NatioNal GuideliNes
For the ManageMent oF hIV and aIdS
NatioNal aiDS CoNtrol
Programme (NaCP)
third edition, 2008
Copyright © 2008 Government of Tanzania.
CoNteNts
Abbreviations - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1
Foreword -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -3
Acknowledgements
-- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 5
Chapter 1: Overview - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 9
Epidemiology of HIV and AIDS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 11
Impact of HIV and AIDS ------------------------------------------12
National Response
-- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 14
Basic Facts about HIV - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 15
Chapter 2: Organization of HIV and AIDS Care and Treatment ------------23
Introduction ----------------------------------------------------25
Identifying People Living with HIV and AIDS in Need of Care and
Treatment and Sensitization of Communities - - - - - - - - - - - - - - - - - - - - - - - - - 25
Scope of Activities to Provide Care and Treatment
-- - - - - - - - - - - - - - - - - - - - - - 26
Organization of Care and Treatment Services ---------------------------27
Linkages Across a Continuum of Care -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 34
Certication of Health Facilities to Deliver HIV and AIDS
Care and Treatment
-- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 35
Management of Antiretroviral Medicines -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - 41
Chapter 3: HIV and AIDS Prevention --- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 47
Introduction ----------------------------------------------------49
Treatment and Prevention of Sexually Transmitted Infections (STIs) -- - - - - - - - 49
Prevention of Mother to Child Transmission (PMTCT) of HIV - - - - - - - - - - - - 49
Condom Programming
-- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 50
Workplace HIV and AIDS Policy and Programme for the Health Sector -- - - - - 51
Prevention of HIV Transmission rough Blood Transfusion ---------------51
HIV and AIDS Prevention for Sex Workers and Other Vulnerable Groups -----51
Youth (in and out of school) and HIV and AIDS
-- - - - - - - - - - - - - - - - - - - - - - - 52
Voluntary Counselling and Testing (VCT) -----------------------------52
Family Planning Services - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 52
Reduction of Stigma and Discrimination -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - 53
Male Circumcision -----------------------------------------------53
Chapter 4: HIV Prevention in a Health Care Setting- - - - - - - - - - - - - - - - - - - - - - 55
Introduction ----------------------------------------------------57
Prevention of HIV Transmission through Standard Precautions
-- - - - - - - - - - - - 57
Post Exposure Prophylaxis (PEP) -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 65
Chapter 5: Laboratory Tests for HIV and AIDS -------------------------79
Introduction ----------------------------------------------------81
Tests for HIV Diagnosis -------------------------------------------81
Tests for Monitoring Disease Progress and Treatment Safety ----------------83
Tests for diagnosing Opportunistic Infections
---------------------------86
Laboratory Safety Procedures ---------------------------------------86
Sample Storage Procedures -----------------------------------------86
Sample Transportation Procedure ------------------------------------86
Chapter 6: Management of Common Symptoms and Opportunistic
Infections in HIV and AIDS in Adolescents and Adults - - - - - - - - - - - - - - - 89
Introduction ----------------------------------------------------91
Clinical Features Commonly Encountered in Patients with HIV and AIDS
-- - - 92
Prophylactic Treatment of Common Opportunistic Infections in HIV
and AIDS with Co-trimoxazole - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 98
Preventive erapy against TB in PLHAs -----------------------------101
Treatment of Opportunistic Infections
-------------------------------101
Chapter 7: Pediatric HIV and AIDS-related Conditions --- - - - - - - - - - - - - - - 109
Introduction ---------------------------------------------------111
Diagnosis of HIV Infection in Infants - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 113
HIV and AIDS Manifestations in Children -- - - - - - - - - - - - - - - - - - - - - - - - - - 115
Management of Infants Born to HIV Positive Women - - - - - - - - - - - - - - - - - - - 117
HIV Diagnostic Protocol for Abandoned Infants
-----------------------118
Care of HIV infected Children -------------------------------------119
Clinical Manifestations of Paediatric HIV Infection ---------------------120
Chapter 8: Antiretroviral erapy in Adults and Adolescents --------------129
Introduction ---------------------------------------------------131
Types of Antiretroviral Drugs --------------------------------------131
Treatment Using ARV Drugs in Adults and Adolescents
------------------133
Recommended ARV Drugs in Tanzania --- - - - - - - - - - - - - - - - - - - - - - - - - - - - 139
Adherence to Antiretroviral erapy - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 145
Changing Antiretroviral erapy -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 147
Second-Line ARV Regimen ---------------------------------------153
Monitoring Patients on ARV erapy
--------------------------------154
Treatment Failure with Second Line Regimens - - - - - - - - - - - - - - - - - - - - - - - - - 161
In Case of Loss to Follow Up -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 162
Contraindications (relative) for initiation of ART -- - - - - - - - - - - - - - - - - - - - - 162
Discontinuation of ART
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 162
What Happens to Adherence Over Time? -- - - - - - - - - - - - - - - - - - - - - - - - - - - 163
Chapter 9: ARV erapy in Infants and Children -- - - - - - - - - - - - - - - - - - - - - 165
Antiretroviral regimens for HIV infected children - - - - - - - - - - - - - - - - - - - - - - 167
Goals of Antiretroviral erapy in Children -- - - - - - - - - - - - - - - - - - - - - - - - - - 168
Selection of Patients for Antiretroviral erapy -------------------------168
Recommended First
-Line ARV Regimens in Infants and Children -- - - - - - - - - 172
Clinical Assessment of Infants and Children Receiving ARV erapy --------173
Reasons for Changing ARV erapy in Infants and Children -- - - - - - - - - - - - - 173
Recommended Second-Line ARV erapy for Infants and Children - - - - - - - - 176
Laboratory Monitoring of Paediatric Patients on ART
-- - - - - - - - - - - - - - - - - - 176
Chapter 10: TB and HIV Co-Infection -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - 179
Introduction ---------------------------------------------------181
TB Management in HIV and AIDS Patients - - - - - - - - - - - - - - - - - - - - - - - - - - 181
Management of Patients Co-infected with HIV and TB ------------------184
Provision of Isoniazid Preventive erapy (IPT) ------------------------189
TB Infection Control in Health Care and Congregate Setting
-- - - - - - - - - - - - 190
Chapter 11: HIV and AIDS in Pregnancy -- - - - - - - - - - - - - - - - - - - - - - - - - - - 193
Introduction ---------------------------------------------------195
Primary prevention of HIV among Women and eir Partners -------------195
Prevention of Unintended Pregnancies among Women Infected with HIV ----196
Prevention of HIV Transmission During Pregnancy, Delivery
and Breastfeeding
-- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 197
Integrating PMTCT into Routine Reproductive and Child Health Service ----200
Comprehensive Antenatal Care for HIV-infected Pregnant Women ---------200
Care During Labour and Deliver - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 202
Follow
-up Care for HIV-infected Mother -----------------------------207
Use of Antiretroviral (ARV) Drugs During Pregnanc -- - - - - - - - - - - - - - - - - - - 208
ARV erapy During Pregnancy- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 211
Chapter 12: Counselling Related to HIV Testing and Treatment Adherence --213
Introduction ---------------------------------------------------215
Provider Initiated Testing and Counselling -- - - - - - - - - - - - - - - - - - - - - - - - - - - 215
Voluntary Counselling and Testing (client-initiated) ---------------------216
ART Adherence Counselling
-- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 216
Counselling Skills -----------------------------------------------217
Counselling for HIV Testing -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 220
Adherence Counselling - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 222
Adherence Monitoring and Evaluation: e Role of the Care
and Treatment Team
-------------------------------------------233
Chapter 13: Management of Mental Health Problems in HIV and AIDS -- - - - 239
Introduction ---------------------------------------------------241
Primary Neurological Complications at Have Secondary Mental Health
Manifestations - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 242
Primary Mental Health Complications
-------------------------------250
Chapter 14: Community and Home Based Care for People
Living with HIV and AIDS ------------------------------------265
Introduction ---------------------------------------------------267
Denitions ----------------------------------------------------268
Coordination at the CTC - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 269
Functions of CHBC Committee - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 269
Benets of Home
-based Care -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 270
Components of Home-based Care -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 271
Palliative Care - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 274
Chapter 15: Nutrition in HIV and AIDS --- - - - - - - - - - - - - - - - - - - - - - - - - - - 281
Nutrition Requirements and HIV Disease Progression -------------------283
Nutrition, Care and Support Priorities by stage -------------------------284
Nutrient Requirements for People Living with HIV and AIDS
-------------284
Good Dietary Practices- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 285
Tips for Healthy and Nutritious Lifestyles for PLHAs -- - - - - - - - - - - - - - - - - - 286
Dietary Practices and Nutrition for AIDS Related Symptoms --------------287
Nutritional Issues Associated with ARVs and Other Modern Medicines
-- - - - - 288
Nutritional Advice in Relation to Multiple Medications --- - - - - - - - - - - - - - - - 288
Nutrition and Antiretroviral erapy --- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 292
Assessment of Nutritional Needs in Relation to ARVs --------------------292
AIDS
-wasting Syndrome -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 293
Body Mass Index (BMI) ------------------------------------------293
Annexes -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 295
Annex 1: WHO Clinical Staging of HIV Disease in Adults and Adolescents --297
Annex 2: WHO Paediatric Clinical Staging
---------------------------299
Annex 3: Presumptive and Denitive Criteria for Recognizing HIV/AIDS-related
Clinical Events in Infants and Children with Established HIV Infection - -302
Annex 4: Dosages of Antiretroviral Drugs for Adults and Adolescents -------312
Annex 5: Paediatric Antiretroviral Dosing
----------------------------313
Annex 6: New WHO Dosing Recommendations for Existing
Paediatrics FDCs -------------------------------------------319
Annex 7: e Role and Sources of Selected Micronutrients -- - - - - - - - - - - - - -320
1
list of abbreviatioNs
3TC Lamivudine
AIDS Acquired Immune Deficiency Syndrome
ANC Antenatal care
ART Antiretroviral treatment
ARV Antiretroviral
ATV Atazanavir
AZT Zidovudine
CBO Community based organization
CHBC Community Home Based Care
CHW Community Health Worker
CoC Continuum of Care
CSF Cerebrospinal Fluid
CTC Care and Treatment Clinic
CTU Care and Treatment Unit (NACP)
d4T Stavudine
ddI Didanosine
DOTS Directly observed therapy, short course
EFV Efavirenz
FBO Faith Based Organisation
FDC Fixed Dose Combination
HAART Highly active antiretroviral therapy
HBC Home Based care
HIV Human Immunodeficiency Virus
IMCI Integrated Management of Childhood Illnesses
INH Isoniazid
IPT Isoniazid Preventive Therapy
IRIS Immune Reconstitution Inflammatory Syndrome
LPV Lopinavir
2 Abbreviations
M&E Monitoring and evaluation
MCH Maternal and child health
MDR Multi-drug resistant
MOHSW Ministry of Health and Social Welfare
MTCT Mother-to-child transmission
NFV Nefinavir
NGO Non-governmental organization
NNRTI Non-nucleoside reverse transcriptase inhibitors
NRTI Nucleoside reverse transcriptase inhibitors
NSAID Non Steroidal Anti inflammatory drugs
NVP Nevirapine
OI Opportunistic infection
PCR Polymerase Chain Reaction
PEP Post-exposure prophylaxis
PI Protease inhibitors
PITC Provider Initiated Testing and Counseling
PLHAs People living with HIV/AIDS
PMTCT Prevention of mother-to-child transmission
RTV Ritonavir
STI Sexually Transmitted Infection
TB Tuberculosis
TDF Tenofovir
THP Traditional Health Practitioners
TLC Total lymphocyte count
VCT Voluntary counselling and testing
VL Viral Load
3
foreWord
During the past 24 years of the HIV epidem ic in Tanzania, the
country has responded in several ways, including putting in place
a series of strategic plans and preventive inter ventions. Since
November 2004, a nation-wide care and treatment programme
aimed a t provi ding ca re and treatment to Peo ple L iving wi th
HIV and AIDS (PLHAs) is being implemented. The main focus
of the prog ram is to improve a ccess to A RVs and Home Bas ed
Care (HBC) for as many PLHAs as possible.
By December 2007 (three years after the program was launched)
and in collaboration with a number of development partners,
a total of 165,000 eligible patients have been started on ARVs
and those who are not eligible yet are being closely monitored
through Care and Treatment Centres (CTCs) spread all over the
country. In spi te of th is impressi ve success in a re latively sh ort
time, there is still a need to expand the servic es to more PLHAs.
This re quires an in creased effor t to ensure the ava ilabili ty of
not only ARVs, but also well-trained staff, adequate space and
supporting facilities such as laboratories and counselling facili-
ties — in short, a quality and functional health system.
HIV and AIDS is a rapidly evolving field. This is particularly
true in the fi eld of care a nd treatmen t of individual s infec ted
with HIV. Newer and more potent drugs are continuously be-
ing developed and used; and knowledge of the existing drugs in
terms of their efficacy, as well as shor t and long-term side effects
is be coming cleare r as we g ain more experien ce. T he se cond
edition of this document, “The National Guidelines for Clinical
Management of HIV and AIDS,” was produced only a few yea rs
4 Foreword
ago. However, re cent develop ments and expe rience in the f ield
of HIV and AID S care and treatme nt has made it ne cessary for
the country to come up with another editi on of these guidelines
to refle ct the changes that have taken place. This wil l help to
improve the quality of care and treatment of our patients.
In this editi on, all c hapters have b een revie wed to inc lude new
information. Due to observed changes and developments the
number of regimens to be used for care and treatment of HIV
and AIDS has been expanded to give clinicians more flexibility
in providing quality c are.
The current edition is also presented in a style that will hopefully
be easy to read, while at the same time serve as a basic reference for
information on HIV and AIDS management. Like the previous
one, it covers Adult and Paediatric HIV and AIDS management;
Nutrition; Manag ement of Opp ortunis tic Infe ctions ; Home
Based Care and the Continuum of Care; and Counselling for
HIV Testing as well as ART adherence. Other areas covered
include : hea lth fa cility certif ication, stand ard pre cautions in
care settings and la boratory ser vices, post exposure prophyla xis,
as well as ARV logist ics and do sages.
As rapid changes will continue to take place in the field of HIV
and AIDS, feedback from users of this manual is vital and
will be used to revise, im prove and update the manual t o keep
abreast with changes. For that reason, your timely feedback will
be highly appreciated.
Dr. Deo Mtasiwa
Chief Medical Officer
Ministry of Health and Social Welfare
5
aCKNoWledGeMeNts
is guideline document is a result of the review of the rst edition
of the National Guidelines for the Management of HIV/AIDS that
was published in April 2005. Current developments and knowledge
in the eld of HIV and AIDS has necessitated the review of the rst
edition and formulation of this document. e new document from
the World Health Organization for the Management of the HIV/
AIDS titled “Antiretroviral erapy for HIV Infection in Adults
and Adolescents in Resource Limited Settings: Towards Universal
Access, Recommendations for a public health approach; 2006 revi-
sion” was especially very resourceful and necessitated the review of
the old guidelines. us, the Ministry of Health and Social Welfare,
first and foremost, appreciates and ac knowledges the va luable
technical guidance obtained from the World Health Organization
(WHO) as well as Family Health International (F HI) and the
Clinton Foundation (CHAI) - both for their important technical
support and nancial assistance towards meeting the expenses for the
initial preparation and consultancy work, including the cost of the
workshops and together with Centres for Disease Control (CDC)
the nalization exercises and printing of this document. Secondly,
the Ministry would like to commend all the other institutions and
organizations that worked hand in hand with the National AIDS
Control Programme towards the production of this document. Of
special note, are the following institutions:
• Muhimb iliUn iversi tyof Heal than dAl lied Scienc es
(MUHAS)
• MuhimbiliNationalHospital(MNH)
• TanzaniaFoodandNutritionCentre(TFNC)and
• NationalTuberculosisandLeprosyProgramme(NTLP).
6 Acknowledgements
We also thank all those who participated in workshops and other
consultations, as individuals or representing their institutions
and organizations. Special tribute goes to the following experts
who excelled in their commitment towards the production and
finalization of this d ocument:
a) Consultants and technical Support
• Prof.FerdinandMugusi,(MUHAS)–Consultant
• Dr.MohamedBakari,(MUHAS)–Consultant
• Dr.EricvanPraag,(FHI)–Consultant
• Dr.KaushikRamaiya,(HinduMandal)–Consultant
• Dr.HelgaNaburi,(MUHAS)–Consultant
•
• Dr.GottliebMpangile,(FHI)–Consultant
• Ms.FeddyMwanga,(WHO/NACP)–Consultant
• Dr.CharlesKagoma,(WHO/NACP)–Consultant
• Dr.ChrisostomLipingu,(MUHAS)–Consultant
• Dr.SylviaKaaya,(MUHAS)–Consultant
• Dr.JessieMbwambo,(MUHAS)–Consultant
• Dr.JosephMbatia,(MOHSW)–TechnicalSupport
• Dr.WernerSchimana,(EGPAF) –TechnicalSupp ort
• Dr.EliudWandwalo,(NTLP)–Consultant
• Ms.JamilaMwankemwa,(TFNC)–Consultant
• Dr.RemiVerduin,(Pharmaccess)–Technicalsupport
B) editorial review Committee
• Prof.FerdinandMugusi,(MUHAS)
• Dr.MohamedBakari, (MUHAS)
• Ms.FeddyMwanga,(WHO/NACP)
Dr.Bwijo Bwijo(NACP)—Consultant
7
• Dr.HelgaNaburi,(MUHAS)
• Dr.EricvanPraag,(FHI)
• Dr.SekelaMwakyusa,(NACP/ClintonFoundation)
• Mrs.EmmaLekashingoMsuya,(NACP)
• Dr.StellaChale,(WHO/NACP)
• Dr.RowlandSwai,(NACP)
• Dr.BennettFimbo,(NACP)
C) Secretari al editing
• Ms.BJHumplinck
• Ms.NaimaManoro
d) editoria l and design S upport
• JimmyBishara,(FHI/Arlington)
• MaryDallao,(FHI/Arlington)
• Dr.TumainiNagu–Consultant
Finally a nd most import ant we thank a ll hea lth wor kers who
have been using the first edition and who provided suggestions
for improvement leading to reviewing the old version and formu-
lating this edition. We still welcome and encourage more input
and suggesti ons during the us e of this docum ent, rememberin g
that learning is a continuous process.
Dr. Donan Mmbando
Director for Preventive Services
Ministry of Health and Social Welfare
8 Acknowledgements
9
Chapter 1:
Overview
10 Chapter 1: Overview
11
Chapter 1: overvieW
epidemiology of hIV and aIdS
HIVandA IDSareamajor globalhealth problem.Bytheen d
of2007,itwasestimatedthatatotalof33.2[30.6–36.1]mil lion
people worldwide were living with HIV and AIDS. Sub-Saharan
Africa is the world’s most severe ly affe cted r egion. With o nly
10% of the world’s population, it shelters about two thirds of the
global total number of people living with HIV and AIDS. One
in 12 adults in this region is reported to be infected with HIV.
Although there are now reports of declining trends in HIV in-
cidence in a number of countries, presumably due to changes in
behaviour and prevention programmes, the number of people with
HIV has continued to rise, due to population growth, and more
recently, the life-prolonging eects of antiretroviral therapy.
Since the rst three AIDS cases were reported in Tanzania in 1983,
the HIV epidemic has spread rapidly to all districts and communities
and has aected all sectors of the society. During the year 2003 a total
of 18,929 AIDS cases were reported to the National AIDS Control
Programme (NACP) from the 21 regions, bringing the cumulative
total of reported cases since the epidemic broke to 176,102.
