Overview of HIV and AIDS

Activity: Buzzing

• Meaning of HIV and AIDS

Meaning of HIV

• HIV = “human immunodeficienc

y virus”
• HIV is the virus that can ultimat
ely lead to AIDS
• Viruses are sub-microscopic pa
rticles that need other cells in or
der to reproduce and survive
• HIV therefore needs to enter ot
her cells in order to replicate
Meaning of AIDS

• AIDS = Acquired Immunodeficiency Syndr

ome
• HIV infection and AIDS are different:
• HIV is the virus that causes immune deficiency
• AIDS is the progression of HIV infection that results fr
om the destruction of immune system leading to the o
ccurrence of diseases
• Everyone with HIV does not have AIDS
• Everyone with AIDS does have HIV infecti
on
Global AIDS Estimates for Adults
and Children, 2016
Global New Infections per Day, 201
3
• About 6,000 new infections a day:
• About 68% are in Sub-Saharan Africa
• About 700 are in children <15 years of age
• About 5,200 are in adults aged 15 year and ol
der, of whom:
• Almost 47% are among women
• About 33% are among young people (15 – 24 year
s)
Adults & Children Estimated to b
e Living with HIV, 2013
Estimated Number of Adults & Childre
n Newly Infected with HIV,2013
Estimated Adult & Child Deaths Fr
om AIDS, 2013
HIV and AIDS in Tanzania (1)

• AIDS was first identified in 1983

• By the end of 1986, AIDS cases had been
report in almost all regions of Tanzania
• It was estimated that, in 2013;
• A total of 1,411,829 people were living with HI
V, of whom;
• Approx. 28% are children below 15 years
• 11.2% are young people aged 15-24 years
• The HIV prevalence for Tanzania is 5.1%
HIV and AIDS in Tanzania (2)

• About 78,843 new HIV infections were estimat

ed to have occurred, of whom;
• Approx. 45.1% were male and
• 54.9% female
• A total of 79,338 deaths due to AIDS occurred
of whom;
• About 40,523 were males and
• 38,815 were females
HIV and AIDS in Tanzania (3)

• Modes of HIV Transmission in Tanzania ar

e;
• Heterosexual mode - 80%
• From mother to child (vertical) – 18%
• Medical transmission – 1.8%
• HIV prevalence is much higher in;
• Females than in males across all age groups
• Key Population (KPs) than in general populati
on
Modes of HIV Transmission

• Unprotected sexual intercourse with infect

ed partner/s:
• Male-to-female, female-to-male, and male-to-male
• Contact with HIV-infected blood-products:
• Blood transfusion, intravenous drug use (IDU) through
needle sharing, needle-stick accidents, unsterilized ne
edles
• Mother-to-child transmission:
• In utero, during delivery, through breastfeeding

HIV CANNOT be transmitted by casual contac

t, surface contact, or insect bites
Risk Factors Transmission of HI
V Infection (2): Individual
• Unprotected sexual in• Circumcision status (male
tercourse s) Individual

• Number of sexual part • Viral load of

ners HIV-positive partner
• Presence of other sex• Receptive partner
ually transmitted infec• HIV-negative member of
tions (STIs) HIV-discordant couple
• Alcohol or drug use • Lack of knowledge of HIV
• Age status (serostatus)
Risk Factors for Transmission of HI
V (3): Community and Societal
• Lack of knowledge and social acceptance about:
• HIV and AIDS
• Condoms and other HIV prevention methods
• Poverty:
• Migration for employment: Societal

• Loss of social support and cohesion Community

• Poor access to:

• STI treatment
• Counselling and testing services
• Care for PLHIV
Risk Factors for Increasing Risk of HI
V Transmission (4): Biological/Viral

• Viral properties (strain of HIV)

