1. HIV -AIDS
with
CRYPTOCOCCAL MENINGITIS
Doney Joseph
PharmD Intern

2.  AIDS (Acquired immune deficiency syndrome) is a disease
caused by a virus called HIV (Human Immunodeficiency Virus).
 The illness alters the immune system, making people much
more vulnerable to infections and diseases.
 India has a population of 1.2 billion people, around half of
whom are adults in the sexually active age group
 The first AIDS case in India was detected in 1986 and since then
HIV infection has been reported in all states and union
territories..

3.  HIV is the virus which attacks the T-cells in the immune
system.
AIDS is the syndrome which appears in advanced
stages of HIV infection.
HIV is a virus.
AIDS is a medical condition

5. Stages of HIV
Stage 1
(Asymptomatic)
 Asymptomatic
 Persistent generalized
lymphadinopathy
Stage 2 (Mild)
 Unexplained moderate weight
loss (<10%)
 Recurrent respiratory tract
infections
 Herpes zoster
 Recurrent oral ulceration
 Papular pruritic eruptions
 Fungal nail infections
Staging of HIV is based
on OIs:
•STAGE 1
•STAGE 2
•Stage 3
•Stage 4

6. Stages of HIV
Advanced:
 Unexplained severe weight loss
(>10%)
 Unexplained chronic diarrhea for
longer than one month
 Unexplained persistent fever (above
37.5oC intermittent or constant for
longer than one month)
 Persistent oral candidiasis
 Pulmonary tuberculosis
 Severe bacterial infections,
 bacteraemia)
 Unexplained anaemia (<8 g/dl),
neutropenia (<0.5 X 109/litre) and or
chronic thrombocytopenia(<50 X
109/litre3)
•Stage 1
•Stage 2
•STAGE 3
•Stage 4

7. Stages of HIV
Severe:
 HIV wasting syndrome
 Pneumocystis pneumonia
 Recurrent severe bacterial
pneumonia
 Chronic herpes simplex infection
Oesophageal candidiasis (or
candidiasis of trachea, bronchi or
lungs)
 Extrapulmonary tuberculosis
 Cytomegalo virus infection
 Toxoplasmosis
 HIV encephalopathy
 Extrapulmonary cryptococcosis
including meningitis
 Disseminated non-tuberculous
mycobacteria infection
•Stage 1
•Stage 2
•Stage 3
•STAGE 4

8. First line ART regimens for adults, adolescents, pregnant and
breastfeeding women and children (June-2013 WHO CONSOLIDATED guidelines)
FIRST LINE ART PREFERRED FRIST
LINE REGIMENS
ALTERNATIVE FIRST LINE
REGIMENS
Adults
(Including pregnant women
and breastfeeding women and
adults with TB and HBV co
infection)
TDF+3TC+EFZ
ZDV + 3TC + EFV
ZDV + 3TC + NVP
TDF + 3TC + NVP
Adolescents (10 to 19 years)
≥35 kg
ZDV + 3TC + EFV
ZDV + 3TC + NVP
TDF + 3TC + NVP
ABC + 3TC + EFV (or NVP)
Children 3 years to less than
10
years and adolescents <35 kg ABC + 3TC + EFZ
ABC + 3TC + NVP
ZDV + 3TC + EFZ/NVP
TDF + 3TC + NVP/EFZ
Children <3 years ABC or
ZDV + 3TC + LPV/r
ABC + 3TC + NVP
ZDV + 3TC + NVP

9. Rationale and supporting evidence
(The move to TDF+3TC+EFZ as preferred first
line option)
 A systematic review comparing 6 regimens showed that a once daily combination
of TDF+3TC+EFZ is less frequently associated with severe adverse events and has
a better virological and treatment response compared with other once/twice
regimens. People receiving NVP are twice likely to discontinue treatment bcoz of
ADRs compared to EFZ
(www.who.int/hiv/pub/guidelines/arv2013/annexes)

10. When to start ART in Adults and adolescents
(June-2013 WHO CONSOLIDATED guidelines)
 ART should be initiated in all individuals with Severe and advanced HIV
clinical disease(WHO clinical stages 3 or 4) and individuals with cd4 count
less than on equal to 350cells/mm3.
 ART should be initiated in all individuals with HIV and CD4 count grater
than 350cells/mm3 and less than or equal to 500cells/mm3 regardless of
WHO clinical staging.
 ART should be initiated regardless of CD4 and Clinical staging in following
conditions:
1. Individuals with HIV and active TB
2. HIV and HBV infection with evidence of chronic liver disease.
3. Pregnant and breastfeeding women with HIV

11. Cryptococcal Meningitis?
 Cryptococcal meningitis is one of the most important opportunistic infections
and a major contributor to high mortality before and after ART is initiated.
 The infection is not contagious.
General symptoms includes:
Headache
Fever
Neck pain
Nausea and vomiting
Sensitivity to light
Altered mental status (Includes confusion to coma)

12. Age:45 years Unit: AKH
Sex: Male Weight:48 Kg

13. PMHx
 Patient is a k/c/o HIV since 5 years and on ART since 1 year (TDF+3TC+EFZ)
FHx:
 2 children –NR, wife –expired (7 yrs ago)

