THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY, AND

CHILDREN

NATIONAL AIDS CONTROL PROGRAMME

NATIONAL GUIDELINES FOR THE MANAGEMENT

OF HIV AND AIDS

7th Edition
APRIL 2019

1
List of Abbreviations

3TC Lamivudine
AA Adherence Assistant
AFB Acid-Fast Bacilli
AIDS Acquired Immune Deficiency Syndrome
ALAT Alanine aminotransferase
ANC Antenatal Care
ART Antiretroviral Therapy
ARV Antiretroviral
ATV Atazanavir
AZT Zidovudine
BBP Blood Borne Pathogen
BCG Bacille Calmette-Guerin
BMI Body Mass Index
BP Blood Pressure
CBO Community Based Organization
CBHS Community Based HIV Services
CHMT Council Health Management Team
CHTC Couples HIV Testing and Counselling
CHW Community Health Worker
CMV Cytomegalovirus
CNS Central Nervous System
CoC Continuum of Care
CPT Cotrimoxazole Preventive Therapy
CrAg Criptococcal Antigen
CrAg LFA Cryptococcal Antigen Lateral Flow Assay
CSF Cerebrospinal Fluid
CTC Care and Treatment Clinic
CTU Care and Treatment Unit

ii
DACC District AIDS Control Coordinator
DBS Dried Blood Spots
DMO District Medical Officer
DOTS Directly Observed Therapy, Short course
DRV Darunavir
DTG Dolutegravir
ECG Electrocardiogram
EFV Efavirenz
EIA Enzyme Immunoassays
EID Early Infant Diagnosis
EPI Expanded Programme of Immunization
EPTB Extra pulmonary Tuberculosis
ESR Erythrocytes Sedimentation Rate
ETR Etravirine
FBO Faith Based Organization
FBP Full Blood Picture
FDC Fixed Dose Combination
FEFO First to Expire, First Out
FP Family Planning
GoT Government of Tanzania
HAART Highly Active Antiretroviral Therapy
HBA Home Birth Attendant
HBC Home Based Care
HBCT Home Based HIV Counselling and Testing
HCP Health Care Provider
HF Health Facility
HIV Human Immunodeficiency Virus
HIVRNA Plasma Viral Load
HLD High-Level Disinfectants
HSV Herpes Simplex Virus

iii
HTC HIV Testing and Counselling
HIVST HIV Self Testing
HVL HIV Viral Load
IDU Injection Drug Users
IEC Information Education and Communication
LAM Urine TB test called Lipoarabinomannan
ILS Integrated Logistic System
IMAI Integrated Management of Adolescence and Adults Illness
IMCI Integrated Management of Childhood Illnesses
INH Isoniazid
IPD In-Patient Department
IPT Isoniazid Preventive Therapy
IRIS Immune Reconstitution Inflammatory Syndrome
ITN Insecticide-Treated Bed nets
KS Kaposi’s Sarcoma
KVP Key and Vulnerable Population
LFT Liver Function Test
LIP Lymphocytic Interstitial Pneumonitis
LPV Lopinavir
LRTI Lower Respiratory Tract Infection
M&E Monitoring and Evaluation
MAC Mycobacterium Avium Complex
MC Male Circumcision
MCH Maternal and Child Health
MDR Multi Drug Resistant
MOHCDGEC Ministry of Health, Community Development, Gender, Elderly, and Children
MSD Medical Stores Department
MSM Men who have Sex with Men
MTCT Mother to Child Transmission
MUAC Mid-Upper Arm Circumference

iv
NACP National AIDS Control Programme
NFV Nelfinavir
NGO Non-Governmental Organization
NNRTI Non-Nucleoside Reverse Transcriptase Inhibitors
NRTI Nucleoside Reverse Transcriptase Inhibitors
NSAID Non Steroidal Anti Inflammatory Drugs
NTLP National TB and Leprosy Programme
NVP Nevirapine
OI Opportunistic Infection
OPD Out-Patient Department
ORS Oral Rehydration Salts
OST Opioid Substitution Therapy
PCP Pneumocystis Jiroveci Pneumonia
PCR Polymerase Chain Reaction
PPE Papular Pruritic Eruption
PPE Personal Protective Equipments
PEP Post Exposure Prophylaxis
PrEPPre Exposure prophylaxis
PGL Persistent Generalized Lymphadenopathy
PHDP Positive Health, Dignity and Prevention
PI Protease Inhibitors
PITC Provider Initiated Testing and Counselling
PLHIV People Living with HIV
PMS Patient Monitoring System
PMTCT Prevention of Mother to Child Transmission
PPE Personal Protective Equipment
QI Quality Improvement
RAL Raltegravir
RCH Reproductive and Child Health
RFT Renal Function Test

v
RHMT Regional Health Management Team
RTV Ritonavir
RUTF Ready to Use Therapeutic Food
SOP Standard Operating Procedures
SP Sulfadoxine Pyrimethamine
STI Sexually Transmitted Infection
SDM Service Delivery Models
STGs Standard Treatment Guidelines
TB Tuberculosis
TDF Tenofovir
TFDA Tanzania Food and Drug Authority
THP Traditional Health Practitioners
TLC Total Lymphocyte Count
VCT Voluntary Counselling and Testing
VIA Visual Inspection with Acetic Acid
VL Viral Load
VZV Varicella Zoster Virus
WBC White Blood Cells
WHO World Health Organization

vi
Foreword
In response to HIV epidemic and with the vision to achieve HIV epidemic control by
2030, Tanzania is implementing preventive, care, treatment and support
interventions towards achieving the Global targets of 90-90-90 by 2020 and 95-95-95
by 2022 as per the Health Sector HIV/AIDS Strategic Plan IV (2017-2022).
According to Tanzania HIV impact survey of 2016/2017, Tanzania has made a good
progress towards attaining the 90 90 90 global targets by 2020 where as 60.6% of
PLHIV are aware of their HIV-positive status, 93.6% of adults who are aware of their
HIV-positive status are on ART and 87.0% of adults who are on ART have
suppressed viral loads.
The Ministry of Health Community Development Gender Elderly and Children
(MOHCDGEC) through the National NACP in collaboration with the implementing
partners, has realized significant achievement as per 2018 progamme Annual report
which shows that out of the total 1,500,000 estimated PLHIV; 1,126,366 (75%) were
enrolled into HIV and AIDS care and treatment and out of those, 1,103,016 (98%)
were currently on ART. Total of 893,559 clients on ART were tested for HIV viral
load, amongst them 780,247 (87%) were virally suppressed. Moreover, the number
of health facilities offering ART services has been increasing over time from the
baseline of 96 in 2005 to 6,206 (2103 CTCs and 4103 Option B+ facilities) as of
December 2018.
These recent recommendations, achievements and experiences in the field of HIV
and AIDS in the country, have deemed it necessary the revision and updating of the
National guidelines for Management of HIV and AIDS. The revision aims to sustain
the attained achievements and to fast-track global and National targets.
This National Guidelines for Management of HIV and AIDS 7th Edition 2019 has adopted
recommendations from scientific researches, informing polices and the supplements
to the 2016 WHO consolidated guidelines on the use of antiretroviral drugs for
treating and preventing HIV infection (i.e., 2017 WHO guidelines for managing
advanced HIV disease and rapid initiation of antiretroviral therapy and 2018 WHO
interim guidelines with updated recommendations on first-line and second-line
antiretroviral regimens and optimization of pediatric ARVs.).
Since rapid changes will continue to take place in the field of HIV and AIDS,
communication of new emerging evidence and science is highly encouraged so as
the contributions from users of these guidelines. In turn they will be used to revise,
improve and update the guidelines, so as to keep abreast with the scientific and
technological changes that have taken place and thus improve the quality of health
services provided.

1
Acknowledgment
The Ministry appreciates and acknowledges the valuable technical and financial
assistance from all the involved stakeholders during the process of revision of the
Guidelines. I would like to recognize and congratulate all staff of the National AIDS
Control Programme who took on this task with great courage and passion. The
strong leadership and guidance of Dr. Angela Ramadhani, the Programme Manager
was critical in its success. It is difficult to mention all who played key roles in the
revision of the Guidelines, hence I would like to appreciate the excellent coordination
and support of Dr. Anath Rwebembera, Prof. Samwel Kalluvya, and the secretariat;
Dr. Mohamed Mnyau and Dr. Yona Mwakabumbe who led the process of
development of this guideline. Without your commitment and dedication, it would
have been very difficult to complete the task on time.
The Ministry commends organizations under the US Government partners and UN
family that worked hand in hand with the National AIDS Control Program in the
revision of the Guidelines.
The Ministry commends all other institutions and organizations as per list in Annex I
that worked hand in hand with National AIDS Control Programme, towards
production of this document.

We thank all stakeholders, who have been using the sixth edition and provided
suggestions for improvement and thus the development of this new edition.

