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National HIV testing and treatment guidelines

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Dr. BISHAL SAPKOTA

1. The document provides guidelines for HIV testing, treatment, and management in Nepal. It summarizes global HIV statistics and outlines the epidemiology of HIV in Nepal. 2. Guidelines are provided for HIV testing services, diagnosis, treatment, monitoring of people on antiretroviral therapy (ART), and management of coinfections. Recommendations include "treat all" and early infant diagnosis. 3. Prevention of mother-to-child transmission (PMTCT), ART for prevention, post-exposure prophylaxis, and combination prevention are discussed. Clinical features and management of pediatric HIV are also reviewed.

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NATIONAL HIV TESTING AND TREATMENT GUIDELINES 2020 Dr. Bishal Sapkota 1st Year MDGP & EM PAHS
Outline of Presentation • Epidemiology Of HIV In Nepal • HIV Testing Services • Diagnosis Of HIV • Management Of HIV • Monitoring Of People On ART • Management Coinfection • PMTCT
GLOBAL HIV STATISTICS • 37.7 million [30.2 million–45.1 million] people globally were living with HIV in 2020. • 1.5 million [1.0 million–2.0 million] people became newly infected with HIV in 2020. • 680 000 [480 000–1.0 million] people died from AIDS-related illnesses in 2020. • 27.5 million [26.5 million–27.7 million] people were accessing antiretroviral therapy in 2020. • 79.3 million [55.9 million–110 million] people have become infected with HIV since the start of the epidemic. • 36.3 million [27.2 million–47.8 million] people have died from AIDS- related illnesses since the start of the epidemic.
Epidemiology 30 000 790 740 - 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Number PLHIV New HIV infections AIDS-related deaths
ART scale up, 2004-2019 30 36 41 46 53 58 63 0 20 40 60 80 100 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 20,000 ART coverage (%) Number % PLHIV on ART Number of people on ART
PMTCT cascade, 2019 239 123 223 8 51% 93% 3% 0% 100% 0 50 100 150 200 250 300 Estimated pregnant women living with HIV Pregnant women receiving ART to prevent vertical transmission Infants tested by 8 weeks of age New child infections Number
HIV Testing Services • Full range of services: 5 C ‘s. ( consent, confidentiality, correct test result, immediate connection) • Pre test information and post test counselling.
Laboratory diagnosis of HIV infection
Diagnostic algorithm for early infant diagnosis.
HIV Testing Algorithm For All Above 18 Months • A three test HIV testing algorithm is adopted. • Test kit selection based on WHO prequalification, dx sensitivity and specificity and performance characteristic. Diagnostic kits used in national algorithm
National HIV TESTING GUIDELINE
Retesting of individuals who test HIV negative every 6 months (or earlier if they have any signs symptoms suggestive of HIV): • people from KPs; • people with a known HIV-positive partner; • individuals with a diagnosis of or receiving treatment for STIs or viral hepatitis; • individuals with a confirmed or presumptive TB diagnosis; • outpatients with clinical conditions indicative of HIV infection; • individuals with recent HIV risk exposure.
Management Of HIV ART should be initiated in all adults living with HIV, regardless of WHO clinical stage and at any CD4 cell count. WHO “TREAT ALL” policy since the revision of the national HIV testing and treatment guidelines in 2017
General care for people living with HIV • WHO has produced summary guidelines on general care and prevention interventions and recommends a package of 13 • Nutritional care and support • Palliative care: symptom management and end-of-life care
HIV clinical services currently provided from : • ART centres • Community-based ART sites • ART dispensing sites
Disclosure • Many children living with HIV survive into adolescence as a result of increased access to ART. • Disclosure of HIV status among pediatric and/or adolescent patients & their families and support structures is a critically important component • The process of disclosure is complex, both emotionally and socially. • Disclosure of HIV status is not a 1 time event, but rather a process, involving ongoing discussions about the disease as the child or adolescent matures cognitively, socially, emotionally and sexually. • The aim of full disclosure by the age of 12–14 years
National HIV testing and treatment guidelines
National HIV testing and treatment guidelines
National HIV testing and treatment guidelines
Recommended follow-up visit 6 months and 12 months for new clients: conduct VL, CD4 Every 12 months for stable clients: conduct VL
WHO definition of failure to switch ART regimens Failure Definition Comments Clinical failure New or recurrent clinical event indicating advanced or severe immunodeficiency (WHO clinical stages 3 and 4 clinical condition with the exception of TB) after 6 months of effective treatment The condition must be differentiated from immune reconstitution inflammatory syndrome occurring after initiation of ART Immunological failure Younger than 5 years Persistent CD4 levels below 200 cells/mm3 Older than 5 years Persistent CD4 levels below 100 cells/mm3 current WHO clinical and immunological criteria have low sensitivity and positive predictive value Virological failure Viral load above 1000copies/mL Detail in algorithm
Monitoring treatment failure
Drug-specific monitoring of people on ART AZT: zidovudine; ATV: Atanzanavir; DRV: darunavir; DTG: Dolutegravir; EFV: efavirenz; LFT: liver function tests; r: ritonavir; RBS: random blood sugar; SGPT/ALT: serum glutamic pyruvate transaminase/alanine aminotransferase; TDF: tenofovir
Immune reconstitution inflammatory syndrome (IRIS) can occur shortly after starting of ART first time. CD4 count rapidly increases due to effective treatment, a sudden increase in the inflammatory response produces non-specific symptoms such as fever. a paradoxical worsening of pre-existing symptoms, e.g. TB, MAC or CMV. In general, people with more severely damaged immune systems before starting HIV therapy are most at risk for IRIS. occurs in 10–30% of patients initiating ART, usually within the first 4–8 weeks but can occur up to six months. The degree of viral suppression is crucial: the lower the VL, the more pronounced the effect of IRIS.
