HIV guidelines - June 2014

HIV TESTING AND COUNSELLING. 

Knowledge of HIV status is the entry point to HIV care treatment and prevention services. Providers should seek every opportunity to offer HIV testing and prevention messages to all clients irrespective of their reasons to visit the health facility.

For those who test HIV negative, retesting should be done after three months; thereafter all the people retesting negative for HIV should be done annually for the general population and quarterly for the key population: long distance drivers, commercial sex workers,discordant couples, homosexuals, etc

The recommendation for HIV testing and counseling (HTC) for different populations involves

a) HTC of infants and children aged less than 18 months.

· Conduct HIV antibody testing for mothers of children less than 18 months of age and of unknown status.

· All HIV exposed infants should be offered routine DNA PCR testing at 6 weeks [immunization visit], or any other time in contact with that child.

· Infants with an initial positive HIV PCR results should be presumed to be HIV infected and started on ART in line with national guidelines. 

b) HIV testing and counseling of children older than 18 months.

· Conduct HTC for all children presenting to the health facility irrespective of reason for their visit to the health facility.

· Conduct HTC for all children of HIV infected adults as soon as possible, within one month of confirming the HIV positive status of the adult.

c) HIV testing and counseling for the pregnant and breastfeeding women.

· All pregnant women should be done HTC at their initial visit and a repeat test after three months for those who test negative.

· All breast feeding mothers who tested HIV negative during ANC visit or whose status is unknown should be offered HTC.

· Conduct HTC to all sexual partners of HIV infected pregnant and breastfeeding women.

d) Disclosure of status to HIV infected children and adolescents 

· Caregivers should be advised to disclose HIV status to the HIV infected child preferably from the age of 6 years. Full disclosure should occur when the child is psychologically ready, ideally by the age of 10 years (before adolescence).

WHEN TO START ART IN CHILDREN. 

· ART should be initiated in HIV infected children aged 10 years and below, regardless of WHO stage or CD4 count.

· ART should be initiated in all HIV infected children above 10 years of age with CD4 cell count equal or less than 500 cells regardless of WHO stage.

· All HIV infected children above 10 years with WHO stage 3 and 4 disease; hepatitis B virus and TB co-infected children should be initiated on ART.

ARV PROPHYLAXIS FOR HIV EXPOSED INFANTS.

Mother diagnosed with HIV during pregnancy and at any stage of gestation, labor, delivery and immediately postpartum should be initiated on maternal ART, and the infant started on nevirapine until when 12 weeks old.

Infant identified as HIV exposed after birth through infant or maternal HIV antibody testing and breastfeeding, should be initiated on nevirapine prophylaxis until 12 weeks old, and the mother put on ART

Infants identified as HIV exposed after birth and not breastfeeding (on replacement feeding): refer the mother for HIV care and evaluation for treatment; no prophylactic drug to the child; conduct PCR after six weeks.

Infants born of mothers not on ART and not ready to take ART: initiate the infants on nevirapine till one week after complete cessation of breastfeeding.

NB. In HIV exposed infants, cotrimoxazole prophylaxis should only be discontinued when there is no further exposure to HIV, and the final HIV result (after complete cessation of breastfeeding) is negative.

WHEN TO START ART IN ADOLESCENTS AND ADULTS.

v All HIV infected adolescents and adults with CD4 count less than 500cells/mm3 irrespective of WHO stage.

v All HIV infected pregnant women irrespective of CD4 counts, WHO stage or gestation stage.

v All HIV infected breastfeeding women irrespective of CD4 count, WHO stage.

v All HIV infected spouses and sexual partners in sero-discordant relationship irrespective of their WHO stage or CD4 count.

v All infected persons with WHO stage 3 or 4 irrespective of CD4 count.

v All hepatitis B virus /HIV co-infected persons irrespective of CD4 count.

v All TB/HIV co-infected persons irrespective of CD4 count.

HIV TESTING ALGORITHM {2014 VERSION}

The new testing algorithm will involve three testing devices which will include

· KHB{SCREENING TEST}

· FIRST RESPONSE TEST{COMFIRMATORY TEST}

· UNIGOLD{TIE BREAKER)

The procedure for testing in each device is shown below

A.KHB

· Put two drops serum or plasma or whole blood

· Add one drop of diluents

· Read results after 15 minutes and not anytime after 30 minutes

· Invalid when there is no color band

B.FIRST RESPONSE TOOL

· Add two drops of whole blood or one drop of serum or plasma

· Add one drop of diluents

· Interpret results after 15 minutes but not after 15 minutes

· Invalid if no color band formed or if no color band at the control line

C.UNIGOLD

· Add two drops of sample [whole blood, plasma or serum]

· Add two drops of wash reagent

· Read at 10 minutes; don’t read after 20 minutes 

· Invalid if no color formed at control line or if no color formed

NB.Make sure all reagents and the three test kits are available before the start of testing.

CHANGES IN CD4 AND VIRAL LOAD TEST

· CD4 count is no more a routine test to patients on ART; it should be done to patients not on ART initially and then after six months until the patient is initiated on ART

· Viral load has been earmarked as the routine test for patients on ART. IT SHOULD BE DONE six months after initiation of ART, then at 12 months, followed by once yearly routinely.

· Viral load of more than 1000 copies marks a detectable value and this patient must be counseled on nutrition, adherence, while all opportunistic diseases must be treated. Then a repeat test should be done after three months.

Martin (for CCC staff), Benson (for Laboratory staff), Dr Beppe