대한에이즈학회 기회감염진료지침 2. 범위 HIV,.. 3. 임상진료지침개정연구진의구성 HIV. HIV. 2) 근거수준 I: II: III: 6. 외부전문가평가 ,,,.. 4. 문헌검색방법 7. 용어및약어정리

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1 Supplementary Infection & Chemotherapy 국내 HIV 감염인의기회감염증치료와예방에관한임상진료지침권고안 : 2015 년개정판 대한에이즈학회 The Committee for Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections of the Korean Society for AIDS was founded in The first edition of the Korean guidelines was published in The guideline recommendations contain important information for physicians working with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) in the clinical field. It has become necessary to revise the guidelines due to new data in this field. These guidelines aim to provide up-to-date, comprehensive information regarding the treatment and prevention of opportunistic infections in HIV-infected Koreans. These guidelines deal with several common opportunistic infections, including pneumocystis pneumonia, tuberculosis, cryptococcal meningitis, etc. A brief summary of the revised guidelines is provided below. Recommendations are rated using the same system used in the previous guidelines. Key Words: Human immunodeficiency virus; Acquired immune deficiency syndrome; Opportunistic infections; Treatment; Prevention 머리말 1. 배경및목적 (human Immunodeficiency virus, HIV) 10,000. HIV CD4+ T HIV. HIV [1]., HIV. * 대한에이즈학회기회감염증치료및예방임상진료지침개발위원회위원장 : 김남중 ( 서울대학교서울대학교병원감염내과 ) 위원원 : 김가연 ( 국립중앙의료원감염내과 ), 김낙현 ( 서울대학교병원감염내과 ), 송준영 ( 고려대학교구로병원감염내과 ), 신소연 ( 가톨릭관동대학교국제성모병원감염내과 ), 위성헌 ( 가톨릭대학교성빈센트병원감염내과 ), 이선희 ( 부산대학교부산대학교병원감염내과 ), 최준용 ( 연세대학교세브란스병원감염내과 ) * 본권고안은 2014년 11월현재국내실정에적합한 HIV 감염인의기회감염증치료와예방에관한임상진료지침을제시하는것으로서, 모든환자에대해서본진료지침을일률적으로적용하는것보다는기본적으로참고하되각환자의여러임상상황들을고려한의사의최종적인판단에의한진료가중요함. * 본권고안은개인적인진료및교육목적으로활용될수있지만상업적인목적이나진료심사목적등으로사용될수없으며어떠한형태로든다른목적으로사용하고자하는경우에는개발위원회에서면요구서를제출하여서면동의를얻어야함. Received: January 11, 2016 Corresponding Author : The Committee for Clinical Guidelines for the Diagnosis and Treatment of HIV/AIDS of the Korean Society for AIDS. The Korean Society for AIDS, 309 Gangnam-daero, Seocho-gu, Korea Business Center Room 512, Seoul 06628, Korea Tel: , Fax: , kosa@kosaids.or.kr

2 대한에이즈학회 기회감염진료지침 2. 범위 HIV,.. 3. 임상진료지침개정연구진의구성 HIV. HIV. 2) 근거수준 I: II: III: 6. 외부전문가평가 ,,,.. 4. 문헌검색방법 7. 용어및약어정리 Pubmed ( KoreaMed ( ( kstudy.com)., HIV (International AIDS Society Conference, Conference on Retroviruses and Opportunistic Infections ) 권고의강도및근거수준 (Table 1) 5 (, ),.,,. 항목별임상진료지침 1. 폐포자충폐렴 DHHS (Department of Health and Human Services) 1 A, B, C 3, I, II, III 3 (Table 1). 1) 권고의강도 A:. B:. C:. 1) 도입 Pneumocystis jirovecii. P. jirovecii, P. jirovecii [2, 3]. CD4+ T 200 /μl.,,,, [4] [5]. HIV Table 1. Strength and Quality of Evidence for Recommendations Strength of recommendation A: Strong recommendation for the statement B: Moderate recommendation for the statement C: Optional recommendation for the statement Quality of evidence for recommendation I: One or more randomized trials with clinical outcomes and/or validated laboratory endpoints II: One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes III: Expert opinion

3 기회감염진료지침 대한에이즈학회 [6]. HIV CD4+ T 16 /μl [6]. 2) 임상상 HIV,. HIV [7] %,, [8].,,. 70 mmhg [A-a] DO 2 35 mmhg, [A-a] DO 2 35mmHg, 45 mmhg, [A-a] DO 2 45 mmhg. [9].,.. [10]. 3) 진단. P. jirovecii. P. jirovecii.,, (bronchoalvelar larvage),. 50% 90%, 90-99%, % [8]. P. jirovecii Giemsa, Diff-Quick, Wright (cyst) (trophozoite). Gomori methenamine silver.. (Polymerase Chain Reaction, PCR) [11]. 4) 치료 (1) trimethoprim-sulfamethoxazole (TMP-SMX) (A-I). TMP-SMX pentamidine [12, 13]. TMP- SMX [13] (A-I). TMP-SMX leukovorin leukovorin [14] (A-II). TMP-SMX TMP-SMX (B-III). TMP-SMX TMP-SMX TMP-SMX [15]. 72,, [16] (A-I) (B-III). TMP-SMX. dapsone + trimethoprim (B-I), clindamycin + primaquine (B-I), atovaquone [17, 18]. Primaquine glucose-6-phosphate dehydrogenase. TMP-SMX clindamycin + primaquine pentamidine [19] (A-I). pentamidine TMP-SMX. pentamidine (A-I). HIV 21 [7] (A-II).,,,..,. [20]. 14 (A-I). TMP-SMX 20-85% [21] %, 30-40%, 30-40%

4 대한에이즈학회 기회감염진료지침, 20%, 15%. HIV TMP-SMX. TMP-SMX (A-III). (Immune Reconstitution Inflammatory syndrome; IRIS) [22]. HIV (A-III). dapsone (B-I), dapone + pyrimethamine + leucovorin (B-I), pentamidine (B-I), atovaquone (B-I) [24, 26]. CD4+ T /μl (A-I). TMP-SMX,, [5]. CD4+ T 200 /μl (A-III). (2) (B-III). 10%.,. TMP-SMX pentamidine clindamycin + primaquine [19] (B-II). atovaquone (B-II). clindamycin + primaquine [23]. (2) (A-I). TMP-SMX, TMP-SMX dapsone, dapsone + pyrimethamine, petamidine, atovaquone. CD4+ T /μl [27] (A-II). CD4+ T 200 /μl, (B-III). CD4+ T 200 /μl (A-III). CD4+ T 200 /μl (B-III). 5) 예방 (1) CD4+ T 200 /μl HIV (A-I), HIV (A-II) [4]. CD4+ T 14%, (B-II). TMP-SMX [24] (A-I). trimethoprim 160 mg + sulfamethoxazole 800 mg (A-I) trimethoprim 80 mg + sulfamethoxazole 400 mg (A-I). TMP-SMX, TMP-SMX (A-II). (B-II), [25] (C-III). TMP-SMX (3) (C-III). 2. 결핵 1) 도입 Mycobacterium tuberculosis (droplet nuclei), 2-12.,,., HIV 1/3

