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Comprehensive Study Guide: HIV Infection in Children & Antiretroviral Therapy (ART)

Sources: Harrison's Principles of Internal Medicine 22E (2025), Red Book 2021 (AAP), Bradley & Daroff's Neurology in Clinical Practice, Comprehensive Clinical Nephrology 7E

PART 1: HIV VIROLOGY & PATHOGENESIS

1.1 The Virus

HIV is a single-stranded RNA retrovirus (family Retroviridae, genus Lentivirus). Two types exist:

HIV-1: Responsible for the global pandemic. Multiple groups (M, N, O, P); Group M is divided into subtypes/clades (A-K), with subtype C predominating globally.
HIV-2: Less virulent, slower progression, mostly West Africa.

Structure: Icosahedral virion. External spikes formed by a trimeric heterodimer of:

gp120 (surface) - binds CD4+ T cells
gp41 (transmembrane) - mediates membrane fusion

Key enzymes encoded by the pol gene:

Reverse transcriptase
Integrase
Protease

1.2 Replication Cycle (Targets for ART)

Step	Mechanism	Drug Target
1. Attachment	gp120 binds CD4 receptor on host T cell	Entry inhibitors (maraviroc)
2. Co-receptor binding	gp120 binds CCR5 or CXCR4	CCR5 antagonists
3. Fusion	gp41 folds to merge viral/cell membranes	Fusion inhibitors (enfuvirtide)
4. Reverse transcription	RNA -> DNA via reverse transcriptase	NRTIs, NNRTIs
5. Integration	Proviral DNA integrated into host genome by integrase	INSTIs
6. Protein processing	Viral polyproteins cleaved by protease	Protease inhibitors
7. Budding	New virions released	(Maturation inhibitors, experimental)

Harrison's Principles of Internal Medicine 22E, pp. 1600-1603

1.3 Cellular Tropism

Primary target: CD4+ T helper lymphocytes (the immune orchestrators)
Also infect: macrophages, dendritic cells, microglia (CNS)
CD4 molecule is the primary receptor; CCR5 is the predominant co-receptor in early/transmitted infection, CXCR4 in late/advanced disease
The cell-to-cell spread is also facilitated by DC-SIGN (C-type lectin on dendritic cells) which captures HIV and passes it to CD4+ T cells

PART 2: HIV EPIDEMIOLOGY

Global Burden (2023 Data)

~39.9 million people living with HIV worldwide
120,000 new HIV infections in children <15 years in 2023 (down from 300,000 in 2010 - a dramatic improvement due to PMTCT programs)
630,000 AIDS deaths in 2023, including 76,000 children <15 years
30.7 million people (77% of all PLHIV) accessing ART as of December 2023
84% of pregnant women with HIV had access to ART to prevent MTCT in 2023
Eastern/Southern Africa: home to >50% of global PLHIV (20.8 million)
South Africa: highest number of PLHIV globally (7.7 million)
Harrison's Principles of Internal Medicine 22E, pp. 1609-1611

PART 3: HIV INFECTION IN CHILDREN

3.1 Routes of Acquisition in Children

A. Perinatal / Vertical Transmission (most common in children)

Occurs in utero (15-20%), during labor/delivery (60-70%), or via breastfeeding (10-20%)
Without any intervention, MTCT rate is 15-45%
Maternal viral load is the dominant predictor of transmission risk; a 2025 meta-analysis confirms a direct linear relationship (PMID: 40652949)
With effective ART + prophylaxis, MTCT can be reduced to <1-2%

B. Blood-borne (rare in developed countries)

Transfusion of unscreened blood products
Contaminated needles

C. Sexual transmission

In adolescents (consensual or non-consensual)
Post-pubertal routes same as adults

3.2 Diagnosis of HIV in Children

Critical principle: Maternal HIV antibodies passively cross the placenta and persist in the infant until ~18 months. Therefore, antibody tests CANNOT diagnose HIV in infants <18 months.

Diagnostic Algorithm by Age

Children < 18 months: Use virologic (NAAT) tests only

Test	Details
HIV-1 DNA PCR	Detects proviral DNA in peripheral blood mononuclear cells; detects 1-10 copies
HIV-1 RNA PCR (qualitative/quantitative)	Detects plasma viral RNA; equally recommended alongside DNA PCR
Performance	Identifies 25-58% of infected infants in week 1; 60% by 1 month; 90-100% by 2-3 months

Recommended virologic testing schedule (Red Book 2021):

At birth (within 48 hours)
At 14-21 days of age
At 1-2 months of age
At 4-6 months of age

A positive virologic test should be confirmed immediately with a repeat test. Two positive results = confirmed HIV infection.

Children ≥ 18-24 months:

HIV antibody/antigen combination assay (4th generation) can be used
Note: 14% of infants remain seropositive after 18 months, 4.3% after 21 months, 1.2% after 24 months - so some may still need NAAT confirmation

Adults and older children:

FDA-recommended algorithm: 4th generation Ag/Ab combo assay → if reactive, HIV-1/HIV-2 antibody differentiation assay → if indeterminate, HIV-1 NAAT
Red Book 2021 (AAP), pp. 695-696

3.3 Clinical Staging in Children

WHO Pediatric Clinical Staging (simplified):

Stage	Description
1 (Asymptomatic)	No symptoms or generalized lymphadenopathy
2 (Mild)	Unexplained persistent hepatosplenomegaly, papular pruritic eruptions, fungal nail infections, angular cheilitis, recurrent oral ulceration, extensive wart virus disease, molluscum contagiosum, parotid gland enlargement
3 (Advanced)	Unexplained moderate malnutrition, unexplained persistent diarrhea (>14 days), unexplained persistent fever (>1 month), oral candidiasis outside neonatal period, oral hairy leukoplakia, acute necrotizing ulcerative stomatitis, pulmonary TB, severe recurrent bacterial pneumonia, symptomatic lymphoid interstitial pneumonitis, chronic HIV-associated lung disease, unexplained anemia
4 (Severe/AIDS)	Unexplained severe wasting, Pneumocystis jirovecii pneumonia (PCP), recurrent severe bacterial infections (empyema, meningitis, osteomyelitis), chronic HSV infection, esophageal candidiasis, CNS toxoplasmosis, HIV encephalopathy, CMV retinitis, cryptococcal meningitis, disseminated non-TB mycobacteria, Kaposi's sarcoma, CNS lymphoma, progressive multifocal leukoencephalopathy

CDC Classification for Children <13 years:

Based on CD4 count (immune categories 1, 2, 3) and clinical categories (N, A, B, C)
AIDS-defining = CD4 <200 cells/µL (for children >5 years) or CD4 <500 in ages 1-5 or CD4 <750 in <1 year

