HIV/AIDS

LEARNING OUTCOMES
• 1.Analyse HIV virus life cycle and
immunology.
• 2. Evaluate risks associated with exposure
to HIV/AIDS-Attitude change training.
• 3. Demonstrate a positive attitude towards
HIV/AIDS management. Behavior Change
Communication (BCC) .
• 4.Integrate counseling approaches –
individual, group.
OBJECTIVES
• Discuss the causes of HIV/AIDS.
• Describe the stages of the HIV/ AIDS
disease.
• Discuss the management of HIV/AIDS
patients.
• Discuss the effects of HIV/AIDS.
INTRODUCTION TO HIV /AIDS
• HIV is a public health threat globally. An estimated
1.5 million Kenyans are living with HIV, of whom
1,136,000 were on antiretroviral therapy by
December 2017.
• The MOH releases updated HIV prevention and
treatment guidelines in line with emerging evidence
every 2 years. These guidelines are aligned with the
Ministry of Health’s mission of providing the highest
standard of health for all Kenyans and one of the
Government of Kenya’s Big Four Agenda on
universal health coverage.
• HIV testing services (HTS) provides the first critical link to
comprehensive HIV treatment and prevention. Additionally,
this initial step provides opportunities to offer other
interventions such as sexual and reproductive health
services, TB screening and referral, substance abuse
screening and referral, information and referral for voluntary
medical male circumcision, pre-exposure prophylaxis (PrEP),
post-exposure prophylaxis (PEP) and other combination HIV
prevention services.
• HIV testing should be voluntary and conducted ethically in
an environment where the five Cs of Consent,
Confidentiality, Counselling, Correct results and Connection
(linkage) can be assured.
DEFINITIONS OF TERMS
• List of Abbreviations and Acronyms
• AIDS- Acquired Immune Deficiency Syndrome
• ART- Antiretroviral Therapy
• HAART- Highly Active Antiretroviral Therapy
• CD4 - Cluster of differentiation 4
• CDC - Centers for Disease Control and Prevention
• DNA - Deoxyribonucleic acid
• HIV - Human Immunodeficiency Virus
• KAIS - Kenya AIDS Indicator Survey
• KDHS- Kenya Demographic Health Survey
 CT
• MSM- Men who have sex with men
• NACC- National AIDS Control Council
• NASCOP- National AIDS and STIs Control
Program
• PLHIV- People Living with HIV
• RNA- Ribonucleic acid
• SSRNA- Single Strand Ribonucleic acid
• UNAIDS - Joint United Nations Programme
on HIV/AIDS
• WHO -World Health Organization.
CT
• FDC- Fixed Dose Combination
• ISTI - Integrase Strand Transfer Inhibitor
• IRIS - Immune Reconstitution Inflammatory Syndrome
• NNRTI -Non-nucleoside reverse transcriptase inhibitor
• NRTI - Nucleoside reverse transcriptase inhibitor
• NRTI - Nucleotide reverse transcriptase inhibitor
• PI - Protease inhibitor
• PEP - Post-exposure prophylaxis
• PrEP - Pre-exposure prophylaxis
• PWID - People who inject drugs
 HISTORICAL BACKGROUND
• The first case of Acquired Immune Deficiency
Syndrome (AIDS) was recognized in 1981 by the Centre
for Disease Control in USA when they reported rare a
lung infection- Pneumocystis jiroveci (carinii)
pneumonia and Kaposis sarcoma in previously healthy
homosexual men and thy later recognized that the
patients were immunosuppressed.
• Between 1983-1984 various people described the
cause of the syndrome as a retrovirus.
• It was given different names e.g. Lymphadenopathy
associated virus, AIDS associated retrovirus, Human T
lymphocapic virus
CT
• However, In 1986 HIV was accepted as the international
designation for the retrovirus and was done by WHO in a
consultative meeting.
• HIV is now known to have originated from a type of
chimpanzee in West Africa. The virus that affects these
chimpanzees (Simian Immunodeficiency Virus, SIV) was
most likely transmitted to humans and mutated into HIV.
• In Kenya the first case of HIV was described in 1984
DESCRPTION OF HIV
EPIDERMIC
• HIV is a worldwide pandemic and has entered the 46th
year.
• Globally, 34-46 million people are having HIV
infection .About half of these people are between15-24
years.
• SUBSAHARAN AFRICA
• It has a population of about 10% of worlds population. It
is a home to more than 60% of people living with
HIV/AIDS. All age groups are affected but most are young
and middle aged . It is a major cause of morbidity and
mortality.
• KENYA
• National HIV preference is 7% between 15-49 years.
Women are more affected than men. Peak age is
WHAT IS HIV AND AIDS?
• HIV –stands for human immunodeficiency virus , is the
virus that causes AIDS.
• HIV destroys certain types of blood cells known as T-
helper cells or CD4 cells.
• A person can be infected with HIV for many years before
any symptoms occur, and during this time an infected
person can unknowingly pass the infection to others.
• AIDS –is acquired immunodeficiency syndrome , an
advanced stage of HIV infection that occurs when the
immune system cannot fight off infections that the body is
normally able to withstand.
• At this stage, the infected person becomes more
susceptible to a variety of infections known as
opportunistic infections.
HOW IS HIV TRANSMITED?
• HIV is spread through three main modes.
• These modes of transmission are as a result of
exposure to body fluids ( blood, semen, vaginal fluids,
and breast milk) of infected individuals.
• Specifically , HIV can be transmitted through:
1. Sexual contact; Vaginal , Anal, Oral.
2. Blood contact; - injections or needles, cutting tools ,
transfusions of blood and blood products , contact
with broken skin ( exposure to blood through cuts or
lesions.
3. Mother –to-child transmission.-pregnancy , delivery
, breastfeeding.
CT
Transmission Route Percentage (%) of total transmission

Sexual intercourse 70 - 80

Mother - to – child transmission 5 - 10

Blood transfusion 3-5

Injecting drug use 5 - 10

Health care – e.g. Needle stick injury <0.01

Determinants of HIV
Transmission
Distal Determinants Proximal Determinants Immediate Determinants

• Health systems • Health care seeking • Viral load.

