Thailand

National Antiretroviral Treatment Guideline

2006/2007

Department of Disease Control, Ministry of Public Health

Thailand MOPH - U.S. CDC Collaboration
The Global Fund
Thai AIDS Society
Pediatric Infectious Disease Society of Thailand
 A
National Library of Thailand Cataloging in Publication Data
Thailand. Department of Disease Control.
Thailand National Antiretroviral Treatment Guideline 2006/2007. - -Bangkok : The Agricultural
Co-operative Federation of Thailand, 2009.
272 p.
1. AIDS (Disease). 2. AIDS - - Thailand. I. Title.
616.9792

Editors for English Translation

Achara Teeraratkul, MD., M.Sc. (Epidemiology)
Thidaporn Jirawattanapisal, M.Sc. (Pharmacy)
Wiphawee Kiatatchasai, M. Ed.
Sanchai Chasombat, MD., MBA.
Nicholas David Kaufman, MA.

List of Translators
Dr. Achara Teeraratkul
Dr. Jintanat Ananworanich
Ms. Kunjanakorn Phokhasawad
Mr. Somboon Nookhai
Assistant Prof. Dr. Thanyawee Puthanakit
Ms. Thidaporn Jirawattanapisal
Ms. Wiphawee Kiatatchasai
Thailand MOPH - U.S.CDC Collaboration
SEARCH, Chiang Mai University
Thailand MOPH - U.S.CDC Collaboration
Thailand MOPH - U.S.CDC Collaboration
The Research Institute for Health Sciences
Department of Disease Control,
Ministry of Public Health
Thailand MOPH - U.S.CDC Collaboration

Editors for Thai version

Somnuek Sungkanuparph, MD.
Kulkanya Chokephaibulkit, MD.
Thanomsak Anekthananon, MD.
Narin Hiransuthikul, MD., Ph.D., MPH.
Rudiwilai Samakoses, MD.
Thidaporn Jirawattanaopisal, M.Sc. (Pharmacy)
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Name of authors for Thai version

Dr. Achara Teeraratkul Thailand MOPH - U.S.CDC Collaboration
Dr. Anupong Chitvarakorn Department of Disease Control,
Ministry of Public Health
Assoc. Prof. Dr. Auchara Tangsathapornpong
Faculty of Medicine, Thammasat University
Assistant Prof. Dr. Angkul Kerdpanich Phramongkutklao College of Medicine
Assoc. Prof. Dr. Chitsanu Pancharoen Faculty of Medicine, Chulalongkorn
University
Ms. Kamoltip Krissadarak Office of Disease Prevention and Control
6th, Khon Kaen
Dr. Keswadee Lapphra Faculty of Medicine Siriraj Hospital,
Mahidol University
Prof. Dr. Khuanchai Supparatpinyo Faculty of Medicine, Chiang Mai
University
Prof. Dr. Kiat Ruxrungtham Faculty of Medicine, Chulalongkorn
University
Mr. Krilerk Suthum Offfice of Disease Prevention and Control
4th, Ratchaburi
Assoc. Prof. Dr. Kulkanya Chokephaibulkit Faculty of Medicine, Siriraj Hospital,
Mahidol University
Dr. Jintanat Ananworanich SEARCH, Chiang Mai University
Dr. Manoon Leechawengwong Vichaiyuth hospital
Assoc. Prof. Dr. Narin Hiransuthikul Faculty of Medicine, Chulalongkorn
University
Dr. Naris Waranawat Queen Sirikit National Institute of Health
Ms. Naparat Pattaraprayoon Department of Disease Control,
Ministry of Public Health
Dr. Noppadon Paibulsin Office of Disease Prevention and Control
12th, Songkhla
Dr. Olarn Prommalikit Faculty of Medicine, Srinakharinwirot
University
Dr. Opart Karnkawinpong Department of Disease Control,
Ministry of Public Health
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Dr. Pacharee Kantipong Chiang Rai Regional hospital

