ส่วนที่ 1 ข้อมูลเอกสาร
| ชื่อ CNPG | การพยาบาลผู้ป่วย HIV/AIDS |
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| วัตถุประสงค์ | ให้การดูแลผู้ป่วย HIV ครอบคลุม ART, OI prevention, adherence support ลด mortality |
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| มาตรฐานอ้างอิง | WHO Consolidated HIV Guidelines 2021, Thai National HIV Guidelines 2564, DHHS Guidelines, EACS |
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1.1 WHO Clinical Staging
| Stage | Features |
|---|
| Stage 1 | Asymptomatic, generalized lymphadenopathy |
| Stage 2 | Weight loss < 10%, minor infections, herpes zoster |
| Stage 3 | Weight loss > 10%, chronic diarrhea, persistent fever, oral candidiasis, TB |
| Stage 4 (AIDS) | Wasting syndrome, PCP, cryptococcal meningitis, Kaposi sarcoma, CMV, CD4 < 200 |
ส่วนที่ 2 Initial Assessment
2.1 Laboratory Baseline
- HIV confirmation: 2 positive tests different assays
- CD4 count + %, CD4/CD8 ratio
- HIV RNA viral load
- HIV drug resistance (if available)
- CBC, CMP, LFT, fasting lipids, glucose/HbA1c
- Hep B (HBsAg, anti-HBs), Hep C, Syphilis (RPR), Toxoplasma IgG
- TB screening: CXR + IGRA/TST + symptom screen
- Pregnancy test (women)
- STD screen: Gonorrhea, Chlamydia (urine, rectal, pharyngeal)
- Urinalysis
- G6PD (before dapsone/primaquine)
2.2 Vaccinations
- Pneumococcal: PCV13 + PPSV23
- Hepatitis B (if non-immune)
- Hepatitis A
- Influenza annually
- HPV (age 9-26)
- Tdap
- ⚠️ Live vaccines contraindicated if CD4 < 200 (MMR, Varicella, Yellow fever)
ส่วนที่ 3 Antiretroviral Therapy (ART)
3.1 When to Start
ทุกผู้ป่วย HIV ควรเริ่ม ART ทันทีหลังยืนยันการวินิจฉัย (test-and-treat, Rapid ART)
3.2 Preferred First-line Regimen
| Regimen | Dose | หมายเหตุ |
|---|
| TDF/3TC/DTG (Tenofovir + Lamivudine + Dolutegravir) | Fixed-dose combination, 1 tab OD | Thai first-line preferred |
| TDF/FTC/EFV | 1 tab OD at bedtime | Alternative, CNS side effects |
| TAF/FTC/BIC | 1 tab OD | Better renal/bone profile |
3.3 Special Populations
- Pregnancy: TDF/3TC/DTG preferred; if < 8 weeks gestation consider EFV
- TB co-infection: DTG 50 mg BID (with Rifampicin); or EFV; start ART 2 weeks after TB treatment
- HBV co-infection: Include TDF/TAF (treats both)
- Renal impairment: Avoid TDF if eGFR < 30; use TAF instead
3.4 Monitoring on ART
| Test | Frequency |
|---|
| CD4 + HIV RNA | Baseline, 3 months, 6 months, then q 6-12 months |
| CBC, CMP, LFT | Baseline, 3 months, then q 6-12 months |
| Urinalysis, eGFR (TDF) | Baseline, 6 months, annually |
| Fasting lipids | Annually |
| Bone density (DEXA) | Age ≥ 50 or risk factors |
3.5 Virologic Success
- Target: HIV RNA < 50 copies/mL by 6 months
- Undetectable = Untransmittable (U=U)
- Virologic failure: HIV RNA > 200 after 6 months — assess adherence + resistance
ส่วนที่ 4 Opportunistic Infections Prevention
4.1 Prophylaxis by CD4
| CD4 | OI | Prophylaxis |
|---|
| < 200 | Pneumocystis (PCP) | TMP-SMX DS 1 tab OD |
| < 100 | Toxoplasma | TMP-SMX (same above) |
| < 100 | Cryptococcus (endemic) | Fluconazole 200 mg weekly |
| < 50 | MAC | Azithromycin 1,200 mg weekly |
Discontinue prophylaxis when CD4 > 200 × 3-6 months
4.2 Common OIs Management
- PCP: TMP-SMX 15 mg/kg/day × 21 days + prednisone if PaO₂ < 70
- Cryptococcal meningitis: Amphotericin B + Flucytosine × 2 weeks → Fluconazole
- Toxoplasma: Pyrimethamine + Sulfadiazine + Leucovorin × 6 weeks
- TB: See TB CNPG
- CMV retinitis: Ganciclovir or Valganciclovir
ส่วนที่ 5 Adherence & Support
5.1 Adherence Strategies
- Education: U=U, importance of ≥ 95% adherence
- Pill organizers, reminders (phone alarms)
- Simplify regimen (once-daily fixed-dose combination)
- Address barriers: side effects, mental health, substance use, stigma
- Peer support groups
- Case management for complex cases
5.2 Psychological Support
- Screen for depression (PHQ-9), anxiety (GAD-7)
- Screen for substance use (AUDIT, DUDIT)
- Address stigma and disclosure
- Partner notification (confidential, legal)
- Referral to mental health
ส่วนที่ 6 Prevention
6.1 PrEP (Pre-exposure Prophylaxis)
- Indication: HIV-negative high-risk (MSM, serodiscordant, multiple partners, IDU)
- Regimen: TDF/FTC (Truvada) 1 tab OD
- Or on-demand (2-1-1) for MSM
- Check HIV q 3 months, STI screen
6.2 PEP (Post-exposure Prophylaxis)
- Occupational (needlestick) or sexual exposure
- Start within 72 hours (sooner better), continue × 28 days
- Regimen: TDF/FTC + Raltegravir or Dolutegravir
- Baseline HIV test + follow-up at 6 weeks, 3 months
ส่วนที่ 7 Infection Control (Nursing)
- Standard precautions (HIV transmitted by blood/body fluids only, NOT casual contact)
- Do NOT isolate (except active TB or opportunistic infections that need isolation)
- Maintain confidentiality strictly
- Sharps safety + needle-stick reporting protocol
- Family + caregiver education about transmission (actually very low if ART-suppressed)
KPIs
| KPI | Target |
|---|
| Same-day ART initiation after diagnosis | ≥ 90% |
| Viral suppression at 6 months | ≥ 85% |
| Retention in care at 12 months | ≥ 80% |
| PCP prophylaxis coverage (CD4 < 200) | ≥ 95% |
| TB screening at ART initiation | 100% |
| PEP initiation within 72h (exposure) | 100% |
References
- WHO. (2021). Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring.
- DHHS. (2024). Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV.
- กรมควบคุมโรค. (2564). แนวทางการตรวจรักษาและป้องกันการติดเชื้อเอชไอวี ประเทศไทย.
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