Aids final 19112017

RECENT ADVANCES in case
management of HIV/AIDS
DR. Madhur Verma
Senior Resident, deptt of community
medicine & school of Public health,
PGIMER Chandigarh

HIV
TESTING
AND
COUNSELING
LINKAGE
TO CARE
ENROLLMENT
IN CARE
 RETENTION
 HIV
PREVENTION
 GENERAL HIV
CARE
 PREPARING
PEOPLE FOR
ART
 MANAGING
COINFECTION
AND
MORBIDITIES
ART
INITIATION
(FIRST
LINE)
 RETENTION AND
ADHERENCE
 MONITORING ART
RESPONSE
 MONITORING ARV
TOXICITY
SECOND
AND THIRD
LINE ART
Continuum of care

WHO HIV clinical stages
Short, flu-like
illness occurs 1-6
weeks after
infection
Infected person
can infect other
people
Average- 10 years
Mild symptoms
HIV in blood drops
to very low levels
Antibodies are
detectable in the
blood
The immune
system
deteriorates
Opportunistic
infections start to
appear
Rapid decline in
the number of
CD4+ T cells
Opportunistic
infections become
severe and cancer
may develop

HIV Infection and Antibody Response
6 month ~ Years ~ Years ~ Years ~ Years
Virus
Antibody
Infection
Occurs
AIDS Symptoms
---Initial Stage---- ---------------Intermediate or Latent Stage-------------- ---Illness Stage---
Flu-like Symptoms
Or
No Symptoms
Symptom-free
<
----
----

HIV Testing and Counselling
VCTC
• Voluntary Counseling and Testing Centres
• People motivated were referred to these centres
VCCTC
• Voluntary Confidential Counseling and Testing Centres
• Emphasis on maintaining confidentiality
ICTC
• Integrated Counseling and Testing Centres
• Integration of VCCTC + PPTCT
PITC • Provider Initiated Counseling and Testing Centres

ICTC
ICTC
Stand-
Alone ICTC
Supported
financially and
logistically by
NACP
Facility
ICTC(F-ICTC)
Staff from existing
facilities trained in
counselling and
testing
PPP-ICTC
Established in
private facilities
based on F-ICTC
model
Mobile
ICTC
Takes the
package of
services to
community
12897
4508 8389

Topic Old Guidelines New Guidelines
HIV Testing
Initiating testing
and counseling
based on
referrals in
hospital set up
Community-based HIV
testing and counseling with
linkage to prevention, care
and treatment services is
recommended, in addition to
old guidelines.
Couples Voluntary HIV testing and counseling
HIV Testing & counselling

Working pattern of ICTC
HIV Suspect ICTC Counselor Reason for testing
Risk Assessment
Pre-test COUNSELING
consent
BLOOD TEST
HIV -ve
Post test COUNSELING
•Change risky life pattern
•Preventive measures
HIV +ve
confirmed
Post test COUNSELING
ART PPTCT Drop-in
Centres

Delivery of HIV treatment and
care
THREE TIER STRUCTURE

COE
CENTRES OF EXCELLENCE
 Provision of second line and
alternative first line ART
 Training, research and mentoring
of ART centers linked to them
ART CENTRES
 CD4 Testing
 Pre ART care and counseling
 ART provision
 Treatment of OI
LINK ART CENTRES
 Accessible and facilitate delivery of
ART
 Monitoring patients on ART
COMMUNITY CARE CENTRES
 Counseling for ARV treatment
preparedness and drug adherence,
nutrition and prevention
 treatment of OI
 referral and outreach services for
follow-up
 Social support services
DROP IN CENTRES
 Psychosocial support
 Counseling
 Sharing and caring
 Referrals to ICTC, DOTS
 Needle and syringe exchange and
STI treatment
10
380
840