2
EXECUTIVE SUMMARY
The National Guidelines for Management of HIV and AIDS 7 th edition, 2019 covers
key areas of adult, adolescent, and pediatric HIV and AIDS management; nutrition;
mental health; management of opportunistic infections; community-based HIV
services and the continuum of care; counselling Care; Counselling for HIV testing;
management of advanced HIV disease as well as art adherence and disclosure.
Other areas covered include, standard precautions in care settings and laboratory
services, pre and post-exposure prophylaxis, and ARV logistics and dosages. There
is also an emphasis on differentiated service delivery models (DSDMs) to support
PLHIV.
The Guidelines, makes the following new recommendations in managing HIV and
AIDS in the country across the HIV and AIDS services cascade;

HIV Testing Services (HTS): Targeted testing complimented with the

introduction and use of HTS screening tool to ensure smart testing and
favourable yield of HIV positive clients; non-health trained and certified HIV
testers (CHW CDOs, SWOs, VHWs, HIV HBC providers) in the community.
HTS should be offered by trained and certified personnel at health facilities and
community settings. For those who test negative, re-testing is recommended
after 4 weeks and, thereafter, routine HIV testing should be offered annually.
All HIV-positive should be re-tested using the same testing strategy and
algorithm before enrolling into care and initiating ART.
Pre Exposure Prophylaxis (PrEP): will be used by people who are at a
substantial risk for HIV acquisition to lower their chances of getting HIV
infection. Populations targeted for PrEP include Sex workers, Men who have
sex with men, People who inject drugs, Vulnerable adolescent girls (15-19)
and Young women (20-24) and Sero-discordant couples. The recommended
PrEP regimen in Tanzania is: Emtricitabine (FTC) 200 mg/Tenofovir
Disoproxil Fumarate (TDF) 300 mg (Truvada) PO Daily.
Post Exposure Prophylaxis (PEP): The guidelines recommend the use of
TLD (TDF+3TC/FTC+DTG) for adults and adolescents for.
Differentiated Service Delivery Models (DSDMs): clients are categories as
early presenters or late presenters with or without advanced disease at
initiation of ART and stable or unstable after being on ART for six months. The
guideline allows classification of clients on second line to be stable provided
that they meet other criteria of being a stable client. Clients on TB Preventive
Therapy (TPT) will be termed as unstable until completion of the preventive
therapy (TPT).
ART Initiation: within 7 days of a positive HIV test, unless there is a medical
or psychosocial contraindication. Facility-led community ART initiation for KVP
with a 1-month starter pack then to continue to receive care in the facility
during the follow up visits.

3
Multi month prescription and dispensing: Initially stable clients will be
offered 6-month prescription with 3monthly dispensing for the first six months.
Thereafter, the client who still meets criteria for stable client should be offered
6-month prescription and dispensing. Unstable clients will attend clinics on
monthly basis.
Screen for serum Cryptococcal antigen: all ART-naive adults and
adolescents with CD4 cell count of <200 cells/mm 3 or WHO stage 3 or 4 if
CD4 testing is not available. Pre-emptive therapy with fluconazole if
Cryptococcal antigen screening test is positive (bloodstream disease) but no
evidence of meningitis. The current guideline does not support the use of
fluconazole monotherapy in the management of Cryptococcal Meningitis.
Management of drug related toxicities during treatment of Cryptococcal and
Cryptococcal IRIS have also been outlined.

Tuberculosis preventive therapy (TPT): using Isoniazid (INH) tablets to

eligible individuals in order to prevent progression to active TB disease. Other
alternative short regimens recommended to be used when available are
Rifapentine+INH (3HP) weekly for 3 months and Rifampicin+INH daily for 3
months.

TB diagnosis: Lipoarabinomannan (LAM) testing is recommended for

diagnosis of TB in HIV-positive patients with either a CD4 count of less than
200 cells/uL or who present with danger signs.

Dolutegravir (DTG)-based regimen -TDF + 3TC + DTG (TLD) is

recommended as the preferred default first-line regimen for adults living with
HIV. TLE will remain as an alternative for clients who will not tolerate and
Women at child bearing potential who will not opt to use DTG. A women-
centered approach is adopted and women of child bearing potential including
those who are using long term effective contraception will be given adequate
information to enable them to make informed decision and informed choice
consent to using DTG. The guidelines adopted recommendations for
optimization of pediatric ARV, introducing the use of LPV/r granules and
phasing out of NNRTI based regimes.
HVL Testing Algorithm for Adolescents and Adults; In case the second
HVL results after Enhanced Adherence Counselling is ≥1000copies /ml and ≥
0.5log drop continue with the same regimen and repeat HVL after 3 months. If
after the third HVL test HIV viral load is ≥ 1000copies /ml switch to
subsequent line. Clients switched to subsequent line will test HVL six month
after starting the new regimen and follow again the algorithm form above.

4
 CHAPTER 1
OVERVIEW OF HIV AND AIDS
1.1 State of HIV Epidemic
Approximately 36.9 million people were living with HIV, globally by 20181. In Tanzania by 2017 it
was estimated that around 1.4 million people were infected with HIV in the country2. Tanzania
mainland is experiencing a generalised HIV epidemic, with an HIV prevalence of 4.7% in general
population. Heterosexual sex remains the commonest (attributing up to 80%) route for HIV
transmission in Tanzania Mainland. HIV prevalence in Tanzania is characterized by significant
heterogeneity across age, gender, socioeconomic status, and geographic location; implying
differentials in the risk of transmission.

HIV prevalence is higher in sub-groups such as in people who inject drugs (PWID) (16-51%)3
men who have sex with men (MSM) (22-42%)4 and mobile populations and sex workers (14-
35%)5. Women are disproportionally more affected, with an HIV prevalence of 6.3 % versus 3.9%
among men. (THMIS 2011-12). The prevalence of HIV among young people aged 15-19 years
was 1% (1.3% among girls, and 0.8% among boys). Furthermore, the percentage of women
aged 20-24 infected with HIV is higher (4.4%) than that of men (1.7%) in the same age group.6

The UNAIDS and international community have set a goal to eliminate new HIV infections by
2030. In order to achieve this goal, an ambitious target of 90-90-90 has been set, that 90% of all
people living with HIV (PLHIV) knowing their HIV status (diagnosed), 90% of those diagnosed to
have HIV infection to be started on anti-retroviral therapy (ART), and 90% of those on ART
achieving sustainable viral suppression by 2020. Attainment of these targets will lead to
reduction of new HIV infections by 90% hence providing an opportunity for ending AIDS
epidemic by 2030.
The government has strengthened efforts to scale up HIV prevention, care, treatment and
support services including the recent adaption of Treat All (test and treat) strategy. These efforts
have resulted into a drop of HIV incidence rates from the peak of 1.34% in 1992 to as low as
0.07% among 15-24 year-olds and 0.25% among adults (aged 15-64) in 2017.2 The country’s
goal was to reduce the incidence in the general population to less than 0.16% by 2017.

1 UNAIDS Global AIDS Report 2018

2
Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission (ZAC). Tanzania HIV Impact Survey (THIS)
2016-2017: Final Report. Dar es Salaam, Tanzania. December 2018.
3 The United Republic of Tanzania, Ministry of Health and Social Welfare; national aids control programme and

Muhimbili university of Health and allied sciences, Dar es salaam. Integrated Bio-Behavioural Survey Among
People Who Inject Drugs in Dar es Salaam. April 16, 2014
4 Leshabari et al. A Prevalence of the Human Immunodeficiency Virus, other sexually transmitted infections, and

health-related perceptions, reflections, experiences and practices among men having sex with men in Dar es
Salaam,2013
5 National AIDS Control Programme; A study of Female Sex Workers in seven Regions: Dar es Salaam, Iringa,

Mbeya, Mwanza, Shinyanga, Tabora and Mara. A Report published in 2014 (ISBN 978-9987-650-83-5)
6 National Bureau of Statistics, ICF International. Tanzania HIV AND AIDS and Malaria Indicator Survey 2011-12.

Dar es Salaam, March 2013

5
1.2 Impact of HIV and AIDS

1.2.1 Health Impact

The HIV and AIDS pandemic causes/predisposes people to other infections such as
Tuberculosis (TB), NCDs, which are among leading causes of morbidity and mortality among the
PLHIV. TB and HIV co-infection has remained at rate of 35-36% for the last three years in 2015,
93% of all people diagnosed with TB infection were also tested for HIV, of whom 35% had co-
infection with HIV.

In Tanzania Mainland, where human and financial resources for the health system are
constrained, the implementation of additional care and management services for HIV infection
has added to the overall health system challenges. Since HIV infection also affects health care
personnel, an additional burden to the human resource crisis has been noted.

1.2.2 Economic Impact

There is a close relationship between HIV and AIDS and economic development. AIDS
negatively affect economic growth, which makes it difficult for countries and individuals to initiate
adequate and comprehensive responses to the epidemic, due to a weak economic base. Poverty
is a powerful co-factor in the spread of HIV infection. The economically and socially
disadvantaged segments of the population, including women, youth and other marginalized
groups, are disproportionately affected by the epidemic. The health status and death due to
AIDS are reported to have reduced the work force, productivity and disposable incomes in many
communities.

1.2.3 Social Impact

HIV and AIDS related deaths among young and middle aged adults has resulted to thousands
orphans. AIDS is widespread in both urban and rural communities and mostly affects persons at
the peak of their sexual and productive lives. The death of a young adult often means loss of
family’s primary income earner. HIV and AIDS epidemic has caused break down of social
networks in African societies. Stigma associated with HIV continues to prevail. Orphans are not
only subjected to material, social and emotional deprivation, but lack of opportunities for
education and health care. Widows and orphans are deprived of their inheritance rights.