5 기회감염진료지침 대한에이즈학회 [28]. CD4+ T, CD4+ T. HIV HIV % [6, 29], HIV , [30]. HIV HIV 9.5 /100 [31], /100 [32] HIV 4.2 /100 [33].. HIV [34, 35]. HIV 5-10%, HIV 10% [35]. HIV. 2) 임상상 HIV [36, 37]. HIV [38, 39]. CD4+ T 350 /μl HIV HIV. HIV HIV CD4+ T. HIV, (cavitation) [36, 40, 41]. HIV., (granuloma) [37]., HIV, HIV HIV HIV [37, 42]. 3) 진단 (1) (tuberculin skin test, TST) Interferon-γ release assay (IGRA). HIV (induration) 5 mm. IGRA QuantiFERON-TB Gold, QuantiFERON-TB Gold In-Tube T-SPOT. TB. IGRA (56-95%) (92-97%) Bacillus Calmette-Guĕrin (BCG) [43, 44]. HIV. CD4+ T 200 /μl,. (A-II). HIV (A-II). IGRA. HIV, IGRA (indeterminate) [44-46]. CD4+ T 200 /μl CD4+ T 200 /μl (B-III). HIV (A-III). HIV (A-I). (2). [40, 47]. IGRA HIV 1/4 [44]. 3.

6 대한에이즈학회 기회감염진료지침 1. HIV HIV [48-50]. HIV [43].. 4) 치료 HIV HIV (A-I). 2 isoniazid, rifampin rifabutin rifamycin, pyrazinamide, ethambutol 4 (A-I), 2 isoniazid rifampin rifabutin rifamycin., rifamycin. HIV. - - Rifamycin - - IRIS paradoxical reaction) (1) (A-I). rifamycin HIV. (2) (A-I).. IRIS [51]., CD4+ T 200 /μl HIV [52].,. HIV 3 [53-55],. CD4+ T < 50 /μl: 2 (A-I). CD4+ T > 50 /μl: 8-12 (A-I). (body mass index), Karnofsky, 2-4, 8-12.,. HIV CD4+ T, CD4+ T HIV. (3) HIV, (A-II). HIV, HIV [56-58]., isoniazid, rifampin, pyrazinamide., isoniazid, rifampin, pyrazinamide 1 (A-III). aminotransferase,

7 기회감염진료지침 대한에이즈학회 bilirubin, alkaline phosphatase. Rifamycin., rifamycin cytochrome P450 UGT1A1 (protease inhibitors, PIs), (non-neucleoside reverse transcriptase inhibitors, NNRTIs), maraviroc, raltegravir, [59, 60]. rifamycin [58] (A-II). Rifamycin rifampin ritonavir-boosted unboosted PIs., PI HIV rifampin rifabutin (A-II), rifampin ritonavir-boosted unboosted PIs. PI NNRTI rifampin NNRTIs efavirenz (A-II), efavirenz rifampin efavirenz 600 mg (B-II). NNRTI PI rifampin rifabutin. Rifabutin PI 150 mg (B-III). (Nucleoside nucleotide reverse transcriptase inhibitor, NRTIs) cytochrome P rifampin. Raltegravir rifampin raltegravir 800 mg 2. Rifamycin 2 NNRTIs, PIs. Table 2. (4) IRIS (paradoxical reaction) IRIS. HIV IRIS Table 2. Drug interactions between anti-mycobacterial drugs and antiretroviral drugs Anti-mycobacterial drugs Antiretroviral drugs Dosing Recommendations and Clinical Comments Clarithromycin ATV May cause QTc prolongation. Reduce clarithromycin dose by 50%. Consider alternative therapy. DRV/r LPV/r EVG/cobi EFV, ETR No dose adjustment in patients with normal renal function. Consider switching to azithromycin No dose adjustment in patients with CrCl > 60 ml/min Reduce clarithromycin dose by 50% in patients with CrCl ml/min Consider alternative agent, such as azithromycin, for MAC prophylaxis and treatment. Rifabutin EFV Increase rifabutin dose to mg/day ATV +/- RTV DRV/r LPV/r RPV ETR Use rifabutin 150 mg daily Co-administration should be avoided Rifampin All PIs Do not coadminister rifampin and PIs EFV ETR RAL EVG/cobi Dose: rifabutin 300 mg once daily if ETR is not coadministered with a RTV-boosted PI. If ETR is coadministered with a RTV-boosted PI, rifabutin should not be coadministered. Maintain EFV dose at 600 mg once daily and monitor for virologic response. Do not coadminister. Increase raltegravir dose to 800 mg twice daily Co-administration should be avoided ATV, atazanavir; QT, interval; DRV/r, darunavir+ritonavir; EVG, elvitegravir; EFV, efavirenz; LPV/r, lopinavir+ritonavir; RTV, ritonavir; ETR, etraviridine; RAL, raltegravir; MAC, mycobacterium avium complex.

8 대한에이즈학회 기회감염진료지침 HIV 3 paradoxical tuberculosis-associated IRIS unmasking tuberculosis-associated IRIS (ART-associated tuberculosis) IRIS [61]. IRIS,,,,. HIV HIV, HIV.. IRIS HIV 8-43%. IRIS 50 /μl CD4+ T,, 30 [51, 62-66]. HIV IRIS IRIS HIV. IRIS, (non-steroidal anti-inflam matory drugs, NSAIDs) (B-III). IRIS (prednisone, 1.5 mg/kg/ 2, 0.75 mg/kg/ 2 ), [66-68] (B-III). (5) 6 (B-III) (A-I). 5) 예방 (1) HIV HIV.. - HIV (A-I) - HIV (A-II) - HIV HIV isoniazid [69]. HIV IGRA isoniazid. 9 isoniazid 1 (A-II). Isoniazid 9 2 (B-II). Isoniazid. 1,.. Isoniazid, isoniazid 4 rifampin 1 (B-III). 1 1, 3 isoniazid rifapentine 9 isoniazid [70], HIV (A-III). HIV,,. 3. 파종성 Mycobacterium avium complex 감염 1) 도입 Mycobacterium avium Complex (MAC). M. avium HIV MAC 95% [71]. 7-12% MAC, MAC.,. MAC

9 기회감염진료지침 대한에이즈학회, -. MAC CD4+ T 50 /μl [72]. MAC 20-40% [73]. HIV MAC 10, 1, [74]. CD4+ T 50 /μl HIV 100,000 copies/ml,, MAC, M. avium MAC. 2) 임상상 MAC..,,,, [75]. ( HIV ) MAC. (,,, ). MAC CD4+ T,,,,,,,. IRIS. IRIS MAC. MAC IRIS IRIS [76]. (unmasking IRIS) MAC CD4+ T 100 /μl., IRIS corticosteroid. 3) 진단 MAC,,, MAC. DNA,.,. 4) 치료 (1) MAC 2 [77] (A- I). Clarithromycin (500 mg ) (A- I), azithromycin MAC [77-79]. clarithromycin azithromycin ( mg) (A-II). MAC clarithromycin azithromycin. Ethambutol (15 mg/kg) (A-I). rifabutin (300 mg) (C-I). MAC rifabutin ethambutol clarithromycin, [77, 79].,. (CD4+ T 50 /μl ), (>2 log 10 colony forming units/ml of blood), 3, 4 (C-III). HIV 3, 4 amikacin (10-15 mg/kg) streptomycin (1 g) (C-III), levofloxacin (500 mg) moxifloxacin (400 mg) fluoroquinolone (C-III), MAC clarithromycin azithromycin [79]. (2) MAC 2 (C-III)., IRIS. 2, (C-III). (C-III)..