• Cultural practices • Sexual networks. • Presence of STDs.
• Social economic • Substance use. • Nature of sex.
/poverty • Knowledge about HIV. • Concurrent sex
• Political systems • Risky behavior. networks.
• Demography • Use of condoms.
• Male circumcision.
EPIDEMIOLOGY
• HIV is caused by a retrovirus from the lentivirus family that is
called human immunodeficiency virus. The genetic material
consists of a single stranded RNA. The viral particle is spherical in
shape with a diameter of 80-100 manometer. There are two types
• HIV TYPE 1
• It is found worldwide. It is responsible for the pandemic and is
easily transmitted from person to person including mother to
child. So far there are many subtypes of HIV TYPE 1 but the ones
in record are A-K
• HIV TYPE 2
• These is mainly found in West Africa , Mozambique, Angola
• It causes similar illness to HIV 1 but is less transmissible.
• It also rarely causes vertical transmission i.e. mother to child.
• It is less aggressive with slower disease progression.
BIOLOGY
• This is the science of the disease and its causative
agent.
• There are two types of HIV strains.
• These are further divided into sub-types as indicated
in . HIV 1 has four sub- types namely M, N, O and P
while type 2 has seven namely A-G.
• The HIV virus belongs to a family called Retroviruses
and a sub-group lentivirus.
• Retroviruses are a unique group of viruses in that
they go against the conventions of genetics.
• You may have learnt in your high school or college
biology that RNA is made from DNA.
 CT
• Retroviruses defy this convention and are able to
form DNA from RNA! The reason for doing this, is to
be able to use the human cell mechanisms.
• Lentiviruses are a sub-group of viruses that are
known for having a long time period between initial
infection and the beginning of serious symptoms.
• This name is drawn from the Christian period,
“Lent” that refers to the long fasting that the faithful
undertake.
• Thus, persons who are infected with this virus will
be unaware of the infection and can spread the
virus unknowingly.
 PATHOPHYSIOLOGY OF HIV
COMPONENTS OF HIV STRUCTURE.
DOUBLE LIPID MEMBRANE
• The virus has a double stranded membrane that is lined by gp17.
• It is strengthened or studded by surface gp120 by transmembrane gp41
• The glycoproteins mediate the entry of the virus into the host cell.
CASPID
• The capsid is made of several proteins but main is gp 24 which forms the
membrane within the capsule area/viral genetic material composed of two
identical strands of RNA.
• Viral enzymes include; reverse transcriptase –It converts viral single
stranded RNA into double stranded DNA.
• This is important during duplication since viral DNA is incorporated into
host DNA.
• Integrase; it facilitates integration of viral DNA into host DNA.
• Protease; help to processes the newly formed viral proteins to form the
new viral particles / virions.
STRUCTURE OF HIV
LIFE CYCLE OF HIV
 BINDING
• This step consists of several interactions between the host
cell and the virus.
• The first one involves the attachment of the virus through
the gp 120 and gp 41 to the CD4 cell receptor of the host
cell.
• Thereafter, there is an interaction between a CD4 cell co‐
receptors and the gp120 complex.
• This step is the most important one in the process, without
which no infection occurs. This works like a key and a lock.
• It is also important to remember this as one of the sites for
medicines called co-receptor antagonists.
FUSION AND ENTRY
• This step involves the fusion of the membranes
of the host cell and that of the virus.
• As noted in the figure above and expounded in ,
this step is the target of drugs such as
enfurvitide.
REVERSE TRANSCRIPTION
• By now you should have realized that the virus
has uncoated itself by engaging in the last two
steps and only the nucleus and its contents
(RNA, reverse transcriptase, integrase, and other
viral proteins) enter the host cell cytoplasm.
• Using one of its enzymes, reverse transcriptase,
the virus is able to transform from a SSRNA to a
dsDNA.
• Can you think of the reason why this virus takes
up the DNA state?
 INTEGRATION
• We have all heard of the adage that when you go to Rome
you do what the Romans do!
• The HIV virus having taken a DNA status is in a form similar
to that in the host cell’s nucleus: DNA.
• It is thus transported into the host nucleus and integrates
into the host cell DNA. This is aided by the viral enzyme
Integrase. Once this happens, the cell becomes infected
permanently until it dies.
• The infected host cell’s mechanisms are taken over by the
virus. As we all know, DNA gives rise to RNA part of which
makes proteins.
• The virus is now able to use the host cell’s transcription.
CT
• mechanisms to make new RNAs and messenger
RNA(mRNA).
• The latter is released into the cytoplasm of the
host cells and translated into long protein
complexes, often known as polypeptide chains.
• The polypeptides are broken further into the
constituent proteins and enzymes that were
discussed in the biology sub‐section. The other
RNAs become the genomic RNA material that
will eventually start off this cycle again.
Viral assembly and Budding
• The second last step is the assembly of the
proteins, enzymes and RNAs into virions.
• The RNA and proteins move to the cell surface,
and new immature viruses bud off from the host
cell taking with them part of the host cell’s
membrane.
• These budding are said to leave ‘holes’ within
the membrane of the host cell, a factor that
contributes towards the death of the CD4 cells.
VIRUS MATURATION
• The protease enzyme is involved in this
final step by way of releasing individual
HIV proteins.
• You recall that this enzyme also took part
in the protein production step above.
• It thus acts both within the host cell’s
cytoplasm and after release of the virus.
Immune System Response to
HIV
• Cells of immune system are found in blood and tissue, they
include ;macrophages, neutrophils, Eosinophil's , B-
lymphocytes makes antibodies i.e.
• 1. T-helper cells ( CD-4) that helps in communication of
immune cells.
• 2.T-killer cells (CD-8) that destroys infected cells.
• HIV attacks the immune system. Specifically, it infects cells with
the CD4 molecule on their surface.
• The following immune cells have CD4 receptors:
• T-Lymphocytes–CD4+ Cells
• Macrophages
• Monocytes
• Dendritic cells.
 CT
• The most important of these is the helper T cells
(often abbreviated as TH). Helper T cells neither
make antibodies -the job of B cells - nor kill infected
cells -the responsibility of killer or cytotoxic T cells
(TC). Instead, they regulate the proliferation of B cells
in response to the presence of a particular antigen.
• When a TH cells recognizes the presence of the
antigen to which it is attuned, it becomes activated
which begins a process that culminates in B cells
proliferation and antibody production towards that
particular antigen.
Implications on the body’s
immunity
• By depleting the population of TH lymphocytes, HIV renders the
body unable to mount an immune response, leaving it vulnerable
to a host of bacterial, fungal, and viral infections (OPPORTUNISTIC
INFECTIONS) .The CD4 + T cell depletion is twofold, that is
reduction in numbers and impairment in function.
• The reduction in the CD4 cell number and the effects on their
function reduces the capacity of the body to fight infectious
diseases.
• The hallmark of HIV/AIDS is a profound immunodeficiency as a
result of depletion of CD4+T lymphocytes.
• Once HIV has entered the body, the immune system initiates anti-
HIV antibody and cytotoxic T cell production. However, it can take
one to six months for an individual exposed to HIV to produce
measurable quantities of antibody.
PHASES OF HIV INFECTION
• STAGE 1-Acute infection (Acute sero-conversion Syndrome) –This is
the first stage of HIV infection , when the virus establishes it self in
the body.
• Acute sero-conversion syndrome is used to describe the period of
time between when a person is first infected with HIV and when
antibodies against the virus are produced by the body. (usually 6-
12 weeks)
• People newly infected with HIV will experience “ flue-like”
symptoms, others do not have any symptoms or are so mild to be
noticed.
• This is the window period and the virus is multiplying inside the
infected persons body and can be passed on to others, but the
usual HIV test (antibody test) will produce a false negative report.
• It takes approximately 2-3 months for an infected person to