In 2007 about 2 million persons were estimated to be living with
HIV and AIDS, with approximately 600,000 (30%) in need of
ART. Recent data based on household surveys estimate the sero -
prevalenceinadultsagedbetween15–49yearsinTanzaniatobe
7%, with a wide variation across the regions. Sexual intercourse is
the main mode of transmission of infection. at is why sexually
active individuals aged between 15 and 49 are most severely aected,
with women being at a higher risk of being infected than men.
12 Chapter 1: Overview
Today, in Tanzania as in most Sub-Saha ran Afric an countr ies,
HIVandAIDSarerecogn izednotonlyasamajorpublichealth
concern, but also as a socio-economic and development prob -
lem. Data from a study conducted by the Adult Morbidity and
Mortal ityProj ect(AM MP)in 2002in thedis trictsof Hai,
Temeke and Morogor o rural showed tha t HIV/A IDS and TB
were the leading causes of mortality in those areas.
Impact of hIV and aIdS
Health Impact
The HIV pandemic has h ad a p rofound i mpact on the he alth
care system of all countries world wide but mostly those in
Sub-Saharan Africa. It has reduced resources available for other
health problems which has had an unfavourable effect on the
quality of health care ser vices being provided. In Tanzania
for example, most of the urban district and regional hospitals
report a bed occupancy rate of up to 50-60% for HIV-related
conditions. And since health care p ersonnel are also infected,
there is a human resource crisis in al l health care faciliti es which
adversely af fects the initiation o f care and treatment pro grams
with antiretrovi ral therapy (ART).
The HIV and AIDS pandemic has interacted with other underly-
ing public health problems, particularly Tuberculosis (TB) which
has been establish ed as one of the princi pal cause s of de ath in
persons with HIV infe ction. Nationa l TB infe ction rates in
Sub-Saharan Africa and South-East Asia have escalated over the
past decade. Since the mid-1980s, annual TB notification rates
in many African countries with well-organized programs have
increased fourfold, reaching peaks of more than 400 case s per
100,000 indivi duals. In some co untries, up to 70% of patient s
with sputum smear-positive pulmonary TB are HIV-infected.
13
Themajorit yofhospitala dmissionsinSub -Saharancountries
are due to HIV-relate d conditions including TB. It is therefore
very important that all HIV infected patients be actively screened
and promptly treated for TB.
Economic Impact
There is a close relationship between HIV/AIDS and economic
development. HIV and AIDS negatively affect economic growth
which makes it difficul t for countries and individu als to initiate
adequate and co mprehensive re sponses to the epidemic, du e to
a weak econom ic bas e. Povert y is a pow erful co-fact or to the
spread of HIV and AI DS. The economically and socially dis-
advantaged sec tions of the popul ation including wo men, youth
and other marginalize d groups in society are disproportionatel y
affected b y the epide mic.
Ill health and death due to AIDS have reduced agricultural labour
force, productivity and disposab le incomes in many families and
ruralcommuni ties.DatafromKager a,oneoftheregi onsmost
severely af fected b y HIV an d AIDS in Tanzania, indicate th at
between 1983 and 1994 respecti vely, the annual Gross Domesti c
Product (GDP ) decline d from USD 268 to USD 91. Altho ugh
thisdeclinewasmulti-faceted,AIDSisbelieved tobeamajor
cause. Similar trends of declining GDP associated with reduced
agricultural production and an increase in number of AIDS cases
were observed in the coastal region of Tanga.
Social Impact
AIDS is widespread in both urban and rural comm unities and
mostly affects persons at the peak of their sexual and produ ctive
lives. The death of a young adult often means loss of a family’s
primaryincomegenerator.StudiesconductedinArusha, Kagera
14 Chapter 1: Overview
and Mwanz a reg ions s how a serious and growing breakd own
of social networks, which have up until now su stained Afr ican
societies. Materialistic practices are on the increase; orphans are
notonlysubjectedtomaterial, socialandemotionaldeprivation,
but also lack opportunities for education and health care. Widows
and orphans are deprived of their inheritance rights (by relatives
of their deceased husbands) due to the application of outdated
traditional practices and customar y laws. And often, widows are
blamed for the premature deaths of th eir husband s.
Despite these challenges, experience has shown that the epidemic
can be stabilized or reversed even in countries with modest re-
sources if a supportive environment exists. Programs to mitigate
the impact of HIV/AIDS should include among other things,
strong and high-level political leadership for HIV prevention;
a national HI V and AIDS strategic p lan; ade quate funding for
a national HIV and AIDS response; strong community involve-
mentandinitiatives,andsup portivepolicies.DatafromKag era
has shown that the de cline in HIV prevalence rat es was a result
of a combination of all these factors.
The components of a minimum packag e for HIV and A IDS
response include but are not limited to: blood safety initia-
tives, STD management and preventi on, and car e and suppo rt
for P LHAs incl uding acce ss t o ant iretrov iral drug s. O thers
are: func tional ref erral sys tems and linkages ; educat ion to th e
general community particularly the youth; condom program-
ming; prevention of mot her to child tr ansmission (PMTCT )
and voluntary counselling and testing (VCT).
national response
The national response to HIV and AIDS has shifted hypotheti-
15
cally from one solely based on interventions aimed at prevention
to one th at puts m ore emphas is on c are and treatment a s well.
Since 2004, the Government, in collaboration with partners,
initiate d a care and treatment prog ramme under the NACP.
Currently, a total of 172,736 HIV-infected people have been
enrolle d at 152 NACP sites thro ughou t Tanzan ia. However,
the scaling up of ART provision remains a challenge. Out of
the estimated 600,000 HIV-infected Tanzanians who qualify
for ART, only 136,700 (22.2%) are currently on ART (NACP,
2007). More vigorous efforts are nee ded to promote VCT; to
reduce HIV s tigma among the public and h ealth profes sionals;
to improve on th e quality and quantity of human resour ces; to
improve ARV s upply mana gement; and to in tegrate H IV care
with other health services, such as TB.
Basic Facts about hIV
Aetiology of HIV
In Tanzania, infection with HIV is caused by HIV-1 subtype. No
infection with HIV-2 has been reported yet. e common HIV-1 sub-
types (clades) in Tanzania are A, C, D and their recombinants.
HIV Transmission
HIV infe ction is acquire d throug h sexual intercour se with an
infected partner, exposure to infected blood and blood products,
and from an infect ed mother to her unb orn child, in the uterus,
during delivery, or from breast milk. More than 90% of adults in
Sub-Saharan Africa including Tanzania acquire HIV infection
from unprotected sexual intercourse with infected partners.
Transmission of HIV throug h bo dy fl uids other than blood
and genita l secretion s such as CSF, pleural fluid, and amniotic
fluids is also possible. However, HIV transmission resulting from
exposure to saliva, urine or sweat is not very likely, if at all.
16 Chapter 1: Overview
Pathophysiology of HIV Infection
Interaction between the viral envelope proteins (gp120) and recep-
tors on the cell membrane is critical for HIV to ent er and infect
the host cell. High concentrations of the CD4 molecu les and
co-receptors have been detected on the surface of T-lymphocytes
and macrophages. Other cells that have been found to have CD4
molecules on their surface include the Langerhans cells (found
in the skin) and the microglial cells of the brain.
Following entry of the virus into a susceptible host cell, using the
enzyme reverse transcriptase, the vira l genome copies itself from
RNA to DNA genetic material. The viral DNA copy then enters
the nucleus of the host cell and becomes intimately incorporated
into the host cell’s own DNA using the enzyme integrase, and the
virus becomes a permanent part of an infected person’s nuclear
proteins of the infected cells. This is followed by a latent period
during which the provirus in the infecte d host cell nucleus waits
for an externa l stimulus to start rep roducing.
When CD4+ T lymphocytes are stimulated by new virus or any
other infection, they will respond to these stimuli by increasing
viral replication. As more and more viruses are produced and leave
the host cell, the cell membr ane weakens and ultimately leads to
the death of the infected CD4+ T lymphocytes. Other factors
which are mostly unknown lead to the rapid depletion of the CD4+
T lymphocytes. e decline in the CD 4+ T lymphocytes count
is a reection of a declining cellular immunity, which eventually
manifests itself by the appearance of opportunistic infections.
The Natural History of HIV Infection
Duringthepastfewyears, majoradvanceshavebeenmadein
understanding the complex pathogenetic mechanisms leading
17
to the spread of HIV infe ction over time and to the prog ression
of HIV disease and AIDS.
Initial infection with HIV (Primary HIV infection, PHI) is charac-
terized by a relatively brief period of high-level acute virus replication.
People who are newly infected are highly infectious although they
may test negative for HIV; particularly if they are tested using the
common tests that depend on detection of antibodies against HIV.
e high level of viraemia present at the time of sero-conversion
may persevere for about three months but eventually stabilize at
an individual “set point.”
This is fo llowed by an asympto matic phase of the infect ion,
whereby the levels of CD4+ T-lymphocytes, the prime target cell
for HIV, gradually decline. The rate of decline varies substantially
amongpatients .Majorfactorsthat areknowntoinfluenc ethe
rate of CD4+ T-lymphocyte decline in a patient include:
• Geneticfactors
• Viral load(numberofHIV-RNAcopies/ml)atthe“set
point”
• Viralcharacteristics
• Age
Studies of co horts of patie nts over long pe riods, both c linically
and b iolog icall y, have dem onstrat ed th e va lue of me asurin g
viral loa d as th e most powerful predictive indicator of di sease
progression. A person’s viral load and the number of circulat-
ing CD4+ T-lymphocytes/mm
3
are the t wo mos t imp ortant
laboratory parameters to consi der when a ssessing th e need for
treatment. Viral load is the measure of disease activity and can
be used to evaluate th e rate of the immune system de terioration
18 Chapter 1: Overview
before a nd durin g treatme nt as well as the risk of de veloping
resistance during treatment. The CD4 count can also be used to
evaluate th e risk of compli cations, in cluding t he develo pment
of opportunistic infections.
A higher “set point” ha s been shown to be a ssociated with ra pid
disease progression than a lower one. Infection with syncytium
forming viruses is associated with a more rapid rate of dis-
ease progression compared to non-syncytium forming viruses.
Development of severe immuno-suppression could occur within
2-4 years but may be delay ed for more than 15 year s. However,
in the “t ypical” HIV inf ected p atient it takes 8 -10 years . The
gradual decline of the immune function ultimately reaches a stage
where the CD4 count is belo w 200 ce ll/μl, o r where a patient
develops specific opportunistic (AIDS-defining) illnesses in a
proportionate amount to severe immunodeficie ncy. This is the
AIDS stag e and if l eft un-treate d, the pat ient ultimate ly dies.
The activa tion of t he im mune s ystem by infect ions such as
TB and worm infestation accelerates the onset of immuno-
suppression. The risk of a rapid onset of immuno-suppression can
be minimized by initiating preventive therapy to opportunistic
infections, early det ection and administr ation of effective and
appropriate treatment of infec tive con ditions i n person s with
HIV infection. Preventive therapies currently used include those
for TB, bac terial infe ctions, Pneum ocystis Car inii Pneumoni a,
(PCP), toxoplasmosis and cryptoccocal meningitis.
Comprehensive and qua lity c linical care of persons with H IV
disease requires health care personnel to have appropriate clinical
knowledge and ex perience and labo ratory support to identif y
patients with subtle and/or gross features of HIV disease. Once
19
diagnosis of HIV infection is made, the goal of any treatment plan
is to limit or delay progression towards AIDS for as long as possible
in order to reduce morbidity and to increase survival rate.
Theoretically, the multiple steps in the replication of HIV provide
opportuniti es for interve ntion. A s shown in th e fig ure belo w,
therapeutic regimens may b e dire cted at one o r sever al of the
following stages essential for viral replication:
• AttachmentofHIVtohostcell
• ReversetranscriptionofviralRNAtoDNA
• IntegrationoftheproviralDNAintothehostcells’DNA
Expression of the vira l gene after it has been integrat ed into the
host cell’s DNA inclu des the process of transc ription o f more
viral RNA and the translation of viral proteins.
Figure 1.1 Processing and post–translational modification
of protein products of the virus.
20 Chapter 1: Overview
Antiretro viral drug s that are current ly av ailabl e in Tanzania
function b y targe ting either the R everse transcriptase enzyme
or the Protease enzyme. This results into a halted viral replica-
tion and a consequ ent halting or rever sal of further de cline in
CD4+ T lymphocytes.
Clinical Progression of HIV Infection (see WHO
Clinical Staging Criteria in Table 8.1 in Chapter 8)
In the absence of anti-retroviral therapy, HIV infected patients
go through the following clinical stages:
Primary Infection (becoming HIV infected)
Most people who become infected with HIV do not immediately
notice tha t they have b een inf ected, although some may have
a short illness soon after acquiring infection. This is known as
sero-conversion illness which may last for a few weeks and is often
accompanied by flu like symptoms with fever, malaise, enlarged
lymphnodes,so rethroat,skinrash,and/or jointpains.During
this period of acute feb rile illness there is a wid espread dispersa l
of the virus to different tissues, especially to the lymphoid system.
However, most newly infected persons are clinically asymptom-
atic in spite of this ongoing extensive immunological battle. At
this po int, re sults f rom HI V blo od test s that are d esigned to
detect the presence of HIV antibodies such as ELISA and Rapid
Immunoassays are usually negative.
Clinically Asymptomatic S tage
This sta ge may last for an averag e of between 8-10 y ears wi th
no sy mptoms, alth ough the infect ed p erson may experie nce
swollen glands or a c ondition medically known as Persistent
Generalized Lymphadenopathy (PGL). All HIV infected indi-
viduals can transmit the virus but the chances of transmission
21
are higher with a higher viral load. Infected persons at this stage
are categorized as WHO stage 1.
Symptomatic HIV
Over time, the i mmune system lose s the strug gle to c ontain
the virus and therefore symptoms develop. Symptomatic HIV
infection is often caused by the emergence of opportunistic
infections. The most common infections include fever, respi-
ratory infecti ons, c ough, TB, weight loss, skin disea ses, v iral
infections, oral thrush , pain an d lymphaden opathy. This st age
encompasses W HO stages 2 and 3 depend ing on the par ticular
opportunistic infection seen.
AIDS
The diagnosis of AIDS is confirmed when a person with HIV
develops one or more of a specific number of severe opportu-
nisticinfectionsorcancers.Suchconditionsinclude Kaposi’s
sarcoma , Cry ptococ cal m eningi tis, P CP, Toxoplas mosis and
CMV retinitis. This is WHO stage 4.
22 Chapter 1: Overview
23
Chapter 2:
Organization of HIV
and AIDS Care and
Treatment
24 Chapter 2: Organization of HIV and AIDS Care and Treatment
25
Chapter 2: orGaNizatioN of hiv
aNd aids Care aNd treatMeNt
Introduction
The Hea lth S ector HIV and A IDS Strateg ic Pla n (HS HSP)
2008-2012 bui lds o n the Nationa l HI V an d AI DS Car e and
Treatment Plan for People Living with HIV and AIDS (PLHAs)
which was developed in 2003. Between 2004 and 2006, a total
of 204 healt h faciliti es, mainly hospitals , had beg un providin g
care and treatment. From 2007 onwards th e program rolle d out
to incl ude an addi tional 500 h ealth centres and dispensa ries.
The HSHSP calls for the provision of quality HIV and AIDS
care and treatment ser vices at all hea lth care faciliti es across the
country. Setting standards in the provision of care and treatment
will requir e the esta blishm ent a nd or ganiz ation of effect ive
Care and Treatment Clinics (CTCs) at all health care facilities.
Different tools for the assessment and c ertification of health
care facilities, the training of health care workers, conducting
supporti ve su pervi sion and c linica l me ntoring as well as f or
monitoring the patients and the programme have already been
developed to facilitate the provision of quality care to PLHAs.
Identifying people Living with hIV and aIdS in
need of Care and treatment and Sensitization of
Communities
In ord er to me et th e g oals of the HIV and AIDS Care and
Treatment Plan an expanded effort involving all segments of
the health care system is required to identif y patients in nee d of
care and treatment. Voluntary Counselling and Testing (VCT)
services are an important but not sufficient mechanism to identify
people in need of care and treatment ser vices. Provider Initiated
26 Chapter 2: Organization of HIV and AIDS Care and Treatment
Testing and Counselling (PITC) is being introduced to allow
more people who attend health facilities at the outpatient clinics
and in-patients wards to get tested and access care and treatment
services. However, pe ople in both urban and rural areas need to
be sensitized using all ava ilable communication channel s within
communities and health facilities, to come forward for testing
and counsellin g so that those in ne ed of care and tr eatment can
be linked to those services.
Scope of ac tivities to pro vide Care and
treatment
The estab lishment of CTCs at health care fac ilities that have
been selected to provide care and treatment services including
ARVs has helped to increase the number of people being enrolled
and p rovide d wi th H IV c are a nd t reatmen t. On ce e nrolle d,
CTC cli ents are also linked to a wide range of o ther ser vices
including T B, reprodu ctive heal th and fam ily planni ng, soc ial
and spiritua l support a nd home ba sed care s ervices.
The core ele ments of HI V servic es that nee d to be provided at
CTC level include basic education regarding the mode of HIV
transmission and disease progression, and management of disease
symptoms. This is done through the following:
• Education about behaviour change andcond omuse for
infected people (prevention for positives)
• Orientationtothecareandtreatmentprogramme
• Educationandregularcounsellingonlife-longdiseaseman-
agement, in particular on treatment adherence
• Education andcouns ellingab outaction sthatma ydelay
disease progression and reduce co-morbidities by addressing
issues reg arding nutriti on, food safety, cle an water an d use
27
of insecticide treated bed-nets
• Routineclinicalcareandnutritionalassistancetomalnour-
ished patients
• Proactiveexclusionofco-morbiditiessuchasTBandeffec-
tive referral to TB clinics
• Prophylaxis forOIsasindicatedbytheseguidelines(see
chapter 6)
• AssessingeligibilityforART(clinicalstaging,socialeligibil-
ity and CD4 counts, see chapter 8).
• Effectivereferralstoessentialhospitalservicessuchasante-
natal clinics for MTCT; family planning advice before and
while on ART; STI or other specialized clinics
• Recordingandreportingaccordingtotheestablishedelec-
tronic and paper system
• Registrationandappointmentsystemsforeffectivetreatment
continuation
• Referraltocommunityservi cessuchasHBC,socialwelfare ,
and legal support
In order to provide effective and quality HIV and AIDS Care
and Trea tment, ser vice del iver y ne eds to be organ ized in a
manner to ensure efficiency, user friendliness and regular and
standardized follow up .
organization of Care and treatment Services
Staffing and Team Approach
For a CTC to function well, adequate and trained staff need
to have clearly outlined roles and responsibilities. Since HIV
and AIDS are now managea ble chronic d iseases, th e principles
of chronic disease management need to be followed . Team ap-
proaches involving a patient and a family carer and a healthcare
team consisting of at least a triage nurse, a doctor and a treat-
28 Chapter 2: Organization of HIV and AIDS Care and Treatment
ment/adherenc e nurse, will ensure the buil ding of an ongoi ng
relationship between patient and the health care team for life-long
care. Regular scheduled visits that minimize drug depletion at
home require easily retrievable record s and files and discip lined
observance to appointment schedules. Weekly CTC team meet-
ings to discuss bottlene cks and case studies will h elp to build
the team spirit, while quarterl y staff meeting s bet ween h eads
of relevant uni ts involved in HIV care suc h as CTC, T B, VCT,
MCH/MTCT and in- patient will help to build better internal
cooperation and patient referrals.