10 대한에이즈학회 기회감염진료지침 (3) 4-8 MAC Clarithromycin azithromycin,,,,,. MAC clarithromycin 1 g (A-I). Rifabutin cytochrome P450 (CYP450) 3A4 clarithromycin 450 mg,, [80-81]. IRIS (C-III), (4-8 ) ( prednisone mg) [82] (C-II). rifabutin. clarithromycin clarithromycin. Efavirenz clarithromycin clarithromycin clarithromycin 14-OH. MAC clarithromycin. Azithromycin cytochrome P450. (4) 4-8. MAC clarithromycin azithromycin. clarithromycin azithromycin MAC [77, 78]. MAC.. Ethambutol, rifabutin, amikacin fluoroquinolone (moxifloxacin, ciprofloxacin, levofloxacin), [83] (C-II). HIV MAC amikacin streptomycin [83] (C-II). clarithromycin azithromycin. Clofazimine (A-I). Ethionamide, thiacetazone, cycloserine clarithromycin azithromycin. MAC (A-III). MAC. 5) 예방 (1) MAC. (2) CD4+ T 50 /μl HIV MAC (A-I), azithromycin (1,200 mg, 600 mg ) clarithromycin (500 mg ) [72] (A-I). Clarithromycin rifabutin [84] (A-I). Azithromycin rifabutin azithromycin,, azithromycin (A-I). Clarithromycin azithromycin. Clarithromycin azithromycin rifabutin (300 mg) (B-II), rifabutin. MAC, MAC rifabutin. MAC MAC MAC clarithromycin, azithromycin, rifabutin MAC. MAC 3 CD4+ T 100 /μl

11 기회감염진료지침 대한에이즈학회 (A-I). MAC,,,,, [85-89]. CD4+ T 50 /μl (A-III). (3) ( ) MAC ( ) (A-II). MAC 12 CD4+ T 100 / μl 6 MAC, [86, 90, 91] (A-I). CD4+ T 100 /μl (A-III). 6) 임신환자에서고려사항 MAC (A-III). Clarithromycin MAC (B-III). 3 clarithromycin 100,, [92, 93]. Azithromycin 3. Azithromycin (B-III). ( ) azithromycin ethambutol (B-III).. MAC ethambutol clarithromycin azithromycin. 4. 점막피부칸디다증 (mucocutaneous candidiasis) 1) 도입 HIV Candida albicans. CD4+ T 200 /μl., HIV.. Fluconazole fluconazole. CD4+ T C. albicans -albicans Candida, C. glabrata [94-96]. 2) 임상상,,,..,. /,..,.,, azole. 3) 진단. KOH.. (hairy leukoplakia). Candida Candida, (brushing). KOH,.. 4) 치료 (1) fluconazole (100 mg ), (A-I).,,. miconazole 50 mg (B1) clotrimazole 10 mg 5 (B-I) [97]. Nystantin (4-6 ml 4-5 ) ( ) [98] (B-II). Itraconazole ( 200 mg) fluconazole [98] (B-I). Posaconazole ( 400 mg, ) fluconazole

12 대한에이즈학회 기회감염진료지침, itraconazole [99] (B-I). Posaconazole fluconazole [99]. fluconazole. Itraconazole fluconazole transaminase. 3 azole (A-II). Echinocandin, histamine, transaminase.. IRIS.. (2) (A-I) Fluconazole (400 mg mg, ) itraconazole ( 200 mg) (A-I).. itraconazole fluconazole (C-II). Voriconazole (200 mg ), amphotericin B (deoxycholate 0.6 mg/kg, 3-4 mg/kg ), caspofungin ( 50 mg ), micafungin ( 150 mg ), anidulafungin ( 100 mg, 50 mg ) (B-I). Echinocandin fluconazole [100,101].,, Candida (A-II). (6) %, CD4+ T 50 /μl azole. azole. Posaconazole (400 mg 28 ) azole 75% [102] (A-I). itraconazole fluconazole 2/3 (B-II). Azole anidulafungin (B-II), caspofungin (B-II), micafungin (B-II), voriconazole (B-II). amphotericin B (B-II), amphotericin B deoxycholate (B-II). Amphotericin B (100 mg/ml 1 ml 4 ) itraconazole (B-II). (3) HIV, fluconazole 150 mg (A-II), azole (clotrimazole, butaconazole, miconazole, ticonazole, terconazole) 3-7 (A-II), itraconazole 200 mg 3-7 (B-II). fluconazole 7 (A-II). (4).. 5) 예방 (1) Candida. (2) fluconazole,,,,, fluconazole (A-III). (5) ,. azole,,, (3) CD4+ T 150 /μl HIV fluconazole ( 3 ),

13 기회감염진료지침 대한에이즈학회 [103]. ( ),,,,, HIV (B-III). fluconazole (100 mg 3 ) (B-I), ( mg ) (B-I), (150 mg 1 ) (B-II) [24, 104,105]. Posaconazole (400 mg 2 ) (B-II). HIV azole azole.,,, [106]. Azole echinocandin, voriconazole, posaconazole (C-I).,, CD4+ T 200 /μl (A-III). 6) 임신환자에서고려사항 Candida.,. (A-III). Fluconazole. fluconazole 400 mg,,, fluconazole [107]. fluconazole amphotericin B (A-III). amphotericin B. Itraconazole,. itraconazole [108]. Posaconazole,. Voriconazole, FDA D.. micafungin, anidulafungin caspofungin. (A-III).,, azole (A-II), HIV (A-III). 5. 크립토코쿠스증 (cryptococcosis) 1) 도입 HIV Cryptococcus neoformans, Cryptococcus gattii. C. neoformans, C. gattii,. HIV 5-8% [109] , HIV [110]. CD4+ T 100 /μl. 2) 임상상 HIV,, [109]., 1/4-1/3.,,,,. HIV..,,.. 3) 진단,,,,, % 25 cmh 2 O.,,. HIV 55%, 95% %.