• Infectiousness of host (amount of the HIV
virus in blood)
• Susceptibility of recipient (presence of a s
exually transmitted infection, health of reci
pient)
Risk Factors for Transmission
of HIV (5): Social (1)
• Socio-economic factors:
• Poverty
• Children leave home to work at earlier age
• Loss of social cohesion at the family/community level
• Migration caused by need for employment:
• HIV and AIDS follows routes of commerce
• Sex work
• Stigma and Denial:
• Denial and silence are still common
• Stigma prevents:
• Acceptance of the problem
• Early seeking of care
17
Risk Factors for Transmission o
f HIV (6): Social (2)
• Cultural factors:
• Traditions, beliefs, and practices
• Non-circumcision of males
• Wife inheritance
• Shared circumcision tools
• Culture can create barriers that prevent peopl
e, and especially women, from taking precauti
ons
• Gender inequalities:
• In some cultures men are expected to have m
any sexual relationships
• Women suffer gender inequalities, often econ
omic in nature 18
Risk Factors for Transmission o
f HIV (7): Social (3)
• Low awareness:
• Lack of information necessary to understand a
nd prevent HIV
• False beliefs about effects of ART
• Conflict and social unrest:
• Civil unrest, especially armed conflict and disp
lacement of people
• High-risk behaviour of military personnel
Risk Factors for Transmission
of HIV (8): Behavioural
• Sex practices:
• Unprotected sexual behaviour, particularly am
ong mobile populations with multiple partners
• Poor reasoning:
• Alcohol consumption and drug use
• Impaired judgement, casual sexual contact
• Sharing of needles and equipment

20
Factors Decreasing Risk of HIV Tra
nsmission
• ABCD’s of risk reduction:
• Abstinence
• Be faithful to 1 partner who has tested negativ
e to HIV
• Correct and consistent use of condoms
• Disclosure
• Proper antiretroviral therapy (ART) – treat
ment as prevention
Activity: Brainstorming

• What is antiretroviral therapy?

Antiretroviral Therapy (ART)

• ARV = Antiretroviral medicines

• ART = Antiretroviral Therapy
• HAART = Highly Active Antiretroviral Ther
apy
Goals of ART

• Maximal and durable suppression of viral l

oad
• Restoration and/or preservation of immuno
logic function
• Improvement of quality of life
• Reduction of HIV-related morbidity and mo
rtality
Benefits of ART

• Reduce HIV viral load

• Improves immune system function and prev
ents opportunistic infections
• Decreases hospitalizations
• Increases survival
• Improves quality of life
• Restores hope
• Reduces HIV transmission
• Benefits both adults and children
Effectiveness of Care and Treatme
nt
Before Care and Treatment After Care and Treatment

ART changes HIV from a fatal to a chronic disease

Key Points

• HIV and AIDS is still a burden in Tanzania

• HIV is transmitted through:
• Unprotected sex with infected partner/s
• Contact with HIV-infected blood
• Mother-to-child
• Various social, behavioural, and biological factors ca
n facilitate the spread of HIV
• HIV works by attacking a person’s immune system,
making that person vulnerable to opportunistic infecti
ons
• Use of ARV is very beneficial in HIV and AIDS treat
ment
Pathophysiology of HIV Infection
The Normal lmmune System (2)

Innate Adaptive I
Immunity mmunity

B Lymphocytes T-Lymphocytes

• Skin, mucosa
• Cells:
CD4 (Helper) CD8 (Killer)
• White blood cell Plasma cells secreting sp cells
s ecific antibodies cells
• Macrophages
• Complement High Specificity/Memory Cells
 The Normal lmmune System (4): R
ole of CD4 Cells
KEY
HIV particle Helper T Cell
(CD4)
Helper T Cell Macrophage
Cytotoxic T Cell
B Cell
Macrophage B Cell Cytotoxic T Cell
(antibody secreting cell)
Cell nucleus (CD8)
Infected
Cell receptor
CD4
HIV antibodies