WHO ARV Guidelines Evolution 2002 to 2015
Topic 2002 2003 2006 2010 2013 2016
When to
start
CD4 ≤200 CD4 ≤ 200 CD4 ≤ 200
- Consider 350
- CD4 ≤ 350 for
TB
CD4 ≤ 350
-Regardless
CD4 for TB
and HBV
CD4 ≤ 500
- Regardless CD4 for
TB, HBV PW and
SDC
- CD4 ≤ 350 as
priority
Towards
treatment
initiation at
any CD4 cell
count
1st Line
ART
8 options
- AZT
preferred
4 options
- AZT
preferred
8 options
-AZT or TDF
preferred
-d4T dose
reduction
6 options &
FDCs
- AZT or TDF
preferred
- d4T phase
1 preferred option &
FDCs
- TDF and EFV
preferred across
all pops
Continue with
FDC approach
and phased
introduction of
new options
(DTG, EFV400)
2nd Line
ART
Boosted
and non-
boosted
PIs
Boosted
PIs
-IDV/r
LPV/r,
SQV/r
Boosted PI
- ATV/r, DRV/r,
FPV/r LPV/r,
SQV/r
Boosted PI
- Heat stable
FDC: ATV/r,
LPV/r
Boosted PIs
- Heat stable FDC:
ATV/r, LPV/r
Add more heat
stable PI
options (DRV/r)
and new
strategies (NRTI
sparing
regimens)
3rd Line
ART
None None None DRV/r, RAL,
ETV
DRV/r, RAL, ETV Encourage HIV
DR to guide
Viral Load
Testing
No No
(Desirable)
Yes
(Tertiary
centers)
Yes
(Phase in
approach)
Yes
(preferred for
monitoring, use of
PoC, DBS)
Support for
scale up of VL
using all
technologies
Earlier initiation
Simpler treatmeno
tut
Less toxic, more robust regimens
Better and simpler monitoring

• The World Health Organisation (WHO) came up with
Option B+ in 2013 that prioritised pregnant women to
receive ART irrespective of their CD4 counts.
• In 2016, WHO guidelines recommended a 'treat all'
strategy offering ART to all those who are found to be
infected irrespective of their CD4 counts even among
resource-limited settings as a public health tool to control
HIV epidemic.
Recent updates in treatment
guidelines

Recent updates in treatment
guidelines
• Joint United Nations Programme on HIV and AIDS (UNAIDS)
has set a goal to end acquired immune deficiency syndrome
(AIDS) by 2030 using 90–90–90 strategy that aims at:
1. detecting 90% of all HIV-infected individuals,
2. linking 90% of these people to ART services,
3. and ensuring that 90% of these linked patients have suppressed
plasma viral loads.

Recommendations from WHO
• WHO recommends initiation of ART for all people living with HIV at any
CD4 cell count
• Fixed dose combinations (FDCs) containing TDF/XTC/EFV remain the
preferred first line regimen for adults, adolescents and older children
• For the first time, DTG and EFV400 have been included as alternative first
line regimens for adults and adolescents.
• DRV/r is an alternative option as part of secondline regimens, along with
LPV/r and ATV/r.
http://apps.who.int/iris/bitstream/10665/204347/1/WHO_HIV_2015.44_eng.pdf?ua=1

First-line regimens
• In 2015, WHO maintains the 2013 recommendation of TDF + 3TC (or FTC) + EFV at standard
doses (600 mg/ day) as the preferred first-line regimen for treatment initiation in
antiretroviral therapy (ART)-naïve adults and adolescents.
• Dolutegravir (DTG) and EFV at lower dose (400 mg/day) are included as new alternative
options in first-line regimens.
• AZT and NVP are maintained as alternative drug options as DTG and EFV 400mg/day are
not likely to be available until beyond 2016

WHO Recommendations
http://apps.who.int/iris/bitstream/10665/198064/1/9789241509893_eng.pdf

2nd line and 3rd line regimens

Current NACO Guidelines- May 2017 When to initiate
ART
All persons diagnosed with HIV
infection are eligible for ART
initiation regardless of CD4 count or
WHO Clinical Staging, Any age or
population
Revised NACO ART Guidelines on First line ART Initiation

Initiation of ART
HIV Status Recommendations*
HIV infected Adults & Adolescents and children aged >5 years
Any Clinical Stage
Treat all Regardless of CD4 count
after baseline clinical assessment
and preparedness
Children below 5 years of age
Any Clinical stage Start ART Regardless of CD4 count
• Patients in Pre-ART care with the latest CD4 count and other
investigations done more than 6 months should undergo a fresh CD4
test and baseline investigations and should undergo at least two
sessions of preparedness counselling as per the existing practice
before initiating ART.
• HIV- TB Co-Infection- Start ATT first; Initiate ART as early as
possible between 2 weeks and 2 months