develop antibodies against HIV after which the test will be positive.
Stage 2: latent or Asymptomic
period(Asymptomic infection
• Acute stage of HIV infection remains latent (in the body)
usually for a period of to 10 years .
• Throughout this period the person stays infected and
infectious, but is unlikely to be aware of status until
he/she has been tested.
• The infected person appears healthy and has no
symptoms which suggest HIV infection.
• The immune response of an infected person is partially
able to suppress the HIV so that the amount of virus in
the body and bloodstream is reduced but not eliminated.
• Through out asymptomatic period there is progressive
damage of immune system as it tries to control the virus.
 CT
• This is demonstrated by a steady decline in
the number of CD4 cells in the blood.
• Some people will have persistently
enlarged nodes or generalized
lymphadenopathy.
• Person is infective and the HIV virus can be
detected in various body fluids and lymph
nodes.
• Also ,the antibody can be demonstrated in
the blood stream.
Stage 3:symptomic HIV Disease
• Eventually ,many individuals develop a variety of indicators
of ill health , weight loss and general weakness (asthenia)
are the most common clinical manifestation.
• HIV virus is beginning to affect the immune system.
• Symptoms may include swollen lymph glands , joint and
muscle pains , sore throat, fatigue , fever , night sweats and
diarrhea. Generally ,these symptoms may come and go
intermittently over a period of weeks or months.
• Mucocutaneous manifestations are common e.g.
Characterized generalized papular pruritic eruptions found in
20-60% of patients with HIV infections, lesions , papule
which releases small drop of fluid when scratched.
 CT
• Recurrent mucocutaneous herpes simplex
infections are found in 5-10 % , over 10% HIV
infection experience varicella Zoster infection.
• Oral candidiasis in the absence of antimicrobial
immuno suppressive therapy or illness is highly
associated with HIV infection
• Its occurrence in an HIV positive patient is often
a bad prognostic sign and an indication of
progression towards “full-blown “ AIDS.
stage 4:AIDS or Late HIV infection
• This is the final stage of HIV infection.
• Acquired - because it is a condition one must acquire or get
infected with.
• Immune – it affects the body’s immune system, the part of the
body which fights the germs such as bacteria and viruses.
• Deficiency –it makes the system deficient-not to work properly.
• Syndrome –someone with AIDS may experience a wide range of
different and opportunistic infections
• AIDS occurs when HIV has destroyed vital aspects of the
immune system leaving the body vulnerable to life threatening
infections e.g. pneumonia, tuberculosis, chronic and acute
meningitis , kaposis sarcoma, other neurological syndromes
WHO Clinical Staging of HIV
Stage 1
• Asymptomatic
• Persistent generalized lymphadenopathy.
Stage 2
• Moderate unexplained weight loss (< 10% of presumed
body weight)
• Recurrent respiratory tract infections
• Herpes zoster
• Angular cheilitis
• Recurrent oral ulcerations
• Papular pruritic eruptions
• Seborrheic dermatitis
• Fungal nail infections.
 CT
Stage 3
• Unexplained severe weight loss (> 10% of presumed body weight)
• Unexplained chronic diarrhoea for more than one month
• Unexplained persistent fever (intermittent or constant, lasting for
>1 month)
• Persistent oral candidiasis
• Oral hairy leukoplakia
• Pulmonary tuberculosis
• Severe bacterial infections (e.g. pneumonia, empyema,
meningitis)
• Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
• Unexplained anaemia, neutropenia and/or thrombocytopenia for
more than one month.
 CT
Stage 4
• HIV wasting syndrome (weight loss > 10%, plus either
chronic unexplained diarrhoea or
chronic unexplained fever)
• Pneumocystis pneumonia
• Recurrent severe bacterial pneumonia
• Chronic herpes simplex infection for more than one month
• Candidiasis of the oesophagus, trachea, bronchi or lungs
• Extra-pulmonary tuberculosis
• Kaposi’s sarcoma
• Cytomegalovirus infection
• Central nervous system toxoplasmosis
• HIV encephalopathy
• Cryptococcal meningitis or other extra-pulmonary cryptococcosis.
 CT
• Disseminated non-tuberculous mycobacteria infection
• Progressive multifocal leuko-encephalopathy
• Chronic cryptosporidiosis
• Chronic isosporiasis
• Disseminated mycosis
• Recurrent non-typhoid salmonella septicemia
• Lymphoma
• Invasive cervical carcinoma
• Atypical disseminated leishmaniasis
• Symptomatic HIV-associated nephropathy or HIV-
associated Cardiomyopathy.
HIV TESTING &COUNSELLING
• HIV testing should be voluntary and conducted ethically in an
environment where Consent, Confidentiality, Counselling, Correct results
and Connection (linkage) can be assured.
• To optimize access to testing services, HIV testing can be conducted in 3
different settings o Facility-based o Community-based o Self-testing
• All HIV-exposed infants (HEI) should have DNA PCR at 6 weeks and if
negative repeat at 6 months and 12 months. An antibody test should be
done at 18 months and then repeated every 6 months during
breastfeeding. The final antibody test should be performed 6 weeks after
complete cessation of breastfeeding
• The package of HIV testing services consists of:
• A pre-test session
• HIV test
• Assessment for other health-related conditions or needs (while HIV tests
are running)
• A post-test session (includes assisted partner notification services (aPNS)
and child testing)
• Referral and linkage to other appropriate health services (as part of the
post test session)
CT
• HTS providers should adopt the 6 approaches which are known to
improve linkage to treatment and prevention
• Provide information
• Support disclosure
• Address barriers to linkage
• Establish systems to facilitate linkage
• Coordinate and integrate service
• Document actions (using linkage registers)
Birth Testing is defined as HIV testing (with DNA PCR) at birth or first
contact within 4 weeks after birth, for infants born to known HIV-positive
mothers.
Birth testing has the potential to greatly improve survival for infants who
are infected during pregnancy and around labour and delivery by
identifying them early for rapid ART initiation.
 CT
• Infant of known HIV-positive mother at birth (or within 4 weeks of
birth)
• Collect DBS for DNA PCR 1
• Start infant ARV prophylaxis
ASSIGNMENT: Outline the information / counselling given to the
client during Pre-testing and Post- testing.
VCT-VOLUNTARY COUNSELING
TESTING
• It is the process by which a person seeks to find out
whether she /he is infected with HIV or not.
• A) VCT is voluntary:-
• VCT services are allowed always voluntary and strictly
confidential.
• The dignity of the client is carefully maintained.
• The client receive complete information about HIV/AIDS.
• CLIENT gives informed consent for the test to be done.
• Counselor's make sure that the client is requesting the
service without any coercion.
 CT
• B)VCT provides professional counseling:
• Profession counseling is a confidential dialogue between the
client and the care provider , with the aim of enabling the
client to cope with stress and to take personal decision related
to HIV/AIDS.
• Counseling help the client decide if they are really ready to
take the test and receive the result this help them understand
the results.
• Counseling helps the clients develop a plan to reduce future
risk of infection.
• C) VCT includes HIV testing:
• HIV testing is done in all VCT centres.
• Results are ready within a short (15-20min) the same day.
• Simple and rapid test are done in most VCT CENTRES.
 CT
• ALL positive results are confirmed within a second test.
• Its done by a trained counselor or lab technique.
• VCT is at the Centre of HIV prevention and care.
• PURPOSE OF VCT.
• To know ones HIV status.
• Help reduce risky behaviour.
• Enable early referrals for appropriate health services.
• Help client plan a future.
• Reduce transmission of HIV.
• Types of HIV testing :- VCT,DCT,RTC-Routine counseling
and testing , MCT-Mandatory counseling and testing,
surveillance testing.
BENEFITS OF VCT TO HIV
POSITIVE CLIENTS
• Prevention of HIV transmission to loved ones.
• Make informed decisions about marriage, pregnancy and
social relations.
• Clients learn about positive living i.e. taking care of ones
health in order to stay healthy and longer:-avoid unprotected
sex, good nutrition, follow up medical care, physical exercises