Killed C
D4
Basic Structure of HIV – 1 Particle
Life cycle of HIV: Major Steps
1. HIV attaches to CD4 cell
2. Releases RNA & enzymes
3. Enzyme Reverse Transcript 5
ase makes a DNA copy of v 1
iral RNA 6
4. New viral DNA integrated u
sing enzyme integrase into 4
CD4 cell nucleus 2 Reve
H rse tr
I an-s
5. New viral components prod V
R
cript
ase
uced, using cell’s “machiner N
A
y”
6. These are assembled toget 3 7
her using enzyme protease
7. Then released as new virus
es
Natural History of HIV Infection in
Adults (1)
• HIV-1 infection is divided into the following
phases:
• Viral transmission
• Primary HIV infection:
• Acute retroviral syndrome
• Sero-conversion
• Clinical latent period
• Early symptomatic HIV infection
• AIDS and severe HIV infection characterized by Clinic
al Stage 4 or a CD4 cell count below 200/mm³
Natural History of HIV Infection in
Adults (3): What we see

2-4 Weeks

2-10 Years

Courtesy of Microsoft Office Clip Art

Natural History of HIV Infection in Adults (1
0): CD4 Count and threshold of OIs
HIV Diagnosis in Adults, Adoles
cents and Children
Methods for Diagnosing HIV Infecti
on (1)
• Antibody detection:
• Rapid Tests (high sensitivity and specificity)
• Enzyme Linked Immunosorbent Assay (ELISA)
• Western Blot (Confirmatory test)
• Antigen detection:
• DNA/RNA detection
Methods for Diagnosis of HIV Infec
tion (2)
• Majority of infected individuals are positive
by ELISA, antigen and/or DNA/RNA tests
6 weeks after infection
HIV Testing for Adults and Childre
n more than 18 Months (1)
• Infected persons of this age group produc
e significant quantities of HIV antibodies
• Diagnosis of HIV infection is done by dete
ction of antibodies using HIV rapid tests
• Antibody testing is used to diagnose HIV i
nfection e.g. ELISA test
National HIV Testing Algorithm
Draw Sample

First HIV
Rapid Test

Non-reactive Reactive

HIV Negative Second HIV Rapid

Test (same sample)

Non-reactive Reactive All clients tested HIV

positive should be re-
Inconclusive HIV Positive tested prior to ART in
itiation
Repeat Test from the beginnin
g using a different sample This should be using
a different sample an
For persistent inconclusive results, inform the client that he/she may be in a d ideally the tests sh
period of acute HIV infection. Discuss with the client/patient on safer sex a
nd to return for another repeat HIV test after 14 days. If results are still inc
ould be performed by
onclusive refer the client to a higher facility or take a sample and refer to ot a different health care
her laboratory for ELISA or DNA PCR testing. worker
Diagnosing HIV infection in Childre
n under 18 months
• HIV DNA polymerase chain reaction (PCR)
method is used to confirm HIV infection
• PCR can be used to diagnose HIV infectio
n in most infected infants at the age of 4 w
eeks
HIV Testing Algorithm for Infants a
nd Young Children
Child presents at clinic

Age < 9 months: virological testing

(DNA-PCR) Age > 9 months: Rapid antibody (Ab) test

Positive PCR Negative PCR Negative Ab test Positive Ab test

Retest using DNA- If not breastfed f Still (or recent) bre If not breastfed f
PCR <18 months: Retest ≥18 months confirmatory
or at least 6 wee ast- or at least 3 mon
(confirmatory) with DNA-PCR Ab test
ks feeding ths

Child is not HIV-infect Child is not HIV-infecte

Start AR Re-test: d
ed -If symptomatic -At 9
T while Re- test: Re- test:
waiting f months -if symptomatic If positive, child is HI
-if symptomatic -6 weeks or more afte
or confir - At 18 months of Age - At 18 months of age V-infected, start ART.
matory r r cessation BF (Ab test)
(Ab test) -At 18 months of age
esults
(Ab test)
HIV Testing for Pregnant Women

• All pregnant women and their partners (unl

ess known HIV positive) should be tested
and counselled for HIV during their first AN
C visit
• For HIV negative pregnant women HIV tes
t should be conducted during the third trim
ester or during labour or at delivery.
HIV Testing for Breastfeeding Wo
men
• All breastfeeding mothers unless known HI
V positive shall be encouraged to undertak
e HIV test during breastfeeding.
• For those who were tested during third tri
mester or at labour or delivery, a repeat HI
V test should be offered in 6 months and t
hereafter as per general population.
HIV Testing for Key and Vulnerable
Populations
• Conduct HIV testing and counselling for key
and vulnerable populations presenting at heal
th facilities or community based testing
• For key and vulnerable populations that test
HIV negative, re-testing should be recommen
ded 4 weeks and there after repeat after 6 m
onths
• Prisoners shall be offered voluntary HTS as p
art of health service whether in prison or in a
ny other setting
 Indications for HIV Re-testing (1)