Programmes to mitigate the impact of AIDS should include: strong and high-level political
leadership, a national strategic plan and adequate funding for HIV and AIDS response; strong
and sustained community involvement and initiatives; and supportive policies.

6
 1.3 National Response to HIV Care and Treatment

The National response to HIV and AIDS includes interventions aimed at prevention, Care,
Treatment and support. The Government, in collaboration with development and implementing
partners, initiated a care and treatment programme under the NACP. The percentage of PLHIV
receiving antiretroviral treatment in Tanzania Mainland have increased from 52 % in 2005 to 72%
in 2018.
Over 6,000 health facilities are registered to deliver HIV care and treatment services, including
provision of ART as of June 2018.7 The country is implementing initiatives to increase HIV testing
services through expansion of Client/Provider Initiated Testing and Counselling (C/PITC) and
Community Based Testing and Counselling (CBTC). Moreover, rigorous strategies such as Index
testing and self-testing are documented for reaching out the most at risk populations, including
but not limited to men and adolescents.
Provision of Long life ART to pregnant and lactating mothers LLAPLA as part of PMTCT
programs has contributed to the decrease the transmission of HIV infection from mother to child
at six weeks from 8.7% in 2012 to 4.4% in 2015. RCH sites providing PMTCT services had
increased to 5,361 out of 5,863 (i.e. about 91% of all RCH facilities) by 2014 and the percentage
of pregnant and lactating women who are receiving ARVs had increased from 71% in 2012 to
90% in 2014.8

1.4 Basic Facts about HIV

1.4.1 Etiology of HIV
In Tanzania, HIV infection is caused by HIV-1 sub-types. The common HIV-1 sub-types
(clades) in Tanzania are A, C, D, and their recombinants. There is no HIV-2 sub-type
infection has been reported up to date.
1.4.2 HIV Transmission
HIV infection is acquired through unprotected sexual intercourse with an infected partner,
exposure to infected blood and blood products, or transmission from an infected mother to
the unborn child in the uterus during delivery or from breast milk. More than 90% of adults in
sub-Saharan Africa acquire HIV infection through unprotected sexual intercourse with
infected partners. Transmission of HIV through body fluids other than blood and genital
secretions such as cerebrospinal fluid, pleural fluid and amniotic fluids are also possible.
However, unless blood is visibly present, saliva, sputum, sweat, tears, faeces, nasal
2
secretions, urine, and vomits carry a very low risk of transmission of HIV .
1.4.3 Pathophysiology of HIV infection

7 Ministry of Health, Community Development, gender, Elderly and Children, The National AIDS Control Program
(NACP). HIV Data Handbook, September 2018.
8 MOH, Prevention of Mother to Child Transmission of HIV, Annual Report 2014

7
The virus through its envelope proteins attaches to the CD4 receptor and co-receptors found
on the surface of T lymphocytes and macrophage to gain entry to the host cells. CD4
molecules are also found on the surface of Langerhans cells of the skin and the microglial
cells of the brain.

Following entry of the HIV into a susceptible host cell using the enzyme reverse
transcriptase, the viral genome copies itself from RNA to DNA genetic material. The viral
DNA copy enters the nucleus of the host cell and becomes intimately incorporated into the
host cell’s own DNA using the enzyme integrase. The virus thus becomes a permanent part of
an infected person’s nuclear proteins. There follows a latent period during which the provirus
in the infected nucleus waits for an external stimulus to start reproducing.

CD4+ T lymphocytes, when stimulated by new HIV, other infections and infestations which
would normally result in the CD4+ T lymphocyte reproducing itself, now responds to these
stimuli by manufacturing HIV. As more and more viruses are produced and leave the host
cell, the cell membrane weakens leading eventually to the death of the infected CD4+ T
lymphocytes.

Other factors, most of which are still unknown, lead to the rapid depletion of the CD4+ T
lymphocytes. The decline in the CD4+ T lymphocytes count is a reflection of the declining
cellular immunity, which manifests as the appearance of opportunistic infections. The
infected CD4+ lymphocytes have a half-life of about two days, which is much shorter than
that of uninfected CD4+ cells. Rates of CD4+ lymphocyte destruction correlate with plasma
HIV level. Typically, during the initial or primary infection, HIV levels are highest (>106
copies/ml), and the CD4 cell count drops rapidly.

However, an immune response to HIV develops, that it restricts viral replication, resulting in
a decrease in viral load and a return of CD4 T-cell numbers to near normal levels. Viral load
remains relatively stable for a certain period (the "set point") and start rising again shortly
before AIDS diagnosis.

For ART-naive adults, a viral set point is reached after six weeks, and the median time to
AIDS is 10 years. Paediatric patients, however, have much higher viral loads than adults; and
a viral set point is reached after five years, and the median time to AIDS is one year.

Theoretically, the multiple steps in replication of HIV provide multiple opportunities for
intervention. Therapeutic regimens may be directed at one or several of the following stages
essential for viral replication: (1) attachment of HIV to the host cell; (2) reverse transcription
of viral RNA to DNA; (3) integration of the pro-viral DNA into the host cells’ DNA; or (4)
expression of the viral gene after it has been integrated into host cell DNA, including the

8
transcription of more viral RNA and the translation of viral proteins. 9 (See Fig. 1.1). Because
of rapid viral mutation, it is usual to recommend treatment that impacts the life of the virus at
more than one site at any given time. As medications are developed, they may be co-
formulated to make them easier for PLHIV to take more than one.

9Chan DC, Kim PS (1998). "HIV entry and its inhibition". Cell. 93 (5): 681–4.

9
Fig.1.1 Processing and Post-Translational Modification of Protein Products of the Virus

ARVs function by inhibiting HIV enzymes essential for HIV replication. These are such as
reverse transcriptase, protease and fusion enzyme. Inhibition of enzymes finally results in
reduction of viral replication and a consequent reduction or reversal of destruction of CD4+T
lymphocytes.

1.5 Clinical Progression of HIV Infection

In the absence of ART, disease progression goes through the following clinical stages: (Also
see WHO Clinical Staging Criteria in Annexes 2 and 3).
1.5.1 Primary Infection or becoming HIV Infected
Most primary infection, i.e. new infection with HIV, usually is not immediately noticed. It
presents with short illnesses and flu-like symptoms such as fever, malaise, enlarged lymph
nodes, sore throat, skin rash, and/or joint pain soon after being infected. It may last for a few
weeks. This acute febrile illness is accompanied by widespread dissemination of the virus to
different tissues, especially the lymphoid system. This is called sero-conversion illness.
1.5.2 Clinically Asymptomatic Stage
This stage is free of symptoms, except for the possibility of swollen glands: Persistent
Generalized Lymphadenopathy (PGL). However, this is the stage where there is ongoing
extensive immunologic fighting/changes and rapid viral replication begins. This may last for
an average of eight to ten years. However, disease progression in children and elderly is
faster due to high set point. This is WHO Stage 1.

10
1.5.3 Symptomatic HIV
Over time, the immune system loses the struggle to contain HIV, resulting in extensive
destruction of CD4 cells. This is characterised by the occurrence of opportunistic infections
(OIs), which is when symptoms develop. The most common symptoms include fever,
respiratory infections, cough, TB tuberculosis, weight loss, skin diseases, viral infections,
oral thrush, pain, and lymphadenopathy.
This is WHO Stage 2 or 3, depending on the particular OI seen. (See Annex 2 and 3 for
reference.)

1.5.4 Acquired Immune Deficiency Syndrome (AIDS)

AIDS is defined as a point when a person with HIV develops severe immunosuppression,
OIs, or malignancies/cancers. Such conditions are: severe weight loss, Kaposi’s sarcoma,
Cryptococcus meningitis, PCP, toxoplasmosis, CMV (Cytomegalovirus) retinitis, etc. This is
WHO Stage 4.
Note: The risk of HIV transmission is higher in primary HIV infection and AIDS when the
viral load is higher in the blood.

11
 CHAPTER 2
HIV AND AIDS SERVICE DELIVERY
2.0 Introduction
This chapter describes the organization of HIV and AIDS services in Tanzania, specifically roles and
responsibilities of care and treatment centre (CTC) staff, client registration, triage of clients, exit
desk and accreditation of health facilities to provide HIV services. In addition, the chapter describes
recommended differentiated service delivery models and quality of CTC services.
2.1. Organization of HIV Care and Treatment Services
Provision of quality HIV and AIDS services requires dedicated space in the outpatient department
(OPD), availability of support services in and out of the clinic, and health care staff with well-
defined roles and responsibilities.
2.1.1 Dedicated Space for the CTC
 Well-ventilated waiting area
 Registration area/desk
 Community-Based Health Services (CBHS) space/desk
 Data management room
 Phlebotomy room
 Record/file designated room/space
 Medicine dispensing room
 Consultation rooms
 Counselling rooms
 Exit space/desk

Note: Registration and recording of vital signs can be placed within the waiting area.
Consultation and counselling rooms must be partitioned to maintain audio and visual privacy.

