ART PPT Final.pptx

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1. Anti Retroviral Therapy Dr . B.K. Shiva Kumar, MD Medical Officer, ART Centre JSS Hospital, Mysuru

2. F O C U S DIAGNOSIS OF HIV CLINICAL ASSESSMENT DRUGS, REGIMEN AND MONITORING PREGNANCY, INFANTS AND CHILDREN WITH HIV HIV-TB CO-INFECTION POST EXPOSURE PROPHYLAXIS

3. H UM A N IM M UN O DEF I C IEN C Y VIR U S First ever known case of HIV infection was diagnosed in June 1981 in Los Angeles, USA. In India, first detected among female sex workers screened for HIV at Chennai in 1986. In Karnataka, at Saudatti in Belgavi district (Devadasi Rituals) in 1987. HIV infection is now considered a chronic manageable disease and majority of the PLHIV remain healthy if correct and timely treatment is started. Prevalence: As per India HIV estimation report 2020, HIV prevalence was estimated at 0.22% (0.24% among males; 0.20% among females). The prevalence continued to decline 0.54 % in 2001 0.33% in 2010 0.22% in 2020 0.21% in 2021 ………………..24.01 Lakhs ( Third Highest in World )

4. Modes of Transmission At Risk Population ! Sex workers Truckers Migrants Trans-genders IV drug abusers Sexual: Heterosexual MSM Blood transfusion Mother to child Injection drug abuse Needle stick injury, blood and body fluids splash.

5. N A T I O NAL A I D S C O NT R O L O R GAN I ZAT I O N ( NAC O ) Policies for prevention and control of HIV infection NACP-I started in 1992 and lasted until 1999. NACP-II (2000–2005) NACP-III (2006-2011) NACP-IV (2012–2017)------( extended till March 2021). NACP-V (2021-2026) 95% of the estimated PLHIV know their status, of which 95% PLHIV are on ART, of which 95% PLHIV have viral suppression

6. In the current phase of NACP-V (2021–2026), the focus is on ensuring PLHIV survive longer and lead productive lives. This will be achieved through improving retention in HIV care and adherence to ART through a client-centric approach to providing care, support and treatment services. The current strategic plan aims to achieve: zero new infections zero AIDS-related deaths zero discrimination for paving the way for an end of AIDS as a public health threat by 2030.

7. SOCH: Strengthening Overall Care for HIV beneficiaries

8. Integrated Counselling and Testing Centre (ICTC) Diagnosis of HIV

9. In adults and children > 18 months: In infants and children < 18 months: Rapid tests (Sensitivity of >99.5 % and Specificity of >98 %) Total Nucleic Acid PCR test on a Dried Blood Spot

10. Window period Window period: the period between infection with HIV and the time when HIV antibodies can be detected in the blood (6–12 weeks). A blood test performed during the window period may yield a negative test result for HIV antibodies.

11. Maternal antibodies to HIV, transferred passively to the infant during pregnancy Usually persist for nearly 9–12 months in the infant. In some children, they may persist for as long as 18 months. Maternal antibodies

12. Features of HIV-2 Less pathogenic and slower progression of disease Longer asymptomatic stage and lower viral loads Slower decline in CD4 counts Lower rates of vertical transmission Patients with dual infection (HIV-1 and HIV-2) tend to present at a more advanced stage of the disease. Infection with both HIV-1 and HIV-2 generally carries the same prognosis as that of HIV-1 single infection. Types of HIV Virus

13. Goals of ART

14. Scope of services Pregnancy and HIV Patients with HIV HIV TB co-infection Infants and Children with HIV Infants and Children with HIV Post Exposure Prophylaxis

15. Patient Registration

16. Clinical Assessment Once the PLHIV are enrolled in an ART centre, a comprehensive clinical assessment should be done to obtain baseline clinical status and to rule out OIs.

17. Medical History 4 symptom screening for TB : Adults: fever, cough, weight loss, night sweats; Children: fever, cough, poor weight gain, h/o contact with a TB case Persistent symptoms – headache, poor concentration, seizures; Medical history for comorbid conditions like Diabetes and Hypertension; History of tuberculosis; Prior exposure to ARVs in the past; History of STI; HIV risk behaviour – multiple partners, key populations, injecting drug use; Substance abuse – alcohol, tobacco, oral or injecting drugs; Allergies/medication/vaccines; Pregnancy and contraception.

