Hiv diagnosis and treatment

1. TROPICAL MEDICINE
Major Tropical Diseases
HIV/AIDS
By
WANYAMA.F.W

2. Major Tropical Diseases
HIV/AIDS-Introduction - 1
• HIV: Human Immunodeficiency Virus
• AIDS: Acquired Immune Deficiency Syndrome
• It’s a pandemic* contemporary killer disease
• HIV is a lentivirus (a subgroup of retrovirus)
that causes AIDS

3. Major Tropical Diseases
HIV/AIDS- Epidemiology* - 2
• Globally HIV affected >39 million by 2013
• In 2013, 1.5 [1.4–1.7] million people died
from HIV-related causes globally
• Sub-Saharan Africa (SSA) is the most affected
region, with 24.7 [23.4–26.2] million people
living with HIV in 2013
• SSA also accounts for almost 70% of the global
total of new HIV infections

4. Major Tropical Diseases
HIV/AIDS- Epidemiology* - 3
• In 2013, 12.9 million people living with HIV
received antiretroviral therapy (ART) globally, of
which 11.7 million are in low- and middle-income
countries
• The 11.7 million people on ART represent 36%
[34–38%] of the 32.6 [30.7–34.8] million people
living with HIV in low- and middle-income
countries
• Paediatric coverage is still lagging, by 2013 (< 1 in
4 children living with HIV had access to ART,
compared to 1 in 3 adults)

5. Major Tropical Diseases
HIV/AIDS- Epidemiology (Kenya)* - 4
An HIV-positive couple and their sons,
Kenya

6. Major Tropical Diseases
HIV/AIDS- Epidemiology (Kenya)* - 5
KENYA (2012 Statistics)
• Kenya has the fourth-largest HIV epidemic in the
world
• In 2012, about 1.6 million adults lived with HIV,
whereby about 57,000 people died from AIDS-
related illnesses
• By 2012, about 1.1 million have been orphaned
by AIDS
• Adult HIV prevalence: 6.1% (down from 10.5% in
1996)

7. Major Tropical Diseases
HIV/AIDS- Epidemiology (Kenya)* - 6
• HIV prevalence among men who have sex with men (MSM)
in Kenya is almost three times that among the general
population
• In 2010, HIV prevalence among MSM was an estimated
18.2 percent
• In the city of Mombasa, one study found that up to 24.5
percent of MSM were living with HIV
• Condom use among MSM is fairly low but has been on the
increase
• In 2013, an estimated 69 percent of MSM reported using a
condom the last time they had anal sex (which has a much
higher risk of HIV transmission than vaginal sex), up from
55 percent in 2011

8. Major Tropical Diseases
HIV/AIDS- Epidemiology (Kenya)* - 7
• In 2011, about18.3% of people who inject
drugs (PWID) in Kenya were living with HIV,
concentrated in specific areas
• PWID have high HIV transmission rates
because of low condom use and unsafe drug
injection practices
• Female sex workers (FSW) have the highest
reported HIV prevalence of any group in Kenya
(2011)

9. Major Tropical Diseases
HIV/AIDS-Virology- 8
HIV Aetiological Classification
• Group: Group VI (ssRNA-RT)
• Order: Unassigned
• Family:Retroviridae (Retroviruses)
• Sub-family: Orthoretrovirinae
• Genus: Lentivirus
• Species: HIV 1 and HIV 2

10. Major Tropical Diseases
HIV/AIDS- Virology * - 9
Comparison of HIV species
Species Virulence Infectivity Prevalence
Inferred
origin
HIV-1 High High Global
Common
Chimpanzee
HIV-2 Lower Low West Africa
Sooty
Mangabey

11. Major Tropical Diseases
HIV/AIDS- Virology * - 10
Diagram of HIV virion

12. Major Tropical Diseases
HIV/AIDS- Replication Cycle- 11
The HIV replication cycle

13. Major Tropical Diseases
HIV/AIDS- Transmission* - 12
HIV is transmitted primarily via :
1. Unprotected sexual intercourse (including anal
and oral sex),
2. Contaminated blood transfusions,
3. Hypodermic needles, and
4. Mother-to-child during pregnancy, delivery or
breastfeeding
Some bodily fluids, such as saliva and tears, do not
transmit HIV

14. Major Tropical Diseases
HIV/AIDS- Transmission* - 13
Average per act risk of getting HIV
by exposure route to an
infected source
[Exposure route/Chancre of
infection- %]
• Blood transfusion (90% )
• Childbirth (to child) (25%[)
• Needle-sharing injection
drug use (0.67%)
• Percutaneous needle stick
(0.30%[)
• Receptive anal intercourse*
(0.04–3.0%)
• Insertive anal intercourse*
(0.03%)
• Receptive penile-vaginal
intercourse* (0.05–0.30%)
• Insertive penile-vaginal
intercourse (0.01–0.38% )
• Receptive oral intercourse§
(0–0.04%)
• Insertive oral intercourse*§
(0.005%[)
• *assuming no condom use
• § source refers to oral intercourse
performed on a man

15. Major Tropical Diseases
HIV/AIDS- Clinical Features - 14
Main symptoms of AIDS

16. Major Tropical Diseases
HIV/AIDS- Clinical Features* - 15
The most common initial conditions that alert to
the presence of AIDS are:
• Pneumocystis pneumonia (40% of cases),
• Cachexia (body wasting), in the form of HIV
wasting syndrome (20%)
• Oesophageal candidiasis
• Other common signs include recurring respiratory
tract infections
• Other opportunistic infections: (e.g. TB)

17. Major Tropical Diseases
WHO Clinical Staging Systems for HIV infection & Disease* - 16
Stage Symptoms/Signs
Primary HIV
infection
•Asymptomatic or associated with acute retroviral syndrome
•Not categorized as AIDS
Stage I •HIV infection is asymptomatic with a CD4+ T cell count (also
known as CD4 count) greater than 500 per microlitre (µl or
cubic mm) of blood.
•May include generalized lymph node enlargement
•Not categorized as AIDS
Stage II •Mild symptoms which may include minor mucocutaneous
manifestations and recurrent upper respiratory tract infections
•A CD4 count of less than 500/µl

