National ART Guidelines 2023 Flashcards
TLD 1 vs TLD 2
TLD 1 = DTG regimen who have never failed any other regimen
TLD 2 = DTG regimen who have failed an earlier regimen
What is the new TDF weight eligibility?
30kg
What is the dose of DTG dispersible tablets?
10mg
When is AZT reserved for use?
Renal failure AND hypersensitivity
What is the definition of virological failure?
> 2 VLs >1000 >2 years of DTG/PI containing regimen with >80% adherence
When can DTG-containing regimen be changed?
Must be confirmed with a resistance test
What is the preferred 1st line regimen in adults?
TLD
What is the preferred 1st line regimen in children?
ALD
When should ART be initiated in a patient with CD4< 50 and DS-TB at a non-neurological site?
Within 2 weeks
When should ART be initiated in a patient with CD4>50 and DS-TB at a non-neurological site?
Within 8 weeks
When should ART be initiated in a pregnant patient with DS-TB at a non-neurological site?
Within 2 weeks
When should ART be initiated in a patient with DR-TB at a non-neurological site?
Within 2 weeks
When should ART be initiated in a patient with TB at a neurological site?
4-8w after TB treatment initiation
When should ART be initiated in a patient with positive serum CrAg but negative CSF CrAg without symptoms?
Immediately
When should ART be initiated in a patient with cryptococcal meningitis?
4-6w after antifungal treatment initiation
When should ART be initiated in a patient with PCP or bacterial pneumonia?
Within 1-2 weeks
When should ART be initiated in a patient with clinical symptoms/sign of liver disease?
Investigate first
How do we test for TB in an HIV positive patient at initiation?
Symptom screen
GXP
When should a U-LAM be done?
Any hospitalised HIV patient
OR
Outpatient with CD4 < 200, AHD or current serious illness
What are the baseline tests at ART intiation?
CD4
Renal function (TDF)
Hb (AZT)
GXP
Cervical cancer screening HBsAg
How should eGFR be calculated in adults >16yo
MDRD equation
What are indications for CPT in a HIV positive child <1yo?
All children regardless of CD4 or clinical stage
What are indications for CPT in a HIV positive child 1-5yo?
CD4% <25%
WHO stage 2, 3, 4
What are indications for CPT in a HIV positive child <5yo with PJP infection?
Start CPT after PJP treatment is complete
What are indications for CPT in a HIV positive child >5yo
CD4 <200
WHO stage 2, 3, 4
When can CTP be stopped in a HIV positive child 1-5yo?
CD4 >25% regardless of clinical stage
When can CTP be stopped in an HIV positive child >5yo?
CD4>200 regardless of clinical stage
When can CTP be stopped in a HIV positive child <5yo with PJP infection?
Continue until 5yo and then stop once CD4>200
What is the criteria for TPT in adults >15yo?
Exclude active liver disease, alcohol abuse or INH sensitivity
Any CD4
What is the dose for TPT in adults >15yo?
INH 300mg po dy x 12 months + pyridoxine 25mg dy
What is the criteria for TPT in children with HIV <15yo
HIV child with positive TB contact
What is the criteria for TPT in children <5yo?
ANY child with positive TB contact
What is the dose for TPT in children <15yo?
INH 10mg/kg/d for 6 months (max 300mg)
What is the criteria for TPT in pregnant women?
Exclude active liver disease, alcohol abuse or INH sensitivity
Any CD4
What is 50mg of film coated DTG tablet equivalent to in dispersible DTG tablets?
30mg
When should antacids be taken in relation to TLD?
2 hours AFTER
6 hours BEFORE
Which anticonvulsants are contraindicated with DTG?
Carbamazepine
Phenobarbital
Phenytoin
Which anticonvulsants are not contraindicated with DTG?
Valproate (C/I in pregnancy)
Lamotrigine
Levetiracetam
Topiramate
If alternative anticonvulsant cannot be used, how do you proceed with DTG-regimen?