Scenarios When to re-test? Future re-test

ing?
Have indeterminate HIV sta Immediately repeat the test following te If still indeterminate st
tus st instructions. OR immediately repeat t atus, retest in 2 week
est by another HTS provider or Laborat s
ory technician

Not involved in HIV risk No need of HIV testing Annually

for the past three month
s

Pregnant women in 1st Tri 3rd Trimester or labor and Delivery After 6 months of deli
mester or early in pregnanc very and with each ne
y w pregnancy

Breast feeding women 4 weeks Every 6 months

With unknown status te
sted at first post natal c
are
Indications for HIV Re-testing (2)

Scenarios When to re-test? Future re-testing?

Have specific incident of 4 weeks With each new known expo
HIV exposure in last 3 mo sure
nths

Have on-going risk of infe 4 weeks After every 6 months

ction (SW,IDU,MSM)
Have a spouse or partner
with unknown HIV status
or known HIV positive

Have STI 4 weeks With each new STI

Have clinical indication of 4 weeks With new exposure
HIV infection

Are victims of sexual viol After at least 4 -6 week 12 weeks

ence or rape or experienc s post-exposure
e occupational exposure
Opportunistic Infections and Other
HIV-Related Conditions
HIV, WHO clinical Staging
WHO Stage Some Typical Diseases
(Staging of diseases is approximate and not the same
for all individuals)

I No symptoms or signs of any illness

Asymptomatic or Patients have enlarged lymph nodes
Persistent Generalized L
ymphadenopathy

II Herpes zoster, Recurrent respiratory tract infecti

Minor Symptoms ons, Unexplained moderate weight loss, Angular
cheilitis, Recurrent oral ulcerations, Papular pruri
tic eruptions, Seborrhoeic dermatitis, Fungal nail
infections
 WHO Stage Some Typical Diseases
(Staging of diseases is approximate and not the same for all individu
als)

III Unexplained severe weight loss, Unexplained chronic diarrh

Moderate Sympto oea, Unexplained persistent fever, Persistent oral candidiasi
ms s, Oral hairy leukoplakia, Pulmonary tuberculosis, Severe ba
cterial infections, Acute necrotising ulcerative stomatitis, ging
ivitis, or periodontitis, Unexplained anaemia or chronic throm
bocytopaenia, HIV nephropathy

IV HIV wasting, Pneumocystis pneumonia, Recurrent severe b

AIDS-defining Illn acterial pneumonia, Oesophageal candidiasis, Extrapulmona
ess ry TB, Kaposi’s sarcoma, Chronic herpes simplex infection,
CNS toxoplasmosis, cervical cancer, HIV encephalopathy
HIV related Gastrointestinal Diseas
es
The main gastrointestinal problems that occ
ur in relation to HIV include:
Oro-oesophageal diseases:
• Oral & oesophagial Candidiasis “thrush”
• Herpes Simplex Virus (HSV)
• Apthous ulcers
• CMV ulcers
• Kaposi sarcoma
Diarrhoeal Illness
Gastrointestinal Disease Rx