ARV For HIV Prevention WHO recommends PrEP to people at substantial risk of acquiring HIV infection. Indications for PrEP (by history over the past 6 month) • HIV-negative individuals AND • sexual partner with HIV, OR • Sexually active in a high-risk group (MSM, Multiple sex partner etc) Contraindications to PrEP • HIV-positive persons & creatinine clearance <60 mL/min • Allergy / CI to any medication in the PrEP regimen Oral pre-exposure prophylaxis
PrEP provides high levels of protection with regularly medicines. PrEP begins to work only after taking seven doses.PrEP can be stopped 28 days after the last possible exposure to HIV.
• 1/200 PrEP have raised sr cr level. 80% self-limiting. can be due to dehydration, exercise or diet, or they could reflect a false-positive result. • Cr cl is < 60 mL/min consider discontinuation of, recheck in 1–3 months and continue if Cr cl > 60 mL/min.
Post-exposure prophylaxis • short-term use of ARV drugs to help prevent HIV transmission • ARVs given immediately after exposure can stop the virus from disseminating in the body. • Risk of transmission following skin punctures from a needle or other sharp objects is about 0.3%. • risk of infection by exposure of mucous membranes (the eyes, nose or mouth) or abraded (broken) skin to HIV-infected material is about 0.09%.
National HIV testing and treatment guidelines
Recommendations for PEP Start as soon as possible, preferably within 2 hrs & maximum within 72 . duration of treatment is 28 days. • Get a baseline HIV antibody test and monitor for seroconversion at 6 weeks, 3 months and 6 months after exposure. • Test for hepatitis B and C. • Counsel the exposed person and take informed consent for initiating PEP.
Counselling for PEP must include the following: • the risk of acquiring HIV infection from a specific exposure; • risk and benefits of HIV PEP; • the importance of having an initial baseline HIV test; • Link to treatment for those who are HIV positive; • Enhanced adherence counselling to take the medicine daily for its effectiveness;
• People with established chronic HBV infection should be monitored for hepatic flare after PEP is discontinued or assessed for the need of ongoing HBV therapyafter discontinuing PEP.
Combination HIV prevention • Male condoms • Needle and syringe programmes (NSP) • Opioid substitution therapy (OST) with methadone or buprenorphine • Voluntary medical male circumcision (VMMC) • Behavioural strategies
Clinical feature of HIV in children • Immunosuppressive effects of HIV are additive to the poor response of the immature immune system at birth, predisposing to an increased frequency of invasive bacterial infections and OIs • Common childhood infections and conditions are more frequent in HIV-infected children and have a higher case fatality rate
common clinical manifestations • Failure to thrive • Lymphadenopathy • Respiratory manifestation • Gastrointestinal and hepatobiliary conditions • Skin manifestations • Hematological manifestation • Neurological manifestation • Malignancy
Differences between pediatric and adult HIV infection • Overall progression of disease is more rapid in children. • The immune system is more immature than in adults, even in those with a high CD4 count. • Recurrent invasive bacterial infections are more common in children. • Disseminated CMV, candidiasis, herpes simplex and varicella zoster are more common. • Lymphocytic interstitial pneumonia occurs almost exclusively in children. • CNS infections are common. Peripheral neuropathy, myopathy and Kaposi sarcoma are rare in children.
