HIV/AIDS Flashcards
Eligibility to start ART:
All adults with confirmed HIV infection, irrespective of CD4 count or WHO clinical
stage. Where a patient is willing and ready, ART should be initiated on the same
day as HIV diagnosis, except in patients with TB or cryptococcal meningitis (see
Timing of ART initiation below).
ART should be initiated immediately in pregnancy and during breastfeeding.
Timing of ART initiation:
» ART should be started as soon as the patient is ready. However, with
some opportunistic diseases early ART initiation can cause harm by
increasing the risk of the immune reconstitution inflammatory syndrome
(IRIS)
» In TB co-infection, start with TB treatment first, followed by ART initiation
according to CD4 count (except TB meningitis – see below):
- CD4 <50 cells/mm3: initiate ART within 2 weeks of starting TB treatment.
- CD4 ≥50 cells/mm3: defer ART until 8 weeks after starting TB treatment,
which has shown to be safe and reduces the risk of deterioration due to
IRIS.
» In patients with TB meningitis (irrespective of CD4
count), defer ART until 8 weeks after initiating TB treatment.
» In patients with cryptococcal meningitis, defer ART until
4–6 weeks after starting antifungal treatment (earlier initiation has been
shown to increase the risk of death).
1ST LINE ART
» Men ≥35kg and ≥10 years of age » WOCP not actively wishing to conceive » Pregnant women ≥6 weeks gestation, and those who make an informed choice to use DTG TDF + 3TC + DTG
1ST LINE ART IN Patients with TB:
TDF (Tenofovir) + FTC (Emtricitabine) + EFV (Efavirenz)
1ST LINE ART IN Pregnant women <6 weeks gestation or
actively wanting to conceive:
TDF (Tenofovir) + FTC (Emtricitabine) + EFV (Efavirenz)
1ST LINE ART IN Contraindications and intolerance to
EFV
TDF + 3TC + DTG » WOCP actively wanting to conceive and pregnant women <6 weeks gestation require adequate counselling to make an informed choice to use DTG.
1ST LINE ART IN Contraindications to EFV and DTG
Start protease inhibitor-based regimen:
TDF + 3TC/FTC + LPV/r
1ST LINE ART IN Contraindication to TDF
» eGFR <50 mL/minute.
» Use of additional nephrotoxic drug
e.g. aminoglycoside.
Replace TDF + 3TC/FTC with either
ABC+ 3TC or AZT + 3TC
1ST LINE ART IN Contraindication to TDF and ABC intolerance » eGFR <50 mL/minute. » Use of additional nephrotoxic agent e.g. aminoglycoside. » Hypersensitivity.
AZT+ 3TC with DTG or EFV
DRUG INTERACTIONS WITH DOLUTEGRAVIR: Anticonvulsants: Carbamazepine Phenobarbital Phenytoin
- Effect of co-administration:
Significant reduction in
concentration of DTG - Recommendation:
Avoid co-administration if possible.
Consider valproate or lamotrigine.
For carbamazepine:
Double DTG dose to 50 mg 12 hourly.
DRUG INTERACTIONS WITH DOLUTEGRAVIR: Metformin
- Effect of co-administration:
Significant increase
in metformin levels - Recommendation: Administer metformin to a maximum of
500 mg 12 hourly.
DRUG INTERACTIONS WITH DOLUTEGRAVIR: Rifampicin
- Effect of co-administration: Significant reduction in concentration of DTG
- Recommendation: Double DTG dose to 50 mg 12 hourly.
Monitoring Prior to
initiating
ART
» Check creatinine (avoid TDF if eGFR <50 mL/minute).
» Check FBC (avoid AZT if Hb <8 g/dl).
» Check HBsAg (if positive, TDF should form part of the regimen).
Monitoring at HIV
Diagnosis?
» Confirm HIV positive result with antibody test.
» WHO staging.
» Check CD4 count. - CD4 <100 cells/mm3 \: Check cryptococcal antigen (If symptomatic, perform LP). - CD4 <200 cells/mm3 \: Fast track for ART initiation, initiate cotrimoxazole prophylaxis. - CD4 <350 cells/mm3 \: Prioritize for ART.
» Screen for pregnancy or ask if planning to conceive.
» Screen for mental health, STIs and NCDs.
» Screen for TB using the WHO screening questionnaire (any one
of cough, fever, night sweats, or weight loss) – in pregnancy do
sputum XpertMTB/RIF Ultra® in all.
» Do urine LAM testing if patients are seriously ill or CD4 ≤100
cells/mm3
and there are signs and symptoms of tuberculosis.
Urine dipstick for proteinuria and hematuria
