests.
Tests for Special Situation
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Tests for monitoring purpose
? HBsAg: for all patients if facility is
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Essential: CD4, Hb, TLC, DLC, ALT (SGPT).available but mandatorily for those with TDF based regimen: Creatinine/ creatinine
history of IDU, multiple blood & blood clearance, every 6 months or earlier if required.
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products transfusion, ALT
AZT based regimen: Hb at 15 days, then every
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> 2 times of ULN, on strong clinicalmonth for initial 3 months, 6 months and then
suspicion. But ART not to be withheld if every 6 months/ as & when indicated.
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HBsAg testing is not available.
NVP based regimen: ALT (SGPT) at 15 days, 1
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? Anti - HCV antibody: only for those with month and then every 6 months.history of IDU, multiple blood & blood EFV based regimen: lipid profile should also be
products transfusion, ALT >2 times of
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done yearly.
ULN, on strong clinical suspicion.
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? For patients with Hepatitis B or C co-ATV based regimen: LFT to be done at 15 days,
infection: further tests may be required 1 month, 3 month, 6 months and then every
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to assess for chronic active hepatitis
6 months. Blood sugar and Lipid profile every 6
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? For patients to be switched to amonths for patients on PI based regimen. All
PI based regimen: Blood Sugar, LFT
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the above tests can be done earlier based on
and Lipid profile to be done at baseline. clinicians assessment/ discretion
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Other investigations during folow up as perrequirement /availability.
Note: Al above investigations other than C04 and viral load estimations (when required), shall be done from
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the health facility where the centre is located, with support from State Health Department
Goals of ARV therapy
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? Clinical goals : Prolongation of life and improvement in quality of life? Virological goals : Greatest possible reduction in viral load for as long as
possible
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? Immunological goals : Immune reconstitution that is both quantitative
and qualitative
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? Therapeutic goals : Rational sequencing of drugs in a fashion thatachieves clinical, virological and immunological goals while maintaining
treatment options, limiting drug toxicity and facilitating adherence
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? Reduction of HIV transmission in individuals : Reduction of HIV
transmission by suppression of viral load
When to start ART in Adults and Adolescents
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WHO Clinical Stage
Recommendations
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HIV infected Adults & Adolescents (Including pregnant women)Clinical Stage I and I
Start ART if CD4 < 500 cells/mm3
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Clinical Stage I I and IV
Start ART irrespective of CD4 count
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For HIV and TB/Kalaazar co-infected patientsPatients with HIV and TB co-infection Start ART irrespective of CD4 count
(Pulmonary/ Extra-Pulmonary)
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and type of tuberculosis (Start ATT
first, initiate ART as early as possible
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between 2 weeks to 2 months whenTB treatment is tolerated)
For HIV and Hepatitis B and C co-infected patients
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HIV and any co-infection ? without Start ART if CD4 < 500 cells/mm3
any evidence of chronic active
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HepatitisHIV and any co-infection ? With Start ART irrespective of CD4 count
documented evidence of chronic
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active HepatitisManaging OIs before starting ART
Clinical Picture
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Action
Drug reaction
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Do not start ART during an acute reactionAny undiagnosed active Diagnose and treat first; start ART when stable
Acute diarrhoea which may Diagnose and treat first; start ART when diarrhoea is
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infection with fever
reduce absorption ofART
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stabilized or control edTB
Treat TB first; start ART as recommended in TB section Non-severe anaemia (Hb < Start ART if no other causes for anaemia are found (HIV
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(within 2 weeks to 2 months)
8 g/litre)
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isPCP
Treat PCP first; start ART when PCP treatment is
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often the cause of anaemia); avoid AZT
completed
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Skin conditions such asStart ART (ART may resolve these problems)
Treat esophageal candidiasis first; start ART as soon as
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PPE and seborrhoeic
Invasive fungal diseases:
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oesophageal candidiasis, the patient can swalow comfortablydermatitis, psoriasis, HIV-
cryptococcal meningitis,
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related exfoliative
Treat cryptococcal meningitis, penicil iosis,
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peniciliosis,dermatitis
histoplasmosis
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histoplasmosis first; start ART when patient is stabilized
or OI treatment is
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Suspected MAC,Start ART (ART may resolve these problems)
completed
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cryptosporidiosis and
microsporidiosis
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Bacterial pneumoniaTreat pneumonia first; start ART when treatment is
Cytomegalovirus infection Treat if drugs available; if not, start ART
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completed
Toxoplasmosis
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Treat; start ART after 6 weeks of treatment and whenMalaria
Treat malaria first; start ART when treatment is
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patient is stabilized
completed
CPT Prophylaxis
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Co-trimoxazole prophylaxis recommendations
When to stop Cotrimoxazole Prophylaxis
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CommencingCD4 awaited
CD4 available
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When to stop prophylaxis
If CD4 count >250 for at least 6 months
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primary CPT(cotrimoxazole or Dapsone) in patients and If patient is on ART for at least 6 months,
WHO clinical stage 3 or Any WHO clinical stage and CD4 <250 on ART
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is asymptomatic and wel
4 (This includes all
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cells/mm3 orpatients with TB)
Any WHO clinical stage, CD4 <350
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cells/mm3 and if patient is symptom- Notes:
* If CPT is started at CD4 levels between 250?350 cel s/mm3: CD4 counts should have increased, patient
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atic oris on ART for at least 6 months, is asymptomatic and well; before CPT is stopped.
