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HIV: Human Immunodeficiency Virus. This is the virus that causes HIV infection and AIDS.

AIDS: Acquired Immune Deficiency Syndrome AIDS is the severest stage of the clinical spectrum of HIV infection. It occurs when the immune system of a person who is HIV- infected becomes so suppressed that they are vulnerable to opportunistic infection and neoplasms.

ART: Antiretroviral Therapy. A combination of antiretroviral drugs used in the management of HIV/AIDS

Clinical Features The WHO clinical staging is used to determine the severity of HIV infection based on the presenting opportunistic infections in a confirmed HIV infected individual. WHO staging can be used to make decisions for switching or stopping ART.

WHO Clinical Staging of HIV disease in Adults and Adolescents

CLINICAL STAGE 1

  • Asymptomatic
  • Persistent generalized lymphadenopathy

CLINICAL STAGE 2

  • Moderate unexplained weight loss (under 100/o of presumed or measured body weight)
    • Unexplained refers to where the condition is not explained by other conditions e.g. nutrition or exercise regime intended to lose weight.
    • Assessment of body weight among pregnant women needs to consider the expected weight gain of pregnancy.
  • Recurrent upper respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis)
  • Herpes zoster in the last 5 years
  • Angular cheilitis
  • Recurrent oral ulceration
  • Papular pruritic eruptions
  • Seborrhoeic dermatitis
  • Fungal nail infections

CLINICAL STAGE 3

  • Unexplained severe weight loss (over 100/o of presumed or measured body weight) Assessment of body weight among pregnant women needs to consider the expected weight gain of pregnancy.
  • Unexplained chronic diarrhoea for long er than one month
  • Unexplained persistent fever (intermittent or constant for longer than one month)
  • Persistent oral candidiasis
  • Oral hairy leukoplakia
  • Pulmonary tuberculosis
  • Severe bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteremia)
  • Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
  • Unexplained anaemia (below 8 g/dl), neutropenia (below 0.5 x 109/ I) and/or chronic thrombocytopenia (below 50 x 109 / l )

CLINICAL STAGE 4

  • HIV wasting syndrome (>10% weight loss and > 1-month diarrhoea and > 1-month fever)
  • Pneumocystis pneumonia
  • Recurrent severe bacterial pneumonia
  • Chronic herpes simplex infection (orolabial, genital or anorectal of more than one month's duration or visceral at any site)
  • Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
  • Extrapulmonary tuberculosis
  • Kaposi sarcoma
  • Cytomega lo virus infection (retinitis or infection of other organs)
  • Central nervous system toxoplasmosis
  • HIV encephalopathy
  • Extrapulmonary cryptococcosis including meningitis
  • Disseminated nontuberculous mycobacterial infection
  • Progressive multifocal leukoencephalopathy
  • Chronic cryptosporidiosis
  • Chronic isosporiasis
  • Disseminated mycosis (extrapulmonary histoplasmosis, coccidiomycosis)
  • Recurrent septicaemia (including non-typhoidal Salmonella)
  • Lymphoma (cerebral or B-cell non-Hodgkin)
  • Invasive cervical carcinoma
  • Atypical disseminated leishmaniasis
  • Symptomatic HIV-associated nephropathy or HIV- associated cardiomyopathy

*Note: This is based on the 2020 Zambia Consolidated HIV Guidelines. HIV treatment may be revised or changed as the disease evolves or new evidence-based national recommendations are released.