The National Stan dard Operati ng Procedures manual outli nes
the followin g staff rol es for the various func tions at the CTC:
• Registrationandappointmentsmanagement;fillingofCTC
1 and CTC 2 basic information; height and weight
• Triage:assessmentofimmediatemedicalneeds,TBscreening
questionnaire, sup port and referri ng the patient to the ne xt
relevant unit or staff at the CTC
• Clinicalmanage ment
• PatientARTpreparednessandadherencecounselling
• Datacollection andmanagement
• Referral managementwithinthehospitalandwithcom-
munity org anizations
Patient Visit Plan
At the initial clinic visit a triage nurse will assess the patient’s needs,
register basic information, issue relevant forms, weigh the patient
and refer him/her to the relevant site. Blood will be drawn for a
conrmatory HIV test if there is doubt on the patient’s status and
CD4 cell count, before the patient meets with a counsellor and
clinician. Given that CD4 test results will typically not be available
29
on the same day, the patient will be scheduled for a follow-up visit
with a clinician to discuss clinical staging and the test results.
At the follow-up visit, aer consultation with a clinician, patients
who are recommended for and agree to initiate therapy will meet
with a counsellor to discuss issues related to adherence, medication
dosing and adverse event management. Another blood sample will
be drawn for tests that will help inform the treatment protocol and
identify baseline values for mon itoring toxicity. Patients will be
scheduled for a follow-up visit aer two weeks, then monthly for
adherence counselling follow up and clinical care and monitoring
of their response to thera py (inc luding to xicity management).
During these visits, the patient wi ll rst meet with a counse llor,
then the evaluating clinician, have further examinations done
if necessary, before picking up their medication from the CTC
or pharmacy. Aer six months, the patient will be requeste d to
continue to visit the clinic once a month for adherence counsel-
ling and medicatio n rells or i f in need o f clinical mana gement.
CD4 counts and basic blood tests will be performed at six month
intervals. e p atients wi ll also see an eva luating cl inician for
follow-up and to evaluate response to therapy.
Those who do not immediately qualify for treatment will require
regular monitoring of their status with assessment of clinical
staging and CD4 count ever y 6 months for all asymptomatic
cases (i.e . WHO stage 1) and all s ymptomatic ca ses (i.e. W HO
stage 2 and stage 3 with CD4 above 350).
All patients are advised to come to the CTC immediately should
their condition deteriorate prior to their next scheduled visit.
Adherence management and lifestyle counselling
Patient non- adhere nce to pr escrib ed medic ation is a g lobal
30 Chapter 2: Organization of HIV and AIDS Care and Treatment
problem. Patients on ARV treatment should be strongly encour-
aged to identify an adherence or treatment assistant. This can
be any person identified by the patient (e.g. a family member,
friend, colleague, or community member) to support the patient
in treatment pro tocols.
During the ir monthl y visit s to the CTC, each patient will b e
screened for TB and provided with cotrima oxazole prophyla xis
as indicated. In addition an adherence and lifestyle counselling
session which will be used to identify possible lapses of adher-
ence and reinforce key practices related to optimal adherence.
Patients will also receive information and counselling on trans-
mission risk r eduction (pos itive pr evention), nutritio nal an d
family planning advice, and adverse event management. Other
psychosocia l needs such as social or legal suppor t, disclosure of
HIV status, mental health, referrals to home based care services
andfacil itationforjoinin gPLHAsupport groupswillal sobe
addressed during the counselling session.
Note: Adherence assessment can be done in various ways includ-
ing pill counting, self reporting, home-based care reporting and
review of patient records.
Medical Records System
Patient identif ication card s (CT C 1), Patien t Re cord Forms
(CTC 2), Regi sters (pre-A RT and ART) and Rep orting Forms
(for Cross- sectional and C ohort an alysis) have bee n desig ned
to facilitate patient identif ication, and patient and pro gramme
monitoring respectivel y. In additio n, an app ointment bo ok to
record booking appo intments and t racking lost to fo llow up
patients is also included in the patient monitoring system.
The Patient Identification Card (CTC1) is a card with a pre-
assign ed un ique patient iden tificat ion n umber issue d at the
31
registr ation section of the facili ty d uring the fi rst v isit. The
card is f or patients on ARV treatment a s well as HIV positive
clients who are no t yet on treatment but are being monitored
by the progra mme. The card s hould be kep t by the patien t and
used for identification purposes at every visit.
It is important that the patient carries treatment relevant informa-
tion with him/her whenever he sees a new clinician, such as when
he transfers to anothe r facilit y. The sam e initial identificati on
number will be reta ined to avoid lost to foll ow up and double
recording o f the patient .
The Patient Record Form (CTC2) is a form initiated at the first
visit for all HIV positive perso ns attending the CTC. It is issued
by the facilit y reg istration unit of the CTC by the attendi ng
clinician or by the att ending c linician’s ord er. The form has a
unique ID number, copied from the Patient Identification Card.
It is kept in a file and retained in the facility registry or dedicated
HIV and AID S care and treatmen t cabinet for r etrieval at ea ch
visit.Keyinformationonpatientmanagementisfilledinbythe
attending cl inician.
Registers
There are two t ypes of reg isters used at the CTC: the Pre-ART
register an d ART regist er.
The Pre-ART register is a tool for tracking and monitoring
the progress of patients that are enrolled in HIV care as they
become eligible for ART. All patients who first enrol for HIV
care, whether t hey are on A RT or not, are in itially li sted in the
pre-ART r egister and counted as enrolle d in HIV care. This
includes patients who transfer in with or without records, who
were previously receiving care at another f acility but are not
32 Chapter 2: Organization of HIV and AIDS Care and Treatment
yet on ART. The only patients who will NOT be entered into
the pre-ART regis ter are patients o n ART who transfer in with
records. Patients who were taking ART but do not have confir-
matory records will be entered into the system as new patients
and screened for eligibility (i.e. new CTC 2, new entry in pre-
ART reg ister, eligib ility scree ning) . Onc e the patie nt beg ins
ART, he/she is transferr ed to the ART reg ister and is no longer
tracked through the pre-ART register.
The ART register is a to ol us ed fo r pati ent a nd pro gramme
monitoring. However, it is only used AFTER a patient has
started ART. The p urpose of the regist er is to co llect the same
information (tran sferred from their indi vidual CTC 2s) about
an entire group of patients in a single location (the register).
Note: The information on the CTC 2 form facilitates the moni-
toring of individual patients and that collected in the register
facilitates the monitoring the whole group of patients.
Reporting
Reporting at the CTC should be done as follows using the ap-
propriate reporting forms and tools:
Monthly and Quarterly Reports
A summary of newly enrolled patients is reported mon thly, and
a cro ss-sec tional (cumu lative tota l) summar y of all pati ents
currently in care and on ART from a single health facility (or
asinglepro jectwithinalarg efacility,withitsow nregisters)is
reported on a quarterly basis. This is done using a cross-sectional
reporting form .
The monthly section covers the first to the last day of the previ-
ous month while the quarterl y section covers the fir st to the last
33
day of the pre vious q uarter. The cross-s ectional form is fill ed
using data from the pre-ART and ART registers. It provides the
following important information:
• Newpati entsenrol ledand eligible forART butnot yet
started on ART
• Newpatie ntsonART (inthe lastre portingp eriod;n ot
transfer in)
• CumulativepatientsenrolledinHIVcare(includingtransfer
in)
• CumulativepatientseverstartedonART
• PatientscurrentlyonARTand currentlyincare(non-ART
plus ART)
• PatientscurrentlyonARTandwhatpropor tionareonfirst
line and second line regimens
• Subsetofpatients ontreatmentorprevent ionforOIs
Programme m onitoring
Programme monitor ing is done at th e faci lity-lev el as well as
higher up in the system using a cohort analys is reporting form
which comprises a collection of indicators for ART start-up
groups (monthly cohort) with their status at 6 months, 12 months,
and 24 months. Data is gradually filled out by a member of the
Care and Treatment Team as results be come availa ble and then
transferred to an identical cohor t analy sis repo rt form that i s
filled out by the District Coordinator/Supervisor for submission
to hig her l evels in the syst em. Th e coh ort an alysis report ing
form provides information that helps the Care and Treatment
Team and district, regional and national levels to monitor how
well the programme is doing with regard to patients started on
ART. It contains information on the following:
34 Chapter 2: Organization of HIV and AIDS Care and Treatment
• Survivingpatients
• Patientsstillonthefirstlineregimen
• Patientsthatwereabletoworkat6and12months
It also provi des a com parison be tween pati ents with 6 months
of ART and other patients with 6 months of ART elsewhere.
Because the data from the cohort analyses are of critical impor-
tance, it is essentia l for the D istrict team’s desi gnated person
in charge of patient moni toring to f ully verif y it. This requires
going back to the reg isters to re-calculate the results for each
monthly coho rt.
An Appointment Book should be kept by a member of the Care
and Treatment Team at the registration unit and filled after the
patient has received the date for the next visit. It should contain
the patient ’s name, da te, uniqu e CTC ID numb er, the reason
for visit and a column for the patient’s show up. Information on
patient show up is crucial for tracking missing patients who can
easily be identified and traced if the patient show up column is
properly filled out.
Each facility participating in the National Care and Treatment
Programme sho uld identif y a spe cific pers on to be r esponsible
for care and Treatment data handl ing and rep orting.
Linkages across a Continuum of Care
Effective lin kages with a variety of ca re-related pr oviding units
within the facility and with partnering programmes in the com-
munity are en courage d at all levels. Partner ships and re gular
dialogue between the CTC and support programs in the commu-
nity need to be estab lished within the dis trict in order to ensure
a continu um of care through function al ref erral m echanism s.
35
Dialogue can be promoted through the expanded Council Health
Managemen t Team (C HMT) or through continuu m of care
subcommitte es. The fo llowing pro grammes or service s should
be considered when developing a continuum of care:
• PMTCT
• VCTandPITC
• STI
• TBClinics
• CommunityandHomeBasedCareincludingPLHAsupport
groups
Certificatio n of health Fa cilities to de liver hIV
and
aIdS Care and treatment
In order to have as many health facilities as possible qualify for the
provision of care and treatment to PLHAs, the National AIDS
Control Programme (NACP) developed a service strengthening
and certication procedure which involves the following steps:
• Assessmentof theavailabilityandqualityofessentialele-
ments to start and/or expand care and treatment
• Identificationofareasforstrengtheningandimprovementto
upgrade health faci lities for the provision of comprehensive
care to PLHAs
• Issuanceofcert ificationtoheal thfacilitiesto enablethem
to start or ex pand care an d treatment onc e they have m et a
minimum set of criteria
The setting of standards helps to ensure that care and treatment
services ar e delivered at an appropria te quality. It al so provides
an opportunity for health facilities to identify needs and channel
resources to meet those needs.
36 Chapter 2: Organization of HIV and AIDS Care and Treatment
Figure 2.1: Preparing facilities for certification
In collaboratio n with other di visions of the MoHSW, the Care
and Trea tment Unit of the NACP conti nues to targe t n ew
faciliti es whe re care and treatment can be a dministe red on a
regular basis. Assessment tools and checklists with minimal
criteria to provide care and treatmen t services have alrea dy been
developed by NACP.
Health authorities at regional and district level such as members
of the RHMT and CHMT and partner organizations supporting
the roll out of care and treatment in respective regions must be
involved in assessing the faci lities as well as in the preparation
and support of strength ening plans .
Between 2004 and 2006 more than 20 0 health faciliti es were
assess ed b y mu ltidis cipli nary ass essment tea ms, compri sing
clinica l, nur sing, labor atory and pharmace utical exper ts and
involving health staff at national, regional and district facilities
and partner organizations.
no
YeS
after 1 year
37
The Strengthening Plan is the key tool in preparing fa cilities for
participationinthecareandtreatmentprogramme.Itisjointly
prepared and agreed upon by assessment team members, facility
officers in charge an d the DMO.
Planning for strengthening the fac ility’s capacity shoul d include
a set of fun ctioning related servi ces wi thin the continuum of
care including among others , VCT serv ices, coord ination with
CHMT and Mul tisecto ral A IDS Committe es ( MACs), and
NGO communi ty based service s.
Table 2.1: Minimum criteria to start/expand ART for hospitals
Organisation of HIV and AIDS Care services within facility
1. Space for registration of HIV and AIDS patients
2.
Clearly described and functioning patient flow plan
(including referral within the facility)
3. Coordination of the HIV and AIDS care and treatment
services at the facility to be done by Project Manager
(this can be a member of the C&T team)
Human resource capacity, training and continuous education
1.
A dedicated Care and Treatment team consisting of
– 1 assessing/prescribing clinician (MD/MO or AMO)
–
1 ARV-evaluating clinician (AMO or CO)
– 1 nurse-counsellor (treatment counselling)
– 1 laboratory technician
–
1 pharmaceutical technician
– 1 data-clerk
2. The above team should have been trained according to
approved national curricula
38 Chapter 2: Organization of HIV and AIDS Care and Treatment
3. Availability of the most recent Guidelines including
National Guidelines for the Clinical Management of HIV
and AIDS, PMTCT, Laboratory, Pharmacy, HBC and VCT
guidelines.
Clinical HIV and AIDS care and treatment services
1.
Confidential consultation room
2. TB-diagnosis and treatment services
3.
STI-diagnosis and treatment services
Patient records and reporting systems
1. An established and working medical record system
2. Locked area with limited and authorized access to
medical records
Continuum of Care: Organisation of HIV and AIDS care
services with and between facility units, outside referral
sites and community support services
1.
A functional referral system from health facilities to the
community and vice versa (linkage with HBC, NGOs,
CBOs, FBOs and other community-based organisations),
and to specialised referral facilities
2.
System for patient tracking
Counselling and Testing services
1. 1 confidential counselling room
2. 1 VCT counsellor
39
Laboratory services
District level
1.
Adequate facilities (enough space, 2-4 rooms)
2. Rapid HIV testing
3. Manual haematology
4.
Manual biochemistry
5. Routine testing stool and urine
6. Malaria blood smears
7.
TB sputum smears
8. Pregnancy testing
9. Screening for blood safety
10.
Refrigerator including freezer compartment
11. Lockable room or cabinet for record storage
12. Lockable inventoried store
13.
SOPs
14. Internal quality system
15. External quality system
16.
Reliable transport
Regional level (should include criteria for district level plus
the criteria listed below)
1. Emergency water reserve
2. Electricity supply back up (generator, solar)
3.
Automated haematology (low volume)
4. Automated biochemistry (low volume)
5. ELISA testing
6.
CD4 testing (low volume)
7. Refrigerator including freezer compartment for samples
40 Chapter 2: Organization of HIV and AIDS Care and Treatment
8. Refrigerator including freezer compartment for reagents
9. Freezer, -20°C
Pharmacy services
1.
Storage space for 1 month supply of ARVs
2. Key policy (with limited access)
3. Functional ARV tracking system
4. SOPs (national ARV pharmacy instructions)
5.
Refrigerator
Finances
1. Budget earmarked for strengthening clinical HIV and
AIDS services
2.
External quality control arrangement
3. Internal quality control arrangement
Roll Out to Certify Health Centres and
Dispensaries
From 2007 onwards Care and Treatment services will reach an
increasing number of people living in rural areas. This wil l be
achieve d throu gh ro ll ou t to health centre s and dispe nsaries.
Assessment tools and minimum criteria lists have been developed
allowing site s to qualif y fo r thre e deg rees of se rvice deliv ery.
These include:
• ACareandTreatmentinitiating site
• AnARTrefilling site or
• Anoutreach service site from the nearest hospital.
41
Facilities a re categ orized on the ba sis of the avail ability of the
following:
1. Supervision from district level
2. Adequate human resource (staff levels and qualifications)
3. Laboratory services
4. Infrastructure, including drug store
5. Proper patient records and reporting system
6. Counseling and testing services
7. Continuum of care (including community home based care)
Management of antiretroviral Medicines
Introductio n
Proper management of medicines ensures optimal use of resources
to avail quality drugs to patients when they need them. e pro-
cess of management involves identication o f the drugs needed,
acquisition of the needed drugs from reliable sources (e.g. MSD)
and ensuring proper utilization of the drugs at end user point.
HIV and AIDS related commodities are relatively expensive and
therefore they require proper handling to ensure effective use.
Rational Drug Use (RDU) of ART
Rational drug use is the process of delivering medication that
is appr opriate to a patie nt’s clin ical needs at t he app ropriate
frequency and duration and at the lowest cost.
ART is a complex undertaking that involves a large variety and
quantity of drugs. It is a l ife long treatment that is in constant
development. It is therefore very important to use drugs rationally
since irrational drug use (especially in the context of ART) may
have unwanted consequences at both indi vidual and population
levels, including:
42 Chapter 2: Organization of HIV and AIDS Care and Treatment
• Treatmentfailure
• Rapiddevelopmentofdrugresistance
• Anincreaseinth eriskoftoxicity 
• Wastageofmoney
Prescriptions
Only trained and authorized prescribers in certified health care
facilities are allowed to write ARV prescriptions.
Dispensing
Antiret rovira l d rugs are pres cript ion-o nly medi cines . Th ey
should only be dis pensed to treatment-read y patients with clear
instructions and adv ice. The dispense r should ensure that the
prescription is appropriately written and signed by an authorized
prescriber before issuing the drugs. The prescription for ARVs
should clearly indicate the name, age, sex of patient, medicines
and dosage, and should include the name, signature and pre-
scriber’s code (where applicab le). Ad ditional ly, ARVs sho uld
only be g iven to th e nam ed p atient or a ppointe d ad herence
assistant. Adeq uate time should be schedule d for antiretrovi ral
dispensing and counselling.
The pha rmacist/ dispense r sho uld ma ke sure that the patient
understa nds the d osag e and dru g int ake schedu le a s we ll a s
instructions re garding the storage an d food requ irements. The
pharmacist/dispenser should also caution patients about possible
side effects, respond to specific questions and problems related
to ARV treatme nt enc ountered by patients and advic e them
on measures to be taken to reduce these side effects including
immediate re turn to the c linic when that happens .
Records
In order to facilitate efficient administration and management
43
of ARVs, all information regarding ARV issuance should be
recorded in a dedicated register book and ART patient card.
Pharmacy Register
The Pharmacist/Dispenser should record and sign all the dis-
pensed ARVs in the dedicated register book located in the
dispensing unit at the p harmacy. Reports on dr ug consumption
and stocks of drugs should be sent to the Ministry of Health and
Social Welfare through the DMO for program monitoring.
Patient Identification Cards
Each patie nt must b e issued with a patient i dentification card,
include for medication (CTC 1). Patients (or appointed adher-
ence ass istants where p atients c an not colle ct the medica tion
themselves) must present the cards to the dispenser every time
they collect medicines and all medications received must be
recorded on the card.
Storage
To ensure proper control and security of ARVs and other drugs, the
following procedures should be used at the facility pharmacy:
Stock must be kept in a high security storage area with a single
pharmacist/pharmaceutical technician (at any one time) respon-
sible for receipts and issues.
Normal sto ck rec ords must be kept for all receipts and issues
along with a running ba lance, and ledgers m aintained for each
item. At the end of each month, the pharmacis t in charge mu st
check the physical stock against the stock records.
ARVs must be stored at the appropriate temperature and/or refriger-
atedsuchasdrugslikeKaletra(Lopinavir/Ritonavir)ifrequired.
44 Chapter 2: Organization of HIV and AIDS Care and Treatment
Commodities must be stored according to the first-to-expire
first-out (FEFO) procedure and stock management.
Damage d a nd e xpire d co mmodi ties shou ld b e im media tely
separated from usable ones in the inventory and disposed using
the laid out procedures.
The pharmacist should maintain adequate stocks of ARVs for all
required medications (first line, second line, adults, paediatrics)
at all times.
Procurement
The procurem ent of ARVs shall be done by the Me dical Sto res
Departm ent w hich will then distr ibute the medic ines to a ll
the accre dite d f acil ities ac ross the cou ntry. Req uisi tion of
antiretrov iral dr ugs fr om the f aciliti es will follo w the no rmal
procedu re fo r oth er dr ugs except that a se parate requ isition
form will be used.