14 대한에이즈학회 기회감염진료지침,, -. -., dipstick lateral flow assay. HIV [111]. 4) 치료 (1), 3. amphotericin B flucytosine (A-I). amphotericin B deoxycholate mg/kg (A-I),, (A-I). CLEAR amphotericin B (ABLC) 4.4 mg/kg 58% [112]. 3 amphotericin B ( 4 mg/kg) amphotericin B deoxycholate ( 0.7 mg/kg) [113]. amphotericin B deoxycholate ( 0.7 mg/kg) amphotericin B (Ambisome ) 3 mg/kg 6 mg/kg amphotericin B 3 mg/kg [114]. amphotericin B 3-4 mg/kg (A-I), amphotericin B 5 mg/kg (B-II). amphotericin B flucytosine (10 mg/kg 4 ) 2 (A-I). flucytosine. amphotericin B flucytosine [115, 116], amphotericin B (1 mg/kg) flucytosine amphotericin B [114]. Amphotericin B fluconazole ( 400 mg) amphotericin B flucytosine amphotericin B [114, 117, 118]. Amphotericin B deoxycholate fluconazole ( 800 mg) amphotericin B flucytosine (B-I). Fluconazole ( mg) flucytosine amphotericin B (B-II). Fluconazole ( 1,200 mg ) amphotericin B [119], 1,200 mg [120] (C-II). 2 (, ), amphotericin B flucytosine fluconazole 400 mg (follow-up ) (A-I), 8 [115, 116, 121] (A-I). fluconazole 200 mg 1. Voriconazole posaconazole, 50%,. Voriconazole efavirenz., (B-III). fluconazole ( 400 mg 12 ).. (2) [20], 10 72, fluconazole stavudine, lamivudine, nevirapine [122]., amphotericin B fluconazole. ( ) ( 2 ) / (10 ). (CD4+ T 50 /μl ) (B-III). IRIS (B-III). azole.

15 기회감염진료지침 대한에이즈학회 (3). 25 cmh 2 O [116, 123]. 2 93% % [123].,,,,.. ( ml) [124]. (B-III). Corticosteroid mannitol (C-III). Acetazolamide IRIS (B-II) amphotericin B flucytosine (B-III)..,. Amphotericin B, ml amphotericin B. 30 acetaminophen (650 mg), diphenhydramine (25-50 mg), hydrocortisone ( mg) (B-III). Meperidine (25-50 mg ) amphotericin B. Flucytosine Cr flucytosine μg/ml. ( 2 ). HIV 30% IRIS [125], HIV RNA. IRIS. IRIS [126, 127]. IRIS (A-II). glucocorticoid (C-III). (4) 2, ( 4 ). fluconazole [128],.. Fluconazole 16 μg/ml fluconazole.. fluconazole amphotericin B (± flucytosine). amphotericin B ( 4-6 mg/kg) amphotericin B ( 5 mg/kg) deoxycholate [113, 129] (A-II). fluconazole flucytosine (B-III). Echinocandin Cryptococcus (A-II). Posaconazole voriconazole fluconazole fluconazole.,, IRIS. 5) 예방 (1). HIV C. neoformans C. gattii.. (2). CD4+ T 100 /μl fluconazole itraconazole [24, 130].,,,, (B-II).

16 대한에이즈학회 기회감염진료지침 (3) 10 fluconazole 200 mg (A-I). Itraconazole fluconazole [131,132] (C-I) 떄 CD4+ T 297 /μl, HIV RNA < 500 copies/ml, 25 [133] HIV RNA 3 CD4+ T 100 /μl [134]. CD4+ T 100 /μl, 3 HIV RNA 3, 1 azole [135] (B-II). CD4+ T 100 /μl (A-III). ) posaconazole,. 3 (A-III). 6. 톡소포자충뇌염 (Toxoplasma gondii encephalitis) 1) 도입 (protozoa) Toxoplasma gondii (cyst), [140, 141]. T. gondii, 12 33%. T. gondii. T. gondii [142, 143]. CD4+T 200 /μl, 50 /μl [140, 143]. 6) 임신환자에서고려사항.. IRIS. Amphotericin B,. amphotericin B. amphotericin B. Flucytosine (C-III). Fluconazole mg, [136]. [137, 138]. FDA 1 fluconazole C D 3 itraconazole, [108, 139]. 3 azole (B-III). Voriconazole ( 2) 임상상 HIV T. gondii,,, [140].,. T. gondii (retinochoroiditis),,. CT MRI, [144, 145]. 3) 진단 HIV IgG [146]. IgG,. CT MRI,. (stereotactic) CT-guided needle biopsy. T. gondii hematoxylin-eosin, immunoperoxidase [147]. PCR %

17 기회감염진료지침 대한에이즈학회 50%, [148, 149]. HIV,,,. 4) 치료 pyrimethamine sulfadiazine, leucovorin [150, 151] (A-I). Pyrimethamine, leucovorin pyrimethamine. sulfa pyrimethamine clindamycin, leucovorin (A-I). 77 TMP- SMX pyrimethamine sulfadiazine [152]. TMP-SMX (B-I). Pyrimethamine,. sulfonamide TMP-SMX sulfamethoxazole. TMP-SMX pyrimethamine clindamycin (C-III). Atovaquone pyrimethamine/leucovorin atovaquone sulfadiazine pyrimethamine sulfadiazine atovaquone (B-II) azithromycin pyrimethamine/leucovorin (B-II), [ ] (B-II). 6 [140, 141] (B-II)., corticosteroid ( dexamethasone) (B-III). corticosteroid, corticosteroid,. (anticonvulsants) (A-III), (B-III). 5) 예방 (1) HIV HIV T. gondii IgG (B-III). CD4+ T 100 /μl [156] (A-III). TMP-SMX double strength tablet [156] (A-II). TMP- SMX double strength tablet 3 (B-III). TMP-SMX dapsone pyrimethamine/leucovorin [ ] (B-I). atovaquone pyrimethamine/leucovorin (C-III). Dapsone, pyrimethamine, azithromycin, clarithromycin (B-II). Pentamidine ( ) [24, 156] (A-I). ( : pentamidine ) IgG CD4+ T 100 /μl IgG (C-III). IgG (A-II). CD4+ T /μl [160, 161] (A-I). CD4+ T 100 /μl 200 /μl, /μl. CD4+ T /μl (A-III). (2) IRIS, [150] (A-I). pyrimethamine, sulfadiazine, leucovorin (A-I). Sulfa pyrimethamine clindamy-

18 대한에이즈학회 기회감염진료지침 cin (B-I). Clindamycin [150] 600 mg 8 (C-III). Pyrimethamine clindamycin (A-II), ( ) pentamidine. Atovaquone pyrimethamine sulfadiazine [154] (B-III),. 2 CD4+ T /μl 2 [161, 162] (B-I). CD4+ T 200 /μl 2 (A-III). 6) 임신환자에서고려사항. Pyrimethamine [163]. Sulfadiazine (kernicterus) [163]. 7. 세균성호흡기질환 1) 도입 HIV 1 2. HIV [164]. HIV [ ]. HIV CD4+ T. HIV B, /,. HIV CD4+ T,, [164]. HIV Streptococcus pneumoniae Haemophilus. S. pneumoniae [168]. Legionella pneumophila, Mycoplasma pneumoniae, Chlamydia [169, 170]. HIV HIV Pseudomonas aeruginosa Staphylococcus aureus [171, 172]. HIV methicillin-resistant S. aureus (MRSA), MRSA [173]. HIV S. pneumoniae [174, 175]. (100,000 1,094 ) HIV (100, ) 55. [176]. HIV [171, 177]. CD4+ T 100 /μl [178].,,. 2) 임상상 HIV HIV. S. pneumoniae Haemophilus,,,,,... HIV.. / (segmental) (lobar).. S. pneumoniae Haemophilus, P. aeruginosa S. aureus. 3) 진단 HIV.