Diagnosis

  • Early Diagnosis
  • (DNA-PCR)
  • HIV Self-Testing (HIV-ST)
    • HIV-ST is a process in which a person collects their oral fluid or blood and then performs an HIV rapid test and interprets the result. An HIV self-test is a screening test which requires further testing and confirmation for any reactive result. Health care providers should ensure that users receive clear information on:
      1. How to perform the test and interpret the result correctly
      2. Where to access HTS and further support services
      3. How to safely dispose of the used test-kits
      4. The ethical and legal obligations (no one should test a third party without their consent)
  • Universal Routine HIV Testing gives an opportunity to provide immediate treatment and care to all HIV infected individuals through the “test and treat” strategy without using CD4 as eligibility criteria for HIV treatment.
  • Health care workers are therefore mandated to offer routine HIV testing to all individuals presenting to health facilities (in the inpatient department, routine testing should be extended to the caregivers).
  • Rapid antibody detention
    1. Screening test - Determine test
    2. Confirmation test - Unigold test
    3. Tiebreaker test – Bioline test.
  • For children <24 months old who are breastfeeding, the mother should be tested first. If she is HIV-positive, perform a Nucleic Acid Test (NAT) which can be done using either a Dried Blood Spot- DBS (by being sent to a central testing lab) or a Point-of-care machine (POC) on the HIV-exposed infant (HEI), regardless of age. Infants who have HIV detectable by NAT at birth are likely infected in utero, will progress to disease rapidly, and, in the absence of treatment, will experience high mortality in the first few months of life. Infants infected at or around delivery may not have virus detectable by NAT for several days to weeks. The ability of NAT to detect the virus in the blood may be affected by ARV drugs taken by the mother or infant for postnatal prophylaxis, resulting in false-negative results. This includes drugs present in breast milk as a result of maternal ART during breastfeeding.
  • The rationale behind this recommendation is that infants who are first identified as HIV-exposed postpartum have a high cumulative risk of already having acquired HIV by the time prophylaxis is initiated; thus NAT should be performed around the time of initiating prophylaxis, which would be at birth. This will help to minimize the risk of development of resistance because of extended prophylaxis in infected infants and help to promote linkage to timely initiation of cART.

Clinical Management

  • Full History
  • History of the presenting complaint
  • ICF for TB (Cough, Fever, Weight loss and night sweats HIV history
  • HIV Risk factors
  • Past medical history Social history
  • Drug history
  • Reproductive history
  • Full Physical Exam

Baseline Laboratory investigations

  • FBC (Hb, Hct), CD4, ALT, Creatinine (CrCl)
  • CD4 count, HBsAg (if not vaccinated), Pregnancy test (Adolescent or woman of reproductive age), Syphilis test (adolescent or adult), Cholesterol and triglycerides (if starting on a PI)
  • HPV test or visual inspection with acetic acid (sexually active adolescent or woman)
  •  BP, BMI, RBS & Urinalysis

Eligibility Criteria for initiating ART

Prior to initiating ART in all patients ensure that:

  1. HIV positive test confirmed and post-test counselling done
  2. Documented treatment preparation is completed
  3. Disclosure is documented
  4. Minimum baseline laboratories are completed: CD4, ALT, Creatinine, Hct/Hgb, etc.
  5. Absence of the danger signs of unresolved Opportunistic Infections (Ols) listed below is documented
    1. Persistent fever
    2. Persistent cough
    3.  Severe persistent headache
    4.  Anaemia (Hgb <8 or Hct <24)
    5.  Weight loss >10%
      If ANY of the above five symptoms are PRESENT then investigate and treat as appropriate (see the review of undiagnosed Ols on next page)
  6. Initiate diagnosis with sputum for AFB, CXR, cryptococcal antigen, and oxygen saturation
  7. Based on test results initiate appropriate therapy
  8. Initiate ART two weeks after documented response to OI treatment
  9. If no clear diagnosis obvious from a diagnostic test, then consult an HIV Specialist before initiating ART.


Zambian recommendations for initiating antiretroviral therapy in adults and adolescents with documented HIV infection is “TREAT ALL” irrespective of CD4 count or WHO staging.

Conditions to initiate ART irrespective of CD4 count

Condition Recommendation
HIV positive partner in Discordant Couple (see below) Hepatitis B Virus Infection (chronic hepatitis B)* Treat all irrespective of CD4 count
*Patients testing HBsAg positive with CD4 counts greater than 350 cells/mm3 should have ALT or AST checked and if elevated initiate ART. For patients with normal baseline ALT or AST recheck ALT or AST and HBsAg in 6-12 months. 
*If ALT or AST are elevated, or persistent HBsAg then start ART regardless of CD4 count or WHO stage. If signs of liver cirrhosis are positive HBsAg start HAART regardless of ALT or AST values.

For patients eligible for ART provide the following risk reduction:
• Finish reduction
• Treat presenting problem
• Identify latent opportunistic infections e.g. screen for TB
• Provide Cotrimoxazole prophylaxis 960mg tablet daily (800mg Sulphadoxine + 160mg Trimethoprim)
• Provide close follow up of patient on ART in the first 2 weeks, after one month and every 3-months
• Conduct laboratory investigations.