Preparation of children for ART • Baseline investigations: CBC,ESR,LFT,RFT,RBS,CD4 COUNT, CHEST X RAY. • Screened for TB • Treat any intercurrent illnesses. • Initiate co- trimoxazole prophylaxis in all children. • Counselling, education and support • ART MUST BE STARTED EVEN IF LAB REPORTS ARE AWAITED
ART for infants and children • When to start ART in children: ART should be started in all children infected with HIV below 18 years of age regardless of WHO clinical staging or CD4 count. • Advent of potent ART has dramatically reduced the rates of mortality and morbidity and has improved the quality of life of infants and children living with HIV
First-line ART regimen for infants and children • >1 month to less than 10 years of age, the NRTI backbone for an ART regimen should be Lamivudine & Abacavir • Dolutegravir is approved for older than 6 years and weighing more than 20 kg (OR Raltegravir) • Lopinavir/ Ritonavir /Nevirapine can be used for neonates after 2 weeks of age. (OR Raltegravir)
First-line ART for infants and children 3TC: lamivudine; ABC: Abacavir; AZT: zidovudine; DTG: Dolutegravir; EFV: efavirenz; FTC: emtricitabine; LPV/r: lopinavir/ ritonavir; NVP: nevirapine; PI/r: protease inhibitor boosted with ritonavir; RAL: Raltegravir
Second-line ART for children 3TC: lamivudine; ABC: Abacavir; AZT: zidovudine; DTG: Dolutegravir; EFV: efavirenz; FTC: emtricitabine; LPV/r: lopinavir/ritonavir; NVP:nevirapine; PI/r: protease inhibitor boosted with ritonavir; RAL: Raltegravir; TDF: tenofovir disoproxil fumarate,DRV:Darunavir,ATV :Atanzanavir
Vaccination for children living with HIV • Adequate responses achieved when vaccines are administered early after HIV infection or after virological suppression and immune reconstitution with ART • Vaccines have better safety and efficacy among people with HIV on ART & without significant immunosuppression, i.e:CD4 > 200 cells/mm3 • should receive all vaccines under routine vaccination according to EIP However, live vaccines should be avoided in children in advanced clinical stages and with severe immunosuppression • An extra dose of measles vaccination at 6 months of age is recommended and vaccine against chickenpox is also recommended
Nutritional care and support of HIV-infected • Ensure adequate energy, protein and micronutrient intake at all stages of HIV • Breastfeeding should be promoted and supported for optimal growth and development of infants • Energy needs of these children are increased by about 10% • Extra 20–30% of energy for chronic lung disease or chronic infections, such as TB or persistent diarrhea • Children with severe malnutrition, i.e. signs of visible wasting, bilateral edema or severely impaired growth need 50–100% extra energy each day
Transition to optimal ART regimens for children stable on ART
Management of Advanced HIV Disease, Coinfections & Comorbidities • Advanced HIV disease :defined as a CD4 cell count <200 cells/mm3 or WHO stage 3 or 4 event. All children >5 years of age with HIV are considered as having advanced HIV • Leading causes of mortality in adult with advanced HIV globally include TB, severe bacterial infections, cryptococcal meningitis, toxoplasmosis and PCP. Among children, TB, severe bacterial infections, PCP, diarrhoeal diseases, malnutrition and wasting are the leading causes of death
National HIV testing and treatment guidelines
National HIV testing and treatment guidelines
Algorithm for TB screening for ambulatory people infected with HIV
TB PREVENTIVE TREATMENT The national HIV programme currently recommends the 6-month isoniazid (6H) regimen for TPT. • Adults : Isoniazid; daily, self-administered therapy for 6 months at a dose of 5mg/kg body weight for people >= 10 years to a maximum of 300 mg/day. • Children: (<10 years) @10 mg/kg (7–15 mg/kg BW) daily for 6 months AND • pyridoxine used prophylactically for prevention of neuropathy among patients taking isoniazid DOSE:25 mg/day and should be provided to all on TPT.
Cryptococcal Meningitis Screening and primary prophylaxis are not recommended for children • Treatment for cryptococcal meningitis PHASE TREATMENT INDUCTION PHASE Amphotericin B deoxycholate (1 mg/kg/day) and flucytosine (100 mg/kg/day, divided into four dose), for 1 week followed by 1 week of fluconazole 12 mg/kg/day CONSOLIDATION PHASE Fluconazole 6–12 mg/kg/day for 8 week MAINTENANCE PHASE Fluconazole 6 mg/kg/day for at least 1 year
ART initiation in cryptococcal meningitis • Immediate ART initiation is not recommended because of the risk of increased mortality. • deferred for 4 weeks following an amphotericin B-based induction regimen or • 4–6 weeks following a fluconazole + flucytosine induction regimen (based on a slower rate and longer time to achieve CSF fungal clearance with fluconazole versus amphotericin B).
Co-trimoxazole prophylaxis • cost-effective intervention, effective against the following infections in HIV-positive patients: • common bacterial infections, including bacterial pneumonia, septicaemia • diarrhoea, including that caused by Isospora belli • malaria • toxoplasmosis (primary or recurrent) • Pneumocystis pneumonia (PCP; primary or recurrent).
