HIV notes for a pharmacy class and quiz
infowaituika
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Oct 26, 2025
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About This Presentation
Summarizing main points and to understand
Slide Content
At the completion of this module, participants shall acquire
information and knowledge on HIV infection, transmission,
progression, management and prevention according to the national
HTC curriculum.
information and knowledge on HIV infection, transmission,
progression, management and prevention according to the national
HTC curriculum.
Define HIV, HIV infection and AIDS
Describe the epidemiology of HIV in Adults and Children
Describe basics of human immune system;
Describe the modes of HIV transmission;
Describe biology and natural progression of HIV in adults and
children;
Describe common HIV related conditions
Describe HIV prevention strategy including stigma reduction
Describe the epidemiology of HIV in Adults and Children
Describe basics of human immune system;
Describe the modes of HIV transmission;
Describe biology and natural progression of HIV in adults and
children;
Describe common HIV related conditions
Describe HIV prevention strategy including stigma reduction
What is HIV?
HIV stands for Human Immunodeficiency Virus. It is a retrovirus.
The virus that attacks the body's immune system. It specifically targets and
destroys CD4 cells (T-cells), which are crucial for fighting off infections.
There are two main types, HIV-1 and HIV-2. HIV-1 is the most common
worldwide
HIV Infection is the state where the virus is in the body. In most instances
this is the asymptomatic state, which is a prelude to AIDS.
AIDS stands for Acquired Immune Deficiency Syndrome. “Acquired”
means it is transmissible, and “Immune-Deficiency” means it damages the
body defense system “Syndrome” refers to a group of illnesses.
The most advanced stage of an HIV infection. A person with HIV is
diagnosed with AIDS when their immune system is severely compromised,
indicated by a very low CD4 cell count (below 200 cells/mm³) or the
presence of one or more "AIDS-defining conditions."
HIV stands for Human Immunodeficiency Virus. It is a retrovirus.
The virus that attacks the body's immune system. It specifically targets and
destroys CD4 cells (T-cells), which are crucial for fighting off infections.
There are two main types, HIV-1 and HIV-2. HIV-1 is the most common
worldwide
HIV Infection is the state where the virus is in the body. In most instances
this is the asymptomatic state, which is a prelude to AIDS.
AIDS stands for Acquired Immune Deficiency Syndrome. “Acquired”
means it is transmissible, and “Immune-Deficiency” means it damages the
body defense system “Syndrome” refers to a group of illnesses.
The most advanced stage of an HIV infection. A person with HIV is
diagnosed with AIDS when their immune system is severely compromised,
indicated by a very low CD4 cell count (below 200 cells/mm³) or the
presence of one or more "AIDS-defining conditions."
AIDS stands for Acquired Immune Deficiency
Syndrome. “Acquired” means it is transmissible, and
“Immune-Deficiency” means it damages the body
defense system “Syndrome” refers to a group of
illnesses.
The most advanced stage of an HIV infection. A
person with HIV is diagnosed with AIDS when their
immune system is severely compromised, indicated
by a very low CD4 cell count (below 200 cells/mm³)
or the presence of one or more "AIDS-defining
conditions."
Syndrome. “Acquired” means it is transmissible, and
“Immune-Deficiency” means it damages the body
defense system “Syndrome” refers to a group of
illnesses.
The most advanced stage of an HIV infection. A
person with HIV is diagnosed with AIDS when their
immune system is severely compromised, indicated
by a very low CD4 cell count (below 200 cells/mm³)
or the presence of one or more "AIDS-defining
conditions."
Antiretroviral therapy or ART: The medicines used to treat
HIV.
Viral load: Amount of HIV in the blood. The measurement of
the amount of HIV in a blood sample. The goal of ART is to
reduce the viral load to an undetectable level.
AIDS-Defining Condition: A specific list of opportunistic
infections or cancers that are rare in people with healthy
immune systems but are common and severe in people with
advanced HIV infection. Examples include certain types of
pneumonia, tuberculosis, and Kaposi's sarcoma.
HIV.
Viral load: Amount of HIV in the blood. The measurement of
the amount of HIV in a blood sample. The goal of ART is to
reduce the viral load to an undetectable level.
AIDS-Defining Condition: A specific list of opportunistic
infections or cancers that are rare in people with healthy
immune systems but are common and severe in people with
advanced HIV infection. Examples include certain types of
pneumonia, tuberculosis, and Kaposi's sarcoma.
CD4 Cells (T-cells): A type of white blood cell that
plays a vital role in the immune system. They signal
other immune cells to fight off infections. HIV infects
and kills these cells, progressively weakening the
body's ability to fight disease.
CD4 Count: A laboratory test that measures the
number of CD4 cells in a sample of blood. It is a key
indicator of the health of a person's immune system
and helps doctors determine when to start or adjust
HIV treatment.
plays a vital role in the immune system. They signal
other immune cells to fight off infections. HIV infects
and kills these cells, progressively weakening the
body's ability to fight disease.
CD4 Count: A laboratory test that measures the
number of CD4 cells in a sample of blood. It is a key
indicator of the health of a person's immune system
and helps doctors determine when to start or adjust
HIV treatment.
Undetectable Viral Load: When the amount of HIV in the
blood is so low that a standard lab test cannot detect it. People
with an undetectable viral load who take their medication as
prescribed have a zero risk of transmitting HIV to their sexual
partners. This is often summarized by the phrase
"Undetectable = Untransmittable" (U=U).
blood is so low that a standard lab test cannot detect it. People
with an undetectable viral load who take their medication as
prescribed have a zero risk of transmitting HIV to their sexual
partners. This is often summarized by the phrase
"Undetectable = Untransmittable" (U=U).
Adherence: The practice of taking HIV medications
exactly as prescribed by a healthcare provider,
without missing doses. High adherence is critical for
the effectiveness of ART and for preventing the
development of drug resistance.
Drug Resistance: The ability of the HIV virus to
mutate and multiply even while a person is taking
antiretroviral drugs. This often occurs when a person
misses medication doses, which allows the virus to
replicate and develop resistance to the drugs.
exactly as prescribed by a healthcare provider,
without missing doses. High adherence is critical for
the effectiveness of ART and for preventing the
development of drug resistance.
Drug Resistance: The ability of the HIV virus to
mutate and multiply even while a person is taking
antiretroviral drugs. This often occurs when a person
misses medication doses, which allows the virus to
replicate and develop resistance to the drugs.
Opportunistic Infection (OI): An infection that occurs
more frequently or is more severe in people with
weakened immune systems, such as those with HIV.
Pre-Exposure Prophylaxis (PrEP): A preventative
medication regimen in which an HIV-negative person
takes a pill daily to significantly reduce their risk of
getting HIV from sex or injection drug use.
Post-Exposure Prophylaxis (PEP): A short course of
HIV medicines taken by an HIV-negative person within
72 hours after a potential exposure to HIV to prevent
infection.
more frequently or is more severe in people with
weakened immune systems, such as those with HIV.
Pre-Exposure Prophylaxis (PrEP): A preventative
medication regimen in which an HIV-negative person
takes a pill daily to significantly reduce their risk of
getting HIV from sex or injection drug use.
Post-Exposure Prophylaxis (PEP): A short course of
HIV medicines taken by an HIV-negative person within
72 hours after a potential exposure to HIV to prevent
infection.
Overview and Epidemiology
•The scientific consensus is that HIV originated from a similar virus
found in non-human primates in Africa. This virus is known as
Simian Immunodeficiency Virus (SIV).
•Zoonotic Origin: HIV is considered a zoonosis, meaning it's an
infection that jumped from animals to humans.
•HIV-1 and Chimpanzees: The most common and global strain of the
virus, HIV-1, is closely related to a strain of SIV found in a subspecies
of chimpanzees in West-Central Africa. The crossover is believed to
have happened in southeastern Cameroon.
found in non-human primates in Africa. This virus is known as
Simian Immunodeficiency Virus (SIV).
•Zoonotic Origin: HIV is considered a zoonosis, meaning it's an
infection that jumped from animals to humans.
•HIV-1 and Chimpanzees: The most common and global strain of the
virus, HIV-1, is closely related to a strain of SIV found in a subspecies
of chimpanzees in West-Central Africa. The crossover is believed to
have happened in southeastern Cameroon.
HIV-2 and Sooty Mangabeys: The less common strain, HIV-
2, which is primarily found in West Africa, is related to a
different strain of SIV that infects sooty mangabey monkeys
The Jump to Humans: The most widely accepted theory is
that the virus was transmitted to humans through the hunting
and butchering of these infected animals for bushmeat. A
hunter may have been exposed to the animal's blood, which
allowed SIV to enter their bloodstream and, over time, mutate
into what we now know as HIV.
2, which is primarily found in West Africa, is related to a
different strain of SIV that infects sooty mangabey monkeys
The Jump to Humans: The most widely accepted theory is
that the virus was transmitted to humans through the hunting
and butchering of these infected animals for bushmeat. A
hunter may have been exposed to the animal's blood, which
allowed SIV to enter their bloodstream and, over time, mutate
into what we now know as HIV.
When and Where: Genetic analysis of early HIV
samples suggests that the most widespread strain of
HIV-1 (Group M) first entered the human population
in the early 20th century, likely around the 1920s, in
or around Kinshasa, in the Democratic Republic of
the Congo.
Factors like increasing urbanization and changes in
transportation in the area are thought to have
contributed to the virus's spread
samples suggests that the most widespread strain of
HIV-1 (Group M) first entered the human population
in the early 20th century, likely around the 1920s, in
or around Kinshasa, in the Democratic Republic of
the Congo.
Factors like increasing urbanization and changes in
transportation in the area are thought to have
contributed to the virus's spread
Evolution and Spread: Once the virus was established
in humans, it began to spread through various human
activities, including sexual contact, and later through
things like the reuse of needles in medical settings.
It took decades for the virus to spread and become a
global pandemic, which was first recognized in the
early 1980s
in humans, it began to spread through various human
activities, including sexual contact, and later through
things like the reuse of needles in medical settings.
It took decades for the virus to spread and become a
global pandemic, which was first recognized in the
early 1980s
No effective cure currently exists for HIV. But with proper medical care, HIV can be
controlled.
Treatment for HIV is called antiretroviral therapy or ART. If people with HIV take ART as
prescribed, their viral load (amount of HIV in their blood) can become undetectable. If it
stays undetectable, they can live long, healthy lives and have effectively no risk of
transmitting HIV to an HIV-negative partner through sex.
Before the introduction of ART in the mid-1990s, people with HIV could progress to AIDS
(the last stage of HIV infection) in a few years. Today, someone diagnosed with HIV and
treated before the disease is far advanced can live nearly as long as someone who does
not have HIV.
controlled.
Treatment for HIV is called antiretroviral therapy or ART. If people with HIV take ART as
prescribed, their viral load (amount of HIV in their blood) can become undetectable. If it
stays undetectable, they can live long, healthy lives and have effectively no risk of
transmitting HIV to an HIV-negative partner through sex.
Before the introduction of ART in the mid-1990s, people with HIV could progress to AIDS
(the last stage of HIV infection) in a few years. Today, someone diagnosed with HIV and
treated before the disease is far advanced can live nearly as long as someone who does
not have HIV.
1981 – Doctors in the United States recognized Kaposi’s
sarcoma (KS) in homosexual males, a condition previously
unreported in healthy adults. Later they recognized that all
these patients were immuno suppressed.
1983/4 – Scientists described the cause of this acquired
immunodeficiency syndrome (AIDS)
as a retrovirus:
1. Lymphadenopathy Associated Virus (LAV).
2. AIDs Associated Retrovirus (ARV).
3. Human T-lymphotrophic Virus ? (HTLV-?).
sarcoma (KS) in homosexual males, a condition previously
unreported in healthy adults. Later they recognized that all
these patients were immuno suppressed.
1983/4 – Scientists described the cause of this acquired
immunodeficiency syndrome (AIDS)
as a retrovirus:
1. Lymphadenopathy Associated Virus (LAV).
2. AIDs Associated Retrovirus (ARV).
3. Human T-lymphotrophic Virus ? (HTLV-?).
1984– The first case in Kenya was described
1986 – Human Immunodeficiency Virus (HIV) was
accepted as the international designation for the
retrovirus in a WHO consultative meeting
1996 – ARVs became available in the world.
1997 – ARVs became available in the private sector in
Kenya.
2003 – ARVs became available in public sector in
Kenya.
2006 – Approximately 90,000 Kenyans were taking
ARV treatment.
1986 – Human Immunodeficiency Virus (HIV) was
accepted as the international designation for the
retrovirus in a WHO consultative meeting
1996 – ARVs became available in the world.
1997 – ARVs became available in the private sector in
Kenya.
2003 – ARVs became available in public sector in
Kenya.
2006 – Approximately 90,000 Kenyans were taking
ARV treatment.
An estimated 40.8 million people globally were living with HIV.
39.4 million adults (15 years and older)
1.4 million children (under 15 years)
53% of all people living with HIV are women and girls
New HIV infections: An estimated 1.3 million people acquired HIV in
2024. This represents a 40% decline since 2010.
AIDS-related deaths: Around 630,000 people died from AIDS-related
illnesses in 2024. This is a 54% reduction since 2010 and a 70% reduction
since the peak in 2004.
39.4 million adults (15 years and older)
1.4 million children (under 15 years)
53% of all people living with HIV are women and girls
New HIV infections: An estimated 1.3 million people acquired HIV in
2024. This represents a 40% decline since 2010.
AIDS-related deaths: Around 630,000 people died from AIDS-related
illnesses in 2024. This is a 54% reduction since 2010 and a 70% reduction
since the peak in 2004.
The UNAIDS "95-95-95" targets aim for 95% of all people
living with HIV to know their status, 95% of those who know
their status to be on treatment, and 95% of those on treatment
to be virally suppressed by 2025.
As of the end of 2024, the global progress toward these targets
was
87% of all people living with HIV knew their status
77% of all people living with HIV were accessing
antiretroviral therapy (ART).
73% of all people living with HIV had a suppressed viral
load.
living with HIV to know their status, 95% of those who know
their status to be on treatment, and 95% of those on treatment
to be virally suppressed by 2025.
As of the end of 2024, the global progress toward these targets
was
87% of all people living with HIV knew their status
77% of all people living with HIV were accessing
antiretroviral therapy (ART).
73% of all people living with HIV had a suppressed viral
load.
People Living with HIV: An estimated 1,326,419
people were living with HIV
This includes 867,571 women and 458,848 men
There is a significant gender disparity, with women
having a prevalence rate of 4.08% compared to 1.95%
for men.
New HIV Infections: There were 20,105 new HIV
infections recorded in 2024, representing a 16% rise
from the previous year.
people were living with HIV
This includes 867,571 women and 458,848 men
There is a significant gender disparity, with women
having a prevalence rate of 4.08% compared to 1.95%
for men.
New HIV Infections: There were 20,105 new HIV
infections recorded in 2024, representing a 16% rise
from the previous year.
Women and girls continue to be disproportionately
affected, accounting for 66% of new infections.
A significant number of new infections are among
adolescents and young people aged 15-24, highlighting
a persistent challenge in this age group.
AIDS-Related Deaths: There were 21,009 AIDS-
related deaths in 2024.
This included 18,321 adult deaths and 2,688 child
deaths.
affected, accounting for 66% of new infections.
A significant number of new infections are among
adolescents and young people aged 15-24, highlighting
a persistent challenge in this age group.
AIDS-Related Deaths: There were 21,009 AIDS-
related deaths in 2024.
This included 18,321 adult deaths and 2,688 child
deaths.
Geographical Disparity: The HIV epidemic in Kenya
has significant geographical variations. A large
proportion of new infections occur in just a handful of
counties. Homa Bay county, for example, has a
prevalence rate significantly higher than the national
average.
Key Populations: Certain groups face a
disproportionately high risk of HIV infection, including
sex workers, men who have sex with men, and people
who inject drugs. Despite their small population size,
these groups contribute a third of all new HIV
infections.
has significant geographical variations. A large
proportion of new infections occur in just a handful of
counties. Homa Bay county, for example, has a
prevalence rate significantly higher than the national
average.
Key Populations: Certain groups face a
disproportionately high risk of HIV infection, including
sex workers, men who have sex with men, and people
who inject drugs. Despite their small population size,
these groups contribute a third of all new HIV
infections.
While Kenya has made remarkable progress in
combating HIV, significant challenges remain, including:
Funding Cuts: A reported decline in donor funding is
threatening to reverse some of the gains made in recent
decades
Youth Infections: The high rate of new infections
among young people, particularly young women and
girls, remains a major concern.
Disparities in Care: Gaps in treatment access and viral
suppression still exist among certain populations and age
groups, such as children and key populations.
combating HIV, significant challenges remain, including:
Funding Cuts: A reported decline in donor funding is
threatening to reverse some of the gains made in recent
decades
Youth Infections: The high rate of new infections
among young people, particularly young women and
girls, remains a major concern.
Disparities in Care: Gaps in treatment access and viral
suppression still exist among certain populations and age
groups, such as children and key populations.
It is estimated that more than 90% of children living with HIV
acquired the virus during pregnancy, birth or breastfeeding—
forms of HIV transmission that can be prevented.