3.4 Clinical Features Unique to Children

Compared to adults, pediatric HIV often presents with:

Lymphocytic interstitial pneumonitis (LIP): common pediatric AIDS-defining illness, rare in adults. Insidious onset, bilateral pulmonary infiltrates, digital clubbing, salivary gland enlargement.
Failure to thrive / growth failure
Developmental delay and HIV encephalopathy - loss of milestones, progressive motor dysfunction, acquired microcephaly
Recurrent bacterial infections (especially Streptococcus pneumoniae, Haemophilus influenzae) - due to impaired humoral immunity
Parotid gland enlargement (uncommon in adults)
Early-onset opportunistic infections: PCP occurs even at CD4 counts that would not trigger prophylaxis in adults
Rapid progressors: ~20-25% of perinatally infected infants (untreated) develop AIDS or die in the first year of life

3.5 Opportunistic Infections in Children

PCP (Pneumocystis jirovecii Pneumonia):

Peak incidence at 3-6 months in perinatally infected infants
Prophylaxis: Trimethoprim-sulfamethoxazole (co-trimoxazole)
- All HIV-exposed infants from 4-6 weeks of age until HIV infection is excluded
- Continue for all HIV-infected children <5 years, and those >5 years with CD4 <200
Co-trimoxazole also prevents listeriosis, toxoplasmosis, and some bacterial infections

Candidiasis, CMV, MAC, Toxoplasma, Cryptococcus - same pathogens as adults, often at higher CD4 counts in children

TB and HIV co-infection (pediatric):

Use 4-drug RIPE (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) for at least 2 months, then INH + Rifampin for 4 months
Rifampin has significant drug interactions with PIs and NNRTIs; rifabutin may be substituted
ART can be safely initiated within 2 weeks of starting anti-TB therapy even with severe immunosuppression
Red Book 2021, pp. 1231-1237; Harrison's Principles of Internal Medicine 22E, pp. 1643-1644

3.6 Monitoring Children with HIV

Parameter	Frequency
CD4 count and %	Every 3-6 months
HIV RNA viral load	Every 3-6 months (monthly in first 3 months of ART)
CBC, chemistry	Every 3-6 months
Growth (weight, height)	Every visit
Neurodevelopmental assessment	Every 6-12 months
Ophthalmology (CMV retinitis)	Annually or per CD4

3.7 Immunizations in HIV-Infected Children

Key considerations:

Live vaccines are generally contraindicated in severely immunocompromised children (CD4 <15% or <200 cells/µL)
MMR and Varicella vaccines: Can be given if CD4 ≥15% (or ≥200 cells/µL in older children) and no severe immunosuppression
Inactivated vaccines (IPV, DTaP, HBV, Hib, PCV13, meningococcal) are safe and recommended - but immune response may be blunted
Pneumococcal vaccine: PCV13 followed by PPSV23 strongly recommended
Annual influenza vaccine (inactivated, not LAIV)
HPV vaccine: Recommended starting age 9-12 years, 3-dose series for immunocompromised (not 2 doses)

3.8 Prevention of Mother-to-Child Transmission (PMTCT)

WHO 'Option B+' (now the global standard): All HIV-positive pregnant women start ART (regardless of CD4) and continue lifelong

Components of complete PMTCT:

Antenatal: Start maternal ART - preferred regimen: Tenofovir disoproxil + Emtricitabine/Lamivudine + Dolutegravir
Intrapartum: Continue maternal ART; IV Zidovudine for high viral load
Postpartum neonatal prophylaxis:
- Low-risk infant (mother virologically suppressed): Zidovudine for 4-6 weeks
- High-risk infant (mother not on ART, high VL): Zidovudine + Nevirapine + Lamivudine x 6 weeks
Infant feeding: In resource-rich settings, formula feeding is recommended; in resource-limited settings, exclusive breastfeeding with maternal ART is acceptable
Virologic testing at 4-6 weeks, 3 months, 6 months; and at cessation of breastfeeding + 6 weeks after

PART 4: STAGES OF HIV DISEASE (ADULT REFERENCE)

4.1 Acute HIV Syndrome (Fiebig Stages I-VI)

Occurs 3-6 weeks post-infection in 50-70% of individuals
Corresponds to high-level viremia and transient CD4 decline

Symptoms of Acute HIV Syndrome:

General	Neurologic	Dermatologic
Fever	Meningitis	Erythematous maculopapular rash
Pharyngitis	Encephalitis	Mucocutaneous ulceration
Lymphadenopathy	Peripheral neuropathy
Headache / retroorbital pain	Myelopathy
Arthralgias/myalgias
Lethargy/malaise
Anorexia, N/V/D

Harrison's Principles of Internal Medicine 22E, Table 208-10, p. 1628

4.2 Chronic Asymptomatic Phase

CD4 count falls slowly (~50-70 cells/µL per year without treatment)
Plasma viremia at a "set point"; viral replication continues in lymphoid tissue
May last 1-20 years (median ~10 years)

4.3 Advanced HIV Disease / AIDS

CD4 <200 cells/µL in adults/children >5 years = AIDS (CDC definition)
Opportunistic infections and malignancies emerge
Untreated: median survival after AIDS-defining illness was only 26 weeks (pre-ART era)
With ART: a 20-year-old newly diagnosed can expect to live 50+ more years

4.4 Long-term Nonprogressors & Elite Controllers

Long-term nonprogressors: HIV-infected ≥10 years, stable CD4 in normal range, low viremia, no ART - ~5-15% of PLHIV
Elite controllers: <1% of PLHIV; undetectable viral load without ART; robust HIV-specific CD8+ CTL responses; associated with HLA-B57-01 and HLA-B27-05 haplotypes

PART 5: ANTIRETROVIRAL THERAPY (ART) - COMPLETE GUIDE

5.1 Drug Classes and Mechanisms

A. Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs)

Mechanism: Competitive inhibitors of reverse transcriptase; incorporated into viral DNA causing chain termination (lack a 3'-OH group)

Drug	Common Name	Dose	Key Toxicity
Lamivudine	3TC	150 mg BID or 300 mg QD	Flare of hepatitis B on discontinuation
Emtricitabine	FTC, Emtriva	200 mg QD	Skin discoloration; hepatitis B flare
Abacavir	ABC, Ziagen	300 mg BID	Fatal hypersensitivity in HLA-B*5701+ individuals (fever, rash, N/V/fatigue)
Tenofovir disoproxil fumarate	TDF	300 mg QD	Renal toxicity, osteomalacia, hepatitis B flare on discontinuation
Tenofovir alafenamide	TAF, Vemlidy	25 mg QD	Less renal and bone toxicity than TDF; nausea
Zidovudine	AZT, ZDV	300 mg BID	Bone marrow suppression, anemia, myopathy, lactic acidosis
Stavudine	d4T	40 mg BID	Peripheral neuropathy, lipodystrophy, lactic acidosis
Didanosine	ddI	400 mg QD	Pancreatitis, peripheral neuropathy