19 기회감염진료지침 대한에이즈학회.. HIV HIV., / 3.. HIV. CD4+ T S. pneumoniae. CD4+ T 50 /μl,,,,, 90,, P. aeruginosa. ( ),,,, S. aureus. /,.,,.. P. jirovecii.,. 4) 치료. Pneumonia Severity Index (PSI) CD4+ T [179]. PSI, PSI CD4+ T 200 /μl [179]. CD4+ T 200 /μl, CD4+ T 200 /μl PSI [180]. HIV HIV. (1) beta-lactam macrolide. beta-lactam amoxicillin amoxicillin-clavulanate, cefpodoxime, cefditoren. Macrolide azithromycin, clarithromycin, erythromycin, roxythromycin. Respiratory fluoroquinolone (gemifloxacin, levofloxacin, moxifloxacin) (macrolide fluoroquinolone ). Respiratory fluoroquinolone respiratory fluoroquinolone HIV. (2) beta-lactam+macrolide (A- II) fluoroquinolone (A-II). beta-lactam ceftriaxone, cefotaxime, ampicillinsulbactam. macrolide azithromycin, clarithromycin. Doxycycline macrolide (C-III). fluoroquinolone moxifloxacin levofloxacin. S. pneumoniae macrolide (B-III). (3) (monotherapy). beta-lactam azithromycin (A-II) fluoroquinolone (moxifloxacin levofloxacin [750 mg/day]) (A-II). Penicillin aztreonam fluoroquinolone (moxifloxacin levofloxacin [750 mg/day]) (B-III). (4) P. aeruginosa pneumococcal, pseudomonal beta-lactam ciprofloxacin levofloxacin 750 mg ) (B-III). beta-lactam piperacillin/tazobactam, cefepime, imipenem, meropenem. (5) S. aureus Vancomycin linezolid (B-III).

20 대한에이즈학회 기회감염진료지침 5) 예방 S. pneumoniae,,. HIV [ ]. [184, 185]. Advisory Committee on Immunization Practices (ACIP) HIV 13 (13-valent pneumococcal conjugate vaccine, PCV13) [186]. HIV,,, 7 (7-valent pneumococcal conjugate vaccine) 74%, CD4+ T 200 /μl [165, 187]. HIV CD4+ T PCV13 [186] (A-I). CD4+ T 200 /μl 8 23 (23-valent pneumococcal polysaccharide vaccine, PPSV23) [ , ] (A-II). CD4+ T 200 /μl 8 PPSV23 (C-III), CD4+ T 200 /μl PPSV23 (B-III). CD4+ T 200 /μl PPSV23 HIV RNA 100,000 copies/ml [188, 190], [185]. PPSV23. PPSV23 5 PPSV23 [191] (B-III). PPSV PPSV23 (B-III). PCV13 PPSV23 HIV (A-II)., PPSV23 1 [186] (B-III). PPSV HIV [192] (A-III).. HIV (A-III). HIV H. influenza type b., H. influenza type b, (B-III). TMP-SM [177]. TMP-SM [193, 194]., TMP-SM TMP-SM., TMP-SM (B-III). MAC clarithromycin azithromycin [195]. (B-III).,., (C-III) (G-CSF) (C-III). HIV. 8. 세균성창자감염 1) 도입 HIV [ ]., Salmonella, Shigella, Campylobacter [196]., - Shigella Campylobacter [201, 202]. Enteroaggregative Escherichia coli (EAEC) HIV. HIV HIV (achlorhydria), HIV [203]. HIV HIV Clostridium difficile, C. difficile [204, 205]. HIV,. 2) 임상상 HIV.,.,,,. Shigella, Salmonella,

21 기회감염진료지침 대한에이즈학회 Campylobacter, Shigella.,,. HIV Salmonella, [ , ]., Salmonella HIV. Salmonella serotype Typhimurium Enteritidis, (45%) [209]. Shigella S. flexneri, [209]. Campylobacter HIV, C. jejuni. HIV, [209]. 3) 진단 lactoferrin. Salmonella, Shigella, Campylobacter. HIV Salmonella [203]. HIV C. jejuni Campylobacter (C. fetus, C. upsaliensis, C. lari ) [203].,, 4-6 CD4+ T 200 /μl, C. difficile C. difficile (enzyme immunoassay, EIA) PCR [210]., PCR.,.. 4) 치료 (1) Salmonella., HIV ( ) (7 ) Salmonella [197, 211] (A-III). Salmonella fluoroquinolone (A-III), ciprofloxacin [212] (A-III). Levofloxacin, moxifloxacin fluoroquinolone. TMP-SMX, 3 cephalosporin (cefotaxime ceftriaxone) (B-III). HIV Salmonella. CD /μl HIV Salmonella 7-14, 14 (B-III)., CD /μl HIV 2-6 (C-III). Shigella, [212] (A-III). Fluoroquinolone 7-10 (A-III). TMP-SMX (7-10 ) azithromycin (5 ) (B-III)., azithromycin Shigella (A-III). TMP-SMX HIV fluoroquinolone 1. Shigella 14 (B-III). CD /μl HIV Shigella 6 (B-III). HIV Campylobacter. Campylobacter fluoroquinolone (7-10 ) azithromycin (5 ), (B-III). Fluoroquinolone 1. 2 (B-III), aminoglycoside 2 (C-III). Campylobacter azithromycin (A-III). CD /μl HIV Campylobacter 2-6 (B-III). HIV 3 cephalosporin, TMP-SMX azithromycin (C-III). C. difficile HIV [204]. (2),,,

22 대한에이즈학회 기회감염진료지침., Salmonella 5-7. HIV IRIS.,,,. C. difficile. 5) 예방 (1), (B-III)., HIV,, (C-III). Fluoroquinolone rifaximin (C-III). TMP-SMX (B-III), (, ). CD /μl HIV ( ),,,, (B-III). (2) CD /μl HIV Salmonella (B-III). Salmonella HIV Salmonella (C-III). Salmonella HIV (CD /μl ) (C-III). Salmonella (CD4+ ) (B-III)., ( CD /μl ) (C-II). HIV Shigella Campylobacter (B-III). Salmonella Shigella HIV, HIV (B-III). 9. 매독 1) 도입 Treponrema pallidum subspecies pallidum. Penicillin HIV, [ ]., 0.5% HIV 10-20% [ ]. HIV,,,. HIV,. 2) 임상상 HIV,. HIV [219]. (, )., 1 ( ) HIV [220, 221]. 2 (,,, ) 80%.,. 2 HIV ( ) [220, 222, 223] (3 ) ( 8%), (10%), ( 15%) [219]. HIV [203]. 3) 진단, /.. (Venereal Disease Research Laboratory [VDRL], rapid plasma regain [RPR]) (FTA-ABS, TPHA), (A-III).