A small fraction of HIV infections in children are caused by
contaminated injections, the transfusion of infected blood or
blood products, sexual abuse, sexual intercourse (although this
is a significant mode of transmission among adolescents), or
scarification
In 2007, an estimated 270 000 [250 000–290 000] HIV-
infected children younger than 15 years died because of AIDS
—more than 90% of them in sub-Saharan Africa
acquired the virus during pregnancy, birth or breastfeeding—
forms of HIV transmission that can be prevented.
A small fraction of HIV infections in children are caused by
contaminated injections, the transfusion of infected blood or
blood products, sexual abuse, sexual intercourse (although this
is a significant mode of transmission among adolescents), or
scarification
In 2007, an estimated 270 000 [250 000–290 000] HIV-
infected children younger than 15 years died because of AIDS
—more than 90% of them in sub-Saharan Africa
Global Sub-Saharan
Africa
Kenyan
estimates
No. living with HIV 2.5 million 2.25 million 204,036
No. Newly infected 700,000 616,000 14,168
No. AIDS deaths 500,000 450,000 11,323
Africa
Kenyan
estimates
No. living with HIV 2.5 million 2.25 million 204,036
No. Newly infected 700,000 616,000 14,168
No. AIDS deaths 500,000 450,000 11,323
60% medical beds- HIV/AIDS
40% Paediatric beds-HIV/AIDS
>50% TB patients – HIV +
>25% STI patients – HIV
Health workers face both the medical and social
challenges of HIV/AIDS on a daily basis
40% Paediatric beds-HIV/AIDS
>50% TB patients – HIV +
>25% STI patients – HIV
Health workers face both the medical and social
challenges of HIV/AIDS on a daily basis
1.Having unprotected sexual contact (vaginal and anal sexual intercourse)
with an infected person,
2.By sharing needles with an infected person e.g. drug users
3.Through blood transfusions (through exposure to blood, blood products,
body fluids and other tissues, e.g. organ transplants)
4.During pregnancy, birth, or breastfeeding from infected mother to child
5.Occupational exposure like for medical personnel
6.Sharing toothbrush if one has bleeding gums
7.Deep kissing if one has wounds in the mouth
8.The fluids from an infected person that can potentially transmit
HIV include:
1.Blood
2.Semen
3.Vaginal fluid
4.Breast- milk
with an infected person,
2.By sharing needles with an infected person e.g. drug users
3.Through blood transfusions (through exposure to blood, blood products,
body fluids and other tissues, e.g. organ transplants)
4.During pregnancy, birth, or breastfeeding from infected mother to child
5.Occupational exposure like for medical personnel
6.Sharing toothbrush if one has bleeding gums
7.Deep kissing if one has wounds in the mouth
8.The fluids from an infected person that can potentially transmit
HIV include:
1.Blood
2.Semen
3.Vaginal fluid
4.Breast- milk
•In Africa sexual contact is the commonest mode of transmission.
Those with multiple partners
•In the health care setting, workers have been infected with HIV
through:
– needle pricks,
–cut wounds,
– splash on mucous membranes or eye.
Those with multiple partners
•In the health care setting, workers have been infected with HIV
through:
– needle pricks,
–cut wounds,
– splash on mucous membranes or eye.
Transmission route %
Sexual intercourse 80-90
Mother-to-child-transmission 5-10
Blood transfusion 3-5
Injecting drug use < 5
Health care – e.g.: needle stick injury <0.01
Transmission modes
Sexual intercourse 80-90
Mother-to-child-transmission 5-10
Blood transfusion 3-5
Injecting drug use < 5
Health care – e.g.: needle stick injury <0.01
Transmission modes
Over the past 2 decades HIV has spread worldwide with
devastating epidemiological consequences particularly in Sub
Saharan Africa
MTCT is the main mode of transmission of HIV infection to children
HIV/AIDS is a major cause of morbidity and mortality.
devastating epidemiological consequences particularly in Sub
Saharan Africa
MTCT is the main mode of transmission of HIV infection to children
HIV/AIDS is a major cause of morbidity and mortality.
Human Immunology & Biology of HIV
Define the cells involved in the immune system and
their function.
Know the host immune response during and after
infection.
Basic HIV structure.
The significance of genetic diversity and classification
of HIV.
The replication cycle of HIV.
The target sites for antiretroviral drugs.
their function.
Know the host immune response during and after
infection.
Basic HIV structure.
The significance of genetic diversity and classification
of HIV.
The replication cycle of HIV.
The target sites for antiretroviral drugs.
1 Found in blood and tissues
2 White blood cells (WBC)- key players in immune
response (humoral and cellular)
– Macrophages act as clearing cells
– Neutrophils attack bacteria
– Eosinophils attack helminths (and mediate allergies)
– B-lymphocytes make antibodies
– T-lymphocytes
•Responsible for attacking viruses, fungi and some bacteria
•T helper cells central in orchestrating function of other
immune cells
•T killer cells are able to destroy infected cells
2 White blood cells (WBC)- key players in immune
response (humoral and cellular)
– Macrophages act as clearing cells
– Neutrophils attack bacteria
– Eosinophils attack helminths (and mediate allergies)
– B-lymphocytes make antibodies
– T-lymphocytes
•Responsible for attacking viruses, fungi and some bacteria
•T helper cells central in orchestrating function of other
immune cells
•T killer cells are able to destroy infected cells
1 HIV attaches to cells of the immune system with
special surface markers called CD4 receptors
2 Immune cells with CD4 receptors include:
T-helper Lymphocytes
Macrophages
Monocytes
Dendritic cells
Microglial cells
special surface markers called CD4 receptors
2 Immune cells with CD4 receptors include:
T-helper Lymphocytes
Macrophages
Monocytes
Dendritic cells
Microglial cells
The hallmark of HIV/AIDS is profound
immunodeficiency as a result depletion of CD4+ T
lymphocytes.
The CD4+ T cell dysfunction is two fold
- Reduction in numbers
- Impairment in function
immunodeficiency as a result depletion of CD4+ T
lymphocytes.
The CD4+ T cell dysfunction is two fold
- Reduction in numbers
- Impairment in function
There are two types of HIV:
HIV-1 (found worldwide and is the main cause of the epidemic)
The strains of HIV-1 can be classified into three groups : the
"major" group
M, the "outlier" group O and the "new" group N. These three
groups may
represent three separate introductions of simian immunodeficiency
virus into humans. Group O appears to be restricted to West-
central Africa and group N discovered in 1998 in Cameroon - is
extremely rare. More than 90% of HIV-1 infections are due to
HIV-1 group M. Within group M there are known to be at least
nine genetically distinct subtypes (or clades) of HIV-1. These
are subtypes A, B, C, D, F, G, H, J and K.
HIV-1 (found worldwide and is the main cause of the epidemic)
The strains of HIV-1 can be classified into three groups : the
"major" group
M, the "outlier" group O and the "new" group N. These three
groups may
represent three separate introductions of simian immunodeficiency
virus into humans. Group O appears to be restricted to West-
central Africa and group N discovered in 1998 in Cameroon - is
extremely rare. More than 90% of HIV-1 infections are due to
HIV-1 group M. Within group M there are known to be at least
nine genetically distinct subtypes (or clades) of HIV-1. These
are subtypes A, B, C, D, F, G, H, J and K.
Found mainly in parts of West Africa, Mozambique
and Angola)
HIV-2 causes a similar illness to HIV-1including AIDS.
It is however less efficiently transmitted, rarely
causes vertical transmission and is less aggressive,
with slower disease progression.
In Kenya the commonest type of HIV is type 1 with
Subtype C as the most predominant in eastern Africa.
However other subtypes are also found and recently
HIV type 2 has also been discovered in the country.
and Angola)
HIV-2 causes a similar illness to HIV-1including AIDS.
It is however less efficiently transmitted, rarely
causes vertical transmission and is less aggressive,
with slower disease progression.
In Kenya the commonest type of HIV is type 1 with
Subtype C as the most predominant in eastern Africa.
However other subtypes are also found and recently
HIV type 2 has also been discovered in the country.
Until about 1994, it was generally thought that
individuals do not become infected with multiple
distinct HIV-1 strains. However, it is now thought that
"superinfection" does occur.
In these cases, the second infection occurs several
months after the first. It would appear that the
body's immune response to the first virus is
sometimes not enough to prevent infection with a
second strain, especially with a virus belonging to a
different subtype. It is not yet known how commonly
superinfection occurs, or whether it can take place
only in special circumstances.
individuals do not become infected with multiple
distinct HIV-1 strains. However, it is now thought that
"superinfection" does occur.
In these cases, the second infection occurs several
months after the first. It would appear that the
body's immune response to the first virus is
sometimes not enough to prevent infection with a
second strain, especially with a virus belonging to a
different subtype. It is not yet known how commonly
superinfection occurs, or whether it can take place
only in special circumstances.
Has an outer double lipid
membrane, (derived from the host
membrane).
The lipid membrane is lined by
a matrix protein.
The lipid membrane is studded
with the surface glycoprotein (gp)
120 and the transmembrane gp 41
protein.
These glycoprotein spikes
surround the cone-shaped protein
core.
The core (capsid) is made up of
several proteins :-
P24 (the main protein) and P16 P9
and P6 Within the capsid are
two identical single strands of
RNA (the viral genetic material).
Viral enzymes
membrane, (derived from the host
membrane).
The lipid membrane is lined by
a matrix protein.
The lipid membrane is studded
with the surface glycoprotein (gp)
120 and the transmembrane gp 41
protein.
These glycoprotein spikes
surround the cone-shaped protein
core.
The core (capsid) is made up of
several proteins :-
P24 (the main protein) and P16 P9
and P6 Within the capsid are
two identical single strands of
RNA (the viral genetic material).
Viral enzymes
Factors affecting how long a person who is HIV positive
stays well prior to developing AIDS
•A number of factors affect how long a person who is HIV
positive will stay well prior to developing AIDS.
•These factors range from:
–Individual’s immunity
–Exposure to risky behaviour
–Use of antiretroviral drugs (ARVs)
–Personal attitude etc.
stays well prior to developing AIDS
•A number of factors affect how long a person who is HIV
positive will stay well prior to developing AIDS.
•These factors range from:
–Individual’s immunity
–Exposure to risky behaviour
–Use of antiretroviral drugs (ARVs)
–Personal attitude etc.
•Among children HIV incubation period is much shorter.
•Not all babies are born from HIV infected mothers get infected with HIV.
•Only about 30-40% of them get infected either before birth, during delivery, or
during breast feeding.
•About 60% of babies who contract HIV perinatally die before their fifth
birthday.
–This explains why countries that have been hard hit with HIV/AIDS in Sub-
Sahara Africa experience an upsurge of < 5 mortality.
–It also explains why children between 5-14 years are usually one of the
least infected by HIV and are therefore widely regarded as our “window of
hope”
•Not all babies are born from HIV infected mothers get infected with HIV.
•Only about 30-40% of them get infected either before birth, during delivery, or
during breast feeding.
•About 60% of babies who contract HIV perinatally die before their fifth
birthday.
–This explains why countries that have been hard hit with HIV/AIDS in Sub-
Sahara Africa experience an upsurge of < 5 mortality.
–It also explains why children between 5-14 years are usually one of the
least infected by HIV and are therefore widely regarded as our “window of
hope”
Behaviours and conditions that put individuals at greater
risk of contracting HIV include:
•having unprotected anal or vaginal sex;
•having another sexually transmitted infection such as
syphilis, herpes, chlamydia, gonorrhoea, and bacterial
vaginosis;
•sharing contaminated needles, syringes and other
injecting equipment and drug solutions when injecting
drugs;
•receiving unsafe injections, blood transfusions, tissue
transplantation, medical procedures that involve unsterile
cutting or piercing; and
•experiencing accidental needle stick injuries, including
among health workers.
risk of contracting HIV include:
•having unprotected anal or vaginal sex;
•having another sexually transmitted infection such as
syphilis, herpes, chlamydia, gonorrhoea, and bacterial
vaginosis;
•sharing contaminated needles, syringes and other
injecting equipment and drug solutions when injecting
drugs;
•receiving unsafe injections, blood transfusions, tissue
transplantation, medical procedures that involve unsterile
cutting or piercing; and
•experiencing accidental needle stick injuries, including
among health workers.
Risk factors for spread of HIV/AIDS cont…
•Poverty
•Lack of sex education
•Fear of revealing one’s sero-status and voluntary testing
•Misuse of drugs
•Urbanization
•Idleness among unemployed youth
•Socio-cultural practices such as
–patriarchy: male domination
–Circumcision: Sharing of knives/razor blades
–Tattooing
–Scarification
–Wife inheritance
•Poverty
•Lack of sex education
•Fear of revealing one’s sero-status and voluntary testing
•Misuse of drugs
•Urbanization
•Idleness among unemployed youth
•Socio-cultural practices such as
–patriarchy: male domination
–Circumcision: Sharing of knives/razor blades
–Tattooing
–Scarification
–Wife inheritance
Special Populations
Couples
Families of patients receiving HIV/AIDS care and treatment
Persons with Disabilities (PWDs)
Populations abusing alcohol and other drugs
Commercial Sex Workers
Couples
Families of patients receiving HIV/AIDS care and treatment
Persons with Disabilities (PWDs)
Populations abusing alcohol and other drugs
Commercial Sex Workers
Vulnerable Populations
Individuals at higher risk of contracting HIV because of their
circumstances, situations and environment These include;
•Orphans and other vulnerable children (OVCs)
•Families and children living on the street
•Children living in a group home
•Children 7-12 years
•Adults older than 50 years
•Refugees, displaced persons and migrants
•Persons separated from their spouses because of employment
•Uniformed Servicemen/women and their families
•Health care workers
•Mentally challenged individuals
Individuals at higher risk of contracting HIV because of their
circumstances, situations and environment These include;
•Orphans and other vulnerable children (OVCs)
•Families and children living on the street
•Children living in a group home
•Children 7-12 years
•Adults older than 50 years
•Refugees, displaced persons and migrants
•Persons separated from their spouses because of employment
•Uniformed Servicemen/women and their families
•Health care workers
•Mentally challenged individuals
Most At Risk Populations [MARPs]
These are individual who are at a higher risk of acquiring HIV due
to their lifestyle or behaviour that predisposes them to HIV
infection.
They include;
•Long distance truck, taxi and bus drivers
•Commercial sex workers (CSWs)
•Men who have sex with men (MSM)
•Intravenous Drug Users (IDUs)
•Fishing communities
These are individual who are at a higher risk of acquiring HIV due
to their lifestyle or behaviour that predisposes them to HIV
infection.
They include;
•Long distance truck, taxi and bus drivers
•Commercial sex workers (CSWs)
•Men who have sex with men (MSM)
•Intravenous Drug Users (IDUs)
•Fishing communities
HIV attacks the Immune system of human being and leads
to profound
immunodeficiency.
Rapid replication of HIV causes genetic diversity of the virus.
Knowledge of the HIV structure is important in
understanding the mechanism of ARV drugs
to profound
immunodeficiency.
Rapid replication of HIV causes genetic diversity of the virus.
Knowledge of the HIV structure is important in
understanding the mechanism of ARV drugs
Natural Progression of HIV
Describe stages of HIV progression - serocoversion,
asymptomatic, symptomatic and AIDS phases
Be able to stage HIV infection by WHO classification
asymptomatic, symptomatic and AIDS phases
Be able to stage HIV infection by WHO classification
Stage 1: Acute HIV infection
Most people infected with HIV do not know that they have
become infected. After the infection; virus is disseminated via
blood to CNS and lymphoid tissue. The Virus trapped in
lymphoid tissue rapidly replicates.
This is accompanied by patient’s immune response with
concomitant development of antibodies to HIV antigens
usually within 6 weeks, but may take up to 3 months, after the
infection. This “sero-conversion” is when a person recently
infected with HIV first tests positive for HIV antibodies.
Some people have a “glandular fever” like illness (fever, rash,
arthalgia, fatigue and lymphadenopathy) at the time of
seroconversion.
Most people infected with HIV do not know that they have
become infected. After the infection; virus is disseminated via
blood to CNS and lymphoid tissue. The Virus trapped in
lymphoid tissue rapidly replicates.
This is accompanied by patient’s immune response with
concomitant development of antibodies to HIV antigens
usually within 6 weeks, but may take up to 3 months, after the
infection. This “sero-conversion” is when a person recently
infected with HIV first tests positive for HIV antibodies.
Some people have a “glandular fever” like illness (fever, rash,
arthalgia, fatigue and lymphadenopathy) at the time of
seroconversion.
Stage 2: Clinical latency (HIV inactivity or dormancy)/
Asymptomatic HIV infection
This period is sometimes called asymptomatic HIV infection or chronic HIV
infection.
During this phase, HIV is still active but reproduces at very low levels.
People may not have any symptoms or get sick during this time.
In adults, there is a long, variable, latent period from HIV
infection to the onset of HIV related disease and AIDS. A person
infected with HIV may be asymptomatic for 2 to 15 years
The vast majority of HIV- infected children are infected in the
peri-natal period. The period of asymptomatic infection is
shorter in children than in adults. A few infants become
ill in the first few weeks of life. Most children start to become ill before 2
years of age. A number of children remain well for several years.