18. Physical Examination Appearance: pallor, icterus, orientation, wasting Vital signs: height, weight, temperature, blood pressure Skin: herpes simplex, herpes zoster, PPE Lymph nodes: cervical, axillary and inguinal Mouth: oral candidiasis, oral hairy leukoplakia Chest: congestion, consolidation Abdomen: hepato-spenomegaly, tenderness Neurological: comprehensive Eyes: fundus examination if CD4 < 100 cells/cu mm. Anogenital : genital lesions, urethral or vaginal discharge

19. Laboratory monitoring Baseline Investigations Haemogram /CBC Fasting blood sugar Blood urea, serum creatinine LFT Lipid profile VDRL HBsAg HCV Serum cryptococcal antigen CD4 count Urine for routine and microscopy X-ray Chest USG Abdomen CBNAAT

20. WHO Clinical Staging - Stage I Asymptomatic Persistent generalized lymphadenopathy Asymptomatic Persistent generalized lymphadenopathy Adults and adolescents Children

21. WHO Clinical Staging -Stage II Children Unexplained hepato-splenomegaly Recurrent respiratory tract infections (Otitis Media, Sinusitis, Tonsillitis) Herpes zoster Lineal gingival erythema Recurrent oral ulceration Papular pruritic eruption Fungal nail infections Extensive wart virus infection Extensive Molluscum contagiosum Persistent parotid enlargement Adults and adolescents Moderate unexplained weight loss < 10 % of presumed or measured body weight) Recurrent respiratory tract infections ( Sinusitis,Tonsillitis , Otitis Media, Pharyngitis) Herpes Zoster Angular Cheilitis Recurrent oral ulceration Papular Pruritic Eruption Fungal nail infections Seborrhoeic Dermatitis

22. Unexplained severe weight loss (>10% of the presumed or measured body weight) Chronic diarrhoea for more than 1 month Persistent fever (intermittent or constant for longer than 1 month) Persistent Oral Candidiasis Oral Hairy Leukoplakia Pulmonary Tuberculosis Severe bacterial infections (such as Pneumonia, Empyema, Pyomyositis, bone or joint infection, Meningitis, bacteraemia) Acute necrotizing ulcerative stomatitis, gingivitis or Periodontitis Unexplained anaemia (Hb < 8 g/dl ) Unexplained moderate malnutrition not responding to standard therapy Chronic diarrhoea (14 days or more) Persistent fever (intermittent or constant, for longer than 1 month) Persistent Oral Candidiasis (after the first 6 weeks of life) Oral Hairy Leukoplakia Lymph node Tuberculosis Pulmonary Tuberculosis Severe recurrent bacterial Pneumonia Acute necrotizing ulcerative stomatitis, gingivitis or Periodontitis Unexplained anaemia (Hb < 8 gm/dl) Adults and adolescents Children WHO Clinical Staging - Stage III

23. Children Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy Pneumocystis ( jiroveci ) Pneumonia Recurrent severe bacterial infections (such as Empyema, Pyomyositis, bone or joint infection, Meningitis, but excluding Pneumonia) Chronic Herpes Simplex infection (orolabial or cutaneous of more than 1 month duration or visceral at any site) Oesophageal Candidiasis (or Candidiasis of trachea, bronchi, or lungs) Extra pulmonary Tuberculosis Kaposi’s sarcoma Cytomegalovirus infection (retinitis or infection of other organs with onset at age > 1 month) Adults and adolescents HIV wasting syndrome Pneumocystis ( jiroveci ) Pneumonia Recurrent severe bacterial Pneumonia Chronic Herpes Simplex infection (orolabial, genital or anorectal of more than 1 month duration or visceral at any site) Oesophageal Candidiasis (or Candidiasis of trachea, bronchi or lungs) Extra pulmonary Tuberculosis Kaposi’s sarcoma Cytomegalovirus infection (retinitis or infection of other organs) Central nervous system Toxoplasmosis HIV encephalopathy Extra pulmonary Cryptococcosis, including Meningitis WHO Clinical Staging - Stage IV