Important NRTI notes:

Screen HLA-B*5701 before prescribing abacavir - positive = contraindicated
TDF preferred over TAF when HBV co-infection is present (greater anti-HBV activity)

B. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)

Mechanism: Non-competitive, bind allosteric site of reverse transcriptase; conformational change blocks function (do NOT require intracellular phosphorylation)

Drug	Notes	Key Toxicity
Efavirenz (EFV)	CYP450 inducer; once-daily	CNS symptoms (vivid dreams, mood changes), teratogenic in 1st trimester
Nevirapine (NVP)	CD4 cutoffs: avoid if CD4 >250 (women) or >400 (men)	Severe hepatotoxicity and Stevens-Johnson syndrome
Rilpivirine (RPV)	Requires food; not with PPIs	QTc prolongation, depression
Etravirine (ETR)	Active against NNRTI-resistant strains	Rash
Doravirine (DOR)	Fewer CNS effects than EFV	Nausea, fatigue

NNRTI resistance: A single mutation (K103N, Y181C, etc.) can cause high-level resistance - low genetic barrier.

C. Protease Inhibitors (PIs)

Mechanism: Inhibit HIV protease enzyme, preventing cleavage of viral polyprotein precursors into functional proteins; result = non-infectious immature virions

Drug	Boosting	Key Toxicity
Darunavir (DRV)	+ Ritonavir or Cobicistat	Rash (sulfonamide moiety), GI side effects
Atazanavir (ATV)	+ Ritonavir	Indirect hyperbilirubinemia, nephrolithiasis (jaundice, scleral icterus)
Lopinavir/Ritonavir (LPV/r)	Co-formulated	Diarrhea, GI intolerance, hyperlipidemia, cardiac conduction
Ritonavir	Pharmacokinetic booster	Full-dose ritonavir rarely used now (GI intolerance)
Cobicistat	Booster only (no ART activity)	Inhibits tubular creatinine secretion (raises creatinine without true renal impairment)

Pharmacokinetic boosting: Ritonavir or cobicistat inhibit CYP3A4, raising PI levels - allows once-daily dosing with lower PI doses.

D. Integrase Strand Transfer Inhibitors (INSTIs)

Mechanism: Block integration of proviral DNA into host genome by inhibiting the strand transfer step of HIV integrase

Drug	Notes	Key Toxicity
Raltegravir (RAL)	Twice daily	Rhabdomyolysis (rare), CPK elevation
Elvitegravir (EVG)	Requires cobicistat booster	Drug interactions (CYP3A4)
Dolutegravir (DTG)	Preferred 1st-line agent globally; once daily; high genetic barrier	Weight gain, neural tube defects (periconceptional use - monitor)
Bictegravir (BIC)	Co-formulated with TAF/FTC	Headache, weight gain
Cabotegravir (CAB)	Injectable long-acting (monthly/bimonthly)	Injection site reactions; note: INSTI resistance risk if started post CAB-LA PrEP

E. Entry/Fusion Inhibitors

Drug	Class	Mechanism	Notes
Enfuvirtide (T-20)	Fusion inhibitor	Blocks gp41-mediated membrane fusion	SC injection, injection site reactions; salvage therapy
Maraviroc (MVC)	CCR5 antagonist	Blocks CCR5 co-receptor	Requires tropism testing first (use only in CCR5-tropic virus); hepatotoxicity
Ibalizumab	Anti-CD4 monoclonal Ab	Blocks CD4-gp120 post-binding conformational change	IV infusion; multi-drug-resistant HIV
Lenacapavir (LEN)	Capsid inhibitor	Blocks multiple steps (capsid assembly, nuclear import)	SC injection every 6 months; newest agent; used in highly treatment-experienced patients

5.2 When to Start ART

Current universal recommendation: Start ART in ALL people living with HIV, regardless of CD4 count. This reflects evidence that early treatment:

Prevents clinical progression
Reduces transmission by >96% (Undetectable = Untransmittable, U=U)
Reduces non-AIDS morbidities (cardiovascular, renal, neurocognitive)

Special urgency to start ART immediately (same-day or within days):

Acute/early HIV infection
Pregnancy (all trimesters)
HIV-associated TB (within 2 weeks)
AIDS-defining opportunistic infections
All pediatric HIV cases

Exception - delay may be appropriate:

CNS cryptococcosis: stabilize first, start ART 4-6 weeks after antifungal treatment to reduce IRIS risk
TB with CD4 >50: can delay ART to 8 weeks

5.3 Preferred First-Line ART Regimens (Adults)

WHO/DHHS recommended preferred initial regimen (2025):

Preferred (NNRTI-based):

Dolutegravir (DTG) + Tenofovir (TDF or TAF) + Lamivudine (3TC) or Emtricitabine (FTC)
- Most widely used globally
- DTG/3TC/TDF co-formulated as a single tablet
- High genetic barrier to resistance
- Well tolerated; once daily

Alternative INSTI-based:

Bictegravir/Emtricitabine/Tenofovir alafenamide (BIC/FTC/TAF) - Biktarvy
- Preferred in US; excellent tolerability
Raltegravir + TDF/FTC - older regimen, twice daily

For suspected INSTI resistance (prior cabotegravir-LA PrEP):

Darunavir/cobicistat + TDF/FTC or TAF/FTC

Two-drug regimens (treatment-experienced, virologically suppressed):

Dolutegravir + Rilpivirine (DTG/RPV) - Juluca (requires VL <100,000 and CD4 >200)
Cabotegravir + Rilpivirine (CAB/RPV) - injectable, every 2 months

5.4 Preferred First-Line ART Regimens (Children)

Infants and children - WHO recommended preferred regimens (age-based):

Age Group	Preferred Regimen	Notes
<4 weeks (neonate prophylaxis)	Zidovudine (AZT) +/- Nevirapine (high-risk)	Treatment differs from prophylaxis
Neonates diagnosed with HIV	Lopinavir/ritonavir (LPV/r) + 2 NRTIs (AZT+3TC)	LPV/r not recommended <14 days (cardiac risk)
Infants 4 weeks - 3 years	Lopinavir/ritonavir + AZT + 3TC	Granule/liquid formulations
Children ≥3 years, <10 kg	Raltegravir + AZT + 3TC
Children ≥10 kg, 3-<6 years	Abacavir + 3TC + Lopinavir/r OR Dolutegravir-based	Check HLA-B*5701 before ABC
Children ≥6 years / ≥20 kg	Dolutegravir + ABC + 3TC (preferred) or TDF + 3TC/FTC + DTG	DTG 10 mg tablet dispersible available
Adolescents ≥25 kg	Same as adults: DTG + TDF + 3TC/FTC