Initially CD4 cell levels are high but gradually declines and immunity
starts weakening. The patients are asymptomatic but are infectious.
Asymptomatic HIV infection
This period is sometimes called asymptomatic HIV infection or chronic HIV
infection.
During this phase, HIV is still active but reproduces at very low levels.
People may not have any symptoms or get sick during this time.
In adults, there is a long, variable, latent period from HIV
infection to the onset of HIV related disease and AIDS. A person
infected with HIV may be asymptomatic for 2 to 15 years
The vast majority of HIV- infected children are infected in the
peri-natal period. The period of asymptomatic infection is
shorter in children than in adults. A few infants become
ill in the first few weeks of life. Most children start to become ill before 2
years of age. A number of children remain well for several years.
Initially CD4 cell levels are high but gradually declines and immunity
starts weakening. The patients are asymptomatic but are infectious.
Stage 3: Acquired immunodeficiency syndrome (AIDS)/Progression to HIV
disease and AIDS
AIDS is the most severe phase of HIV infection.
As disease progresses without any intervention, production of CD4 cells cannot
match destruction.CD4 cell count decreases and immune system starts failing leading
to increase in viral load.
People with AIDS have such badly damaged immune systems that they get an
increasing number of severe illnesses, called opportunistic illnesses (OIs).
Without treatment, people with AIDS typically survive about 3 years.
Common symptoms of AIDS include chills, fever, sweats, swollen lymph glands,
weakness, and weight loss.
People are diagnosed with AIDS when their CD4 cell count drops below 200
cells/mm or if they develop certain opportunistic illnesses.
People with AIDS can have a high viral load and be very infectious.
The World Health Organization (WHO) classification of HIV/AIDS is internationally
accepted as the standard classification, for use in diagnosis and treatment.
disease and AIDS
AIDS is the most severe phase of HIV infection.
As disease progresses without any intervention, production of CD4 cells cannot
match destruction.CD4 cell count decreases and immune system starts failing leading
to increase in viral load.
People with AIDS have such badly damaged immune systems that they get an
increasing number of severe illnesses, called opportunistic illnesses (OIs).
Without treatment, people with AIDS typically survive about 3 years.
Common symptoms of AIDS include chills, fever, sweats, swollen lymph glands,
weakness, and weight loss.
People are diagnosed with AIDS when their CD4 cell count drops below 200
cells/mm or if they develop certain opportunistic illnesses.
People with AIDS can have a high viral load and be very infectious.
The World Health Organization (WHO) classification of HIV/AIDS is internationally
accepted as the standard classification, for use in diagnosis and treatment.
Clinical
stage
Selected symptoms
Stage I 1. Asymptomatic
2. Persistent generalized lymphadenopathy
3. Acute retroviral infection
Stage II 1. Weight loss but <10% of body weight
2. Minor mucocutaneous manifestations (seborrhoeic dermatitis,
prurigo,
fungal infections, recurrent oral ulcerations, angular cheilitis)
3. Herpes zoster
4. Recurrent upper respiratory tract infections (e.g: bacterial
sinusitis,
tonsilitis, otitis media, pharyngitis)
stage
Selected symptoms
Stage I 1. Asymptomatic
2. Persistent generalized lymphadenopathy
3. Acute retroviral infection
Stage II 1. Weight loss but <10% of body weight
2. Minor mucocutaneous manifestations (seborrhoeic dermatitis,
prurigo,
fungal infections, recurrent oral ulcerations, angular cheilitis)
3. Herpes zoster
4. Recurrent upper respiratory tract infections (e.g: bacterial
sinusitis,
tonsilitis, otitis media, pharyngitis)
Stage III 1. Weight loss: >10% of body weight
2. Unexplained chronic diarrhoea, >1 month
3. Unexplained prolonged fever >1 month
4. Oral candidiasis (thrush)
5. Vulvovaginal candidiasis, chronic (>1 month or poorly
responsive to
therapy)
6. Oral hairy leucoplakia
7. Pulmonary tuberculosis, within past year
8. Severe bacterial infections (eg: pneumonia, pyomyositis)
2. Unexplained chronic diarrhoea, >1 month
3. Unexplained prolonged fever >1 month
4. Oral candidiasis (thrush)
5. Vulvovaginal candidiasis, chronic (>1 month or poorly
responsive to
therapy)
6. Oral hairy leucoplakia
7. Pulmonary tuberculosis, within past year
8. Severe bacterial infections (eg: pneumonia, pyomyositis)
Stage IV 1. HIV wasting syndrome
2. Pneumocystis jerovecii pneumonia (PCP)
3. Toxoplasmosis of the brain
4. Cryptosporidiosis, with diarrhoea >1 month
5. Cryptococcosis (extrapulmonary)
6. Cytomegalovirus (CMV) disease of an organ (other than liver,
spleen, or
lymph nodes)
7. Herpes simplex virus (HSV) infection, mucocutaneous >1
month,
8. Progressive multifocal leukoencephalopathy
9. Any disseminated endemic mycosis (eg: histoplasmosis)
10. Candidiasis of the oesophagus or airways
11. Atypical mycobacteriosis, disseminated
12. Non-typhoid salmonella septicaemia
13. Extrapulmonary tuberculosis
14. Lymphoma
15. Kaposi’s sarcoma (KS)
16. HIV encephalopathy
17. Invasive cervical carcinoma
2. Pneumocystis jerovecii pneumonia (PCP)
3. Toxoplasmosis of the brain
4. Cryptosporidiosis, with diarrhoea >1 month
5. Cryptococcosis (extrapulmonary)
6. Cytomegalovirus (CMV) disease of an organ (other than liver,
spleen, or
lymph nodes)
7. Herpes simplex virus (HSV) infection, mucocutaneous >1
month,
8. Progressive multifocal leukoencephalopathy
9. Any disseminated endemic mycosis (eg: histoplasmosis)
10. Candidiasis of the oesophagus or airways
11. Atypical mycobacteriosis, disseminated
12. Non-typhoid salmonella septicaemia
13. Extrapulmonary tuberculosis
14. Lymphoma
15. Kaposi’s sarcoma (KS)
16. HIV encephalopathy
17. Invasive cervical carcinoma
Clinical
Stage
Selected symptoms
Stage I 1. Asymptomatic
2. Progressive Generalized Lymphadenopathy
3. Hepatospleenmegaly
Stage II 1. Skin conditions
• Herpes Zoster
• Papular pruritic eruptions(PPE)
• Seborrheic Dermatitis
• Fungal nail infections
• Extensive HPV or Molluscum infection (>5% of body area/face)
2. Mouth conditions
• Angular chelitis
• Linear gingival erythema
• Parotid enlargement
3. Respiratory conditions
• Recurrent or chronic URI: otitis media, otorrhoea, sinusitis (>2
episodes/6
months)
Stage
Selected symptoms
Stage I 1. Asymptomatic
2. Progressive Generalized Lymphadenopathy
3. Hepatospleenmegaly
Stage II 1. Skin conditions
• Herpes Zoster
• Papular pruritic eruptions(PPE)
• Seborrheic Dermatitis
• Fungal nail infections
• Extensive HPV or Molluscum infection (>5% of body area/face)
2. Mouth conditions
• Angular chelitis
• Linear gingival erythema
• Parotid enlargement
3. Respiratory conditions
• Recurrent or chronic URI: otitis media, otorrhoea, sinusitis (>2
episodes/6
months)
Stage III 1. Unexplained moderate malnutrition (-2SD or Z score) not
responding to standard therapy
2. Unexplained persistent diarrhea (>14 days)
3. Unexplained persistent fever (intermittent or constant, > 1mo)
4. Oral candidiasis (outside neonatal period 6-8 wks)
5. Oral hairy leukoplakia
6. Pulmonary tuberculosis
7. Severe recurrent presumed bacterial pneumonia (> 2
episodes/12 months, excluding
pneumonia)
8. Acute necrotizing ulcerative gingivitis/periodontitis
9. Lymphoid interstitial pneumonitis (LIP)
10. Unexplained anemia (<8g/dl), neutropenia (<500/mm3), or
thrombocytopenia
(<50,000/mm3) for >1 month
11. HIV-related cardiomyopathy
12. HIV-related nephropathy
responding to standard therapy
2. Unexplained persistent diarrhea (>14 days)
3. Unexplained persistent fever (intermittent or constant, > 1mo)
4. Oral candidiasis (outside neonatal period 6-8 wks)
5. Oral hairy leukoplakia
6. Pulmonary tuberculosis
7. Severe recurrent presumed bacterial pneumonia (> 2
episodes/12 months, excluding
pneumonia)
8. Acute necrotizing ulcerative gingivitis/periodontitis
9. Lymphoid interstitial pneumonitis (LIP)
10. Unexplained anemia (<8g/dl), neutropenia (<500/mm3), or
thrombocytopenia
(<50,000/mm3) for >1 month
11. HIV-related cardiomyopathy
12. HIV-related nephropathy
Stage
IV
Conditions where a presumptive diagnosis can be
made using clinical signs or simple
investigations:
1 Unexplained severe wasting/stunting or severe
malnutrition not adequately responding to
standard therapy
2 Pneumocystis pneumonia
3 Recurrent severe presumed bacterial infections (e.g.
empyema, pyomyositis, bone or joint
infection, meningitis, but excluding pneumonia )
4 Chronic orolabial or cutaneous Herpes simplex infection
(>1 month duration)
5 Extrapulmonary tuberculosis
6 Oesophageal Candida
7 CNS Toxoplasmosis
8 HIV encephalopathy
9 Kaposi's sarcoma
IV
Conditions where a presumptive diagnosis can be
made using clinical signs or simple
investigations:
1 Unexplained severe wasting/stunting or severe
malnutrition not adequately responding to
standard therapy
2 Pneumocystis pneumonia
3 Recurrent severe presumed bacterial infections (e.g.
empyema, pyomyositis, bone or joint
infection, meningitis, but excluding pneumonia )
4 Chronic orolabial or cutaneous Herpes simplex infection
(>1 month duration)
5 Extrapulmonary tuberculosis
6 Oesophageal Candida
7 CNS Toxoplasmosis
8 HIV encephalopathy
9 Kaposi's sarcoma
Stage IV
Conditions where confirmatory diagnostic testing is
necessary:
10 CMV infection (CMV retinitis or infection of organ other than
liver, spleen, or lymph
nodes onset at age 1 month or more)
11 Extrapulmonary cryptococcosis (incl meningitis)
12 Any disseminated endemic mycosis (e.g. extra-pulmonary
Histoplasmosis,
Coccidiomycosis, Penicilliosis)
13 Cryptosporidiosis
14 Isosporiasis
15 Disseminated non-tuberculous mycobacteria infection
16 Candida of trachea, bronchi or lungs
17 Acquired HIV related fistula
18 Non-Hodgkins lymphoma
19 Progressive multifocal leucoencephalopathy
Conditions where confirmatory diagnostic testing is
necessary:
10 CMV infection (CMV retinitis or infection of organ other than
liver, spleen, or lymph
nodes onset at age 1 month or more)
11 Extrapulmonary cryptococcosis (incl meningitis)
12 Any disseminated endemic mycosis (e.g. extra-pulmonary
Histoplasmosis,
Coccidiomycosis, Penicilliosis)
13 Cryptosporidiosis
14 Isosporiasis
15 Disseminated non-tuberculous mycobacteria infection
16 Candida of trachea, bronchi or lungs
17 Acquired HIV related fistula
18 Non-Hodgkins lymphoma
19 Progressive multifocal leucoencephalopathy
1. HIV targets the CD4 cell
2. Reduction in number of CD4 cells destroys the
immune system of the host
3. Patients with low CD4 cells are susceptible to many
infections
4. All HIV positive patients should be staged as per
WHO classification
2. Reduction in number of CD4 cells destroys the
immune system of the host
3. Patients with low CD4 cells are susceptible to many
infections
4. All HIV positive patients should be staged as per
WHO classification
Opportunistic Illnesses
HIV RELATED
CONDITION
CLINICAL FEATURES DIAGNOSIS TREATMENT
Acute Bacterial
pneumonia
Productive cough, fever, chest
pain,
abnormal chest auscultation
Clinical and physical
examination. CXR, CBC,
Sputum exam.
Antibiotics e.g. Erythromycin
OR Amoxicillin OR
cephalosporin
Pneumocystis
carinii
pneumonia
Cough-usually dry, fever,
tachypnoea, cyanosis, chest
auscultation-mostly normal
High index of clinical
suspicion, CXR- may be
normal Pulse oximetry,
blood gases, BAL
IV/Oral
cotrimoxazole,supportive
treatment-O2,Prednisolone etc.
Pulmonary TB Cough with or without
hemoptysis> 3 weeks, fever,
weight loss, night sweats
Sputum for AFB, CXR+/-RHZE X 2 months then EH x6
months, Add pyridoxine
Toxoplasmosis Headache, usually no
meningism,
focal neurological deficit,
confusion, convulsions
High index of clinical
suspicion, CT scan if
available(>/2 ring
enhancing
lesions
Cotrimoxazole (TMP SMX)
TMP 5 mg / kg +SMX 25mg/kg PO or IV BD-
3-6 weeks OR Pyrimethamine-200 mg
loading dose followed by 50mg
OD+Sluphadiazine-1-1.5 gm OD + folinic
acid 20 mg OD
Cryptococcal
Meningitis
Severe headache-can come on
over
weeks, Fever+/-, neck
stiffness+/-,
confusion, convulsions, coma
High index of suspicion,
LPIncreased
ICT(intracranial
pressure),India ink stain
for CSF,CRAG test
IV amphotericin B 0.7 -1 mg/ kg daily X 2
weeks or until clinically stable, then
Fluconazole 400 mg OD X 8-10 weeks OR
Fluconazole
400-800 mg OD X 10-12 weeks
CONDITION
CLINICAL FEATURES DIAGNOSIS TREATMENT
Acute Bacterial
pneumonia
Productive cough, fever, chest
pain,
abnormal chest auscultation
Clinical and physical
examination. CXR, CBC,
Sputum exam.
Antibiotics e.g. Erythromycin
OR Amoxicillin OR
cephalosporin
Pneumocystis
carinii
pneumonia
Cough-usually dry, fever,
tachypnoea, cyanosis, chest
auscultation-mostly normal
High index of clinical
suspicion, CXR- may be
normal Pulse oximetry,
blood gases, BAL
IV/Oral
cotrimoxazole,supportive
treatment-O2,Prednisolone etc.
Pulmonary TB Cough with or without
hemoptysis> 3 weeks, fever,
weight loss, night sweats
Sputum for AFB, CXR+/-RHZE X 2 months then EH x6
months, Add pyridoxine
Toxoplasmosis Headache, usually no
meningism,
focal neurological deficit,
confusion, convulsions
High index of clinical
suspicion, CT scan if
available(>/2 ring
enhancing
lesions
Cotrimoxazole (TMP SMX)
TMP 5 mg / kg +SMX 25mg/kg PO or IV BD-
3-6 weeks OR Pyrimethamine-200 mg
loading dose followed by 50mg
OD+Sluphadiazine-1-1.5 gm OD + folinic
acid 20 mg OD
Cryptococcal
Meningitis
Severe headache-can come on
over
weeks, Fever+/-, neck
stiffness+/-,
confusion, convulsions, coma
High index of suspicion,
LPIncreased
ICT(intracranial
pressure),India ink stain
for CSF,CRAG test
IV amphotericin B 0.7 -1 mg/ kg daily X 2
weeks or until clinically stable, then
Fluconazole 400 mg OD X 8-10 weeks OR
Fluconazole
400-800 mg OD X 10-12 weeks
Oesophageal
candidiasis
Oropharyngeal thrush with
painful swallowing,
dehydration, wasting
Clinical diagnosis,
Oesophagoscopy +/-
Fluconazole 200 mg stat, then
100mg OD X14 days OR
Ketoconazole 200 mg OD X 14 days
Oropharyngeal
candidiasis
white plaques in mouth,
palate,
pharynx, erythema
Clinical diagnosis Topical Nystatin oral drops
500,000 IU QDS/Miconazole
oral gel/tabs, if no response systemic
antifungals
Acute infective
diarrhea
Diarrhoea <2 weeks,
abdominal
pain+/-,cramps+/-,Dehydrati
on+/-
stool examination ORS,IV fluids, Antimicrobials (e.g.
Ciprofloxain 500 mg
BDx 10-14 days.