23 기회감염진료지침 대한에이즈학회 1% [219]., VDRL 1:8., (HIV,, B C ),.,. HIV, (A-II). 48,, 12~24 [224]. HIV (, ). HIV., HIV (prozone phenomenon).,, 2-4 [219]. HIV., /, ( 1 ), 3 (A-III). HIV [223, 225]. HIV ( ),. ( cells/μl),,, VDRL [203, 219]. VDRL.,., FTA-ABS [203]. HIV (, CD /μl ) (5-15 cells/μl),. PCR., 1, 2,, 30%, 60%, 40%, 7% [226]., [203]., HIV., HIV HIV [203, 226]. [226]. IgG.,,,. 4) 치료 (1) HIV [203]. Penicillin (A-I). (1, 2, ) HIV benzathine Penicillin G 240 (120 ) 1 (A-II). Penicillin benzathine Penicillin G (A-III). doxycycline (100 mg 2, 14 ) (B-II). azithromycin 2 g 1 [ ], penicillin doxycycline / (B-II).,, azithromycin (A-II). benzathine Penicillin (A-III). doxycycline 100 mg 2 28 HIV Penicillin (B-III). Penicillin /. 3,. Penicillin G 1,800-2, (A-II)., procaine Penicillin 240 probenecid 500 mg 4 (B-II). HIV probenecid (B-III). Penicillin (B-III).,, ceftriaxone (2 g 1 ) [232] (B-II).

24 대한에이즈학회 기회감염진료지침, benzathine Penicillin (C-III). [203, 219]., HIV 1 benzathine Penicillin 2 (B-III). Penicillin, (A-III). Erythromycin azithromycin [233, 234] (A-II), ceftriaxone [235] (B-III). 12 (Jarish-Herxheimer reaction), [236]., (2) (1, 2 ) 3, 6, 9, / ( VDRL RPR) (A-III). VDRL RPR [219] %, %., 15-20% 1:8., (6, 12, ), 4. 6, 4 (A-III). 6, VDRL HIV ( CD /μl ) [237, 238]. HIV IRIS. (3) 4 (B-III) (B-III). benzathine Penicillin (B-III)., 15% 1 4 [239]. 1 4, benzathine Penicillin G 240 (120 ) 1, (C-III)., 4, (> 1:32) 24 4 (B-III)., penicillin G (A-III). benzathine Penicillin (B-III)., (C-III). 6, 24. [240] (B-III). 5) 예방,. HIV. 10. Cryptosporidiosis/Isosporiasis 1) 도입 Cryptosporidiosis Cryptosporidium.,., CD4+ T 100 /μl HIV [241]. C. hominis, C. parvum, C. meleagridis 3 [242].

25 기회감염진료지침 대한에이즈학회 Cryptosporidium cryptosporidiosis Cryptosporidium. cryptosporidiosis,.,,.. Isosporiasis /., [243]. Isospora belli (life cycle) [244].,. HIV 40 crytosporidiosis, isosporiasis 2 [245], 67 Cryptosporidium parvum (10.5%; 7/67), Isospora belli (7.5%; 5/67) [246] HIV 34% Cryptosporidium parvum IgG [247] CD4+ T 100 /μl HIV crytosporidiosis isosporiasis. 2) 임상상 Cryptosporidiosis,,, [248]., 1/3. Cryptosporidium CD4+ T. Cryptosporidium [249]. Isosporiasis,,,,,., [250].,. 3) 진단 Cryptosporidium,. Cryptosporidiosis [251], 10. Cryptosporidium, PCR Cryptosporidium [252]. Cryptosporidium, (brush border) hematoxylin-eosin. 1. Isosporiasis μm μm Isospora [244]., ( ) UV [244, 253].. 4) 치료 CD4+ T 100 /μl cryptosporidiosis, [254]. cryptosporidiosis (A-II). (A-III). Loperamide (A-III). HIV nitazoxanide, paromomycin, spiramycin [255]. Nitazoxanide (helminth),, C. parvum. CD4+ T 50 /μl HIV 500-1,000 mg 14 [256]. Nitazoxanide,, cryptosporidiosis nitazoxanide (C-III). (A-III). Isosporiasis (A-III). TMP-SMX isosporiasis (A-I), sulfa

26 대한에이즈학회 기회감염진료지침 TMP-SMX (A-III). TMP-SMX (160/800 mg) 4 10 [257] (A-II), TMP-SMX (160/800 mg) 2 [258] (B-I)., TMP- SMX (160/800 mg) (B-III). TMP-SMX. HIV TMP- SMX,,,,. pyrimethamine-sulfadiazine pyrimethaminesulfadoxine (C-III). Pyrimethaminesulfadoxine Stevens-Johnson. Pyrimethamine pyrimethamine-leucovorin sulfa (B-III). Ciprofloxacin 500 mg 2 7 TMP-SMX sulfa [258] (C-I). Cryptosporidiosis/Isosporiasis IRIS. 5) 예방 Cryptosporidiosis (A-II). MAC rifabutin clarithromycin cryptosporidiosis cryptosporidiosis. Isosporiasis CD4+T 200 /μl TMP- SMX (A-I). TMP-SMX 160/800 mg 3 (A-I), 160/800 mg, 320/1,600 mg 3 (B-III). Sulfa pyrimethamine-leucovorin(b-iii) ciprofloxacin 500 mg 3 (C-I). CD /μl 6 (B-III). 11. 거대세포바이러스감염증 1) 도입 (Cytomegalovirus; CMV) DNA (double strand DNA virus) (end organ disease). 98% CMV IgG.. CD4+ T 50 /μl, (> 100,000 copies/ml) [ ]. 2) 임상상., (, CD4+ T 50 /µl ) [262]., (floaters), (scotoma), (peripheral visual field defect), (macula).,. 5-10%,,,,,, [260].,,,,..,, [263].,, HIV.,.,. CT MRI., -. (flaccid paraplegia). (hypoglycorrhachia). 3) 진단,. (inclusion body) [260]. [260].