Key pediatric considerations:

Weight-based dosing required; adjust as child grows
Palatability and formulation availability (liquids, granules, dispersible tablets) critical for adherence
Pharmacokinetics differ significantly from adults - require pediatric-specific dosing studies
Screen all children for HLA-B*5701 before abacavir
LPV/r has good barrier to resistance but poor palatability

5.5 Monitoring ART Response

Virologic monitoring:

Goal: HIV RNA <50 copies/mL (undetectable) within 6 months of starting ART
Check viral load at 2-4 weeks after starting, then every 4-8 weeks until undetectable, then every 3-6 months

Indications for changing ART regimen:

Reason	Details
Virologic failure	<1-log drop in VL by 4 weeks; or ≥3-fold rise from nadir not explained by infection/vaccine
Immunologic failure	Persistently declining CD4 count
Clinical failure	Disease progression despite therapy
Toxicity	Side effects (simple 1-drug substitution acceptable)
Resistance	Confirmed by genotype/phenotype testing
Drug interactions	New medications with incompatible PK profiles

CD4 response:

Brisk CD4 rise in first month of therapy
Then ~50-100 cells/µL per year increase until near-normal levels

5.6 Drug Resistance and Resistance Testing

Principles:

HIV mutates rapidly (no proofreading reverse transcriptase)
Genotypic testing: cDNA sequencing - detects mutations associated with resistance; detects variants present at ≥10%
Phenotypic testing: Measures viral enzyme activity at various drug concentrations
Next-generation sequencing: Can detect minor variants at ≥1%

Resistance testing indications:

Before initiating ART (transmitted resistance)
At virologic failure
When HIV RNA >500-1,000 copies/mL despite therapy
In pregnancy (all HIV-infected pregnant women)
When prior CAB-LA PrEP exposure before treatment

High genetic barrier (harder to develop resistance):

INSTIs (especially DTG, BIC) - require multiple mutations
Boosted PIs (especially DRV/r)

Low genetic barrier (single mutation confers resistance):

NNRTIs (K103N, Y181C for NVP/EFV)
3TC/FTC (M184V - but this mutation also reduces viral fitness)

5.7 Long-Acting ART Regimens (2025 Update)

Injectable regimens for treatment:

Cabotegravir LA + Rilpivirine LA (CAB/RPV - Cabenuva): Monthly or every-2-month IM injections; used in virologically suppressed adults; EACS guidelines 2025 endorse this as a maintenance option (PMID: 41088922)

Injectable PrEP:

Cabotegravir LA (CAB-LA) for PrEP: every-2-month IM injection; highly effective

Oral ultra-long-acting:

Lenacapavir (LEN): SC injection every 6 months (capsid inhibitor); for highly treatment-experienced patients with multi-drug-resistant HIV

5.8 Immune Reconstitution Inflammatory Syndrome (IRIS)

Occurs weeks to months after starting ART
Paradoxical worsening as recovering immune system mounts response to previously subclinical pathogens
Unmasking IRIS: New opportunistic infection revealed as immune system recovers
Paradoxical IRIS: Known infection previously treated worsens after ART initiation
Risk highest with CD4 <50 at ART start, rapid CD4 recovery
High-risk OIs for IRIS: TB, MAC, CMV, Cryptococcus, KS (especially Kaposi's in HHV-8-endemic countries)
Management: Continue ART; treat underlying OI; steroids for severe reactions (except when infection not controlled)

5.9 Special Populations

Pregnancy:

ART mandatory throughout pregnancy
DTG + TDF + FTC is preferred (neural tube defect risk with DTG in periconception very low; benefits outweigh risks)
Avoid EFV in 1st trimester
Zidovudine IV during labor if VL >1,000 copies/mL near delivery

Renal Impairment:

Avoid TDF in eGFR <50; substitute TAF
Dose-adjust NRTIs (TDF, 3TC, FTC, AZT) based on GFR
Dose-adjust based on pharmacokinetics

Hepatic Impairment:

Use NRTIs with caution (lactic acidosis/hepatosteatosis risk especially with stavudine/ddI)
HBV co-infection: do NOT use single-agent anti-HBV therapy (use TDF or TAF-containing regimen to prevent HBV resistance; discontinuing ART containing anti-HBV agents can cause hepatitis flare)
Child-Pugh C: Avoid protease inhibitors; some INSTIs may be used with monitoring

HIV-TB Co-infection:

Rifampin induces CYP3A4 - significantly reduces PI and some NNRTI levels
Preferred ART with rifampin: Efavirenz (with standard dose) or Dolutegravir (with doubled dose to 50 mg BID)
Rifabutin substituted for rifampin when using PIs

PART 6: OPPORTUNISTIC INFECTION PROPHYLAXIS (Summary)

OI	Indication	Preferred Agent
PCP	CD4 <200 (adults) or all HIV+ children <5 yrs	Co-trimoxazole (TMP-SMX)
Toxoplasma encephalitis	CD4 <100 + IgG positive	Co-trimoxazole (also covers PCP)
MAC (Mycobacterium avium complex)	CD4 <50 (if not on ART)	Azithromycin weekly
Cryptococcus (secondary prophylaxis)	After treatment of cryptococcal meningitis	Fluconazole (until CD4 >200 for 3+ months on ART)
CMV (secondary prophylaxis)	After CMV retinitis treatment	Valganciclovir

Prophylaxis can be stopped when CD4 count rises above threshold on ART (sustained ≥3-6 months):

PCP prophylaxis can stop when CD4 >200 for >3 months
Toxoplasma prophylaxis can stop when CD4 >200 for >3 months
MAC prophylaxis can stop when CD4 >100 for >3 months

PART 7: AIDS-DEFINING MALIGNANCIES

Three AIDS-defining cancers:

Kaposi's Sarcoma (KS): Caused by HHV-8; mucocutaneous violaceous lesions; visceral involvement (GI, lung, lymph nodes). In children: unusual presentation without skin lesions - prominent firm lymphadenopathy, cytopenias. IRIS-KS can occur post-ART especially in children from HHV-8-endemic countries.
Non-Hodgkin Lymphoma (NHL): Often high-grade B-cell lymphomas (Burkitt's, immunoblastic, primary CNS lymphoma). Treatment: chemotherapy ± rituximab + effective ART. Survival improved significantly with ART era.
Invasive Cervical Cancer: HPV-associated; more aggressive in HIV.