Herpes ZosterMultidermatomal acute,
severe painful vesicular
lesions, eye involvement can
lead to blindness, Post
herpatic neuralgia common
Clinical IV Acyclovir 800 mg x5/day- 7-10 days
Analgesics, Calamine lotion. PHN:
Amitryptyline 25-50 mg nocte or
carbamezipine 100mg OD
CNS Lymphoma Headache, confusion,
memory loss,
focal signs without fever
CT scan, Biopsy Systemic che motherapy
candidiasis
Oropharyngeal thrush with
painful swallowing,
dehydration, wasting
Clinical diagnosis,
Oesophagoscopy +/-
Fluconazole 200 mg stat, then
100mg OD X14 days OR
Ketoconazole 200 mg OD X 14 days
Oropharyngeal
candidiasis
white plaques in mouth,
palate,
pharynx, erythema
Clinical diagnosis Topical Nystatin oral drops
500,000 IU QDS/Miconazole
oral gel/tabs, if no response systemic
antifungals
Acute infective
diarrhea
Diarrhoea <2 weeks,
abdominal
pain+/-,cramps+/-,Dehydrati
on+/-
stool examination ORS,IV fluids, Antimicrobials (e.g.
Ciprofloxain 500 mg
BDx 10-14 days.
Herpes ZosterMultidermatomal acute,
severe painful vesicular
lesions, eye involvement can
lead to blindness, Post
herpatic neuralgia common
Clinical IV Acyclovir 800 mg x5/day- 7-10 days
Analgesics, Calamine lotion. PHN:
Amitryptyline 25-50 mg nocte or
carbamezipine 100mg OD
CNS Lymphoma Headache, confusion,
memory loss,
focal signs without fever
CT scan, Biopsy Systemic che motherapy
Papular pruritic
eruptions
severe itching with hyperpigmented,
hyperkeratotic, excoriated papules and
nodules, associated skin thickening &
scarring
Clinical Chlorhexidine, Cetrimide
ointment, antihistaminics,
ART
Scabies very itchy skin, may be treated empiricallyClinical BB lotion, symptomatic
Cryptococcal
meningitis
Headache, Fever+/-, Neck stiffness
+/-, abnormal gait, confusion,
convulsions, coma
High of clinical
suspicion, LP
for india ink,
CRAG
Amphotericin B-gold standard
of treatme nt., IV/Oral
fluconazole, supportive
TB-Pleural effusionConstitutional symptoms, S/S of
pleural effusion
Pleural fluid exam.
For protein s, AFB,
CXR
Anti TB treatment
TB meningitis Constitutional symptoms, Head
ache, Confusion, Localizing signs
CSF exam. For
protein,
Lymphocytes, AFB,
CT scan
Anti TB treatment
TB
lymphadenopathy
Constitutional symptoms, asymmatrical,
enlarged, matted Lymphnodes
FNA, Biopsy, ZN
stain of aspirate
Anti TB treatment
Candidiasis-
Vaginal
–Not strictly an OI unless chronic
(>1month) or unresponsive to treatment
Anti fungals
eruptions
severe itching with hyperpigmented,
hyperkeratotic, excoriated papules and
nodules, associated skin thickening &
scarring
Clinical Chlorhexidine, Cetrimide
ointment, antihistaminics,
ART
Scabies very itchy skin, may be treated empiricallyClinical BB lotion, symptomatic
Cryptococcal
meningitis
Headache, Fever+/-, Neck stiffness
+/-, abnormal gait, confusion,
convulsions, coma
High of clinical
suspicion, LP
for india ink,
CRAG
Amphotericin B-gold standard
of treatme nt., IV/Oral
fluconazole, supportive
TB-Pleural effusionConstitutional symptoms, S/S of
pleural effusion
Pleural fluid exam.
For protein s, AFB,
CXR
Anti TB treatment
TB meningitis Constitutional symptoms, Head
ache, Confusion, Localizing signs
CSF exam. For
protein,
Lymphocytes, AFB,
CT scan
Anti TB treatment
TB
lymphadenopathy
Constitutional symptoms, asymmatrical,
enlarged, matted Lymphnodes
FNA, Biopsy, ZN
stain of aspirate
Anti TB treatment
Candidiasis-
Vaginal
–Not strictly an OI unless chronic
(>1month) or unresponsive to treatment
Anti fungals
HIV RELATED
CONDITION
CLINICAL FEATURES DIAGNOSIS TREATMENT
Candidiasis
Oropharyngeal
White pseudomembraneous
plaques, atrophic /erythematous,
angular cheilitis
Clinical by mouth exam Anti fungals
Candidiasis –
Oesophageal
Oropharyngeal candidiasis with
difficulty and pain in swallowing
Clinical, Endoscopy when
failed emperical treatment
systemic anti fungals
Herpes simplex
Virus
infectiongenital
Red, raisedder vesicles or lesions
may occur anywhere on the vulva, in
the vagina, or on the cervix or anal
area.
Multiple vesicles may
occur.
Clinical systemic anti virals-
Acyclovir
Kaposis sarcomaFirm dark purple nodules on skin or
mouth GIT and Lungs, usually not
symptomatic
Clinical diagnosis Chemotherapy,
Radiotherapy,
ART
Cervical cancerIrregular PV bleeding Cervical screening, PAP
smear ,
Colposcopy, Biopsy
CONDITION
CLINICAL FEATURES DIAGNOSIS TREATMENT
Candidiasis
Oropharyngeal
White pseudomembraneous
plaques, atrophic /erythematous,
angular cheilitis
Clinical by mouth exam Anti fungals
Candidiasis –
Oesophageal
Oropharyngeal candidiasis with
difficulty and pain in swallowing
Clinical, Endoscopy when
failed emperical treatment
systemic anti fungals
Herpes simplex
Virus
infectiongenital
Red, raisedder vesicles or lesions
may occur anywhere on the vulva, in
the vagina, or on the cervix or anal
area.
Multiple vesicles may
occur.
Clinical systemic anti virals-
Acyclovir
Kaposis sarcomaFirm dark purple nodules on skin or
mouth GIT and Lungs, usually not
symptomatic
Clinical diagnosis Chemotherapy,
Radiotherapy,
ART
Cervical cancerIrregular PV bleeding Cervical screening, PAP
smear ,
Colposcopy, Biopsy
OI/conditionSigns/symptoms Diagnosis Prophylaxis & specific Rx
Herpes ZosterSkin: Acute severe pain,
multidermatomal, disfiguring
keloids
Eye: permanent visual loss
Genital: tender vesicles/lesions on
vulva, vagina, cervix or anal area.
May form large ulcers
Clinical
diagnosis
Severe cases should be hospitalised and
treated, if possible, with IV acyclovir
30mg/kg/day divided into 8 hourly doses for a
total of 7 days, or 2 days after cessation of new
lesion formation, whichever is longer
Pain relief, prevention of secondary bacterial
infection of lesions
PTB Cough > 3 weeks, fever, wasting,
crepitations, effusion
Sputum negative
Abnormal CXR
Isoniazid 5 – 10 mg/kg/d (max 300mg)
Rifampicin 10 - 20 mg/kg/d
Pyrazinamide 25 – 35 mg/kg/d (2 months)
Ethambutol 15 – 25 mg/kg/d (max 2.5g)
Duration of treatment is according to National
guidelines, but longer courses (9 months) are
recommended for the HIV- infected child Add
prednisone (2 mg/kg OD x 2- 4 weeks) in TBM,
miliary TB, massive pleural effusion and
pericarditis
Cryptococcal
Meningitis
Headache, fever, stiff neck
Convulsions, papilledema
Clinical
suspicion key
Raised ICP,
CRAG
Lymphocytosis
LP- Indian ink
Initial treatment Amphotericin B 0.7-1mg/kg
for 14 days then Fluconazole 3-6mg/kg OD X 8
weeks Maintenance treatment (secondary
prophylaxis) Fluconazole 3 mg/kg OD for life
Herpes ZosterSkin: Acute severe pain,
multidermatomal, disfiguring
keloids
Eye: permanent visual loss
Genital: tender vesicles/lesions on
vulva, vagina, cervix or anal area.
May form large ulcers
Clinical
diagnosis
Severe cases should be hospitalised and
treated, if possible, with IV acyclovir
30mg/kg/day divided into 8 hourly doses for a
total of 7 days, or 2 days after cessation of new
lesion formation, whichever is longer
Pain relief, prevention of secondary bacterial
infection of lesions
PTB Cough > 3 weeks, fever, wasting,
crepitations, effusion
Sputum negative
Abnormal CXR
Isoniazid 5 – 10 mg/kg/d (max 300mg)
Rifampicin 10 - 20 mg/kg/d
Pyrazinamide 25 – 35 mg/kg/d (2 months)
Ethambutol 15 – 25 mg/kg/d (max 2.5g)
Duration of treatment is according to National
guidelines, but longer courses (9 months) are
recommended for the HIV- infected child Add
prednisone (2 mg/kg OD x 2- 4 weeks) in TBM,
miliary TB, massive pleural effusion and
pericarditis
Cryptococcal
Meningitis
Headache, fever, stiff neck
Convulsions, papilledema
Clinical
suspicion key
Raised ICP,
CRAG
Lymphocytosis
LP- Indian ink
Initial treatment Amphotericin B 0.7-1mg/kg
for 14 days then Fluconazole 3-6mg/kg OD X 8
weeks Maintenance treatment (secondary
prophylaxis) Fluconazole 3 mg/kg OD for life
Toxoplasmosis Headache, neurologic deficit,
personality change, blindness,
cerebellar signs
CT Scan >/= 2 ring
enhancing lesions;
Signs of SOL with
relatively normal
CSF
Fansidar
Pyrimethamine 2mg/Kg/day; for 2 days
maximum
25mg, then 1mg/kg/OD three times a week
until 1-
2 weeks beyond resolution of symptoms.
Sulphadiazine 50 mg/kg q12h for 6 weeks
plus
folinic acid 5-20 mg 3 times weekly
Kaposi’s
Sarcoma
Firm, dark nodules, papules, patches
on skin, oropharyngeal, GI, lungs
Biopsy Chemotherapy + ART
personality change, blindness,
cerebellar signs
CT Scan >/= 2 ring
enhancing lesions;
Signs of SOL with
relatively normal
CSF
Fansidar
Pyrimethamine 2mg/Kg/day; for 2 days
maximum
25mg, then 1mg/kg/OD three times a week
until 1-
2 weeks beyond resolution of symptoms.
Sulphadiazine 50 mg/kg q12h for 6 weeks
plus
folinic acid 5-20 mg 3 times weekly
Kaposi’s
Sarcoma
Firm, dark nodules, papules, patches
on skin, oropharyngeal, GI, lungs
Biopsy Chemotherapy + ART
Pneumocystis
jiroveci
Pneumonia
Usually less than 1 year
Tachypnoea Dyspnoea Low grade
fever or afebrile Cough Hypoxemia
(paO2 < 90%)
Clinical suspicion key CXR
may be normal Sputum or
bronchial lavage
IV Cotrimoxazole Trimethoprim (TMP): 15-
20 mg/kg/day 6-8 hourly Sulphamethoxazole
(SMX): 75- 100mg
Oral Cotrimoxazole TMP: 20 mg/kg/day 6-8
hourly SMX: 100mg OR
1. IV Pentamidine 4mg/kg/day OD
2. Dapsone 2mg/kg/OD
Course: 2-3 weeks; add prednisone 2 mg/kg
for 7- 14 days in severely ill children
Herpes
simplex virus
Neonatal infection usually is
disseminated with high case fatality
Skin or CNS manifestations; may
recur
Oro-labial infection
(gingivostomatitis):
fever, irritability, superficial painful
ulcers of skin and mucosa. May
extend to oesophageal mucosa
causing difficulty in swallowing.
Encephalitis (>95% type 1
Clinical diagnosis
based on the typical
appearance of vesicles
and oral ulcers.
Viral isolation
(culture/PCR)
Rising serum HSV
titres and increased
ratio of CSF-to-serum
concentration of HSV
antibody;
Immunofluorescence
staining of fluid
IV Acyclovir 20 mg/kg given 3 times a day for
21
days for CNS and disseminated disease
For oral 200 – 400 mg 5 times a day for 7-10
days.
jiroveci
Pneumonia
Usually less than 1 year
Tachypnoea Dyspnoea Low grade
fever or afebrile Cough Hypoxemia
(paO2 < 90%)
Clinical suspicion key CXR
may be normal Sputum or
bronchial lavage
IV Cotrimoxazole Trimethoprim (TMP): 15-
20 mg/kg/day 6-8 hourly Sulphamethoxazole
(SMX): 75- 100mg
Oral Cotrimoxazole TMP: 20 mg/kg/day 6-8
hourly SMX: 100mg OR
1. IV Pentamidine 4mg/kg/day OD
2. Dapsone 2mg/kg/OD
Course: 2-3 weeks; add prednisone 2 mg/kg
for 7- 14 days in severely ill children
Herpes
simplex virus
Neonatal infection usually is
disseminated with high case fatality
Skin or CNS manifestations; may
recur
Oro-labial infection
(gingivostomatitis):
fever, irritability, superficial painful
ulcers of skin and mucosa. May
extend to oesophageal mucosa
causing difficulty in swallowing.
Encephalitis (>95% type 1
Clinical diagnosis
based on the typical
appearance of vesicles
and oral ulcers.
Viral isolation
(culture/PCR)
Rising serum HSV
titres and increased
ratio of CSF-to-serum
concentration of HSV
antibody;
Immunofluorescence
staining of fluid
IV Acyclovir 20 mg/kg given 3 times a day for
21
days for CNS and disseminated disease
For oral 200 – 400 mg 5 times a day for 7-10
days.
Cytomegalo virus
Basic manifestation Congenital: LBW,
hepatosplenomegaly, retinitis,
microcephaly, intracranial
calcifications on skull x-ray or CT
Acquired form:
o Retinitis (presents with visual
problems)
o Meningoencephalitis
o Pneumonia
o Colitis – Abdominal pain and
diarrhea
Clinical
presentation
Fundoscopy
Serology (IgM)
Culture PCR
Histopathology
Ganciclovir 7.5-10 mg/kg/d b.d for 2-3
wks
followed by lifelong maintenance
therapy
Candidiasis
Oral thrush
Oesophageal: Painful swallowing,
dehydration, malnutrition, wasting
Endoscopy,
culture or
barium swallow
Local treatments (Nystatin, GV)
Fluconazole 3-6 mg/kg/OD for 2-3 wks.
Ketoconazole 5-10mg/kg/in 1or 2 divided
dose
Basic manifestation Congenital: LBW,
hepatosplenomegaly, retinitis,
microcephaly, intracranial
calcifications on skull x-ray or CT
Acquired form:
o Retinitis (presents with visual
problems)
o Meningoencephalitis
o Pneumonia
o Colitis – Abdominal pain and
diarrhea
Clinical
presentation
Fundoscopy
Serology (IgM)
Culture PCR
Histopathology
Ganciclovir 7.5-10 mg/kg/d b.d for 2-3
wks
followed by lifelong maintenance
therapy
Candidiasis
Oral thrush
Oesophageal: Painful swallowing,
dehydration, malnutrition, wasting
Endoscopy,
culture or
barium swallow
Local treatments (Nystatin, GV)
Fluconazole 3-6 mg/kg/OD for 2-3 wks.
Ketoconazole 5-10mg/kg/in 1or 2 divided
dose
Extrapulmonary
TB
Hepatosplenomegaly, septic arthritis,
peritonitis
Very difficult to
diagnose
clinically
Therapeutic trial of anti- TB drugs:
RHZE x 2 mos then EH x 6 mos +
pyridoxine Cotrimoxazole prophylaxis
Infective
Dermatoses
Scabies: papular, itchy rash
Norwegian scabies: extensive skin rash
with crusting lesions
Papular Pruritic Eruption: itching,
hyperpigmented, hyperkeratotic
excoriated papules & nodules; thick skin
Clinical
diagnosis
Empirical trial with BBE at night for 3
nights (itchiness may persist 2 wks)
Fungal infections: Clotrimazole cream. If
severe: Griseofulvin or Fluconazole
Calamine lotion; Steroids last resort
PPE: Chlorhexidine/cetrimide ointment,
antihistamines
Bacterial
pneumonia
Acute, productive cough, fever,
breathlessness
Clinical sign of
consolidation,
CXR
Amoxicillin OR
Erythromycin OR
Cephalosporin
TB
Hepatosplenomegaly, septic arthritis,
peritonitis
Very difficult to
diagnose
clinically
Therapeutic trial of anti- TB drugs:
RHZE x 2 mos then EH x 6 mos +
pyridoxine Cotrimoxazole prophylaxis
Infective
Dermatoses
Scabies: papular, itchy rash
Norwegian scabies: extensive skin rash
with crusting lesions
Papular Pruritic Eruption: itching,
hyperpigmented, hyperkeratotic
excoriated papules & nodules; thick skin
Clinical
diagnosis
Empirical trial with BBE at night for 3
nights (itchiness may persist 2 wks)
Fungal infections: Clotrimazole cream. If
severe: Griseofulvin or Fluconazole
Calamine lotion; Steroids last resort
PPE: Chlorhexidine/cetrimide ointment,
antihistamines
Bacterial
pneumonia
Acute, productive cough, fever,
breathlessness
Clinical sign of
consolidation,
CXR
Amoxicillin OR
Erythromycin OR
Cephalosporin
Illnesses which are common in HIV + as well as
HIV – children
Respiratory infections
Diarrhoea
Measles
Septicemia, Meningitis
Skin infections
Above illnesses manifest in more severe forms and
recurrently in HIV + children as compared to HIV -
children.