On re ceipt of the drug s at the faci lity, the pharma cist shall
check the ARVs brought by MSD and sign the delivery note.
An adequate buf fer stock of dr ugs must be kept at all times an d
closely monitored to avoid stock outs.
Ordering ARVs
Ordering of ARVs will be done by the p harmacist using the
“Integrated Logistic System” (ILS) register which is made of two
forms: Form A 1 - Dispensi ng Regist er for Antire troviral dr ugs
(ARVs) and Form A2 - R eport and Reques t for An tiretroviral
drugs (ARVs). The built-in inventory control system is design ed
to ensure that drugs are ordered on a monthly basis using existing
stock level s and not morbidity data.
45
Relevant d ata on th e consumptio n of anti retroviral medicines
must b e kept and sent to the M inistr y of Healt h and Soc ial
Welfare every quarter as per the MSD indent format.
Orders t o the Medica l Stor es Dep artment (MSD) should be
timely and made well in advance to allow supplies to reach the
facilities in time.
Collaborati ng with Clinic al Staff
The pha rmacist will not be r equired to re-ord er ARVs u sing
morbid ity data bec ause consu mption dat a wi ll b e av ailab le.
However, the pharmacist will need to work with cl inical staff
to obtain an estimate of the number of patients expected to be
enrolled on therapy.
The ph armacist also nee ds to keep clini cal s taff i nformed of
the current stock le vels of A RVs, particu larly of i tems near ing
stock-o ut. In the eve nt o f nat ion-wi de su pply shor tage, the
pharmacis t shou ld co mmunicate this informa tion t o clin ical
staff so that th ey can pursue the bes t cours e of ac tion.
Monitoring of Adverse Drug Events
Monitoring involves continuous reviewing of program perfor-
mance against its targets. Drug Management system monitoring
helps to ensure that
• clientsg ettheh ealthcomm oditiesth eyneed whenthe y
need them
• planned logisticsactivitiesarecarriedoutaccordingto
schedule
• recordsarecorrectlymaintainedandreportssubmittedin
a timely manner for re-supply and decision making
46 Chapter 2: Organization of HIV and AIDS Care and Treatment
Monitoring and reporting of adverse drug events should be done
according t o the Tanzania Food and Drug Authorit y (TF DA)
guide lines . Ad verse dru g re action s re portin g fo rms (yel low
forms) will be di stributed to facili ties that have been certifie d
to deliver ART.
Audit
Procurement, storage, distributio n and dispensing procedure s
andreco rdsandstock inhandwi llbesubje cttointernal and
external audit. Given the cost and complexities of handling
ARVs, frequent audi ting is antic ipated.
47
Chapter 3:
HIV and AIDS
Prevention
48 Chapter 3: HIV and AIDS Prevention
49
Chapter 3: hiv aNd aids preveNtioN
Introduction
The provision of quality HIV clinical care at the various levels of
the health care system in Tanzania offers a unique opportunity
to de liver preven tion messag es a nd in terven tions. Peopl e in
need of care who have establi shed a trusted relation ship wi th
health care providers are motivated and hence likely to accept
the need for behav iour chang e and pr actices n ecessary to stop
further HIV transmission. Abstinence, faithfulness, condom use
and early diagn osis and treatment of S TIs can be hi ghlighte d
during clinic al care.
treatment and pre vention of Sex ually
transmitted Infections (StIs)
STIs are co-factors for HIV transmission and therefore health care
workers should ensure the provision of quality STI services in all
health facilities through the use of simple diagnostic pro cedures
and the syndromic approach. This can be achieved through
• Regulartraini ngofhealthcarew orkers
• Supportivesuper vision
• Regularsupp lyofessential commoditiesand consumables,
includi ng ma le a nd f emale condo ms fo r ST I pr eventio n
purposes.
prevention o f Mother to Ch ild transmission
(pMtCt) of hIV
PMTCT interventions aim at reducing the risk of HIV trans-
mission from infected mother s to their babies during pregnanc y,
childbirth and during brea st-feeding. Qua lity PMTCT ser vices
should be integrated within Reproductive and Child Health
50 Chapter 3: HIV and AIDS Prevention
services in all health care deli very se ttings in the co untry, and
should include:
• CounsellingandTestingataReproductiveandChildHealth
services setting
• ProvisionofARVprophylaxistotheHIVpositivemother
and her infant to prev ent Mother to Child Transmission
(MTCT)
• Infantfeedingcounsellingandsupport
• Saferdeliverypractices
Community members, particularly men and other close fam-
ily memb ers shou ld be educate d to play a more a ctive pa rt in
supporti ng mo thers to a ccess and use PMTCT serv ices and
in reducing stigma, denial and discrimination. In addition,
postpartum services including family planning and reproduc-
tive heal th informati on and service s shoul d be offered within
PMTCT settings or through referral to all women who wish to
prevent future unintended pregnancies.
Condom programming
Both male and female condoms provide effective protection
against sexual transmission of HIV. The key elements to suc-
cessful condom programming include:
• Easyaccesstocondomswithinandoutsidethehealthcare
setting
• Provisionof educationon consistentan dpropercon dom
use by all healthcare staff
• Appropriatesocial marketingprogrammes forcondoms
51
Workplace hIV and aIdS policy and programme
for the hea lth Sector
e Health Sector has about 60,000 health personnel in dierent
categories. Many of them are in direct contact with infected per-
sons and face the risk of infection through occupational exposure.
ey are also at risk by virtue of being sexually active memb ers of
the population (depending on thei r sexual behaviour) and other
situations that increase their v ulnerability to H IV infection.
As hi ghly respe cted membe rs of thei r co mmunitie s who are
frequently sought for gen eral advice on healthy life styles, health
personnel ne ed to be trained, sensitized , and capac itated to b e
“HIV and AIDS-competent.” This can be done by
• Providingappropri atemeansof protectioninclud ingPost
Exposure Prophy laxis (PE P) as det ailed in Chapter 13
• Ensuringthatprotectivegearandsupportivepolicies/environ-
ment for workplace HIV interventions are available on site
• Orientationon basicprincip lesandinter ventionsofHI V
prevention, care, treatment and support
prevention o f hIV transmission through Blood
transfusion
Transfusion of HIV contaminated blood is the surest way of trans-
mitting HIV infection. An eective and well functioning National
Blood Transfusion Service will ensure the regular availability of
adequate amounts of safe blood in all transfusing health facilities.
e government w ill ensure reg ular availab ility of reagents and
supplies for safe blood transfusion through the pull system.
hIV and aIdS prevention for Sex Workers and
other Vulnerable groups
Sex workers and their clients, men who have sex with men, and
52 Chapter 3: HIV and AIDS Prevention
intravenous drug users, have disproportionately higher HIV
prevalence rates compared to the rest of the population. Increasing
access to services and interventions for these groups will reduce
the transmission of HIV infec tion not only among these g roups,
but also within the general population . NGOs, CBOs and other
agencies working with these groups need to be supported particu-
larly in ensuring an adequate supply of condoms.
Youth (in and out of school) and hIV and aIdS
Priority health sector interventions for youth comprise the
expansion of quality youth-friendly health care services, imple-
mentation of youth-focused prom otion activities and behavio ur
tracking thro ugh sentin el surve illance. There is also a need to
design innovative condom promotion programmes with the
full p articip ation a nd invo lvement of the youth to ensure a n
appropriate link between intention and outcomes.
Voluntary Counselling and testing (VCt)
Voluntary Counselling and Testing has prove d to be effective in
influencing change in sexual behaviour and practices. However,
in order for VCT services to function properly they need to be
easily acce ssible, user- friendly an d be linked t o a health fa cility,
home based care ser vice and o ther HIV s upport ser vices.
Family planning Services
Family planning and effective use of contraceptives can pre-
vent unintend ed preg nancies a mong women who ar e infect ed
with HIV, thu s decrea sing the likeliho od of HIV inf ection i n
children and a s well respon d to their repro ductive rig hts. Most
contraceptive methods , including hormona l contraceptives and
Intra-uterinedevices(IUDs),areappropriate forthemajorityof
HIV infected women. Service providers should assist women who
53
want to avoid pregnancy to make informed, voluntary choices
of contraceptive methods that are best for them. Condom use
should be promoted for dual protection, since other family
planning methods that are more effective for the prevention of
pregnancy, do not offer protection against STI/HIV. Condoms
(both male and female) are the only contraceptive method that
provides pro tection ag ainst HI V and other STIs.
reduction of Stigma and discrimination
Stigmaanddiscriminationconstitutemajorfactorsininhibiting
service util ization and a prop er response to th e HIV and AID S
epidemic. Information Education and Communication/Behaviour
Change C ommunication (IEC/B CC) in tervention s aime d at
stigma reduc tion need to distingui sh between felt and enac ted
stigma. Felt stigma is a collection of prevalent feeling s that in-
dividuals harbour about their condition and the likely reactions
of others, while enacted stigma refers t o actual experien ces of
stigmatization and discrimination, such as the attitude of health
workers, relatives and other members of the community.
Health workers need to be targeted with interventions to reduce
stigma and d iscrimin ation w ithin the h ealth servic e del ivery
setting. As bearers of health-relate d information and knowledge
in their co mmunities, h ealth workers need to be approp riately
informed and sensitized on the issues surrounding HIV and
AIDS so that they can use this knowledge to re duce stigma
within the g eneral pop ulation.
Male Circumcision
There is sufficient evidence on male circumcis ion (MC) as an
HIV preventi on strateg y. A number of studies in South Africa ,
KenyaandUganda,amongothers,havedemonstratedthatMC
54 Chapter 3: HIV and AIDS Prevention
has a signi ficant prote ctive benefi t against HIV infect ion with
reported redu ction in HI V inc idences rang ing fro m 50- 60%
among circumcised men. Countries are being encouraged to roll
out MC plans in order to prevent new HIV infections especially
among its youth p opulation. How ever, planning fo r large-sca le
MC interventio ns needs to take into acc ount the medi cal risks
and ben efits, as w ell a s the socia l, cu ltural, econom ic, s exual,
and other risks and benefits. Thes e must be fully addressed and
community buy-in assured at all levels. Priority should be given
to areas with low MC prevalence and high HIV prevalence for
comparison purposes. MC interventions must run concurrently
with all oth er preventio n strategie s.
55
Chapter 4:
HIV Prevention in a
Health Care Setting
56 Chapter 4: HIV Prevention in a Health Care Setting
57
Chapter 4: hiv prev eNtioN iN a
health Care settiNG
Introduction
HIV and other blood borne pathogens (BBPs) such as Hepatitis B
and Hepatitis C may be transmitted in health care settings from a
patient to a health care worker, from a health care worker to a patient
or from a patient to a patient. e occupational risk of becoming HIV
infected from patients in health care settings is mostly associated
withinjuriesfromsharpssuchasneedlestickinjuries,splashesof
blood or other body uids. Patient to patient transmission usually
results from contaminated equipment and other materials, which
have been incorrectly or inadequately processed.
is can be prevented by implementing the following infection
prevention and control measures: adherence to standard precautions
such as hand hygiene; use of Personal Protective Equipment (PPE)
such as gloves; proper h ealthcare waste management; processing
of instruments by dec ontamination; cleaning and steril ization
using High-Level Disinfectants (HLDs); and observing safe work
practices. e use of such measures will help to minimize the risk
of HIV transmission in the health care setting.
prevention of hIV transmission
through Standard
precautions
Standard precautions are a simple set of effective practice guide-
lines that create a physical, mechanical and chemical barrier to
protect health care workers and patients from infection with a
range of pathog ens including blo od borne pathog ens. Standard
precautions are use d when caring fo r all patients regardless of
diagnosis, (WHO).
58 Chapter 4: HIV Prevention in a Health Care Setting
Components of Standard Precautions
The key components of standard precautions include:
• Consideringe veryperson (patientor staff)a spotentially
infectious and susceptible to infection
• Handhygienepracticesincludinghandwashing,useofhand
antiseptics, alcohol hand rub and surgical hand scrubs
• UseofPPEsuchasgloves,masks,goggles,caps,gowns,boots
and aprons
• Useofantisepticagentsforcleansingskinormucousmem-
branes prior to surgery, cleaning wounds, or doing hand rubs
or surgical hand scrubs
• Safe workpracticessuchasavoidingrecappingorbend-
ing used needles, proper handling of sharps, linen, p atient
resuscitation and patient care equip ment
• Safedisposalofinfectiouswastematerialsandsharpwastes
• Processingofinstrumentsbydecontaminatingandthoroughly
cleaning and sterilizing them with HLDs using recommended
procedures
Implementation of Standard precautions
In practic e, impl ementation of st andard p recautions includ es
the following interventions:
Hand Hygien e
Hand hygi ene tech niqu es s ign ifica ntly red uce the numb er
of dis ease- causi ng mi cro-o rgan isms o n hand s and minim ize
cross- conta minat ion of heal thcar e-rel ated inf ectio ns, such
as tho se fr om he alth care w orker to pat ient. Commo n hand
hygi ene pr oce dure s incl ude ro uti ne hand w ash ing , hand
washin g wi th a ntisep tics, anti septic han d ru bs a nd s urgic al
hand scrubs.
59
The need to apply hand hygiene procedures is determined by
• intensityofconta ctwithpatientsand/o rbloodandbodil y
fluids
• likelihoodofmicrobialtransmission
• patients’susceptibi litytoinfections
• proceduresbeingperformed
Personal Protective Equipment (PPE)
Personal protective equipment safeguards clients and health care
staff fr om bei ng conta minated or in fected by di sease causing
micro-org anisms. Ex amples of PPE includ e:
• Gloves(surgical,examination,elbow-lengthorheavyduty)
• Fluidimpermeableaprons
• Masksandcaps
• Protectiveeyewear
• Boots
Gloves
The use of a separate pair of gloves for each patient helps prevent
the transmission of infection from person-to-person. HCWs
should use gloves when:
• theya nticipate contact withb lood,o therbo dilyflu ids,
mucous membra nes, broken or cut skin
• handlingitemscontaminatedwithblood,otherbodilyfluids
and/or secretions
• performinghousekeepingactivities
• handlinghealthcarewaste(shoulduseutilitygloves)
• theyhaveskinlesionsontheirhands
• performingsurgicalproceduresandvaginalexaminations
in labour (must use sterile gloves)
60 Chapter 4: HIV Prevention in a Health Care Setting
Gloves are not required for routine care activities during which
contact is limited to a patient’s intact skin.
Aprons
Rubber or plastic aprons provide a protective waterproof barrier
for the healthcare worker while at work.
Protective eyewear
Eye-wear, such as plastic goggles, safety glasses, face shields, or
visors that protec t the eyes shou ld b e use d whe n a splash of
blood is anticipated such as during labour and delivery and in
surgical or casualty units.
Boots
Rubber boots or leather shoes provide extra protection to feet
frominjurybysharpsorheavyitemsthatmayaccidentallyfall.
They must be kept clea n. He althc are worker s sh ould avoi d
wearing sandals or shoes made of soft materials.
Handling an d Disposal of Healthcare Was te,
Such as Sharp Instruments
The mos t c ommo n m ode of tr ansm issi on of blo od bor ne
pathogens in a hea lthcare setting is through skin punc ture with
contaminatedneedle sorsharps.Suchinjuriesoftenoccurwhen
sharps are recapped, cleaned, or inappropriately discarded.
The following should be taken into consideration when using
sharps:
• Useasterilesyringe(preferablyaretractablesyringe)and
needleforea chinjectionandreconsti tutionofeachunitof
medication.
• Neverleaveaneedleinsertedinavialcapwhenwithdrawing
multiple doses.
61
• Minimizehandlingofinjectionequipmentwheneverpos-
sible.
• Alwayskeepyourfingersbehindtheneedle.
• Donotdisassembleneedlesandsyringesafteruse.
• Donotrecap,bendorbreakneedlespriortodisposal.
• Donotover-f illsharpsconta iners;filling themmorethan
three-quarter s(3/4)fullma ycauseneedle stickinjuries.It
is also forbidde n to press overflowin g waste bins in order to
push waste down.
• Ifitisnecessarytorecapneedles,such aswhenusingava-
cutainer i n venopunc ture, use the si ngle-hande d scoop ing
method.
Sharps containers (safety boxes)
Usingsafety boxeshelpsto preventinjuriesfr omsharpswaste.
Safety boxes should be puncture-proof, leak-proof, and tamper-
proof. In other words, difficult to open or break.
Safe use of sharps containers (safety boxes)
1. All sharp containers should be clearly marked “SHARPS”
and/or have pictorial instructions for the use and
disposal of the containers.
2. Place sharp containers away from high-traffic areas and
within arm’s reach to where the sharps will be used.
3.
Do not place containers near light overhead fan
switches, or thermostat controls where people might
accidentally touch them.
4.
Never reuse or recycle sharps containers for other
purposes.
5.
Dispose safety boxes when 3⁄4 full.
6.
Ensure that no sharp items are sticking out of containers.
7.
Dispose sharps containers by incineration, burning,
encapsulating, or burying.
62 Chapter 4: HIV Prevention in a Health Care Setting
Safe Disposal of Waste Contaminated with Bodily
Fluids
Proper waste management involves the following steps:
• Segregation
• HandlingandStorage
• Transport
• TreatmentorDestruction 
• Finaldisposal 
Segregation
This refers to separation of waste by type at the point and time
it is gene rated. Diffe rent t ypes of waste should be place d in
containers that are color-coded. In the absence of color-coded
containers, other containers may be used but they should be
properly and visibly labeled.
Refer to appropriate document(s) for further information.
Note: The segre gati on o f wa ste at the point an d ti me i t i s
generated will help to achieve proper waste disposal of infec-
tious w aste and p rotect other staff at the wo rkplace and the
neighbouring community.
Home-based Healthcare Waste Management
Commu nit y Heal th Nurs es and o ther h eal thca re ser vic e
providers providing care in ho mes and the communit y should
handl e and disp ose s harps and other infe ctiou s was te (s uch
as soil ed dres sing s a nd supp lies ) i n t he same ma nner it is
done in a heal thcar e set ting .
63
Proper Proc essing of Inst ruments and Ot her
Contaminated Equipment
There are three basic infection prevention processes recom-
mended fo r the r eduction of dise ase transm ission f rom soile d
instruments and other reusable items. These are: decontamina-
tion, cleaning, and sterilization or high-level disinfection (HLD).
Regardless of the operative procedure, the steps in processing
surgical in struments and other items are the sam e.
Figure 4.1: Infectio n prevention processes fo r instruments and
reusable items
64 Chapter 4: HIV Prevention in a Health Care Setting
Decontaminationisa processt hatmakes inanimateob jects
safer to be han dled by sta ff before cl eaning. It ina ctivates HBV,
HBC and HIV and reduces, but does not eliminate, the number
of other contaminating micro-organisms.
Cleaning is the physically removal of all visible dirt, soil, blood
orothe rbodily fluidsfrom inanimate objects.Cl eaningalso
removes a sufficient number of micro-org anisms hence reduc-
ing risk of in fection by t hose who tou ch the skin o r handle the
object.Theprocessentai lsthoroughlywashingwithwater,soap
or detergent, rinsing with clean water and drying.
High-level disinfection (HLD) is a process that eliminat es all
micro-organisms except some bacterial endospores from inani-
mateobjects. Itentailsboiling,ste amingortheuseofchemica l
disinfectants.
Sterilization is a process that eliminates all micro-organisms (bac-
teria, viruses, fungi and parasites) including b acterial endospores
frominanimateob jectsthroughtheuse ofhigh-pressuresteam
(autoclave), dry heat (oven), and chemical sterilants or radiation.