24. Children Central nervous system Toxoplasmosis (after the neonatal period) HIV encephalopathy Extra pulmonary Cryptococcosis, including Meningitis Disseminated nontuberculous mycobacterial infection (NTM) Progressive Multifocal Leukoencephalopathy Chronic Cryptosporidiosis (with diarrhoea) Chronic Isosporiasis Disseminated mycosis (extra pulmonary Histoplasmosis, Coccidioidomycosis, Penicilliosis ) Cerebral or B-cell non-Hodgkin’s Lymphoma HIV-associated nephropathy or cardiomyopathy Adults and adolescents Disseminated non-tuberculous mycobacterial infection (NTM) Progressive Multifocal Leukoencephalopathy (PML) Chronic Cryptosporidiosis Chronic Isosporiasis Disseminated mycosis (extra pulmonary Histoplasmosis, Coccidioidomycosis) Lymphoma (cerebral or B-cell nonHodgkin’s ) HIV-associated nephropathy or cardiomyopathy Recurrent septicaemia (including nontyphoidal Salmonella) Invasive cervical carcinoma Atypical disseminated leishmaniasis WHO Clinical Staging - Stage IV ...... cont’d...

25. Association between CD4 and opportunistic infections

26. Management of OI’s before ART initiation Clinical Picture Action Tuberculosis ART should be started as soon as possible within 2 weeks of initiating TB treatment, regardless of CD4 cell count Pneumocystis pneumonia (PCP) Treat PCP first; start ART when PCP treatment is completed Oesophageal candidiasis Cryptococcal meningitis Treat oesophageal candidiasis first; start ART as soon as the patient can swallow Cytomegalovirus Retinitis Treat CMV urgently; start ART after 2 weeks T o x o p l a s m o s i s Treat Toxoplasmosis; start ART after 6 weeks Treat cryptococcal meningitis, start ART after 4-6 weeks when the patient is stabilized

27. HIV life cycle and ARV targets

28. A R T DR U GS ENTRY INHIBITORS : HIV enters CD4 cells via CD4 receptor in conjugation with one of its co-receptors – CCR5 & CXCR4. CCR5 Antagonist – MARAVIROC – used only in treatment experienced patients with drug resistant virus. FUSION inhibitors – ENFUVIRTIDE – bind to GP41 (envelope protein of HIV) and prevent their fusion with T-cell. ATTACHMENT inhibitor – FOSTEMSAVIR – approved in 2020 that bind to GP120 (envelope protein of HIV) and prevent HIV fusion with CD4 T cell.

29. REVERSE TRANSCRIPTASE INHIBITORS: A. Nucleotide Reverse Transcriptase Inhibitors (NtRTI) TENOFOVIR* – Alafenamide (TAF) & Disoproxil fumarate (TDF)* B. Nucleoside Reverse Transcriptase Inhibitors (NRTI) ABACAVIR (ABC) * LAMIVUDINE (3TC) * ZIDOVUDINE (AZT)* EMTRICITABINE (FTC) DIDANOSINE (ddi) STAVUDINE (d4T) C. Non- Nucleoside Reverse Transcriptase Inhibitors (NNRTI) NEVIRAPINE (NVP) * EFAVIRENZ (EFV) * DELAVIRIDINE RILPIVIRINE ETRAVIRINE

30. INTEGRASE INHIBITORS: DOLUTEGRAVIR (DTG) * RALTEGRAVIR (RGV) * ELVITEGRAVIR BICTEGRAVIR CABOTEGRAVIR PROTEASE INHIBITORS: RITONAVIR (RTV) * LOPINAVIR (LPV) * ATAZANAVIR (ATV) * DARUNAVIR (DRV) * SAQUINAVIR NELFINAVIR INDINAVIR AMPRENAVIR