Non-AIDS-defining cancers with increased frequency: Hodgkin lymphoma, lung cancer, anal cancer, hepatocellular carcinoma.

PART 8: NEUROLOGIC COMPLICATIONS OF HIV

HIV-Associated Neurocognitive Disorders (HAND)

Spectrum from asymptomatic neurocognitive impairment (ANI) → mild neurocognitive disorder (MND) → HIV-associated dementia (HAD)
Direct HIV neuroinvasion via infected macrophages/monocytes; gp120 and Tat protein toxic to neurons
Children: developmental regression, loss of milestones, acquired microcephaly, spasticity
ART reduces but does not eliminate CNS disease (CNS is a viral reservoir)

CNS Opportunistic Infections

OI	Key Features	Treatment
CNS Toxoplasmosis	Ring-enhancing lesions on MRI, CD4 <100, serology (+)	Pyrimethamine + Sulfadiazine + Leucovorin
Cryptococcal meningitis	Subacute meningitis, India ink (+), cryptococcal antigen	Liposomal amphotericin B + Flucytosine → fluconazole
PML (JC virus)	White matter lesions (no enhancement), CD4 <200	No specific therapy; ART (IRIS risk)
CMV encephalitis/retinitis	Retinal hemorrhages/exudates; periventricular enhancement	Ganciclovir/Valganciclovir
HIV encephalopathy (children)	Cognitive regression, motor delay, basal ganglia calcifications on CT	ART + CNS-penetrating regimens

QUICK REFERENCE: KEY NUMBERS

Parameter	Value
CD4 threshold for AIDS (>5 yrs)	<200 cells/µL
Normal CD4 count	600-1,500 cells/µL
ART initiation goal (viral load)	<50 copies/mL by 6 months
MTCT rate without ART	15-45%
MTCT rate with optimal ART	<1-2%
Global children <15 yr with HIV	~1.4 million (2023)
Global ART coverage	77%
Antibody test valid age in children	≥18-24 months
PCP prophylaxis threshold (adults)	CD4 <200
MAC prophylaxis threshold	CD4 <50
Toxoplasma prophylaxis threshold	CD4 <100 + IgG+

KEY MNEMONICS

ART Drug Classes (NIPPE):

NRRTIs (Nucleosides)
INSTIs (Integrase)
PIs (Protease)
Prevention/Entry inhibitors
ENNRTIs (Non-nucleosides)

Preferred 1st-line regimen components:

DTG (integrase) + TAF/TDF (backbone) + FTC/3TC = "DTF"

Indications to change ART (VICS):

Virologic failure
Immunologic failure
Clinical failure
Side effects/toxicity

AIDS-defining malignancies: KNC

Kaposi's sarcoma
NHL
Cervical cancer (invasive)

Sources consulted: Harrison's Principles of Internal Medicine 22E (2025, McGraw Hill) pp. 1600-1660; Red Book 2021: Report of the Committee on Infectious Diseases (AAP) pp. 695-716; Comprehensive Clinical Nephrology 7E; Bradley & Daroff's Neurology in Clinical Practice; EACS Guidelines v13.0, 2025 (PMID: 41088922). HIV vertical transmission meta-analysis: Lancet 2025 (PMID: 40652949).