18. Major Tropical Diseases
HIV/AIDS- WHO (2007) Clinical Staging Systems* - 17
Stage Symptoms/Signs
Stage III •Advanced symptoms which may include unexplained chronic
diarrhea for longer than a month, severe bacterial infections
including tuberculosis of the lung, and a CD4 count of less than
350/µl
Stage IV (AIDS) •Severe symptoms which include toxoplasmosis of the brain,
candidiasis of the esophagus, trachea, bronchi or lungs and
Kaposi's sarcoma (these diseases are used as indicators of AIDS)
•CD4 count of less than 200/µl.

19. Major Tropical Diseases
HIV/AIDS- CDC (2008) Clinical Staging Systems* - 18
Stage Symptoms/Signs
Stage 1 CD4 count ≥ 500 cells/µl and no AIDS defining conditions
Stage 2 CD4 count 200 to 500 cells/µl and no AIDS defining conditions
Stage 3 CD4 count ≤ 200 cells/µl or AIDS defining conditions
Unknown •Is so classified if insufficient information is available to make
any of the above classifications.
•For surveillance purposes, the AIDS diagnosis still stands even
if, after treatment, the CD4+ T cell count rises to above 200 per
µL of blood or other AIDS-defining illnesses are cured

20. Major Tropical Diseases
WHO Clinical Staging Systems for HIV in Adults & Adolescents -19
[Revised (WHO, 2006)]*
Clinical Staging Signs and Symptoms
Primary HIV infection •Asymptomatic
•Acute retroviral syndrome
Clinical Stage 1 •Asymptomatic
•Persistent generalized lymphadenopathy
Clinical Stage 2 Moderate unexplained* weight loss
(under 10% of presumed or measured
body weight)**
Recurrent respiratory tract infections
(sinusitis, tonsillitis, otitis media,
pharyngitis)
Herpes zoster
Angular chelitis
Recurrent oral ulceration
Papular pruritic eruptions
Seborrhoeic dermatitis
Fungal nail infections

21. Major Tropical Diseases
WHO Clinical Staging Systems for HIV in Adults & Adolescents -20
[Revised (WHO, 2006)]*
Clinical Staging Signs and Symptoms
Clinical Stage 3 Conditions where a presumptive diagnosis can be made on the
basis of clinical signs or simple investigations
Unexplained chronic diarrhoea for longer than one month
Unexplained persistent fever (intermittent or constant for longer
than one month)
Severe weight loss (>10% of presumed or measured body weight)
Oral candidiasis
Oral hairy leukoplakia
Pulmonary tuberculosis (TB) diagnosed in last two years
Severe presumed bacterial infections (e.g. pneumonia, empyema,
meningitis, bacteraemia, pyomyositis, bone or joint infection)
Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
Conditions where confirmatory diagnostic testing is necessary
Unexplained anaemia (< 80 g/l), and or neutropenia
(<500/µl/<0.5billion/L) and or thrombocytopenia (<50 000/
µl/<50billion/L) for more than one month

22. Major Tropical Diseases
WHO Clinical Staging Systems for HIV in Adults & Adolescents -21
[Revised (WHO, 2006)]*
Clinical Staging Signs and Symptoms
Clinical Stage 4 Conditions where a presumptive diagnosis can be made on the
basis of clinical signs or simple investigations
HIV wasting syndrome
Pneumocystis pneumonia
Recurrent severe or radiological bacterial pneumonia
Chronic herpes simplex infection (orolabial, genital or anorectal of
more than one month's duration)
Esophageal candidiasis
Extrapulmonary tuberculosis
Kaposi's sarcoma
Central nervous system toxoplasmosis
HIV encephalopathy

23. Major Tropical Diseases
WHO Clinical Staging Systems for HIV in Children-23
[Revised (WHO, 2006)]*
Clinical Staging Signs and Symptoms
Stage I
(Children)
•Asymptomatic
•Persistent Generalised lymphadenopathy
Stage II
(Children)
•Unexplained persistent hepatomegaly and splenomegaly
•Papular itchy skin eruptions
•Extensive skin warts
•Extensive molluscum contagiosum
•Recurrent oral ulcerations
•Unexplained persistent parotid gland enlargement
•Linear gingival erythema
•Herpes zoster
•Recurrent or chronic respiratory tract infections
(sinusitis,otorrhoea, tonsillitis, otitis media)
•Fungal nail infections

24. Major Tropical Diseases
WHO Clinical Staging Systems for HIV in Children-24
[Revised (WHO, 2006)]*
Clinical Staging Signs and Symptoms
Clinical Stage 3
(Children)
•Moderate unexplained malnutrition not responding to standard
therapy
•Unexplained persistent diarrhea for longer than 14 days
•Unexplained persistent fever above 37.5 (intermittent or constant
for more than one month)
•Persistent oral candida (outside the first 6-8 weeks of life)
•Oral hairy leukoplakia
•Acute necrotizing ulcerative gingivitis or periodontitis
•TB lymphadenopathy
•Pulmonary tuberculosis
•Severe recurrent presumed bacterial pneumonia (2 or more
episodes in a 6mo period)
•Symptomatic lymphoid interstitial pneumonitis (LIP)
•Chronic HIV-associated lung disease, including bronchiectasis
•Unexplained anaemia (<8g/dl), neutropaenia (<500/mm3) or
thrombocytopenia (<50,000/mm3)