Considerations before
ART initiation
All people with confirmed HIV infection should be
referred to ART centre for:
1. Registration in HIV care– Pre ART registration is to
be done even with current guidelines on TREAT ALL
2. Comprehensive clinical and laboratory evaluation
to assess baseline status
3. Treatment of pre-existing opportunistic infections
4. Treatment preparedness counselling
5. Timely ART initiation

Check list to be followed before ART initiation
• The patients should have undergone HIV counselling
and Testing at NACO Integrated Counselling Testing
Centre (ICTC) & should have HIV positive result with
PID (Person Identification Digit) number
• Gone through adequate preparedness counselling
• Should have correct residential address with proof
• Identification of appropriate care-giver
• Should have signed the consent form

Step 1: Clinical History
 HIV specific symptoms: Present & past
 Past history: TB, HIV related co morbid conditions,
complications like jaundice, dyslipidemia & others
 Sexual history: Multiple sex partners, Genital ulcers,
other STIs, etc.
 Personal history: Smoking, alcohol & substance abuse
 Family history: Tuberculosis and HIV
 Treatment history: ARVs, H/O of Blood transfusion,
treatment for coexisting conditions, contraceptives
pills, herbal drugs, etc.

Assessment continued
 Behavioural / psychosocial assessment: Educational
level, employment status and financial resources
 Social support and family / household structure:
Identification of primary care giver
 Nutritional assessment
 Assessment of mental health: Mini mental score

Step 2: Physical Examination
 Weight, height & BMI
 Vital signs
 Oral cavity, lymph nodes, skin, eyes and fundus
examination
 Systemic examination: all systems in detail
 Genital examination
 Evaluation for diabetes and hypertension

Step 3: Essential / Mandatory Tests for all PLHIV under HIV
Care
Lab monitoring before starting ART
Phase of HIV
management
Recommended Desirable (if feasible)
HIV diagnosis
HIV serology,
CD4
TB screening
HBV (HBsAg) serology
Cryptococcus antigen if CD4 ≤100
Screening for STIs
Assessment for major noncommunicable
chronic diseases and comorbidities
F/U before ART CD4 cell count (every 6–12 mths)
ART initiation CD4 cell count
Hemoglobin for AZT
Pregnancy test
Blood pressure
Urine dipsticks for glycosuria and (eGFR)
and serum creatinine for TDF
ALT for NVP

Receiving ART CD4
(every 6 months)
HIV viral load
(at 6months after
initiating ART and
every 12 months )
Urine dipstick for glycosuria and
Serum creatinine for TDF
Treatment
failure
CD4
HIV viral load
HBV (HBsAg) serology
(before switching ART regimen if
not done or negative at baseline)
Lab monitoring during ART
Phase of HIV
management
Recommended Desirable (if feasible)

Additional Tests for all PLHIV to be started
on ART
 Physicians directed Investigations like Sputum
Smear microscopy for AFB / CBNAAT, USG abdomen,
CSF analysis, depending on clinical presentation /
suspicion
 Efforts to be made to fast-track these
investigations and do not delay ART initiation.
 Fundus examination and PAP smear examination
shall be undertaken; however ART initiation shall not
be delayed for performing these tests

Tests for Special Situations
 HBsAg: for all patients, if facility is available
 Mandatory for PLHIV with H/o IDU, Multiple Blood
and blood products transfusion, ALT (SGPT) >2
times ULN, on strong clinical suspicion
 ART shall not be withheld, if HBsAg testing facility
is not available
 Anti HCV antibody Test:
 Only for PLHIV with H/o IDU, Multiple Blood and
blood products transfusion, ALT (SGPT) >2 times
ULN, on strong clinical suspicion
 For patients to be initiated on PI based regimen:
Base line Blood sugar, LFT & lipid profile are to be
performed

Step 4: Preparedness Counselling
 Treatment “PREPAREDNESS” counselling
 “ART is not an emergency intervention”
 Accepting HIV result / diagnosis
 Management of Opportunistic Infections
 Accepting life-long treatment under National ART
Programme conditions
 Readiness for Treatment Adherence (100%)
 Accepting to positive prevention methods
 Healthy & hygienic way of living to prevent OIs

Considerations before ART initiation Basic
Principles
 Treatment should be started based on a person’s informed
decision and preparedness to initiate ART on the benefits of
treatment, understanding of lifelong medication, adherence
issues and positive prevention
 A caregiver should be identified for each person to provide
adequate support. Caregivers must be counselled and
trained to support treatment adherence, follow-up visits
and shared decision- making
 All patients with CD4 less than 350 cells/cmm need to be put
on Cotrimoxazole Preventive Therapy (CPT)