social support, being optimistic.
• Helps client cope with the psychological issues related to HIV
especially stigma.
• Assist disclosure to partners, families and children.
• Ensure early referrals for other services e.g. nutritionist, FP,
PMTCT, treatment of opportunistic infection, ART.
• Refer clients for legal assistance incase of need.
BENEFITS OF VCT TO
NEGATIVE CLIENTS
• Negative results are strong motivator to reduce risky behavior.
• Reduces fear, anxiety and hopelessness associated with past
risky behavior.
• Clients can seek treatment to other health problems without
fear.
• Clients can get married and plan pregnancy without doubt and
fear.
 LABORATORY TESTING
• The purpose is to establish presence of HIV infection.
• The diagnostic tests are two:- serological test-ELIZA.
• Viral detection methods- P24 marker.
• 1.SEROLOGICAL TESTS :-
• Are based on antibody-antigen reaction.
• They detect presence of antibodies in the blood
• Only reliable after window period i.e. time between the
onset of infection and appearance of detectable antibodies.
• Are common and widely used.
• Blood and blood serum are the sample used
• The serological test include :-
ELIZA-Enzyme Linked Immuno-
sorbent Assay
• They are both long and rapid –Elisa test used in the diagnosis
of HIV infection.
• Long test are done in the laboratory and takes about 3 days to
produce results.
• Rapid tests are simple and commonly done in the VCT
Centre's.
• They produce results in less than 20 min. a test kit from the
manufacturer is used e.g. determine , Unigold e.t.c
• CONFIRMATORY TEST:-
• Are used to confirm all the positive test , they are very specific
and sensible even to very low level of antibodies.
• They include :- Western blot , immuno-fluorescent antibody
assay.
2.VIRAL DETECTION METHOD
• Its used to detect viral antigens, the antigen may be viral DNA
or RNA or viral proteins or the viral particles .
• They include :-
• Polymerase chain reaction- PCR
• P24 Antigen Assay.
Comprehensive Care Clinic - CCC
• It is chronic care clinic that embrace chronic care model of providing health
care services to patients requiring long term care and treatment.
• HIV infection has no cure, and treatment is life-long. With HAART, persons
infected with HIV can live long and productive lives; it is our onus as health
care workers to support their care and treatment in a comprehensive
manner to help them live long, healthy and productive lives. The key focus is
to:-
• Promote- Promote healthy living (better diet, more physical activity and
tobacco cessation) and healthy societies, especially for the poor and those
living in disadvantaged populations.
• Prevent: Prevent premature deaths and avoid unnecessary disability due to
chronic diseases. The solutions exist now, and many are simple, cheap and
cost effective.
• Treat- Treat chronic diseases effectively, using latest available knowledge.
Make treatment available to all, especially those in the poorest settings.
• Care -Help provide appropriate care by facilitating equitable and good
quality health care for major chronic disease
Components of the Chronic Care
Model
• Health system-organization of Health care: Visible support of
improvements provided by senior leadership . Incentives for care
providers.
• Self-management Support:- educational resources, skills training
and psychosocial support provided to patients to assist them
managing their own care.
• Decision Support :Wide dissemination of practice guidelines.
Educational specialists support provided to healthcare team.
• Delivery System Design: Planned visits and sustained follow-up.
Clearly define roles of healthcare team.
• Clinical Information Systems: Surveillance system that provides
alerts, recall and follow-up information.
• Community Resources and Policies: Identify effective programs
and encourage appropriate participation. Referral to relevant
community-based services.
TRIAGE OF PATIENTS IN THE
HIV CLINIC
• Triage- can be defined as the process where treatment of
patients is prioritized based on the severity .The term
comes from the French verb “trier”, meaning to
separate, sift or select.
• PRINCIPLES OF TRIAGE:-
• Patients should be quickly assessed upon arrival at the
Health Facility.
• Assessment should be done by a qualified HCW who can
rapidly classify patients based on severity of illness or
likelihood of deteriorating rapidly.
• Patients identified as requiring urgent medical attention
are seen by a senior HCW immediately before other
patients are attended.
Importance of Triage
• Patients who are critically ill or who may deteriorate rapidly
(such as young children) are quickly identified and
immediately stabilized. If these patients wait on the queue
they may die before being attended to .
• Triage can be part of the facility infection prevention protocol
by identifying coughing patients who can be seen early or
asked to wait in a special well-ventilated area to reduce air
borne disease transmission like TB .
• Triage can enhance task shifting by identifying stable patients
who can be seen by less experienced HCWs e.g. prescription
for the drug pick ups .
• Triage can identify patients who need attention at specific
departments, such as pregnant women who may need to be
seen at the MCH
Process of Triage
• Identifying patients who need to be seen urgently
• Documenting the triage findings
• Providing urgent medical management for the priority
patient.
 Management of HIV clinic
Activities that take place in HIV clinic:-
• Patient education .
• Triage of patients.
• Provision of medication.
Initial clinical evaluation of PLHIV entails:
• Providing counseling, assessing for ART readiness, and providing/linking
to psychosocial support
• Taking a complete medical history
• Conducting a thorough physical examination
• Appropriate laboratory investigations, although laboratory assessment
is not a prerequisite to ART initiation
2.CD4 monitoring, which is recommended for:-
• Baseline investigation for all PLHIV
• Any patient with suspected treatment failure
• Any patient on fluconazole maintenance therapy or on dapsone as
prophylaxis, to determine when prophylaxis can be discontinued
Frequency of routine VIRAL
LOAD monitoring
• For PCR positive HEIs: at baseline at the time of ART initiation
• Age 0-24 years old: every 6 months
• Age ≥ 25 years old: at month 6, 12, and then annually.
• Pregnant or breastfeeding: at confirmation of pregnancy (if
already on ART) or 3 months after ART initiation (if ART initiated
during pregnancy/breastfeeding), and then every 6 months until
complete cessation of breastfeeding
• Before any drug substitution (if no VL result available from the
prior 6 months)
• Three months after any regimen modification (including single-
drug substitutions)
NB- PLHIV should receive differentiated care based on initial
evaluation (advanced vs. well) and follow up (unstable vs. stable)
Role of the Nurse in HIV clinic
• Triage patients.
• Continuation of clinical care of stable
patients.
• Nursing care.
• Adherence counseling.
• Detection of side effects and adverse
effects of medication.
Management of HIV infection
• CLINICAL SUPPORT:-
• Management of opportunistic infections and conditions.
• Antiretroviral therapy
• Opportunistic infections.
• The occurrence of an OI depends on both.
• Rate of progression of HIV infection.
• Extent of suppression of immune system.
• Management of opportunistic infections and conditions.
• NB: The main burden of disease in PLWHIV is from opportunistic infections.
• NON –CLINICAL SUPPORT:-
• Spiritual support.
• Psychosocial support .
• Emotional support.
• Human Rights and Legal support.
• Physical .
• Social .
CT
• NUTRITIONAL INTERVENTIONS
• Identify available, accessible healthy foods.
• Counsel and/or plan a diet with a patient taking into
consideration the following issues.
• Recommended additional energy intake.
• Encourage a healthy diet.
• Promote food safety.
• Drug –food interaction.
• Special concerns – pregnancy, children.
Standard package of Care for
PLWHIV-8 components of care
• Antiretroviral therapy.
• Positive Health ,Dignity and Prevention.
• Screening for and prevention of specific
opportunistic infections.
• Reproductive health services.
• Screening for and management of Non-
communicable diseases.
• Mental health screening and management.
• Nutrition services.
• Prevention of other infections.
Components of the Standard
Package of Care for PLHIV
Component of Standard Package of Subcomponents
Care