25. Major Tropical Diseases
WHO Clinical Staging Systems for HIV in Children-24
[Revised (WHO, 2006)]*
Clinical
Staging
Signs and Symptoms
Clinical
Stage 4
(Children)
Unexplained severe wasting, stunting, or severe malnutrition not
responding to treatment
Pneumocystis carinii (jeroveci) pneumonia
Recurrent severe presumed bacterial infections (eg. Empyema,
pyomyositis, bone or joint infections, meningitis, sepsis, but excluding
pneumonia)
Toxoplasmosis of the brain
Cryptosporidiosis with diarrhea>1 month
Isosporiasis with diarrhea > 1 month
Cryptococcosis, extrapulmonary
Cytomegalovirus of an organ other than liver, spleen or lymph node
Chronic herpes simplex infection (orolabial or cutaneous for > 1 month)
Progressive multifocal leukoencephalopathy

26. Major Tropical Diseases
WHO Clinical Staging Systems for HIV in Children-24
[Revised (WHO, 2006)]*
Clinical
Staging
Signs and Symptoms
Clinical Stage
4
(Children-
Continued)
Any disseminated endemic mycosis
Candidiasis of oesophagus, trachea and bronchus
Atypical mycobacteriosis, disseminated or lungs
Extrapulmonary tuberculosis excluding TB lymphadenopathy
Lymphoma (cerebral or B cell non-Hodgkin)
Kaposi’s sarcoma
HIV encephalopathy
HIV-associated cardiomyopathy or HIV-associated nephropathy

27. Major Tropical Diseases
HIV/AIDS- Diagnosis - 25
• HIV/AIDS is diagnosed via laboratory testing and then
staged based on the presence of certain signs or symptoms
• Most people infected with HIV develop specific antibodies
(i.e. sero-convert) within three to twelve weeks of the
initial infection
• Diagnosis of primary HIV before sero-conversion is done by
measuring HIV-RNA or p24 antigen
• Positive results obtained by antibody or PCR testing are
confirmed either by a different antibody or by PCR
• Antibody tests in children younger than 18 months are
typically inaccurate due to the continued presence of
maternal antibodies

28. Major Tropical Diseases
HIV/AIDS- Management* - 26
(1) Specific Management:
• Treatment consists of highly active antiretroviral therapy
(HAART) which slows progression of the disease
• Management of opportunistic infections: done according to
clinical presentation (e.g TB; Diarrhoea; PCP, Meningitis; etc)
(2) Supportive management:
• Nutritional , Spiritual/Psychological/Emotional support
(3) Preventive Management:
• Early diagnosis and treatment of opportunistic infections &
ARVs
• Currently there is no cure or effective vaccine against HIV!

29. Major Tropical Diseases
HIV/AIDS- Management Updates - 27
• Based on WHO consolidated recommendations
on use of ARVs (June,2013)
• New MOH (Kenya) guidelines recommend:
Early HIV diagnosis for all populations,
Earlier initiation of ARV therapy for children,
adolescents and adults *
Use of simplified ‘once-daily-fixed-dose
combination of ARV pill to improve adherence
Routine viral load testing for all clients on ART
(ARV therapy)

30. Major Tropical Diseases
HIV/AIDS- Management Updates - 28
 Adults included in the earlier ARV initiation guidelines are:
1. HIV-infected pregnant & breastfeeding women
2. HIV-infected spouses & sexual partners in sero-discordant
relationships
• The guidelines are to be implemented by all categories of health
care providers in MOH*, who directly or indirectly provide HIV care
services
• The guideline only contains specific revised updates that require
special emphasis;
• However, other existing guidelines on HIV Prevention, Care and
Treatment/Comprehensive care remain unchanged

31. Major Tropical Diseases
1. HIV TESTING & COUNSELING- 29
• HIV testing and counseling is the entry point to
HIV care, treatment and prevention
• Service providers should therefore seek every
opportunity to offer the services to all clients, at
the earliest (first visit to health facility for
whatever reason)
• Reference should be made to the national
guidelines for HIV Testing and Counseling (HTC) in
Kenya

32. Major Tropical Diseases
1. HIV TESTING & COUNSELING- 30
• For those who test negative, re-testing
should be done after 3 months
• Thereafter, HIV testing should be done:
Annually for the general population and
Quarterly (3mo) for special key [target]
populations * with linkage to HIV prevention,
care and treatment services

33. Major Tropical Diseases
1. HIV TESTING & COUNSELING- 31
Topic and Population Recommendations
HIV testing and counseling for infants
and children aged < 18 months
•HIV exposure status of all infants
established at 6-wk immunization visit or
1st contact thereafter, using maternal
medication information
•Establish HIV status for mother and
children < 18months and of unknown
status, by HIV antibody testing
•Routine DNA-PCR testing at 6-wk visit or
earliest contact thereafter for all HIV-
exposed infants
•Initially HIV-positive infants (DNA PCR
testing) should be presumed to be so;
hence started on ARV therapy (ART) in
line with national guidelines

34. Major Tropical Diseases
1. HIV TESTING & COUNSELING- 32
Topic and Population Recommendations
HIV testing and counseling for
Adolescents (10- 19 years of age)
•Conduct HIV testing for adolescents/key
populations during 1st opportunity visit to
health facility, regardless of visit’s reason
•Link all identified HIV-positive
adolescents to PCT services
•Counsel them on appropriateness of
disclosure of HIV status
(empower/support to determine when,
how, whom to disclose status)
• Extend services to sexual
contacts/partners and their children

35. Major Tropical Diseases
1. HIV TESTING & COUNSELING- 33
Topic and Population Recommendations
HIV testing and counseling for Pregnant
and Breastfeeding Women
•Testing guidelines for all adults apply
•All breastfeeding women who test HIV-
negative at 1St visit/ANC/unknown status,
repeat testing as for other adult national
guidelines
• For those who decline testing during 1st
visit, offer to do so during subsequent
visit (s)
•Mandatory HIV testing for spouses of all
HIV-positive pregnant/breastfeeding
mothers