2.1.2 Support Services

These include:
 Laboratory
 Pharmacy
 Radiology

2.1.3 Staffing at CTC

The execution of CTC services depends on skills mix of health workers. The required staffs to run a
CTC is composed of: Clinicians, Nurses, Laboratory Technologists, Pharmaceutical staff ,
Radiographers, and other support staff. The shortage of these staff limits accessibility for clients and
negatively impacts health outcomes. To mitigate the acute shortage of health workers, these

12
guidelines recognise that Task Sharing practises and the NIMART approach can increase access to
healthcare services. Roles and responsibilities of CTC staff are as stipulated in Annex 4

2.2 Types of services at Client Waiting Area, Registration, Triage and Exit
This section outlines the procedures starting with the client arrival until the time when she/he exits
the health facility.
2.2.1 Waiting Area
This is an area where clients are expected to gather before receiving services. The healthcare
provider at the waiting area will do the following:

1) Inform clients about services provided and whom they can expect to meet.
2) Inform clients on the clinic flow of services.
3) Provide group health education on the selected topics.

Triage
• Identify the seriously sick clients from the waiting area to fast-track for immediate service.
• Obtain brief history and assess the client needs.
• Link clients to relevant services according to their needs.

2.2.2 Registration
a) Initial visit
 Obtain a written referral form that confirms HIV positive test from the client.
 Perform retest for HIV verification for all clients with a prior positive antibody test regardless
of the place where the initial test was performed (Refer to chapter 3 Section 3.3.7).
 Register all clients in an Appointment register and in Pre-ART Register for paper-based
facilities.
 Elicit index contacts using elicitation form.
 Ensure availability of DTG consent form for women of child bearing potential age who are
willing to start DTG based regimen.
 Fill in correctly and complete CTC1 and CTC2 cards.
Give CTC1 card to the client and tell them to bring with them at every visit.
Fill in correctly and completely the demographic data on TB screening tool.
 Ensure the HIV Exposed Infant Card (HEIC) is properly filled where applicable.
 Link the client to the relevant service.
 Keep and retain the file in the facility registration unit.
 Perform baseline laboratory investigations (CD4 count, Full Blood Picture (FBP), Liver
Function Tests (LFT) and Renal Function Tests (RFT).
 Conduct first session of adherence counseling.

13
b) Follow-up visits
 Prepare client’s files using either appointment book or existing CTC2 database one day
before the clinic.
 Retrieve the client file number at every visit for all unscheduled clients.
 Up-date Client CTC1 and CTC2 card including index elicitation at each visit
 Record the clients in the appointment register.
 Check and ensure that CTC2 card, clinical forms, TB and STI screening questionnaire, client
physical address, laboratory results, and nutritional assessment forms are in the file.
 Assess willingness and readiness to start ARVs and address any pending issues.
 If willing and ready, initiate ART within 7 days.
 Continue with adherence counseling.
 Direct the client to exit desk for next appointment.

2.2.3 Exit
 Countercheck if the client has been informed and given the date for the next appointment.
 Record in the client CTC1 card the date and time for the next clinic visit.
 Let the client mention the date and time for the next visit and advise to report back to the
clinic as soon as she/he is not feeling well.
 Confirm contact details and willingness to be tracked.
 Record in the appointment register the date and time for the client’s next clinic visit.
 Ensure the clients are linked to PLHIV support groups, CBHS, and other services as needed.

Note: Adolescents and youth require special consideration to ensure quality prevention, care,
treatment, and support services.
Special consideration should focus on:
 Arranging youth clinics on special days and times.
 Establish clubs (pre-teen, teen, youth clubs)
 Involve peer educators in providing services.
 Fast-track registration and retrieval of their records.
 Guarantee privacy and confidentiality.
 Involve adolescents and youth in planning their services and in deciding on their treatment
choices.
 Encourage adolescents to consult healthcare workers (HCWs) when they have concern with
health-related issues, and ensure availability of equipment and supplies (e.g. condoms or
other family planning methods, fliers, job aides, posters, etc.) at their clinics.

2.3 Establishing Care and Treatment Services at a Health Facility

For health facilities (HF) to qualify for the provision of HIV and AIDS Services to PLHIV the
National HIV Programme developed a tool that is used to assess HF to provide care and treatment
services (Refer Annex 5). The tool assesses adequacy of space, availability of support services, and
minimum required staff to establish and maintain a CTC and PMTCT Option B+ HF.

14
Assessment of HF for provision of care and treatment services is done by the Council Health
Management Teams (CHMTs) in collaboration with the Regional Health Management Teams
(RHMTs).
If the HF meets the minimum criteria for establishment of a CTC, the District Medical Officer
(DMO) should inform the Regional Medical Officer (RMO) who shall request an approval and
provision of a CTC code number through NACP.
If the HF does not meet the minimum criteria for establishment of a CTC, the CHMT shall identify
the areas for strengthening and plan for improvement to upgrade the HF.
Reassessment of the HF shall be conducted to ensure the improvement plan has been implemented.
Note:
For HF providing LLAPLa, i.e., a stand-alone PMTCT site, the HF must follow the same procedures.
Upon approval, the assessed PMTCT HF will continue to use same PMTCT code numbers for
running CTC services.
For an HF which does not meet the minimum criteria can be considered as either Outreach site or
ART refill site.
2.4 Differentiated Service Delivery Models (DSDMs)
Differentiated HIV Care is a client-centred approach that simplifies and adapts HIV services across
the treatment cascade. The aim is to reflect the preferences and expectations of various groups of
people living with HIV (PLHIV) whilst reducing unnecessary burdens on the health system.
Differentiated Service Delivery Models are approaches that when applied result in delivery of HIV
and AIDS services in a differentiated care perspective.
With the “Treat All” strategy, there are an increasing number of clients on ART. These clients will
have a diverse range of needs challenging the capacity of health care system to manage all clients.
Basing on this, differentiated service delivery models have been adopted to reach a diversity of
clients, from those who present well, to those presenting with the advanced disease.
Three elements are considered in provision of client-centred care including:
1. The clinical characteristics of the clients: Based on clinical characteristics, clients are
defined as Stable, Unstable, clients with early presentation and clients with late presentation
(with or without advanced disease).

Table 2.1 Definitions of Different Categories of Clients for DSDMs

At ART initiation
Clients with Early presentation: These are the clients who present with WHO clinical stage 1 or 2,
and CD4 count > 350cell/ mm3. These clients require additional and targeted adherence support in
order to commit themselves to lifelong ART.
Clients with late presentation:
These are the clients who present with WHO clinical stage 3 or 4, or CD4 count ≤ 350 cell/ mm3.

15
Late Presenters are further subdivided into clients with Advanced HIV Disease or without Adavanced HIV
Disease.

Clients with advanced disease: These are clients who present with low CD4 count <200 cells/mm3 or
WHO clinical stage 3 or 4 for adults and adolescents, and all children below five years who are HIV
positive. This group of clients requires expedited clinical investigations, management and
prophylaxis for opportunistic infections prior to initiation of ART in order to reduce ilhealth and
prevent death.
After six months on ART a client can be categorized to stable or unstable client.
Stable Clients: These are clients who are on ART for at least six months and meet ALL of the
following criteria:
 Age ≥5 years.
 Have no adverse drug reactions that require regular monitoring.
 No current illnesses (OIs and uncontrolled co-morbidities)
 Have good understanding of lifelong adherence of 95% and kept clinic visit appointments for
the past six months.
 Undetectable viral load of less than 50 copies/ml.
 In the absence of HIV viral load monitoring, rising CD4 counts >350 cells/mm3.
 On first or second line ART
This group represents the majority of people on ART. The clients on this group should be offered
less frequent clinical visits and extended drug refills.
Unstable Clients: These are the clients who are on ART for at least six months and meet ANY of
the following criteria:
 Age below 5 years
 Presence of an active OIs (including TB) or uncontrolled co-morbidities in the past six
months.
 Poor or questionable adherence to scheduled clinic visits in the past six months.
 Recent detectable VL above 50 copies/ml,
 In absence of HIV viral load monitoring, decreasing CD4 cell count or CD4 ≤ 350 cell/mm3
 People Who Inject Drugs (PWID).
 Pregnant and Breastfeeding Women.
 On TB Preventive Therapy (TPT).
 Clients on third line ART regimen.

These clients require additional clinical care, adherence support and timely switch to subsequent
ART regimens in the case of treatment failure.

While these four groups have distinct needs, clients may change in between categories over the
course of their lifetime in care.
2. The sub-population: ART delivery should also be differentiated based on the challenges of
different sub-populations such as adults, children, adolescents, pregnant and breastfeeding
women, men, key and vulnerable populations.

16
 3. The context: In order to maintain quality ART delivery, specific modifications are required
when dealing with challenging settings such as conflict, urban/rural, high migration and low
prevalence.

Differentiated Service Delivery Models are designed using the building blocks approach with four
delivery components: (i) the types of services delivered; (ii) the location of service delivery; (iii) the
provider of services; and (iv) the frequency of services. The four components are guided by the
following key questions:
 When is care provided?
 Where is care provided?
 Who is providing care?
 What kind of care or services are provided?