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Running Command

mkdir -p /tmp/workspace/art-quick-ref && python3 << 'PYEOF' from reportlab.lib.pagesizes import A4, landscape from reportlab.lib.units import mm, cm from reportlab.lib import colors from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.platypus import (SimpleDocTemplate, Table, TableStyle, Paragraph, Spacer, HRFlowable, KeepTogether) from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_RIGHT from reportlab.platypus import BaseDocTemplate, Frame, PageTemplate from reportlab.lib.colors import HexColor # --- Colour palette --- DARK_BLUE = HexColor('#0D3B66') MED_BLUE = HexColor('#1A73A7') LIGHT_BLUE = HexColor('#D6EAF8') GREEN = HexColor('#1E7E34') LIGHT_GREEN = HexColor('#D4EDDA') ORANGE = HexColor('#E65100') LIGHT_ORANGE = HexColor('#FFF3E0') RED = HexColor('#C62828') LIGHT_RED = HexColor('#FFEBEE') YELLOW_BG = HexColor('#FFFDE7') PURPLE = HexColor('#6A1B9A') LIGHT_PURPLE = HexColor('#F3E5F5') GREY_BG = HexColor('#F5F5F5') DARK_GREY = HexColor('#424242') MID_GREY = HexColor('#757575') WHITE = colors.white BLACK = colors.black PAGE_W, PAGE_H = landscape(A4) # ── header/footer ───────────────────────────────────────────────────────────── def draw_header_footer(canvas, doc): canvas.saveState() # Top banner canvas.setFillColor(DARK_BLUE) canvas.rect(0, PAGE_H - 22*mm, PAGE_W, 22*mm, fill=1, stroke=0) canvas.setFillColor(WHITE) canvas.setFont('Helvetica-Bold', 16) canvas.drawCentredString(PAGE_W/2, PAGE_H - 12*mm, 'ART QUICK REFERENCE CARD · HIV Antiretroviral Therapy') canvas.setFont('Helvetica', 8) canvas.drawRightString(PAGE_W - 10*mm, PAGE_H - 19*mm, 'Based on WHO/DHHS/EACS Guidelines 2025 | Harrison\'s 22E') # Bottom bar canvas.setFillColor(DARK_BLUE) canvas.rect(0, 0, PAGE_W, 7*mm, fill=1, stroke=0) canvas.setFillColor(WHITE) canvas.setFont('Helvetica', 7) canvas.drawCentredString(PAGE_W/2, 2*mm, 'FOR EDUCATIONAL USE ONLY · Always verify current guidelines before clinical use · Orris Medical Education 2025') canvas.restoreState() # ── document ────────────────────────────────────────────────────────────────── OUTPUT = '/tmp/workspace/art-quick-ref/ART_Quick_Reference_Card.pdf' doc = BaseDocTemplate(OUTPUT, pagesize=landscape(A4), leftMargin=10*mm, rightMargin=10*mm, topMargin=25*mm, bottomMargin=12*mm) frame = Frame(doc.leftMargin, doc.bottomMargin, PAGE_W - doc.leftMargin - doc.rightMargin, PAGE_H - doc.topMargin - doc.bottomMargin, id='normal') doc.addPageTemplates([PageTemplate(id='main', frames=frame, onPage=draw_header_footer)]) styles = getSampleStyleSheet() def H(text, color=DARK_BLUE, size=9, bold=True): return Paragraph(f'{text}', ParagraphStyle('h', fontName='Helvetica-Bold' if bold else 'Helvetica', fontSize=size, leading=size+2, textColor=color, spaceAfter=1)) def P(text, size=7.5, color=DARK_GREY): return Paragraph(text, ParagraphStyle('p', fontName='Helvetica', fontSize=size, leading=size+2.5, textColor=color, spaceAfter=0)) def BOLD(text, size=7.5, color=DARK_GREY): return Paragraph(f'{text}', ParagraphStyle('pb', fontName='Helvetica-Bold', fontSize=size, leading=size+2, textColor=color, spaceAfter=0)) def small(text, color=MID_GREY): return Paragraph(f'{text}', ParagraphStyle('sm', fontName='Helvetica-Oblique', fontSize=6.5, leading=8, textColor=color)) def section_header(title, bg=DARK_BLUE): t = Table([[Paragraph(f'{title}', ParagraphStyle('sh', fontName='Helvetica-Bold', fontSize=8.5, textColor=WHITE, leading=10))]], colWidths=['100%']) t.setStyle(TableStyle([ ('BACKGROUND', (0,0), (-1,-1), bg), ('TOPPADDING', (0,0), (-1,-1), 3), ('BOTTOMPADDING', (0,0), (-1,-1), 3), ('LEFTPADDING', (0,0), (-1,-1), 5), ])) return t # ─── helper: make a styled table ────────────────────────────────────────────── TS_BASE = [ ('FONTNAME', (0,0), (-1, 0), 'Helvetica-Bold'), ('FONTSIZE', (0,0), (-1, 0), 7.5), ('BACKGROUND', (0,0), (-1, 0), DARK_BLUE), ('TEXTCOLOR', (0,0), (-1, 0), WHITE), ('FONTNAME', (0,1), (-1,-1), 'Helvetica'), ('FONTSIZE', (0,1), (-1,-1), 7), ('ROWBACKGROUNDS',(0,1), (-1,-1), [WHITE, GREY_BG]), ('GRID', (0,0), (-1,-1), 0.3, HexColor('#BDBDBD')), ('TOPPADDING', (0,0), (-1,-1), 3), ('BOTTOMPADDING', (0,0), (-1,-1), 3), ('LEFTPADDING', (0,0), (-1,-1), 4), ('RIGHTPADDING', (0,0), (-1,-1), 4), ('VALIGN', (0,0), (-1,-1), 'MIDDLE'), ] def make_table(data, col_widths, extra_styles=None): t = Table(data, colWidths=col_widths, repeatRows=1) s = list(TS_BASE) if extra_styles: s.extend(extra_styles) t.setStyle(TableStyle(s)) return t # ═══════════════════════════════════════════════════════════════════════════════ # CONTENT # ═══════════════════════════════════════════════════════════════════════════════ story = [] # ── ROW 1: Three columns ─────────────────────────────────────────────────────── # Col 1: Drug Classes | Col 2: Preferred Regimens Adults | Col 3: Peds + Monitoring # ─── Column 1: Drug Classes ─────────────────────────────────────────────────── col1 = [] col1.append(section_header('DRUG CLASSES & MECHANISMS')) col1.append(Spacer(1, 2)) classes = [ ['Class', 'Abbrev', 'Mechanism', 'Key Toxicity'], ['NRTIs\n(Nucleoside/tide\nReverse Transcriptase\nInhibitors)', 'ABC, TDF,\nTAF, 3TC,\nFTC, AZT', 'Chain termination of\nviral DNA synthesis', 'ABC: hypersensitivity\n(HLA-B*5701!)\nTDF: renal/bone\nAZT: anemia, myopathy'], ['NNRTIs\n(Non-Nucleoside\nRTIs)', 'EFV, NVP,\nRPV, ETR,\nDOR', 'Allosteric RT\ninhibition (non-\ncompetitive)', 'EFV: CNS effects\nNVP: hepatotoxicity,\nSJS (CD4 cutoffs!)