Proper Handling of Soiled Linen
Key Steps in Processing Linen
• Housekeeping andlaundry personnel shouldwear utility
gloves and other personal protective equipment as indicated
when collecting, handling, transporting, sorting and washing
soiled linen.
• Whencollectingandtran sportingsoiledlinen,the yshould
handleitwithminimumcontacttoavoidaccidentalinjury
and spreading of micro-organisms.
• Allclothitems(suchassurgicaldrapes,gowns,wrappers)used
during a procedure should be considered as infectious. Even if
65
there is no visible contamination the item must be laundered.
• Soiled linenshouldbecarriedincoveredcontainersor
plastic ba gs to pr event spill s and spl ashes, an d confined to
designated are as (interim st orage area) unt il transported to
the laundry.
• Alllineninthelaundryareashouldbecarefullysortedbefore
washing. Do not pre-sort or wash linen at the point of use.
• Whenhand-wa shingsoile dlinen,so akinhot waterwith
0.5% sodium hyp ochlorite solution fo r thirty (30) minute s,
wash separat ely in hot water and th en air dr y.
• Cleanlinenmustbewrappedorcoveredduringtransporta-
tion to avoid contamination.
Cleaning Floors
Detergents and hot water are adequate for routine cleaning of
oors, beds and toilets. In case of spillage of blood or other bodily
uids, the area should be cleaned with a chlorine-based disinfectant
followed by thorough cleaning with soap and hot water.
All health care workers must be conversant with standard pre-
cautions.
post exposu re prophylaxis ( pep)
The most common method of exp osure to HIV infection is
through unprote cted sexual intercourse (se xual exposure ) such
as during sexual assault. Other potential areas of risk of HIV
infection include contact with infectious bodily fluids, such as
during acc idents o r when safety precaution s are not fo llowed
(occupational exposure).
Post Exp osure Pro phylaxis (PEP ) is the imm ediate provisi on
of prevent ive meas ures and medicati on foll owing exp osure to
potentia lly i nfecte d blo od or othe r bod ily fluids in order to
66 Chapter 4: HIV Prevention in a Health Care Setting
minimize the risk of acqu iring infection. Se veral clinical stud ies
have demonstrat ed that HI V transmissi on can be signific antly
reduce d by 81% fol lowing the imme diate adm inistr ation of
antiretroviral agents.
Occupational Exposure
Exposure prevention is the primary strategy for reducing occupa-
tional HIV transmission, that is, the chance of acquiring infection
following exposure to blood and other bodily uids (semen, vaginal
secretions and breast milk) from an infected person. ese bodily
uids should be considered as being infectious.
Effective post-exposure management entails the following ele-
ments: Mana gemen t of Exp osure Site , Exp osure Rep orting ,
Assessment of Infection Risk, Appropriate Treatment, Follow-up
and Counselling
Management of Exposure Site
Wounds and skin sit es that have been in c ontact with blood or
bodily fluids should be was hed with soap and water and mucous
membranes flush ed with water. There is no evidence tha t using
antiseptics fo r wound care o r expressing fluid by sq ueezing the
wound reduce s the risk of blood-born e pathogen transmission .
While the use of antiseptics is not contraindicated, the applica-
tionofcausticagents(e.g.bleach)orinjectionofantisepticsor
disinfectants into the wound is not recommended.
Exposure Re porting
When an occupational exposure occurs, the circumstances and
post exposure management procedure applied should be recorded
in the expos ed p erson’s co nfidenti al fo rm for eas y fol low up
and ca re. Informati on to be recor ded in th e hea lth w orker’s
confidential medical report should include:
67
• Dateandtimeofexposure
• Detailso ftheproc edurebeing performed andthe useof
protective equipment at the time of exposure
• Type,severityandamountoffluidthatthehealthcareworker
was exposed to
• Detailsoftheexposuresourceperson
• Medical documentationthatprovidesdetailsabout post-
exposure management
Risk Assessment for Occupational Exposure
In additi on to the type of bod ily f luids, the ri sk of acquir ing
HIV also dep ends on the ty pe and sever ity of expos ure and the
HIV status o f the sourc e person.
Depending on the sero-status of the source person, the following
criteria can be used to determine the risk of exposure:
• Percutaneousinjury
• Mucusmembraneexposure
• Nonintactskinexposure
• Bites resultingtobloo dexposuretoeitherpersonin-
volved
Table 4.1: Risk of transmission after occupational exposure
BBP Mode of exposure Risk of infection/
exposure
HIV Percutaneous 0.3%
HIV Mucous membrane 0.03-0.09%
HBV Percutaneous 10-30%
HCV Percutaneous 0-10%
Note: Standard precautions should be ad hered to when contact
with any type of body fluid is anticipated.
68 Chapter 4: HIV Prevention in a Health Care Setting
Evaluation of the Exposed HCW
Healthcare workers exposed to HIV should be evaluated within
hours rather than days. A starter pack should be initiated within
2 hrs aer exposure and before testing the exposed person. ereaer,
exposed healthcare workers should be counselled and tested for
HIV at baseline in order to establish infection status at the time
of exposure. PEP should be discontinued if an exposed healthcare
worker refuses to test. To facilitate an eective choice of HIV PEP
drugs, the evaluation shou ld include information on the type of
medication the exposed person might be taking and any current or
underlying medical conditions or circumstances (such as pregnancy,
breast feeding, renal or hepatic disease) that might inuence drug
selection. Vaccination against Hepatitis B should be considered in
thecaseoflargevolumeneedle-stickinjury.
Evaluation of the Source Person
Evaluation of the so urce person sh ould be perf ormed when the
exposed he althcare wor ker agrees to take PE P.
If the HIV, HBV and HCV status of the source person is un-
known perform these tests after obtaining consent. The exposed
healthcare wor ker should not b e involved in o btaining cons ent
from the sour ce person.
If the sourc e pe rson is un known, eval uation will depe nd on
other risk criteria.
Do not test discarded needles or syringes for viral contamination.
Drugs for HIV PEP
For most cases of exposure to HIV a combination of AZT
and 3TC should be used. However, for exposure that poses an
increased risk for transmission see the following table.
69
Table 4.2: Recommended regimen
following percutaneous HIV exposure
INFECTION STATUS OF THE SOURCE
Exposure
type
HIV-
positive
Class 1
+
HIV-
positive
Class 2
+
Source of
unknown HIV
status
†
Unknown source
§
HIV-
Negative
Less
severe
Recommend
basic 2-drug
PEP
++
Recommend
expanded
3-drug PEP
Generally, no
PEP warranted
however,
consider basis
2- drug PEP**
for source with
HIV risk factors
Generally, no
PEP warranted;
however, consider
basic 2-drug PEP**
in setting where
exposure to HIV
infected persons is
likely
No PEP
warranted
Large
volume
§§
Recommend
expanded
3-drug PEP
Recommend
expanded
3-drug PEP
Generally, no
PEP warranted;
however,
consider basic
2-drug PEP**
for source
with HIV risk
factors
++
Generally, no PEP
warranted; however,
consider basic 2-
drug PEP** in setting
where exposure to
HIV-infected persons
is likely
No PEP
warranted
Legend:
* - HIV positive
Class 1 – asymptomatic HIV infection or known low viral load (i.e. <1,500 RNA copies /
mL)
Class 2 – symptomatic HIV infection, AIDS, acute sero-conversion, or known high
viral load. If drug resistance is a concern, obtain expert consultation. Initiation of post
exposure prophylaxis (PEP) should not be delayed pending expert consultation, and,
because expert consultation alone cannot substitute for face-to-face counselling,
resources should be available to provide immediate evaluation and follow- up care for
all exposed persons.
† Source of unknown HIV status (e. g. deceased source person with no samples
available for HIV testing)
§ Unknown source (e. g. a needle from a sharps disposal container)
¶ Less severe (e. g. solid needle and superficial injury)
** The designation “consider PEP” indicates that PEP is optional and should be based on
an individualized decision between the exposed person and the treating clinician. If PEP
is offered and taken and the source is later determined to be HIV- negative, PEP should
be discontinued.
§§ More severe (e. g. large-bore hollow needle, deep puncture, visible blood on device,
or needle used in patient’s artery or vein)
70 Chapter 4: HIV Prevention in a Health Care Setting
Table 4.3: Recommended regimen following mucous membrane or
non-intact skin* exposure
INFECTION STATUS OF THE SOURCE
Exposure
type
HIV-
positive
Class 1
+
HIV-
positive
Class 2
+
Source of
unknown HIV
status
†
Unknown source
§
HIV-
Negative
Small
volume**
Consider
basic 2-drug
PEP
++
Recommend
basic 2-drug
PEP
Generally, no
PEP warranted
however,
consider basis
2- drug PEP
††
for source with
HIV risk factors
Generally, no
PEP warranted;
however, consider
basic 2-drug PEP
††
in setting where
exposure to HIV
infected persons is
likely
No PEP
warranted
Large
volume§§
Recommend
basic 2-drug
PEP
Recommend
expanded
3-drug PEP
Generally, no
PEP warranted;
however,
consider basic
2-drug PEP
††
for source with
HIV risk factors
Generally, no PEP
warranted; however,
consider basic 2-
drug PEP
††
in setting
where exposure to
HIV-infected persons
is likely
No PEP
warranted
Legend:
* For skin exposures, follow-up is indicated only if there is evidence of compromised
skin integrity (e.g. dermatitis, abrasion, or open wound).
† HIV- Positive:
Class 1 - asymptomatic HIV infection or known low viral load (e. g. <1,500 RNA copies/
mL)
Class 2 - symptomatic HIV infection, AIDS, acute seroconversion, or known high viral load.
If drug resistance is a concern, obtain expert consultation. Initiation of post-exposure
prophylaxis (PEP) should not be delayed pending expert consultation, and, because expert
consultation alone cannot substitute for face-to-face counselling, resources should be
available to provide immediate evaluation and follow-up care for all exposures.
§ Source of unknown HIV status (e.g. deceased source person with no samples
available for HIV testing).
¶ Unknown source (e.g. splash from inappropriately disposed blood)
** Small volume (i.e. a few drops).
†† The designation, “consider PEP,” indicates that PEP is optional and should be based
on an individualized decision between the exposed person and the treating clinician. If
PEP is offered and taken and the source is later determined to be HIV- negative, PEP
should be discontinued.
§§ Large volume (i.e. major blood splash)
71
Table 4.4 ARV regimens according to level of risk
Risk category ARV regimen Drug regimen
Low risk Dual therapy( two
drugs)
Zidovudine
(ZDV)+Lamivudine
(3TC)
High risk Triple therapy (three
drugs)
ZDV+3TC+Efavirenz
(EFV), or Lopinavir/r
Timing of Post Exposure Prophylaxis (PEP)
PEP should be initiat ed as soo n as possi ble prefera bly within 2
hours after exposure. Studies suggest that PEP may be substan-
tially less effective if started more than 24-36 hours post-exposure
and not effective after 72 hours.
Follow-up of HIV Exposed Persons
Follow-up is based on clinical examination and laboratory
testing to det ermine the ser o-conversi on and advers e effects o f
the ARV drugs.
HIV antibo dy tests sh ould be p erformed f or at lea st 6 months
post-exposure (i.e. at 6 weeks, 12 weeks and 6 months).
HIV testing should also be performed for any exposed person
who has an illness that is compatible with an acute retroviral
syndrome, ir respective of the inter val sinc e exposure.
If PEP is administered, the exposed person should be monitored
for drug toxicity by testing at baseline and 2 weeks after starting
PEP. Minima lly, it should include a f ull b lood p icture ( FBP),
renal function test (RFT) and hepatic function tests (LFTs).
Exposed persons should be re-evaluated within 72 hours, aer ad-
72 Chapter 4: HIV Prevention in a Health Care Setting
ditional information about the source including serologic status, viral
load, current treatment, any resistance test results or information
about factors that would modify recommendations is obtained.
Prophylaxis should be continued for four weeks if tolerated.
If ARV prophylaxis fails and the exposed person becomes HIV
infected, he/she should be referred to a CTC for proper HIV
care and management.
HIV PEP in Sexual Exposure
Sexual ex posure com prises an act o f unprotec ted volun tary or
forced sexual intercourse (r ape/sexual a ssault), as well as in the
case of slippe d or broken co ndom duri ng sex with d iscordant
partner. The consequences of sexual exposure include a potential
risk of acquiring sexually transmitted diseases including HIV/
HBV and unwante d/unplanned pregnanc y.
Appropriate Management of Exposed Persons
Informed consent (whenever possible) should be obtained before
examination and collection of any forensic evidence that might
be needed in subsequent investigations. Younger children need to
be managed at special ised sites that have the expertise in dea ling
with traumatized children and the prescription of ART.
Healthcare providers are responsible to provide appropriate
comprehensive care for rape survivors, including
• Managementoflifethreateningconditionsandsustained
injuries
• Immediatedetaile dhistorytakin g,precisedo cumentation
of the victim’s details and circumstances of the assault as
well as co nfidential r eporting to appropriate institutions
73
• Thoroughphysicalandgenitalexaminationaswella scol-
lection of specimen (blood/saliva/hair/semen/high vaginal
swab/dry and wet mount preparations, etc.) for laboratory
investigations for STIs and forensic evidence, as soon as
possible (within 24 hours) after the rape incident
• EvaluationandprophylaxisforHIV,HBV,STIsandpregnancy
when indicated, i.e. PEP using antiretroviral therapy, presump-
tive treatment of STIs and emergency contraception
• Counselling ,crisis preventionand provision ofon-goin g
psychosocial support to rape survivors, so as to reduce/
minimize immedia te rape trauma disorder and long-ter m
post-traumatic s tress disord er
• Provisionofmentalhealthcare
• Follow-up caretom onitorothe rpossible infection sand
provision of psychological support, regardless of whether
PEP prophyla xis has b een starte d or not
• Referralofthesurvivortoappropriateorgans(police/legal
services) , according to local laws and re gulations
Risk of HIV Transmission after Sexual Exposure
Risk of transmission of HIV varies with ty pe of sexual expos ure
as shown in the table below:
Table 4.5: Risk of HIV transmission after sexual exposure
Types of exposure (from an HIV
positive source)
Risk of infection per exposure
Receptive oral sex 0-0.04%
Insertive vaginal sex 0.03-0.09%
Receptive vaginal sex 0.1-0.3%
Insertive anal sex 0.03%
Receptive anal sex 0.5-3%
74 Chapter 4: HIV Prevention in a Health Care Setting
When deciding whether to oer PEP or not, consider that risk
of transmission following sexual exposure is high if any of the
following factors were present:
• Blood
• Survivor orassai lantwith asexual lytransmi tteddise ase
with inflammat ion such as gono rrhoea, chlamydia, herpes,
syphilis, bacterial vaginosis , trichomon iasis, etc .
• Multipleassailantsormultiplepenetrationsbyassailant(s)
• Ejaculationbyassailant
• Analpenetration
• Obvioustraumatothegenitalarea
• Theassailant(s)isHIVpositive
Factors to be Considered before Initiation of PEP
Factors to be considered before initiation of PEP for non-
occupational exposure are similar to those for occupational
exposure. They include:
• HIVstatusofpo tentiallyexposed person
• HIVstatusofexposuresourcepersonifavailable.Ifunknown,
PEP can be initiated while the status is being assessed and
disco ntinue d i f s erosta tus of expo sure sour ce p erso n is
confirmed n egative
e decision to begin PEP should not be base d on the likelihood
that the perpetrator is infected or delayed pending the test results
of the exposure source (unless immediately avai lable). Rather, it
should be based on the perpetrator’s transmission risk behavio ur
and the presence of other sexually transmitted diseases, particularly
genital ulcers, which can facilitate HIV transmission .
Note: Exposure to persons who have recently seroconverted may
carry a higher risk of transmission because of high HIV viremia.
75
Basic Steps to be Taken after Sexual Expos ure
• Performcounsellingandtestingatbaselinebeforeadmin-
istering PEP. It is important to establish survivor’s baseline
HIV sta tus bef ore adm inistering PEP in ord er to prevent
the p otentia l fo r de velopin g dr ug re sistan ce, should the
individual be HIV positive.
• Iftherape survivoris HIVnegative administerthe initial
(first) dose of PEP as early as p ossible. T he efficac y of PEP
decreases with the length of time. Offer PEP promptly,
preferab ly wi thin 2 hou rs but not later than 72 h ours of
being rape d. If the rape su rvivor i s HIV positive, refer the
person to CTC for enrolment and further management. Do
not offer PEP.
• Rapesurvivorspresentinglaterthan72hoursafterbeing
raped should not be offered PEP.
• Iftherapesurvivorisnotpsy chologicallyready,thebaseline
HIV test can be delayed by up to 3 days aer commencement
of PEP. If the test result is positive, PEP should be stopped
and the patient should be referred to a CTC. It should also be
explained to the rape survivor that the HIV infection is not the
consequence of the sexual assault but from previous exposure.
• Providepsychosoci alsupportandensureadher encetoPEP
regime. The rate of lost to follow-up is high in this g roup
of patients.
• MonitorforARVdrugtoxicityandmanagetheconditions
(if present) accordingly.
76 Chapter 4: HIV Prevention in a Health Care Setting
Drug Regimen
The recommended treatment regimen is
AZT 300 mg 12 hourly+150mg 3TC 12 hourly daily for 4 weeks
A third drug, EFV or Lopinavir/r should be added if:
• Therehavebeenmultipleperpetrators
• Analpenetrationoccurred
• Thereisobvioustraumatothegenitalareas
• OneoftheperpetratorsisknowntobeHIVpositive
The noted contraind ications for each of the listed drugs should
be considered as per details in appropriate chapters.
Patient Monitoring
Routine te sting with a f ull blo od count and liver enz ymes for
patients on AZT and 3TC is not recommend ed due to short
duration of ther apy. Any blood tests to be perform ed sho uld
be based on patient’s condition.
Three months after the PEP period, the individual should return
for a c onfirmatory set of HIV tests t o determi ne whethe r the
treatment was effective. If treatment was not effective and the
individual becam e infe cted, he/she should be enr olled in the
care prog ram at the C TC and monitor ed appro priately as al l
HIV positive individuals.
77
Figure 4.2: Post Exposure Prophylaxis after Sexual Assault
78 Chapter 4: HIV Prevention in a Health Care Setting
79
Chapter 5:
Laboratory Tests for
HIV and AIDS
80 Chapter 5: Laboratory Testing in HIV
81
Chapter 5: laboratory tests for
hiv aNd aids
Introduction
Laboratory testing is an important integral part of HIV and AIDS
care and treatment. The tests that are done provide additional
information on an indi vidual’s HIV status, the level of disease
progress, treatment eligibility and response to treatment, and
drug adverse reactions.
tests for hIV diagnosis
HIV Testing in Adults and Children over 18 Months
Diagnosis of HI V infec tion in adults and chil dren old er than
18 months is commonly done by detecting antibodies to HIV
using rap id test s or Enzyme Immunoassay s (EIA). Accord ing
to the national testing algorithm, HIV infection is tested and
confirmed based on conc ordance results of two or thre e HIV
rapid tests done se rially. The secon d test should on ly be done if
the first t est is rea ctive (p ositive) an d the thir d test on ly if the
two initial tests are discordant.
The national HIV ra pid testing algori thm is mad e up of three
main HIV rapid tests. These are:
1. Bioline HIV1/2 for the first te st
2. Determine HIV1/2 f or the sec ond test an d
3. Uni-Gold HIV for the third t est
The three rap id tests c an be don e using who le blood , serum or
plasma sampl es. Whene ver possibl e, rapid t esting will be done
with a finger prick sample. HIV rapid testing can be performed
in the laboratory or in non-laboratory hospital, clinic or com-
82 Chapter 5: Laboratory Testing in HIV
munity settings by health care workers trained to performed
HIV rapid test s. However, all te sting done outsi de a laborator y
setting must be super vised by qua lified labo ratory personn el to
ensure accurate and quality results.