36. Major Tropical Diseases
1. HIV TESTING & COUNSELING- 34
Topic and Population Recommendations
HIV testing and counseling for Sexual
Partners & Children of Index Case
(HIV positive person already in HIV care)
•Offer HIV testing and subsequent
services to all sexual partners and
children with linkage to index case
Disclosure of HIV Status to infected
Children and Adolescents
•Health Service Providers should provide
appropriate guidance and support on this
(especially to children > 6 years of age)
•Full disclosure should be done before
adolescence (i.e. ideally > 10 yrs of age -
when the child is developmentally
mature/ready for it)

37. 2. ARV Therapy in Children*
2.1 When to Start ART in Children- 35
Population Recommendations
When to Start ART in Children < 15 years •Initiate ART for all HIV-+ve children ≤10
yrs, regardless of WHO staging of HIV or
CD4 count (%)
•Initiate ART for all HIV-+ve children >10
yrs with CD4 cell count of ≤ 500
cell/mm3, regardless of WHO staging
•Initiate ART, for all HIV-+ve children with
WHO stage 3 & 4 disease/HBV/TB-
HIV/co-infection, irrespective of CD4
count
•Initiate ART in all children < 18 months
old, who meet the criteria for
presumptive treatment for severe HIV, in
absence of confirmatory DNA PCR testing
(but confirmatory DNA PCR testing
should be done soonest possible)

38. 2. ARV Therapy in Children*
2.2 1st-Line ART in Children - 36
Age Preferred Regimen Recommendations
Children < years of age ABC + 3TC + LPV/r* AZT + 3TC + LPV/r*
Children ≥ 3-10 yrs and
Adolescents < 35Kg
ABC + 3TC + EFV ABC + 3TC +NVP
AZT + 3TC + EFV
AZT + 3TC + NVP
Adolescents (> 10-14 yrs
and weighing ≥ 35Kg) **
TDF + 3TC + EFV TDF + 3TC + NVP
ABC + 3TC + EFV
ABC + 3TC +NVP
AZT + 3TC + EFV
AZT + 3TC + NVP

39. 2. ARV Therapy in Children*
2.3 2nd Line ART in Children - 37
If first line ART regimen was: Then Second Line regimen will be:
ABC + 3TC + EFV/NVP AZT + 3TC + LPV/r
AZT/D4T + 3TC + EFV/NVP AZT + 3TC + LPV/r
ABC + 3TC + LPV/r
AZT + 3TC + LPV/r
AZT + 3TC +DRV/r*
ABC + 3TC + DRV/r
TDF + 3TC + EFV Preferred: AZT + 3TC + LPV/r
Alternative: AZT + 3 TC + ATV/r**

40. 2. ARV Therapy in Children
2.4 ART in Children with TB+HIV Co-infection* - 38
Age Preferred
Regimen
Alternative
Regimen
Comments
0-3
years
ABC + 3TC + LPV/r
+ RTV (add extra
dose of RTV to
make the RTV/LTV
ratio of 1: 1
[super-boosted
LPV])
AZT + 3TC + LPV/r
ABC + 3TC + EFV**
AZT + 3TC + EVF**
ABC + 3TC + AZT***
** US FDA has approved use of EFV
in children ≥ 3months and weighing
> 3.5Kg
** Currently in Kenya, use of EFV in
children < 3yrs, weighing <10Kg is
recommended ONLY in TB/HIV co-
infection management without
prior to NVP for PMTCT
*** ABC + 3TC + AZT (triple
nucleotide) is an inferior regimen
and should only be used if other
regimens are not tolerated.
*** After completing TB treatment,
change the triple nucleotide based
ART regimen to ABC + 3TC + LPV/r

41. 2. ARV Therapy in Children
2.4 ART in Children with TB+HIV Co-infection* - 39
Age Preferred Regimen Alternative Regimen Comments
≥ 3-10 yrs ABC + 3TC + EFV AZT + 3TC + EFV
> 10-14 yrs
(< 35kg)
ABC + 3TC + EFV AZT + 3TC + EFV
> 10-14 yrs
(> 35kg)
TDF + 3TC + EFV

42. 2. ARV Therapy in Children
2.4 ART in Children with TB+HIV Co-infection* - 40
Age Current Regimen Recommended ART
Substitution while on
TB treatment
Comments
0-10 years If on EFV-based ART Continue EFV-based
ART
Conduct viral load to
rule out treatment
failure and manage as
per the national
guidelines
0-10 years If on NVP-based ART Change NVP to EFV As above
0-10 years If on LPV/r-based ART Super-boost LPV/r
(LPV: Ritonavir= 1:1)
•As above
•Switch back to
normal LPV/r after
completing normal TB
treatment

43. 2. ARV Therapy in Children
2.4 ART in Children with TB+HIV Co-infection* - 41
Age Current
Regimen
Recommended ART
Substitution while
on TB treatment
Comments
0-10
years
Alternative (ABC +
3TC + AZT) triple
nucleotide regimen
•Triple nucleotide regimen should not
be used on children who have failed
1st line ART; in such cases clinician
should refer for more specialized
management.
•Switch back to normal LPV/r after
completing normal TB treatment
•ABC + 3TC + AZT (triple nucleotide) is
an inferior regimen and should only
be used if other regimens are not
tolerated.
•After completing TB treatment,
change the triple nucleotide based
ART regimen to ABC + 3TC + LPV/r

44. 2. ARV Therapy in Children
2.4 ART in Children with TB+HIV Co-infection* - 42
Age Current
Regimen
Recommended ART
Substitution while on
TB treatment
Comments
>10 years EFV-based
ART
Continue EFV-based
ART
Conduct viral load to rule out
treatment failure and manage as
per the national guidelines
>10 years NVP-based
ART
Change NVP to EFV-
based ART
•As above
>10 years If on
LPV/r-
based ART
If <35Kg: Super-boost
LPV/r (LPV : r = 1:1)
with Rifampicin-based
TB Treatment
•As above
•Switch back to normal LPV/r after
completing normal TB treatment
If on
LPV/r-
based ART
If > 35Kg: Continue
current regimen and
substitute rifampicin
with Rifabutin (150mg
once daily)**
•Conduct viral load to rule out
treatment failure and manage as
per the national guidelines