\nRPV: avoid with PPIs'], ['PIs\n(Protease\nInhibitors)', 'DRV, ATV,\nLPV/r', 'Block viral\npolyprotein cleavage\n→ immature virions', 'Metabolic: dyslipidemia,\nGI intolerance\nATV: hyperbilirubinemia\nDRV: rash (sulfa)'], ['INSTIs\n(Integrase Strand\nTransfer Inhibitors)', 'DTG, BIC,\nRAL, EVG,\nCAB', 'Block proviral DNA\nintegration into\nhost genome', 'DTG/BIC: weight gain\nDTG: neural tube\ndefects (periconception)\nCAB: injection site rxn'], ['Entry/Fusion\nInhibitors', 'ENF, MVC,\nIBA, LEN', 'Block attachment,\nco-receptor binding,\nor fusion', 'MVC: requires tropism\ntesting (CCR5 only)\nENF: injection site rxn\nLEN: SC q6 months'], ['Pharmacokinetic\nBoosters\n(not ART alone)', 'RTV, COBI', 'CYP3A4 inhibition\n→ ↑ PI/EVG levels', 'COBI: falsely ↑Cr\n(inhibits tubular\nsecretion, not true\nrenal impairment)'], ] col1.append(make_table(classes, [32*mm, 18*mm, 40*mm, 45*mm], extra_styles=[ ('FONTSIZE', (0,1),(-1,-1), 6.5), ('ROWBACKGROUNDS',(0,1),(-1,-1),[WHITE, LIGHT_BLUE]), ('BACKGROUND',(0,1),(0,1), LIGHT_PURPLE), ('BACKGROUND',(0,2),(0,2), LIGHT_ORANGE), ('BACKGROUND',(0,3),(0,3), LIGHT_GREEN), ('BACKGROUND',(0,4),(0,4), LIGHT_BLUE), ('BACKGROUND',(0,5),(0,5), YELLOW_BG), ('BACKGROUND',(0,6),(0,6), GREY_BG), ('ROWBACKGROUNDS',(0,1),(-1,-1), [None,None]), # override to keep class colors ] )) # ─── Column 2: Adult Preferred Regimens ─────────────────────────────────────── col2 = [] col2.append(section_header('PREFERRED ART REGIMENS — ADULTS', bg=GREEN)) col2.append(Spacer(1, 2)) # First-line box fl_data = [ [Paragraph('FIRST-LINE PREFERRED (Naïve Patients)', ParagraphStyle('flh', fontName='Helvetica-Bold', fontSize=8, textColor=WHITE))] ] fl_tbl = Table(fl_data, colWidths=[135*mm]) fl_tbl.setStyle(TableStyle([ ('BACKGROUND',(0,0),(-1,-1), GREEN), ('TOPPADDING',(0,0),(-1,-1),3), ('BOTTOMPADDING',(0,0),(-1,-1),3), ('LEFTPADDING',(0,0),(-1,-1),5), ])) col2.append(fl_tbl) regimens_adult = [ ['Regimen', 'Frequency', 'Notes'], ['DTG + TDF/TAF + 3TC/FTC\n(e.g. Triumeq, Biktarvy*)', 'Once daily', '★ PREFERRED globally\nHigh resistance barrier\n*BIC/FTC/TAF = Biktarvy'], ['BIC/FTC/TAF (Biktarvy)', 'Once daily', 'Preferred US DHHS\nExcellent tolerability'], ['DTG + 3TC (dual)\n(Dovato)', 'Once daily', 'VL <500k, no HBV co-inf\nNot if HBV co-infected'], ] col2.append(make_table(regimens_adult, [55*mm, 22*mm, 58*mm], extra_styles=[('BACKGROUND',(0,0),(-1,0), GREEN)])) col2.append(Spacer(1,3)) # Alternative first-line alt_data = [ [Paragraph('ALTERNATIVE FIRST-LINE', ParagraphStyle('flh2', fontName='Helvetica-Bold', fontSize=7.5, textColor=WHITE))] ] alt_tbl = Table(alt_data, colWidths=[135*mm]) alt_tbl.setStyle(TableStyle([ ('BACKGROUND',(0,0),(-1,-1), MED_BLUE), ('TOPPADDING',(0,0),(-1,-1),2), ('BOTTOMPADDING',(0,0),(-1,-1),2), ('LEFTPADDING',(0,0),(-1,-1),5), ])) col2.append(alt_tbl) alt_regimens = [ ['Regimen', 'Notes'], ['RAL + TDF/TAF + FTC/3TC', 'Twice daily; older INSTI backbone'], ['DRV/COBI or DRV/r + TDF/TAF + FTC/3TC', 'Prior CAB-LA PrEP; boosted PI'], ['EFV/TDF/FTC (Atripla)', 'Avoid in 1st trimester; CNS side effects'], ['RPV/TDF/FTC (Complera)', 'VL <100k; CD4 >200; take with food; no PPIs'], ] col2.append(make_table(alt_regimens, [65*mm, 70*mm], extra_styles=[('BACKGROUND',(0,0),(-1,0), MED_BLUE)])) col2.append(Spacer(1,3)) # Maintenance / switch sw_data = [ [Paragraph('MAINTENANCE / SWITCH REGIMENS (virologically suppressed)', ParagraphStyle('flh3', fontName='Helvetica-Bold', fontSize=7.5, textColor=WHITE))] ] sw_tbl = Table(sw_data, colWidths=[135*mm]) sw_tbl.setStyle(TableStyle([ ('BACKGROUND',(0,0),(-1,-1), PURPLE), ('TOPPADDING',(0,0),(-1,-1),2), ('BOTTOMPADDING',(0,0),(-1,-1),2), ('LEFTPADDING',(0,0),(-1,-1),5), ])) col2.append(sw_tbl) sw_regimens = [ ['Regimen', 'Route', 'Frequency', 'Criteria'], ['DTG/RPV (Juluca)', 'Oral', 'Once daily', 'VL <100k, CD4 >200'], ['CAB-LA + RPV-LA\n(Cabenuva)', 'IM inject', 'Monthly or Q2M', 'Suppressed; no INSTI Rx'], ['LEN (Sunlenca)', 'SC inject', 'Every 6 months', 'Salvage: MDR HIV'], ] col2.append(make_table(sw_regimens, [50*mm, 20*mm, 25*mm, 40*mm], extra_styles=[('BACKGROUND',(0,0),(-1,0), PURPLE)])) # ─── Column 3: Pediatric + Monitoring ───────────────────────────────────────── col3 = [] col3.append(section_header('PREFERRED ART REGIMENS — CHILDREN', bg=ORANGE)) col3.append(Spacer(1, 2)) peds_data = [ ['Age / Weight', 'Preferred Regimen', 'Notes'], ['Neonates\n(<4 wks) - PEP', 'AZT ± NVP (high-risk)\n(PMTCT prophylaxis)', 'Not treatment; PEP only'], ['Infants <3 yrs\n(HIV-confirmed)', 'LPV/r + AZT + 3TC\n(granules/liquid)', 'LPV/r not <14 days\n(cardiac risk)'], ['≥3 yrs, <10 kg', 'RAL + AZT + 3TC', 'Weight-based dosing'], ['≥3 yrs, ≥10 kg\n(3-<6 yrs)', 'ABC/3TC + LPV/r OR\nDTG-based (≥10 kg)', '★ Check HLA-B*5701\nbefore ABC'], ['≥6 yrs / ≥20 kg', '★ DTG + ABC + 3TC\n(dispersible tablet)', 'DTG 10 mg dispersible\nonce daily preferred'], ['Adolescents\n≥25 kg', '★ DTG + TDF + 3TC/FTC\n(same as adults)', 'Transition to adult\nformulations'], ] col3.append(make_table(peds_data, [30*mm, 50*mm, 40*mm], extra_styles=[ ('BACKGROUND',(0,0),(-1,0), ORANGE), ('FONTSIZE', (0,1),(-1,-1), 6.5), ])) col3.append(Spacer(1, 4)) # Monitoring col3.append(section_header('MONITORING ON ART', bg=DARK_GREY)) col3.append(Spacer(1, 2)) mon_data = [ ['Parameter', 'Timing', 'Goal'], ['HIV RNA VL', '2-4 wks post-start,\nthen q4-8 wks until\nundetectable, then q3-6M', '<50 