Human Immunodeficiency Virus (HIV/).pptx

HIV infection, Clinical staging, Management in Uganda

1. HIV Infection Presenter: Raymond Alinetu Tutor: Dr. Jacob B. Date: 27-02-2025

2. Case KG 30/F known pt of HIV Dx 10 yrs ago & initiated on unknown regimen but has defaulted for 1 yr (reportedly destitute) was adm 25/2/25 with: c/o Cough x 2/12 ass. with chest pain, DIB & B-symptoms; palpitations x 2/12 ass. with dizziness & easy fatiguability; vomiting x 1/12 – 4x a day, projectile, yellow, with loss of appetite. PSHx – Unremarkable FSHx - has 3 children, doesn’t live with the partner

3. O/E GE – Sick looking, some dehydration, pale, axillary nodes, (JCCO)0 Vitals – BP 89/54, HR – 117, SpO2 – 93% RA, Temp – 37.4 C Resp – Trachea central, equal exp, Fine basal crepitations on L CVS – Pulse regular, normal & full volume, cap. refill 3 sec, HS I+II GIT – abdomen scaphoid, no masses, no tenderness Imp: 30/F known ISS off meds with: CAP r/o PTB Gastritis?

4. Investigations CBC/ FBC Electrolytes Chest Xray Sputum genexpert for TB Urine Tb LAM LFT’s/ RFT’s Serum CRAG CD4 Count Viral load Urinalysis & Urine hCG RBS

5. Results & Management CBC – WBC 45.45 / Hb – 12.9 / PLT – 389 RBS – 3.1 mmol/dl Started on: IV D50% stat IV Ceftriaxone 2g OD x 5/7 Tabs Azithromycin 500mg OD x 5/7 Tabs TMP/SMX 960mg OD x 2/52 Tabs Paracetamol 1g TDS x 3/7 IV fluids 1L NS stat, then 3L in 24 hours

6. CONSOLIDATED GUIDELINES FOR THE PREVENTION AND TREATMENT OF HIV AND AIDS Structured along the continuum of HIV testing, prevention, Rx & care. 2014 - “test and treat” policy for all key populations 2016 - Lifelong ART to people living with HIV irrespective of CD4 count or clinical stage. 2018 - Rx using DTG + TDF + 3TC as first line 2022 – HIV prevention ( PrEP , eMTCT , Circumcision and HIV services with a focus on case finding)

7. Chapter 2- HIV TESTING SERVICES - Prioritize case finding approaches HIVST (HIV Self Testing) Consent now 15 years and above. Target populations to include adolescent girls, Adolescent Girls, Youths and Women Blood based HIVST now in use INDEX TESTING Biological Children recommended aged between 18 months to 19 years

8. LINKAGE Intra-facility linkage revised to 7 days or on the same day, Inter-facility and community linkages is at 14 days HIV tester and site certification Guidance provided on the verification and confirmation of the requirements needed for HIV testers and sites certification.

9. Chapter 3: PRE-EXPOSURE PROPHYLAXIS FOR HIV PREVENTION Recommended Use of Dapivirine vaginal ring Injectable cabotegravir (LA-CAB) Chapter 4: CARE AND SUPPORT FOR PLHIV - TB SCREENING AND DIAGNOSIS Systematic screening for TB among People living with HIV PLHIV should be systematically screened for TB disease at each visit to a health facility with a combination of; Intensified Case finding ( ICF) - form C-Reactive Protein(CRP) and or CXR

10. WHO clinical staging of established HIV infection Clinical stage 1 Asymptomatic Persistent generalized lymphadenopathy

11. Clinical stage 2 Moderate unexplained weight loss (<10% of presumed or measured) Recurrent respiratory tract infections sinusitis, tonsillitis, otitis media and pharyngitis) Herpes zoster Angular cheilitis Recurrent oral ulceration Papular pruritic eruptions Seborrhoeic dermatitis Fungal nail infections