Dr. Panumard Yarnawetsakul Office of Disease Prevention and Control
11th, Nakornsrithummarat
Dr. Pasakorn Akarasewi Thailand MOPH - U.S.CDC Collaboration
Mr. Pathom Saraipoom Office of Disease Prevention and Control
11th, Nakornsrithummarat
Assistant Prof. Dr. Peninnah Oberdorfer Faculty of Medicine, Chiang Mai
University
Prof. Dr. Ploenchan Chetchotisakd Faculty of Medicine, Khonkhen University
Mr. Prakit Yothipitak Chonburi hospital
Mr. Prayut Kaewmarung Maharat Nakorn Ratchasima hospital
Dr. Piyaporn Bowonkiratikachorn Charoenkrung Pracharak hoapital
Dr. Piyarat Suntarattiwong Queen Sirikit National Institute of Health
Assoc. Prof. Dr. Pope Kosalaraksa Faculty of Medicine, Khonkhen University
Dr. Rangsima Lolekha Thailand MOPH - U.S.CDC Collaboration
Dr. Rawiwan Hansudewechakul Chiang Rai Regional hospital
Assoc. Prof. Dr. Rudiwilai Samakoses Phramongkutklao College of Medicine
Ms. Vallerut Pobkeeree Thailand MOPH - U.S.CDC Collaboration
Assoc. Prof. Dr. Veerachai Watanaveeradej Phramongkutklao College of Medicine
Prof. Virat Sirisanthana Faculty of Medicine, Chiang Mai
University
Assoc. Prof. Dr. Wanchai Buppanharun Faculty of Medicine, Srinakharinwirot
University
Dr. Warunee Punpanich Queen Sirikit National Institute of Health
Assistant Prof. Dr. Wasun Chantratita Faculty of Medicine, Ramathibodi
hospital,
Dr. Weerawat Manosuthi Bamrasnaradura Infectious Disease
Institute
Assistant Prof. Dr. Wichai Techasathit Faculty of Medicine Siriraj Hospital,
Mahidol University
Assistant Prof. Dr. Winai Ratanasuwan Faculty of Medicine Siriraj Hospital,
Mahidol University
Dr. Wirat Klinbuayam Sanpatong hospital
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Assoc. Prof. Dr. Woraphot Tantisiriwat Faculty of Medicine, Srinakharinwirot

University
Assistant Professor Sakchai Dettrairat Department of Medical Technology,
Chiang Mai University
Dr. Sanchai Chasombat Department of Disease Control,
Ministry of Public Health
Assistant Prof. Dr. Sasisopin Kiertiburanakul Faculty of Medicine Ramathibodi hospital,
Mahidol University
Ms. Sirirat Likanonsakul Bamrasnaradura Infectious Disease
Institute
Mr. Somboon Nookhai Thailand MOPH - U.S.CDC Collaboration
Mr. Somchai Niyomthai Lumpang Provincial hospital
Assistant Prof. Dr. Somnuek Sungkanuparph Faculty of Medicine Ramathibodi hospital,
Mahidol University
Dr. Somsit Tansuphasawadikul Bamrasnaradura Infectious Disease
Institute
Dr. Sunee Sirivichayakul Faculty of Medicine, Chulalongkorn
University
Prof. Dr. Surapol Suwanagool Faculty of Medicine Siriraj Hospital,
Mahidol University
Mr. Surapol Kohreanudom Department of Disease Control,
Ministry of Public Health
Mr. Suthon Wongcheeree National Institute of Health,
Department of Medical Science,
Ministry of Public Health
Mr. Teerasak Eua-ariyukun Office of Disease Prevention and Control
9th,
Assistant Prof. Dr. Thanomsak Anekthananon
Faculty of Medicine Siriraj Hospital,
Mahidol University
Assistant Prof. Dr. Thanyawee Puthanakit The Research Institute for Health
Sciences
Ms. Thidaporn Jirawattanapisal Department of Disease Control,
Ministry of Public Health
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Contents
Figures, Charts and Tables H