Figure 5.1: The National HIV Rapid Test Algorithm
The national testing algorithm for HIV enzyme immuno-assays
(EIA) is curre ntly being d eveloped by MOHSW.
Diagnosing HIV Infection in
Children under 18 months
A positive antibody test (rapid test or EIA) in infants below 18
months does not confirm HIV infection, rather exposure to
HIV ( see f or de tails chapter 7). The laborato ry d iagno sis of
HIV infection in infants and childr en aged <18 months is done
by detecti on of v iral nucl eic acid (RNA or pro-vira l DNA) or
viral antige ns (p24).
83
HIV DNA polymerase chain reaction (PCR) method is used
to confirm HI V infectio n in infants and childr en ≤ 18 months
of age. PCR can be used to diagnose HIV infection in most
infected infants by the age of 6 weeks. Capacity for PCR testing
has be en de veloped at the fo ur zona l con sultant hospita ls in
Tanzania. Samples for PC R testing can be whole blood or dried
blood spo ts (DBS) on speci al filter paper car ds which need to
be transport ed to the zonal hospi tal labora tories.
Figure 5.2: HIV Testing Algorithm for Children below 18 months
tests f or mon itorin g Dise ase P rogress and
treatment Safety
Tests for HIV Disease staging
CD4 cells progress ively decr ease as HIV dis ease adva nces and
immune status detoriates. Measurements of CD4 counts will be
important immunologi cal marke rs of disease progres sion and
assist in decision making on when to start antiretroviral treatment.
In adolescents and adults , CD4 counts are reported in absolute
numbers (for details see chapter 8) while for children under 6
84 Chapter 5: Laboratory Testing in HIV
years CD4 are reported in %. (For details see chapter 7, table 7.1).
Capacities for mea suring CD4 couints have been establis hed at
all zona l, reg ional an d distri ct hospi tal lab oratories. However
equipment t o measure CD4% is currently only avai lable at all
zonal and some regional and hospital laboratories.
Tests for Monit oring Response s to antiretr oviral
Treatment
Succesful antiretroviral therapy results in decrease of viral load,
immune recovery and therefore increase in number of CD4 cells.
Periodically e very 6 months the CD 4 count is used to mo nitor
the immunological response to antiretroviral therapy.
When availa ble, viral loa d may be consid ered in a dditi on to
clinical and immunological measurements to diagnose treatment
failure earlier or to access discordant clinical and immunologic
findings in patients in whom it is suspected that ART has fai led.
Capacity for viral load mea surements is currently limi ted to
zonal consultant hospitals.
Tests for Monit oring antiretr oviral Treatment
safety (toxicity)
Antiretroviral drugs are known to produce short- and long
term side ef fects in s ome patients . Clinical follow up is crucia l
supported by laboratory investigations. Capacity for testing hae-
matology ind ices and clini cal biochemis try has been de veloped
at laboratories of all hospitals with a CTC in the country. The
frequenc y of monito ring d epends on th e ART regimen used
and is summarized in table 8.5 in chapter 8.
Furthermore toxicity ART drug varies in severity which determines
the clinical action to take. e following tables show the grading of
adverse events as a result of ARV drugs for adults and children.
85
Table 5.1: Grading adverse reactions in adults
LABORATORY TEST ABNORMALITIES
Item
Grade I
Toxicity
Grade II
Toxicity
Grade III Toxicity
Grade IV
Toxicity
Haemoglobin 8.0-9.4 g/dL 7.0-7.9 g/dL 6.5-6.9 g/dL <6.5 g/dL
Absolute Neutrophil
Count
1-1.5 x 10
9
/L 0.75–0.99 x
10
9
/L
0.5-0.749 x 10
9
/L <0.5 x 10
9
/L
ALT 1.25-2.5 x
upper normal
limit
>2.5-5 x
upper normal
limit
>5.0-10 x
upper normal limit
>10 x
upper normal limit
Triglycerides 3-4.51 mmol/L 4.52-8.48
mmol/L
8.49-13.56 mmol/L >13.56 mmol/L
Cholesterol >1.0-1.3 upper
normal limit
>1.3-1.6
upper normal
limit
>1.6-2.0
upper normal limit
>2.0
upper normal limit
MANAGEMENT Continue ART
Repeat test 2 weeks after the
initial test and re-assess
Continue ART
Repeat test 1 week after initial test
and reassess; if ALT still grade 3
consult expert about stopping ART
Consult expert
immediately before
stopping ART
Table 5.2: Grading the severity of adverse reactions in children
LABORATORY TEST ABNORMALITIES
Item
Grade I
Toxicity
Grade II
Toxicity
Grade III
Toxicity
Grade IV Toxicity
Haemoglobin
> 3 mo. – < 2 y. o.
9.0-9.9 g/dL 7.0-8.9 g/dL <7.0 g/dL Cardiac failure
secondary to anaemia
Haemoglobin
≥ 2 y.o.
10-10.9 g/dL 7.0-9.9 g/dL <7.0 g/dL Cardiac failure
secondary to anaemia
Absolute Neutrophil
Count
0.75-1.2 x 10
9
/L 0.4-0.749 x 10
9
/L 0.25-0.399 x 10
9
/L <0.25 x 10
9
/L
ALT (SGPT) 1.25-2.5 x upper
normal limit
2.6-5 x upper normal
limit
5.1-10 x
upper normal limit
>10 x
upper normal limit
Triglycerides — 1.54-8.46 mmol/L 8.47-13.55 mmol/L >13.56 mmol//L
Cholesterol — 4.43-12.92 mmol/L 12.93-19.4 mmol/L >19.4 mmol/L
86 Chapter 5: Laboratory Testing in HIV
tests for diagno sing opportuni stic Infection s
Common OIs including the laboratory investigations to confirm
diagno sis are d iscusse d in cha pter 6. For laborat ory di agnosi s
of common OIs such as TB, upper respiratory tract infections,
meningi tis, di arrhoea s and septica emia, diagno stic pr otocol s
are avai lable as stan dard o perating proce dures a nd shou ld be
used. Labora tory capaci ty for TB AF B and general microscopy
exists at all hospitals and health centres. Culture for bacterial
infections c an be perfo rmed at all zonal and re gional ho spitals.
Close te am wor k betw een la borator y and clini cal sta ff at the
CTC is required to optimize diagnostic capacities.
Laboratory Safety procedure s
Adherence to safety precautions in the laboratory should be
done at a ll s teps starti ng fr om s pecim en co llect ion, stora ge,
transportation and disposal of biohazard wastes so as to minimize
occupational risks. The risk of transmission of HIV, hepatitis
B viru s (HBV ) a nd oth er bl ood-bor ne di sease agents can be
minimi zed if la borato ry w orkers obser ve safet y pre caution s
/procedures at all times. All spec imens shoul d be treat ed a s
infectious. For more details, see chapter 4.
Sample Storage procedures
All samples should b e stored in tightly clo sed and labelle d tubes
and kept in an upright position in racks. Temperature require-
ments should be obs erved during sp ecimen storag e and records
of all samples kept. Always dispose used or old specimens timely
by autoclaving and incineration.
Sample transportation procedure
Whenever the capac ity for a particu lar test does not exist in the
laboratory on-site, effor ts shoul d be ma de by l aboratory staff
87
to pre pare sample s for tran sporta tion to th e nea rest facil ity
with such capac ity. When transp orting sample s from the cli nic
to laboratory or from one laboratory to another, the following
should be observed:
• Specimensshouldbepackagedappropriatelyaccordingtothe
Standard Operating Procedures (SOPs) and put in appropriate
and safe containers before transporting them by road (bus or
vehicle) or air
• Driedb loodspot ssamples (DBS) onblotti ngpaper are
considered to be non-infe ctious an d can be put in a letter
envelope and transported by mail or courier. Consult courier
and receivi ng laborator y for pro cedures an d timing.
• Aspecimendelive rychecklistshou ldbeusedtoverif ythat
there is a requisition form for all samples transported.
• Dispatchandreceiptrecords oftransportedsamplesshould
be maintained.
(For mo re de tails on DBS collec tion and t ranspor tation see
EID guidelines)
88 Chapter 5: Laboratory Testing in HIV
Chapter 6:
Management of
Common Symptoms
and Opportunistic
Infections in HIV and
AIDS in Adolescents
and Adults
90 Chapter 6: Management of Common Symptoms and Opportunistic Infections in
HIV and AIDS in Adolescents and Adults
91
Chapter 6: MaNaGeMeNt of CoMMoN
syMptoMs aNd opportuNistiC
iNfeCtioNs iN hiv aNd aids iN
adolesCeNts aNd adults
Introduction
Despite the availability of ART, it is important to bear in mind
that there is still no cure for HIV inf ection and AI DS. It is also
important to remember that HIV infected patients do not die
from HIV infection per se; rather from the various complications
resulting from the HIV induced immune deterioration. A size-
able proportion of HI V infected patients yield to opportunis tic
illnesses . Fortun ately, mo st of these illnes ses are amenab le to
therapy, and their early reco gnition a nd prompt trea tment can
significa ntly re duce H IV ass ociated morbidi ty and morta lity.
And e ven wh ere s uch i llness es ca nnot be c ured, a lo t can be
done to substan tially improve the dur ation a nd qual ity o f an
HIV infected patient’s life.
This chapter highlights the following:
• Clinicalfeature sandtreatmentof thecommonsymp toms
encountered in persons infected with HIV
• Preventionofcommonopportunisticinfectionsandoffers
guidance to their management
• Dia gnosisandtreatmentofsomeopportunisticillnesses
seen in persons infected with HIV
92 Chapter 6: Management of Common Symptoms and Opportunistic Infections in
HIV and AIDS in Adolescents and Adults
Clinical Fe atures Commonly encountered in
patients with hIV and aIdS
Fever
Fever in a patient may be due to a variety of causes. However,
the associated clinical features may inform the diagnosis. If no
pointing features to a diagnosis are present, as a minimum the
following sh ould be d one:
• Bloodslidefo rmalariaparasites
• SputumforAFB
• ChestX-ray
• Urinalysis
• Hemogram(FBP,ESR)
Where f aciliti es are avail able, and if indi cated, the followin g
tests should also be done:
• Urinecultures
• BloodcultureforTBandotherorganisms
• Bloodforwidaltest(Extendedwidal)
Cough and Dyspnoea
Persistent co ugh and or dysp noea can usually be attri buted to
one of the following:
• PulmonaryTB
• Bacterialpneumonia
• Pleuraleffusion,commonlyduetoTB
• PulmonaryKaposi’ssarcoma
• Viralpneumonia
• Cardiacfailure,commonlyduetodilatedCardiomyopathy
• Pericardialeffusion,commonlyduetoTB
93
Sometimes, it may not be possible to determine the underlying
cause of cough and dyspnoea on clinical history and physical ex-
amination alone. At such times, laboratory tests may be of critical
value. e recommended laboratory investigations include:
• SputumforAFBx3(canbedoneatalllevels)
• Sputumforpyogeniccultureandsensitivity
• Chestx-ray
• Bronchoscopy(consultanthospitals)
• ECGandEchocardiography(whereavailable)
Oral, Oropharyngeal and Oesophageal Candidiasis
Patients with oropharyngeal and oesophageal candidiasis may
complain of pain and/or difficulty in swallowing, which may be
due to infection of the esophagus with Candida. On examina-
tion white painless plaque (“curd like”) on buccal or pharyngeal
mucosa or tongue surface that can easily be scrapped off will be
seen.Whereavailable,abariumswallowX-raycanbeperformed.
For treatment, any of the following may be used:
• Fluconazoleoral ly
• Miconazole
• Nystatinoralsuspension
• 2%sodiumbenzo ateorGentianviolet solution
• Ketoconazole
Vaginal Candidiasis
This is one of the common illnesses presenting with itchy curd-
like discharge. The diagnosis is largely clinical, and it can be
managed with:
• Clotrimazolepessaries
• Miconazolepessaries
94 Chapter 6: Management of Common Symptoms and Opportunistic Infections in
HIV and AIDS in Adolescents and Adults
• Fluconazoletakenorally(incaseofpessariesfailure)
Weight Loss
Weight loss in persons with HIV induced illnesses including
AIDS may be due to:
• Reducedfoodintake
• Difficult/painfulswallowing
• Diminishe dgastrointestinaluptake(malabsorption,diar-
rhoea),
• TB(afrequentcauseofrapidweightloss)
• Intestinalworms
• Otherconcomitantdebilitatingdiseasessuchascancer
• Intractablevomiting
• HIVitself
The treatment of weight loss includes
• Highcaloriean dproteinfeeds
• Treatmentoftheunderlyingcause
Diarrhoea
Diarrhoea in persons with HIV induced illnesses including
AIDS may be have a variety of causes including:
• CommonpathogenssuchasSalmonellaorShigella
• Amoebiasis
• Chronicmalabsorption
• Cryptosporidiosis
• Mycobacteriumaviumcomplex(MAC)infection
• Isosporidiosis
• Clostridiumdifficileinfection
95
Investigations:
• ExaminestoolsfortreatablecausessuchasSalmonella, Shigella,
V. cholerae, Amoeba, Mycobacterium avium complex (MAC)
and Isosporium
Diarrhoea ca n be treate d in the fo llowing way s:
• Rehyd ration with Ora lR ehydra tion Salts (OR S) or
Intravenous (IV) fluids
• Treatmentofunderlyingcauses
• Nutritionaltherapy(seedetailsinchapter15)
• Anti-diarrhoeal drugssuchasLoperamide(inpersistent
diarrhoea am ong adults with no ob vious treatab le causes)
Persistent Generalized Lymphadenopathy (PGL)
Lymphadenopathy may be due to a number of causes inclu ding
the following:
• HIVitself
• Mycobacteriumtuberculosisinfection
• Kaposi’sSarcoma
• Lymphomas
• Other causess uchas pyogen icbact eriali nfection with
regional lymphadenitis
Investigations m ay include :
• Aspiration ofthe fluctuant nodewit ha21G needle and
staining the aspirate f or acid-fas t bacilli (AFB)
• Lymphnodebiopsy forhistologica ldiagnosis
• ChestX-ray
• FBPandESR
Treatment is mainly of the underlying cause.
96 Chapter 6: Management of Common Symptoms and Opportunistic Infections in
HIV and AIDS in Adolescents and Adults
Skin Rashes, Sores and Generalized Pruritis
General causes for the above conditions include:
• GeneralizedPruriticPapularEruption(PPE)
• Infestationwithexternalparasitessuchasscabies
• Fungalskininfec tions(Dermatomycoses) .
• Viralinfec tionsherpesz oster,herpessi mplex,mollusc um,
HPV
• Kaposi’ssarcoma(KS)
• BacterialskininfectionsuchasImpetigo
• SeborrheicdermatitisandSebo-psoriasis
Investigations:
e diagnoses are mostly based on clinical presentation; however,
when necessary the following investigations can be performed:
• Skinscrapings(forfungalelementandSarcoptesscabiei)
• Pusswabforcultureandsensitivity
• SkinbiopsyforKS
The foll owing ar e recomm ended actions for the managem ent
of different causes:
Scabies:
• BenzylbenzoateEmulsion,or1%lindanelotion
• CloxacillinorErythromycinifsecondarilyinfected
Dermatomycoses :
• Whitfield’sointmentorGriseofulvintabletsforTinea
• ClotrimazoleorMiconazolecreamforCandidiasis
Impetigo:
• Cloxacillin
• Erythromycin
97
Herpes simplex & Herpes zoster:
• Acyclovir
• Cloxacillin
• Analgesics
Pruritic Papular Eruption (PPE):
• Antihistamine,e.g.Cetirizine
• Antibiotics,e.g.Cloxacillinorerythromycin
• Antiretroviraltherapy
Seborrheic dermatitis:
• Antifungal(systemicifsevere)
• Steroids(carefulifconcomitantTBissuspected)
• 3%salicylicacidointment
Kaposi’s sarcoma
is depends on the extent and severity and the options include:
• Surgicalexcision
• Radiotherapy
• Chemotherapy
• Anti-retroviraltherapy(preferablyPI-based,especiallywhen
extensive)
It should be noted that cancer conditions in HIV infected
patients are ma naged in t he sam e way as when th ey o ccur in
patients that a re not infe cted.
Altered Men tal Status and Persistent
Severe Headache
The following are some of the possible causes for altered mental
status and severe headaches:
• Fungalmeningitis,especiallycryptococcal
98 Chapter 6: Management of Common Symptoms and Opportunistic Infections in
HIV and AIDS in Adolescents and Adults
• TuberculousMeningitis
• BacterialMeningitis
• Cerebralmalaria
• Severedehydration
• Septicemia
• Hypoglycemia
• Toxoplasmaencephalitis
• HIV-dementia
• Depression
• Psychoticconditions
Recommended investigations include:
• Bloodslideformalariaparasites
• Lumbar punctureforCSFexaminationincludingIndian
ink stain for cryptoccocal meningitis
• Salmonellaandsyphilisserology
• Bloodcultures+sensitivitystudies.
• Bloodsugar
• Serumbiochemistrywherepossible
prophylactic treatment of Common
opportunist ic Infections in hIV and aId S with
Co-trimoxazole
Many opportunistic infections can be prevented by using cotri-
moxazole pro phylaxis, particular ly in the c ase of
• Bacterialpneumonias
• Pneumocystis jiroveci pneumonia (PCP), a nd
• Toxoplasmosis
99
Indications for Prophylactic Treatment using Co-
trimoxazole
Prophylactic treatment using co-trimoxazole should be provided
for any of the following:
• Adults
• AllHIV infected patients,in WHOStag e2,3a nd4
(see Chapter 8 for WHO staging criteria)
• AsymptomaticHI VinfectedindividualswithCD4
counts of <35 0 cells/m l
Pregnancy
• Allpregnantwome nthroughouttheirpr egnancy
• HIVexposedchildren
• AllchildrenborntoHIVpositivewomenstartingatfour
weeks of life or as soon as p ossible there after of age and
maintained in their first 18 months of li fe unless proven
HIV n egativ e and mothe r has stop ped breastf eeding
completely
• HIVinfectedchildren
• Children lessthan12monthswithconfirmedHIV
infection regardless of CD4% or clinical stage
• Children1–4yearswhohavesymptomaticHIV(WHO
stage 2, 3 or 4) regardless of their CD4 %
• Children1 –4yearsandhaveandhaveCD4<25%
regardless of their cl inical sta ge
• AllHIV-infected children>5y earsoldshoul dstartor
continue CPT according to adult g uideline s
Note:
1. Baseline haematology (FBC) is required before long-term
administration of co-trimoxazole.
2. Caution should be exe rcised when in itiating CPT d uring
100 Chapter 6: Management of Common Symptoms and Opportunistic Infections in
HIV and AIDS in Adolescents and Adults
the first trimester of pregnancy in women who may not have
access to g ood nutrition , because c o-trimoxaz ole can caus e
a deficiency in folic acid.
3. Pregnant women who are receiving CPT do not need sul-
fadoxine pyrime thamine (SP), an additional medication to
prevent malaria
Dosage:
For adults: One double strength tablet (160/800 mg) or two single
strength tablets once a day on a daily basis.
For children: See Annex 5, Paediatric Antiretroviral Dosing.
Duration :
If treatment with ARV is not available, CPT for adults and children
who qualify but are not on ARVs, should continue for life.
For those on ARVs, co-trimox azole prophyla xis can be sto pped
ifCD4count is>350cells/ml .
Children who are born to HIV infected women can stop prophy-
laxis when HIV infection ha s been reasonably rule d out and the
risk of exposure, for instanc e, through breast-feed ing has ceased.