12. Clinical stage 3 Unexplained severe weight loss (>10% of presumed or measured) Unexplained chronic diarrhea for longer than one month Unexplained persistent fever (above 37.6°C > one month) Persistent oral candidiasis Oral hairy leukoplakia Pulmonary tuberculosis (current) Severe bacterial infections (such as pneumonia, empyema, pyomyositis, bone or joint infection, meningitis or bacteremia) Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis Unexplained anemia (<8 g/dl), neutropenia (<0.5 × 109 per liter) or chronic thrombocytopenia (<50 × 109 per liter)

13. Clinical stage 4 HIV wasting syndrome Pneumocystis pneumonia Recurrent severe bacterial pneumonia Chronic herpes simplex infection (orolabial, genital or anorectal > one month’s duration or visceral at any site) Esophageal candidiasis (or candidiasis of trachea, bronchi or lungs) Extrapulmonary tuberculosis Kaposi’s sarcoma Cytomegalovirus infection (retinitis or infection of other organs) Central nervous system toxoplasmosis HIV encephalopathy

14. Extrapulmonary cryptococcosis including meningitis Disseminated non-tuberculous mycobacterial infection Progressive multifocal leukoencephalopathy Chronic cryptosporidiosis (with diarrhoea ) Chronic isosporiasis Disseminated mycosis ( coccidiomycosis or histoplasmosis) Recurrent non-typhoidal Salmonella bacteraemia Lymphoma (cerebral or B-cell non-Hodgkin) or other solid HIV-associated tumours Invasive cervical carcinoma Atypical disseminated leishmaniasis Symptomatic HIV-associated nephropathy or symptomatic HIV-associated cardiomyopathy

15. Chapter 5: INITIATING ART AMONG PLHIV WITH TB Treatment for drug sensitive TB ART should be started at two weeks of initiating TB treatment, regardless of CD4 cell count, among people living with HIV (Except when signs and symptoms of meningitis are present) Treatment of people with drug-resistant TB all people with HIV and drug-resistant TB, requiring second-line anti-TB drugs irrespective of CD4 cell count, should start ART as early as possible (within the first eight weeks) following initiation of anti-TB treatment

16. Chapter- 5: CARE AND SUPPORT FOR PLHIV- Mgt of CCM Induction phase (2 weeks) - Recommended: Amphotericin B liposomal single high dose (10mg/kg) + Flucytosine (100mg/kg/day in four divided doses) + Fluconazole 1200mg/ day for 14 days OR Amphotericin B deoxycholate (1mg/kg/day) + Flucytosine (100mg/kg/ day in four divided doses) for 1 week, followed by 1 week of fluconazole (1200 mg/day for adults, 12 mg/kg/day for children and adolescents) OR Fluconazole (1200 mg daily for adults, 12 mg/kg/day for children and adolescents) + Flucytosine (100 mg/kg/day, divided into four doses per day OR Amphotericin B deoxycholate (1mg/kg/day) + high-dose Fluconazole 1200mg/day.

17. Recommended first - line ARV regimens

18. Chapter 7: ART FOR PLHIV: MONITORING RESPONSE TO ART- VL 6 months after ART initiation, then 12 months after ART initiation, and thereafter when established on ART 1 year for adults; 6 months for children & adolescents 0-19 years; and 3 months for pregnant and lactating women POC- VL testing may be used to monitor treatment. HIV DR recommended for all PLHIV to guide the next course of treatment

19. Recent HIV Infection Surveillance Uganda moving closer towards reaching 95-95-95 goals and sustained epidemic control Pre-exposure Prophylaxis PrEP using the dapivirine vaginal ring (25 mg of the NNRTI dapivirine ) The dapivirine vaginal ring may be offered as an additional prevention choice for women at substantial risk of HIV infection as part of combination prevention approaches.

20. Providing Post-Exposure Prophylaxis PEP should be started as early as possible, ideally within first 2 hours but not beyond 72 hours after exposure Recommended regimens include: i) Preferred : TDF+3TC+DTG or TAF+FTC+DTG ii) First Alternative: TDF+3TC+ATV/r or TAF+FTC+ATV/r iii) Second Alternative: TDF+3TC+EFV or TAF+FTC+EFV iv) Children weighing <30kg v) Preferred: ABC+3TC+LPV/r Alternative: ABC+3TC+DTG Adults and adolescents weighing>30Kg

21. Take Home Points