31. Optimal Regimen Based on the evidence supporting better efficacy and fewer side effects, the preferred first-line ART regimen for PLHIV is as follows: Age > 10 yrs and weight > 30 kg Tenofovir(300mg) + Lamivudine (300 mg) + Dolutegravir(DTG 50 mg) TLD regimen as FDC in a single pill once daily PLHIV with body weight < 30 kg ABC (600 mg) + Lamivudine (300mg)+ DTG (50 mg) ABC (600 mg OD) + Lamivudine (as per creatinine clearance**) and DTG (50 mg) All patients with high serum Creatinine Values(above ULN) PLHIV on Rifampicin-containing ATT regimen TLD + additional dose of DTG 50 mg (12 hours after taking their regular dose) until 2 weeks after completion of ATT

32. Monitoring and follow up Patients are advised to visit ART regularly every month Body weight (Height in children) Treatment Adherence 4-Symptom TB screening Screening for HTN, Diabetes Every visit Every visit Every visit Every visit Lab Investigations: Hb, RBS, SGOT, SGPT, Urea, Creatinine Every 6 Months CD4 count: CD4 must be done every 6 months, can be discontinued if it reaches > 350 cells/mm3 and viral load is < 1000 copies/ml (when both tests are conducted at the same time). Viral load: Viral load at 6 months, 12 months and then every 12 months For patients on second/third-line ART, Viral Load testing to be done every 6 months Advanced HIV Disease : PLHIV with advanced HIV disease are defined as presenting with CD4 count < 200 cells/cu.mm. or WHO clinical stage 3 or 4 or children aged < 5 years

33. Expected response to ART Virological response to ART: The plasma viral load done 6 months after initiation of ART should come down to<1000 copies/ml and should be maintained at undetectable or <1000 copies/ ml throughout the treatment course Immunological response to ART: is defined as an increase of at least 50 CD4 cells/mm3 at 6 months of ART. This increase is usually 50–100 cells/mm3 within 6–12 months of ART initiation in ARV-naive patients, who are fully adherent to ART Clinical response to ART: Clinical monitoring should include evaluation of weight, general well-being (functional status), adverse reaction to drugs and keeping an eye out for IRIS, especially in patients with low CD4 count

34. IRIS Immune Reconstitution Inflammatory Syndrome The worsening of signs and symptoms due to known infections, or the development of disease due to occult infections within 6 weeks to 6 months after initiating ART, with an increase in CD4 count . IRIS should be diagnosed by excluding the following; Active OI, b) Treatment failure, c) Side effect from ARV, d) Failure to antimicrobial therapy The most serious and life-threatening forms of paradoxical IRIS are TB and Cryptococcosis. Important steps to reduce the development of IRIS include; Earlier HIV diagnosis and initiation of ART before decline of CD4 below 200 cells/mm3 Improved screening for OIs before ART, especially TB, Cryptococcus, CMV and optimal management of OIs before initiating ART. IRIS is generally self-limiting and interruption of ART is rarely indicated Anti microbial therapy is required to reduce and eliminate triggering pathogen Short-term therapy with corticosteroids or non-steroidal anti-inflammatory drugs Temporary cessation of ART must be considered, only in potentially life-threatening forms of IRIS Risk factors for IRIS : 1) People with CD4 counts below 100 cells/cu mm at ART initiation 2) People with rapid initial fall in HIV viral load due to therapy 3) Shorter interval between OI therapy initiation and ART initiation 4) Higher HIV RNA at ART initiation

35. Adverse drug effects of ARVs Dr u gs Tenofovir (TDF) Zidovudine (AZT) Lamivudine (3TC) Abacavir (ABC) Adverse effects Renal toxicity, bone demineralization Anaemia, neutropenia, bone marrow suppression gastrointestinal intolerance, headache, insomnia, myopathy, lactic acidosis, hyperpigmentation of skin and nail Minimal toxicity, rash (very rare) Hypersensitivity reaction in 3% to 5% (can be fatal), fever, rash, fatigue, nausea, vomiting, anorexia, respiratory symptoms (sore throat, cough, shortness of breath); rechallenging after reaction can be fatal

