Guidelines for diagnosis and treatment of HIV/AIDS in China (2005)

Abstract

Acquired immunodeficiency syndrome (AIDS), caused by the human immunodeficiency virus (HIV), has become a major public health issue in China. It not only posesses formidable challenges for the health of the Chinese people, but has also influenced China's economic development and social stability. Tasked by the Ministry of Health, the Chinese Medical Association organized experts to develop these Guidelines for Diagnosis and Treatment of HIV/AIDS. Based on the latest national and international research developments, these guidelines adopt an evidence-based approach, taking into account the characteristics of China's situation. Topics include epidemiology, etiology, pathogenesis, pathological changes, clinical presentation and staging, laboratory tests, diagnosis, highly active antiretroviral therapy (HAART), diagnosis and treatment of common opportunistic infections (OIs), prevention of mother-to-child transmission (PMTCT), and postexposure prophylaxis. Special attention focuses on the antiretroviral therapy. Features of these guidelines include: 1) systematic and comprehensive coverage from basic science to the clinical, from treatment to prophylaxis; 2) evidence-based medicine that avoids recommending views and approaches yet to be proven; 3) clinically practical and innovative, building upon the consensus from Chinese experts (particularly in regard to HIV clinical staging and diagnostic criteria), epidemiology of HIV and AIDS in China and the clinical characteristics of Chinese AIDS patients; 4) recommendation of HAART regimens based on in-country drug availability. The essence of clinical medicine is the adoption of appropriate diagnosis and treatment approaches with consideration of the specific conditions of patients and available medical resources. Given the rapid development of modern medicine and the perpetual emergence new theories, views, and diagnosis/prevention/treatment approaches, these Guidelines will be regularly revised and updated based on the latest developments in clinical medicine. EPIDEMIOLOGY From the first cases of HIV/AIDS reported in the United States in 1981 to the end of 2003, approximately 69 million cases of HIV infections have been reported globally and 27 million of them were dead. The first case of AIDS in China was reported in 1985. Since that time, it is estimated that approximately 840 000 individuals were infected by the virus by the end of 2003, including 80 000 cases of AIDS. To date, the infection has been reported in all provinces, autonomous regions, and municipalities of China and it is spreading from high-risk populations such as drug users and commercial sex workers to the general population. Source of the infection People living with HIV/AIDS (PLWHA) are the sole sources of HIV infection. Routes of transmission of HIV The virus presents predominantly in the PLWHA's blood, semen, vaginal discharge, and breast milk. HIV transmission occurs through sexual contact (including homosexual, heterosexual and bi-sexual contact), blood or blood products (such as via intravenous drug use with needle sharing or invasive medical operations) and mother-to-child (including prenatal, intrapartum and postpartum transmission).1 It is not transmitted through day to day contact with PLWHAs, such as shaking hands, hugging, kissing for etiquette purposes, dining or drinking together; nor is it transmitted through sharing toilets, restrooms, offices, public transportation or recreational facilities. Vulnerable populations All populations are vulnerable to HIV infection. HIV infection is closely associated with behavior such that men who have sex with men, intravenous drug users (IDUs), those who have frequent sexual contact with HIV infected persons and those who frequently receive transfusions of blood or blood products (such as hemophiliacs) are at high risk of acquiring HIV. Case reporting Once a new infection is identified, the case should be immediately reported to the local CDC. Medical management Follow the principle of confidentiality, strengthen follow-up with the PLWHA, and provide medical and psychological counseling. Precautions Develop healthy sexual practices; use condoms correctly, and engage in safer sex. Refrain from drug use and needle and syringe sharing. Promote non-commercial blood donation and conduct HIV screening among blood donors. Reinforce hospital management; strictly follow disinfection procedures; control nosocomial cross infections, and prevent infections via occupational exposure. Control mother-to-child transmission. Provide medical examinations, HIV testing, and appropriate counseling services to PLWHA spouses, children of PLWHA, other sexual partners, men who have sex with men and anyone with whom the PLWHA may share needles and syringes.2 VIROLOGY HIV is a retrovirus belonging to a group of cytopathic lentiviruses. The virus has a diameter of 100—120 nm and is spherical in shape. It is composed of an interior viral core and an outer viral envelope. The viral core contains two single strands of HIV RNA, core structural proteins and enzymes necessary for viral replication, including reverse transcriptase (RT, P51/P66), integrase (INT, P32) and protease (PI, P10). It has a coat called HIV capsid proteins (P24, P17). The exterior coat of HIV is the viral envelope, embedding two glycoproteins: gp120 (envelope glycoprotein) and gp41 (transmembrane glycoprotein). HIV has a 9.8 kb genome, containing 3 structural genes (gag, pol, and env), 2 regulatory genes (tat— trans-activator; rev — regulator of virion protein expression) and 4 auxiliary genes (nef—negative regulatory factor; vpr — viral protein R; vpu — viral protein U; and vif—viral infectivity factor). HIV is highly variable. Various genes have different variabilities; env has the highest variability. Major causes for HIV variation include: random variation results in a dysfunctional reverse transcriptase; host's immunoselection pressure; gene recombi-nation between viral DNA and host DNA; and drug selective pressure. Nonstandard and no adherence to antiretroviral therapy is a major cause for drug resistance. HIV is classified into type HIV-1 and type HIV-2. The two viruses share a 40% — 60% amino acid sequence homology. Currently, HIV-1 is globally prevalent (unless otherwise noted, HIV refers to HIV-1 in this document). HIV-1 can be further classified into different subtypes, including subtype groups M (the major group), O and N. The group M has 11 subtypes: A, B, C, D, E, F, G, H, I, J and K. In addition, multiple recombinants have been identified in recent years. HIV-2 is biologically similar to HIV-1, but features lower infectivity, slower AIDS clinical progression and HIV-2 has at subtypes: A, B, C, D, E, and HIV-1 is the major in China. have been identified in the including A, and C, D, E, and G, in to different with HIV-2 have been reported and in China. and of HIV is for of diagnosis as as development of new and HIV via on the of include type major and type 2 of and Based on the of auxiliary by HIV is classified into HIV and HIV. and and HIV is a virus and is not to the It is by and and for are also for HIV. can or HIV is also to It is to to high HIV in will infectivity to at for this HIV in HIV can be at for HIV laboratory include those for HIV HIV and is the for diagnosis of HIV infection. and are two for to and can be by a acid two acid to a diagnosis of HIV infection. HIV HIV infection. 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