Foreword K

Acknowledgements L

Chapter 1 1
Laboratory Diagnosis and Monitoring for HIV/AIDS

Chapter 2 19
Antiretroviral Therapy for Adult and Youth HIV/AIDS Patients
2.1 Acute HIV Infection 21
2.2 Initiation of Antiretroviral Therapy in Na ve Adult Patients 24
2.2.1 Before initiation of Antiretroviral Therapy (ART) 24
2.2.2 Initiation of Antiretroviral Therapy 25
2.2.3 Indications for initiation of Antiretro-viral Therap 26
(as table IV)
2.2.4 Antiretroviral regimen for Thai HIV infection 29
patients
2.2.5 Recommended preferred and alternative 30
antiretroviral drugs (as table VI)
2.2.6 Not recommended antiretroviral regimen 34
2.2.7 Antiretroviral dosing modification in patients with 34
renal or hepatic insufficiency
2.2.8 Antiretroviral Therapy in Patients with 39
Opportunistic Infections
2.2.9 Antiretroviral Therapy in Patients with HIV/TB 39
Co-infection
2.3 Monitoring of Antiretroviral Therapy 42
 F

2.4 Adverse drug reactions to antiretro-viral agents 45

2.4.1 Adverse drug reactions to NRTIs 45
2.4.2 Side effect from NNRTIs 47
2.4.3 Adverse drug reactions to PIs 49
2.5 Management of adverse drug reactions and 51
complications from Antiretroviral Therapy
2.5.1 Life-threatening adverse effects 51
2.5.2 Serious adverse drug reactions 60
2.5.3 Long-term complications 67
2.6 Immune Reconstitution Inflammtory Syndrome (IRIS) 73
2.7 Diagnosis of treatment failure 77
2.8 Management of Treatment Failure 79

Chapter 3 91
Management of Infants Born to HIV-Infected Women
3.1 Management of infants and children born to 94
HIV-infected mothers
3.2 Antiretroviral therapy in na ve HIV-infected children 100
3.2.1 When to start ARV in children 100
3.2.2 Choosing ARV regimen for ARV-na ve children 102
or for children exposed to AZT or 3TC as part
of PMTCT
3.2.3 Steps for starting ARV in children 103
3.3 Antiretroviral therapy in children with HIV/tuberculosis 105
co-infecti
3.4 Diagnosis and management of treatment failure in 107
HIV-infected children
3.5 Monitoring and Management of Antiretroviral-Related 120
Complications
3.6 Immune Reconstitution Inflammatory Syndrome (IRIS) 123
3.7 Adherence to Antiretroviral Treatment in Children 126
3.8 Social and Psychological Support 129
3.9 Disclosure of HIV Status to HIV-Infected Children 131
 G

Chapter 4 135
Prevention of HIV Mother-to-Child Transmission
4.1 Antiretroviral drugs in pregnant HIV-infected women for 142
maternal health and to reduce perinatal HIV transmission
4.2 Comprehensive care for HIV-infected pregnant women 146
and family during pregnancy period through post partum
period (PMTCT – plus)

Chapter 5 151
Post Exposure Prophylaxis
5.1 Occupational Post Exposure Prophylaxis 153
5.2 Non-occupational Post-exposure Prophylaxis 166

Chapter 6 173
Opportunistic Infections : Prophylaxis and Treatment
6.1 Candidiasis 175
6.2 Tuberculosis 177
6.3 Pneumocytis pneumonia or PCP 182
6.4 Cryptococcosis 188
6.5 Penicillosis and Histoplasmosis 191
6.6 Toxoplasmic encephalitis 193
6.7 Cytomegalovirus infection 197
6.8 Mycobacterium avium complex (MAC) 199

Appendix
A CDC Classification system for HIV-Infected Children 205
B WHO Classification system for HIV-Infected Children 213
C Dose and route of HIV medication in Pediatrics References 219

Reference 229
 H

Figures, Charts and Tables

Figures
I Presented codon and mutation of RT gene of HIV 87
that is associated with NRTIs and NNRTIs resistance.
(from International AIDS Society–USA Topics in HIV
Medicine. Volume 14 Issue 3 August/September
2006. www.iasusa.org)
II Presented codon and mutation of Protease gene of 88
HIV that is associated with PIs resistance.
(from International AIDS Society–USA Topics in HIV
Medicine. Volume 14 Issue 3 August/September
2006. www.iasusa.org)

