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ART 2023 Guidelines

Summary of the 2023 South African guidelines for HIV management

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Desiree
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2 views

ART 2023 Guidelines

Summary of the 2023 South African guidelines for HIV management

Uploaded by

Desiree
Copyright
© © All Rights Reserved
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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2023 ART CLINICAL

GUIDELINES
DR DM DILEBO
AUGUST 2024
The objectives of the updated guidelines are to:

Provide guidance on initiation of ART in


antiretroviral-naïve clients as well as those
returning to care in the era of dolutegravir (DTG)
Provide guidance for switching of clients already
on ART to DTG-containing regimens

Provide guidance on routine management of


clients on ART to promote viral suppression
ART ELIGIBILITY

• All people living with HIV (PLHIV) are eligible to start ART regardless of age, CD4 cell
count and clinical stage.
• For all clients without contra-indications, ART should be initiated within 7 days, and on
the same day if possible.
• Pregnant women, infants and children under five years, and clients with advanced HIV
disease should be prioritised for rapid initiation.
• Many clients (including pregnant women) may be able to initiate ART on the same day
as their HIV diagnosis, provided that they are clinically well, and are motivated to start
ART.
Medical Indications to Defer ART
INDICATION ACTION
• Investigate symptomatic clients for TB before initiating ART. If TB is
excluded, proceed with ART initiation and TB preventive therapy
(after excluding contraindications to TPT). If TB is diagnosed,
TB symptoms (cough, initiate TB treatment and defer ART. The timing of ART initiation
night sweats, fever, recent will be determined by the site of TB infection and the client’s CD4
weight loss) cell count

• Defer ART initiation as follows:


Diagnosis of drug- • If CD4 < 50 cells/μL – initiate ART within 2 weeks of starting TB
treatment, when the client’s symptoms are improving, and TB
sensitive (DS) TB at a non- treatment is tolerated
neurological site (e.g. • If CD4 ≥ 50 cells/μL – initiate ART 8 weeks after starting TB treatment
pulmonary TB, abdominal • In pregnant and breastfeeding women (PBFW) initiate ART within 2
weeks of starting TB treatment, when the client’s symptoms are
TB, or TB lymphadenitis) improving, and TB treatment is tolerated. Defer ART for 4-6 weeks if
symptoms of meningitis are present
Cont…
INDICATION ACTION

Diagnosis of drug-resistant (DR) TB at a non-neurological site Initiate ART after 2 weeks of TB treatment, when the client’s
(e.g. pulmonary TB, abdominal TB, or TB lymphadenitis) symptoms are improving, and TB treatment is tolerated

Diagnosis of DS-TB or DR-TB at a neurological site (e.g. TB Defer ART until 4-8 weeks after start of TB treatment
meningitis or tuberculoma)

Signs and symptoms of meningitis Investigate for meningitis before starting ART

Cryptococcal antigen (CrAg) positive in the absence of Defer ART until the first 2 weeks of fluconazole prophylaxis
symptoms or signs of meningitis and if lumbar puncture is has been completed
(LP) negative for cryptococcal meningitis (CM)
Defer ART until the first 2 weeks of fluconazole prophylaxis Defer ART until 4-6 weeks of antifungal treatment has been
has been completed completed

Other acute illnesses e.g. Pneumocystis jirovecii pneumonia Defer ART for 1-2 weeks after commencing treatment for the
(PJP) or bacterial pneumonia infection

Clinical symptoms or signs of liver disease Confirm liver injury using ALT and total bilirubin levels. ALT
elevations > 120 IU/L with symptoms of hepatitis, and/or
total serum bilirubin concentrations > 40 µmol/L are
Baseline clinical evaluation
Nutritional assessment
Screen for TB and symptoms of meningitis
Screen for depression and other mental d/o
Screen for other NCDs
Screen for pregnancy
Screen for STIs
Neurodevelopmental screening
WHO staging
Baseline laboratory evaluations
Laboratory Purpose
evaluation
CD4 cell count/ % To identify eligibility for CPT. To identify eligibility for cryptococcal antigen (CrAg) screening