WHO stage 3 or 4 irrespective of CD4
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count
Commencing sec- For al patients who have completed successful treatment for PCP
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ondary CPTuntil CD4 is >200 (at least on two occasions, done 6 months apart)
Timing the initiation Start co-trimoxazole prophylaxis first.
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of co-trimoxazole in Start ART about two weeks later if the patient can tolerate
relation to initiating co-trimoxazole and has no symptoms of alergy (rash,
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ARThepatotoxicity) Meanwhile, make use of the time for adherence
and treatment preparation
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Dosage of
One double-strength tablet or two single-strength tablets once
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cotrimoxazoledaily? total daily dose of 960 mg (800 mg SMZ + 160 mg TMP)
Cotrimoxazole for Women who fulfill the criteria for CPT should continue on it
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pregnant women
throughout pregnancy.
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If a woman requires CPT during pregnancy, it should be startedregardless of the stage of pregnancy
Breastfeeding women should continue CPT where indicated
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Patients al ergic to Dapsone 100 mg per day, if available
sulpha-based
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Co-trimoxazole desensitization may be at empted but not inmedications
patients with a previous severe reaction to CTX or other sulpha-
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containing drugs
Monitoring
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No specific laboratory monitoring is required in patientsreceiving co-trimoxazole
ART in Adults and Adolescents
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Nucleoside reverse
Non-nucleoside reverse
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transcriptase inhibitors Protease inhibitors (PI)transcriptase inhibitors (NNRTI)
(NRTI)
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Zidovudine (AZT/ZDV)* Nevirapine* (NVP)Saquinavir* (SQV)
Stavudine (d4T)*
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Efavirenz*(EFV)
Ritonavir* (RTV)
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Lamivudine (3TC)*Delavirdine (DLV)
Nelfinavir* (NFV)
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Didanosine (ddl)*
Fusion inhibitors (FI)
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Amprenavir (APV)Zalcitabine (ddC)*
Enfuviritide (T-20)
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Indinavir* (INV)
Abacavir (ABC)*
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Integrase InhibitorsLopinavir/Ritonavir (LPV)*
Emtricitabine (FTC)
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Raltegravir
Foseamprenavir (FPV)
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(NtRTI)CCR5 Entry Inhibitor
Atazanavir (ATV)*
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Tenofavir (TDF)*
Maraviroc
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Tipranavir (TPV)* Available in India
Revised NACO ART Regimen 2012
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Regimen IZidovudine + First line Regimen for patients with Hb 9
Regimen I I(a)
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Zidovudine +
For patients of Regimen I I who develop severe
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Lamivudine + gm/dl and not on concomitant ATTLamivudine
Atazanavir toxicity First line regimen for patients
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Nevirapine
+ Lopinavir /
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with HIV-2 infection with Hb 9 gm/dlRitonavir
Regimen IV
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Tenofovir +
Second line regimen for those who are on
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Regimen I (a)Tenofovir +
First line Regimen for patients with Hb <9
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Lamivudine+
AZT/d4T containing regimen in the first line.