Patient Education & Treatment Adherence
ART is not curative, but prolongs life
 ARV Treatment is lifelong
High level of adherence is critical (100%)
 Short and long term: adverse events
 Drug interactions
 Safer sex still essential
 Do not share drugs with friends, family members

Considerations before ART initiation Basic
Principles
 All patients need to be screened for TB, using the 4- symptom
tool (current cough, fever, night sweats and weight loss) and
those who do not have TB need to be placed under Isoniazid
Preventive Therapy (IPT) in addition to ART
 If IPT is to be used in conjunction with antiretroviral therapy, a
rational approach would be to start ART first and initiate IPT
three months after ART initiation
 ART should not be started in the presence of severe form of
Opportunistic Infection (OI). In general, OIs should be treated
or stabilized before commencing ART

Opportunistic Infections and ART initiation
Clinical Picture Action
Any undiagnosed active
infection with fever
Diagnose and treat first; start ART when stable
TB
Treat TB first; start ART as soon as possible after
2 weeks and before 2 months. For those with CD4
cells <50/cmm, start ATT first (Category I or II)
and then ART within 2 weeks of ATT initiation,
with strict clinical and lab monitoring
PCP Treat PCP first; start ART when PCP treatment is
completed (3 weeks)
Invasive fungal
diseases:
oesophageal
candidiasis,
cryptococcal
meningitis,
penicilliosis,
histoplasmosis
Treat oesophageal candidiasis first; start ART as
soon as the patient can swallow comfortably.
Treat cryptococcal meningitis, penicilliosis, and
histoplasmosis first; start ART when patient is
stabilized or OI treatment is completed.

Bacterial pneumonia
Treat pneumonia first; start ART when
treatment is completed
Malaria
Treat malaria first; start ART when
treatment is completed
Acute diarrhoea
which may reduce
absorption of ART
Diagnosis the cause and treat diarrhoea
first; start ART when diarrhoea is
stabilized or controlled
Non-severe
anaemia (Hb<9
g/dL)
Start ART if no other causes for
anaemia are found (HIV is often the
cause of anaemia)

Skin conditions such as
PPE and seborrhoeic
dermatitis, psoriasis, HIV-
related exfoliative
dermatitis
Start ART (ART may resolve these problems)
Suspected MAC,
cryptosporidiosis and
microsporidiosis
Start ART (ART may resolve these problems)
Cytomegalovirus
Retinitis
Start Treatment for CMV urgently and start ART after
2 weeks of CMV treatment
Toxoplasmosis
Treat; start ART after 6 weeks of treatment and
when patient is stabilized

Highly Active Anti Retroviral
Therapy(HAART)

HAART RegimensH
FIRST LINE
2NRTI+ 1NNRTI
PREFFERED REGIMEN
TDF + 3TC (or FTC) + EFV
SECOND LINE
2NRTI+ RITONAVIR
BOOSTED PI
PREFFERED REGIMEN
TDF + 3TC (or
FTC) + ATV/RTV
THIRD LINE
INTEGRASE
INHIBITOR+2ND
GENERATION
NNRTI+ PI
PREFFERED REGIMEN
RAL + RTV/DRV +ETV

Goals of ART
Clinical goals Improvement in quality of life and
prolongation of life
Virological goals Greatest possible sustained reduction in
viral load
Immunological goals Immune reconstitution, that is both
quantitative and qualitative
Therapeutic goals
Rational sequencing of drugs in a manner
that achieves clinical, virological and
immunological goals while maintaining
future treatment options, limiting drug
toxicity and facilitating adherence
Prevention goals Reduction of HIV transmission due to
suppression of viral load

What ART Regimen to start with in PLHIV with HIV-1
infection?
Two NRTIs (Nucleotide / Nucleoside Reverse Transcriptase Inhibitors)
Tenofovir (TDF) + Lamivudine (3TC)
+
One NNRTI (Non Nucleoside Reverse Transcriptase Inhibitor)
Efavirenz(EFV)
PreferredRegimen:
Tenofovir (300 mg) + Lamivudine (300 mg) +
Efavirenz (600 mg), one tablet daily at bedtime