HIV – children
Respiratory infections
Diarrhoea
Measles
Septicemia, Meningitis
Skin infections
Above illnesses manifest in more severe forms and
recurrently in HIV + children as compared to HIV -
children.
Illnesses which are more prevalent in HIV + children
Tuberculosis
Pneumocystis Jerovecii Pneumonia (PCP)
Oropharyngeal candidiasis
Cryptosporidiasis
Cryptococcal Meningitis
Toxoplasmosis
Herpes simplex virus
Herpes Zoster
Cyto megalo virus
Lymphoid Interstitial pneumonia
Kaposis sarcoma
HIV encephalopathy
Tuberculosis
Pneumocystis Jerovecii Pneumonia (PCP)
Oropharyngeal candidiasis
Cryptosporidiasis
Cryptococcal Meningitis
Toxoplasmosis
Herpes simplex virus
Herpes Zoster
Cyto megalo virus
Lymphoid Interstitial pneumonia
Kaposis sarcoma
HIV encephalopathy
Vaccine Asymptomatic HIV Symptomatic HIV Optimal of timing
immunization
BCG Yes No Birth
DPT Yes Yes 6,10,14 weeks
OPV* Yes Yes 0, 6, 10, 14 weeks
Measles Yes Yes 6 and 9 weeks
Hepatitis B Yes Yes As for uninfected
children
Yellow fever Yes No**
Tetanus toxoidYes Yes 5 doses***
immunization
BCG Yes No Birth
DPT Yes Yes 6,10,14 weeks
OPV* Yes Yes 0, 6, 10, 14 weeks
Measles Yes Yes 6 and 9 weeks
Hepatitis B Yes Yes As for uninfected
children
Yellow fever Yes No**
Tetanus toxoidYes Yes 5 doses***
*IPV an alternative for children with symptomatic HIV
**Pending further studies
***5 doses TT for women of children
bearing age
**Pending further studies
***5 doses TT for women of children
bearing age
HIV Prevention
Behavior change communication.
Advocacy and lobbying for societal change and reduction of
denial
Condom promotion and availability
Sexually transmitted infection management
Voluntary counseling and testing.
Prevention of mother to Child Transmission
Blood Safety
Stigma Reduction
Harm Reduction for Injecting drug users
Advocacy and lobbying for societal change and reduction of
denial
Condom promotion and availability
Sexually transmitted infection management
Voluntary counseling and testing.
Prevention of mother to Child Transmission
Blood Safety
Stigma Reduction
Harm Reduction for Injecting drug users
This includes the management of the HIV positive person
starting to develop HIV/AIDS.
This is a holistic approach that involves physical, social,
psychological and spiritual interventions.
The provision of sexually transmitted diseases care.
The provision of Anti-Retro viral medications.
Reducing fertility. This alludes to encouraging women who
have the infection not to have children.
Health promotion strategies must be pursued aggressively
starting to develop HIV/AIDS.
This is a holistic approach that involves physical, social,
psychological and spiritual interventions.
The provision of sexually transmitted diseases care.
The provision of Anti-Retro viral medications.
Reducing fertility. This alludes to encouraging women who
have the infection not to have children.
Health promotion strategies must be pursued aggressively
A Abstain from sex
B Being faithful to your partner.
C Condoms use (correct and consistent use)
D Discuss about HIV testing
Drugs for STI
Delay sexual début
E Empowerment in negotiating sex
B Being faithful to your partner.
C Condoms use (correct and consistent use)
D Discuss about HIV testing
Drugs for STI
Delay sexual début
E Empowerment in negotiating sex
Male Circumcision
Ministry of Health published policy guidelines on VMMC and
HIV prevention to guide it’s implementation
VMMC services to be provided alongside HTC services
However, HIV testing should not be a precondition to access
male circumcision services
Not expensive surgical procedure
Can be done at any age grade
Done only once in a lifetime
Ministry of Health published policy guidelines on VMMC and
HIV prevention to guide it’s implementation
VMMC services to be provided alongside HTC services
However, HIV testing should not be a precondition to access
male circumcision services
Not expensive surgical procedure
Can be done at any age grade
Done only once in a lifetime
Voluntary Male Medical
Circumcision Vs HIV infection
3.9
13.2
0
5
10
15
20
Circumcised Men Uncircumcised Men
H
IV
P
r
e
v
a
le
n
c
e
(
%
)
Uncircumcised men aged
15 -64 are three times
more likely to be infected
with HIV than circumcised
men (13.2% vs. 3.9%
respectively)
National male HIV
prevalence,5.3%
84
Ref: KAIS 2007
Circumcision Vs HIV infection
3.9
13.2
0
5
10
15
20
Circumcised Men Uncircumcised Men
H
IV
P
r
e
v
a
le
n
c
e
(
%
)
Uncircumcised men aged
15 -64 are three times
more likely to be infected
with HIV than circumcised
men (13.2% vs. 3.9%
respectively)
National male HIV
prevalence,5.3%
84
Ref: KAIS 2007
Benefits of VMMC
Reduces the risk of HIV transmission up to 3 times
according to KAIS 2007
Reduces risk of transmission of other STIs.
Male Circumcision reduces female to male HIV
transmission by approximately 60 % (KAIS 2007)
Unlike behavior based approaches (ABC) VMMC has
few “user requirements” beyond a period of post-
procedure abstinence
Reduces the risk of HIV transmission up to 3 times
according to KAIS 2007
Reduces risk of transmission of other STIs.
Male Circumcision reduces female to male HIV
transmission by approximately 60 % (KAIS 2007)
Unlike behavior based approaches (ABC) VMMC has
few “user requirements” beyond a period of post-
procedure abstinence
Benefits of VMMC cont’....
86
Unlike pre-exposure prophylaxis and treatment for
prevention there is no risk of promoting ARV resistance
VMMC is highly acceptable even among non-circumcising
communities
Male circumcision is inexpensive (less than Ksh.3000/= per
procedure)
VMMC is not only cost effective, but also cost saving
considering HIV care and treatment costs
86
Unlike pre-exposure prophylaxis and treatment for
prevention there is no risk of promoting ARV resistance
VMMC is highly acceptable even among non-circumcising
communities
Male circumcision is inexpensive (less than Ksh.3000/= per
procedure)
VMMC is not only cost effective, but also cost saving
considering HIV care and treatment costs
ANTI RETROVIRAL THERAPY
NRTIs - inhibit reverse transcription by being
incorporated into the newly synthesized viral DNA and
preventing its further elongation.
NNRTIs- inhibit reverse transcriptase directly by binding
to the enzyme and interfering with its function
PIs (Protease Inhibitors) - target viral assembly by
inhibiting the activity of protease, an enzyme used by HIV
to cleave nascent proteins, for final assembly of new
virons
incorporated into the newly synthesized viral DNA and
preventing its further elongation.
NNRTIs- inhibit reverse transcriptase directly by binding
to the enzyme and interfering with its function
PIs (Protease Inhibitors) - target viral assembly by
inhibiting the activity of protease, an enzyme used by HIV
to cleave nascent proteins, for final assembly of new
virons
Entry Inhibitors/Fusion inhibitors - interfere with
binding, fusion and entry of HIV-1 to the host cell
by blocking one of several targets – maraviroc &
enfurvitide
Integrase Inhibitors - inhibit the enzyme integrase
which is responsible for integration of viral DNA
into the DNA of the infected cell – Raltegravir
Maturation inhibitors - inhibit the last step
binding, fusion and entry of HIV-1 to the host cell
by blocking one of several targets – maraviroc &
enfurvitide
Integrase Inhibitors - inhibit the enzyme integrase
which is responsible for integration of viral DNA
into the DNA of the infected cell – Raltegravir
Maturation inhibitors - inhibit the last step
◦Zidovudine (AZT, ZDV, Retrovir)
◦Didanosine (ddI, Videx, Videx EC)
◦Zalcitabine (ddC, Hivid)
◦Stavudine (d4T, Zerit)
◦Lamivudine (3TC, Epivir)
◦Abacavir (ABC, Ziagen)
◦Combivir (AZT/3TC)
◦Trizivir (AZT/3TC/ABC)
◦Tenofovir (TDF, Viread)
◦Emtricitabine (FTC, Emtriva )
◦Epzicom (ABC/3TC)
◦Truvada (TDF/FTC)
◦Didanosine (ddI, Videx, Videx EC)
◦Zalcitabine (ddC, Hivid)
◦Stavudine (d4T, Zerit)
◦Lamivudine (3TC, Epivir)
◦Abacavir (ABC, Ziagen)
◦Combivir (AZT/3TC)
◦Trizivir (AZT/3TC/ABC)
◦Tenofovir (TDF, Viread)
◦Emtricitabine (FTC, Emtriva )
◦Epzicom (ABC/3TC)
◦Truvada (TDF/FTC)
◦Nevirapine (NVP, Viramune)
◦Delavirdine (DLV, Rescriptor)
◦Efavirenz (EFV, Sustiva)
◦Etravirine (Intelence™)
◦Delavirdine (DLV, Rescriptor)
◦Efavirenz (EFV, Sustiva)
◦Etravirine (Intelence™)
◦Saquinavir-HGC (SQV-HGC, Invirase)
◦Ritonavir (RTV, Norvir)
◦Indinavir (IDV, Crixivan)
◦Nelfinavir (NFV, Viracept)
◦Amprenavir (APV, Agenerase)
◦Lopinavir/ritonavir (KAL, Kaletra®)
◦Atazanavir (ATV, Reyataz®)
◦Fosamprenavir (fos-APV, Lexiva®)
◦Tipranavir (TPV, Aptivus®)
◦Darunavir (DRV, Prezista™)
◦Ritonavir (RTV, Norvir)
◦Indinavir (IDV, Crixivan)
◦Nelfinavir (NFV, Viracept)
◦Amprenavir (APV, Agenerase)
◦Lopinavir/ritonavir (KAL, Kaletra®)
◦Atazanavir (ATV, Reyataz®)
◦Fosamprenavir (fos-APV, Lexiva®)
◦Tipranavir (TPV, Aptivus®)
◦Darunavir (DRV, Prezista™)
Factors to consider:
◦Efficacy- Viral suppression
◦Quality of life- toxicity, pill burden
◦Future options
◦Improvement in immune function
◦Resistance patterns
◦Co-morbidities
◦Efficacy- Viral suppression
◦Quality of life- toxicity, pill burden
◦Future options
◦Improvement in immune function
◦Resistance patterns
◦Co-morbidities
Base/backbone
Base- NNRTI or PI
◦EFV preferable to NVP
Backbone-2 NRTIs
◦TDF/FTC
◦TDF/3TC
◦ABC/3TC
◦ABC/FTC
◦Local- AZT/3TC or TDF/3TC
Base- NNRTI or PI
◦EFV preferable to NVP
Backbone-2 NRTIs
◦TDF/FTC
◦TDF/3TC
◦ABC/3TC
◦ABC/FTC
◦Local- AZT/3TC or TDF/3TC
All HIV-infected adolescents and adults with
CD4 count <500 cells/mm3 irrespective of WHO
stage
All HIV-infected pregnant women irrespective
of CD4 count, WHO stage or gestation age*
All HIV-infected breastfeeding women
irrespective of CD4 count, WHO stage*
All HIV-infected spouses and sexual partners in
sero-discordant relationships irrespective of
their WHO stage or CD4 cell count
CD4 count <500 cells/mm3 irrespective of WHO
stage
All HIV-infected pregnant women irrespective
of CD4 count, WHO stage or gestation age*
All HIV-infected breastfeeding women
irrespective of CD4 count, WHO stage*
All HIV-infected spouses and sexual partners in
sero-discordant relationships irrespective of
their WHO stage or CD4 cell count
• The goal of ART is to suppress viral replication with the aim of reducing the
patient’s VL to undetectable levels
• All individuals with confirmed HIV infection are eligible for ART,
irrespective of CD4 count/%, WHO clinical stage, age, pregnancy or
breastfeeding status, co-infection status, risk group, or any other criteria,
provided that the individual is willing and ready to take ART and adhere to
follow-up recommendations
• ART should be started in all patients as soon as possible (preferably within 2
weeks of confirmation of HIV status)
• Preferred first-line ART for infants, children, adolescents and adults o Birth
to 4 weeks: AZT + 3TC + NVP
o 4 weeks - < 15 years: ABC + 3TC + DTG
o < 30 kg body weight): ABC + 3TC + DTG
o ≥ 15 years (or ≥ 30 kg body weight): TDF + 3TC + DTG
patient’s VL to undetectable levels
• All individuals with confirmed HIV infection are eligible for ART,
irrespective of CD4 count/%, WHO clinical stage, age, pregnancy or
breastfeeding status, co-infection status, risk group, or any other criteria,
provided that the individual is willing and ready to take ART and adhere to
follow-up recommendations
• ART should be started in all patients as soon as possible (preferably within 2
weeks of confirmation of HIV status)
• Preferred first-line ART for infants, children, adolescents and adults o Birth
to 4 weeks: AZT + 3TC + NVP
o 4 weeks - < 15 years: ABC + 3TC + DTG
o < 30 kg body weight): ABC + 3TC + DTG
o ≥ 15 years (or ≥ 30 kg body weight): TDF + 3TC + DTG
• Treatment failure is suspected when a patient has a high VL ≥ 1,000 copies/ml
after at least 6 months of using ART
• Treatment failure is only confirmed when VL is ≥ 1,000 copies/ml after
assessing for and addressing poor adherence or other reasons for high VL, and
then repeating VL after at least 3 months of excellent adherence to allow for
viral re-suppression
• Persistent low-level viremia (PLLV) is defined as having a detectable VL
(above the LDL value) but < 1,000 copies/ml on two or more consecutive
measures. These patients are at increased risk of progression to treatment
failure, development of ARV resistance and death and therefore require a
similar case management approach as patients with VL ≥ 1,000 copies/ml
after at least 6 months of using ART
• Treatment failure is only confirmed when VL is ≥ 1,000 copies/ml after
assessing for and addressing poor adherence or other reasons for high VL, and
then repeating VL after at least 3 months of excellent adherence to allow for
viral re-suppression
• Persistent low-level viremia (PLLV) is defined as having a detectable VL
(above the LDL value) but < 1,000 copies/ml on two or more consecutive
measures. These patients are at increased risk of progression to treatment
failure, development of ARV resistance and death and therefore require a
similar case management approach as patients with VL ≥ 1,000 copies/ml
•All PLHIV with a detectable VL (any value above LDL): assess for and
address potential reasons for viremia, including intensifying adherence
support, repeat the VL after 3 months of excellent adherence
o If the repeat VL is ≥ 1,000 copies/ml, change to an effective regimen
o If the repeat VL is detectable but < 1,000 copies/ml consult the Regional or
National HIV Clinical TWG
o If the repeat VL is undetectable then continue routine monitoring
address potential reasons for viremia, including intensifying adherence
support, repeat the VL after 3 months of excellent adherence
o If the repeat VL is ≥ 1,000 copies/ml, change to an effective regimen
o If the repeat VL is detectable but < 1,000 copies/ml consult the Regional or
National HIV Clinical TWG
o If the repeat VL is undetectable then continue routine monitoring
• Prevention of mother-to-child transmission of HIV (PMTCT) should be
offered as part of a comprehensive package of fully integrated, routine antenatal
care interventions
• Lifelong ART should be initiated in all pregnant and breastfeeding
women living with HIV, regardless of gestational age, WHO clinical stage
and at any CD4 count
• ART should be started, ideally, on the same day as HIV diagnosis is made
with ongoing enhanced adherence support
• The preferred first line ART regimen for pregnant and breastfeeding women is
TDF + 3TC + DTG
offered as part of a comprehensive package of fully integrated, routine antenatal
care interventions
• Lifelong ART should be initiated in all pregnant and breastfeeding
women living with HIV, regardless of gestational age, WHO clinical stage
and at any CD4 count
• ART should be started, ideally, on the same day as HIV diagnosis is made
with ongoing enhanced adherence support
• The preferred first line ART regimen for pregnant and breastfeeding women is
TDF + 3TC + DTG
• For pregnant and breastfeeding women newly initiated on ART, obtain VL 3
months after initiation, and then every 6 months until complete cessation of
breastfeeding
• For HIV positive women already on ART at the time of confirming pregnancy
or breastfeeding, obtain a VL irrespective of when prior VL was done, and then
every 6 months until complete cessation of breastfeeding
• For pregnant or breastfeeding women with a detectable VL (any value above
LDL): assess for and address potential reasons for viremia, including
intensifying adherence support, repeat the VL after 3 months of excellent
adherence
o If the repeat VL is ≥ 1,000 copies/ml, change to an effective regimen
o If the repeat VL is detectable but < 1,000 copies/ml consult the Regional or
National HIV Clinical TWG
o If the repeat VL is undetectable then continue routine monitoring
• All HEI should receive infant ARV prophylaxis consisting of 6 weeks of AZT
+ NVP and thereafter NVP should be continued until 6 weeks after complete
cessation of breastfeeding
months after initiation, and then every 6 months until complete cessation of
breastfeeding
• For HIV positive women already on ART at the time of confirming pregnancy
or breastfeeding, obtain a VL irrespective of when prior VL was done, and then
every 6 months until complete cessation of breastfeeding
• For pregnant or breastfeeding women with a detectable VL (any value above
LDL): assess for and address potential reasons for viremia, including
intensifying adherence support, repeat the VL after 3 months of excellent
adherence
o If the repeat VL is ≥ 1,000 copies/ml, change to an effective regimen
o If the repeat VL is detectable but < 1,000 copies/ml consult the Regional or
National HIV Clinical TWG
o If the repeat VL is undetectable then continue routine monitoring
• All HEI should receive infant ARV prophylaxis consisting of 6 weeks of AZT