Charts
I Guidelines for HIV Diagnosis in Adult and Children 7
Over 18 Months of Age
II Guidelines for HIV diagnosis in children 10
under 18 months of age
III Diagnosis of treatment failure 109
IV Management of children with ARV treatment failure 110
V Management of children who are receiving dual 117
NRTI therapy
VI Diagnosis and treatment of Immune Restoration 124
Syndrome (IRS)
VII Guidelines for Prevention of HIV Mother-to-Child 138
Transmission service at the antenatal clinic
VIII Guidelines for service of HIV-infected pregnant 139
women : at delivery visit
IX Care for pregnant women with unknown HIV status 140
and no antenatal care
X Management of occupational exposure to patient’s 165
blood or body fluid
 I

Tables
I The specifications of each viral load assay which 14
has been available in Thailand (January 2007).
II Laboratory for diagnosis and monitoring care and 17
treatment in HIV/AIDS patients
III Associated Signs and Symptoms of Acute Retroviral 23
Syndrome
IV Indications for initiation of Antiretroviral Therapy (ART) 26
V US CDC classification of AIDS-defining illnesses 27
VI Recommended preferred and alternative antiretroviral 30
drugs
VII NRTIs dosing modification in patients with renal 35
or hepatic insufficiency
VIII NNRTIs dosing modification in patients with renal 36
or hepatic insufficiency
IX PIs dosing modification in patients with renalor 37
hepatic insufficiency
X Child-Pugh Score calculation 38
XI Recommended Initiation of Antiretroviral Therapy in 41
HIV-TB co-infection
XII Recommended laboratory monitoring before and 44
after initiation of antiretroviral therapy
XIII Clinical signs of IRIS separated by opportunistic 76
infection
XIV Recommended second regimen for patients with 84
first regimen failure
XV Immunization for HIV-infected and HIV-exposed 97
children according to the recommendation of the
Pediatric Infectious Diseases Society, 2007
 J

XVI ARV initiation criteria in children with HIV Infection 101

XVII Choose 2NRTI according to ARV history 112
XVIII Choose PI in new ARV regimen 112
XIX Choosing double boosted PI 113
XX Interpretation of genotyping and choosing NRTI for 115
new regimen (please always consult expert)
XXI Interpretation of NNRTI genotyping 115
XXII Recommendations for use of antiretroviral drugs in 144
pregnant HIV-infected women for maternal health
and to reduce perinatal HIV transmission according
to the Thai Ministry of Public Health
XXIII Recommended HIV postexposure prophylaxis for 160
per cutaneous injuries
XXIV Recommended HIV postexposure prophylaxis for 161
mucous membrane exposures and nonintact skin
exposure
XXV Standardized ARV regimen for occupational post 162
exposure prophylaxis (only ARV that are available
in Thailand, 2006)
XXVI Laboratory screening for monitoring of adverse 164
drug reactions after ARV post exposure prophylaxis
XXVII Estimations of HIV Transmission Risk by Type of 170
Non-Occupational Exposure
XXVIII Immunological categories in HIV-infected children 210
based on CD4+ T-cell count
XXIX Staging of HIV-infected children 211
XXX Dose of HIV medication in Pediatrics 221
XXXI Split dose of GPO-VIR S 30 and GPO-VIR Z 250 227
are recommended for pediatric by WHO
National Antiretroviral Treatment Guideline
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National Antiretroviral Treatment Guideline
2006/2007
National Antiretroviral Treatment Guideline
2006/2007
National Antiretroviral Treatment Guideline
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National Antiretroviral Treatment Guideline
2006/2007
National Antiretroviral Treatment Guideline
2006/2007
National Antiretroviral Treatment Guideline
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National Antiretroviral Treatment Guideline
2006/2007
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Foreword
This English edition of Thailand National Antiretroviral Treatment
Guideline 2006/2007 is translated from the 3rd Thai edition,
published in 2007. The Thai edition is primarily aimed for providing
technical recommendation for physicians at community and general
hospitals in Thailand. It was written by a group of medical experts in
care and antiretroviral treament, using internationally recommendations
and results of research that had been conducted in Thailand. The
Thain edition has been revised periodically from the first edition that
was written 1997. The 3rd edition, which is the most recent one,
focuses on diagnosis of HIV infection and ART management for adults
and children, prevention of mother-to-child transmission, management
of children born to HIV-infected mothers, post-exposure prophylaxis,
and diagnosis and treatment of common opportunistic infections.
The information presented herein is provided as technical
resources for physicians, researchers, and other health care
professionals, providing diagnosis, care and treatment to patients with
HIV/AIDS. The English edition is expected to be internationally shared
to physicians and health care professionals who are interested in
Thailand Antiretroviral Treatment Program.
Every possible effort has been made to ensure the reliability and
accuracy of the material presented here. However recommendation in
this guideline could be revised to the new edition if there is newly
updated technical knowledge from research. In addition, opinion on
care and treatment might be controversial for some circumstance.
Physician or health care professional need to use their best medical
judgment in determining appropriate diagnosis, care and treatment
for each individual patient.