45. 2. ARV Therapy in Children
2.5 Efavirenz Dosing in Children - 43
Weight (Kg) EFV (mg) Tablets Quantities
3.5 – 4.9 100 Half of the 200mg double scored tablet
5.0 – 7.4 150 Three quarters of double scored tablet
7.5 – 13.9 200 One of 200mg double scored tablet
14.0 – 19.9 300 One and a half of 200mg double scored tab
20.0 – 24.9 300 One and a half of 200mg double scored tab
25.0 – 34.9 400 Two of the 200mg double scored tablet
35 and above 600 One of the 600mg tablet

46. 2. ARV Therapy in Children (taking Rifampicin)
2.6 Ritonavir Super-boosting Dosing for TB/HIV Co-infection - 44
Weight
Range
(Kg)
Liponavir/Ritonav
ir
(LPV/r) Additional Dosing of Ritonavir
for Children taking Rifampicin
TWICE daily TWICE daily TWICE daily
80mg LPV/20mg r
Solution
200mgLPV/50mg r
Tablets
Rotonavir Liquid (80mg/ml in
90ml bottle*
3.0 – 5.9 1.5 ml - 1 ml
6.0 – 9,9 1.5 ml - 1 ml
10.0 – 13.9 2 ml - 1.5 ml
14.0 -
19.9
2.5 ml 1 tablet B.D 2ml or 2 of 100mg capsules B.D
20.0 – 24.9 3 ml 1 tablet B.D 2.5ml or 2 of 100mg capsules
B.D
25 – 34.9 4 ml 2 tab in am &
1 tab in pm
4ml am & 2ml pm or 2 of 100mg
cap am & 3 of 100mg cap
evening

47. 2. ARV Therapy in Children
2.7 ARV Prophylaxis for HIV-Exposed Infants- 45
Scenario Maternal ARV
Prophylaxis
Infant ARV
Prophylaxis
Duration of Infrant ARV
Prophylaxis
1 Mother
diagnosed
with HIV*
Initiate
maternal ART
NVP •Immediately initiate NVP
prophylaxis for 12 weeks
•Do HIV PCR test according to
national recommended early
infant diagnosis guidelines.
•Initiate treatment if infant is
infected
2 HIV infant** Initiate
maternal ART
NVP •Immediately initiate NVP
prophylaxis
•Do HIV PCR testing as above.
•If HIV positive, initiate ART
•If negative, continue NVP
prophylaxis up to 12 weeks.

48. 2. ARV Therapy in Children
2.7 ARV Prophylaxis for HIV-Exposed Infants- 46
Scenario Maternal ARV
Prophylaxis
Infant ARV
Prophylaxis
Duration of Infrant ARV
Prophylaxis
3 HIV infant*** Refer mother
for HIV care
and
evaluation for
treatment
No drug •Do testing as above,
•No infant ARV prophylaxis.
•Initiate ARV if infant is infected.
4 Mother
receives ART
but interrupts
ART
regimen****
Determine
alternative
ART
regimen/solut
ion; counsel
appropriately
to continue
ART therapy
NVP •Initiate NVP until 12 wks after
maternal ART is re-started or until
1 week after breastfeeding has
ended if mother doesn’t restart
ART.
•Do HIV testing as recommended
above.

49. 2. ARV Therapy in Children
2.8 Niverapine Dosing for HIV-Exposed Infants - 47
Age Niverapine Dose
0 – 6 weeks •Birth weight < 2.5Kg: 10mg (1ml) once daily;
•Birth weight > 2.5Kg: 15mg (1.5ml) once daily
6 – 14 weeks 20mg (2ml) once daily
14 weeks – 6 months 25mg (2.5ml) once daily
6 – 9 months 30mg (3ml) once daily
9 – 12 months 40mg (4ml) once daily
> 12 months 50mg (5ml) once daily

50. 2. ARV Therapy in Children
2.9 Cotrimoxazole Dosing for HIV-Exposed Infants/Infected Children*-48
Weight (Kg) Suspension 240mg
per 5ml
Single Strength
(SS) 480mg
Tablets
Double Strength (DS)
960mg Tablets
1-4 2.5 ml 0.25 tab SS -
5-8 5 ml 0.5 tab SS 0.25 DS
9-16 10 ml 1 tab SS 0.5 DS
17-30 15 ml 2 tab SS 1 DS
> 30 (Adults and
Adolescents) - 2 tab SS 1 DS

51. 3.0 ART Use in Adults & Adolescents
BENEFITS- 49
1. Transformation of HIV from a chronic debilitating and fatal
disease to a chronic and manageable disorder
2. Evidently reduced death rate, hospitalization and
incidence of opportunistic infections among the infected
people
3. Markedly reduced HIV transmission between discordant
HIV-infected sexual partners and from mother to child
(MTCT)
4. Life-long co-trimoxazole also prolongs life and improves
health of HIV-infected breastfeeding mothers

52. 3. ART Use in Adults & Adolescents
3.1 Current ART Recommendations -50
• (1) Earlier initiation of ART for:
 Adults and Adolescents
 HIV-positive pregnant and breastfeeding women
 Sero-discordant relationships (spouses, others)
• (2) Use of once-a day fixed dose of ARV pill
• (3) Routine viral load for treatment monitoring

53. 3. ART Use in Adults & Adolescents (≥ 15yrs)
3.2 Recommendations When to Start ART -51
1. All within the age bracket (≥ 15yrs), with < 500cells/ mm3
CD4 count, irrespective of WHO stage
2. All HIV-infected pregnant mothers, irrespective of CD4
count, WHO stage or gestation age*
 MOH recommends immediate initiation of life-long ART
upon HIV diagnosis with continuous adherence support
3. All sero-discordant relationships, irrespective of CD4 count
and WHO stage