36. Adverse drug effects of ARVs . ..... cont’d … D rug s Dolutegravir (DTG) Raltegravir (RAL) Atazanavir/ ritonavir (ATV/r) Lopinavir/ritonavir (LPV/r) Adverse effects Hepatotoxicity, weight gain, allergic reaction, insomnia Hepatotoxicity, allergic reaction, myalgia/rhabdomyolysis Hyperbilirubinaemia, Hyperglycaemia, fat maldistribution, nephrolithiasis Diarrhoea, nausea, vomiting, abnormal lipid profiles, glucose intolerance Note: PI’s should not be prescribed with Simvastatin as they significantly increase the level of Simvastatin leading to Rhabdomyolysis, resulting in severe kidney failure.

37. ADHE R E N CE Adherence signifies that the patient and physician collaborate to improve the patient’s health by integrating the physician’s medical opinion and the patient’s lifestyle, values and preferences to care. Patients starting ART should be willing and able to commit to treatment and understand the benefits and risks of therapy and the importance of adherence. For ART, a high level of sustained adherence is necessary to suppress viral replication and improve immunological and clinical outcomes; decrease the risk of developing ARV drug resistance; and reduce the risk of transmitting HIV Adherence should be assessed and routinely reinforced by everyone in the HIV care team at each of the patient’s visit to the ART centre. Studies indicate that >95% of adherence is required for optimal viral load suppression. Lesser degree of adherence is often associated with virological failure

38. P r o p h y l a x is Co-trimoxazole prophylaxis : CPT must be initiated in all HIV-infected adults and adolescent with CD4 count <350 cells/mm3 or those with WHO clinical stage 3 or 4, to prevent PCP and Toxoplasmosis. One tablet of Cotrimoxazole -DS (Trimethoprim 160 mg + Sulphamethoxazole 800 mg) to be taken daily preferably after food. Note : For patient’s allergic to co- trimoxazole , Dapsone 100mg is given as prophylaxis. TB Preventive Therapy: Three months after initiation of ART, All patients who do not have active TB should be considered for prophylaxis to prevent latent TB from progressing to active TB. It also prevents re-infection after exposure to an open case of TB. One tablet of Isoniazid 300 mg to be taken daily preferably after food for 6 months . Note: IPT does not promote Isoniazid resistance when used to treat latent TB infection In latent TB, the Mycobacterium tuberculosis bacilli are fewer in number and are dividing slowly, resulting in an extremely low risk of selecting drug-resistant mutants.

39. Stable Adults and adolescents (>10 years) PLHIV (Adult/Adolescent) shall be termed ‘stable’ if they fulfil all the following criteria: On ART for at least 6 months No adverse effects of ART that require regular monitoring No current illness/OI/medical condition that requires management Suppressed plasma viral load (< 1000 copies/ml) Treatment adherence ≥ 95% consecutively over the last 3 months

40. D e f i n i t io n s o f t r e a t ment f ail u r e Failure Definition Comment s Virological failure Plasma viral load ≥1000 copies/ml An individual must be taking ART for at least 6 months before it can be determined that a regimen has failed. Immunological failure CD4 count at 250 cells/ mm3 following clinical failure Persistent CD4 count below 100 cells/mm3 Concomitant or recent infection may cause a transient decline in the CD4 cell count. Clinical failure New or recurrent clinical event indicating severe immuno- deficiency (WHO clinical stage 4) after 6 months effective treatment . The condition must be differentiated from IRIS

41. Substitution, Step-up Adherence and Switch SUBSTITUTION: Substitution refers to replacement of ARV drug in a virally suppressed PLHIV due to adverse effects of drug, drug–drug interactions or programme policy. This does not indicate change of regimen due to treatment failure. STEP-UP ADHERENCE: In all patients with treatment failure (Plasma viral load ≥ 1000 copies/ml), Step-up adherence counselling is done for three months and viral load test repeated if adherence is > 95% in the three consecutive months. SWITCH: Treatment failure refers to the loss of antiviral efficacy to the current regimen. When the ARV regimen is changed because of treatment failure, it is referred as the switch of the entire regimen.