Editors
National Antiretroviral Treatment Guideline
2006/2007
National Antiretroviral Treatment Guideline
2006/2007
National Antiretroviral Treatment Guideline
2006/2007
National Antiretroviral Treatment Guideline
2006/2007
National Antiretroviral Treatment Guideline
2006/2007
National Antiretroviral Treatment Guideline
2006/2007
National Antiretroviral Treatment Guideline
2006/2007
National Antiretroviral Treatment Guideline
2006/2007
National Antiretroviral Treatment Guideline
2006/2007
 L

Acknowledgements
The Thailand National Antiretroviral Treatment Guideline 2006/
2007, English edition is prepared by a joint collaboration of The Thailand
Ministry of Public Health (MOPH) and Thailand MOPH - U.S.CDC
Collaboration (TUC). The working group for translation include
Dr. Sanchai Chasombat (Deparment of Disease Control, MOPH),
Ms. Thidaporn Jirawattanapisal (Department of Disease Control, MOPH),
Dr. Achara Teeraratkul (TUC),
Ms. Wiphawee Kiatatchasai (TUC), Ms. Kunjanakorn Phokhasawad
(TUC), Mr. Somboon Nookhai (TUC), Dr. Jintanat Ananworanich (SEARCH,
Chiang Mai University), Assistant Prof. Dr. Thanyawee Puthanakit (The
Research Institute for Health Sciences) and Nicholas David Kaufman
(Global fund M&E BATS Care project, Department of Disease Control,
MOPH).
The working group would like to thank Dr.Thawat Suntrajarn
(Director General of Department of Disease Control), Dr. Somchai
Pinyopornpanich (Duputy Director General of Department of Disease
Control), Dr. Anupong Chitawarakorn (Senior advisor of Department of
Disease Control), Dr. Pachara Siriwongrungsan (acting director of Bureau
of AIDS, TB and STIs, Department of Disease Control), Dr. Pasakorn
Akarasewi (Adjunct Director of Thailand MOPH - U.S.CDC Collaboration),
Dr. Panumard Yarnawetsakul (Acting Director of Office of Disease
Prevention and Control 11th, Nakornsrithummarat),
Dr. Somyot Kittimankong (Chief of AIDS Cluster, Bureau of AIDS,
TB and STIs, Department of Disease Control), Ms.Chutima Wannadit
and Ms. Nattaporn Kongsakunkrai (Pharmaceutical supporting team
of Global Fund BATS Care project), Thai AIDS Society, Pediatric
Infectious Disease Society of Thailand, The Global Fund, and Thailand
MOPH - U.S.CDC Collaboration for their full supports.
National Antiretroviral Treatment Guideline
2006/2007
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2006/2007
National Antiretroviral Treatment Guideline
2006/2007
National Antiretroviral Treatment Guideline
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National Antiretroviral Treatment Guideline
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National Antiretroviral Treatment Guideline
2006/2007
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National Antiretroviral Treatment Guideline
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National Antiretroviral Treatment Guideline
2006/2007