Creatinine and eGFR To assess renal insufficiency


if TDF used
Haemoglobin (Hb) To identify and manage anaemia; to determine eligibility for zidovudine (AZT) where necessary. Treat with
ferrous sulphate tds if Hb < 10 g/dL. Refer if < 8 g/dL and symptoms, if anaemia diagnosed at 36 weeks
gestation or later, or if no response to treatment
GeneXpert (MTB/Rif To diagnose TB. For any client with a positive TB symptom screen.
Ultra) For people living with HIV, regardless of TB symptoms: • At the time of HIV diagnosis • On enrolment in
antenatal care for pregnant women
Cryptococcal antigen To identify asymptomatic clients who need pre-emptive fluconazole treatment. If CrAg-negative, no
test (CrAg) if CD4 < fluconazole is required. If CrAg-positive, the client will require treatment of the infection. All CrAg-positive
100 cells/ μL clients should be referred for a lumbar puncture, regardless of symptom.
Cervical cancer To identify women with cervical lesions and manage appropriately. All HIV-positive women should be
screening screened for cervical cancer at diagnosis and subsequently every 3 years if the screening test is negative.
Pregnancy does not preclude screening for cervical cancer and it can be performed up to 20 weeks of
gestation
HBsAg To identify those co-infected with hepatitis B (HBV)
If positive, exercise caution in stopping TDF-containing regimens, to prevent hepatitis flares
TB Preventative Therapy
ART Initiation

• The preferred first-line ART regimen is tenofovir disoproxil fumarate-lamivudine-


dolutegravir (TLD) for those adult and adolescent clients initiating ART, and abacavir-
lamivudine-dolutegravir (ALD) in children .
• All clients already on ART and not on dolutegravir (DTG), whether on first-line or
second-line regimens, should be evaluated for switch to a dolutegravir containing
regimen.
• TLD1: Clients on a DTG-containing regimen, having never failed a previous regimen
(old “first-line” terminology)
• TLD2: Clients on a DTG-containing regimen, who have failed a previous regimen (old
“second- line” terminology)
Cont…

• The safety of DTG in women of childbearing-potential has been firmly established and
neural tube defects are no longer a concern that influences regimen choice in women.
However, the integration of family planning and ART services remain of paramount
importance, and issues of family planning and contraception should be discussed at
every clinical interaction to understand the client’s current fertility desires and
healthcare needs.
• All people either currently on ART, or newly initiated on ART, should be screened for
TB and assessed for TB preventive therapy (TPT) as indicated. All individuals should be
assessed for advanced HIV disease (AHD) and provided with a comprehensive package
of care, including cotrimoxazole prophylaxis, as needed.
TLD: Drug interaction
Rifampicin Rifampicin ↓level of DTG

TB treatment: Add another dose of DTG (50mg) 12hr after the TLD

Anticonvulsants They ↓level of DTG


(Phenytoin,
Carbamazepine, Avoid these anticonvulsants (can use Valproate, lamotrigine). Double DTG dose to 50mg BD if
Phenobarb) an alternative cannot be used

Metformin DTG ↑level of Metformin

Do not exceed 500mg bd for metformin

(Mg2+, Fe2+, Ca and Fe supplement ↓ DTG on empty stomach, take with food
Ca2+) e.g.
antacids, Mg ↓ DTG, take at least 2 hrs apart or 6 hrs before DTG
multivitamin
Women and adolescents diagnosed
during labour…

• During labour, give a stat single fixed-dose combination tablet of TLD


and a stat single dose of nevirapine (NVP).
• Lifelong ART should be initiated the following day. TLD and a
contraceptive method is recommended. Provide information on
different contraceptive methods available.
• Appropriate ART literacy education should be given to the woman
before she leaves the facility. Also provide her with information on
infant feeding, infant HIV prophylaxis, and follow-up infant HIV
testing.
Re-initiating treatment interrupters
Monitoring: clinical, virological, side-effects

Determine clinical response


• Trends in weight
• Screen for TB and other OIs
• Screen for pregnancy and desire for
children
Determine the virological & immunological
responses
• VL: At month 3 and month 10 on ART , then repeat every 12 months
• CD4 count: after 10 months/DCs on ART(aligned with VL) Thereafter, stop CD4
monitoring unless:
• CD4 still ≤ 200 cells/mm3: repeat every 6 months until CD4 > 200
• • VL ≥ 1000 c/mL: repeat CD4 every 6 months until VL < 1000 c/mL
• • A clinical indication arises, such as a new WHO Stage 3 or 4 condition in a
previously well client
• Repeat CD4 for clients returning > 90 days after missing a scheduled appointment
• Stop CD4 monitoring if client's VL remains below 1000 c/mL
Monitor drug side-effects:
• TDF: Cr & eGFR at months 3 and 10 , then
every 12 months
• PIs (Dyslipidaemia): Total cholesterol and
triglycerides (TGs) at month 3
• AZT (Anaemia and neutropenia): FBC and
differential WCC at months 1 and 3.
Thereafter, repeat if clinically indicated
Screening for TB at follow up visits:
What to do: VL 50-999, OR greater than 1000

Check: A: Adherence problem


B: Bugs
C: incorrect dose
D: Drug interactions
E: REsistance
Repeat VL after 3-months

• 50-999: continue adherence


support, repeat 6 month
• ≥1000: change to 2nd line
THE END

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