Rationale: One Regimen For All
Preferred First line regimen: TDF + 3TC + EFV
Simplicity: Tenofovir + Lamivudine + Efavirenz regimen is very
effective, well tolerated regimen.
available as a single, once-daily FDC tablet and therefore easy
to prescribe and easy for patients to take – facilitates treatment
adherence
 This regimen has the advantage of harmonization of treatment
for all adults, adolescents, pregnant women and those with
HIV- TB and HIV Hepatitis co-infections
 Simplifies drug procurement
 Safety in pregnancy
 Efficacy against HBV
 Efavirenz is preferred NNRTI for PLHIV with TB & HIV

What ART Regimen to start with in PLHIV with HIV-2
infection?
• The patients with HIV-2 and HIV-1 and HIV-2 co-
infections need to be initiated on a PI containing
regimen, as NNRTIs (EFV/NVP) are not active against
HIV-2 virus.
• For patients with HIV-2 infection, the preferred first line
ART regimen shall be
• Tenofovir (300mg) plus Lamivudine (300mg) plus
• Lopinavir/Ritonavir (800/200 mg)

First line ART Regimens in specific situations
ART Regimen Recommended For
Tenofovir + Lamivudine +
Efavirenz
First line ART Regimen for: All ARV naive
patients except those with known renal
disease (or) HIV-2 or HIV-1 & 2 infection (or)
women with single dose Nevirapine exposure
in past pregnancy
Abacavir + Lamivudine +
Efavirenz
First line ART Regimen for: All patients
with known renal disease
Tenofovir + Lamivudine +
Lopinavir/ritonavir
First line ART regimen for: All women
with single dose Nevirapine exposure
in a past pregnancy;
All confirmed HIV-2 or HIV- 1 & HIV-2 co-
Infection
• Zidovudine + Lamivudine
+ Nevirapine
• Zidovudine + Lamivudine
+ Efavirenz
All Patients who are on either of these
first line regimens initiated earlier in
the programme need to be continued
on the same regimens

First line ART: General Guidance
• A single pill of TLE should be taken at bed time, 2-3 hours after
dinner; fatty food should to be avoided as far as possible
• Patients with severe diabetes and Hypertension should be
monitored more closely for TDF toxicity
• For Adults / Adolescents weighing <30 kg: Since we do not
have the 150 mg or 200 mg formulations of TDF in the
programme, treat all adults/adolescents, regardless of body
weight, with standard adult dose of 300 mg TDF. However,
considering that low body weight is a risk factor for TDF
toxicity, frequent assessment for TDF toxicity should be done

Cotrimoxazole Prophylaxis
Commencing primary
CPT
Cotrimoxazole Prophylaxis Therapy (CPT) has
to be initiated in PLHIV with CD4 count
<350/cmm or with clinical staging 3 and 4
Commencing
secondary CPT
For all patients who have completed successful
treatment for PCP and toxoplasma infection
Timing the initiation of
Cotrimoxazole in
relation to initiating
ART
Start Cotrimoxazole prophylaxis first.
Start ART 5-6 days as soon as CPT is tolerated
and patient has completed the “preparedness
phase” of counselling
Dosage of
Cotrimoxazole in
adults & adolescents
One double-strength tablet or two single-
strength tablets once daily
When to Stop CPT
CD4 is >350 cells/cmm (at least on two occasions,
done 6 months apart), and devoid of any WHO
clinical stage 3 and 4

ART Scale up for PLHIV in
India, 2005 - 2012

HIV-TB Co-infection
• A setting with a high burden of TB and HIV refers to
settings with adult HIV prevalence ≥1% or HIV prevalence
among people with TB ≥5%
• Among PLHA, TB is the most frequent life-threatening
opportunistic infection and a leading cause of death(25%).
• HIV care settings should implement the WHO Three I’s
strategy:
– Intensified TB case-finding,
– Isoniazid preventive therapy (IPT)
– Infection control at all clinical encounters

DIAGNOSIS OF TB IN HIV
• Frequently negative sputum smears
• Atypical radiographic findings
• Resemblance to other opportunistic pulmonary infections like
pneumonia
WHY is it difficult to diagnose TB in HIV infected patient
Arrow points to
cavity in
patient's right
upper lobe
--typical finding
in patient with
TB