Criteria for initiation and discontinuation of co-trimoxazole population Criteria for initiation of cotrimoxazole prophylaxis Criteria for discontinuation of co-trimoxazole prophylaxis Children and adolescent Initiate in all regardless of WHO clinical stage or CD4 cell count As a priority: (1) initiate in all < 5 years of age, regardless of WHO clinical stage or CD4 cell count; (2) initiate in all >5 years & with severe/ advanced HIV disease (WHO clinical stage 3 or 4) or CD4 count ≤350 cells/mm3 In settings with a high prevalence of malaria and/or severe bacterial infections: should be continued until adulthood. In settings with a low prevalence of both malaria and severe bacterial infections: may be discontinued for > 5 years of age who are clinically stable, with evidence of immune recovery and/or viral suppression on ART HIV- exposed uninfected infants Initiate in all starting at 4–6 weeks after birth Until the risk of HIV transmission ends or HIV infection is excluded People living with HIV and TB Initiate in all with active TB regardless of CD4 cell count Until criteria for discontinuation in children are met
The prophylactic regimen is: • 1 double-strength (DS) tablet (160 trimethoprim [TMP]/800 sulfamethoxazole [SMX]) every day; or • 2 single-strength (SS) tablets (80 TMP/400 SMX) every day. • dapsone 100 mg per day can be used as an alternative
HIV/HCV coinfection • Both ART and treatment for HCV infection may slow the progression of HCV-related liver disease; • treating both infections is a priority for persons with HCV coinfection • For most HCV-coinfected , including those with cirrhosis, the benefits of ART outweigh concerns regarding drug induced liver injury. • can be treated with DAA combinations of sofosbuvir plus velpatasvir and sofosbuvir plus daclatasvir as pangenotypic regimens for adults 18 years old and more (refer to the National hepatitis C guidelines for detailed case management)
HIV/HBV coinfection • progress to cirrhosis and hepatocellular carcinoma, liver-associated mortality and decreased treatment response compared with people who do not have HIV. • recommended drugs -against HBV are TDF with 3TC or FTC. • TDF should be recommended for use in hepatitis-coinfected patients; otherwise, hepatitis B flares can occur. Similarly, discontinuation of 3TC can lead to HBV flares
Pneumocystis Pneumonia Recommendation for treatment of PCP TMP–SMX: (TMP 15–20 mg and SMX 75–100 mg)/kg/day IV/PO given every 6 or 8 hours. May switch to PO formulations after clinical improvement if on IV for Total duration 21 days Adjunctive corticosteroids for moderate to severe PCP • Prednisone doses (beginning as soon as possible and within 72 hours of PCP therapy) • Days 1–5: 40 mg PO twice daily • Days 6–10: 40 mg PO daily • Days 11–21: 20 mg PO daily • IV methylprednisolone can be given as 75% of the prednisone dose.
Elimination of Vertical transmission of HIV
• In 2019, 431 912 pregnant women were tested for HIV during ANC in Nepal and 73 new cases were identified and linked to care
1 Primary prevention 2. Family Planning 3. Testing and ARV Intervention for mother and baby 4. Keeping mother, dad and any positive baby alive as well The four pillars of PMTCT ?
Pillar 3: Identification of HIV positive women Delivery of maternal ART Management of the exposed infant
Elimination of vertical transmission of HIV four elements of eVT should be considered for women identified as HIV positive during labour and the postpartum period: • provide ART to the mother and the baby following delivery; • implement safer delivery practices; • provide ongoing counselling and support for safer infant feeding; • provide counselling and support for EID at birth and at 6 weeks
National HIV testing and treatment guidelines
Neonatal/infant prophylaxis Low risk HIV exposed High risk HIV exposed • Pregnant mother on ART & Maternal viral load suppressed • 6 week of prophylaxis Nevirapine or zidovudine • pregnant mothers have received ART for less than 8 weeks, VL is more than 1000 copies/mL; or the mother is diagnosed as HIV positive during labour and delivery and even breastfeeding • dual prophylaxis with NVP and AZT for 12 weeks
ARV dosages for infant prophylaxis
Immediate new-born care • Maintain universal precautions throughout care and treatment: • During cord clamping after birth - avoid “milking” the cord towards the baby; - cover the cord with a gloved hand or gauze before cutting. • Use suction only when meconium-stained liquid is present; use mechanical suction at less than 100 mmHg pressure. • Determine the mother’s infant feeding choice, encourage breastfeeding according to the national breastfeeding protocol. • Administer vitamin K, and bacillus Calmette –Guerin (BCG; TB) vaccine according to the national guidelines. • Administer the first dose of ARV prophylaxis within 6–12 hours of delivery. • Handled with gloves until maternal blood and secretions have been washed off
References • NATIONAL HIV TESTING AND TREATMENT GUIDELINES May 2020 • UNAIDS 2019 HIV Estimates and UNAIDS Data 2020

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National HIV testing and treatment guidelines

  • 1. NATIONAL HIV TESTING AND TREATMENT GUIDELINES 2020 Dr. Bishal Sapkota 1st Year MDGP & EM PAHS
  • 2. Outline of Presentation • Epidemiology Of HIV In Nepal • HIV Testing Services • Diagnosis Of HIV • Management Of HIV • Monitoring Of People On ART • Management Coinfection • PMTCT
  • 3. GLOBAL HIV STATISTICS • 37.7 million [30.2 million–45.1 million] people globally were living with HIV in 2020. • 1.5 million [1.0 million–2.0 million] people became newly infected with HIV in 2020. • 680 000 [480 000–1.0 million] people died from AIDS-related illnesses in 2020. • 27.5 million [26.5 million–27.7 million] people were accessing antiretroviral therapy in 2020. • 79.3 million [55.9 million–110 million] people have become infected with HIV since the start of the epidemic. • 36.3 million [27.2 million–47.8 million] people have died from AIDS- related illnesses since the start of the epidemic.