1. Antiretroviral therapy (ART)

• Patient preparation
• ART
• Monitoring (clinical and laboratory)

2. Positive health, dignity and

prevention; gender-based violence • Positive health, dignity and
(GBV) and intimate-partner violence prevention components o Disclosure
(IPV) screening; and HIV o Partner/family testing
education/counselling o Condom use
o Family planning
o STI screening, prevention, and
treatment
o Adherence counselling and support

• GBV/IPV screening and support

CT
3. Specific opportunistic infection
screening and prevention • Cotrimoxazole preventive therapy
• Tuberculosis (TB) o Intensified case
finding
o Isoniazid preventive therapy
o ART for TB/HIV co-infected patients

• Cryptococcal meningitis ( fluconazole

200mg )

4. Reproductive health services

• Sexually transmitted infections
screening and management
• Family planning and pre-conception
services
• Maternal healthcare
• Cervical cancer screening
CT
5.Non-communicable diseases
screening and management • Hypertension
• Diabetes mellitus
• Dyslipidaemia
• Chronic kidney disease
• Other NCDs

6. Mental health screening and

management • Depression
• Alcohol and drug use/addiction

7. Nutritional services
• Assessment
• Counselling and education
• Management and support
CT
8.Prevention of other infections
• Immunizations
• Malaria
• Safe water, sanitation and hygiene
OTHER ESSENTIAL PACKAGE
OF CARE FOR PLWHIV
• Counselling and psychological support.
• Prevention with positives.
• Co-trimoxazole prophylaxis therapy.
• Tuberculosis prevention and treatment among PLHIV.
• Sexually transmitted and other reproductive tract
infections.
• Screening for cervical cancer.
• Preventing Malaria.
• Vaccination and immunization.
• Reproductive Health and Family Planning.
• Nutrition .
• Safe water, sanitation and hygiene.
ANTRETROVIRAL DRUGS
• OBJECTIVES:-
• Define ARVS and state their mode of actions.
• List the major classes of ARVS with examples.
• Describe the mechanism of action for each major
class of ARVS.
• State the standard dosages for first and second
line regimens of the HAART concept.
• Explain the principles of ART treatment.
• State the goals of ART.
• Outline the benefits of ART
 Define ARVS
• ARVS are medicine that reduce the number of
circulating HIV virus(virological goal).
• They prevent the HIV from making new copies of
itself.
• Ensure there’s reduced damage to immune
systems leading to improved immune
functioning and delay in onset of AIDS
(immunological goal).
• Enhance quality of life and reduce emergency of
opportunistic infection (therapeutic goal)
• Reduces the impact of HIV transmission in the
community (epidemiological goal)
 Indications for ARVS
1.Antiretroviral therapy-treatment of infected
persons meeting treatment criteria.
2.ARVS for Prophylaxis:-
• Prevention of mother to child HIV
transmission(PMTCT)
• Post Exposure Prophylaxis (PEP)-prevention of
infection in exposed uninfected person e.g needle
stick injury , sexual assault.
• Pre - Exposure Prophylaxis (PreP)-prevention of
infection in exposed most at risk persons e.g PWID
, commercial sex workers , discordant couples
Principles of ART treatment
• ART is part of the comprehensive care of HIV infection.
• Current ART does not cure HIV infection.
• Treatment should be planned and started in good time.
• Regular follow-up and monitoring is essential.
• Adherence and compliance is key to successful
treatment.
• Treatment should be stopped or changed when
necessary .
• The choice of drug should take into account:-
• Efficacy
• Dosing schedule.
• Affordability .
• Availability .
• Tolerability .
 GOALS OF ART
• 1.Improvement of quality of life –ART is used to prolong and
improve quality of life in people living with HIV VIRUS .Therefore the
good of therapy.
• 2.Maximal and durable suppression of HIV replication :- viral load is
a measure of viral replication. ARVS drugs should achieve
suppression of HIV replication. Hence a combination of 3 ARV drug
from two different classes are used to achieve the above suppression
of HIV replication results in:-
• Stoppage of disease progression.
• Delay in emergency of drug resistance subtype virus.
• 3.Restoration and preservation of immunology function:-CD4 count
is the measure of immune status of a person.
• Suppression of HIV replication- prevents CD4 cell destruction by HIV ,
Allow CD4 cells to recover both in number and improve function
 CT
• Reduce the risk of opportunistic infection which may
weaken the immune status. Hence there is improved
overall function of the immune system.
• This takes time and also the drugs should adhered to.
• With effective ART the median increase is CD4 count is
100 to 150 cells per year.
• CD4 count in patients on ART should be monitored after
every 6months.
• 4.Reduction of HIV related morbidity and mortality:-
This is evidenced by decrease hospitalization, decreased
risk of illness, reduction of all opportunistic ,
inflammation and malignancies, reduction of HIV related
deaths. Ability to return to work and live a longer more
productive life.
Classification of ARV DRUGS
• Major classes of ARVS:-
• Reverse Transcriptase Inhibitors (RTIs)-
Nucleoside Reverse Transcriptase inhibitors
(NRTIs) , Nucleotide Reverse Transcriptase
Inhibitors (NtRTIs) , Non-nucleoside Reverse
Transcriptase Inhibitors.
• Protease inhibitors (PI)
• Fusion inhibitors.
• Integrase inhibitors
TARGETS OF ARV DRUGS
 CT
• Antiretroviral drugs are combined to achieve good results.
• The drugs are grouped into three different classes according to
how they work on the HIV virus.
• They have been found to provide Highly Active Anti-retroviral
Therapy.
• Reverse Transcriptase Inhibitors:-
• NRTIs inhibit reverse transcription by competitively blocking
reverse transcriptase enzyme activity due to their
resemblance in structure to the viral nucleosides i.e it sits on
the active site of the enzyme receptor . Form the back bone of
the ART regimen.
• NtRTIs work in the same way as the NRTIs but differ in
chemical structure. NtRTIs already has a phosphate group but
NRTIs get phosphorylated in the
ABBREVIATIONS &NAMES OF
ARVs
• 3TC – Lamivudine
• ABC – Abacavir.
• ATV – Atazanavir
• ATV/r –Atazanavir/ritonavir
• AZT –Zidovudine.
• DRV – Darunavir.
• DRV/r – Darunavir/ritonavir.
• DTG – Dolutegravir.
• EFV – Efavirenz.
• ETR – Etravirine.
• FTC – Emtricitabine.
• LPV – Lopinavir.
• LPV/r – Lopinavir/ritonavir.
• NVP – Nevirapine.
• RAL – Raltegravir.
• RTV- Ritonavir.
• TDF – Tenofovir Disoproxil Fumarate.
Examples of NRTIs & NtRTIs
GENERIC NAME ADULT DOSAGE PEDIATRIC DOSAGE
Stavudine d4T 30mg BD 1MG/KG BD
Lamivudine 3TC 150mg BD/300mg OD 4mg/kg BD
Zidovudine AZT or ZDV 300mg BD 180-240mg/m2
Didanosine ddi 125mg BD and 200mg 120 mg /m2 BD
BD for <60kg and >60kg
respectively
Abacavir ABC 300mg BD/600mg OD 8mg /kg BD
Tenofovir TDF 300mg OD Not recommended .
It causes decreased bone
marrow density for
children and
adolescents<18years
GENERIC NAME
NNRTI
ADULT DOSAGE PAEDIATRIC DOSAGE
Nevirapine NVP 200mg OD for 2 weeks 120-160 mg /m2 OD for
then 200mg BD weeks then BD

Efavirenz EFV 600mg OD

Efavirenz dosages for As per kg weight dosages
children
Avoid fatty meals with
EFV –Increases
absorption by 50%
ETR – Etravirine.