+ NVP and thereafter NVP should be continued until 6 weeks after complete
cessation of breastfeeding
• All infants irrespective of HIV status should be exclusively breastfed for the
first 6 months of life, with timely introduction of appropriate complementary
foods after 6 months, and continued breastfeeding up to 24 months or beyond
first 6 months of life, with timely introduction of appropriate complementary
foods after 6 months, and continued breastfeeding up to 24 months or beyond
• PEP should be offered as soon as possible (< 72 hours) after high risk
exposure
• The recommended ARV agents for PEP are
<15 years old ▪ < 30 kg: ABC + 3TC + DTG
▪ ≥ 30 kg: TDF + 3TC + DTG
▪ ≥ 15 years old ▪ TDF + 3TC + DTG
exposure
• The recommended ARV agents for PEP are
<15 years old ▪ < 30 kg: ABC + 3TC + DTG
▪ ≥ 30 kg: TDF + 3TC + DTG
▪ ≥ 15 years old ▪ TDF + 3TC + DTG
• Oral PrEP should be offered to HIV negative individuals at substantial
ongoing risk of HIV infection (including the seronegative partner in a
discordant relationship)
• The recommended ARV regimen for use as PrEP is: TDF (300 mg) + FTC
(200 mg) once daily
• PrEP does not eliminate the risk of HIV infection and it does not prevent STIs
or unintended pregnancies
• PrEP should only be offered after assessment to establish eligibility, readiness
for effective use, required follow-up (including HIV testing every 3 months)
and absence of contraindications to TDF and/or FTC
ongoing risk of HIV infection (including the seronegative partner in a
discordant relationship)
• The recommended ARV regimen for use as PrEP is: TDF (300 mg) + FTC
(200 mg) once daily
• PrEP does not eliminate the risk of HIV infection and it does not prevent STIs
or unintended pregnancies
• PrEP should only be offered after assessment to establish eligibility, readiness
for effective use, required follow-up (including HIV testing every 3 months)
and absence of contraindications to TDF and/or FTC
• PWID should be offered regular HIV testing and counselling and be linked to
comprehensive HIV treatment and prevention services including harm
reduction counselling and support
• PWID should be offered screening, diagnosis, treatment and prevention of
STIs as part of comprehensive HIV prevention and care
• PWID should have the same access to TB prevention, screening and treatment
services as other populations at risk of or living with HIV
• PWID should be screened for HBV (by HBsAg) and HCV (by HCV serology)
at first contact
• All PWID should be linked to Needle and Syringe Programmes (NSP) to
access sterile injecting equipment
• All PWID should be linked to Medically Assisted Therapy (MAT)
comprehensive HIV treatment and prevention services including harm
reduction counselling and support
• PWID should be offered screening, diagnosis, treatment and prevention of
STIs as part of comprehensive HIV prevention and care
• PWID should have the same access to TB prevention, screening and treatment
services as other populations at risk of or living with HIV
• PWID should be screened for HBV (by HBsAg) and HCV (by HCV serology)
at first contact
• All PWID should be linked to Needle and Syringe Programmes (NSP) to
access sterile injecting equipment
• All PWID should be linked to Medically Assisted Therapy (MAT)
All HIV-infected adolescents and adults with WHO stage 3
and 4 disease irrespective of CD4 count
All Hepatitis B Virus/HIV co-infected persons irrespective
of CD4 count
All TB/HIV co-infected persons irrespective of CD4 count of
WHO stage
and 4 disease irrespective of CD4 count
All Hepatitis B Virus/HIV co-infected persons irrespective
of CD4 count
All TB/HIV co-infected persons irrespective of CD4 count of
WHO stage
Agent Adverse Drug Reaction High Risk Situations/Comments
NRTIs
ABC ABC hypersensitivity reaction
(see Table 6.10)
Do not re-challenge
AZT Anaemia, neutropenia
(see Table 6.8)
Risk factors: CD4 count < 200
cells/mm3; BMI < 18.5 (or body weight
< 50 kg); anaemia at baseline;
concurrent use of other drugs with
similar ADR (cotrimoxazole,
gancyclovir, ribavirin)
Lactic acidosis Risk factors: Pregnancy; obesity
Lipoatrophy Risk factors: Low CD4 count
TDF Renal dysfunction
(see Figure 6.4)
Risk factors: Underlying renal disease;
age > 40 years; BMI < 18.5 (or body
weight < 50 kg); diabetes; hypertension;
concomitant PI use or nephrotoxic drug
NRTIs
ABC ABC hypersensitivity reaction
(see Table 6.10)
Do not re-challenge
AZT Anaemia, neutropenia
(see Table 6.8)
Risk factors: CD4 count < 200
cells/mm3; BMI < 18.5 (or body weight
< 50 kg); anaemia at baseline;
concurrent use of other drugs with
similar ADR (cotrimoxazole,
gancyclovir, ribavirin)
Lactic acidosis Risk factors: Pregnancy; obesity
Lipoatrophy Risk factors: Low CD4 count
TDF Renal dysfunction
(see Figure 6.4)
Risk factors: Underlying renal disease;
age > 40 years; BMI < 18.5 (or body
weight < 50 kg); diabetes; hypertension;
concomitant PI use or nephrotoxic drug
Agent Adverse Drug
Reaction
High Risk Situations/Comments
NNRTIs
All NNRTIs Rash/
hypersensitivity
(NVP>>EFV>ETR)
Risk factors: for NVP hypersensitivity,
women with CD4 count > 250
cells/mm3, men with CD4 count > 400
cells/mm3
Manage rash as per Table 4.4
EFV CNS side-effects Risk factors: Pre-existing psychiatric
disorder
Gynaecomastia Switch from EFV to an alternative, and
consult if gynecomastia does not improve
NVP Hepatotoxicity
(see Table 6.9)
Risk factors: HBV or HCV co-infection;
concomitant use of hepatotoxic drugs;
women with CD4 count > 250 cells/
mm3; men with CD4 count > 400
cells/mm3
Reaction
High Risk Situations/Comments
NNRTIs
All NNRTIs Rash/
hypersensitivity
(NVP>>EFV>ETR)
Risk factors: for NVP hypersensitivity,
women with CD4 count > 250
cells/mm3, men with CD4 count > 400
cells/mm3
Manage rash as per Table 4.4
EFV CNS side-effects Risk factors: Pre-existing psychiatric
disorder
Gynaecomastia Switch from EFV to an alternative, and
consult if gynecomastia does not improve
NVP Hepatotoxicity
(see Table 6.9)
Risk factors: HBV or HCV co-infection;
concomitant use of hepatotoxic drugs;
women with CD4 count > 250 cells/
mm3; men with CD4 count > 400
cells/mm3
Agent Adverse Drug
Reaction
High Risk Situations/Comments
PIs
All PIs boosted with
RTV
GI intolerance
(LPV/r>DRV/r>AT
V/r)
Consult
Dyslipidaemia (LPV/r>DRV/r>ATV/r) Risk factors: Obesity; sedentary lifestyle; diet
high in saturated fats and cholesterol
ATV/r Hyperbilirubinemia This only requires drug substitution if
cosmetic effect of jaundice is likely to
interfere with patient adherence
DRV/r Rash/
hypersensitivity
Risk factors: sulfa allergy
INSTIs
DTG Insomnia Give in the morning; if no improvement
then try giving with low fat meal or on
empty stomach
All INSTIs Rash/
hypersensitivity
Consult
Reaction
High Risk Situations/Comments
PIs
All PIs boosted with
RTV
GI intolerance
(LPV/r>DRV/r>AT
V/r)
Consult
Dyslipidaemia (LPV/r>DRV/r>ATV/r) Risk factors: Obesity; sedentary lifestyle; diet
high in saturated fats and cholesterol
ATV/r Hyperbilirubinemia This only requires drug substitution if
cosmetic effect of jaundice is likely to
interfere with patient adherence
DRV/r Rash/
hypersensitivity
Risk factors: sulfa allergy
INSTIs
DTG Insomnia Give in the morning; if no improvement
then try giving with low fat meal or on
empty stomach
All INSTIs Rash/
hypersensitivity
Consult
109
Adherence to HIV
Therapy
Adherence to HIV
Therapy
110
Adherence
The act or quality to stick to something, steady devotion or the
act of adhering.
It describes the patient’s behavior of taking drugs correctly; in
the right dose, with the right frequency, and at the correct
time.
A critical aspect of adherence is the patient’s involvement in
deciding whether or not to take the drugs.
[Patients acceptance to take an active role in own health care].
Adherence
The act or quality to stick to something, steady devotion or the
act of adhering.
It describes the patient’s behavior of taking drugs correctly; in
the right dose, with the right frequency, and at the correct
time.
A critical aspect of adherence is the patient’s involvement in
deciding whether or not to take the drugs.
[Patients acceptance to take an active role in own health care].
111
Compliance
The act of conforming, yielding or acquiescing.
Compliant patients will do what he or she
has been told by the health care provider.
[There is lack of sharing in the decision making].
Compliance
The act of conforming, yielding or acquiescing.
Compliant patients will do what he or she
has been told by the health care provider.
[There is lack of sharing in the decision making].
112
Counseling—Very vital
Participation of the patient in a plan of care. Don’t rush to
ARV, patient must be ready!
Information/Education/Communication on ARV drugs:
Provide simple written information
Educate and motivate: basic drug info, importance of
adherence, timing of medications, drug interactions,
etc
Warn patients about common side effects
Counseling—Very vital
Participation of the patient in a plan of care. Don’t rush to
ARV, patient must be ready!
Information/Education/Communication on ARV drugs:
Provide simple written information
Educate and motivate: basic drug info, importance of
adherence, timing of medications, drug interactions,
etc
Warn patients about common side effects
113
Positive treatment outcomes.
Slower clinical progression of diseases
Decreasing viral load.
Economic benefits – Minimal drug. Resistance reduced
utilization and costs of drugs and services.
Improving quality of life and therefore functioning. ( Physical,
Psychological, Social etc… ).
Positive treatment outcomes.
Slower clinical progression of diseases
Decreasing viral load.
Economic benefits – Minimal drug. Resistance reduced
utilization and costs of drugs and services.
Improving quality of life and therefore functioning. ( Physical,
Psychological, Social etc… ).
114
Active psychiatric illness (especially depression)
Active drug and/or alcohol use
History of non-adherence
Medication side effects
Lack of education about treatment.
Active psychiatric illness (especially depression)
Active drug and/or alcohol use
History of non-adherence
Medication side effects
Lack of education about treatment.
115
116
1. Acceptance of ART (Readiness)
2. Ability to take and adhere to ART
3. Maintenance of adherent behavior
1. Acceptance of ART (Readiness)
2. Ability to take and adhere to ART
3. Maintenance of adherent behavior
117
Drug related
Number, food/ fluid
restrictions, side-effects,
Pill burden,
Drug interactions,
Storage needs
Patient variables
Sex, age, education, alcohol,
social support, readiness
Lifestyle, Socio-Economic, Traveling
Forgetfulness, depression
Clinical
setting
Friendly, supportive
non-judgmental staff
confidentiality, convenient
appointments
Disease
Characteristics
Prior OI
Patient/Provider
Relationship
Trust and confidence
Drug related
Number, food/ fluid
restrictions, side-effects,
Pill burden,
Drug interactions,
Storage needs
Patient variables
Sex, age, education, alcohol,
social support, readiness
Lifestyle, Socio-Economic, Traveling
Forgetfulness, depression
Clinical
setting
Friendly, supportive
non-judgmental staff
confidentiality, convenient
appointments
Disease
Characteristics
Prior OI
Patient/Provider
Relationship
Trust and confidence
118
Communication difficulties
Low literacy, if written
Unstable living conditions- lack of social support
Discomfort with disclosure of HIV status, which
may became known when medications are taken
Stigmas, denial and discrimination
Difficulties in accessing adequate health care
Competing priorities- Work, Child care, lifestyle [may be seen as more
pressing than taking medications regularly]
Alcohol and drug use
Depression
Communication difficulties
Low literacy, if written
Unstable living conditions- lack of social support
Discomfort with disclosure of HIV status, which
may became known when medications are taken
Stigmas, denial and discrimination
Difficulties in accessing adequate health care
Competing priorities- Work, Child care, lifestyle [may be seen as more
pressing than taking medications regularly]
Alcohol and drug use
Depression
ARVs not a cure for HIV/AIDS
Life long treatment.
Taken with specific timing.
Side effects
No sharing of drugs
Appointment dates.
Avoid re-infection
Balanced diet Nutrition
Life long treatment.
Taken with specific timing.
Side effects
No sharing of drugs
Appointment dates.
Avoid re-infection
Balanced diet Nutrition
Avoid herbal medication /Treatment, alcohol,
Cigarettes.
Be wise and informed in faith/miracle/prayer
healing.
Disclosure- encouraged for support.
Cigarettes.
Be wise and informed in faith/miracle/prayer
healing.
Disclosure- encouraged for support.
121
Patients /Guardian involvement in planning the
treatment regimen is critical
Patients Guadian should help in making final
decision of when to initiate ARV therapy
Initiate ART after counseling has been given
regarding specific issues relevant to his/her
own clinical situation.
Patients /Guardian involvement in planning the
treatment regimen is critical
Patients Guadian should help in making final
decision of when to initiate ARV therapy
Initiate ART after counseling has been given
regarding specific issues relevant to his/her
own clinical situation.
1.An exposed child whose mother is on ART: At
birth, give NVP & AZT syrup septrin at 6 weeks.
Do a PCR, if NEG, stop AZT and continue with
NVP and septrin if still exposed. If child turns
+ve, start ART.
At 9 months, do an Antibody test, if child turns
+VE, start ART.
birth, give NVP & AZT syrup septrin at 6 weeks.
Do a PCR, if NEG, stop AZT and continue with
NVP and septrin if still exposed. If child turns
+ve, start ART.
At 9 months, do an Antibody test, if child turns
+VE, start ART.
HIV and Nutrition
HIV and Nutrition
Vit A deficiency- Accelerated progression,
increased mortality, higher MTCT
Low levels of vitamin B12, vitamin E and
selenium acclerate HIV disease progression
HIV progressively destroys the immune system,
leading to opportunistic infections (OI) and
debilitation
Vit A deficiency- Accelerated progression,
increased mortality, higher MTCT
Low levels of vitamin B12, vitamin E and
selenium acclerate HIV disease progression
HIV progressively destroys the immune system,
leading to opportunistic infections (OI) and
debilitation
125
Poor nutrition
Weight loss, muscle
wasting, macro or
micronutrient deficiency
Impaired immune
system
Poor ability to fight HIV
and other infections
Increased
nutrition needs
because of malabsorption,
decreased food intake,
infections, and viral
replication
Increased vulnerability
to infection and increased
frequency and duration of
opportunistic infections
HIV
Adapted from
Poor nutrition
Weight loss, muscle
wasting, macro or
micronutrient deficiency
Impaired immune
system
Poor ability to fight HIV
and other infections
Increased
nutrition needs
because of malabsorption,
decreased food intake,
infections, and viral
replication
Increased vulnerability
to infection and increased
frequency and duration of
opportunistic infections
HIV
Adapted from
HIV and nutrition
HIV effects on nutrition:
Reduce food consumption
Impair nutrient absorption
Increase energy needs
Cause HIV-associated wasting
Increased metabolism
Change in body composition
Poor nutrition effects on HIV:
Decrease immunity
Slow the healing process
Hasten disease progression
HIV effects on nutrition:
Reduce food consumption
Impair nutrient absorption
Increase energy needs
Cause HIV-associated wasting
Increased metabolism
Change in body composition
Poor nutrition effects on HIV:
Decrease immunity
Slow the healing process
Hasten disease progression
Prevention of HIV transmission is an important aspect of reducing
new infections.
Services here include:
◦voluntary counselling and testing (VCT),
◦provider initiated testing and counselling (PITC), and
◦prevention of mother to child transmission (PMTCT) of HIV.
These are services through which clients are supported to make
informed decisions relating to testing, treatment and care.
In addition, caregivers must maintain standards of care to avoid
infection, hence the importance of observing infection prevention
steps when providing care
new infections.
Services here include:
◦voluntary counselling and testing (VCT),
◦provider initiated testing and counselling (PITC), and
◦prevention of mother to child transmission (PMTCT) of HIV.
These are services through which clients are supported to make
informed decisions relating to testing, treatment and care.
In addition, caregivers must maintain standards of care to avoid
infection, hence the importance of observing infection prevention
steps when providing care
Counselling and testing services provide an entry point to the
provision of care and accurate information on HIV/AIDS.