  • 5. ART scale up, 2004-2019 30 36 41 46 53 58 63 0 20 40 60 80 100 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 20,000 ART coverage (%) Number % PLHIV on ART Number of people on ART
  • 6. PMTCT cascade, 2019 239 123 223 8 51% 93% 3% 0% 100% 0 50 100 150 200 250 300 Estimated pregnant women living with HIV Pregnant women receiving ART to prevent vertical transmission Infants tested by 8 weeks of age New child infections Number
  • 7. HIV Testing Services • Full range of services: 5 C ‘s. ( consent, confidentiality, correct test result, immediate connection) • Pre test information and post test counselling.
  • 8. Laboratory diagnosis of HIV infection
  • 9. Diagnostic algorithm for early infant diagnosis.
  • 10. HIV Testing Algorithm For All Above 18 Months • A three test HIV testing algorithm is adopted. • Test kit selection based on WHO prequalification, dx sensitivity and specificity and performance characteristic. Diagnostic kits used in national algorithm
  • 12. Retesting of individuals who test HIV negative every 6 months (or earlier if they have any signs symptoms suggestive of HIV): • people from KPs; • people with a known HIV-positive partner; • individuals with a diagnosis of or receiving treatment for STIs or viral hepatitis; • individuals with a confirmed or presumptive TB diagnosis; • outpatients with clinical conditions indicative of HIV infection; • individuals with recent HIV risk exposure.
  • 13. Management Of HIV ART should be initiated in all adults living with HIV, regardless of WHO clinical stage and at any CD4 cell count. WHO “TREAT ALL” policy since the revision of the national HIV testing and treatment guidelines in 2017
  • 14. General care for people living with HIV • WHO has produced summary guidelines on general care and prevention interventions and recommends a package of 13 • Nutritional care and support • Palliative care: symptom management and end-of-life care
  • 15. HIV clinical services currently provided from : • ART centres • Community-based ART sites • ART dispensing sites
  • 16. Disclosure • Many children living with HIV survive into adolescence as a result of increased access to ART. • Disclosure of HIV status among pediatric and/or adolescent patients & their families and support structures is a critically important component • The process of disclosure is complex, both emotionally and socially. • Disclosure of HIV status is not a 1 time event, but rather a process, involving ongoing discussions about the disease as the child or adolescent matures cognitively, socially, emotionally and sexually. • The aim of full disclosure by the age of 12–14 years
  • 20. Recommended follow-up visit 6 months and 12 months for new clients: conduct VL, CD4 Every 12 months for stable clients: conduct VL
  • 21. WHO definition of failure to switch ART regimens Failure Definition Comments Clinical failure New or recurrent clinical event indicating advanced or severe immunodeficiency (WHO clinical stages 3 and 4 clinical condition with the exception of TB) after 6 months of effective treatment The condition must be differentiated from immune reconstitution inflammatory syndrome occurring after initiation of ART Immunological failure Younger than 5 years Persistent CD4 levels below 200 cells/mm3 Older than 5 years Persistent CD4 levels below 100 cells/mm3 current WHO clinical and immunological criteria have low sensitivity and positive predictive value Virological failure Viral load above 1000copies/mL Detail in algorithm
  • 23. Drug-specific monitoring of people on ART AZT: zidovudine; ATV: Atanzanavir; DRV: darunavir; DTG: Dolutegravir; EFV: efavirenz; LFT: liver function tests; r: ritonavir; RBS: random blood sugar; SGPT/ALT: serum glutamic pyruvate transaminase/alanine aminotransferase; TDF: tenofovir
  • 24. Immune reconstitution inflammatory syndrome (IRIS) can occur shortly after starting of ART first time. CD4 count rapidly increases due to effective treatment, a sudden increase in the inflammatory response produces non-specific symptoms such as fever. a paradoxical worsening of pre-existing symptoms, e.g. TB, MAC or CMV. In general, people with more severely damaged immune systems before starting HIV therapy are most at risk for IRIS. occurs in 10–30% of patients initiating ART, usually within the first 4–8 weeks but can occur up to six months. The degree of viral suppression is crucial: the lower the VL, the more pronounced the effect of IRIS.