27 기회감염진료지침 대한에이즈학회 (brush) [264]. [265]. [259, 266]. PCR, [263, 264, 267, 268]. 4) 치료 (1) valganciclovir (A-I), ganciclovir (A-I), ganciclovir valganciclovir (A-I), foscarnet (A-I), cidofovir (B-I) [ ] (A-I).,,, (A-III). ( 1,500 microns ) gancyclovir foscarnet valganciclovir (A-III)., valganciclovir (A-I)., valgancyclovir CMV 3-6 (B-II). ganciclovir foscarnet (C-II). (C-III). ganciclovir valganciclovir (B-I). Ganciclovir ganciclovir foscarnet (B-III). valganciclovir (B-III). ganciclovir, foscarnet, cidofovir (C-III)., ganciclovir foscarnet (C-III). (B-III). (1st trimester) ganciclovir (B-III). Valganciclovir (B-III), cidofovir (A-III). (2) IRIS CMV HIV CMV 2 (C-III). 2 (C-III).,., 2,. (fundus photograph). 3. Ganciclovir foscarnet CBC,, 2 (A-III). Cidofovir BUN/Cr,. Cidofovir CD4+ T IRIS (immune recovery uveitis). 50%. valganciclovir [275]. CMV (C-III). (3) [276]. [277] (A-II). [277] (A-III). Ganciclovir foscarnet (B-I)., ganciclovir CMV UL97, UL97 UL54. (sequencing), PCR UL97 48 [278]. U97 foscarnet, foscarnet (C-III).

28 대한에이즈학회 기회감염진료지침 (4) [175, 263, 266, 271, 279] (A-I). ganciclovir, valganciclovir, foscarnet, ganciclovir foscarnet, cidofovir (A-I). 3-6 CD4+ T 100 /µl [280] (A-I).,, (B-II). 3-6 CD4+ T 100 /µl [ ] (A-II). 3 (A-III). (B-II). CD4+ T 100 /µl (A-III). 100 /µl CMV DNA PCR valganciclovir valganciclovir [288] (A-I)., (B-III), CD4+ T 50 /µl (C-III). 12. 단순헤르페스바이러스감염증 (herpes simplex virus disease) 1) 도입 (HSV-1, HSV-2),. HSV-2 HIV HSV-2 HIV-RNA. (5) Gancyclovir valganciclovir,,,,,,,. Foscarnet,,. Cidofovir (hypotony). 5) 예방 (1) CMV, HIV CMV (B-III). HIV CMV,, CMV (A- II). CMV (B-I). CMV (A- II). CMV HIV CMV (leukocyte reduced cellular blood product) (B-III). (2) CD4+ T 100 / µl. CD4+ T 2) 임상상 HSV-1, (papule), (vesicle), (ulcer), (crust) HSV-2,., [289]., CD4+ T 100 /µl.... 3) 진단, HSV DNA PCR, HSV., HSV-2, HIV, HIV HSV-2.

29 기회감염진료지침 대한에이즈학회 4) 치료 (1) valacyclovir, famciclovir, acyclovir 5-10 (A-III). acyclovir, [290, 291] (A-III). valacyclovir, famciclovir, acyclovir 5-14 (A-I). HIV HSV, HSV. acyclovir [292] (A-III). valacyclovir famciclovir [293]. valacyclovir (C-III). HSV-2 HSV-2 [294] (B- II). acyclovir valacyclovir [295] (B-II). (2) IRIS,,. acyclovir 1-2. (3) Acyclovir, [296] (A-II). Acyclovir foscarnet [297] (A-I) cidofovir. trifluridine, cidofovir, imiquimod (21-28 ) (C-III). (4), [298] (A-I). acyclovir, valacyclovir, famciclovir [ ] (A-I). HIV valacyclovir 500 mg (A-I). Acyclovir famciclovir. (5) Acyclovir, valacyclovir, famciclovir,. acyclovir. valacyclovir (8 g/day) HIV (thrombotic thrombocytopenic purpura) (hemolytic uremic syndrome). 5) 예방 HIV HSV-1 HSV-2,. HSV-2 HSV-2 [301] (B-II). HSV [302] (A-II). (A-II). HSV (B-III). 13. 수두대상포진바이러스질환 1) 도입 %, %, 50 97%, 60 95% [303] %, %, 11 90% 20 90% [304]. (Varicella-zoster virus, VZV) (dorsal root ganglia) % [203]. HIV 15, CD4+ [305]. CD /μl [306, 307] IRIS 2-4, CD8 [308, 309]. 2) 임상상. 1-2.,,.,.,,,,

30 대한에이즈학회 기회감염진료지침. 39 C 2-3.., HIV ( ) [310] % 2-3 ( ), ( ). 3-5., (crust) (7-10 ) , 1. (40-50%), (20-25%), (15-20%), (15%),. HIV 20-30% 1, 10% % (postherpetic neuralgia, PHN) [203, ]. CD /μl HIV, [314]. HIV,,,,,,,. (necrotizing retinopathy) (acute retinal necrosis, ARN) (progressive outer retinal necrosis, PORN).,,. CD /μl, [315].. 3) 진단... PCR.., HIV.. Tzank 60% [316]. PCR. 4) 치료 (1) HIV. famciclovir (1 500 mg, 3 ) valacyclovir (1 1,000 mg, 3 ) 5-7 (A-II). acyclovir (1 20 mg/kg [ 800 mg], 5 ) (B-II). HIV 7-10 acyclovir [310, 317, 318] (A-III)., [319] (B-III). HIV acyclovir valacyclovir (B-III), acyclovir (A-II). (2), acyclovir. 1,. HIV famciclovir (1 500 mg, 3 ) valacyclovir (1 1,000 mg, 3 ) acyclovir (1 800 mg, 5 ) (B-II). acyclovir ( mg/kg, 8 3 ) [320] (A-II)., acyclovir (A-III). [316] (A-III). (A-III). HIV

31 기회감염진료지침 대한에이즈학회 acyclovir, valacyclovir famciclovir (B-III). (3) (PORN), [203]. (PORN) acyclovir (10-15 mg/kg, 8 ), ganciclovir (5 mg/kg, 12 ) foscarnet (90 mg/kg, 12 ) ganciclovir (2 mg/0.05 ml, 2 ) foscarnet (1.2 mg/0.05 ml, 2 ) [321, 322] (A-III). ganciclovir foscarnet (A-III). Cidofovir (A-III). HIV PORN [322] (A-III).. (ARN), acyclovir (1 10 mg/kg, 3 ) (6 ) valacyclovir (1 1,000 mg, 3 ) (A-III). ganciclovir 1-2 (B-III). (A-III). (4) acyclovir 10,. Acyclovir foscarnet (1 40 mg/kg, 3 ) [323] (A-II). cidofovir (A-III). 5) 예방 (1) HIV (A-II). HIV, 96 (125 IU/10kg, 625 IU) [203, 316] (A-III). (> 400 mg/kg) 3 3., (CD /μl ) (5-7 ) (acyclovir valacyclovir) (C-III). (D-III). ( PORN) (A-III). (2) CD /μl 8 [324]., 8 HIV CD /μl (3 2 ) (C-III).,, acyclovir (A-III). HIV (D-III) % HIV. CD /μl HIV (A-III). HIV. 14. Progressive multifocal leukoencephalopathy/jc virus infection 1) 도입 (Progressive multifocal leukoencephalopathy, PML) polyomavirus JC virus(jcv). JCV 85% [325].. (30%) (40%). HIV PML [326]. alpha-4 integrin natalizumab B CD20 rituximab PML. PML 3%-7% [327]. PML [328]., HIV PML. CD4+ T /μl PML