Children older than 18 months can continue with prophylaxis only
if the diagnosis of HIV infection has been conrmed by serology.
Criteria for stopping:
• Occurrenceof severeside effectssuch asseverecutan eous
reactions or fixed drug reactions
• IfARTisinitiatedand CD4countisabove350 cells/mlin
adults or above 25% in children
• Ifuseof antiretroviral agentsca usesrenal and/orhepatic
insufficienc y or sever e haematolog ical toxi city
101
Follow up and monitoring:
Regular follow up is recommended, initial ly every month for the
first three months, then ever y three months if the me dication
is well tol erated.
It is ma ndato ry to moni tor for side ef fect s a nd adher ence.
Monitoring includes assessment of skin reactions, measurements
of haemoglobin, and white blood counts every six months and
when clinica lly indic ated.
preventive therapy against tB in pLhas
There is sufficient evidence on the benefits of preventive therapy
against Mycobacterium tuberculosis for HIV infected individuals
in whom active TB has be en excluded . In this cate gory of HIV
patients, Isoniazid Preventive Therapy (IPT) can be offered at
a dosage of 300 mg daily for 6 months for adults. For children
if active TB can be excl uded , the dosag e is 5mg/kg body we ight
daily for six months. IPT provides upto 18 months of protection
against TB. Further details on this are provided in chapter 10.
treatment of opp ortunistic Inf ections
It is very important that all efforts are made to deal with such
treatable conditions in people with HIV and AIDS, particularly
because they are managed at various levels of care in the health
care delivery system. Emphasis should be placed on early detection,
treatment and proper referral where necessar y. What follows are
recommendations on how to identify and handle treatable causes
of morbidity as a result of selected opportunistic infections in
HIV infect ed individ uals.
Viral Infec tions
Viruses that are commonly associated with HIV and AIDS
include:
102 Chapter 6: Management of Common Symptoms and Opportunistic Infections in
HIV and AIDS in Adolescents and Adults
• Herpessimplexvirus
• Varicellazostervirus
• Humanpapillomavirus
Herpes Simplex Virus infection (HSV)
The classical presentation of primary HSV infection includes:
• Fever
• Lymphnodeenlargement
• Smallpainfulvesicles
• Painfululcersonthemucosaandskin
• Painalongglutealandupperthighmuscles(Sacralradicu-
lomyelitis) may occur with genital/rectal HSV
• Lesionsthatusuallyresolvewithin10-21daysafterprimary
infection. Th e HSV then be comes latent in trigemina l and
sacral nucle i and may r eactivate
e clinical features in patients with HIV and AIDS may also include
persistent/erosive genital/peri-rectal ulcerations which are mainly
associated with HSV-2 and more recurrent herpetic lesions.
e diagnosis is usually based on clinical history and physical nd-
ings. Laboratory tests include serology, culture, immunoorescence
or immunoassay, but these are not practical in Tanzania.
Treatment
• Acyclovir400mgorallythreetimesdailyfor7daysformild
and moderate cases of HSV
• Acyclovir8 00mgorally, five(5)ti mesdailyf or5days for
severe and recurrent HSV
• AntibioticssuchasCloxacillinorErythromycinshouldbe
used when there is secondary bacterial infection
• Analgesicswhen painissevere
103
Varicella-zoster Virus (Herpes zoster or shingles)
Clinical features of herpes zoster:
• Earlysymptomsincludepain(oftensevereandradicular)and
fever followed by vesicular rash over involved dermatome(s)
2-4 days later
• Primaryvaricella-zostervirus(VZV)infectionusuallyresults
in chicken pox
Herpes zoster in HIV inf ected ind ividuals may be more se vere,
with more recurrences and may involve more dermatomes in-
cluding the following:
• Morelesions
• Disseminateddiseaseassociatedwithpneumonitis ,hepatitis
and hemorrhagic skin lesions
• CNSmanifesta tionsincluding encephalitisa ndcerebellar
ataxia
• Prolongedhealingtime
• Bacterialsuper-infection
The diagnosis of herpes zoster is usually based on findings of
characteristic painful skin lesio ns at different stages of evolution
(e.g. eryth ema, papule, vesic les, and c rusts) in a dermat omal
distribution.
Treatment
• Analgesicstorelievepaineventhoughthepainmaysome-
times be unman ageable
• Acyclovir800mg 5timesperdayfor 7-10days
• IV/Oral Acyclovir 10mg/kg/da y8hourl yfor7 daysfor
disseminated VZV or ophthalmic nerve involvement
104 Chapter 6: Management of Common Symptoms and Opportunistic Infections in
HIV and AIDS in Adolescents and Adults
• ErythromycinorCloxacillin500mgthreetimesdailyfor7
days for ba cterial sup er-infection
• Paracetamol/Aspirinor Diclofenac,alsoAmitriptylin25-
50mg nocte for post-her petic pain (neuralg ia)
Note: Use of steroids (prednisolone) in herpes zoster is not
recommended.
Bacterial Infections
Bacterial infections that occur with increased frequenc y in
persons with HIV and AIDS include:
• Respiratoryinfections:Streptococcus pneumoniae, Haemophilus
influenzae
• Septicemia:Nontyphoidsalmonella,Pseudomonas aerugi-
nosa
• Cutaneousinfections:Staphylococcusaureus
Note: Treatment of b acterial infection s is the same as in non-
HIV infected individuals.
Fungal Infections
Fungal infections commonly found in association with HIV and
AIDS include: Cry ptococcus neoform ans, Pn eumocysti c jirov eci,
Candida spe cies, and Hi stoplasma c apsulatum.
Cryptococcus neoformans
Thisi samajor causeof meningitis inHIV infectedp ersons.
Contrar y to bacter ial mening itis, the p atient may not s uffer
from fever in this case. However, severe headache with or with-
out meningism or altered level of consciousness is a common
presenting feature. Diagnosis depends on demonstration of
positive CSF Indian Ink preparation.
105
Treatment
• ThepreferredregimenisAmphotericinB0.7mg/kg/dayIV
+ 5 Fl ucytos ine 100m g/kg/day admin istered orally for 14
days (induction phase), followed by Fluconazole 400mg/
day for 8 weeks or until CSF is sterile (consolidation phase).
Thereafter the patient is gi ven mai ntenance therapy with
Fluconazole 200mg per day (suppressive phase).
• Iftheaboveisnotavailable,giveFluconazole IV400mg/
day for 10 days or until the drug can be admin istered ora lly
then continue with the same dose for 10 weeks. Thereafter
maintain 200 mg daily on alternate days as secondary chemo-
prophylaxis.
Candidia sis
Candidiasis is the most commo n fungal infection in HIV and
AIDS. Its d iagnos is i s mai nly b ased on c linica l fin dings and
the clinical manifestations depend on the site of disease, which
includes oral mucosa, pharynx, oesophagus, and vagina.
Note: Candidiasis in the oes ophagus, trac hea, bronchi or lungs
is diagnostic of AIDS.
Treatment
The f ollowin g dr ugs are recomme nded for the treatmen t of
Candidiasis:
• Miconazolenitrat e
• Clotrimazole
• 2%sodiumbenzoatesolution
• Nystatinoralsuspension
• Fluconazole 150mg/dayo r200mg/day for2-3 weeks(for
oro-pharyngeal candidiasis and others)
106 Chapter 6: Management of Common Symptoms and Opportunistic Infections in
HIV and AIDS in Adolescents and Adults
Note: Treatment should be continued until symptoms resolve.
Pneumocy stis Jirove ci Pneumo nia (PCP)
This condition is quite common in Tanzania especially among
HIV infecte d children. Patie nts with PCP usua lly present with
non-productiv e coug h, fever, chest tightness and shortness of
breath that has evolv ed o ver 2 -4 wee ks. Chest sign s may be
minimal despite severe shortness of breath.
A chest x-ray may show increased diffuse and symmetrical in-
terstitial marki ngs or diff use alveol ar pattern with i nfiltrations
characterized by asymmetry, nodularity or cavitations. Normally
there is a “bat’s wing’s appearance” although the chest radiograph
may appear normal in 10-30% of patients.
Diagnosis:
Usually in clinical circumstances diagnosis is based on clinical
presentation and exclusion of other common causes of severe
dyspnoea.
Treatment of PCP
• Cotrimoxazole1920mg3times/dayfor21daysandinsevere
cases give IV cotrimo xazole
• Forthoseallergictosulphur,andifavailable,giveTrimethoprim
12-15mg/kg/day + Dapsone 100mg/day for 21 days as well as
Clindamycin + Primaquine f or 21 days
• Adjuvantth erapywith steroidsma yalsob ebenefici alin
severe cases. Give Prednisolone 40mg twice daily for days 1
to 5, then 40mg once dail y for days 6 t o 10, and then 20 mg
once daily for days 11 to 21
• ForprophylaxistherapygiveTrimethoprim-sulphamethoxazole
(TMP-SMX)asshownabove
107
Protozoa
toxoplasma encephalitis
Clinical features include:
• Focalparalysi sormotorweakn essdependingon thebrain
area affected
• Neuro-psychiatricmanifestationscorrespondingtotheaf-
fected area in the brain
• Alteredmentalstatus(forgetfulnessetc.)
Diagno sis is p redom inantly bas ed o n cl inica l fi nding s af ter
exclusion of other common cause s of neurol ogical defi cit. If
available, a CT scan is very useful for confirmation.
Treatment
For acute infection Sulphadiazine tabs 1 gm 6 hourly +
Pyrimet hamine tabs 100mg load ing d ose, then 50mg /day +
Folinic acid tabs 10mg /day for 6 weeks.
After six wee ks o f tr eatmen t g ive prophy laxi s th erapy with
Sulphadiazine tabs 500mg 6 hourly + Pyrimethamine tabs 25-
50mg /day + Folinic aci d tabs 10mg / day.
For those alle rgic to sulp hur rep lace Su lphadiaz ine ta bs with
Clindamycin capsules 450mg 6 hourly.
DiscontinuemaintenancetherapywhenCD4countis>200cells/
ml, initial therapy is completed and patient is asymptomatic.
Primary prophylaxis therapy for toxoplasmosis can be accom-
plishedwithTrimethoprim–Su lphamethoxazole(TMP-SM X)
tabs 160/800 mg adminis tered oral ly/day.
For thos e all ergic to s ulphur, give Dapsone tabs 50mg/d ay +
108 Chapter 6: Management of Common Symptoms and Opportunistic Infections in
HIV and AIDS in Adolescents and Adults
Pyrimethamine tabs 50mg per week + Folinic Acid tabs 10 mg
3 times a week.
intestinal Protozoa
For intestinal protozoa which is a common cause of diarrhoea and
difficult to diagnose, the recommended treatment is Albendazole
tabs 800 mg BD (400 mgr twice daily) for one week.
109
Chapter 7:
Pediatric HIV
and AIDS-related
Conditions
110 Chapter 7: Pediatric HIV and AIDS-related Conditions
111
Chapter 7: pediatriC hiv aNd aids-
related CoNditioNs
Introduction
Themajorit yofchildrenwithH IVacquiretheinfe ctionfrom
their m others during pregnan cy, lab our an d del ivery or af ter
birth dur ing brea stfeeding . The absolut e risk of tra nsmission
without any intervention is between 5-10% during pregnancy;
10-20% during labour and delivery, and 10-20% during breast
feeding . The child of a n HIV infec ted mo ther a cquires HIV
antibodies from his/her mother during pregnancy and via breast
milk if bre astfed.
HIV inf ected infants may not have a ny sign s or symptoms of
infection soon after birth but usually develop features of infection
in the early infancy period, although these features may overlap
with those of o ther common c hildhood d iseases. The passivel y
acquired maternal antibodies may persist in the infant for be-
tween9–18monthsof ageevenifthechildisnotHI Vinfected.
The correct te rminolog y used to d escribe the i nfant of an H IV
infected mother is “HIV- exposed infant.” Children under 18
months of ag e with a po sitive antib ody test ( rapid test o r EIA)
born of HIV-infecte d mothers or whose mo ther’s HIV status is
unknown are also referred to as “HIV-exposed infants.”
The natural history of perinatal HI V infection in infants fits
into one of the following three categories:
• Rapidprogressorswhoarelikelytohaveacquiredtheinfec-
tion in utero or during early perinatal period. ese usually
die within the rst year of life and constitute fro m 25-30%;
112 Chapter 7: Pediatric HIV and AIDS-related Conditions
• Childrenwhodevelopsymptomsearlyinlifethendeteriorate
and die at the age of between 3-5 years. ese constitute about
50-60%;
• Longtermsurvivorswholivebeyond8year swhoconstitute
between 5-25%.
There are age specif ic dif ferences in immun ologic markers of
disease, virological pattern and clinica l manifestation of HIV
infection between adults and children. The HIV viral load
(VL) is relatively h igher in children t han in adul ts, most l ikely
because of the inability of the infant’s immature immune system
to contain viral replication as wel l as t he presenc e of a greater
number of HIV susceptible cells in the expanding lymphoid mass
during infancy. In this regard, the progno sis of HIV infection in
children is worse than in adults. In the absence of HAART, one
third of children who acquire HIV through vertical transmission
die during the first year, another third die during the second and
third year, an d the remain ing third su rvive for up to 15 ye ars.
Unlike in adults, in children there are age-specic dierences in the
immunologic markers of disease, virological pattern and clinical
manifestation of HIV infe ction. e basic eect of HI V on the
immune system is CD4 cell depletion and dysfunction. Absolute
CD4 count is h igher in healthy children than in adults and the
CD4 count varies with age and slowly declines to adult levels by the
age of 6 years. erefore measurement of the CD4 percent is the
preferred immunologic marker for monitoring disease progression
in younger children rather than absolute CD4 count.
e HIV viral load (VL) is relatively higher in children than in adults,
most likely because of the inability of the infant’s immature immune
system to contain viral replication as well as the presence of a greater
113
number of HIV susceptible cells in the expanding lymphoid mass
during infancy. In that connection, the prognosis of HIV infection
in children is worse than in adults. In the absence o f ARVs, one
third of children who acquire HIV through vertical transmission
die in the rst year, another third die in the second and third year,
and the remaining third survive for between 3 to 15 years.
diagnosis of hIV Infection in Infants
All infants born of HIV-infected women have passively transferred
antibodies that persist until 9 to 18 months of age. These passively
transferre d mate rnal H IV a ntibodi es ma ke inte rpretatio n of
positive antibody tests difficult in children below 18 months of
age. Assays that detect the virus or its components (i. e. virologic
tests) are required in order to positi vely diagnose HIV inf ection
in children <18 months of age. The two most commonly used
tests for such a diagnosis are DNA PCR or RNA PCR. However,
DNA PCR is the preferr ed method of choice .
PCR tests s hould be d one at 4-6 we eks or at th e second M CH
visit (i.e. eight weeks after delivery):
• Forachildthatwasnever breastfed: A single negative PCR
test after the age of 4 weeks excludes HIV infection.
• Forachildthatwasweaned for more than 6 weeks prior to
virologic (DNA PCR) testing, a negative PCR test excludes
HIV infection.
• Ifthechildisbeing breastfed, a negative virologic test does
not exclude i nfection. O n-going ex posure to HI V through
breastfeeding continues to put the child at risk of infection.
Confirmatory testing should be done 6 weeks after a complete
ceassation of breastfeeding as described above to determine
final infec tion status.
114 Chapter 7: Pediatric HIV and AIDS-related Conditions
Children between the ages of 9 and 18 months at the first health
encounter should have a rapid HIV antibody test since maternal
HIV antibodies diminish rapidly between 9-18 months of age. All
positive tests should be confirmed with a DNA PCR test. If the
antibody test is negati ve and the infant is still breas tfeeding, the
antibody test should be repeated at least 6 weeks after complete
cessation of breastfeed ing. However, if the child is sympt omatic,
fulfilling WHO stage 3 or 4 criteria and virological tests a re not
available but HIV antibodies are present, a presumptive diagnosis
should be made and ART started.
A presumptive diagnosis of severe HIV disease should be made if:
• Aninfant<18monthshasanHIVantibody testpositive
AND:
• HasdiagnosisofanyAIDS-indicatorcondition(s)OR
• Symptomaticwithtwo or more of the following:
- Oral thrush
- Se vere pneumonia
- Se vere sepsis
• Otherfactorsthatsupportthediagnosisinclude:
- Rec ent HIV-related maternal death
- Advanced HIV disease in the mother
- CD4< 25%
The HIV status should be confirmed as soon as possible.
Presumptive diagnosis shouldNOT bedone inchildre n>18
months old. In the se infants HI V infection mu st be confirme d
or excluded using widely available antibody tests.
For details see Annex 3 Presumptive and definitive criteria for
recogniz ing HI V/AIDS related clinica l event s in infants and
children with established HIV infection
115
hIV and aId S Manifestatio ns in Children
Clinical signs and symptoms of HIV infection are useful p a-
rameters in ma king a n HIV diag nosis, but i n chi ldren, these
features sometimes overlap with those of other common child-
hood diseases and are therefore more reliable in children with
severe clinical diseases.
Signs/conditions specific to HIV infection
• Pneumocystispneumonia
• Oesophagealcandidiasis
• Extrapulmonarycryptococcosis
• Invasivesalmonellainfection
• Lymphoidinterstitialpneumonitis
• Herpes zoster(shingles)withmulti-dermatomalinvolve-
ment
• Kaposi’ssarcoma
• Lymphoma
• Progressivemultifocalencephalopathy
Signs/ condi tions comm on in H IV-inf ected ch ildren an d
uncommon in uninf ected chil dren
• Severebacterialinfections,particularlyifrecurrent
• Persistentorrecurrentoralthrush
• Bilateralpainlessparotidenlargement
• Generalizedpersistentnon-inguinallymphadenopathy
• Hepatosplenomegaly(innon-malariaendemicareas)
• Persistentand/orrecurrentfever
• Neurologicdysfunction
• Herpeszoster(shingles),singledermatome
• Persistentgeneralizeddermatitisunresponsivetotreatment
116 Chapter 7: Pediatric HIV and AIDS-related Conditions
Signs/conditions common in HIV-infected children but also
common in uninfected children
• Chronic,recurrentotitiswitheardischarge
• Persistentorrecurrentdiarrhoea
• Severepneumonia
• Tuberculosis
• Bronchiectasis
• Failuretothrive
• Marasmus
Diagnosis using the Int egrated Managem ent of Childh ood
Illnesses (IMCI) Algorithm
IMCI guidelines are a useful tool at the first level referral facility
to screen chil dren with poss ible HIV inf ection who ne ed to be
referred for HIV testing or that have the test performed and are
referred for care and treatment if they test positive.
The IMCI criterion includes symptoms sugg estive of HIV in
which a child is class ified as having sympt omatic HIV infectio n
if the IMCI practitioner identifies any four of the following
symptoms:
• Recurrentpneumonia
• Oralthrush
• Persistenteardischarge
• Persistentdiarrhoea
• Verylowweight
• Enlargedlymphnodes
• Parotidenlargement
NB: IMCI criteria is not used to consider ARV initiation
117
WHO Paediatric Clinical Staging (see Annex 2)
e clinical stage is useful for assessment at baseline (rst diag-
nosis of HIV infection), entr y into long-term HIV care, an d in
the follow-up o f patients in care and treatment programmes. It
should be used to guide decisions on when to start cotrimoxazole
prophylaxis and other HIV-related interventions, including when
to start antiretroviral therapy. e clinical stages have been shown
to be r elated to survival , progno sis and progression of cl inical
disease without antiretroviral therapy in adults and children.