copies/mL\nby 6 months'], ['CD4+ count', 'q3-6M', '↑ 50-100/µL/yr;\neventually normal'], ['CBC/Chem/LFTs', 'q3-6M', 'Monitor toxicity'], ['Lipids/Glucose', 'Annually', 'Metabolic effects\n(esp. PIs)'], ['Resistance\ntesting', 'At failure\n(VL >200 copies/mL)', 'Guide regimen change'], ['Adherence', 'Every visit', '>95% required for\nviral suppression'], ] col3.append(make_table(mon_data, [28*mm, 42*mm, 38*mm], extra_styles=[ ('BACKGROUND',(0,0),(-1,0), DARK_GREY), ('FONTSIZE', (0,1),(-1,-1), 6.5), ])) # ─── Assemble 3-column layout ───────────────────────────────────────────────── main_table_data = [[col1, col2, col3]] main_table = Table(main_table_data, colWidths=[137*mm, 138*mm, 122*mm]) main_table.setStyle(TableStyle([ ('VALIGN', (0,0), (-1,-1), 'TOP'), ('LEFTPADDING', (0,0), (-1,-1), 3), ('RIGHTPADDING', (0,0), (-1,-1), 3), ('TOPPADDING', (0,0), (-1,-1), 0), ('BOTTOMPADDING',(0,0), (-1,-1), 0), ])) story.append(main_table) story.append(Spacer(1, 4)) # ══ BOTTOM STRIP: Key numbers + OI prophylaxis + Change indications ══════════ story.append(HRFlowable(width='100%', thickness=0.5, color=MED_BLUE)) story.append(Spacer(1, 3)) bot_col1 = [] bot_col1.append(section_header('OI PROPHYLAXIS THRESHOLDS', bg=RED)) bot_col1.append(Spacer(1,2)) oi_data = [ ['OI', 'CD4 Threshold', 'Drug of Choice', 'Stop When'], ['PCP', '<200/µL (adult)\nAll HIV+ kids <5 yrs', 'TMP-SMX (Co-trimoxazole)', 'CD4 >200 × 3 months on ART'], ['Toxoplasma', '<100/µL + IgG+', 'TMP-SMX (dual coverage)', 'CD4 >200 × 3 months'], ['MAC', '<50/µL\n(if not on ART)', 'Azithromycin 1200 mg weekly', 'CD4 >100 × 3 months'], ['Crypto (2°)', 'After Rx, until\nCD4 >200 ×3M', 'Fluconazole 200 mg daily', 'CD4 >200 × 3 months on ART'], ['CMV (2°)', 'After retinitis Rx', 'Valganciclovir', 'CD4 >100-150 × 6 months'], ] bot_col1.append(make_table(oi_data, [22*mm, 35*mm, 45*mm, 47*mm], extra_styles=[ ('BACKGROUND',(0,0),(-1,0), RED), ('FONTSIZE', (0,0),(-1,-1), 6.5), ])) bot_col2 = [] bot_col2.append(section_header('INDICATIONS TO CHANGE ART (VICS)', bg=PURPLE)) bot_col2.append(Spacer(1,2)) change_data = [ ['Criterion', 'Definition / Action'], ['V - Virologic\nFailure', '<1-log drop at 4 wks; OR confirmed VL >200 copies/mL\n→ Resistance test; change ≥2 active drugs'], ['I - Immunologic\nFailure', 'Persistently declining CD4 despite therapy\n→ Assess adherence; resistance test'], ['C - Clinical\nFailure', 'Disease progression / new AIDS-defining event\n→ Assess VL + resistance; optimize regimen'], ['S - Side Effects /\nToxicity', 'Drug-specific adverse effects\n→ Can substitute single agent; monitor off-drug'], ['Special: IRIS', 'Paradoxical worsening after ART start\n→ Continue ART; treat OI; steroids for severe IRIS'], ] bot_col2.append(make_table(change_data, [30*mm, 90*mm], extra_styles=[ ('BACKGROUND',(0,0),(-1,0), PURPLE), ('FONTSIZE', (0,0),(-1,-1), 6.5), ])) bot_col3 = [] bot_col3.append(section_header('KEY NUMBERS & ALERTS', bg=DARK_BLUE)) bot_col3.append(Spacer(1,2)) kn_data = [ ['Parameter', 'Value'], ['ART goal (viral load)', '<50 copies/mL by 6 months'], ['AIDS (CD4, adults >5 yrs)', '<200 cells/µL'], ['Normal CD4 range', '600-1,500 cells/µL'], ['CD4 loss (untreated)', '~50-70 cells/µL per year'], ['MTCT without ART', '15-45%'], ['MTCT with optimal ART', '<1-2%'], ['Antibody test valid (children)', '≥18-24 months'], ['★ HLA-B*5701', 'Test BEFORE abacavir'], ['★ CCR5 tropism', 'Test BEFORE maraviroc'], ['★ HBV co-infection', 'Include TDF/TAF; NEVER\nstop anti-HBV drug alone'], ['★ DTG periconcept.', 'Low NTD risk; benefits\noutweigh risks in pregnancy'], ] bot_col3.append(make_table(kn_data, [38*mm, 47*mm], extra_styles=[ ('BACKGROUND',(0,0),(-1,0), DARK_BLUE), ('FONTSIZE', (0,0),(-1,-1), 6.5), ('BACKGROUND',(0,9),(0,12), LIGHT_ORANGE), ('BACKGROUND',(1,9),(1,12), LIGHT_ORANGE), ('FONTNAME', (0,9),(-1,12), 'Helvetica-Bold'), ])) bottom_row = Table([[bot_col1, bot_col2, bot_col3]], colWidths=[152*mm, 125*mm, 90*mm]) bottom_row.setStyle(TableStyle([ ('VALIGN', (0,0), (-1,-1), 'TOP'), ('LEFTPADDING', (0,0), (-1,-1), 3), ('RIGHTPADDING', (0,0), (-1,-1), 3), ('TOPPADDING', (0,0), (-1,-1), 0), ('BOTTOMPADDING',(0,0), (-1,-1), 0), ])) story.append(bottom_row) # ── Build ────────────────────────────────────────────────────────────────────── doc.build(story) print("PDF created successfully:", OUTPUT) PYEOF

Running Command

ls -lh /tmp/workspace/art-quick-ref/ART_Quick_Reference_Card.pdf

The PDF is ready. Here's a summary of what's on the card:

Your ART Quick Reference Card is ready:

ART Quick Reference Card

PDF Document · PDF

Format: A4 Landscape (single page), colour-coded by section

What's included:

Section	Content
Drug Classes & Mechanisms	All 6 classes (NRTIs, NNRTIs, PIs, INSTIs, Entry inhibitors, Boosters) with mechanism and key toxicities
Adult Preferred Regimens	First-line preferred (DTG/BIC-based), alternative first-line, and maintenance/switch regimens (including CAB-LA injectables)
Pediatric Regimens	Age/weight-based regimens from neonates through adolescents
ART Monitoring	Viral load goals, CD4 targets, timing of labs
OI Prophylaxis Thresholds	PCP, Toxoplasma, MAC, Cryptococcus, CMV - thresholds and when to stop
Indications to Change ART	VICS framework (Virologic, Immunologic, Clinical, Side effects)
Key Numbers & Alerts	CD4 thresholds, MTCT rates, critical pre-prescribing tests (HLA-B*5701, CCR5 tropism, HBV co-infection warnings)

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