42. Change of Line of Regimen First-line ART : is the initial regimen prescribed for an ART-naive patient. Second-line ART : is the subsequent regimen used in sequence immediately after first-line therapy has failed (as recommended by SACEP at ART Plus Centre). Third-line ART : is the subsequent regimen used in sequence immediately after second-line therapy has failed (as recommended by COE at Bengaluru and treatment at ART Plus centre). Current Recommendation for Second-line ART is based on the following : an integrase strand transfer inhibitor (INSTI)-DTG, if first line was NNRTI based „ a Ritonavir-boosted PI (Atazanavir/ritonavir or Lopinavir/ritonavir), if first line was INSTI based Supported by at least one new and unused NRTI (Zidovudine or Tenofovir) Continued Lamivudine administration ensures reduced viral fitness. Initiation of third-line ART : Third-line regimens should include new drugs with minimal risk of cross-resistance to previously used regimens such as INSTIs and second-generation NNRTIs and PIs. The regimen is Dolutegravir (50 mg) +[ Darunavir (600 mg) + ritonavir (100 mg) BD].

43. ARV for Pregnant Women and Exposed Infant All Pregnant women should be screened for HIV and HIV-positive pregnant women including those presenting in labour and breastfeeding should be initiated on a triple-drug (TLD) regimen regardless of CD4 count and clinical stage for preventing MTCT and should continue lifelong ART. The incidence of neural tube defects with the use of DTG is < 0.2% Women of childbearing potential or pregnant women (first trimester) who do not wish to take DTG based ART after adequate and optimal counselling are given Tenofovir (300 mg) + Lamivudine (300 mg) once daily Lopinavir (200 mg) + ritonavir (50 mg) twice daily Viral load test is done between 32 and 36 weeks of pregnancy to assess high or Iow risk of transmission to the infant ARV Prophylaxis is advised to the infant based on the risk of HIV transmission.

44. HIV risk assessment of infants and ARV Prophylaxis Low-risk infants: Infants born to mothers with suppressed viral load(<1000 copies/ ml) done anytime after 32 weeks of pregnancy or up to delivery High-risk infants: Infants born to HIV-positive mother not on ART Maternal viral load not done after 32 weeks of pregnancy till delivery Maternal viral load not suppressed between 32 weeks of pregnancy till delivery Mother newly identified HIV positive within 6 weeks of delivery HIV Risk Status Option for ARV Prophylaxis Syrup Nevirapine (NVP) or Syrup Zidovudine (where NVP will not be effective): Infant born to a mother with confirmed HIV-2 or HIV-1 and HIV-2 combined infections Infant born to a mother who had received single dose of NVP during earlier pregnancy or delivery Infant born to a mother who is on PI-based ART regimen due to treatment failure Duration of ARV prophylaxis: From birth till 6 weeks of age Options for dual prophylaxis: Syrup Nevirapine + Syrup Zidovudine Duration of Dual ARV Prophylaxis: In case of Exclusive Replacement Feeding (ERF): From birth till 6 weeks of age In case of Exclusive Breastfeeding (EBF): From birth till 12 weeks of age

45. Infant feeding The two infant feeding options available for the HIV-positive mother are Exclusive breast feeding (EBF) or Exclusive replacement feeding (ERF) EBF means giving a baby only breast milk and no other liquids or solids. ERF is the process of feeding a baby, who is not breastfeeding, with a diet that provides the baby its nutrient requirements which includes feeding the baby animal milk, dairy milk, and infant formulas. It is important to counsel parents that the feed must be prepared in a hygienic manner and should be give with a spoon and bowl. Avoid bottle feeding. Mothers living with HIV should breastfeed for at least 12 months while being fully supported for ART adherence Breastfeeding is made safe by giving ART to the mother and ARV prophylaxis to the baby. Mixed feeding increases the risk of transmission of HIV and should be avoided.