14. Reasons for admission:
 C/o fever, vomiting, headache since 1 week
 Difficulty in hearing and confusion (4 days)

15. Day 1
BP : 130/80mm Hg Pulse: 82 bpm
Temp:101f
o/e: CVS: S1 S2 +
RS:B/L NVBS +
CNS: Conscious disoriented
P/A:soft, non tender
Adv: Hb, TC, DC, Platelet count, ESR, S/E, IgG antibodies, CSF
analysis, India ink stain test, CD4 cells

16. Drug Dose Route
Frequency
IVF DNS WITH
MULTIVITAMIN dex:5g+Nacl:0.9g+MV
I:10ml
IV stat
T.Paracetamol 650mg PO SoS
Inj.Ondansetron 2mg IV SoS

17. Day 2
BP- 130/80mm Hg Pulse- 80bpm
Temp: 100f
o/e: vomiting decreased
CVS: S1 S2 +
RS:B/L NVBS+
P/A:soft, non tender
CNS: conscious disoriented
Adv: CST

18. Lab Parameters
Hematology
HB:12g%
WBC: 9000cells/mm3
N: 70%
L: 23%
M: 04%
E: 03%
PLT: 2.07 lakhscells/cumm
ESR: 80mm/hr
CSF analysis:
Glucose - 40mg/dl
Protein - 200mg/dl
WBC – 300 cells/μl
CD4 Count: 265 cells
Serum Electrolytes
Na : 134 mmol/L
K : 3.6 mmol/L
Cl : 101 mmol/L

19. Day 3
BP- 120/80mm Hg Pulse- 82bpm
o/e:
Afebrile
CVS: S1 S2 +
RS:B/L NVBS +
P/A:soft ,non tender
CNS: conscious disoriented
Lab Report:
AFB – Negative
India ink stain – Positive
IgG antibodies – Not detected

20. Drug Dose Route
Frequency
Fluconazole 400 mg PO 1-0-1
Amphotericin B 50 mg IV 1-0-0

21. Day 4,5
BP- 120/80mm Hg Pulse- 82bpm
o/e:
CVS: S1 S2 heard
RS:B/L NVBS Heard
P/A:soft, non tender
CNS: conscious disoriented
ADV:CST

22. Day 6
BP- 120/80mm Hg Pulse- 80bpm
o/e:
CVS: S1 S2 heard
RS:B/L NVBS Heard
P/A:soft ,non tender
CNS: conscious disorientation decreased
(able to hear without difficulty)
ADV: Continue

23. Pharmaceutical care plan

24. Subjective evidence Objective evidence
Headache CSF analysis
Vomiting India ink stain
Fever

25. Provisional Diagnosis
HIV
with
cryptococcal meningitis

26. Goals of the treatment
 Clinical goals: Prolongation of life and improvement in quality of life
 Virologic goals: Greatest possible reduction in viral load as long as possible
 Therapeutic goals:limiting drug toxicity and facilitating adherence.

27. Treatment Options
HIV
 Lamivudine+Tenofovir+Efavirenz
Fever-Paracetamol
Vomiting-Ondansetron

28. Cryptococcal meningitis
 Administer Amphotericin-B at 0.7-1mg/kg/day for 2 weeks with/without 2 weeks of
Flucytosine at 100mg/kg/day in 4 divided doses, followed by fluconazole at 400mg/day
for minimum of 8-10 weeks.
 Alternate initial therapy includes lipid formulation of Amphotericin-B in doses of 4-
6mg/kg/day for 3 weeks with fluconazole 400mg BID.
 {Treat Cryptococcal meningitis first, start ART when patient is stabilized or OI
treatment is completed}.

29. Goals Achieved
 Vomiting decreased by day 2
 Fever decreased by day 3
 Reduction in Hearing difficulty by day 6

30. Monitoring Parameters
Disease:
 Viral load (every 6 months after ART and every 12 months thereafter)
{June-2013 WHO guidelines}
 CD4 count if viral load not available.
Drugs:
 Renal function tests (TDF,3TC, Fluconazole, Amphotericin-B)
 Serum transaminases, cholesterol (EFZ,)
 Liver function tests (Fluconazole, Amphotericin-B)
 Potassium levels (Fluconazole, Amphotericin-B)

31. Problems Identified
Nill

32. Patient counseling
 About disease
This particular virus can only infect human beings
HIV weakens immune system by destroying important cells that fight disease and
infection. A "deficient" immune system can't protect the person.

33. About drugs:
Importance of medication adherence.
 Mobile phone text messages could be considered as a reminder tool
for promoting adherence to ART as part of a package of adherence
interventions (June 2013 WHO guidelines)
 If missed doses (even 2 doses in a month) DRUG
RESISTANCE can develop. This is bad for the patient
(These drugs will stop working.)
 Drugs must be taken twice daily, and miss no doses.
 If forget a dose, do not take a double dose.
 Drugs MUST NOT be shared with family and friends.

34. Life style modification:

36.  THANK..UUUUU