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close this bookNational Guidelines for the Clinical Management of HIV/AIDS - Tanzania (NACP; 2005; 131 pages)
View the documentLIST OF ABBREVIATIONS
View the documentACKNOWLEDGEMENTS
View the documentFOREWORD
Open this folder and view contentsCHAPTER 1: INTRODUCTION
Open this folder and view contentsCHAPTER 2: ORGANIZATION OF HIV/AIDS CARE AND TREATMENT
Open this folder and view contentsCHAPTER 3: HIV/AIDS PREVENTION
Open this folder and view contentsCHAPTER 4: PROTECTIVE MEASURES AGAINST HIV TRANSMISSION
Open this folder and view contentsCHAPTER 5: LABORATORY TESTS IN HIV/AIDS
Open this folder and view contentsCHAPTER 6: HIV/AIDS AND PREGNANCY
Open this folder and view contentsCHAPTER 7: PEDIATRIC HIV/AIDS AND RELATED CONDITIONS
Open this folder and view contentsCHAPTER 8: COMMUNITY AND HOME BASED CARE FOR PEOPLE LIVING WITH HIV/AIDS (PLHA)
Open this folder and view contentsCHAPTER 9: COUNSELLING RELATED TO HIV-TESTING AND TREATMENT ADHERENCE
Open this folder and view contentsCHAPTER 10: MANAGEMENT OF COMMON SYMPTOMS AND OPPORTUNISTIC INFECTIONS IN HIV/AIDS
Open this folder and view contentsCHAPTER 11: MANAGEMENT OF MENTAL HEALTH PROBLEMS IN HIV/AIDS
close this folderCHAPTER 12: MANAGEMENT OF HIV INFECTED PATIENTS USING ANTIRETROVIRAL DRUGS
View the document12.1 Introduction
Open this folder and view contents12.2 Types of Antiretroviral drugs
close this folder12.3 Treatment using ARV drugs in adults and adolescents
View the document12.3.1 Criteria of initiation of ART in Adults and Adolescents Patients
View the document12.3.2 Before initiating therapy
View the document12.3.3 Goals of Therapy
Open this folder and view contents12.4 Recommended ARV drugs in Tanzania
Open this folder and view contents12.5 Adherence to Antiretroviral Therapy
Open this folder and view contents12.6 Changing of Antiretroviral Therapy
View the document12.7 Second-Line ARV Regimen
Open this folder and view contents12.8 Monitoring Patients on ARV Therapy.
Open this folder and view contents12.9 Laboratory Monitoring of patients on second line drugs
Open this folder and view contents12.10 Treatment failure with second line regimen
View the document12.11 Contraindications (relative) for initiation of ART
View the document12.12 Discontinuation of ART
Open this folder and view contentsCHAPTER 13: ARV THERAPY IN INFANTS AND CHILDREN
Open this folder and view contentsCHAPTER 14: USE OF ARVS IN SPECIAL CIRCUMSTANCES
Open this folder and view contentsCHAPTER 15: HIV/AIDS AND NUTRITION
Open this folder and view contentsCHAPTER 16: MANAGEMENT OF ANTIRETROVIRAL MEDICINES
Open this folder and view contentsCHAPTER 17: CERTIFICATION OF HEALTHCARE FACILITIES AS CARE AND TREATMENT SITES
 

12.3.1 Criteria of initiation of ART in Adults and Adolescents Patients

Although there is theoretical benefit to antiretroviral therapy for patients with CD4 counts >200cells/mm3, a major dilemma confronting patients and practitioners is that the antiretroviral regimens currently available that have the greatest potency in terms of viral suppression and CD4+ T-lymphocytes preservation, are medically complex, are associated with a number of specific side effects and drug interactions, and pose a substantial challenge for adherence. Furthermore, the development of mutations associated with drug resistance can render therapy less effective or ineffective. Thus, decisions regarding treatment of asymptomatic, chronically infected individuals with CD4+ T-lymphocyte counts >200 cells/mm3 must balance a number of competing factors that influence risk and benefit.

The treatment of patients with WHO Stage IV disease (clinical AIDS) therefore should not be dependent on a CD4 cell count determination. Any individual in Stage IV should be started on treatment. However CD4 measurement can be helpful in categorizing patients with Stage III conditions with respect to their need for immediate therapy. For example, pulmonary TB can occur at any CD4 count level and, if the CD4 cell count level is well maintained (i.e. >350/mm3), it is reasonable to defer therapy and continue to monitor the patient. For Stage III conditions a threshold of 350cells/mm3 has been chosen as the level below which immune deficiency is clearly present such that patients are eligible for treatment when their clinical condition portends rapid clinical progression. A level of 350cells/mm3 is also in line with other consensus guideline documents. Any patient with a CD4 cell count <200/mm3 should be started on treatment, regardless of clinical stage.