Such services are available in many communities through:
◦VCT centres,
◦PITC,
◦Home testing and counselling,
◦PMTCT, and
◦diagnostic testing and counselling.
provision of care and accurate information on HIV/AIDS.
Such services are available in many communities through:
◦VCT centres,
◦PITC,
◦Home testing and counselling,
◦PMTCT, and
◦diagnostic testing and counselling.
The package of HIV testing services consists of
o A pre-test session
o HIV test
o Assessment for other health-related conditions or needs (while
HIV tests are running)
o A post-test session (includes assisted partner notification
services (aPNS) and child testing)
o Referral and linkage to other appropriate health services (as
part of the post-test session)
HTS providers should adopt the 6 approaches which are known to
improve linkage to treatment and prevention
o Provide information
o Support disclosure
o Address barriers to linkage
o Establish systems to facilitate linkage
o Coordinate and integrate service
o Document actions (using linkage registers)
o A pre-test session
o HIV test
o Assessment for other health-related conditions or needs (while
HIV tests are running)
o A post-test session (includes assisted partner notification
services (aPNS) and child testing)
o Referral and linkage to other appropriate health services (as
part of the post-test session)
HTS providers should adopt the 6 approaches which are known to
improve linkage to treatment and prevention
o Provide information
o Support disclosure
o Address barriers to linkage
o Establish systems to facilitate linkage
o Coordinate and integrate service
o Document actions (using linkage registers)
TYPES OF HIV TESTING AND
COUNSELLING
130
COUNSELLING
130
© MOH/NASCOP/JHPIEGO
Draft April, 2010
131
Draft April, 2010
131
1.Client initiated HIV Testing & Counselling.
(VCT)
2. Provider-Initiated HIV testing & Counselling
(PITC).
3. Other Types- Self Testing,Required HIV
testing eg by Millitary, court of Law.
(VCT)
2. Provider-Initiated HIV testing & Counselling
(PITC).
3. Other Types- Self Testing,Required HIV
testing eg by Millitary, court of Law.
In Blood and Tissue Donation
HIV Testing for Research & Surveillance.
HIV Testing for Research & Surveillance.
Supportive documents :
• Public Health Act,
• HIV & AIDS prevention and controll Act
(2006 )
• Constitution of Kenya :Bill of rights.
• Public Health Act,
• HIV & AIDS prevention and controll Act
(2006 )
• Constitution of Kenya :Bill of rights.
NB/
All HTC Services should be conducted with the
best interest of the client.
HTC Should never be coercive or mandatory.
All HTC Services should be conducted with the
best interest of the client.
HTC Should never be coercive or mandatory.
•Consent- Should be informed consent.
•Confidentiality – Sharing of information
should only be done with the consent of the
client.
•Counselling – Pre test and post test
counselling.( According to
individual/couple/family needs)
•Confidentiality – Sharing of information
should only be done with the consent of the
client.
•Counselling – Pre test and post test
counselling.( According to
individual/couple/family needs)
Consent is based on sufficient, Accurate, and
Voluntary information.
HIV&AIDS prevention and controll Act provides
for testing without consent for those not able
to give consent.
In children, get consent from the
parents/guardians.
Voluntary information.
HIV&AIDS prevention and controll Act provides
for testing without consent for those not able
to give consent.
In children, get consent from the
parents/guardians.
Persons with disability preventing them from
giving consent should be tested with consent
of parents /guardians / partner/caretaker.
giving consent should be tested with consent
of parents /guardians / partner/caretaker.
The only circumstances where consent for HIV
test is not a requirement :
• In requirement for testing under the
provisions of a written law.
•Unconscious patient and unable to give
consent,
•Test medically necessary for a clinical
diagnosis.
test is not a requirement :
• In requirement for testing under the
provisions of a written law.
•Unconscious patient and unable to give
consent,
•Test medically necessary for a clinical
diagnosis.
Encourage disclosure.
Psycho- social support eg joining support
groups/clubs etc.
Open group discussions.
Economic support.
Proper counselling- to client and
spouse/caretakers.
Health Education and couselling to
employers,teachers,workplaces etc.
Psycho- social support eg joining support
groups/clubs etc.
Open group discussions.
Economic support.
Proper counselling- to client and
spouse/caretakers.
Health Education and couselling to
employers,teachers,workplaces etc.
HTC Testing approaches
There are two main HIV testing approaches
Client Initiated Testing Counselling (CITC)
Provider Initiated Testing Counselling (PITC)
Under each approach there are various strategies
CITC
•Self testing
•Stand alone VCT
•Integrated VCT
•Workplace
•Mobile VCT outreaches
•Moonlight VCT
PITC
•HBTC (door to door)
•PMTCT
•Health facility based
•HIV testing for blood and tissue donation
•HIV testing for research and surveillance
141
There are two main HIV testing approaches
Client Initiated Testing Counselling (CITC)
Provider Initiated Testing Counselling (PITC)
Under each approach there are various strategies
CITC
•Self testing
•Stand alone VCT
•Integrated VCT
•Workplace
•Mobile VCT outreaches
•Moonlight VCT
PITC
•HBTC (door to door)
•PMTCT
•Health facility based
•HIV testing for blood and tissue donation
•HIV testing for research and surveillance
141
HTC Approaches and Strategies
142
HTC
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142
HTC
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Client-Initiated HIV Testing and
Counseling [CITC]
Refers to a situation whereby an individual, couple or
group actively seeks out HIV testing and counselling
Puts emphasis on tailored risk reduction counselling
to help the client or couple identify a plan for the
prevention of HIV transmission or acquisition
143
Counseling [CITC]
Refers to a situation whereby an individual, couple or
group actively seeks out HIV testing and counselling
Puts emphasis on tailored risk reduction counselling
to help the client or couple identify a plan for the
prevention of HIV transmission or acquisition
143
Provider-Initiated HIV Testing and
Counseling [PITC]
Refers to a situation in which the HTC service provider offers
an HIV test to a client or patient regardless of their reason for
attending the facility
PITC is significantly different from DTC. DTC targets patients
with HIV related signs and symptoms
PITC opens up HTC to all patients in the health facility and
therefore makes HTC part of routine care in Kenya
144
Counseling [PITC]
Refers to a situation in which the HTC service provider offers
an HIV test to a client or patient regardless of their reason for
attending the facility
PITC is significantly different from DTC. DTC targets patients
with HIV related signs and symptoms
PITC opens up HTC to all patients in the health facility and
therefore makes HTC part of routine care in Kenya
144
PITC cont...
145
•Maternal and Child health
services
•General outpatient services
•Inpatient adult and pediatric
facilities
•Tuberculosis (TB) clinics
•Sexually transmitted infection
(STI) clinics
•Post rape patients
•Occupational exposure clients
•Promotion health services (i.e.
family planning) etc.
Is considered
unacceptable
and negligence
F
a
il
u
r
e
t
o
o
ff
e
r
P
I
T
C
a
t
:
145
•Maternal and Child health
services
•General outpatient services
•Inpatient adult and pediatric
facilities
•Tuberculosis (TB) clinics
•Sexually transmitted infection
(STI) clinics
•Post rape patients
•Occupational exposure clients
•Promotion health services (i.e.
family planning) etc.
Is considered
unacceptable
and negligence
F
a
il
u
r
e
t
o
o
ff
e
r
P
I
T
C
a
t
:
Prevention of Mother To Child HIV
Transmission (PMTCT)
prevalence of HIV infection among pregnant women
in Kenya is currently estimated at 13 %
high infection rates is noted among women aged 15-
49 years
50,000 – 60,000 children's under five years of age are
estimated to be infected with HIV per annum due to
mother to child transmission
146
Transmission (PMTCT)
prevalence of HIV infection among pregnant women
in Kenya is currently estimated at 13 %
high infection rates is noted among women aged 15-
49 years
50,000 – 60,000 children's under five years of age are
estimated to be infected with HIV per annum due to
mother to child transmission
146
Benefits of PMTCT
Reduction of MTCT of HIV:
decreases numbers of HIV infected children
increases child health and survival
decreases the load on the health system
gives an opportunity to improve and expand health
services as well as to strengthen the existing health
infrastructure
Reduction of MTCT of HIV:
decreases numbers of HIV infected children
increases child health and survival
decreases the load on the health system
gives an opportunity to improve and expand health
services as well as to strengthen the existing health
infrastructure
Prongs of PMTCT Comprehensive Care
Primary
prevention of
HIV
Prevention of unintended
Pregnancies in HIV
infected
women
PMTCT
Provide Care & support
to HIV infected women
their infants and
families
148
Primary
prevention of
HIV
Prevention of unintended
Pregnancies in HIV
infected
women
PMTCT
Provide Care & support
to HIV infected women
their infants and
families
148
Mother to child transmission of HIV
149
Pregnancy
5-10%
Labour
10 -20%
Delivery
10 – 20%
Breast
feeding
10 – 20%
New Infant
Infections
Breast feeding through:
6 Months
05 – 10%
18 – 24 Months
05 – 10%
149
Pregnancy
5-10%
Labour
10 -20%
Delivery
10 – 20%
Breast
feeding
10 – 20%
New Infant
Infections
Breast feeding through:
6 Months
05 – 10%
18 – 24 Months
05 – 10%
What is new in PMTCT
more efficacious regimen
dual prophylaxis regimen
highly active anti-retroviral therapy (HAART)
increased linkage to care ,treatment and support
diagnosing children within 6 weeks after delivery
no staging of children – treatment is straight away
availability of FP methods for stressed mothers
cervical cancer screening
150
more efficacious regimen
dual prophylaxis regimen
highly active anti-retroviral therapy (HAART)
increased linkage to care ,treatment and support
diagnosing children within 6 weeks after delivery
no staging of children – treatment is straight away
availability of FP methods for stressed mothers
cervical cancer screening
150
What is new in PMTCT....
Increasing the use dual protection methods of FP and STI
prevention
Availability of cotrimoxazole for children
Development of new schedule for following up children
Testing mothers and children in MCH clinics
Entry point to care ,treatment and support for other family
members
Integration of PMTCT with existing MCH services
Decentralization and task shifting of services
More emphasis on the role of men in the prevention of HIV
transmission
151
Increasing the use dual protection methods of FP and STI
prevention
Availability of cotrimoxazole for children
Development of new schedule for following up children
Testing mothers and children in MCH clinics
Entry point to care ,treatment and support for other family
members
Integration of PMTCT with existing MCH services
Decentralization and task shifting of services
More emphasis on the role of men in the prevention of HIV
transmission
151
Self-Testing for HIV
Self testing is conducting of an HIV test upon one-self
A national operational manual for self testing will give further
guidance on this
Disadvantages ,the client does not receive :
•basic HIV&AIDS education
•pre-test counselling on one to one
•supportive post test counselling
•referrals and linkages to care ,treatment and
support
152
Self testing is conducting of an HIV test upon one-self
A national operational manual for self testing will give further
guidance on this
Disadvantages ,the client does not receive :
•basic HIV&AIDS education
•pre-test counselling on one to one
•supportive post test counselling
•referrals and linkages to care ,treatment and
support
152
Required HIV Testing
HIV testing may be performed without specific consent in
special circumstances e.g. when ordered by a court of law
The following should be ensured
•confidentiality
•adequate counselling
In these settings the client must
•be informed of the test
•have access to the results in an appropriate setting
•be provided with the necessary referrals
153
HIV testing may be performed without specific consent in
special circumstances e.g. when ordered by a court of law
The following should be ensured
•confidentiality
•adequate counselling
In these settings the client must
•be informed of the test
•have access to the results in an appropriate setting
•be provided with the necessary referrals
153
HIV testing of blood and tissue
donations
All blood for transfusion must pass the infectious
disease screening tests including HIV
The following should be ensured
•consent
•counselling
•confidentiality
The donor must
•be informed of the test
•have access to the results in an appropriate setting
•be provided with the necessary referrals
154
donations
All blood for transfusion must pass the infectious
disease screening tests including HIV
The following should be ensured
•consent
•counselling
•confidentiality
The donor must
•be informed of the test
•have access to the results in an appropriate setting
•be provided with the necessary referrals
154
HIV testing for research and
surveillance
Research in Kenya may only be conducted once the research
protocol has been cleared by the relevant ethical review
committee (or board)
Written informed consent is required for all research
participation and should include consent for HIV testing
Except in very exceptional circumstances, all study subjects
should receive their test results with appropriate post-test
counseling
HIV testing conducted as part of research must be
accompanied by an appropriate counselling in line with the
national policies and guidelines
155
surveillance
Research in Kenya may only be conducted once the research
protocol has been cleared by the relevant ethical review
committee (or board)
Written informed consent is required for all research
participation and should include consent for HIV testing
Except in very exceptional circumstances, all study subjects
should receive their test results with appropriate post-test
counseling
HIV testing conducted as part of research must be
accompanied by an appropriate counselling in line with the
national policies and guidelines
155
Key Messages
Major HTC approaches in Kenya, CITC and PITC
PMTCT strategy can further reduce the number of infant infected
with HIV as a result of mother to child transmission
In all cases of required HIV testing, services must be confidential,
and performed with adequate counselling
All blood for transfusion must pass the infectious disease
screening tests agreed upon by the MoH before being made
available to the recipient including testing for HIV, as well as other
transfusion or tissue transmissible infections
156
Major HTC approaches in Kenya, CITC and PITC
PMTCT strategy can further reduce the number of infant infected
with HIV as a result of mother to child transmission
In all cases of required HIV testing, services must be confidential,
and performed with adequate counselling
All blood for transfusion must pass the infectious disease
screening tests agreed upon by the MoH before being made
available to the recipient including testing for HIV, as well as other
transfusion or tissue transmissible infections
156
HTC SETTINGS
UNIT 3
157
UNIT 3
157
Health facility settings
Integrated HIV testing and counseling centre's within an
health facility
Public, private, and faith based hospitals or clinics
158
Integrated HIV testing and counseling centre's within an
health facility
Public, private, and faith based hospitals or clinics
158
Community based settings
Stand-alone HIV testing and counseling centre's
Outreach HIV testing and counseling e.g. Mobile and
moonlight
Home-based HIV testing and counseling
159
Stand-alone HIV testing and counseling centre's
Outreach HIV testing and counseling e.g. Mobile and
moonlight
Home-based HIV testing and counseling
159
CONSIDERATIONS FOR HTC IN
DIFFERENT POPULATIONS
UNIT 4
160
DIFFERENT POPULATIONS
UNIT 4
160
Eligible populations
HIV testing and counselling (HTC) services should be offered
to persons of all age groups
Special groups within the general population may require
specific consideration due to their potential for increased risk
of HIV e.g. MARPS
General population
•Adults
•Youth (including adolescents)
•Infants and Children
161
HIV testing and counselling (HTC) services should be offered
to persons of all age groups
Special groups within the general population may require
specific consideration due to their potential for increased risk
of HIV e.g. MARPS
General population
•Adults
•Youth (including adolescents)
•Infants and Children
161
Special Populations
Couples
Families of patients receiving HIV/AIDS care and treatment
Persons with Disabilities (PWDs)
Populations abusing alcohol and other drugs
Commercial Sex Workers
162
Couples
Families of patients receiving HIV/AIDS care and treatment
Persons with Disabilities (PWDs)
Populations abusing alcohol and other drugs
Commercial Sex Workers
162
Initial clinical evaluation of PLHIV entails o Providing counseling,
assessing for ART readiness, and providing/linking to psychosocial
support
o Taking a complete medical history
o Conducting a thorough physical examination
o Appropriate laboratory investigations, although laboratory
assessment is not a prerequisite to ART initiation
CD4 monitoring, which is recommended for o Baseline investigation
for all PLHIV
o Any patient with suspected treatment failure
o Any patient on fluconazole maintenance therapy or on dapsone
as prophylaxis, to determine when prophylaxis can be
discontinued
assessing for ART readiness, and providing/linking to psychosocial
support
o Taking a complete medical history
o Conducting a thorough physical examination
o Appropriate laboratory investigations, although laboratory
assessment is not a prerequisite to ART initiation
CD4 monitoring, which is recommended for o Baseline investigation
for all PLHIV
o Any patient with suspected treatment failure
o Any patient on fluconazole maintenance therapy or on dapsone
as prophylaxis, to determine when prophylaxis can be
discontinued
Frequency of routine VL monitoring
o For PCR positive HEIs: at baseline at the time of ART initiation
o Age 0-24 years old: every 6 months
o Age ≥ 25 years old: at month 6, 12, and then annually
o Pregnant or breastfeeding: at confirmation of pregnancy (if already on
ART) or 3 months after ART initiation (if ART initiated during
pregnancy/breastfeeding), and then every 6 months until complete cessation
of breastfeeding
o Before any drug substitution (if no VL result available from the prior 6
months)
o Three months after any regimen modification (including single-drug
substitutions)
PLHIV should receive differentiated care based on initial evaluation
(advanced vs. well) and follow up (unstable vs. stable)
o For PCR positive HEIs: at baseline at the time of ART initiation
o Age 0-24 years old: every 6 months
o Age ≥ 25 years old: at month 6, 12, and then annually
o Pregnant or breastfeeding: at confirmation of pregnancy (if already on
ART) or 3 months after ART initiation (if ART initiated during
pregnancy/breastfeeding), and then every 6 months until complete cessation
of breastfeeding
o Before any drug substitution (if no VL result available from the prior 6
months)
o Three months after any regimen modification (including single-drug
substitutions)
PLHIV should receive differentiated care based on initial evaluation
(advanced vs. well) and follow up (unstable vs. stable)
Consists of 8 components:
1. Antiretroviral Therapy
• All PLHIV are eligible for ART irrespective of CD4 cell count or percentage, WHO
clinical stage, age, pregnancy status, or comorbidities
• ART should be initiated as soon as the patient is ready to start, preferably within