32 대한에이즈학회 기회감염진료지침 [ ]. PML (95% CI ) 1.8 (95% CI , ) 1 50% [331]. 2) 임상상 PML..,, /,, (ataxia)... PML PML [332]. PML. 20% [333]. 3) 진단 PML. MRI. T2 T1. T1 HIV PML %. PML. PML. JCV.,. PCR JCV DNA % [334] JCV DNA [335]. JCV PCR VZV, EBV PCR VZV. PML (intranuclear inclusion),, JCV, (in situ hybridization),. PML. PML IRIS PML.. JCV JCV. 4) 치료 JCV.. PML (A-II). (A-III). PML. enfuvirtide 4. PML [336, 337]... PML CD4+ T (100 /μl 2.71) [336]. JCV

33 기회감염진료지침 대한에이즈학회, CNS penetration effectiveness (CPE) score. anti- JCV PML. cytarabine, cidofovir, interferon-alpha PML JCV serotonergic 5HT2a (C-III). Topotecan topoisomerase inhibitor JCV [338] [339] (B-III). In vitro JCV mefloquine phase I/II. PML PML. PML HIV PML. HIV PML IRIS [340]. PML PML...,., (B-III).. PML 3 JCV. PML [341]. CD4+ T (A-II) 5) 예방 JCV. JCV PML. HIV PML HIV (A-III). 15. 헤르페스바이러스-8 감염증 (human herpesvirus-8; HHV-8) 1) 도입 -8(Human herpesvirus-8; HHV-8) (, ; primary effusion lymphoma) (, ; multicentric Castleman s disease) Kaposi s sarcoma-associated herpesvirus. HHV-8 [342]. HHV-8 (seropositive) HHV-8 9 [343], HHV-8 [344]. 2) 임상상 HHV-8 [345]. HHV-8,,, [346, 347]. [348]...,,. 3) 진단 PCR HHV-8. PCR HHV-8,, [344]. 4) 치료 HHV-8 -HHV-8 -HHV-8. HHV-8,

34 대한에이즈학회 기회감염진료지침. (1) Ganciclovir, foscarnet, cidofovir HHV-8 ganciclovir foscarnet., ganciclovir valganciclovir (C-II), 2 ganciclovir valganciclovir 3 [349]. valganciclovir zidovudine 7-21 [350] (C-II). rituximab [351, 352] (C-II). rituximab 1/3 [353, 354]. (A-I), (B-III). valganciclovir (C-III).,, (A-II). # HHV-8. - : - : + - : valganciclovir, ganciclovir, valganciclovir + zidovudine - : + ± valganciclovir (2) IRIS IRIS HIV, (A-III). (3) HIV (A-II), (A-III). 5) 예방 [345, 355, 356]. HHV-8 (C-III). HHV-8 (B-III). 16. 사람유두종바이러스관련질환 1) 도입 [357]. 100 (genotype) 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68 [358] %, % [359] % [360]. [361]. HIV [362].,,,, [358, 363]. 16 HIV [362, 364]. HIV. (cervical intraepithelial neoplasia, CIN), [ ]. HIV [368, 369]. HIV.

35 기회감염진료지침 대한에이즈학회 2) 임상상, / /, CIN, vulvar intraepithelial neoplasia (VIN), vaginal intraepithelial neoplasia (VAIN), anal intraepithelial neoplasia (AIN),, ) 진단 (1) / /.. (2) CIN, CIN HIV.,. (3) AIN, VAIN, VIN, AIN CIN. VAIN, VIN,. (4) 22 HIV. 4) 치료 (1) / /. Podophyllotoxin imiquimod (5% cream) % (B-II). HIV (B-III), trichloroacetic acid bichloroacetic acid (B-III), (B-III), (C-III),.. (2) CIN CIN HIV.,, loop electrosurgical excision procedure (LEEP), cone biopsy. CIN, (A-II). high-grade CIN CIN (B-II). (3) VIN,, VAIN, Low-grade VIN, VAIN. VIN, VAIN,. (4) AIN, AIN,,.,,,.,. 5) 예방 (1) 72% [370]. HIV (A-II). HIV. HIV. HIV. (2) HIV 6 Pap 2 1 (A-I). CD4+ T, HIV Pap atypical squamous cells, cannot exclude high

36 대한에이즈학회 기회감염진료지침 grade SIL (ASC-H) (B-II), low-grade squamous intraepithelial lesions (LSIL) (A-II), high-grade squamous intraepithelial lesions (HSIL) (A- II), (A-II). Atypical glandular cell (AGC) (A-II) (B-II). High-grade CIN Pap (A-III). Lugol s iodine (A-III). VAIN, (C-III). VIN (A-II).. [371] (B-III), HIV. ASC-US, ASC-H, LSIL, HSIL (B-III) (B-III). 17. HIV 감염자의예방접종 1) 도입 CD4+ T 200 /μl (, MMR,, BCG,,,,, Ty21a ), (DTaP,,, Hib,, A, B ) [372, 373]., CD4+ T 200 / μl. CD4+ T,, [374].,,, A, B,,. 2) 권장사항 (1) HIV HIV, HIV., HIV HIV [68]. CD4+ T 400 /µl 102 HIV,, CD4+ T [375]. CD4+ T, HIV CD4+ T. HIV, [376]., HIV. HIV, CD4+ T,. CD4+ T 200 /μl HIV, 200 /μl. CD4+ T 200 /μl HIV CD4+ T 200 /μl. 19 HIV PCV13 PPSV23 [377]. PCV13, 1 PPSV23. PPSV23 1 PPSV23 1 PCV13. PCV13 1 PPSV23 5 PPSV23. PPSV PCV13 1. HIV 5,. (2) - / Td., HIV DTaP, Td

37 기회감염진료지침 대한에이즈학회. 10. Tdap, Tdap Td, Td 1 Tdap 1, Td 10., [379]. HIV. 2, 5. A HIV,, A. HIV A,, C A A 7 CD4+ T 200 /μl, /μl, 500 /μl 11%. 53%, 73%.,, A CD4+ T, CD4+ T CD4+ T. B B HIV HIV B, B, HIV. HIV B. HIV 0, 1, HIV B 20 μg 40 μg (34% vs 47%), CD4+ T 350 /μl HIV RNA 10,000 copies/ml [378]., HIV 2 40 μg. HIV.,,,,,,. HIV,. 4 0, 2, 6 2 0, 1, 6. HIV, MMR, CD4+ T 200 /μl, CD4+ T 200 /μl. 맺음말 1. 본임상진료지침의제한점및향후추가되어야할내용 HIV, HIV,,., HIV HIV. 2. Conflict of interest,,. 3. 지침개정에대한계획. References 1. Choe PG, Park WB, Song JS, Kim NH, Park JY, Song KH, Park SW, Kim HB, Kim NJ, Oh MD. Late presentation of HIV disease and its associated factors among newly diagnosed patients before and after abolition of a government policy of mass mandatory screening. J Infect 2011;63: Pifer LL, Hughes WT, Stagno S, Woods D. Pneumocystis

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