Oro-oesophageal d’ses
• Candidiasis “thrush”→ fluconazole 150-200mg/day
for 2-3weeks.
• Herpes Simplex Virus (HSV) → acyclovir 200-400
mg x5/day for 10days.
• Apthous ulcers → prednosolone 10-20mg + mouth
wash.
• CMV ulcers → gancyclovir
• Kaposi sarcoma
Diarrhoeal Illness (isosporiosis, cyrptosporiosis, gi
ardiasis bacterial diarrhoea)
- ART improves diarhoea from cryptosporiosis.
 HIV-Related Respiratory Illness
There are 3 main pneumonias which tend to affect HIV positive pe
rsons
Tuberculosis (TB)
• Can occur at any CD4 level
• As CD4 declines, increasing risk of developing extra-pulmonary and atypical
forms of TB
Rx: ANTI-Tbs + supportive treatment
Bacterial Pneumonia (BP) which occur at any CD4 level
• Often one of the first OIs that a patient develops
• When recurrent, they are WHO stage 4 defining
Rx: CTX 8/40mg per kg/day + supportive treatment
Pneumocystis Jirovecii Pneumonia --formerly known as Pneumocystis carinii pn
eumonia (PCP) (dyspnea + desaturating on oxygen)
Rx: high dose CTX 20/100mg per kg/day + prednisolone 40mg
BD + oxygen + IV fluids.
HIV-Related CNS Disease

HIV-related central nervous system (CNS) disease

can be infectious or non infectious:
- Infectious causes
Fungal: e.g. cryptococcus neofomans
Bacteria: e.g. streptococcus pneumonia, TB
Viral: e.g. CMV, HIV
Protozoa: e.g. toxoplasma gondii
- Non infectious conditions are usually malignancie
s
Eg CNS lymphoma, HIV encephalopathy, HIV demential.
Cryptococcal Meningitis: Manage
ment
If Cryptococcal Meningitis treat with:
during the induction stage
Amphotericin B 0.7-1 mg/kg/day IV + Flucytosine 100mg/kg
/day PO x 14 days
(if flucytosine not available, give fluconazole 1200mg/ day).
consolidation phase
Fluconazole 800mg/days PO for 8 weeks
maintenance phase
Oral Fluconazole 200mg OD for 52weeks or until patient ha
s sustained CD4 increase greater than 200.

Supportive treatment: IVF +/- KCl (AmB can cause nephrotoxicity and hypokale
mia), Analgesics, start ART after 5weeks in a naive pt.
Dermatologic Diseases in HIV

Malignancies Parasitic
e.g Kaposi sarcoma (KS) e.g Scabies
Viral infections Fungal infection
e.g. Herpes zoster, Molluscum co e.g candida, tinea infection of the
ntagiosum body
Drug reactions Bacterial skin infection
e.g. Steven Johnson Syndrome e.g Impetigo, recurrent and multipl
Immunologic dissorders/alle e abscesses
rgic conditions Others
e.g. Psoriasis, Papular Pruritic Er e.g Seborrhoeic dermatitis
uptions (PPE)
Opportunistic Infection Prophylaxi
s
Opportunistic infection prophylaxis is:
Preventive treatment to avoid disease
Very useful among HIV-infected persons
Strategies used in Tanzania include:
01. Cotrimoxazole Prophylaxis Therapy (CPT) to prevent
pneumocystis pneumonia and other infections (CD4 <350 u
ntil CD4 raise above 350, used in treatment of most Ois) D
ose: 960mg/day.
02. Isoniazid Preventive Therapy (IPT or TPT) to prevent
TB (any HIV stage without active TB, any HIV pt after comp
leting TB treatment) duration: 6months – once in life time.
QN

01. a. What are the indication of CTX prophylaxis?

b. After initiating CTX prophylaxis when do we
stop? (for adilts & children)

02. i. Mention the indications of Isoniazid preventiv

e therapy.
ii. Isoniazid is known to cause perpheral neuro
pathy, what do we do to prevent such complicati
ons?
Antiretroviral Therapy (ART)
Major Steps of HIV Life Cycle

1. Attachment – HIV attaches to CD4 cell receptors and co-receptors

2. Fusion – HIV fuses with cell membrane and releases genetic materi
als (enzymes & RNA) into the host cell
3. Reverse transcription – enzyme Reverse Transcriptase makes a pr
oviral DNA using viral RNA
4. Integration – the proviral DNA becomes integrated into CD4 cell DN
A (facilitated by the enzyme Integrase)
5. Synthesis – new viral components produced, using cell’s “machiner
y”
6. Assembling – the viral components are assembled together and mo
dified using protease enzyme
7. Release – the new virions are then released as new viruses and the
cycle repeats
Classes of Antiretroviral Drugs (2): Are
as of action in the HIV life cycle