Dilaviirdine 600mg BD

NNRTI –work by binding

directly on to reverse
transcriptase preventing
the conversion of RNA to
DNA and this stops HIV
production
PROTEASE INHIBITORS
• Works at the last stage of the virus reproduction cycle.
• They prevent HIV virus from being successfully assembled and
released.
• Inhibits the cutting down of the core multi-protein molecule to
functional viral protein molecules essential for HIV replication.
• Enzymes , core proteins , envelop proteins regulatory proteins
• Enzymes and building block proteins are needed to make
complete copies of the virus which can infect the cells.
• ATV/r –Atazanavir/ritonavir , LPV – Lopinavir , DRV – Darunavir
, RTV- Ritonavir.
Examples of PIs
GENERIC NAME ADULT DOSAGE PEDIATRIC DOSAGE
•
Indinavir IDV 800mg TDS
Liponavir/ritonavir 400mg/100mg BD <15KG=12mg LPV/kg
LPV/r >15kg = 10mg LPV/kg
Twice daily
Ritonavir RTV 200/400mg
daily(booster dose) or
600mg BD
Saquinavir SQV/r 600mg tds/1000mgbd
1200 MG TDS
Amprenavir/ 1400mg BD
Fosaprenavir
(fosamprenavir)
Atazanzvir ATV/r 400mg OD
Nelfinavir 750mg-1200mg BD
ENTRY & FUSION INHIBITORS
• Prevent HIV from entering healthy CD4 cells, most of them are
still being investigated.
• The only drug marketed in this category is ENFURVITIDE.
• It is provided as a powder to be reconstructed before
subcutaneous injection once daily. NOT feasible for public
health use.
• Very expensive , used as salvage therapy.
• Anew fusion inhibitor is MAROVERIC .Not yet in use.
• Block entry of virus into the host CD 4 receptors, dendritic
cells , monocytes , T-lymphocytes.
INTEGRASE INHIBITORS
• Inhibit the integrase enzyme which is responsible for integration of the
virus DNA .
• RALTEGRAVIR –recently approved for use by food and drugs association
FDA and registered in Kenya by PPB pharmacy and poisons board.
• DOLUTEGRAVIR (DTG) -
• ≥ 15 years (or ≥ 35 kg body weight): DTG 50 mg once daily, preferably as a
morning dose .
• DTG is preferred in first line ART in combination with two other ARVs for
adolescents and adults. DTG is not recommended for women and
adolescent girls of childbearing potential.
• NB- HAART is the Gold standard, it is a combination of three or more ARVs
in the treatment of HIV infection:
• Ensures maximal effect on suppressing the virus.
• Ensures prolonged effect.
• Delays emergence of drug resistance
• These ARVs work in different ways to prevent the HIV from multiplying and
infecting new cells.
 Recommended HAART
regimens
• Drug combination from different classes.
• 2 NRTIs/NtRTI +NNRTI
• 2NRTIs + 1PIs
• 2 NRTIs/NtRTI+ 2PIs
• 3NRTIs (one drug must be ABC)
• All individuals with confirmed HIV infection are eligible for
ART ,irrespective of CD4 count , WHO clinical stage ,
pregnancy or breastfeeding status , co-infection status ,
risk group or any other criteria provided that the client is
willing and ready to take ART and adhere to follow –up
recommendations.
• ART should be started in all patients as soon as possible
preferably within 2 weeks of confirmation of HIV status.
CT
• Preferred first-line ART for infants , children ,
adolescents and adults - :
• Birth to 4 weeks; AZT+3TC+NVP
• 4 weeks<3years:ABC+3TC+LPV/r
• 3-14Years(and <35kg body
weight):ABC+3TC+EFV.
• > 15 years(or>35kg body
weight):TDF+3TC+DTG(or TDF+3TC+EFV for
women and adolescent girls of childbearing
potential).
BENEFITS OF ART
• Allows CD4 cells to increase and strengthen the immune
system .
• Prevents multiplication of virus.
• Reduces incidences of opportunistic infections.
• Improves quality of life.
• Decreases morbidity and mortality.
 PREVENTION OF MOTHER
TO CHILD HIV
TRANSMISSION (PMTCT)
• Routine antenatal care (ANC) offers an important opportunity to
provide high quality combined HIV prevention through targeted health
education and counselling; HIV testing for the woman, partners and
family members; linkage to HIV prevention and treatment; and to
discuss and plan for future contraception needs.
• Prevention of mother-to-child transmission (PMTCT, also known as
prevention of vertical transmission), refers to interventions to prevent
transmission of HIV from an HIV-positive mother to her infant during
pregnancy, labor, delivery, or breastfeeding.
• Over 90% of new infections in infants and young children occur through
MTCT.
• Prevention of mother-to-child transmission of HIV (PMTCT) should be
offered as part of a comprehensive package of fully integrated, routine
antenatal care interventions.
Risk Factors For MTCT
Transmission Of HIV
1. High viral load
2. Immune deficiency (low CD4 count)
3. HIV infection acquired during pregancy or breastfeeding period
4. Vaginal delivery
5. Premature delivery
6. Duration of breast feeding, mixed feeding and breast disease
(mastitis/cracked nipples)
Essential Package of Antenatal
Care
• Group & Individual Education.
• Counselling.
• PHDP, IPV and HIV education/ counselling: For HIV positive
women, encourage and support disclosure of HIV status,
partner/ family testing, condom use, post-partum
contraception, STI screening, prevention, and treatment,
adherence counselling and support, assessment for and
prevention of Intimate Partner Violence (IPV) and continued
HIV education/counselling.
• Clinical Evaluation.
• Antenatal Profile.
• Additional tests for HIV positive.
CT
• Offer appropriate preventive and treatment services E.g:
• Maternal TT immunization
• Iron, folate and multivitamins
• Syndromic STI treatment if indicated
• Malarial prophylaxis (Note: women who are on CPT do not
require SP)
• Insecticide-treated nets
• For HIV positive pregnant women: Start or continue lifelong
ART (Section 6), IPT (isoniazid 300 mg once daily for 6 months)
and CPT. Perform VL for women starting ANC while on ART
 HIV infection confirmed in HIV Exposed
Infants (HEI) and Children 18 Months and
below
• Confirmation of HIV infection in All HEI should be tested with DNA
PCR within 6 weeks of age or first contact
• thereafter; if negative then another DNA PCR at 6 months,
• and if negative then repeat DNA PCR again at 12 months. This
replaces previous guidelines to perform antibody testing for infants
at 9 months.
• An antibody test should be performed for all HEI at 18 months old
and every 6 months thereafter during breastfeeding, and also 6
weeks after complete cessation of breastfeeding
NATIONAL PMTCT PROGRAM
• MTCT transmission rate of Elimination for this purpose is
defined as a MTCT transmission rate of <5% (UNAIDS)
• The elements of the elimination plan include:
• i. Health services delivery strengthening
• ii. Community participation strengthening
• iii. Effective partnerships and advocacy
• iv. Tracking progress
CT
• The plan emphasizes on collective responsibility
for all community programs and healthcare
workers to ensure that:
• All pregnant women in the community attend
early ANC and are tested for HIV .
• All health facilities deliver full ART as the PMTCT
regimen of choice to HIV positive pregnant
women
• All HIV positive women and their infants receive
chronic longitudinal care.
4-PRONGS OF PMTCT OR
ELEMENTS
• The 4 prongs are:
• Primary prevention of HIV: supporting women to remain
HIV negative before and during pregnancy as well as during
lactation
• Prevention of unwanted pregnancies: all women of
reproductive age including HIV positive women have access
to effective family planning services
• Prevention MTCT of HIV among infected women: using
recommended interventions for the HIV positive mother
and for the exposed infant
• Chronic care, treatment and follow up: for HIV infected
women, the exposed and infected infants and other family
members
CT
• The primary prevention of HIV infection :
• Health information and education
• HIV testing and counseling - regular retesting for those with
exposure
• Couple counseling and partner testing
• Safer sex practices, including dual protection (condom
promotion)
• Delay of onset of sexual activity
• Behavioral change communications to avoid high risk
behaviour
CT
• The prevention of unintended pregnancies among HIV-infected
women.
• FP counseling and services to ensure women can make informed
decision about their reproductive health
• HIV testing and counseling in RH/FP services
• Safer sex practices, including dual protection (condom promotion
• Prevention HIV transmission from HIV-infected women to their infants.
• Quality antenatal and delivery care
• HIV testing and counselling in ANC, retesting in late pregnancy .
• Clinical (staging) and immunological (CD4) assessment of pregnant
women
• ART for pregnant women eligible for treatment
• Safer obstetric practices
• Infant feeding counseling and support
CT
• Provision of treatment, care and support for HIV-infected
mothers, their infants and family.
• To the mother:
• ART for women eligible for treatment
• Co-trimoxazole prophylaxis
• Continued infant feeding counselling and support
• Nutritional counselling and support
• Sexual and reproductive health services including FP
• Psychosocial support
services that you will offer to
the mother and the infant
during
• Infant
this visit
• Infant prophylaxis o AZT+NVP for 6 weeks, NVP should be
continued until 6 weeks after complete cessation of breastfeeding
• The infant prophylaxis regimen applies to all infants irrespective of
age when identifying HIV exposure (e.g. mother diagnosed HIV-
positive in the postpartum period)
• DBS or whole blood for PCR at 6 weeks at first contact
• All routine CWC services.
• Nutritional counselling
CT
Mother
• If mother not on ART, initiate ART as soon as possible (preferably same
day)
• Linkage and referral for prevention, care and support services
• All HIV positive and breastfeeding women enrolled into care should
receive counselling and support (including assisted disclosure), case
managed linkage and follow-up for comprehensive treatment and
prevention (including lifelong ART)
• All spouses/partners of pregnant and breastfeeding women should be
offered HIV testing and counselling and all children if the mother is HIV
positive
• All breastfeeding women should receive information on risk reduction
• Post-partum contraception: counsel on contraception methods and
help patient develop a plan for effective contraception to avoid
unplanned pregnancies