two weeks from time of HIV diagnosis (except for patients with cryptococcal
meningitis or TB meningitis)
2. Positive Health, Dignity, and Prevention, GBV/IPV & Health Education and
Counselling
• All patients should be counselled and supported for disclosure of HIV status;
partner/ family testing and engagement; condom use; family planning; sexually
transmitted infections screening; and treatment adherence services
• All females aged 15-49 years and emancipated minors accessing HIV care services
should be screened for Intimate Partner Violence (IPV) as part of the standard
package of care
• All PLHIV should be provided with HIV education and counselling
1. Antiretroviral Therapy
• All PLHIV are eligible for ART irrespective of CD4 cell count or percentage, WHO
clinical stage, age, pregnancy status, or comorbidities
• ART should be initiated as soon as the patient is ready to start, preferably within
two weeks from time of HIV diagnosis (except for patients with cryptococcal
meningitis or TB meningitis)
2. Positive Health, Dignity, and Prevention, GBV/IPV & Health Education and
Counselling
• All patients should be counselled and supported for disclosure of HIV status;
partner/ family testing and engagement; condom use; family planning; sexually
transmitted infections screening; and treatment adherence services
• All females aged 15-49 years and emancipated minors accessing HIV care services
should be screened for Intimate Partner Violence (IPV) as part of the standard
package of care
• All PLHIV should be provided with HIV education and counselling
3. Screening for and Prevention of Specific Opportunistic Infections
• All PLHIV should receive lifelong cotrimoxazole preventive therapy (CPT)
unless they have allergy to sulfa drugs or develop toxicity from CPT
• During pregnancy, CPT should be initiated irrespective of the gestational age
and should continue throughout pregnancy, breastfeeding, and thereafter for life
• When dapsone (as a substitute for CPT) is being used as PCP prophylaxis, it is
only recommended for patients in WHO Stage 4 and/or absolute CD4 count ≤
200 cells/mm3 (or CD4% ≤ 25% for children ≤ 5 years old), and should be
discontinued once a patient achieves viral suppression and a sustained CD4
count of > 200 cell/mm3 (or > 25% for children ≤ 5 years old) for at least 6
months
• All PLHIV should be screened for TB at every visit using the Intensified Case
Finding (ICF) tool and assessed for Isoniazid Preventive Therapy (IPT) if
screened negative for TB
• All adolescent and adult PLHIV with a baseline CD4 count of ≤ 200 cells/mm3
should be screened for cryptococcal infection using the serum CrAg test
• All PLHIV should receive lifelong cotrimoxazole preventive therapy (CPT)
unless they have allergy to sulfa drugs or develop toxicity from CPT
• During pregnancy, CPT should be initiated irrespective of the gestational age
and should continue throughout pregnancy, breastfeeding, and thereafter for life
• When dapsone (as a substitute for CPT) is being used as PCP prophylaxis, it is
only recommended for patients in WHO Stage 4 and/or absolute CD4 count ≤
200 cells/mm3 (or CD4% ≤ 25% for children ≤ 5 years old), and should be
discontinued once a patient achieves viral suppression and a sustained CD4
count of > 200 cell/mm3 (or > 25% for children ≤ 5 years old) for at least 6
months
• All PLHIV should be screened for TB at every visit using the Intensified Case
Finding (ICF) tool and assessed for Isoniazid Preventive Therapy (IPT) if
screened negative for TB
• All adolescent and adult PLHIV with a baseline CD4 count of ≤ 200 cells/mm3
should be screened for cryptococcal infection using the serum CrAg test
4. Reproductive Health Services
• All PLHIV should be screened for STI at every clinic visit
• Pregnancy status should be determined for all women of reproductive age at
every visit and their contraception need determined and met
• All HIV positive women between the ages of 18 - 65 years should be screened
for cervical cancer
5. Screening for and Management of Non-Communicable Diseases
• All PLHIV should be screened for hypertension, diabetes mellitus,
dyslipidaemia, and renal disease
• Lifestyle modifications are always the first line of prevention and
management for hypertension, diabetes mellitus, and dyslipidaemia
• All PLHIV should be screened for STI at every clinic visit
• Pregnancy status should be determined for all women of reproductive age at
every visit and their contraception need determined and met
• All HIV positive women between the ages of 18 - 65 years should be screened
for cervical cancer
5. Screening for and Management of Non-Communicable Diseases
• All PLHIV should be screened for hypertension, diabetes mellitus,
dyslipidaemia, and renal disease
• Lifestyle modifications are always the first line of prevention and
management for hypertension, diabetes mellitus, and dyslipidaemia
6. Mental Health Screening and Management
• All PLHIV should receive basic screening for depression before initiating ART,
and annually thereafter, and whenever there is a clinical suspicion
• All adults, adolescents should be screened for alcohol and drug use before
initiating ART and regularly during follow-up
• All caregivers should also receive baseline and follow-up screening for
depression and alcohol/drug use
7. Nutrition Services
• All PLHIV should receive nutritional assessment, counselling, and support
tailored to the individual needs of the patients
• All infants irrespective of HIV status should be exclusively breastfed for the
first 6 months of life, with timely introduction of appropriate complementary
foods after 6 months, and continued breastfeeding up to 24 months or beyond
8. Prevention of Other Infections
• PLHIV (including children) should receive vaccinations as
recommended by the National Vaccines and Immunization Programme
• All PLHIV should receive basic screening for depression before initiating ART,
and annually thereafter, and whenever there is a clinical suspicion
• All adults, adolescents should be screened for alcohol and drug use before
initiating ART and regularly during follow-up
• All caregivers should also receive baseline and follow-up screening for
depression and alcohol/drug use
7. Nutrition Services
• All PLHIV should receive nutritional assessment, counselling, and support
tailored to the individual needs of the patients
• All infants irrespective of HIV status should be exclusively breastfed for the
first 6 months of life, with timely introduction of appropriate complementary
foods after 6 months, and continued breastfeeding up to 24 months or beyond
8. Prevention of Other Infections
• PLHIV (including children) should receive vaccinations as
recommended by the National Vaccines and Immunization Programme
BEHAVIOUR CHANGE AND COMMUNICATION
Behavior change communication (BCC) is an interactive process with communities
to develop tailored messages and approaches using a variety of communication
channels to:
◦ develop positive behaviors;
◦promote and sustain individual, community and societal behavior change; and
◦maintain appropriate behaviors.
BCC is an essential part of a comprehensive program that includes both:
◦services (medical, social, psychological and spiritual) and
◦commodities (e.g., condoms, needles and syringes).
Before individuals and communities can reduce their level of risk or change their
behaviors, they:
must first understand basic facts about HIV and AIDS,
adopt key attitudes,
learn a set of skills and be given access to appropriate products and services.
must also perceive their environment as supporting behavior change and the
maintenance of safe behaviors, as well as supportive of seeking appropriate
treatment for prevention, care and support.
to develop tailored messages and approaches using a variety of communication
channels to:
◦ develop positive behaviors;
◦promote and sustain individual, community and societal behavior change; and
◦maintain appropriate behaviors.
BCC is an essential part of a comprehensive program that includes both:
◦services (medical, social, psychological and spiritual) and
◦commodities (e.g., condoms, needles and syringes).
Before individuals and communities can reduce their level of risk or change their
behaviors, they:
must first understand basic facts about HIV and AIDS,
adopt key attitudes,
learn a set of skills and be given access to appropriate products and services.
must also perceive their environment as supporting behavior change and the
maintenance of safe behaviors, as well as supportive of seeking appropriate
treatment for prevention, care and support.
In most parts of the world, HIV is primarily a sexually transmitted
infection (STI).
Development of a supportive environment requires national and
community-wide discussion of:
◦ relationships,
◦sex and sexuality,
◦risk, risk settings,
◦risk behaviors and
◦cultural practices that may increase the likelihood of HIV
transmission.
A supportive environment is also one that deals, at the national and
community levels, with stigma, fear and discrimination, as well as with
policy and law. The same issues apply in parts of the world where
unsafe injection of illegal drugs is the chief source of new infections.
infection (STI).
Development of a supportive environment requires national and
community-wide discussion of:
◦ relationships,
◦sex and sexuality,
◦risk, risk settings,
◦risk behaviors and
◦cultural practices that may increase the likelihood of HIV
transmission.
A supportive environment is also one that deals, at the national and
community levels, with stigma, fear and discrimination, as well as with
policy and law. The same issues apply in parts of the world where
unsafe injection of illegal drugs is the chief source of new infections.
BCC is an integral component of a comprehensive HIV/AIDS prevention, care and
support program. It has a number of different but interrelated roles. Effective BCC can:
Increase knowledge. BCC can ensure that people are given the basic facts about HIV
and AIDS in a language or visual medium (or any other medium that they can
understand and relate to).
Stimulate community dialogue. BCC can encourage community and national
discussions on the basic facts of HIV/AIDS and the underlying factors that contribute to
the epidemic, such as risk behaviors and risk settings, environments and cultural
practices related to sex and sexuality, and marginalized practices (such as drug use)
that create these conditions. It can also stimulate discussion of healthcare-seeking
behaviors for prevention, care and support.
Promote essential attitude change. BCC can lead to appropriate attitudinal changes
about, for example, perceived personal risk of HIV infection, belief in the right to and
responsibility for safe practices and health supporting services, compassionate and
non-judgmental provision of services, greater open-mindedness concerning gender
roles and increasing the basic rights of those vulnerable to and affected by HIV and
AIDS.
support program. It has a number of different but interrelated roles. Effective BCC can:
Increase knowledge. BCC can ensure that people are given the basic facts about HIV
and AIDS in a language or visual medium (or any other medium that they can
understand and relate to).
Stimulate community dialogue. BCC can encourage community and national
discussions on the basic facts of HIV/AIDS and the underlying factors that contribute to
the epidemic, such as risk behaviors and risk settings, environments and cultural
practices related to sex and sexuality, and marginalized practices (such as drug use)
that create these conditions. It can also stimulate discussion of healthcare-seeking
behaviors for prevention, care and support.
Promote essential attitude change. BCC can lead to appropriate attitudinal changes
about, for example, perceived personal risk of HIV infection, belief in the right to and
responsibility for safe practices and health supporting services, compassionate and
non-judgmental provision of services, greater open-mindedness concerning gender
roles and increasing the basic rights of those vulnerable to and affected by HIV and
AIDS.
Reduce stigma and discrimination. Communication about HIV prevention and AIDS
mitigation should address stigma and discrimination and attempt to influence
social responses to them.
Create a demand for information and services. BCC can spur individuals and
communities to demand information on HIV/AIDS and appropriate services.
Advocate. BCC can lead policymakers and opinion leaders toward effective
approaches to the epidemic.
Promote services for prevention, care and support. BCC can promote services for
STIs, intravenous drug users (IDUs), orphans and vulnerable children (OVCs);
voluntary counseling and testing (VCT) for mother-to-child transmission (MTCT);
support groups for PLHA; clinical care for opportunistic infections; and social and
economic support. BCC is also an integral component of these services.
Improve skills and sense of self-efficacy. BCC programs can focus on teaching or
reinforcing new skills and behaviors, such as condom use, negotiating safer sex and
safe injecting practices. It can contribute to development of a sense of confidence
in making and acting on decisions.
mitigation should address stigma and discrimination and attempt to influence
social responses to them.
Create a demand for information and services. BCC can spur individuals and
communities to demand information on HIV/AIDS and appropriate services.
Advocate. BCC can lead policymakers and opinion leaders toward effective
approaches to the epidemic.
Promote services for prevention, care and support. BCC can promote services for
STIs, intravenous drug users (IDUs), orphans and vulnerable children (OVCs);
voluntary counseling and testing (VCT) for mother-to-child transmission (MTCT);
support groups for PLHA; clinical care for opportunistic infections; and social and
economic support. BCC is also an integral component of these services.
Improve skills and sense of self-efficacy. BCC programs can focus on teaching or
reinforcing new skills and behaviors, such as condom use, negotiating safer sex and
safe injecting practices. It can contribute to development of a sense of confidence
in making and acting on decisions.
Behavior change communication goals need to be developed in
the context of overall program goals and specific behavior
change goals. The following highlights the place of BCC goals
within an overall program.
Program goal: Reduce HIV prevalence among people in
society.
Behavior change goals:
Increase condom use
Increase appropriate STI care-seeking behavior
Delay sexual debut
Reduce number of partners
the context of overall program goals and specific behavior
change goals. The following highlights the place of BCC goals
within an overall program.
Program goal: Reduce HIV prevalence among people in
society.
Behavior change goals:
Increase condom use
Increase appropriate STI care-seeking behavior
Delay sexual debut
Reduce number of partners
BCC goals:
Increase perception of risk or change attitudes toward use of condoms
Increase demand for services
Create demand for information on HIV and AIDS
Create demand for appropriate STI services
Interest policymakers in investing in youth-friendly VCT services (services must be in
place)
Promote acceptance among communities of youth sexuality and the value of
reproductive health services for youth (services must be in place)
BCC goals are related to specific issues identified when assessing the situation,
knowledge, attitudes and skills that may need to be changed to work toward behavior
change and program goals.
Increase perception of risk or change attitudes toward use of condoms
Increase demand for services
Create demand for information on HIV and AIDS
Create demand for appropriate STI services
Interest policymakers in investing in youth-friendly VCT services (services must be in
place)
Promote acceptance among communities of youth sexuality and the value of
reproductive health services for youth (services must be in place)
BCC goals are related to specific issues identified when assessing the situation,
knowledge, attitudes and skills that may need to be changed to work toward behavior
change and program goals.
GUIDING PRINCIPLES
BCC should be integrated with program goals from the start. BCC is an essential element
of HIV prevention, care and support programs, providing critical linkages to other program
components, including policy initiatives.
Formative BCC assessments must be conducted to improve understanding of the needs
of target populations, as well as of the barriers to and supports for behavior change that
their members face (along with other populations, such as stakeholders, service providers
and community).
The target population should participate in all phases of BCC development and in much
of implementation.
Stakeholders need to be involved from the design stage.
Having a variety of linked communication channels is more effective than relying on one
specific one.
Pre-testing is essential for developing effective BCC materials.
Planning for monitoring and evaluation should be part of the design of any BCC program.
BCC should be integrated with program goals from the start. BCC is an essential element
of HIV prevention, care and support programs, providing critical linkages to other program
components, including policy initiatives.
Formative BCC assessments must be conducted to improve understanding of the needs
of target populations, as well as of the barriers to and supports for behavior change that
their members face (along with other populations, such as stakeholders, service providers
and community).
The target population should participate in all phases of BCC development and in much
of implementation.
Stakeholders need to be involved from the design stage.
Having a variety of linked communication channels is more effective than relying on one
specific one.
Pre-testing is essential for developing effective BCC materials.
Planning for monitoring and evaluation should be part of the design of any BCC program.
BCC strategies should be positive and action-oriented.
PLHA should be involved in BCC planning and implementation.
PLHA should be involved in BCC planning and implementation.
Increased safer sexual practices (more frequent condom use, fewer partners)
Increased incidence of healthcare-seeking behavior for STIs, TB and VCT (for
example, calls or visits to facilities)
Increased use of universal precautions to improve blood safety
Increased blood donations (where appropriate)
Improved compliance with drug treatment regimens
Adherence by medical practitioners to treatment guidelines
Increased use of new or disinfected syringes and needles by IDUs
Decline in stigma associated with HIV/AIDS
Reduced incidence of discriminatory activity directed at PLHA and other
identified high- risk groups
Improved attitudes and behavior among healthcare, social service and other
service delivery workers who interact with PLHA, SWs, IDUs and other
marginalized groups
Increased incidence of healthcare-seeking behavior for STIs, TB and VCT (for
example, calls or visits to facilities)
Increased use of universal precautions to improve blood safety
Increased blood donations (where appropriate)
Improved compliance with drug treatment regimens
Adherence by medical practitioners to treatment guidelines
Increased use of new or disinfected syringes and needles by IDUs
Decline in stigma associated with HIV/AIDS
Reduced incidence of discriminatory activity directed at PLHA and other
identified high- risk groups
Improved attitudes and behavior among healthcare, social service and other
service delivery workers who interact with PLHA, SWs, IDUs and other
marginalized groups
Increased involvement of opinion leaders and policymakers, private sector
managers and community members
Increased involvement in self-help and homecare initiatives
managers and community members
Increased involvement in self-help and homecare initiatives
THANK YOU
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