46. C h il d r en a n d H IV Age less than 6 years and body weight less than 20 kg Age between 6 and 10 years and body weight between 20 kg and 30 kg Age more than 10 years and body weight more than 30 kg First-line ART regimens for infants and children with HIV-1 and HIV-2 infection Particulars Recommended Regimen Abacavir + Lamivudine + Lopinavir/ritonavir (AL+LPV/r) Abacavir + Lamivudine + Dolutegravir (ALD) Tenofovir + Lamivudine + Dolutegravir (TLD) Please note: Any infant or child initiated on any regimen must be based on body weight. On every visit, check body weight of the infant/child before writing the prescription. Even though the drug regimen remains the same, drug dosages have to be modified according to change in body weight.

47. Prophylaxis in children Weight (kg) Age Syrup 5 ml (40 TMP/200 SMX) Child tab. (20 TMP/100 SMX) < 5 6 wks –2 months 2.5ml 1 tablet 5 - 10 2- 12 months 5ml 2 tablets 10 - 15 1- 2 years 7.5ml 3 tablets 15 – 22 2 - 5 years 10ml 4 tablets >22 > 5 years 15ml 1 ½ (adult) tablets Co- trimoxazole prophylaxis: (Weight and Age based dosing)

48. IPT Prophylaxis: Dosage of Isoniazid in children Weight range (kg) Number of 100 mg tablets of INH (total dose 10 mg/kg/day) < 5 ½ tablet 5.1– 9.9 1 tablet 10– 13.9 1 ½ tablets 14– 19.9 2 tablets 20– 24.9 2 ½ tablets > 25 3 tablets or one adult tablet (300mg)

49. Stable Child For children >2 years to 10 years of age, satisfying all the following criteria: Receiving ART for at least 6 months Viral load is suppressed (Plasma viral load < 1000 copies/ml) Should be on the same regimen ( with no dose or formulation change) for at least 3 months Should not have any active illness or medical condition that requires further management Treatment adherence > 95% in each of last 3 months Weight for age is more than 2SD

50. HIV-TB coinfection The general principles for management of HIV-TB coinfected patients: Intensified Case Finding (ICF) using 4S Complex, fast tracking and referral of symptomatic patients for CBNAAT. Prompt treatment of active TB and continuation of ART in PLHIV. Cotrimoxazole Preventive Therapy (CPT) in all PLHIV with TB co-infection. Intensive phase : (IP) for 8 weeks: Isoniazid (H), Rifampicin (R), Pyrazinamide (Z) and Ethambutol (E) given in daily dosages as per adult and children weight band categories. Continuation phase: (CP) for 16 weeks: Isoniazid, Rifampicin and Ethambutol in daily dosages. Note: 1. The CP may be extended by 12–24 weeks in certain forms of TB like CNS TB, skeletal TB, disseminated TB, etc. 2. Dolutegravir 50 mg (at an interval of 12 hrs with the regular dose of DTG) is given and continued for 2 weeks after completion of ATT.

51. HIV-TB coinfection……cont’d… Adverse drug effects of first-line anti-TB drugs D ru g • Isoniazid • Ri f a m p i ci n • Pyrazinamide • Ethambutol Main Effects Peripheral neuropathy S k i n r a s h Hepatitis Sleepiness and lethargy Abdominal pain, nausea, vomiting Hepatitis General cutaneous reactions Thrombocytopenic purpura Arthralgia Hepatitis Gastrointestinal problems Retrobulbar neuritis

52. Post-exposure Propyhlaxis (PEP) Management of Exposure Site – First Aid Skin: If the skin is pierced by a needlestick or sharp instrument: Immediately wash the wound and surrounding skin with water and soap. Do not scrub. Do not use antiseptics or skin washes. Do not use bleach, chlorine, alcohol, betadine . After a splash of blood or body fluids: Wash the area immediately. Do not use antiseptics. Unbroken skin: Wash the area immediately. Do not use antiseptics. Eye: Irrigate exposed eye immediately with water or normal saline. If wearing contact lenses, leave them in place while irrigating, as they form a barrier. Mouth: Spit fluid out immediately. Rinse the mouth thoroughly using water or saline and spit again. Repeat this process.