© I-TECH
ARVs- Mechanisms of Action

1. Attachment : Maraviroc blocks CCR5 co-recepto

rs
2. Fusion : Blocked by Enfuvirtide
3. Reverse transcription: Blocked by NsRTI/NtRT
I and NNRTI.
4. Integration : Blocked by INSTIs (Dolutegravir an
d Raltegravir)
5. Synthesis, Assembling and Release of new vi
rions is blocked by Protease Inhibitors (PIs)
 Classes of Antiretroviral Drugs
 Nucleoside/Nucleotide reverse transcriptase inhibitors, NRTI/Nt
RTI:
 Nucleoside = Zidovudine(AZT), Abacavir (ABC), Lamivudine (3T
C) and Emtricitabine (FTC).
 Nucleotide = Tenofovir disoproxil fumarate (TDF) and Tenofovir
alafenamide (TAF)
* Non-nucleoside reverse transcriptase inhibitors, NNRTI:
 1st gneration = Nevirapine (NVP), Efavirenz (EFV),
 2nd generation = Etravirine (ETV)
 Protease inhibitors, PI:
 Lopinavir boosted with Ritonavir (Lopinavir/r)
 Atazanavir boosted with Ritonavir (ATV/r)
 New PI – Darunavir boosted with Ritonavir (DRV/r)
 Integrase Strand Transfer Inhibitors, INSTIs:
 Dolutegravir (DTG), Raltegravir (RAL)
Eligibility Criteria for ART

 All HIV infected individuals regardless of a

ge, clinical stage, CD4 level, HIV risk grou
p, pregnancy status, associated comorbidit
ies are eligible for ART

(test and treat, however r/o opportunistic infe

ctions first to avoid risk of IRIS)
Qn

01. what is immune reconstitution inflammat

ory syndrome (IRIS)?
02. when do we start ART in naive pt diagno
sed with,
(a) TB
(b) cryptococcal meningitis

HIV guideline 2019 page 90-92

WHO goals on HIV

95% RULE (previous 90% rule)

- 95% of world population to know their HIV
status.
- 95% of those who have HIV disease to be
on treatment (ART).
- 95% of diseased patients on ART to have
undetectable viral loads.
ART regimen

Ideal regimen:
 composed of 3drug combination (aim: prev
ent resistances)
 Life long treatment regardless undetectabl
e viral load.

1st line:
2nd line:
3rd line:
1st line regimen in adults >15yrs (T
Z)
New 1st line regimen (2020):
 3drugs = 2NRTI + 1INSTI
- TDF + 3TC + DTG [TLD] (recommended)

others: ABC+3TC+DTG, TDF+3TC+EFV [T

LE] (previous guideline), AZT+3TF+NVP.
N:B- 3TC → FTC
1st line regimen in adults >15yrs (T
Z)
Advantages of TLD regimen
- high genetic barrier (difficult for resistance)
- few side effects and drug interactions eg n
o interaction with methadone in people inj
ecting drugs.
- causes rapid decline in Viral load (within 1
month), other combinations eg TLE takes
6months.
School of concepts (prof kaluvya)

01. avoid using AZT as first line in a combin

ation regimen.
WHY? Use of AZT has risk of TAMS mutatio
n if resisted by virus.
Effects of TAMS mutation – causes resistan
ce to all other NRTI and NNRTI.
Challenge – no drug reserve in both first and
second line regimens.
School of concepts (prof kaluvya)

02. the use of 3TC or FTC has benefit in any line tr

eatment (even if is showing resistance).
WHY ? - increase efficacy of other ARTs
- 3TC makes the virus less fit to replicate.