 HIV infection increases the likelihood that new infection
with M. tuberculosis (due to immune suppression) will
progress rapidly to TB disease.
 Among HIV-infected individuals, lifetime risk of developing
active TB is 50%, compared to 5-10% in persons who are not
HIV-infected.
 In a person infected with HIV, the presence of other
infections, including TB, allows HIV to multiply more
quickly. This may result in more rapid progression of HIV
infection
 HIV infected persons have approximately an 8‐times greater
risk of TB than persons without HIV infection
HIV-TB Co-infection

CD4 Cell count
ART Regimen ATT Regimen
CD4 < 50/ mm3 Start immediately Start immediately
CD4 < 250/ mm3 Start as soon as ATT
tolerated (2-4 wks)
Start immediately
CD4 250 -350/ mm3 Start after the initial
phase of TB treatment
completed
Start immediately
CD4 >350/ mm3 Re-evaluate with repeat
CD4 count after TB
treatment
Start immediately

PPTCT :4 Pronged approach
Prevention of HIV in women
Prevention of unintended
pregnancies in HIV+ women
Prevention of HIV transmission
from HIV+ women to infants
Provision of care, treatment and
support to mothers living with HIV
and their families

• Without any intervention risk of transmission of HIV
from infected mother to her child is between 20 to 45%.
• SD-NVP is highly effective in reducing risk of
transmission from about 45% to less than 10%
• multiple drugs for PPTCT can reduce transmission to less
than 5% if started early in pregnancy and continued
throughout period of delivery and breast feeding.
Adults
57 %
Children
35%

PMTCT
program option
Pregnant and breastfeeding
women with HIV
HIV-exposed infant
Use lifelong ART
for all pregnant
and breastfeeding
women
(“Option B+”)
Regardless of WHO clinical
stage or CD4
Breastfeeding
Replacement
feeding
Initiate ART and maintain
after delivery & cessation
of breastfeeding
6 weeks of
infant
prophylaxis
with
once-daily NVP
4–6 weeks of infant
prophylaxis with
once-daily NVP (or
twice-daily AZT)
Use lifelong ART
only for pregnant
and breastfeeding
women eligible
for treatment
(“Option B”)
Eligible for
treatment
Not eligible
for
treatment
Initiate ART
and maintain
after delivery
and cessation
of
breastfeeding
Initiate ART
and stop after
delivery
and cessation
of
Breastfeeding

Establish HIV Status of Pregnant Women
HIV -venewly detected HIV infection
Continue ART
From ICTC collect the blood
Sample for CD4 and sent it to
ART center and refer women to
there
ART Center: Initiate ART to HIV +ve pregnant mother regardless of
WHO Clinical Stage and CD4counts
Preferred Regimen : TDF+3TC+EFV
ART center will collect sample for baseline and other investigations
Repeat HIV as
per guidelines for
window period
&h/o risk factor
Known HIV infected case
and already receiving ART

Mother :Continue ART during
labour and
delivery(intrapartum)
Mother: Continue ART(Postpartum)
Infant: Daily NVP from birth until 6 weeks of
age then stop
(Irrespective of choice of infant feeding)
Exclusive BF/RF
Continue ART
Continued

ARV drugs and duration of BF
• Mothers known to be infected with HIV (and whose
infants are HIV uninfected or of unknown HIV
status) should exclusively breastfeed their infants for
the first 6 months of life, introducing appropriate
complementary foods thereafter, and continue
breastfeeding for the first 12 months of life.
• Breastfeeding should then only stop once a
nutritionally adequate and safe diet without breast-
milk can be provided.

HIV: Prophylaxis
• Standard Precautions:
 Hand washing
 Use of protective barriers e.g-gloves, masks, goggles ,gowns
 Safe handling and safe disposal of sharps
 Respiratory hygiene and cough etiquettes
 Safe decontamination and disposal of contaminated waste
Oral pre-exposure prophylaxis (PrEP) containing TDF should be offered as
an additional prevention choice for people at substantial risk2 of HIV infection as part
of combination HIV prevention approaches (strong recommendation, high quality
evidence).