Figure 2.1 The Building Blocks of Differentiated Service Delivery Models

WHO Clien

Physician
Clinical officer
Nurse
Pharmacist
Community health worker
Patient / peer / family

Adapted from International AIDS Society (IAS). Differentiated Care for HIV: A decision framework for
antiretroviral therapy delivery. July 2016 . DSDMs should be designed and implemented as a direct
response to specific challenges or barriers identified among clients and/or healthcare workers. To
decide which models are appropriate in any given setting, an assessment of local data,
healthcare worker and client experience needs to be made. The following tables (1-5)
summarize the recommended service delivery models that are used in Tanzania.
17
Table 2.2 Differentiated HIV Testing Services
When Where Who What
General Population
HTS should be Targeted testing Trained Peers should Index testing
available for 24 hours (PITC/CITC) should be mobilise
CITC
daily for facilities offered in all entry points communities to
providing maternity of the health facilities. access HTS. HIV self-testing
and in-patient care. These include general
Trained and certified PITC
OPD, IPD CTC, TB, STI,
For other facilities HCW to perform
and RCH/PMTCT and in Integrated
HTS should be HTS.
specialized clinics. approaches
available in all
facilities beyond Facility and community- should be
official working based index client testing implemented in
Capacitated non
hours depending on should be offered from all community
healthcare workers
local needs. facilities. testing strategies.
cadres (CHW,CDOs,
SWOs, VHWs and This may include
Targeted testing should
CBHS providers) to HIV testing, TB
also be offered as
conduct education and STI
community-based
and testing (including screening, blood
outreach testing from all
HIV self-testing) pressure, blood
facilities.
glucose checks,
Every facility to
and nutrition
ensure that there is
assessments.
always a HCW on
duty who has been
trained to perform
HTS.

Special Considerations for Children and Adolescents

18
Extended hours, Targeted outreach testing Trained peer Integrate EID
weekends and public to schools, colleges, street adolescent should DBS, HTS into
holidays children and orphanages mobilise adolescents outreach Health
should be included in the for testing. services e.g. EPI,
outreach planning. TB, NCD and
All cadres of existing
Family planning
PITC should be offered in health care workers
services
all entry points of the should be trained to
health facilities including prepare DBS samples
for EID testing.
RMNCH, VMMC clinics
adolescent-friendly All facilities should
settings, malnutrition and ensure there is always
paediatric wards. a HCW on duty who
has been certified to
provide HTS and
trained to prepare
DBS samples for EID
testing.
Trained health care
workers should
perform HTS and
EID DBS during
mobile outreach
activities.

Special Considerations for Pregnant and Breastfeeding Women

HTS should be Re-testing of HIV Trained and certified Index testing
available for 24 hours negative pregnant and Healthcare workers to
PITC
daily for facilities breastfeeding women provide HTS
providing maternity should be integrated in HIV retesting
care facility and outreach EPI
and Family Planning
activities.
Special Considerations for Key and Vulnerable Populations (KVP)
Key and vulnerable Districts should locate Trained KVP peers KVP should be
populations should be where specific KVP will should mobilise offered an
consulted to access HTS and offer their communities to integrated
determine the most targeted outreach testing access HTS. package of
appropriate time to from the facility serving services with
Trained and certified
offer community or the defined location HTS as a core
Healthcare providers
facility-based HTS service e.g. for
to provide HTS
e.g. moonlight testing sex workers:
for female sex HTS, Condom
workers, long distribution,
distance truck drivers Family planning,
and miners, peak STI screening and

19
seasons Fisher folks treatment, GBV
and farmers. services,
Prevention
services (PEP and
PrEP).

20
Table 2.3 Linkage to Care
All HIV-positive clients identified at a facility should be guided (with their consent) to
the CTC for enrolment into ART care. This should ideally be done by the HCW who
has performed the test or other community health worker.
All HIV-positive clients identified should be linked, with their consent, with a
community health worker or other community-based services providers. A duplicated
referral form should be completed for anyone testing positive in the community. A
copy of the referral will remain with community-based HIV services providers for
follow up of effective referral. The community-based providers should encourage the
client to attend the facility of their choice.
Any client who has tested HIV positive should be asked for their consent to be traced
by a service provider. Any client who has not linked to care after one month should be
traced. Tracing should initially be by phone followed by a home visit.

21
Table 2.4a Differentiated ART Initiation for Clients with Early presentation
Eligibility Criteria for Early presentation: WHO clinical stage 1 or 2, and CD4 Count >350 cell/ mm3
When Where Who What
General Population
All clients should be assessed for the option of rapid At all Initiation may be performed by a trained An assessment of both clinical (OI
initiation. This must include an assessment of both facility healthcare worker (Clinician, NIMART screening) and psychosocial readiness
clinical and psychosocial readiness. levels trained nurse). must be carried out before ART
initiation.
Initiation should take place within 7 days of a positive Counselling including basic HIV and
HIV test, unless there is a medical or psychosocial ART education and assessment for Counselling should include basic HIV
contraindication. readiness to start ART (Nurse, doctor, and ART education and assessment
AMO, clinical officer). for readiness to start ART.
Management of any other conditions
Adherence counselling should be done rapidly before
ART initiation ART initiation

Following ART initiation, the client should be seen

after 2 weeks and then monthly until the patient is
stable. Additional visits may be needed to address any
medical or psychosocial concerns

22
Table 2.4b Differentiated ART Delivery for Late presenters with Advanced Disease.
Eligibility Criteria for Late presenters with Advanced Disease: All children below 5 years or Clients with WHO clinical stage 3 or 4, or CD4
Count < 200 cell/ mm3
When Where Who What
At all facility levels. Initiation may be An assessment of both
performed by a trained clinical and
healthcare worker psychosocial readiness
Early initiation ofART will decrease Management of clients is done at any care (Clinician, NIMART must be carried out
risk of disease progression, including and treatment centre/service delivery point. trained nurse). before ART initiation.
wasting and OIs Referral to a higher-level facility when
feasible if consultation is not adequate to
stabilize the client.
Initiation should take place within 7
CD4 testing
days of a positive HIV test, unless
there is a medical contraindication or
psychosocial contraindication.
Assessment for
Cryptococcal disease if
CD4 <200 cell/mm3

Following ART initiation, the client

should be seen after 2 weeks and
then monthly until the patient is
TB screening.
stable.
TPT
Cotrimoxazole
More frequent visits or

23
hospitalization may be required to prophylaxis.
stabilize acute medical conditions
STI screening.
and address psychosocial and other
concerns.

Counselling should
include basic HIV and
ART education and
assessment of readiness
to start ART.

ART Initiation.

Table 2.5 Differentiated ART Delivery for Stable Clients

Eligibility for Stable Clients: Stable clients are defined as those who are five years of age and above, received ART for at least six months
and have no adverse drug reactions that require regular monitoring, no current illnesses (OIs and controlled co-morbidities’), have good
understanding of lifelong adherence of 95% and keeping clinic visit appointments for the past six months, on first or second line ARVs,
recent undetectable Viral Load i.e. below 50 Copies/mls and in the absence of HIV viral load monitoring, rising CD4 counts and >350
cells/mm3.
Note: A stable patient should meet all the above criteria.
 All clients on ART should have a booked appointment for their clinical and refill visits.

 All clients should be asked for their consent to be traced if they default.

When Where Who What

General population

24
Clients should have a clinical review ART refill should be done in all Follow up on ART may be Full clinical review
twice a year approved care and Treatment performed by any trained should be done during
Clinics, Option B+ facilities and healthcare Worker (Clinician, clinical consultations.
Initially stable clients should be offered
Facility led community Outreach nurse).
6-month prescription with 3 monthly ART refills should be
or Mobile visit.
dispensing. Thereafter, the client who provided to clients
still meets the stable client criteria according to
should be offered 6-month prescription Differentiated Service
and dispensing. Delivery Model in use.
Clients should receive ART at
Clients should choose a “blocked 6-month prescription and
the health facility of their choice.
appointment time (AM /PM)” as well as dispensing
an appointment date.
Clinics should provide extended
opening hours for specific sub-
populations (e.g. Adolescent and
youth). Frequency of extended hours
should be determined based on local
demand.

Recommended ART Refill models include:

Facility based Individual fast-track from Health Facility pharmacy - clients are seen individually within health care facilities and are fast-
tracked for collection of the ARVs.
Community based individual ART delivery through facility led mobile outreach services/visit - clients are seen individually outside the
healthcare facilities by HCW as part of routine mobile outreach visits.
Note: Provision of ART refill model in both settings should comply with Tanzania eligibility criteria for stable clients (Annex…)
Family member or treatment supporter refill - client nominates a family member or treatment supporter to collect their ART refill.