• Nutritional counselling
 ARVs for Post-exposure
Prophylaxis (PEP)
• Post-exposure prophylaxis (PEP) is short-term use of antiretroviral
treatment to reduce the likelihood of HIV infection after potential
exposure. People can be accidentally exposed to HIV through healthcare
work or due to exposures outside healthcare setting, for example, through
unprotected sex or sexual assault among adults and children.
• Healthcare workers are at increased risk of exposure to HIV through
contact with contaminated blood and other body fluids containing HIV
through needle stick injuries and injuries by other sharp objects or through
non-intact skin and mucous membranes.
• To avoid exposure to HIV, precautions should be taken when handling
possibly contaminated body fluids including the use of appropriate barriers
such as gloves, gowns and goggles; care with sharps including minimizing
blind surgical procedures and proper handling and disposal of sharps; safe
disposal of contaminated waste; safe handling of soiled linen; adequate
disinfection procedures and universal Hepatitis B vaccination of non-
immune at risk groups including HCWs, police, prison staff and rescue
workers
indications for PEP eligibility
• Exposed individual is HIV negative at baseline
• Exposure must have occurred within the past 72 hours
• Exposure must be high-risk (high-risk type AND material) o Type:
mucous membrane; non-intact skin, or; percutaneous injury o
Material: blood or bloody body fluids; breast milk; semen; vaginal
secretions; synovial, pleural, pericardial, amniotic fluids; CSF, or; HIV
cultures in lab
• Note: HIV status of the source is no longer part of the risk
stratification for PEP, because even if the source tests HIV negative by
rapid antibody test they may still be in the window period of acute
HIV infection so should be assumed to be positive
• Note: if a breastfeeding mother starts PEP because of HIV exposure,
the infant does not require PEP or infant prophylaxis as well. The
infant should continue breastfeeding
 CT
• PEP should be offered as soon as possible (< 72 hours) after high risk
exposure
• The recommended ARV agents for PEP are 0-14 years (and < 35 kg):
ABC + 3TC + LPV/r o ≥ 15 years old (or ≥ 35 kg): TDF + 3TC + DTG (or TDF
+ 3TC + ATV/r for women and adolescent girls of childbearing potential)
AZT can be used as an alternative when TDF or ABC cannot be used
• For children who cannot tolerate LPV/r: RAL or DRV/r can be used
instead
• Follow up client at 7 days, 14 days, 28 days, and 12 weeks after
starting PEP
• Follow-up HIV testing at 4 weeks, if negative, test again at 12 weeks
after which test as per risk category.
• Assess for and manage side effects due to PEP
 CT
• Other services for sexual assault:
• STI prophylactic treatment to all (treat for vaginal/urethral discharge
syndrome following the national STI algorithms)
• Emergency contraception for non-pregnant women
• Tetanus toxoid for any physical injury of skin or mucous membranes
• Documentation of clinic evidence of assault and collection of forensic
evidence
• Refer to post-rape care guidelines for additional details
Oral Pre-Exposure Prophylaxis
(PrEP)
• Oral PrEP should be offered to HIV negative individuals at
substantial ongoing risk of HIV infection (including the
seronegative partner in a discordant relationship)
• The recommended ARV regimen for use as PrEP is: TDF (300 mg)
+ FTC ( 200 mg) once daily.
• Alternative regimen: TDF 300 mg once daily OR TDF/3TC 300
mg/300 mg as FDC once daily (TRUVADA)
• PrEP does not eliminate the risk of HIV infection and it does not
prevent STIs or unintended pregnancies.
• PrEP should only be offered after assessment to establish
eligibility, readiness for effective use.
• Required follow-up (including HIV testing every 3 months) and
absence of contraindications to TDF and/or FTC .
.
Indications and Criteria for PrEP
Indications
• PrEP is offered to sexually active HIV-negative individuals who are at
substantial risk of acquiring HIV infection as defined by any of the following:
• Sexual partner is known HIV positive and: not on ART, or on ART < 6 months,
or suspected poor adherence to ART, or most recent VL is detectable
• Sexual partner/s are of unknown HIV status and are at high-risk for HIV
infection (has multiple sexual partners, has had STIs, engages in transactional
sex, injects drugs, from high HIV burden settings)
• Engaging in transactional sex
• History of recent sexually transmitted infection
• Recurrent use of post-exposure prophylaxis
• History of sex whilst under the influence of alcohol or recreational drugs as a
habit
• Inconsistent or no condom use or unable to negotiate condom use during
intercourse with persons of unknown HIV status
• Injection drug use where needles and syringes are shared
• Sero-discordant couples trying to conceive
CT
• Criteria: To qualify for PrEP, patients must meet ALL of the following
criteria:
• Confirmed HIV negative (rapid antibody testing following the HTS
algorithm on the day of PrEP initiation is adequate confirmation of HIV-
negative status)
• Does not have a current or recent (within past one month) illness
consistent with acute HIV infection (fever, sore throat, muscle or joint
pains, swollen glands, diarrhoea or headache) in combination with a
preceding high-risk exposure for HIV
• Assessed as ready to adhere to PrEP and willing to attend follow-up
evaluations including repeat HIV testing and monitoring for side effects
• No contraindication to use of TDF +/- FTC (or 3TC)
NB: PrEP does not eliminate the risk of HIV infection and it does not
prevent STIs or unintended pregnancies. It should, therefore, be
offered as part of a combination prevention package that includes risk
reduction counselling, HIV testing, condoms and lubricants, STI
screening and treatment, contraception, needle exchange and opioid
replacement therapy
Opportunistic infections
• These are infections/conditions which manifest when a person
is immunosuppressed.
• Common Ois include:
• Bacterial infections-systemic, respiratory and skin infections eg
pneumonia , TB, PCP, Non typhi salmonella e.t.c
• Fungal infections-systemic and cutaneous infections e.g
candidiasis , cryptococcosis, histoplasmosis , aspergillosis.
• Parasitic infections-toxoplasmosis , cryptosporidiosis ,
microsporidiosis.
• Viral infections – herpes simplex , varicella zoster ,
cytomegalovirus , hepatitis A,B etc.
• HIV related malignancies – kaposi’s sarcoma ,primary CNS
lymphoma , carcinoma of the cervix , other lymphomas.
Principle of management of OIs
• Identification and diagnosis.
• Treatment ;general , symptomatic specific.
• Adherence to treatment is key to success of any disease condition.
• All patients need support to adhere and complete treatment.
• Treat Opportunistic infections first where applicable.
• Introduce ART when patients has tolerated the treatment and
ready to take more pills.
• Always enquire about side effects and offer appropriate advice on
the same.
• NB: opportunistic infections cause vast majority of morbidity and
mortality associated with HIV.
• Most are readily treatable and /or preventable.
• Most of these treatment are available , simple and affordable.
• Duration of treatment is usually short except TB which takes 6
months.
PROPHYLAXIS TO PREVENT
OPPORTUNISTIC INFECTIONS
• Cotrimoxazole Prophylaxis Therapy – CPT
• Isoniazide Prophylaxis Therapy. - IPT
• fluconazole maintenance therapy.
• Dapsone as prophylaxis.
Screening for and Prevention of
Specific Opportunistic Infections
• All PLHIV should receive lifelong cotrimoxazole preventive therapy (CPT) unless
they have allergy to sulfa drugs or develop toxicity from CPT
• During pregnancy, CPT should be initiated irrespective of the gestational age and
should continue throughout pregnancy, breastfeeding, and thereafter for life
• When Dapsone (as a substitute for CPT) is being used as PCP prophylaxis, it is only
recommended for patients in WHO Stage 4 and/or absolute CD4 count ≤ 200
cells/mm 3 (or CD4% ≤ 25% for children ≤ 5 years old), and should be
discontinued once a patient achieves viral suppression and a sustained CD4 count
of > 200 cell/mm3 (or > 25% for children ≤ 5 years old) for at least 6 months.
• All PLHIV should be screened for TB at every visit using the Intensified Case
Finding (ICF) tool and assessed for Isoniazid Preventive Therapy (IPT) if screened
negative for TB.
• All adolescent and adult PLHIV with a baseline CD4 count of ≤ 200 cells/mm3
should be screened for cryptococcal infection using the serum CrAg test and
started on fluconazole maintenance therapy of 200mg tablet daily until the CD4
count of > 500 cells/mm3.
PSYCHOSOCIAL CARE &
COUNSELLING
• INDIVIDUAL /GROUP COUNSELLING
• Psychosocial Concerns at Different Level:
• At Individual level;
• Self- stigmatization and isolation
• Poor parenting
• Caring for HIV infected parents and siblings
• Separation and isolation from sibling and other family
members
• Chronic illness
• Death or sickness of the parents
• Loss of home and property
At family level;
• HIV illness in multiple family members
• Poverty
• Stigma and discrimination
• Multiple losses
• Dysfunction al relationship
• Single parenting
• Child headed house holds
• Elderly care givers chronic illness e.g. hypertension, diabetes
and arthritis
• Death and bereavement
At community level:
• Lack of knowledge on HIV
• Lack of knowledge of children’s need worsening poverty
• Stigma and discrimination
• Increased numbers of orphans and vulnerable children
• Peer influence
Primary prevention of HIV
infection strategies in Kenya
• Prevention HIV infection comprises of 7key elements/
Strategies
• These are:-
• Behavioral interventions- the ABC (abstinence , Be faithful ,
condom , condom use ) prevention strategy.
• HIV testing and counselling , using individual risk as the basis
for counselling.
• Voluntary Medical Male Circumcision (VMMC)
• Health facility HIV prevention.
• Treatment of sexually Transmitted infections (STIs)
• Community engagement in HIV prevention.
• ART for MTCT and HIV prevention.
 Counseling and Psychosocial
support
• Mitigation of fear, anger, self-stigma and discrimination,
• Alleviation of grief, bereavement and stress among partners and family