Post-exposure Prophylaxis
Comprehensive management given to minimize the risk of infection
following potential exposure to blood-borne pathogens e.g. HIV.
This includes:
1. First aid
2. Counseling
3. Risk assessment
4. Relevant laboratory investigations based on informed
consent of the source and exposed person.
5. Depending on the risk assessment, the provision of short
term (4 weeks) of antiretroviral drugs.
6. Follow up and support

Post exposure prophylaxis
• A two-drug PEP regimen is effective, but three drugs are preferred (conditional
recommendation, low quality evidence).
• Preferred antiretroviral regimen for adults and adolescents:
1. TDF + 3TC (or FTC ) is recommended as the preferred backbone regimen for HIV
PEP in adults and adolescents (strong recommendation, low to moderate quality
evidence).
2. LPV/r or ATV/r are suggested as the preferred third drug for HIV PEP in adults and
adolescents. Where available, RAL, DRV/r or EFV can be considered as alternative
options (conditional recommendation, very low quality evidence).
3. Preferred antiretroviral regimen for children ≤10 years: ZDV10 + 3TC is
recommended as the preferred backbone for HIV PEP in children aged ≤10 years.
ABC11 + 3TC or TDF + 3TC (or FTC) can be considered as alternative regimens
(strong recommendation, low quality evidence).
4. LPV/r is recommended as the preferred third drug for HIV PEP in children aged ≤10
years. An age-appropriate alternative regimen can be identified among ATV/r, RAL,
DRV, EFV, and NVP. (conditional recommendation, very low quality of evidence).
• Prescribing practices:
– A full 28-day prescription of antiretrovirals should be provided for HIV PEP following
initial risk assessment (strong recommendation, very low quality evidence).
– Enhanced adherence counselling is suggested for all individuals initiating HIV PEP
(conditional recommendation, moderate quality evidence).

Oral pre-exposure prophylaxis
Serodiscordant couples daily oral PrEP (either TDF or TDF + FTC)
Men and transgender
women
daily oral PrEP (Specifically TDF + FTC)
ART for prevention
among serodiscordant
couples
PLHIV in serodiscordant couples who
start ART for their own health, ART is also
recommended to reduce HIV transmission
to the uninfected partner.
HIV-positive partners with a CD4 count
≥350 cells/mm3.
HIV prevention based on ARV
drugs

Post-exposure prophylaxis for occupational
and non-occupational exposure to HIV
Post-exposure
prophylaxis
for women
within
72 hours of
a sexual assault
• Recommended duration of PoEP is
28 days,
• First dose as soon as possible
within 72 hours
• The choice based on first-line ART
regimen.

HIV Vaccine
Need
Despite the remarkable achievements in development of anti-retroviral
therapies and recent advances in new prevention technologies, the rate of new
HIV infections continues to outpace efforts on prevention and control.
Challenges
• H.I.V. mutates rapidly; H.I.V. mutates in one day as much as flu viruses do
in a year.
• the virus has developed multiple mechanisms to evade the body’s defenses
• targets the very cells(CD4) that coordinate the immune response to viral
infections.
• Broadly neutralising antibodies usually appear between two and four years
but by that time the powerful antibodies cannot save them because they are
overwhelmed by the mutating virus.

HIV Vaccine:the new hope
• AIDSVax
recombinant protein (HIV gp120)
adjuvant with alum
Recombinant adeno associated
virus vaccine(rAAV)
recombinant adenovirus type-5 vaccine
containing HIV gag, pol and nef genes
RV144
canarypox vector prime + monomeric
gp120 boost
Failed in Phase II
trials
 Failed in MSM
 Paradoxically increased
the risk of infection
among uncircumcised
men with exposure to
the virus used in the
vaccine.
 vaccine with the
greatest promise till
date.
 31% efficacy in Phase
III trials

NACP – IV: Priorities
 Preventing new infections
 Preventing of Parent to child transmission
 Focusing on IEC strategies for behaviour change in
HRG, awareness among general population and
demand generation for HIV services
 Providing comprehensive care, support and treatment to
eligible PLHIV
 Integrating HIV services with health systems in a
phased manner
 Reducing stigma and discrimination through greater
involvement of people living with HIV(GIPA)

•Targeted Interventions for High Risk Groups (FSW,
MSM, IDU, Truckers & Migrants)
• Link Worker Scheme for rural population
•Prevention & Control of Sexually Transmitted Infections
•IEC, Social Mobilization & Mainstreaming
•Condom promotion
•Blood safety
•Counselling & Testing Services (ICTC, PPTCT, HIV/TB)
•Needle-Syringe Exchange Programme and Opioid
Substitution Therapy for IDUs
•First line & second line
ART
• Care &Support Centres
•HIV-TB Coordination
•Focus on PPTCT
•Treatment of
Opportunistic Infections
Prevention is the main stay
High risk
populations
Low risk
populations
People living with
HIV/AIDS
Care, Support and Treatment
NACP IV Strategies
Institutional StrengtheningStrategic Information Management