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Lamivudine +gm/dl and not on concomitant ATT
Atazanavir/
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Also for patients on TDF containing first line
Nevirapine
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Ritonavirregimen who develop toxicity to both NVP
and EFV
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Regimen I
Zidovudine + First line Regimen for patients with Hb 9
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Regimen IV (a)Tenofovir +
For patients on Regimen IV who develop
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Lamivudine + gm/dl and on concomitant ATT
Lamivudine+
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severe Atazanavir toxicity First line RegimenEfavirenz
Lopinavir/
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for patient with HIV 2 infection with Hb < 9
Ritonavir
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gm/dl First line Regimen for all womenexposed to sd-NVP in the past
Regimen I (a)
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Tenofovir +
First line Regimen for patients with Hb <9 gm/dl Regimen V
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Stavudine+Second line for those who are on TDF containing
Lamivudine +
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and on concomitant ATT First line for al
Lamivudine+
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regimen in the first line if Hb < 9 gm/dlEfavirenz
patients with Hepatitis B and/or Hepatitis C co-
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Atazanavir/
infection First line Regimen for pregnant
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Ritonavirwomen, with no exposure to sd-NVP in the
past
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Regimen V(a)
Stavudine+
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For patients on Regimen V who developLamivudine+
severe Atazanavir toxicity
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Regimen I I
Zidovudine +
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Regimen for patients on AZT Containing firstLopinavir/
Lamivudine
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line regimen, who develop toxicity to both
Ritonavir
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+ Atazanavir/NVP and EFV Also Second line regimen for
Ritonavir
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those who are on TDF containing first line
regimen if Hb 9 gm/dl
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Choice of NRTIsNRTI
Advantages
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Disadvantages
3TC
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Good safety profile, non-teratogenic OnceLow genetic barrier to resistance
daily Ef ective against hepatitis B Widely
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available, including In FDCs
FTC**
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An alternative to 3TC Good safety profileNo added advantage over 3TC except as daily
Same efficacy as 3TC against HIV and hepatitis dose Can be used as once-
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B and the same resistance profile
a-day dose in combination with TDF and
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EFV.(i.e. reduced pill burden and dosingschedule)
TDF*
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Good efficacy, safety profile Once daily
Renal dysfunction has been reported Safety in
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regimens Metabolicpregnancy not established Adverse ef ects on
complications, such as lactic acidosis and
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foetal growth
lipoatrophy, are less common than with d4T and bone density reported Limited availability
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at SACS on case-to-case basisAZT
Generally wel tolerated Widely available,
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Initial headache and nausea Severe anaemia
including in FDCs Metabolic complications less and neutropenia Haemoglobin monitoring
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common than with d4Trecommended
ABC**
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Good efficacy profile Once daily Causes the Severe hypersensitivity reaction in 2-5% of
least lipodystrophy and lactic acidosis
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adultsD4T
Good efficacy profile and cheap No or limited Most associated with lactic acidosis,
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laboratory monitoring Widely available in lipoatrophy and peripheral neuropathy
FDCs
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* Shall be available on case to case basis* * Not supplied by NACO at present
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Routine Monitoring of Patients on ARTPPTCT Services
Prong 1: Primary prevention of HIV, especially
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among women of childbearing age
Prong 2: Prevention of unintended pregnancies
among women living with HIV
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Prong 3: Prevention of HIV transmission frompregnant women infected with HIV to their child
Prong 4: Provide care, support and treatment to
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women living with HIV, her children and family.What to Expect in the First Six Months
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of Therapy1. CD4 recovery
2. Early ARV toxicity
3. Mortality on ART
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4. Immune reconstitution inflammatorysyndrome (In India, the agreed practical definition
of IRIS would be the "occurrence or manifestations of
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new OIs or existing OIs within six weeks to six months
after initiating ART; with an increase in CD4 count")
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What Toxicities to Expect after Commencing
First-line ART
Clinical, immunological and virological definitions
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of treatment failure for first-line regimen (WHO,
2010)
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ClinicalNew or recurrent WHO stage 4 condition,
failure
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after at least 6 months of ART
Immunologi ? Fall of CD4 count to pre-therapy
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cal failure ? 50% fall from the on-treatment peakvalue
? Persistent CD4 levels below 100
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cells/mm
Virological Plasma viral load >5,000 copies/ml after
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Failureat least 6 months of ART
IDIOPATHIC CD4+ T LYMPHOCYTOPENIA
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Recognized in 1992 characterized by:
?An absolute CD4+ T cell count of <300/l or
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<20% of total T cells on a minimum of twooccasions at least 6 weeks apart;
?No evidence of HIV-1, HIV-2, HTLV-1, or HTLV-2
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on testing; and
?The absence of any defined
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immunodeficiency or therapy associated withdecreased levels of CD4+ T cells
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Development of vaccineDevelopment of vaccine is fraught with several problems unique to this
virus. These include-
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1) HIV can mutate rapidly, thus, it is not possible to design antibodies
against all antigens.
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2) Antibody alone is not sufficient, cell mediated immunity may also benecessary.
3) Virus enters the body not as free virions but also as infected cells, in
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which the virus or the provirus is protected against antibody or cell
mediated lysis.
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4) Virus readily establishes life long latent infection hiding from antibodies.Thank you