  • 25. ARV For HIV Prevention WHO recommends PrEP to people at substantial risk of acquiring HIV infection. Indications for PrEP (by history over the past 6 month) • HIV-negative individuals AND • sexual partner with HIV, OR • Sexually active in a high-risk group (MSM, Multiple sex partner etc) Contraindications to PrEP • HIV-positive persons & creatinine clearance <60 mL/min • Allergy / CI to any medication in the PrEP regimen Oral pre-exposure prophylaxis
  • 26. PrEP provides high levels of protection with regularly medicines. PrEP begins to work only after taking seven doses.PrEP can be stopped 28 days after the last possible exposure to HIV.
  • 27. • 1/200 PrEP have raised sr cr level. 80% self-limiting. can be due to dehydration, exercise or diet, or they could reflect a false-positive result. • Cr cl is < 60 mL/min consider discontinuation of, recheck in 1–3 months and continue if Cr cl > 60 mL/min.
  • 28. Post-exposure prophylaxis • short-term use of ARV drugs to help prevent HIV transmission • ARVs given immediately after exposure can stop the virus from disseminating in the body. • Risk of transmission following skin punctures from a needle or other sharp objects is about 0.3%. • risk of infection by exposure of mucous membranes (the eyes, nose or mouth) or abraded (broken) skin to HIV-infected material is about 0.09%.
  • 30. Recommendations for PEP Start as soon as possible, preferably within 2 hrs & maximum within 72 . duration of treatment is 28 days. • Get a baseline HIV antibody test and monitor for seroconversion at 6 weeks, 3 months and 6 months after exposure. • Test for hepatitis B and C. • Counsel the exposed person and take informed consent for initiating PEP.
  • 31. Counselling for PEP must include the following: • the risk of acquiring HIV infection from a specific exposure; • risk and benefits of HIV PEP; • the importance of having an initial baseline HIV test; • Link to treatment for those who are HIV positive; • Enhanced adherence counselling to take the medicine daily for its effectiveness;
  • 32. • People with established chronic HBV infection should be monitored for hepatic flare after PEP is discontinued or assessed for the need of ongoing HBV therapyafter discontinuing PEP.
  • 33. Combination HIV prevention • Male condoms • Needle and syringe programmes (NSP) • Opioid substitution therapy (OST) with methadone or buprenorphine • Voluntary medical male circumcision (VMMC) • Behavioural strategies
  • 34. Clinical feature of HIV in children • Immunosuppressive effects of HIV are additive to the poor response of the immature immune system at birth, predisposing to an increased frequency of invasive bacterial infections and OIs • Common childhood infections and conditions are more frequent in HIV-infected children and have a higher case fatality rate
  • 35. common clinical manifestations • Failure to thrive • Lymphadenopathy • Respiratory manifestation • Gastrointestinal and hepatobiliary conditions • Skin manifestations • Hematological manifestation • Neurological manifestation • Malignancy
  • 36. Differences between pediatric and adult HIV infection • Overall progression of disease is more rapid in children. • The immune system is more immature than in adults, even in those with a high CD4 count. • Recurrent invasive bacterial infections are more common in children. • Disseminated CMV, candidiasis, herpes simplex and varicella zoster are more common. • Lymphocytic interstitial pneumonia occurs almost exclusively in children. • CNS infections are common. Peripheral neuropathy, myopathy and Kaposi sarcoma are rare in children.
  • 37. Preparation of children for ART • Baseline investigations: CBC,ESR,LFT,RFT,RBS,CD4 COUNT, CHEST X RAY. • Screened for TB • Treat any intercurrent illnesses. • Initiate co- trimoxazole prophylaxis in all children. • Counselling, education and support • ART MUST BE STARTED EVEN IF LAB REPORTS ARE AWAITED
  • 38. ART for infants and children • When to start ART in children: ART should be started in all children infected with HIV below 18 years of age regardless of WHO clinical staging or CD4 count. • Advent of potent ART has dramatically reduced the rates of mortality and morbidity and has improved the quality of life of infants and children living with HIV