54. 3. ART Use in Adults & Adolescents (≥ 15yrs)
3.2 Recommendations When to Start ART -52
4. All HIV-infected Adults and Adolescents with WHO
stage 3 or 4 disease, regardless of CD4 count
5. All HIV/HBV co-infected people, regardless of CD4
count
6. All HIV/TB co-infected persons, regardless of CD4
count

55. 3. ART Use in Adults & Adolescents (≥ 15yrs)
3.3 1st Line ART in Adolescents & Adults*-53
First Line ART Category Preferred Regimen Alternative Regimen
For Adolescents (≥ 15yrs)
& Adults
TDF** + 3TC + EFV TDF + 3TC + NVP
AZT + 3TC + EFV
AZT + 3TC + NVP
HIV-+ve Sero-discordant
Relationship Partners
TDF** + 3TC + EFV As above
Pregnant & Breastfeeding
Women
TDF** + 3TC + EFV*** As above
<24months since previous
NVP Exposure
TDF** + 3TC + ATF/r**** TDF + 3TC + LPV/r
AZT + 3TC + ATV/r
AZT + 3TC + LPV/r
>24months since previous
NVP Exposure
TDF** + 3TC + EFV TDF + 3TC + NVP
AZT + 3TC + EFV
AZT + 3TC + NVP

56. 3. ART Use in Adults & Adolescents (≥ 15yrs)
3.4 2nd Line ART in Adolescents & Adults-54
1st Line ART Preferred 2nd Line ART Alternative 2nd Line ART
TDF + 3TC + EFV AZT + 3TC + ATV/r AZT + 3TC + LPV/r*
AZT +3TC + EFV/NVP
D4T + 3TC + EFV/NVP
TDF + 3TC + ATV/r TDF + 3TC + LPV/r
TDF + 3TC + ATV/r or LPV/r AZT + 3TC + DRV/r** -

57. 3. ART Use in Adults & Adolescents (≥ 15yrs)
3. 5 ART in Adolescents & Adults with HIV/TB co-infection*-55
Scenario ART Regimen Comments
Newly diagnosed
HIV+TB (ART-naive)
Preferred: TDF+ 3TC + EFV
Alternative: AZT + 3TC + EFV
•Continue same ART regimen
after completing TB treatment.
•ART isn’t considered failed
within 6months of initiation.
If on NVP-based 1st
line ART regimen
Change NPV to EFV •Assess for treatment failure
•Continue additional adherence
counseling and support
If on LPV/r or ATV/r-
based regimen
Continue current regimen
and use Rifabutin (150mg
once-daily) for TB treatment
instead of Rifampicin**
•Assess for treatment failure
•Continue additional adherence
counseling and support

58. 4. 3rd Line ART for Children, Adults &
Adolescents*-55
• Currently there are limited options beyond 2nd ART drug regimen;
these: include: Integrase Inhibitors, new-generation NNRTIs &
Protease Inhibitors (PIs)**
• Durable viral load suppression on 1st line ART is the key to ART
treatment success and long life (Hence adherence to 1st line ART is
key and should therefore be vigorously supported)
• If 3rd line treatment becomes necessary, special treatment
guidance from NASCOP is required
• Meanwhile, continue appropriate 2nd line treatment, with
intensified adherence and counseling efforts, Direct Observed
Treatment (DOT) and home visits

59. 5. Intensive Case Finding (ICF) and
Isoniazid Preventive Therapy - 56
• Symptom-based TB screening using ICT tool must be done
at every visit for all people living with HIV (PLWHIV) to rule
out active TB
• Infection control measures should be prioritized to reduce
TB transmission in all settings that provide patient care
• TB investigations should be performed according to
National guidelines
• Although Chest radiograph is not mandatory as part of
routine screening, it should may be done for those
suspected to have TB, if sputum testing is not possible

60. 5. Intensive Case Finding (ICF) and Isoniazid
Preventive Therapy (IPT)
5.1 Indications for Isoniazid Preventive Therapy*- 56
1. HIV-infected children aged < 12months, who have had
recent contact with active TB but with no TB evidence
2. All PLWHIV aged above 12months, screened negative for
TB using ICF tool
3. All children aged < 5 yrs, regardless of HIV status, who
had recent (within past 12 months) close contact with
smear +ve TB case
4. Prisoners, irrespective of HIV status

61. 5. Intensive Case Finding (ICF) and Isoniazid
Preventive Therapy (IPT)
5.2 INH Dose &Duration for IPT* - 57
Weight range (Kg) Dose (mg) No. of 100mg tabs No. of 300mg tabs
(Adults)
<5 50 0.5 -
5.1-9.9 100 1 -
10-13.9 150 1.5 0.5
14-19.9 200 2 -
20-24.9 250 2.5 -
>25 300 3 1
Adults 300 - 1

62. 5. Intensive Case Finding (ICF) and Isoniazid
Preventive Therapy (IPT)
5.3 Pyridoxine dosing for IPT* - 58
Weight (Kg) No. of pyridoxine tablets (50mg)
5-7 Quarter (0.25) tablet daily
8-14 Half (0.5) tablet daily
≥ 15 One (1 full) tablet daily

63. 5. Intensive Case Finding (ICF) and Isoniazid
Preventive Therapy (IPT)
5.4 Follow-up on patients on IPT* - 59
IPT patients should be:
Reviewed monthly and adherence reinforced
Screened for active TB, during each re-visit
Reviewed during re-visits to update all
treatment records (registration/therapy
outcome/TB contact register maintained)
Monitored during re-visits for INH side-
effects and appropriately treated p.r.n

64. 5. Intensive Case Finding (ICF) and Isoniazid
Preventive Therapy (IPT)
5.5 Contraindications for IPT - 60
• IPT is contraindicated in case of :
1. Presence of active hepatitis (acute or
chronic)
2. Regular and heavy alcohol consumption
3. Presence of peripheral neuropathy
symptoms
• IPT discontinued if LFT values of ALT/AST
exceed three times their upper normal
limits, in symptomatic patients

65. 5. Intensive Case Finding (ICF) and Isoniazid
Preventive Therapy (IPT)
5.6 GeneExpert TB Diagnosis - 61
• GeneExpert is a new TB diagnostic tool:
It can detect TB disease & DNA/TB resistance
to rifampicin from sputum in <2hrs
It’s more sensitive than microscopy method
Able to detect smear-negative TB in PLHIV
Now increasingly recommended in Kenya by
MOH, for TB diagnosis in PLHIV (using ICF/IPT
screening tool)

66. 6. Laboratory Monitoring for PLHIV
6.1 CD4 Count Indications*** - 62
• CD4 count Indications for monitoring PLHIV:
1. When enrolling all PLHIV into care, (to support ART
eligibility criteria*)
2. All PLHIV not on ART (6-monthly CD4 to determine
eligibility for ART)
3. All PLHIV on secondary fluconazole prophylaxis (6-
monthly CD4 to determine when to discontinue the
prophylaxis)
4. Where viral load monitoring is not readily available,(
6-montly CD4 monitoring recommended for
monitoring ART response)
5. To aid differential diagnosis in new TB suspects**

67. 6. Laboratory Monitoring for PLHIV
6.4 Viral Load (VL) Testing Recommendations - 63
1. All PLHIV (children, adolescents and adults)
initiating 1st, 2nd or 3rd line ART regimens should
receive VL testing 6 and 12 months after ART
initiation then annually thereafter, for
monitoring ART response
2. All PLHIV (children, adolescents and adults)
with detectable viral loads (> 1000viral RNA
copies/ml) on routine viral loading should
receive VL after 3 months of confirming ART
failure, despite intensified adherence efforts

68. 6. Laboratory Monitoring for PLHIV
6.4 Viral Load (VL) Testing Recommendations - 64
3. All HIV-infected pregnant women initiating ART
should receive VL testing 6months after
initiating ART*
4. All HIV-infected women who become pregnant
while on ART and have had no VL testing during
preceding 6moths should get VL done soonest*
5. VL testing should be done before substituting
any single ARV, if patient has been on ART for at
least 6 months already

69. 6. Laboratory Monitoring for PLHIV
6.1 CD4 Count Indications* - 62
1. Performed during initial enrolment into ART
support of all PLHIV *
2. All PLHIV not already on ART*
3. All PLHIV on ART and prophylactic fluconazole*
4. Where viral load monitoring is not readily
available*
5. To aid differential diagnosis of PLHIV with new
signs/symptoms of ?HIV, regardless of ART
status*

70. 6. Laboratory Monitoring for PLHIV
6.2 Who doesn’t need CD4 ? - 63
The following child populations don’t need CD4
count to determine their ART eligibility (start
ART immediately for them):
1. HIV children < 18months (with ? Severe HIV)*
2. HIV children <10yrs(regardless of WHO stage) *
3. HIV Children >10yrs (*with CD4 ≤500cells/ mm3;
WHO stage 3&4, with TB, hepatitis B co-
infection)

71. 6. Laboratory Monitoring for PLHIV
6.3 Who doesn’t need CD4 ? - 64
The following Adult/Adolescent populations don’t need
CD4 count to determine their ART eligibility (start ART
immediately for them):
1. HIV Pregnant /Breastfeeding women*
2. HIV Adolescents/Adults (CD4 ≤ 500 cells / mm3,
regardless of WHO stage)
3. HIV Adolescents/Adults (WHO stage 3 & 4, regardless
of CD4 count)
4. HIV Spouses/Sero-discordant relationships*
5. HIV co-infections (HBV, TB)*

72. 6. Laboratory Monitoring for PLHIV
6.4 Viral Load Testing Recommendations -65
The following are recommended for viral load
(VL) testing during ART monitoring*:
1. All HIV Children, Adolescents, Adults
initiating ART (1st, 2nd , 3rd line ART)*
2. All HIV Children, Adolescents, Adults
continuing ART*
3. All HIV Children, Adolescents, Adults with
detectable VL*
4. All HIV pregnant women*

73. 7. Pre-conception Care (PCC)*-66
• Pregnancy intention assessed routinely*
• Effective contraception provided*
• HIV testing upon disclosure*
• Important concerns of PCC are:
1. PCC for concordant positive or discordant
couples**
2. Discordant couples who want to conceive; male
is HIV-positive**
3. Discordant couples who want to conceive;
female is HIV-infected**

74. 7. Pre-conception Care (PCC)
7.1 PCC for concordant +ve or discordant couples-67
• Intensive counseling to prevent HIV transmission
• Initiate ART regardless of CD4 or WHO stage for those eligible for PCC
• Defer pregnancy till viral load (VL) is undetectable
• Unprotected intercourse only during ovulation if pregnancy is desired
[enhanced using temperature /on-line fertility calculator - calendar
monitoring];
• Unprotected intercourse also deferred till VL suppression is confirmed
• Prenatal Care: Nutrition counseling; folic acid supplements to pregnant
women; both partners to participate in birth planning

75. 7. Pre-conception Care (PCC)
7.1 PCC for concordant +ve or discordant couples-68
• Pre-conception investigations include: -
1. Hb level estimation (manage anaemia
earliest possible)
2. Syphilis screening: VDRL; RPR
3. STI symptom screening [syndromic managnt]
4. Cervical cancer screening: Pap smear