53. Mild exposure Types of exposur e Exposure to mucous membrane/non-intact skin with small volumes, contact with the eyes or mucous membranes or subcutaneous injections following small-bore needle Exposure to mucous membrane with large volumes or percutaneous superficial exposure with solid needle. e.g., a superficial cut or needlestick injury penetrating gloves Percutaneous exposure with large volume e.g. an accident with a high-calibre needle (>18 G) visibly contaminated with blood a deep wound (haemorrhagic wound and/or very painful); transmission of a significant volume of blood an accident with material that has previously been used intravenously or intra-arterially Post-exposure Prophylaxis ……cont’d… Moderate exposure Severe exposure

54. HIV Exposure Codes (EC) Whether the material is blood, bloody fluid or other potentially infected material (OPIM) or instrument contaminated with one of these substances Yes No PEP not required What type of exposure occurred? Mucous membrane or skin integrity compromised Intact skin Percutaneous exposure Volume Small volume/ a few drops short duration EC 1 Large volume/ major splash long duration EC 2 Severity Less severe, solid needle, superficial scratch More severe, hollow-bore needle deep injury EC 2 EC 3 PEP not required Post-exposure Prophylaxis ……cont’d…

55. HIV Source Codes (SC) Source of exposure: HIV status HIV-negative HIV-positive HIV status unknown PEP not required Low titre exposure asymptomatic high CD4 count High titre exposure advanced disease low CD4 count HIV SC: Unknown HIV SC 1 HIV SC 2 Post-exposure Prophylaxis……cont’d…

56. Post-exposure Prophylaxis……cont’d… NACO recommendations for PEP Exposure Code HIV Source Code Recommendation for PEP 1 1 Not warranted 1 2 Recommended PEP 2 1 ………………... 2 2 ………………... 3 1 or 2 ………………… 2 or 3 Unknown Consider PEP if HIV prevalence is high in population in the region and risk categorization

57. Post-exposure Prophylaxis……cont’d… Exposure to Body Fluids Considered `at Risk' Blood Semen Vaginal secretions Cerebrospinal fluid Synovial, pleural, peritoneal, pericardial fluid, Amniotic fluid Other body fluids contaminated with visible blood Exposure to Body Fluids Considered ‘Not at Risk‘ ( Unless these Fluids Contain Visible Blood ) Tears Sweat Urine and faeces Saliva Sputum Vomitus

58. Post-exposure Prophylaxis……cont’d… Blood transfusion Perinatal (without any intervention) Sexual intercourse Vaginal Anal Oral Injecting drugs use Needle Stick exposure Mucous membrane splash to eye, oro-nasal HIV transmission risk by different routes (WHO data) Exposure Route HIV Transmission Rate > 98% 20 - 40% 0.1–10% 0.05-0.1 0.065–0.5% 0.005–0.01% 0.67% 0.3% 0.09% Note : Comparative risk after needle-stick injury for HBV is 9% to 30% and for HCV is 1% to 1.8%

59. Post-exposure Prophylaxis…… cont’d… E x po s e d P e r s o n Regimen for PEP Alternate Regimen Adolescents and Adults (> 10 yrs and >30 kg) TL D TL + Lopinavir/Ritonavir Children (> 6 yrs and <10 yrs and >20 kg) Z L D Children (<6 yrs and <20 kg) Zidovudine + Lamivudine + Lopinavir/ritonavir if Hb < 9 gm/dl Abacavir + Lamivudine + Dolutegravir if Hb < 9 gm/dl Abacavir + Lamivudine + Lopinavir/ ritonavir Duration of PEP is 28 days, regardless of PEP regimen Check for HIV-Ab after 6 weeks, 3 months and 6 months PEP must be initiated ideally within 2 hrs and preferably within 72 hours

60. JSS ART Statistical data as on 1-12-2022 Pre - ART Registered 19 1 1 S t a r t e d o n A R T 17 4 9 Alive on ART 11 62 ANC’S on ART 02 CLHIV 10 HIV-TB co-infection 09 From 1 st December 2012

61. Key Points... Ad h eren c e t o AR T i s t h e ke y . ART i s not a n e m er g en cy . First treat ongoing opportunistic infections. TLD is the most commonly used regimen. Pr e venti on of M T C T i s o f u t m ost i m por t an c e. PE P s h o u l d be t ake n a s ear l y a s pos s i ble.