Based on the above discussion, there are 3 classes of individuals who are clinically eligible to begin treatment:

All who are in WHO stage IV clinical criteria, regardless of CD4+ cell count

Those in WHO Stage III and CD4 cell <350/mm3 as an indicator of their progression to AIDS.

All who have a CD4 count < 200cells/mm3, regardless of symptoms

This is summarized in figure 11.2.

Beyond clinical eligibility, it is important that the patient’s willingness, readiness and ability to be on ART adherently be assessed and addressed. Psychosocial considerations (not exclusion criteria) therefore need to be evaluated before initiation of therapy during several (three to six) pre-treatment visits:

Demonstrated reliability, i.e. has attended three or more scheduled visits to an HIV clinic.

No active alcohol or other substance abuse that could affect adherence

No untreated active depression.

Disclosure: It is strongly recommended that clients have disclosed their HIV status to at least one friend or family member who will become the adherence assistant (AA) and, if possible, should join support groups.

Insight: Clients need to have accepted their HIV positive status, and have insight into the consequences of HIV infection, the role of ART, and the very real need to adhere strictly before commencing therapy.

Able to attend the CTC on a regular basis (transport may need to be arranged for patients in rural areas or for those remote from the treatment site) or have access to services able to maintain the treatment chain.


Figure 5: Clinical Criteria for ART in Adults and Adolescents

Table 12: PROPOSED WHO CLINICAL STAGING OF HIV INFECTION FOR ADULTS AND ADOLESCENTS

(For use in those 15 years of age or more with positive HIV antibody test or other laboratory evidence of HIV infection)

PRIMARY HIV INFECTION

 

Unrecognized

 

Acute retroviral syndrome

CLINICAL STAGE 1

 

Asymptomatic

 

Persistent generalized lymphadenopathy (PGL)

CLINICAL STAGE 2

 

Moderate unexplained weight loss (<10% of presumed or measured body weight)

 

Recurrent upper respiratory tract infections (sinusitis, bronchitis, otitis media, pharyngitis)

 

Herpes zoster (past or current episodes in last 2 years)

 

Angular cheilitis

 

Recurrent oral ulcerations (2 or more episodes in 6 months)

 

Papular pruritic eruptions

 

Seborrhoeic dermatitis

 

Fungal nail infections of fingers

CLINICAL STAGE 3

 

Severe weight loss (>10%presumed or measured body weight)

 

Unexplained chronic diarrhoea for longer than one month

 

Unexplained persistent fever (intermittent or constant, for longer than 1month)

 

Oral candidiasis

 

Oral hairy leukoplakia

 

Pulmonary tuberculosis(diagnosed in last two years)

 

Severe presumed bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteremia)

 

Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis

 

Unexplained Anaemia (<8gm/dl), neutropenia (<1,000/mm3) or thrombocytopenia (<50,000/mm3) for more than 1 month

CLINICAL STAGE 4

Conditions where a presumptive diagnosis can be made using clinical signs or simple investigations:

 

HIV wasting syndrome

 

Pneumocystis pneumonia

 

Recurrent severe or radiological bacterial pneumonia (2 or more episodes within one year)

 

Chronic orolabial, genital, or anorectal Herpes simplex infection (of more 1 month duration)

 

Candidiasis of the oesophagus

 

Extrapulmonary tuberculosis

 

Kaposi's sarcoma

 

CNS toxoplasmosis

 

HIV encephalopathy

Conditions where confirmatory diagnostic testing is necessary:

 

Cryptococcal meningitis or other extrapulmonary disease

 

Disseminated non-tuberculous mycobacteria infection

 

Progressive multifocal leukoencephalopathy (PML)

 

Candida of trachea, bronchi, or lungs

 

Extrapulmonary Cryptococcsis

 

Cryptosporidiosis (diarrhoea more 1 month)

 

Isosporiasis

 

Cytomegalovirus infection (retinitis or of an organ other than liver, spleen, or lymph nodes)

 

Any disseminated mycosis (e.g. Histoplasmosis, Coccidiomycosis, Penicilliosis)

 

Recurrent non-typhoidal salmonella septicaemia (2 or >episodes in one year)

 

Lymphoma (Cerebral or B cell non-Hodgkin's)

 

Invasive cervical carcinoma

 

Leishmaniasis, visceral

 

American trypanosomiasis reactivation

STAGE ON TREATMENT

 

Above clinical events occurring on ART

2 Acute febrile illness 2-4 wks post-exposure often with lymphadenopathy and skin manifestations, pharyngitis.

3 TB may occur at any CD4 count, and this must be considered where available. If CD4 is less than 200 it should be considered as a stage 4 event. Diagnosis and treatment of both pulmonary and extrapulmonary TB should be in line with international and national guidelines

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