Double DTG dose to 50mg bd
What is first line ART for neonates 2-3kg and <4 weeks old?
AZT + 3TC + NVP
What is first line ART for infants >3kg and >4 weeks old?
ALD
What is first line ART for children >30kg and >10yo?
TLD
How do you initiate ART in an adult diagnosed during labour?
Stat dose TLD and stat dose NVP
How do you re-initiate ART in a non-pregnant client with interrupted treatment?
<28d missed - continue routine care and routine VL monitoring
>28d missed - assess clinically
Clinically well, missed appointment <90d - continue ART
Clinically well, missed appointment >90d - Restart ART and do CD4
Clinically unwell - Restart ART and do CD4
For all above, repeat VL after 3 months
How long should ART boosting regimen continue after stopping rifampicin?
2 weeks
Which ARVs interact with TB treatment?
DTG
NVP
LPV/r
Atazanavir
Darunavir
How do you adjust LPV/r in TB treatment?
a) double dose 800/200 bd
OR
b) superboost 400/100 bd PLUS 300mg ritonavir bd
Can you double dose LPV/r syrup?
NO! Only tablets
Superboosting can be done with tablets and syrup
At what age and weight can EFV be used?
> 10kg and >3yo
Can you crush LPV or ritonavir tablets?
NO!
What is the criteria for a switch from a LPV/r or ATV/r regimen to a DTG-regimen to be non VL-dependent?
Must have been on the regimen <2y
What is the criteria for switching to a DTG-regimen from a LPV/ATV/r regimen with >2 VL >1000 2 years after starting the regimen?
Adults:
Adherence <80% - do not do resistance test, same day switch
Adherence >80% - do resistance test, do not same-day switch
OR
Children
Adherence <80% with solution/pellets - change to 4 in 1 capsules to improve adherence and repeat VL in 3 months
Adherence <80% with tablets - change to ALD
Adherence >80% - discuss with HIV expert and do resistance test
How can you measure good adherence?
- Pharmacy refills >80% in last 6-12 months
- Attendance >80% in last 6-12 months
- ARV detection in blood or urine
If you change from an NNRTI based regimen to an InSTI-based regimen in adults do you need to do resistance testing?
No
If you change from an InSTI based regimen to an PI-based regimen in adults do you need to do resistance testing?
Yes
What is the visit schedule for all patients >5yo on ART?
Initiation - baseline eGFR, CD4
Month 1 - review results
Month 3 - VL, eGFR
Month 4 - review results
Month 7 - collect medicine
Month 10 - VL, eGFR, CD4
Month 11 - review then begin annual monitoring
When do you repeat CD4?
- Every 6 months until CD4 >200
- Every 6 months until VL<1000
- New WHO stage 3/4 condition
- Treatment interruption >90d
When do you check for dyslipidemia on a PI-based regimen?
Month 3
When do you repeat FBC on an AZT-based regimen?
Month 1, month 3 and if clinically indicated
What is the schedule for TB screen at follow up visits?
At every f/u, symptom screen
Every 12 months, GXP
Hospitalisation, U-LAM
Outpatient CD4<200, AHD or serious illness, U-LAM
How often should VL be monitored in BF women?
Every 6 months from start of breastfeeding
What are the ABCDEs of elevated VL?
Adherence
Bugs
Correct dose
Drug interactions
REsistance
What do you do for a patient on TLD1 with confirmed virological failure?
Repeat VL in 6 months
When do you do resistance testing in TLD confirmed virological failure?
Patients on TLD2 - discuss with HIV expert
Which special circumstances warrant a resistance test on TLD1?
Perinatally affected adolescents
Existence of drug interactions
When do you repeat TB smear?
Week 7
Week 23
What is the ART regimen in neonates 2kg >35w GA?
AZT + 3TC + NVP
What is the ART regimen in infants >3kg and >4w?
ABC + 3TC + DTG