25
Facility based healthcare worker managed group - clients are seen for a group counselling service e.g. teen clubs or youth clubs.
Special Considerations for Children and Adolescents
ART delivery should be provided outside school hours, during weekends or holidays.
Stable Children and their guardians should be booked on the same day. Group counselling activities may be deployed for children and
guardian and will be coordinated by the health care worker to facilitate disclosure, peer support and adherence.
Adolescents and youth should be encouraged and offered a group counselling approach and peer support. They should be grouped
according to age and consideration of disclosure status. Group counselling activities will be coordinated by the health care worker to
facilitate disclosure, peer support and adherence.
Children and adolescents attending boarding schools should be offered additional support while at school and follow up appointment during
their school holidays.
Special Considerations for Pregnant and Breastfeeding Women
PMTCT and RCHS services should be integrated.
Clients should receive PMTCT/SRH services in the same manner as HIV negative clients – i.e. a special room does not need to be dedicated
for HIV positive clients.
HIV positive pregnant women should be encouraged to join PLHIV groups for additional peer support.
HIV positive breastfeeding women and their exposed infants should be seen on the same day “family approach”.
Special Considerations for Key and Vulnerable Populations
Facility-led community ART initiation for KVP with a 1-month starter pack and follow up at health facility of choice for refill. The second
visit should be facility based.
An integrated package of medical care should be offered tailored to the specific needs of the key and vulnerable population (e.g. should
receive STI screening and treatment, condom distribution, GBV services, Hepatitis B vaccination and prevention services).
Services for key and vulnerable populations should be friendly and integrated into existing services. Health care workers should provide the

26
integrated package of services in a non-judgemental manner. If feasible specific times of clinics for key and vulnerable populations may be
allocated by individual sites.
Peers should be trained to provide psychosocial support, adherence counselling and linkages.
Clients who are stable should be offered the same refill options as the general population except for people who inject drug (PWID)
Clients within a specific key and vulnerable population group may choose to form their own group for peer support.
Special Considerations for Mobile Populations
Mobile populations (clients working in other countries or cities from their CTC sites, nomadic pastoralists, truck drivers, fishermen) should
be offered longer ART refills adapted to their travel plan.
Clients in this sub-population should agree to attend for their annual review, which should be booked when they are in their area of
residence or area of their ART facility.

27
Table 2.6 Differentiated ART Delivery for Unstable Clients
These are the clients who are on ART for at least six months and meet any of the following criteria:
 Age below five years,
 Presence of an active OIs (including TB) or uncontrolled co-morbidities in the past 6 months
 Poor or questionable adherence to scheduled clinic visits in the past 6 months
 Recent detectable VL above 50 copies/ml
 In absence of HIV viral load monitoring decreasing CD4 cell count or CD4 ≤350 cell/mm3
 People Who Inject Drugs (PWID)
 On TB Preventive Therapy (TPT)
 Clients on third line ART regimen.
When Where Who What
General Population
Every month. At all facility levels All levels of healthcare Case management to address reason(s) for not
workers who have received meeting stable criteria
Additional visits as required to address Management of the client is
training should be able to
any medical or psychosocial concerns done at any ART service Enhanced adherence counselling should be
prepare a VL sample.
delivery point. Referral to a available both at facility and community levels
higher-level facility when Clinicians who have been
Viral load monitoring according to the national
feasible if consultation is not trained to assess clients with
algorithm.
adequate to stabilize the client treatment failure should be
able to initiate process to Appropriate switch to second or third line ART
Third line initiation should be
switch clients to third line
done as per guidelines
(Section 10.7.3)

28
2.5 Quality of CTC Services
Quality refers to the totality of features and characteristics of an entity that bears on its ability
to satisfy a stated or implied need. It is associated with excellence, superiority, value,
performance according to standards and compliance with requirements or specifications.
Quality of CTC services in the country base on the following global principals: effective,
safe, people-centred, timely, equitable, integrated and efficient.
Quality Management is responsible for the coordination and facilitation of these activities in
an organization. Building a national HIV quality management program and ensuring quality
services requires attention to specific process and activities that are driven by Quality
Assurance (QA) and Quality Improvement (QI) approaches. These processes should be
implemented across the health system from national, regional/partner down to health facility
level.
Quality assurance measures are in place to ensure that services offered at CTC conform to the
standards stipulated in the Health Sector Strategic Plan IV as well as in the Health Sector
HIV and AIDS Strategic Plan IV.
2.5.1 Quality Assurance
Quality Assurance (QA): Quality Assurance can be done either internally or externally. QA
involves planned, step-by-step activities that let one know that health service is being carried
out correctly, results are accurate, and errors are found and corrected to avoid adverse
outcomes.
Internal Quality Assurance
The facility and CTC in charge are responsible for planning regular check-ups to ensure
quality of care. This includes establishing and facilitating the work improvement teams
(WITs).
External Quality Assurance
National, regional and district QA team will visit CTC to conduct quality assurance
supervision visits. During such visits, areas that might need to be strengthened will be
identified and the supervising team will work with CTC staff to develop an implementation
plan. This plan will be documented for future reference.
2.5.2 Quality Assurance for CTC Services
This is implemented by the Work Improvement Team (WIT) at the CTC. The health facility
management has an obligation on ensuring that the CTC WIT remains functional throughout.
The WIT should conduct assessment of the health facility performance on all indicators that
are monitored as per the M& E framework and guidelines. The WIT should document the
assessed indicators’ performance using the Standard Evaluation System (SES) forms and
fulfil all the criteria of data management as described in the national guidelines on
management of quality HIV and AIDS data.

29
2.5.3. Quality Improvement
Quality Improvement (QI) is a systematic process of assessing performance of a health
system and its services, identifying gaps and causes, and introducing measures to improve
procedures so as to obtain the desired outcome.
For the HIV and AIDS QI, the PDSA cycle model (i.e. a Plan, Do, Study and Act) has been
selected as a reference QI model. In addition, the 5S and Improvement Collaborative
approaches are deployed for improving the quality of the HIV and AIDS services.
At regional, district and Health Facility levels, QI Teams (QIT) and Work Improvement
Team (WIT) should be formed and be active to carry out their roles and responsibilities as
stipulated in the QI guidelines. The National Quality Improvement Framework (NQIF) also
describes roles and responsibilities of QIT and WIT and should be referred to for these roles
and responsibilities.
The initiatives for QI focus on nine dimensions and five principles of quality, hence a need
for the QIT and WIT to have training on QI so as to be able to effectively apply the
improvement science.

30
 CHAPTER 3
HIV TESTING SERVICES
3.0 Introduction
HIV testing services (HTS) is the gateway to access HIV care, treatment, prevention, and
support services. Provision of HTS in all settings should be voluntary and conducted ethically
following 5 core HTS guiding principles which include Consent, Confidentiality,
Counselling, Correct test results and Connecting clients to services, including care, treatment,
prevention and support services. Key components of HTS package are Demand creation, pre-
test session, HIV testing, post-test session, referral and linkage services. The main approaches
for HTS include Provider Initiated Testing and Counselling (PITC), Client initiated Testing
and Counselling (CITC) and HIV self-testing (HIVST). HIV self-testing (HIVST) has been
recommended by WHO as an additional approach for delivering HIV testing services. The
introduction of HIVST will be based on the recommendations from the ongoing 2018
Implementation Science on HIVST. In addition, there should be trained HTS provider CDOs,
SWOs, Has, VHWs, HIV HBC providers, & members of health facility governing committee
capable to offer testing services. Both are provided in facility or community.

3.1 HIV Testing Service Settings

HTS is the primary entry point for HIV diagnosis, counselling, prevention and management.
The current recommendation on managing HIV requires early identification of PLHIV in
order to link them to ART care. Therefore, HTS services should be provided with reflection
to the preferences and expectations of various groups of people living with HIV (PLHIV)
whilst reducing unnecessary burdens on the health system. By differentiating service
delivery, HTS need to target and refocus resources to the most in need clients.
HTS delivery approaches shall extend beyond traditional provider-initiated HIV testing and
counselling (PITC) and stand-alone client-initiated testing and counselling (CITC) sites.
Thoughtful delivery points and approaches shall aim for co-location of services for key
populations who were and reach them in their natural environments and therefore reducing
access barriers. HTS shall also prioritize reaching key populations together with their sexual
partners, where appropriate (For differentiated HTS services see Chapter 2 section 2.5).
3.1.1 Health Facility Based Testing
HTS should be recommended for all patients/clients including adults, adolescents, infants and
children attending health facilities, regardless of whether they show signs or symptoms of
HIV infection. Trained HTS providers shall provide HTS at every service delivery points but
not limited to OPD, IPD, TB Clinic, Sexual and Reproductive Health (SRH), STI Clinic,
VMMC, Laboratory, CTC and specialized clinics.
3.1.2 Community Based Testing
Community Based HTS is a service that is offered outside the health facility to all population
groups. It is an important approach to reach first-time testers and people who seldom use
clinical services, including people from key and vulnerable populations and their sexual
partners, orphan and vulnerable children, index clients, adolescents, youth and men.
Targeted Community-based HTS is useful for children and partners of index clients,

31
adolescents as well as for outreach HTS for key and vulnerable population. This also plays an
important role in providing work place, mobile, home testing (door to door and index test),
hot spots, campaign and National events.
Note: Provision of HTS in both settings should comply with Tanzania National Guidelines
for HIV Testing Services, 2019.
3.2 Key Components of HTS Package
The HTS package recommended in Tanzania includes demand creation, pre-test information,
HIV testing, post-test counselling, and successful linkages to prevention, treatment, care and
support services for both HIV positive and HIV negative individuals.

3.2.1 Demand creation

This involves promotion of HIV testing services, mass and social media, information,
education and communication materials (IEC material), signboards, combination, prevention,
intervention, advocacy, sensitization and mobilization.

3.2.2: Pre-Test Session

Pre-test session is a dialogue between the client and HCW before HIV testing. This is done
either through one to one (individual) or group sessions. These sessions can also be
conducted through a short recorded pre-test video clips shown in waiting rooms or printed
materials such as posters and brochures. For children and adolescents HTS information
should be presented in an age-appropriate manner to ensure comprehension. HTS provider
shall assess whether testing is in the best interest of a child and if it promotes the child’s
physical and emotional welfare.