members,
• Behaviour change in support of healthy living and prevention of further
HIV transmission,
• Disclosure and partner’s notification, and age appropriate disclosure for
children
• Family/partner counselling to identify family members, who may need
care and treatment,
• Skills-building on how to live a healthy and productive life,
• Identification and treatment of depression and substance abuse.
Mental illness and substance and alcohol dependence are common
conditions among PLHIV. These conditions, besides affecting the quality
of life of patients can cause non-adherence to prophylactic and ART
regimens as well as undermine safer sex practices; and
Evidence based behavioral
interventions
• ABC approach.
• Reduction of sexual partners.
• Delay sexual debut.
• Control of alcohol consumption and substance abuse.
• In your opinion what are some of the social cultural factors
that influence behavior change adoption.
• Stigma , HIV status , Gender inequality , substance use.
• Power dynamics .
• Multiple partners and concurrent partnerships.
• Social-cultural norms.
• Legal factors.
• Cultural issues e.g. wife inheritance.
BEHAVIOR CHANGE
COMMUNICATION (BCC)
• Behavior change communication (BCC) is an interactive process with
communities (as integrated with an overall program) to develop
tailored messages and approaches using a variety of communication
channels to develop positive behavior's ;promote and sustain
individual, community and societal behavior change.
• In context with HIV/AIDS BCC is an essential part of a comprehensive
program that includes both services(medical , social, psychological
and spiritual) and commodities ( condoms , needles and syringes).
• Both individuals and communities can reduce their level of risk or
change behaviors after understanding basic facts about HIV and AIDS.
• Adopt key attitudes , learn a set of skills and be given access to
appropriate products and services.
• They must also perceive their environment as supporting behavior
change and the maintenance of safe behaviors, seeking appropriate
treatment for prevention , care and support.
ROLE OF BEHAVIOR CHANGE
COMMUNICATION
• Effective BCC can :
• Increases knowledge – BCC can ensure that people are given the basic
facts about HIV and AIDS in a language or visual medium or any other
medium that they can understand.
• Stimulate community dialogue – encourage national discussion on the
basic facts of HIV , the underlying factors to the epidemic , such as risk
behaviors , environments and cultural practices related to sex and
sexuality and practices such as drug use. It can also stimulate
discussion of healthcare seeking behaviors for prevention , care and
support.
• Promote essential attitude change – e.g. perceived personal risk of HIV
infection , belief in the right to and responsibility for safe practices and
health supporting services , compassionate and non-judgmental
provision of services, greater open-mindedness concerning gender
roles and increasing basic rights of those vulnerable to affected by HIV
and AIDS.
 CT
• Reduce stigma and discrimination- communication about HIV
prevention and AIDS mitigation should address stigma and
discrimination and attempt to influence social responses to them.
• Create a demand for information and services – BCC ca spur
individuals and communities to demand information on HIV/AIDS and
appropriate services.
• Advocate - can lead policymakers and opinion leaders toward
effective approaches to the epidemic.
• Promote services for prevention , care and support. – BCC can
promote services for STIs , IDUs , orphans and vulnerable children ,
voluntary counseling and testing for mother to child transmission ,
support groups for PLHA; clinical care for opportunistic infections ,
social and economic support.
• Improving skills and sense of self –efficacy – BCC programs can focus
on teaching or reinforcing new skills and behaviors such as condom
use , negotiating safer sex , safer injecting practices . It can contribute
to development of a sense of confidence in making and acting on
decisions
THE PROCESS OF BEHAVIOR
CHANGE
Stages of behavior Enabling factors channels
change continuum
Unaware Providing effective Mass media
communication
Aware
Concerned Creating an enabling Community networks
environment – policies , and traditional media
community values ,
human rights
Knowledgeable
Motivated to change
Practicing trial behavior Providing user-friendly , Interpersonal / group
accessible services and communication.
commodities
Practicing sustained
behavior change
BCC GOALS
• Increase condom use.
• Increase appropriate STI care seeking behavior.
• Delay sexual debut.
• Reduce number of partners.
• increase perception of risk or change attitudes towards use of
condoms.
• Increase demand for services.
• Create demand for information on HIV and AIDS.
• Create demand for appropriate STI services
• Interest policymakers in investing in youth –friendly VCT
services.
• Promote acceptance among communities of youth sexuality
and the value of reproductive health services for youth.
GUIDING PRINCIPLES
• BCC should be integrated with program goals from start – it is an
essential element of HIV prevention , care and support programs ,
providing critical linkages to other program components , including
policy initiatives.
• Formative BCC assessments – must conduct to improve understanding
of the needs of target populations , barriers , support for behavior
change.
• The target population should participate in all phases of BCC
development and in much of implementation.
• Stakeholders need to be involved from the design stage.
• Having a variety of linked communication channels is more effective
than relying on one specific one.
• Pre-testing is essential for developing effective BCC materials.
• Planning for monitoring and evaluation should be part of the design of
any BCC program.
• BCC strategies should be positive and action-oriented.
• PLHA should be involved in BCC planning and implementation.
Steps in developing a behavior
change
State program.
communication
Involve stakeholder.
Identify target populations.
Conduct formative BCC assessments.
Segment target populations.
Define behavior change objectives.
Design BCC strategies and monitoring and evaluation plan.
Develop communication products.
Pretest.
Implement and monitor.
Evaluate .
Analyze feedback and revision.
Challenges to BCC programs
• BCC versus IEC –INFORMATIONEDUCATION,COMMUNICATION in
practice , production of discrete communication materials.
• Integrating BCC in all programs – it is a component of all successful
interventions but in reality it is not included in their original design.
• Limited training resources –limited capacity and availability of
trained , advertising agencies and media outlets.
• Political and physical environments- geography and populational
diversity can complicate the development of BCC programs.
• Sustainability .
• Expanding the response- to have a real impact on the epidemic ,
responses must be expanded in quality , scope of activities and
geographic coverage.
• Budgets .
• Linkages and coordination –for BCC to be effective , their messages
and information should be coordinated , building and maintaining
linkages.
Attitude change training.
• EVALUATE RISKS ASSOCIATED WITH EXPOSURE TO
HIV/AIDS:-
• What is the criteria of being at risk/not at risk of HIV/AIDS?
• What do you understand by the term ‘’exchange of fluids’’.
• What are some of the sensitive issues related to sex?
• What factors prevent people from talking about the risks of
having sex?
• Identify some of the gender issues involved in HIV/AIDS
transmission.
• What specific information should be communicated about
HIV/AIDS?
• Identify cultural practices ,attitudes and beliefs towards
HIV/AIDS.
• State the ethical issues related to disclosure of HIV status.
GROUPS DISCUSSION AND PRESENTATION
UNIT SUMMARY QUESTIONS
• Outline the main mode of HIV/AIDS transmission.
• Describe the implication of HIV infection to immune system.
• Describe the HIV virus replication cycle (life cycle).
• Identify the cells that have CD4 receptor in the body.
• Define HAART.
• State the areas of ARVs target in the HIV life cycle.
• State the recommended ARVs regimen and their classifications.
• Outline the goals of ART therapy.
• State the benefits of ART therapy.
• Outline the indications of ARVs.
• State the importance of triage in HIV management.
• Describe the role of the nurse in HIV management.
• Discuss the effects of STIs infections in HIV disease progression.
CT
• State Standard package of Care for PLWHIV-8 components of care.
• Explain the impact of HIV/AIDS infection on the following:
a) family
b) Community
c) Health care system
• Describe the key primary prevention strategies of HIV in Kenya.
• Define PMTCT.
• Outline the 4 prongs of PMTCT.
• Explain behaviour change communication
• Outline the role of behaviour change communication (BCC)
References and Further
Reading
• Kenya Demographic and Health Survey 2008-09. Ministry of Health,
Republic of Kenya. (2009). Modes of Transmission Study
• Ministry of Health, Republic of Kenya. (2018). Guidelines for
Antiretroviral Therapy in Kenya, 4th Edition.
• National AIDS Control Council, Office of the President, Kenya. (2008).
UNGASS 2008 Country Report for Kenya, 3. UNAIDS 2013 Global
Report
• National HIV training curriculum modules (NHITC) Ministry of Heath.
• Fundamentals of Global HIV Medicine. AAHIVM 2009. Z Temesgen
• Kenya National Manual for the Management of HIV-Related
Opportunistic
• Infections and Conditions (Ministry of Health),2008
• Medical Management of HIV Infection. 15th edition 2009-2010. Bartlett
• Sanford guide to anti-microbial therapy of HIV 2010
 CT
• Antenatal Clinic Sentinel Surveillance
2010:https://www.google.co.ke/search?
biw=1366&bih=609&noj=
1&sclient=psyab&q=ANC+sentinel+surveillance+2010&oq=ANC
+sentinel+surveillance+2010&gs_l=serp.12...40188.64642.1.664
1
3.54.42.6.5.5.4.2421.17191.11j5j5j4j6j1j5j3j0j1.41.0....0...1c.1.4
4. serp..23.31.4313.DvwGuXXVaVE#
• National PMTCT Guidelines 4th edition 2012, Nairobi, Kenya
National HIV Care and Treatment guidelines 4th Edition 2011,
Nairobi, Kenya