  • 39. First-line ART regimen for infants and children • >1 month to less than 10 years of age, the NRTI backbone for an ART regimen should be Lamivudine & Abacavir • Dolutegravir is approved for older than 6 years and weighing more than 20 kg (OR Raltegravir) • Lopinavir/ Ritonavir /Nevirapine can be used for neonates after 2 weeks of age. (OR Raltegravir)
  • 40. First-line ART for infants and children 3TC: lamivudine; ABC: Abacavir; AZT: zidovudine; DTG: Dolutegravir; EFV: efavirenz; FTC: emtricitabine; LPV/r: lopinavir/ ritonavir; NVP: nevirapine; PI/r: protease inhibitor boosted with ritonavir; RAL: Raltegravir
  • 41. Second-line ART for children 3TC: lamivudine; ABC: Abacavir; AZT: zidovudine; DTG: Dolutegravir; EFV: efavirenz; FTC: emtricitabine; LPV/r: lopinavir/ritonavir; NVP:nevirapine; PI/r: protease inhibitor boosted with ritonavir; RAL: Raltegravir; TDF: tenofovir disoproxil fumarate,DRV:Darunavir,ATV :Atanzanavir
  • 42. Vaccination for children living with HIV • Adequate responses achieved when vaccines are administered early after HIV infection or after virological suppression and immune reconstitution with ART • Vaccines have better safety and efficacy among people with HIV on ART & without significant immunosuppression, i.e:CD4 > 200 cells/mm3 • should receive all vaccines under routine vaccination according to EIP However, live vaccines should be avoided in children in advanced clinical stages and with severe immunosuppression • An extra dose of measles vaccination at 6 months of age is recommended and vaccine against chickenpox is also recommended
  • 43. Nutritional care and support of HIV-infected • Ensure adequate energy, protein and micronutrient intake at all stages of HIV • Breastfeeding should be promoted and supported for optimal growth and development of infants • Energy needs of these children are increased by about 10% • Extra 20–30% of energy for chronic lung disease or chronic infections, such as TB or persistent diarrhea • Children with severe malnutrition, i.e. signs of visible wasting, bilateral edema or severely impaired growth need 50–100% extra energy each day
  • 44. Transition to optimal ART regimens for children stable on ART
  • 45. Management of Advanced HIV Disease, Coinfections & Comorbidities • Advanced HIV disease :defined as a CD4 cell count <200 cells/mm3 or WHO stage 3 or 4 event. All children >5 years of age with HIV are considered as having advanced HIV • Leading causes of mortality in adult with advanced HIV globally include TB, severe bacterial infections, cryptococcal meningitis, toxoplasmosis and PCP. Among children, TB, severe bacterial infections, PCP, diarrhoeal diseases, malnutrition and wasting are the leading causes of death
  • 48. Algorithm for TB screening for ambulatory people infected with HIV
  • 49. TB PREVENTIVE TREATMENT The national HIV programme currently recommends the 6-month isoniazid (6H) regimen for TPT. • Adults : Isoniazid; daily, self-administered therapy for 6 months at a dose of 5mg/kg body weight for people >= 10 years to a maximum of 300 mg/day. • Children: (<10 years) @10 mg/kg (7–15 mg/kg BW) daily for 6 months AND • pyridoxine used prophylactically for prevention of neuropathy among patients taking isoniazid DOSE:25 mg/day and should be provided to all on TPT.
  • 50. Cryptococcal Meningitis Screening and primary prophylaxis are not recommended for children • Treatment for cryptococcal meningitis PHASE TREATMENT INDUCTION PHASE Amphotericin B deoxycholate (1 mg/kg/day) and flucytosine (100 mg/kg/day, divided into four dose), for 1 week followed by 1 week of fluconazole 12 mg/kg/day CONSOLIDATION PHASE Fluconazole 6–12 mg/kg/day for 8 week MAINTENANCE PHASE Fluconazole 6 mg/kg/day for at least 1 year
  • 51. ART initiation in cryptococcal meningitis • Immediate ART initiation is not recommended because of the risk of increased mortality. • deferred for 4 weeks following an amphotericin B-based induction regimen or • 4–6 weeks following a fluconazole + flucytosine induction regimen (based on a slower rate and longer time to achieve CSF fungal clearance with fluconazole versus amphotericin B).
  • 52. Co-trimoxazole prophylaxis • cost-effective intervention, effective against the following infections in HIV-positive patients: • common bacterial infections, including bacterial pneumonia, septicaemia • diarrhoea, including that caused by Isospora belli • malaria • toxoplasmosis (primary or recurrent) • Pneumocystis pneumonia (PCP; primary or recurrent).