3.2.3 HIV Testing Session

HIV testing is the central component of HTS and is conducted after the pre-test and client has
to consent for the test. Rapid HIV Test kits are recommended for use in all HIV testing
settings and results are established on the same day and do not require laboratories or
specialized laboratory equipment. The HIV Rapid testing shall be conducted by Laboratory
and non-laboratory healthcare workers, once they have been appropriately trained using the
National training package and deemed competent. HIV rapid testing shall be performed in
health facilities or community settings, using finger prick specimen collection. In special
situations like External Quality Assurance (EQA) procedure and where multiple tests are
performed, different types of specimens, such as dried tube specimen or venous blood
samples may be used. (Note: Venous blood collection for the multiple testing will be
performed only by trained and authorized personnel).
The National HIV Testing Algorithm and procedures shall be followed when performing the
HIV test, as outlined in Figure 4.1 (Chapter 4). In order to provide accurate and reliable HIV

32
Test results, HTS providers shall adhere to good laboratory practices and quality assurance
standards as stipulated in the National Guidelines for HIV Testing services, 2019.
3.2.4 Post-Test Session
All individuals who undertook an HIV test should be offered quality post-test counselling
when being given their HIV test results. Post-test counselling shall be client-centred and
focus on the specific risks and needs of the client or patient, based on their HIV test results,
stated risk behaviours, and prior knowledge about HIV and AIDS.
Post-test counselling may be delivered to individuals, couples or families, depending on what
they agreed to, during pre-testing counselling. However, couples shall be encouraged to
receive post-test counselling together, when possible, to encourage mutual disclosure and to
support couples’ communication.
Post-Test Session for People Who Test HIV Positive
Post-test counselling should at a minimum, include five key messages that begin ART
treatment preparation process for all PLHIV:
 Re-test of HIV Positive should be done for verification before enrolment to care and
treatment.
 Treatment (ARV) is available and is recommended to all clients having HIV.
 Assess client readiness and willingness before initiation of ARV.
 Start treatment as soon as possible (preferably within 7 days after testing positive).
 ART should be taken as prescribed without missing a dose to allow long and
productive life.
33
Retesting Messages for individuals who test HIV Negative
Scenario When to repeat HIV test When to do future HIV tests
A: GENERAL POPULATION
General Population who No “window” period Re-test annually
test HIV Negative with no retesting
an ongoing risk

Inconclusive Immediately repeat HIV If still in inconclusive retest in 2

(Indeterminate test results) test following the national weeks. If still inconclusive take
HIV status HIV testing algorithm OR the sample for PCR or refer the
repeat test by another client to a higher level facility/
tester or laboratory laboratory
practitioner
Have a spouse or partner 4 weeks Every 3 months until the HIV
who is HIV Negative positive partner has confirmed
(discordant couples) viral suppression i.e. Viral Load
less than 1000 copies/millilitre.
Thereafter re-testing every 6
months.
Individuals on PrEP 4 weeks Every visit
Have specific incident of 4 weeks With each new known exposure
HIV exposure past 3 and if still negative, as for
months general population i.e. annually.
Have an ongoing risk of 4 weeks 6 months
HIV infection (SW, IDU,
MSM)
Has STIs/ RTIs 4 weeks With each new STI, if still HIV
Negative test annually
Survival of sexual 4 weeks As per PEP guidelines
violence or rape or
experience occupational
exposure
Adolescents and young 4 weeks Annually if sexually active
people
B: PMTCT SETTINGS
Pregnant women and Third trimester, or during Six months after delivery, if still
partners counselled and labour/delivery negative test annually and with
tested during first ANC each new pregnancy
visit

34
 Pregnant women who had 4 weeks then Six months after delivery. If still
specific sexual risk negative test annually and with
third trimester, or during
behaviour in past 3 each new pregnancy.
labor/delivery
months.
Breastfeeding women 6 months after last test If still negative test annually and
with each new pregnancy
who were tested during
pregnancy, labour/delivery
Breastfeeding women with 6 months; If still negative test annually and
unknown HIV status: test with each new pregnancy
at first postnatal contact.
HIV Exposed infants PCR test at 6 weeks after Conduct Rapid antibody testing
birth. at 18 months for confirmation of
HIV status. Repeat testing six
weeks after cessation of breast
feeding.
*High risk HIV exposed DNA –PCR at birth, then 12 weeks after cessation of
infants at 6 weeks of age. breastfeeding and a Final
antibody (Ab) at 18 months.

3.2.3 Assessment of Other Health Related Conditions and Needs

The HTS provider should also assess other health related conditions and referred to
appropriate services such as TB, STIs/RTIs, Cancer screening, Family planning, Gender
based violence, VMMC, PMTCT, alcoholism, non-communicable diseases, and psychosocial
issues.

Effective Referral and Linkage

HTS providers have a crucial responsibility to ensure that all individuals with a confirmed
reactive HIV test are immediately linked to care and treatment services for enrolment to ART
and other supportive and preventive services
Also Link people who test HIV-negative with an ongoing HIV risk to appropriate prevention
services.

Figure: HIV Post-test Linkages to Prevention, Care and Treatment Services

35
 Figure3.1PostTestLinkages toTreatmentCareand
SupportServices

3.3 HIV Testing Services for Different Populations

3.3.1 HIV-Exposed Infants (HEIs)
All infants born to mothers known to be HIV positive and on ARV should be offered routine
HIV DNA PCR testing at 6 weeks after birth or at first contact thereafter. Infants with initial
positive HIV DNA PCR result should be presumed to be HIV infected and started on ART. A
second confirmatory HIV DNA PCR should be taken at the time of ART initiation. In case a
High risk HIV exposed infants is identified, DNA PCR test should be offered at birth (see
annex 12).
36
3.3.2 HIV Testing for Infants and Children Less than 18 Months
To establish an HIV exposure status of a child less than 18 months, conduct HIV antibody
test to mother with unknown HIV status or previously tested negative during antenatal care.
The 6-week and six month immunization visit offers an excellent opportunity to establish the
HIV exposure status of the child. Health care workers shall recommend HIV test for exposed
infants during this visit.

3.3.3 HIV Testing for Children Older than 18 Months up to 17 Years

Conduct HIV testing by using HIV rapid test for all children with unknown HIV status.
Parents or guardians must give their consent to have their children tested.

3.3.4 HIV Testing for Pregnant and Breastfeeding Women and their Partners
All pregnant women and their partners (unless known to be HIV positive) should be tested
and counselled for HIV during their first ANC visit. For HIV negative pregnant women HIV
test should be conducted during the third trimester or during labour or at delivery.
All breastfeeding mothers unless known to be HIV positive shall be encouraged to undertake
HIV test during breastfeeding. For those who were tested during third trimester or at labour
or delivery, a repeat HIV test should be offered at six months and thereafter as per general
population.
3.3.5 HIV Testing for Key and Vulnerable Populations
Conduct HIV testing and counselling for key and vulnerable populations presenting at health
facilities or community based testing; for key and vulnerable populations that test HIV
negative, re-testing should be recommended four weeks and thereafter repeat after six
months.
Prisoners shall be offered voluntary HTS as part of health service whether in prison or in any
other setting.

3.3.6 HIV testing for Partners and Children of Index Clients

HIV testing and counselling should be encouraged (health facility or community based) for
all partners and children of index clients and linkage to prevention, care and treatment
services as appropriate. All PLHIV enrolled into HIV care should receive disclosure
counselling and be supported to disclose their HIV status (assisted disclosure).

37
3.3.7 Re- testing to verify HIV – seropositive status prior to ART initiation
All individuals who have tested HIV positive should be re-tested to verify their HIV status
prior to enrolling in care and starting ART.
Modalities of conducting re-testing for verifications
 The re-testing should be conducted by a different provider using different sample and
the same testing algorithm.
 Re-testing should preferably be conducted at the site where the decision about ART
initiation is made.
 If the HIV status is the same upon re-testing, the individual’s HIV-positive status
should be considered as verified.
 If the test status is not the same upon re-testing, the individual or their sample should
be referred for additional testing at nearby higher level facility testing site.

3.4 Referral and Linkage Services

HTS providers have a crucial responsibility to ensure prompt linkage to care and treatment
for people diagnosed with HIV infection. All clients undergoing HTS must either be
connected to HIV prevention services if tested Negative, or referred and linked HIV care and
Treatment services if positive. If available, use of mobile phones to verify that the person has
been enrolled in care may be helpful. Collaboration and communication between HTS and
ART providers is important to ensure effective referral support. This is important in the
context of “treat all”.
3.4.1 Strategies for Effective Referral and Linkage
 All people who test HIV-positive need immediate linkage to ART services.
 All people who test positive in community settings should be referred to the health
facility for verification of HIV test results and assessment for ART.
 People who test HIV-negative with an ongoing HIV risk shall be linked to prevention
services.
 Where possible, trained health care workers or peers and those who act as peer
navigators, and Community Workers shall be used for effective linkage.
 Communication technologies, such as mobile phones and text messaging, may assist
with disclosure, adherence and retention, particularly for adolescents and young
people.
 Promotion of partner testing may increase rates of HIV testing and linkage to care.
Male partners testing shall be encouraged in HTS including PMTCT settings.