Table 7.1: WHO immunological classification for
established HIV infection
HIV-associated
immunodeficiency
Age-related CD4 values
0-11 months
(%)
12-59 months
(%)
> 5 years
(Count & %)
Not significant > 35 > 30 > 500
Mild 30-35 25-30 349-499
Advanced 25-30 20-25 200-349
Severe < 25 < 20 < 200 or 15%
Management of Infants Born to hIV positive Women
The counsel ling of parents on the care of infants born to HIV
positive moth ers is an essenti al component of the managem ent
of HIV exp osed chil dren. Manag ement strateg ies inclu de:
• HIVdiagnostictestingforboththemotherandchild
• Scheduledclinicvisitsforcare
• ChemoprophylaxiswithCotrimoxazole,afixeddosecom-
binationofTrimethoprim/Sulfamethoxazole(TM P/SMX)
even if HIV status is unconfirmed
118 Chapter 7: Pediatric HIV and AIDS-related Conditions
• InfantsofHIVinfectedmothersshouldreceiveprophylactic
treatment aga inst PCP and other opportuni stic infec tions
usingTMP-SMXfrom4–6weeksofage(oratfirstencounter
with the health care system if th e child was no t seen within
4–6weeksofdelivery),andcontinueduntilHIVinfection
can be excluded. Th is should be give n orally as per req uired
dosing(seepaediatricdosingchart).TMP-SMXmayneed
to continu e until 6 wee ks aft er cess ation of breastf eeding
when infection can be excluded.
• Mothersshouldbecounselledontheadvantagesanddisad-
vantages of breastfeeding, with particular attention to the risk
of breastfe eding fo r short or long duration, m ixed fee ding
and advantag es of exclu sive breast -feeding . (Please refer to
the Infant Feeding Guidelines in HIV and AIDS provided
in the PMTCT guidel ines of the Ministry of He alth an d
Social Welfare).
• Careof themo therafte rdelive ryand duringf ollowup
including treatment of opportunistic infections should also
be emphasized. Mothers should receive psychosocial support
through counselling in the postnatal period.
hIV diagnostic protocol for abandoned Infants
In the absence of a mother, the guardian/care taker needs to be
counselled and the child started on co-trimoxazole prophylaxis.
In such a case, since the mother’s HIV status is unknown, the
HIV exposure status of the baby will have to be established by
performing a rapid HIV antibody test and then PCR (if available)
at 6 weeks and aga in at 3 months if the antib ody test is positive.
119
1. Immediately: Rapid test
2. At 6 weeks of age: HIV PCR
3.
At 3 months of age: Repeat HIV PCR to confirm 6-8
week negative result
Notes:
1.
A clinical examination to assess for signs and symptoms of HIV
infection should be performed during all visits, and especially
at 6 weeks and 3 months of age. ereaer, the infant should
be followed up as per recommendations for all children.
2. Postnatal transmission of HIV infection is likely to be evident
by 6 weeks aer breastfeeding has been terminated. Nevertheless,
it is recommended that the nal qualitative HIV PCR test on
abandoned infants be performed 3 months aer breastfeeding
has ceased.
3. If PCR is unavail able, clin ical monit oring and prophylaxis
should continue until the child reaches clinical stage III, upon
which ART can be started. HIV testing (EIA or rapid) should
be performed as soon as the child attains 12 months of age.
Care of hIV infected Children
• AllchildrenshouldbeassessedforsymptomsrelatedtoHI V
as well as the nee d for treatment and prophylaxis for op-
portunistic infections and other HIV related conditions.
• Baselinelabor atorytestssho uldbeperforme dtoestablish
viral and immunological status whenever possible.
• Acomplete medicaland immunizationh istoryshoul dbe
obtained, with particu lar emphasi s on the susp ected mo de
of HIV transmission, history of ARV exposure (pre-, intra-,
post-partum, and during breastfee ding) an d timing of HIV
120 Chapter 7: Pediatric HIV and AIDS-related Conditions
diagnosis . Family mem bers who are aware of the dia gnosis
should also be known.
• HIV-infectedchildrenshouldreceiveroutinepaediatriccare
and be monit ored f or the ir HIV dise ase st atus. Children
under the age of 1 year should be seen monthly and thereafter
every three months. At each visit, a complete physical exami-
nation shoul d be done paying p articular attention to signs
commonly asso ciated with HIV infecti on (e.g. ade nopathy,
hepatomega ly and sple nomegaly) .
• Growthanddevelopm entshouldbeevaluate dandcharted
at all stages of development right through adolescence.
• Theneedformedicationshouldbereviewedbasedonhis-
tory, physica l examinati on and labo ratory fi ndings.
• Dosesofprophy lacticortreatment medicationsshoul dbe
adjustedonthebasisofgrowthand complianceandtoler-
ability sh ould be a ssessed at every vi sit.
• Medicationplans( OIprophylaxisandA RVtherapy)need
to be d iscussed intensively with p arents or guardia ns. It i s
advisable that one single person in the household is identified
as the consist ent care provid er resp onsible for d ispensing
treatment to the child.
• HIVrelatedcareneedsofparentsorguardiansthemselvesneed
to be discussed and appropriate referrals made accordingly.
• ChildrenexposedtoARVsshouldbecloselymonitoredatevery
visit for signs of toxicity (i.e. clinical or laboratory indications)
and adverse events should be properly documented and reported
to the Ministry of Health and Social Welfare.
Disclosure
Disclosure of the HIV status to the child should be discussed with
the parents or guardians. e process of disclosure can be done over
121
time, beginning when the child starts asking questions about the
disease or the medication he/s he is taking or acting in a way that
suggests that he/she is feeling isolated from other children because
of the dise ase. Close coordination wi th the gua rdian/parent of
the chid in question is crucial. Usually, one can start mentioning
toa4–6years oldHIV-infectedchildthattheyhave achronic
disease that requires regular clinic visits and medicines every day.
Atabout8–10yearsitisrecommendedthattheissueofHIVand
AIDS be mentioned but in a caring and supportive manner and
environment. Before their early teen years HIV-infected children
should know that they are infected with HIV, how it is spread and
how to stay healthy. It has been shown that children cope bett er
with their HIV status when properly counselled. It is particularly
important that adolescents be informed of their HIV status so
that they can become active participants in their own care.
Clinical Manifestations of paediatric hIV Infection
Respiratory Conditions in Children with HIV Infection
Pneumonia and chronic lung diseases contribute to the increased
morbidity and mortalit y of HIV-infected children. It is difficult
to differentiate between different respiratory conditions that
are of ten f atal in i mmune comprom ised childr en. The m ost
common respiratory conditions include:
Bacterial Pneumonias
Caused by Streptococcus pneumoniae, Haemophilus influenzae,
Staphylococcus aureus, and gram negative bacteria such as Klebsiella
pneumoniae.
Clinical Presentati on
• Historyoffever,coughandfastbreathing(tachypnoea)
• Withorwithoutsignsofseverepneumonia(chestindrawing,
122 Chapter 7: Pediatric HIV and AIDS-related Conditions
cyanosis and lethargy)
• Onauscultationofthechestonehearsunilateralorbilateral
crepitations (crackles), decreased breath sounds or bronchial
breathing (lobar pneumonia)
When pul se oxime try is availa ble it will demonstrate hypoxia
(02 saturation less than 95%).
Diagnosis
• Completebl oodcounts; raisedwhit ebloodce lls(WBC)
with a neutrophilia suggest bacterial pneumonia.
• Becausesymptomsofpneumoni aandmalariaoftenoverlap,
in malaria endemic areas remem ber to d o a mal arial smea r
and treat for malaria if in dicated. Where bl ood cultures can
be done they may assist in identifying the causative agent
• Achestx-rayisnotnecessaryfordiagnosisofacutepneumo-
nia but may be usef ul in r uling out complicati ons or oth er
pulmonary conditions.
• Sputuminductionandnasopharyngealaspiratemayassist
in the diagnosis of PCP or TB.
Management at outpatient level
• Oralamoxicillinorpenicillinisadequate.
• WherethechildisalreadyonCotrimoxazoleprophylaxisCTX
should not be used to treat pneumonia unless PCP is suspected.
IfPCPissuspectedthenhighdoseCTXshouldbeused.
• Ifthechildis underoneyearof agetheriskof PCPisvery
high and should be considered.
• GiveParacetamolforfever.
Manageme nt of Seve re Pneumon ia
Severe pneumonia should be managed in hospital and should
include both supportive and specific therapy.
123
Supporti ve Care
• Pulse oximeteriscriticalfortheassessmentof02 satura -
tion and the need for supplemental oxygen where the child
presents with chest indrawing, cyanosis or hypoxia.
• Ensureadequatehydration(eitherIVororaldependingon
the severity) and monitor.
• Remembertogiveparacetamolforfeverandpain.
Specific therapy:
• UseChloramphenicol orCeftriaxone/Cefotaxime(3rd
generation) if available.
• UseAmpicillin/CloxacillinandGentamicinasalternatives.
• Antibioticther apyforHIV-inf ectedchildren needsto be
longer 7-14 days.
• Ifthechildisund eroneyear,PCPmust beconsideredasa
possible diagnosis and treatment with high dose cotrimox-
azole and steroids prescribed.
• Ifaninfantpresentswiths everepneumoniatheysho uldbe
treated for both bacterial pneumonia and PCP and investi-
gated for possible H IV.
• ChildrentreatedforPCPshouldcontinueonPCPprophy-
laxis unti l the d iagnosis of H IV expo sure or infection has
been excluded.
• Ifpneumoniaisassociate dwithtypicalStaphylococ calskin
lesions, a positive blood culture for staphylococcus aureus, and
poorresponseto1stlineantibiotics,andifthechildjusthad
measles, consider staphylococcal pneumonia. A chest x-ray
(if availab le) will sh ow very smal l cavities ( pneumatocel es).
For such children, treatment should also include Cloxacillin
or Vancomycin.
124 Chapter 7: Pediatric HIV and AIDS-related Conditions
Lymphocytic Interstitial Pneumonitis (LIP)
LIP usually occurs in children more than two years of age.
Clinical Symptoms
• Chroniccough
• Cyanosis
• Digitalclubbing
• Difficultyinbreathingandterminalhypoxia
• Associated withparo titis,gener alisedLymp hadenopathy
and hepatosplenomegaly
• PoorresponsetoTBtherapy
Radiological Picture
• Diffuse bilatera lretic ulonodula rinfilt ratesma yappear
similar to m iliary TB
• Maydevelopconsol idation,cysticlesi ons;bilateralhilar or
mediastinal lymph nod e enlargem ent
• ParticularlydifficulttodifferentiatefromTB
Manageme nt
It is particularly dicult to dierentiate from TB management.
• SteroidsareneededwhenchildrenwithLIPhavesign ificant
respiratory distress
• Prednisone 2mg/kg/day -initial lyfor4 weeksdail yand
then alternate day maintenance for 2-3 months and review
• Oxygentherapyduringepisodesofhypoxia
• Bronchodilatorslikesalbutamolwherewheezingisaprob-
lem
• Antibioticsareneede dduringepisodesofconcur rentsuper
infection with pneumonia
• Chestphysiotherapyandposturaldrainageifthereissecond-
ary Bronchiectasis
125
• Supportivecareincludescorrectionofanaemiaespecially
iron supplementation
• Antiretroviraltherapyasspecifictherapy
• Referforspeci alistcareifresi stanttotherapy
Pneumocystis Jiroveci Pneumonia (PCP)
PCPisthemajorcauseofseverepneumoniaanddeathinHIVinfected
infants. Incidence is highest during the rst year of life and usually
peaks at 3 to 6 months of age. Infants are usually in a good nutrition
state and may have no clinical features that indicate the presence of
HIV. However, it may be the rst AIDS dening illness.
Clinical features
• Nofeverorlowg rade
• Markedrespiratorydistress(chestindrawing,cyanosis,in-
ability to drink)
• Onauscultationonehearsclearchestordiffusefinecrepita-
tions
• Poorresponsetostandardantibiotictreatment
• Withpulseoximetryseverepersistenthypoxia(paO2<90%)
will be demonstrated
• Theymayhaveothersi gnsofHIVincluding splenomegaly,
oral thrush, lymphadenopathy and weight loss
Investigations
• ThemainstayofPCPdiagnosisinTanzaniaismainlyclinical
therefore, where there is a high index of suspicio n, clinicians
should promptly initiate therapy along with treatment for
bacterial pneumonia
• Achestx-raymayshowhyperinfl ation,diffuseinfiltrates or
normal
• Sputumind uctionwit hnasophar yngeal aspirates tained
126 Chapter 7: Pediatric HIV and AIDS-related Conditions
with Giemsa or Silver stain or Immunofluorescent stain
• Bronchoalveolar lavagewhereavaila blecanalsobe usedto
produce a sp ecimen fo r staining
Management of PCP
Supportive:
• Oxygentherapy
• Maintainandmonitorhydration
• Paracetamolforpain
• Continuetherapyforbacterialpneumonia
• Nutritionsupport
Specific:
• HighdoseCotr imoxazole(CTX )IV20mg/kg TMP/day
given every 6 hours for 21 days
• Oralcotrimoxazol eatthesamedosemay alsobeusedifI V
not available
• Prednisoneat2mg/kg /dayfor7-14day(taperifmorethan
7 days)
• Secondary prophylaxisusing cotrimoxazole afteranacut e
episode of PCP
• Allchildrenyoungerthanoneyearofag edocumentedtobe
living with HIV shou ld receiv e cotrimoxaz ole prophy laxis
regardless of symptoms or CD4 p ercentage.
• Aeroneyearofage,initiationofcotrimoxazoleprophylaxisis
recommended for symptomatic children (WHO clinical stages
2, 3 or 4 for HIV disease) or children with a CD4 of <25%.
• Allchildrenwhobegincotrimoxazoleprophylaxis(irrespec-
tive of whether co trimoxazole was initiated in the first year
127
of life or after that) sh ould c ontinue until th e age of five
years when t hey can be reassesse d.
• Adult clinicalstagingandCD4countthresholdsforcot-
rimoxazole initiation or discon tinuation app ly to chi ldren
older than five years of age.
TB in Children
See TB/HIV co infection in chapter 10
128 Chapter 7: Pediatric HIV and AIDS-related Conditions
129
Chapter 8:
Antiretroviral
Therapy in Adults
and Adolescents
130 Chapter 8: Antiretroviral Therapy in Adults and Adolescents
131
Chapter 8: aNtiretro viral
therapy i N adults aNd
adolesCeNts
Introduction
Since 19 96, when more extensi ve use of potent antiretrov iral
therapy for HIV started, there has been a significant improvement
in the safety and tolerability of regimens used for initial treatment.
The pill burden and dosi ng frequ ency hav e been reduced and
short-term and long-term adverse events minimized; all of which
have contributed to the success rates in initial treatment.
e past few years have seen dramatic advances in the development
of ARVs, which now oers extended patient survival and improved
quality of life. New medications including protease inhibitors (PIs)
and non-nucleos ide reverse transcriptase inhibitors (NNRTIs)
combined with older nucleoside reverse transcriptase inhibitors
(NRTIs) have increased the potential to reduce HIV replication.
Therapeutic regimens may be d irected at one o r severa l of the
replication sites in the life cycle of the virus.
types of antiretroviral drugs
The currently existing and commercially available antiretroviral
drugs fall into the following five main categories:
1. Binding and Fusion Inhibitors
2. Nucleoside reverse transcriptase inhibitors (NRTIs)
3. Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
4. Nucleot ide rever se tr anscri ptase inh ibito rs ( Nucleo tide
analogues )
5. Protease inhibitors (Pls)
132 Chapter 8: Antiretroviral Therapy in Adults and Adolescents
Binding and Fusion Inhibitors
Fusion inhibitors prevent HIV from entering target cells. Drugs
of this class b ind to the HI V envelop e protein gp41, which is
involved in viral entry. These are a new class of antiretroviral drugs
(e.g. Enfuvirtide) that are currently not available in Tanzania.
Nucleoside Reverse Transcriptase Inhibitors
(NRTIs)
This was the first group of drugs to be used and was the mainstay
of antiretroviral therapy in the country. The primary mechanism
of action of this class is inhibition of viral RNA-dependent DNA
polymerase (reverse transcriptas e) enzyme . The dru gs that a re
available in Tanzania under this class include:
• Zidovudine(AZT)
• Stavudine(d4T)
• Lamivudine(3TC )
• Abacavir(ABC)
• Emtricitabine(FTC )
• Didanosine(ddI)
Non-Nucleos ide Reverse Transc riptase Inhib itors
(NNRTIs)
Similar to the NRTIs, NNRTIs also act by disrupting the reverse
transcription of viral RNA into DNA which is then incorporated
in the cell’s nucleus. However, unlike the NRTIs, they are not
directly incorporated into the viral DNA; instead they inhibit
replication directly by binding to the enzyme reverse transcriptase.
Resistance to these drugs develops rapidly, especially when used
alone. Drugs under this class that are available in Tanzania are
Nevirapine (NVP) and Efavirenz (EFV).
133
Nucleotide Reverse Transcriptase Inhibitors
(Nucleotide analogues)
Nucleotide analogues resemble monophosphorylated nucleosides,
and therefore re quire only two additio nal phosphor ylations to
become active inh ibitors of DNA synth esis. An example of this
relatively new class of antiretroviral drugs is Tenofovir (TDF).
Protease In hibitors (PIs)
PIs competitively inhibit the HIV protease enzyme whose activity
is critical for the terminal maturation of infectious virions. is
inhibition prevents the maturation of virions capable of infecting
other cells. Drugs available in Tanzania that fall under this class are
Lopinavir (LPV), Ritonavir (RTV) and Atazanavir (ATV).
treatment Using arV drugs in a dults and
adolescents
From the moment a patient tests HIV-positive, he/she should
be referred to the CTC. The initial management requires a
complete assessme nt of the patient startin g with WHO clinica l
staging. Thereafter the following tests should be done:
• Completebloodcount
• Renaltest(throughurinalysis)
• Liverfunctiontests
• Urineforpregnancytest(ifpregnancyispossible)
• CD4T-lymphocyt escount
• Viralload(wh ereavailableandin dicated)
Treatment decisions should be based on the extent of clinical disease
progression and readiness of the patient. e gold standard for evalu-
ating immune function remains to be CD4+ T lymphocyte counts.
e determination of viral load has more of a prognostic value and
is routinely used in clinical practice in developed countries.
134 Chapter 8: Antiretroviral Therapy in Adults and Adolescents
e tests mentioned above, when available, should be done at baseline
and as needed for clinical care (e.g. in cases of toxicity), and at least
every six months for patients on treatment.
Criteria of Initiation of ART in Adults and
Adolescents Patients
Despite a theoretical benefit to antiretroviral therapy for patients
withhigh CD4counts,there aremajordilemmas confronting
patients and practi tioners when ART is ini tiated too earl y. The
currently available antiretro viral regimens that have the greatest
potency in terms of viral suppression and CD4+ T-lymphocytes
preservation are medically complex, are associated with a number
of specific side effects and drug interactions, and pose a substantial
challenge for adherence. Also, the development of mutations
associated with drug resistance can make therapy less effective
or ineffec tive in the future. In this regard, decisions regardin g
treatment of asympto matic, chroni cally infec ted i ndividu als
with hig h CD 4 counts must balance a num ber of compe ting
factors that influence r isk and be nefit.
On the other hand, the treatment of patients with WHO Stage
4 disease (clinical AIDS) should not be dependent on their CD4
cell count. Any individual in Stage 4 should be started on ART
immediately. For patients wi th Stage 3 diseas e, the upp er limit
of 350cells/mm
3
has been selected and such patients are eligible
for treatment . (See Annex 1: WHO cl inical staging for adult s
and adolescents).
Patients with a CD4 cell count of <200/mm
3
should also be
started on treatment, regardless of the clinical stage.
There are therefore 3 classe s of patients that are elig ible to begin
treatment: