Management of HIV-Infected Populations

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Treatment of HIV Infected Populations

  • To improve ART initiation and adherence, counselling must be done so that the individual (or caregiver) understands its benefits. The benefits of starting ART earlier include:
  • Reduced rates of HIV-related morbidity and mortality
  • Reduced MTCT (in pregnant and breast-feeding women)
  • Potential reductions in the incidence and severity of chronic conditions (e.g., renal disease, liver disease, certain cancers, and neurocognitive disorders)
  • Reduction in infectious complications (e.g., TB)
  • Reduced sexual transmission
  • High levels of adherence to ART are needed to attain these objectives

Table 105: Eligibility Criteria for ART Initiation in Children, Adolescents, Pregnant and Breast-feeding Women and Adults

Specific populations

Description

Pregnant & Breast-feeding Women

 

 

Treat irrespective of WHO clinical stage or CD4 count

Children (0 to < 10 years old)

Adolescents (10 to ≤ 19 years old)

Adults

Under these new guidelines: Treat ALL, the assessment through WHO Clinical Staging (Table XX) guides the evaluation and management of HIV; however, initiating ART does not require a CD4 count

First-Line ART

Providing optimized, fixed-dose ART regimens in all populations have consistently demonstrated that there are better clinical and laboratory outcomes if HIV treatment is initiated early. Reduce the time between HIV diagnosis and ART initiation. This is based on an assessment of the person’s readiness, and it is preferred that initiation is done immediately or within 7 days.

Table 106: Preferred First-Line ART and Alternative Regimens by Specific Populations

Specific Populations

Description

Preferred 1st line ART

Alternative Regimen

Children (0-4 weeks)

All

AZT + 3TC + NVP

Get Expert Opinion or call 7040 for advice

 

 

Children (≥ 4weeks),

adolescents and adults

3 – 24.9kg

ABC + 3TC + pDTG*

ABC + 3TC + LPV-r

≥ 25kg

TAF + XTC + DTG

ABC + 3TC + DTG

≥ 30kg

TDF + XTC + DTG**

TDF + XTC + DRV-r*** ABC + 3TC + DTG TDF + XTC + LPV-r

TAF + XTC + DTG

 

Children, adolescents, and adults Co-infected with TB

3 – 29.9kg

ABC + 3TC + DTG

ABC + 3TC + AZT ABC + 3TC + LPV-r

≥ 30kg

TDF + XTC + DTG

Increase the frequency of DTG to 50mg twice daily if on Rifampicin- based ATT (continue DTG bd for extra 2 weeks after ATT completion)

ABC + 3TC + DTG TDF + XTC + DRV-r***

* pDTG 10mg is available for children weighing 3 – 19.9kg. Children and adults weighing ≥ 20kg, DTG 50mg is available and should be given once daily

** For children and adolescents who have their weight ≥ 30kg, the preferred 1st line regimen should be TafED

*** DRV-r should be given to children aged ≥ 12 years and ≥ 40kg, otherwise consult Expert opinion or call 7040. Avoid if on Rifampicin-based ATT

Advanced HIV Disease (AHD)

Description

For adults and adolescents, and children older than five years, AHD is defined as CD4 count < 200 cells/ mm3 or WHO stage 3 or 4 event. All children younger than five years old with HIV are considered as having AHD. To reduce HIV associated mortality, it is recommended that the following categories of HIV+ patients are reflexively screened for advanced HIV disease using a CD4 count test or WHO Clinical Staging where the CD4 count test is not available. These include:

  • Those newly diagnosed with HIV
  • Those re-initiating into care following treatment interruption
  • Those with a high viral load
  • Those hospitalized with a serious illness defined as respiratory rate ≥30 breaths per minute; Heart Rate

≥120 beats per minute, temperature ≥ 39°C, or unable to walk unaided

Treatment

Package of Care for People With AHD

Table 107: Screenig, Diagnosis, Prophylaxis and Pre-emptive Treatment

 

Intervention

CD4 Cell Count

Adults

Adolescents

Children

Screening & Diagnosis

Sputum Xpert MTB/ RIF as the first test for TB diagnosis among symptomatic people

Any

Yes

Yes

Yes

LF-LAM for TB diagnosis among people with symptoms and signs of TB

≤ 200 cells/ mm3 or at any CD4 count if seriously ill

Yes

Yes

Yes (limited data for children)

Cryptococcal antigen screening

≤ 200 cells/

mm3

Yes

Yes

No

Prophylaxis and Pre- emptive Treatment

Co-trimoxazole prophylaxis

≤ 350 cells/ mm3 or clinical stage 3 or 4

Yes

Yes

Yes (regardless of CD4 for under 5)

TB preventive treatment

Any

Yes

Yes

Yes

Fluconazole pre-emptive therapy for cryptococcal antigen–positive people without evidence of meningitis

< 200 cells/ mm3

Yes

Yes

Not applicable (Screening not advised)

 

 

Intervention

CD4 Cell Count

Adults

Adolescents

Children

 

Defer initiation if clinical symptoms suggest TB or Cryptococcal meningitis

Any

Yes

Yes

Yes

ART initiation

Rapid ART initiation

Any

Yes

Yes

Yes

Defer initiation if clinical symptoms suggest TB or Cryptococcal meningitis

Any

Yes

Yes

Yes

Individualised Adherence Support

Tailored counselling to ensure optimal adherence to the AHD

package, including home visits if feasible

< 200 cells/ mm3

Yes

Yes

Yes

Table 108: Common ART Toxicities and recommended substitutes

ARV drug

Common Associated Toxicity

Recommended ARV Substitute

ABC

Hypersensitivity reaction

TAF (if CrCl ≥ 30mL/min and weight ≥ 25kg), or

TDF (if normal Creatinine Clearance or if child ≥30kg), or AZT

(if child < 25kg)

AZT

Severe anaemia or neutropenia, severe gastrointestinal intolerance, lactic acidosis

Substitute TDF or ABC

DTG

Hepatotoxicity, hypersensitivity reactions

Substitute another therapeutic class: EFV or boosted PIs

Insomnia, body weight gain or obesity**

Consider morning dose or substitute EFV or boosted PI Monitor body weight and promote anti-obesity measures (such as diet and physical exercise). If significant increase despite measures, consider substituting EFV or boosted PI

EFV

Persistent CNS toxicity (e.g., dizziness,

insomnia and abnormal dreams) or mental symptoms (anxiety, depression and mental confusion) or convulsions

Substitute DTG or boosted PIs

Hepatotoxicity, Severe skin and hypersensitivity reactions, gynaecomastia

For severe hepatotoxicity or hypersensitivity reactions, substitute another therapeutic class (INSTIs or boosted PIs)

ARV drug

Common Associated Toxicity

Recommended ARV Substitute

LPV-r

Hepatotoxicity (common if underlying hepatic disease, coinfection with hepatitis B or C

Substitute another therapeutic class (INSTIs) or boosted PIs

Pancreatitis (in Advanced HIV Disease, alcohol abuse)

 

Dyslipidemia (Cardiovascular risk factors such as obesity and diabetes)

 

Diarrhoea (Risk factors unknown)

 

DRV-r

Hepatotoxicity, Severe skin and hypersensitivity reactions

Substitute with LPV-r. When it is used in third line ART, limited options are available

For hypersensitivity reactions, substitute another therapeutic class

NVP

(or EFV)

Rash, Stevens Johnson Syndrome, hepatitis

DTG or LPV-r

TAF

Dyslipidemia and Body weight gain (common in female sex, concomitant use of DTG)

Monitor body weight and promote anti-obesity measures (such as diet, physical exercise). If significant increase despite measures, consider substituting EFV or boosted PI

TDF

Chronic kidney disease and Acute kidney injury, Fanconi syndrome, Decreases in bone mineral density,

Lactic acidosis or severe hepatomegaly with steatosis

Substitute with another ARV, except for ROC with HBV/HIV co-infection who need TDF to be maintained on adjusted doses or switch to Entecavir

TAF may be used if CrCl ≥ 30mL/min

DTG is an option if HIV-1 RNA < 500,000 copies/mL, no HBV, and if there are no contraindications (in consultation with an HIV and/or renal expert)

Refer to tertiary level of care if unable to monitor ROC with CKD or if deterioration in CrCl falling below 30mL/min

Monitoring HIV-Infected Populations on ART Clinical and Laboratory Monitoring

  • Monitoring consists of two components: Clinical and Laboratory
  • Clinical monitoring includes history and examination, as well as evaluation of adherence, side effects and relevant drug toxicities
  • Laboratory tests need to be conducted routinely and as It includes CD4 count, viral load and toxicity monitoring
  • The purpose of monitoring includes:
  • Evaluation of treatment response and diagnose treatment failure early
  • Evaluation of adherence
  • Screening for Pulmonary tuberculosis
  • Detection of toxicity to ARV drugs
  • Viral load is recommended as the preferred monitoring approach to determine the performance of ART in an individual prophylaxis for at least 12 weeks, there should be a current suppressed viral load result before stopping the HIV prophylaxis.

Monitoring Drug Side Effects and Toxicities

Serious adverse reactions due to ART are uncommon. Therapy should only be switched in the presence of Grade 3 or 4 adverse drug reactions. Changing an ARV drug should only be done after careful review of adherence. The indication for changing needs to be addressed.

Table XX: Common ART Toxicities and Recommended Substitutes (For All Populations)

*Hyperbilirubinaemia and icterus do not reflect hepatic disease and are not contraindications to continued

therapy. Only substitute ATV-r if the condition is intolerable to the ROC.

**For ROC with weight gain, a patient centred approach must be taken considering a patient’s concerns, the level of BMI (> 30) and the proportion of change (> 10%). A healthy lifestyle must be promoted. Consider monitoring for serum glucose level, BP and serum lipid level.