76. 7. Pre-conception Care (PCC)
7.2 Discordant Couples Conception*-69
• If Discordant Couple want Conception; Male is HIV-
infected:
 Ensure viral load suppression in the male prior to partner’s
conception [to minimize HIV transmission to partner and baby]
 Sperm-washing then artificial insemination if feasible; (O/G
specialist management required for this option)
• If Discordant Couple want Conception; Female is
HIV-infected:
 Artificial insemination useful to minimize male becoming HIV-
infected
 Sperm-washing not beneficial for such couple

77. 8. Post-Exposure Prophylaxis (PEP)
8.1 Risk Assessment after Exposure to Body Fluids* -70
Post Exposure Low Risk High Risk
Type of Exposure Intact skin Mucous membrane/non-
intact skin; percutaneous
injury
Source HIV negative Unknown HIV status;
Clinically well/unwell
Material Saliva, Tears, Sweat,
Faeces, Urine, Sputum,
Vomit
Semen, Vaginal Secretions;
Synovial, Pleural,
Pericardial, Peritoneal,
Amniotic fluids;
Blood/blood products
(bloody bodily fluids); CSF;
viral cultures in
laboratories

78. 8. Post-Exposure Prophylaxis (PEP)
8.2 Medical Management of medical PEP*- 71
Considerations Recommended Action
Eligibility •High risk exposure
•Exposure within 72 hours
•Exposed individual not HIV-infected
•Source individual HIV+ve or unknown status;
Counseling and Testing
exposed individual
• Offer information on risks and benefits
•Verbal consent is adequate
•Base-line HIV test in HIV-exposed person
•VCT for both Exposed and Source individuals
ARV agents for PEP x 1
month
1. Adults; preferably: TDF + 3TC + ATV/r
2. Children; preferably: ABC + 3TC + LPV/r
Time of Initiation Soonest possible after exposure, but not beyond 72 hours
Duration of Therapy 28 days
Dose of PEP As indicated for ART; Use dosing wheel for children

79. 8. Post-Exposure Prophylaxis (PEP)
8.2 Medical Management of medical PEP*- 72
Considerations Recommended Action
Follow up •Follow up client at 7th , 14th and 28th days
•For up HIV testing 3 and 6 months after exposure
•Pregnancy testing
•Hb (if AZT-containing regimen is used for PEP)
•Hepatitis B vaccination if not already immunized
•Management of PEP side effects
Counseling •Adherence, risk reduction, trauma and mental health
counseling, social support or safety
Other services for
sexual assault
• STI prophylactic treatment to all
• Emergency contraceptives for non-pregnant women
• Tetanus toxoid for any physical injury of skin/mucous
membranes
• Documentation of clinical evidence of assault and
collection of forensic evidence
 Refer to National Guidelines on management of Sexual
Violence in Kenya, for comprehensive management
 Counseling on behaviour change and risk reduction to
those with repeated risks

80. 9. Pre-Exposure Prophylaxis (PrEP) -73
• Pre-exposure prophylaxis (PrEP) for HIV refers to
the daily use of ARV drugs by HIV negative (un-
infected people) to prevent the acquisition of
HIV
• PrEP is currently not routinely recommended In
Kenya, except in research settings
• Refer to Tables and Charts on
Formulations, Dosages of various
prophylactic ARVs

81. Major Tropical Diseases
10.1 HIV/AIDS- Prevention - 74
• A: Abstinence
• B: Be faithful to your sexual partner
• 4Cs: Condom use; Counseling; Compliance;
Contact tracing
• D: Drugs for support [(ARVs); ? Vaccination]

82. Major Tropical Diseases
10.2 HIV/AIDS- Prognosis - 75
• HIV/AIDS has become a chronic rather than an acutely fatal disease in
many areas of the world
• Prognosis varies between people, and both the CD4 count and viral load
are useful for predicted outcomes
• Without treatment, average survival time after infection with HIV is
estimated to be 9 to 11 years, depending on the HIV subtype
• After the diagnosis of AIDS, if treatment is not available, survival ranges
between 6 and 19 months
• HAART and appropriate prevention of opportunistic infections reduces
the death rate by 80%, and raises the life expectancy for a newly
diagnosed young adult to 20–50 years

83. Major Tropical Diseases
10.3 HIV/AIDS- Prognosis - 76
• If treatment is started late in the infection,
prognosis is not as good
• Half of infants born with HIV die before two years
of age without treatment
• The primary causes of death from HIV/AIDS are
opportunistic infections and cancer, both of
which are frequently the result of the progressive
failure of the immune system

84. Major Tropical Diseases
10.4 HIV/AIDS- Prognosis - 77
• TB/HIV co-infection also carries high morbidity and mortality
• Hepatitis C is another very common co-infection where each disease
increases the progression of the other
• The two most common cancers associated with HIV/AIDS are Kaposi's
sarcoma and AIDS-related non-Hodgkin's lymphoma
• Even with anti-retroviral treatment, over the long term HIV-infected
people may experience neurocognitive
disorders,[osteoporosis,neuropathy, cancers, nephropathy and
cardiovascular disease
• It is not clear whether these conditions result from the HIV infection
itself or are adverse effects of treatment

85. References
• Anjaiah, B. (2009). Clinical Paediatrics. 4th edition. Paras Publishing.
• Britannica Concise Encyclopedia Britannica Concise Encyclopedia. ©
1994-2014 Encyclopædia Britannica, Inc.
• Geoff, G & Nick, B. 2004. Lecture notes: Tropical Medicine. 6th edition
• Gordon, C. C & Alimuddin, I . Z. 2009. Manson’s Tropical Diseases.
22nd Edition. Saunders Elsevier Publishers.
• Kliegman, R.M, et al., (editors). (2011). Nelson Textbook of Pediatrics.
19th edition. Elsevier Saunders Publishers.
• Lichtman, M.A., et al (editors). (2006). Williams Hematology. 7th
edition. McGraw-Hill Medical Publishers.
• MOH (June, 2014). Guidelines on ARV Drugs for Treating and
Preventing HIV infection: Rapid Advice.