Key points
• NACO’s “TREAT ALL concept” means “All persons
diagnosed with HIV infection are eligible for ART initiation
regardless of CD4 count or WHO Clinical Staging
• All people with confirmed HIV infection should be referred to
ART centre for Registration in HIV care, Comprehensive
clinical and laboratory evaluation to assess baseline status,
Treatment of pre-existing opportunistic infections, Treatment
preparedness counselling and Timely ART initiation
• Continued treatment adherence counselling during ART
ensures PLHIV lead healthy quality life for very many years,
while remaining on the robust first line ART regimen

What Does “Treat All” mean
• Provide ART to irrespective of their CD4 or viral Load
values after appropriate baseline and psychological
assessment and preparedness.
• Treat all does not mean initiating ART immediately after
getting a HIV sero- reactive report or same day
initiation
• START ONLY WHEN PATIENT IS READY BUT
• Efforts should be made to reduce the time between
HIV diagnosis and ART initiation based on
assessment of a patient's readiness

1. Programmatic Challenges
2. Technical Challenges
3. Viral Challenges
Challenges for implementation of Treat
ALL

Programmatic Challenges
• Early identification
• Accessibility and Linkages
• Concerns over overloading of facilities
• Retention of patients and Care Continuum
• Supply chain issues
• Affordability and Sustainability

Early identification
Challenges Recommendations
• Late presentation, still most
patients present with lowCD4
count, late presentation partially
nullifies advantages of treat all
• Missed opportunities in
diagnosis
• Training of health care providers,
private sector involvement,
education and awareness on risk
identification, partner testing
• Testing right people at right
places
• Inadequate HIV testing
services
• Cross referrals required to TB, STI,
and ANC sites, losses in referrals
• Community based testing, use of
RDTs, self testing, integrated HIV
testing services and PITC

Accessibility and Linkages
• ART available mostly at stand alone
ART centres at tertiaryor secondary
level of health system
• ART services being decentralized to
more LACs and plan to cover all
districts
• 18-20 % linkage losses from
HIV testing site to ART centre
• Have Unique identifiers at
ICTC
• Implement case based
reporting
• Low utilization of services by KPs • Peer led model for testing and linkage
through TIs

Facility overloaded Issues
• Overcrowding at ART sites due to
additional numbers, inadequate trained
manpower, long waiting hours, delayed
services
• How much increase? 12-15%,
• Differentiated care service delivery
model for stable patients, more
LACs, multi month dispensing
• Laboratory overloading • Minimal Baseline tests,
additional tests only if
indicated
• Inadequate counseling
opportunities
• Identify priority population for
counseling, asymptomatic patients with
higher CD4 count, peer counselors,
community outreach activities

Retention in Care
• High LFU, particularly in asymptomatic
patients, poor patient understanding
on adherence if no symptoms
• Distance from facility,
transportation costs
• Unique identifier, follow retention
cascade regularly at regional, district
and facility level, SMS based reminders
• Decentralization planned on
ART intitation, travel subsidy
• ART induced side effects –
treatment interruptions - emergence
of DR
• Adequate counselling, Toxicity education

Affordability
• Declining donor funding
• Prevention Vs treatment funding,
particularly in low prevalence
settings
• Advocacy for increased domestic
funding, ART is prevention also,
modelling to show long term benefits
of investment in ART
• HIV/AIDS bill guarantees
treatment

Supply chain issues
• Frequent stock outs • Develop robust supply chain
systems, Robust real time
monitoring of drug
consumption and stocks

Technical challenges
• Need for routine viral load for monitoring response to
ART
• Complicated drug regimen, especially for multi- NRTI
exposed patients and treatment failure.
• Need to simplify drug regimen while adopting newer
guidelines.
• Monitoring and supervision- particularly with
differentiated and decentralized models.
• Regular sensitization of health care providers

Viral Challenges
• Emergence of drug resistance strains
• Limited future options for drug resistance
cases

TREAT ALL is doable
• Decentralized delivery, expansion of service delivery points
• multi month delivery
• Community involvement
• Robust supply chain
• Differentiated care model- WHO 2016 ART Guidelines
• CST team has developed an India specific model

Aids final 19112017

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