03. use of NVP is CD4 dependent. NVP is prefferd

in pt with low CD4 (high CD4 increases risk of he
patotoxicity if given NVP). For men give if CD4 <
400, female <250.
Common toxicity substitution in fir
st line drugs
Substitution within First Line Antir
etroviral Regimens
Changing antiretroviral therapy due to t
reatment failure (1st line → 2nd line)
Switching ART lines

Note: only virological failure is recently considered a

s the indication of switching lines. (and this is don
e after Enhanced Adherence Counselling for som
etime and VL measures).
* It is recommended that treatment failure diagn
osis should be based on virological criteria be
cause it is the earliest marker of treatment fail
ure *

NB- before a conclusion of Rx failure make sure

drug adherence is well r/o.
Viral load monitoring of ART and criteria for
switching to second/third line
HIV viral load will be tested:
 6 months after starting ART
 Any patient with clinical or suspected with immu
nological failure

HVL 1000 copies / ml HVL 1000 copies / ml In cases of severe immun

 Continue current regime  Refer for Enhanced Adherence Counselli osuppression with signs a
nt ng (EAC) nd symptoms of stage 3/4
 1st EAC session on day of result disease and HVL > 1000 c
 Repeat HVL after 6 mont
 2nd EAC session after 4 weeks opies/mL with good adher
hs
 3rd EAC session after 4 weeks ence a switch to second lin
(12 months from starting ART)
(If required, additional EAC session may be gi e may be considered earli
ven)
er and without repeat of H
VL in some cases
Repeat HVL 3 months after 1st EAC
session if EAC has been successful
and adherence has improved
HVL 1000 copies / ml
HVL 1000 copies / ml
 Continue current regiment
 If HVL 1000 copies / ml but 0.5 log
 Repeat HVL yearly
drop repeat VL after 3 months
 At subsequent yearly HVL if HV 100O copies/ ml and 0.5 log
 If HVL
L 1000 copies / ml drop switch to second line
 algorithm from the top
2nd line ART regimen

Principles
3drugs = 2NRTIs (one must be that which w
as not used in 1st line & 3TC/FTC) + PI
For PI
- majority have risk of metabolic disturbances (met
abolic syndrome) except Atazanavir (ATV) is meta
bolic friendly. Therefore prefer using ATV over oth
er PI except in TB pt who use rifampicin.
- all PI are boosted with ritonavir to increase efficac
y and incerase genetic barrier (ATV/r, LPV/r, DRV/
r).
Recommended 2nd line ARV regim
ens
Recommended 3rd line ARV regim
ens
3rd line

There is no a fixed 3rd line Rx.

KEY POINTS:
01. Viral load testing should be the gold stan
dard for diagnosing treatment failure.
02. Resistance test should be used to deter
mine the third-line regimen. (genotyping fo
r drug resistance must be done to obtain a
third line regimen)
Monitoring HIV patient
Meaning of Monitoring HIV Progres
sion (1)
 Keeping track of HIV progression and com
plications involves monitoring:
 Immune system status:
 CD4 cell count/percentage
 Viral load
 Drug toxicity:
 Chemistry and haematology
 Diagnosis of OIs (TB)
 STIs
Markers of Disease Progression
 Disease progression can be monitored by:
 Clinical markers:
 Weight loss
 New HIV and AIDS-related conditions
 Worsening clinical stage
 Laboratory markers:
 Decrease in CD4 cell count/CD4 %
 Increase in viral load

 Eventually, disease progresses to a point t

hat body can no longer fight off infection =
immune failure
Pre exposure prophylaxis (PrEP)
and Post exposure prophylaxis (P
EP)
- criteria for both scenarios (indications)
- drug used in each scenario
- for how long is (a) PEP (b) PrEP used

(group discussion qn)

Qn

A 32year old man known HIV but has never

been on medications presents to OPD wit
h hx of severe headaches. Relatives repor
ted for the past few days he seems confus
ed. No hx of fevers or convulsions. On exa
mination: not oriented, cachexic, afebrile. I
nvestigations done results shows CD4 cou
nt 70cells awaiting VL results. Discuss ma
nagement of this pt.
Qn

21year old female known HIV since childhoo

d who has been on irregular ART for the p
ast 1yr (was worried her fellow colleages
may notice her condition if she will be taki
ng meds daily), presented to the hosp with
C/C of dry cough and DIB. No hx of cyano
sis reported however she keeps desaturati
ng to 80s. CXR no clear features were not
ed. Discuss management of this patient.
 Thank you
(ahiJn)

More reference: TZ HIV guideline