  • 53. Criteria for initiation and discontinuation of co-trimoxazole population Criteria for initiation of cotrimoxazole prophylaxis Criteria for discontinuation of co-trimoxazole prophylaxis Children and adolescent Initiate in all regardless of WHO clinical stage or CD4 cell count As a priority: (1) initiate in all < 5 years of age, regardless of WHO clinical stage or CD4 cell count; (2) initiate in all >5 years & with severe/ advanced HIV disease (WHO clinical stage 3 or 4) or CD4 count ≤350 cells/mm3 In settings with a high prevalence of malaria and/or severe bacterial infections: should be continued until adulthood. In settings with a low prevalence of both malaria and severe bacterial infections: may be discontinued for > 5 years of age who are clinically stable, with evidence of immune recovery and/or viral suppression on ART HIV- exposed uninfected infants Initiate in all starting at 4–6 weeks after birth Until the risk of HIV transmission ends or HIV infection is excluded People living with HIV and TB Initiate in all with active TB regardless of CD4 cell count Until criteria for discontinuation in children are met
  • 54. The prophylactic regimen is: • 1 double-strength (DS) tablet (160 trimethoprim [TMP]/800 sulfamethoxazole [SMX]) every day; or • 2 single-strength (SS) tablets (80 TMP/400 SMX) every day. • dapsone 100 mg per day can be used as an alternative
  • 55. HIV/HCV coinfection • Both ART and treatment for HCV infection may slow the progression of HCV-related liver disease; • treating both infections is a priority for persons with HCV coinfection • For most HCV-coinfected , including those with cirrhosis, the benefits of ART outweigh concerns regarding drug induced liver injury. • can be treated with DAA combinations of sofosbuvir plus velpatasvir and sofosbuvir plus daclatasvir as pangenotypic regimens for adults 18 years old and more (refer to the National hepatitis C guidelines for detailed case management)
  • 56. HIV/HBV coinfection • progress to cirrhosis and hepatocellular carcinoma, liver-associated mortality and decreased treatment response compared with people who do not have HIV. • recommended drugs -against HBV are TDF with 3TC or FTC. • TDF should be recommended for use in hepatitis-coinfected patients; otherwise, hepatitis B flares can occur. Similarly, discontinuation of 3TC can lead to HBV flares
  • 57. Pneumocystis Pneumonia Recommendation for treatment of PCP TMP–SMX: (TMP 15–20 mg and SMX 75–100 mg)/kg/day IV/PO given every 6 or 8 hours. May switch to PO formulations after clinical improvement if on IV for Total duration 21 days Adjunctive corticosteroids for moderate to severe PCP • Prednisone doses (beginning as soon as possible and within 72 hours of PCP therapy) • Days 1–5: 40 mg PO twice daily • Days 6–10: 40 mg PO daily • Days 11–21: 20 mg PO daily • IV methylprednisolone can be given as 75% of the prednisone dose.
  • 58. Elimination of Vertical transmission of HIV
  • 59. • In 2019, 431 912 pregnant women were tested for HIV during ANC in Nepal and 73 new cases were identified and linked to care
  • 60. 1 Primary prevention 2. Family Planning 3. Testing and ARV Intervention for mother and baby 4. Keeping mother, dad and any positive baby alive as well The four pillars of PMTCT ?
  • 61. Pillar 3: Identification of HIV positive women Delivery of maternal ART Management of the exposed infant
  • 62. Elimination of vertical transmission of HIV four elements of eVT should be considered for women identified as HIV positive during labour and the postpartum period: • provide ART to the mother and the baby following delivery; • implement safer delivery practices; • provide ongoing counselling and support for safer infant feeding; • provide counselling and support for EID at birth and at 6 weeks
  • 64. Neonatal/infant prophylaxis Low risk HIV exposed High risk HIV exposed • Pregnant mother on ART & Maternal viral load suppressed • 6 week of prophylaxis Nevirapine or zidovudine • pregnant mothers have received ART for less than 8 weeks, VL is more than 1000 copies/mL; or the mother is diagnosed as HIV positive during labour and delivery and even breastfeeding • dual prophylaxis with NVP and AZT for 12 weeks
  • 65. ARV dosages for infant prophylaxis
  • 66. Immediate new-born care • Maintain universal precautions throughout care and treatment: • During cord clamping after birth - avoid “milking” the cord towards the baby; - cover the cord with a gloved hand or gauze before cutting. • Use suction only when meconium-stained liquid is present; use mechanical suction at less than 100 mmHg pressure. • Determine the mother’s infant feeding choice, encourage breastfeeding according to the national breastfeeding protocol. • Administer vitamin K, and bacillus Calmette –Guerin (BCG; TB) vaccine according to the national guidelines. • Administer the first dose of ARV prophylaxis within 6–12 hours of delivery. • Handled with gloves until maternal blood and secretions have been washed off
  • 67. References • NATIONAL HIV TESTING AND TREATMENT GUIDELINES May 2020 • UNAIDS 2019 HIV Estimates and UNAIDS Data 2020

Editor's Notes

  • #41: LPV/r syrup or granules can be used after 2 weeks of age. b. RAL should be used as an alternative regimen only if LPV/r solid formulations are not available. c. For age and weight groups with approved DTG dosing
  • #42: a. DRV should not be used for children younger than 3 years and should be combined with appropriate dosing of ritonavir. b. ATV/r can be used as an alternative to LPV/r for children older than three months, but the limited availability of suitable formulations for children younger than 6 years, the lack of a fixed-dose formulation and the need for separate administration of the ritonavir booster should be considered when choosing this regimen
  • #45: The HIV PDR survey showed 10% resistance to NNRTI, so the use of NVP/EFV is discontinued
  • #61: PMTCT is not just about providing antiretroviral therapy The four pillars of PMTCT include primary prevention of HIV , family planning, HIV testing and provision of ART for those positive mother and infant prophylaxis and testing for exposed infants and ensuring lifelong therapy for the family.