38
3.4.2 Principles and Steps of Referral and Linkages
Regardless of whether a client is newly diagnosed with HIV infection, or has been previously
diagnosed, or is HIV negative, the steps for making a referral and ensuring linkage to health
services, risk-reduction, and/or other services follows the same basic process. The following
are principles of referral; information will be available for referring and HIV care and
treatment service provider, respect client willingness and readiness to be referred, preference
on how the referral should take place, maintain confidentiality and obtained informed
consent, The HTS provider should follow the following when making referral and linkages:-
Assess Referral Needs: Identify the factors that are most important in terms of their influence
on a client’s ability or willingness to engage in medical care or risk-reduction services;
Prioritize Referral Needs: There are often multiple factors that influence a client’s ability or
willingness to reduce risk that influences a client’s health or that impact a client’s ability or
willingness to accept and access referral services;
Plan the Referral: Identify the strategies or methods you will use to facilitate a successful
referral. Help the client to identify challenges that he or she may have in completing referrals
(e.g. cost, lack of transportation). Identify strategies to overcome such challenges;
Facilitate Access to Services: Provide clients with both information and support necessary to
access referrals. Information about the referral can, at minimum, include information about
the referral agency (e.g. name, address, telephone number, contact name, hours of service,
cost), eligibility, and the processes and timelines for making and getting appointments. As
much as possible, linkage should be done on site care and treatment service through patient
escort. When this is not possible (due to patient preference or service are not available) the
testing facility should book the appointment with the receiving facility and follow up to
ensure the patient is registered at the receiving facilities. Provide the patient with referral
information, referral form and contact details of facility;
Follow Up and Confirm Linkage: Assess whether the client successfully completes a referral
(i.e. has been linked to the service) and obtain client feedback, if possible. If the client was
not successfully linked to services, attempt to determine the reasons for this and provide
additional assistance, if appropriate. Where referrals are necessary such referrals should be
coordinated (communication and documentation) between referring and receiving service
delivery points;
Document Referral and Linkage Activities: Documentation is essential that referrals made
and linkage completed be recorded in a client’s file or chart. Uses of referral forms help staff
follow up on referrals made and assess their completion. Monitoring referrals and linkage the
main strategies for assessing client includes self-report and confirmation from referral
providers through call phone, text message or completing referral forms and returns the form.

39
3.5 Documentation
HTS provider should make sure HTS information are accurate, correct and filled in the HTS
register and HIV log book for tracking implementation of HT.

40
 CHAPTER 4
LABORATORY TESTS FOR DIAGNOSIS AND MONITORING OF HIV AND AIDS
4.0 Introduction
Laboratory investigations are important for HIV and AIDS prevention, care, treatment and
support services. Laboratory investigations provide important information on individual’s
HIV status and disease progression, detection of specific organ failure and toxicities. CD4 is
used to determine immunological response while viral load is used to monitor the treatment.
HIV Drug Resistance test is used to determine presence and pattern of resistance associated
mutations (RAMs).
4.1 Tests for HIV Diagnosis
4.1.1 HIV Testing in Adults and Children over 18 Months
In adults and children older than 18 months, diagnosis of HIV infection is done by detection
of antibodies using HIV rapid tests as indicated in the National HIV testing algorithms (See
Figure 4.1 below).
HIV testing algorithm describes the number, type and order of tests that need to be
performed. The first test to be conducted is highly sensitive (detects all true positive and a
few false positive results), and the second test is highly specific (detects only true positive
results). Inconclusive result repeat test from the beginning using a different sample.
The National HIV testing algorithm follows a ‘serial’ testing strategy. That is, blood sample
is first tested using highly sensitive test, followed by a second highly specific test. A second
test is only done when the first HIV test revealed an HIV- reactive result.
Although HIV rapid test is done using whole blood, serum or plasma samples, it is
recommended to conduct HIV rapid test using a sample obtained from a finger prick. The
HIV rapid testing can be performed in the laboratory or outside the laboratory setting by
healthcare workers and non-healthcare workers trained and certified to perform HIV rapid
tests.

41
Figure 4.1 Tanzania National HIV Rapid Testing Algorithm for Adults and Children over 18
Months

Draw Sample

First HIV
Rapid Test

Non-reactive Reactive

Second HIV Rapid Test

HIV Negative
(same sample)

Reactive
Non-reactive

Inconclusive
HIV Positive

Repeat Test from the beginning

using a different sample

For persistent inconclusive results, inform the client that he/she may be in a period of
acute HIV infection. Advise him/her to return for another repeat HIV test after 14 days.
If results are still inconclusive refer the client to a higher facility or take a sample and
refer to other laboratory for ELISA or DNA PCR testing.

4.1.2 Verification of HIV results

Perform re-test for HIV verification before initiation of ART using the national approved
HIV testing algorithm, to all HIV positive clients referred from any HIV testing points to
CTC using different sample and the Test should be performed by a different HCW.

4.1.3 Diagnosing HIV infection in Children under 18 months

HIV DNA polymerase chain reaction (PCR) method is used to confirm HIV infection in
infants and children ≤18 months of age. PCR can be used to diagnose HIV infection in most
infected infants at the age of six weeks. Further details on diagnosis of HIV infections in
children under 18 months, is outlined in Chapter 7 (Section 7.1.1).

42
4.2 Monitoring progression of HIV
CD4 cells progressively decrease as HIV advances and immune status deteriorates.
Measurements of CD4 cells counts are important immunological markers of the disease
progression. CD4 cells counts are reported in absolute numbers in clients five years and
above while in children under five years, CD4 cells counts are reported in percentage (%).
CD4 testing will be measured as a baseline test and for suspected treatment failure for those
clients on ART (See Figure 4.2 below).

Figure 4.2 CD4 Testing Process for Adults, Adolescents, and Children ≥5 Years

CD4 cell count will be tested

 As baseline testing before initiation of ART

 Any client suspected with treatment failure or IRIS

CD4 cell count ≤350 cells/mm 3 CD4 cell count >350 cells/mm 3

 Continue follow up CD4 test after  If the client is clinically stable, with
every six months until CD4 cell viral suppression (<50copies/ml)
count is >350 cells/mm3 stop CD4 monitoring unless there is
an indication of treatment failure or
IRIS
 For children <5 years, continue CD4
monitoring after every six months

4.3 Tests for Monitoring Responses to Anti-retroviral Treatment and Diagnosis of

Treatment Failure
Clinical assessment and laboratory tests play a key role in assessing individuals before ART
is initiated, monitoring treatment response and possible toxicity of ARV drugs. HIV Viral
Load test is a preferred approach to monitor early treatment failure. Successful antiretroviral
therapy result in decrease of HIV viral load, immune recovery and therefore increase in
number of CD4 cells.

43
4.3.1 Cryptococcal Antigen (CrAg) Screening
Primary infection with Cryptococcusneoformans is typically asymptomatic. In HIV-infected
patients with advanced HIV and AIDS and CD4 count below 200 cells/mm3, the infection
can be re-activated and spread through the blood stream.
Cryptococcal Antigen (CrAg), is a serological assay that detects the presence of C.
neoformans capsular antigen in serum or CSF. Laboratory –based ‘reflex’ CrAg screening
should be performed on every blood sample with CD4 <200 cells/mm3.

Algorithm for Screening Cryptococcal meningitis in clients with Advanced HIV Disease.

4.3.2 HVL Testing Algorithm for Adolescents and Adults

Perform 1st HVL test at six months after initiation of ART. Repeat HVL test six months later
if the initial HVL test result was less than 1000 copies/mL Then HVL test will be performed
annually if two preceding HVL test results were less than 1000 copies/mL.
If the preceding HVL test result was more than 1000 copies/mL, perform HVL test after three
months of enhanced adherence counselling.
For clients who have been on ART and immunological monitoring for more than six months
without being tested for HVL test performed at any time of clients encounter.
NOTE: Thereafter, during subsequent HVL tests, if the results are greater than or equal to
1000cp/ml, the client should be subjected to Enhanced Adherence Counselling (EAC) and
repeat the HVL test after three months from first EAC session.
Where HVL monitoring is unavailable, CD4 cell count monitoring are recommended.
Figure 4.3 HVL Monitoring Algorithm for Adolescents and Adults

44
4.3.2 HVL Testing Algorithm during Pregnancy and Breastfeeding
Purpose: Early identification and management of adherence challenges and treatment failure.
Minimize the risk of MTCT due to high maternal VL.

Figure 4.4: HVL Monitoring Algorithm for Pregnant and Breastfeeding Mothers

HIV viral load will be tested:

• For pregnant and breastfeeding women already on ART: Conduct VL on first ANC visit, review results in 2
weeks upon receiving them
• For pregnant and breastfeeding women not yet on ART/newly diagnosed: conduct VL after 3 months from
ART initiation
• All HIV+ pregnant and lactating women should have routine HVL 6 monthly until cessation of breast feeding
• Then follow the protocol below for HVL <1000 copies/ml (left) or ≥1000 copies/ml (right

HVL <1000 copies/ml HVL ≥1000 copies/ml

 Continue current regimen and routine  Refer for enhanced adherence counselling
6 months VL monitoring counselling (EAC)
 At each subsequent 6 month VL  1st EAC session will be for 3 consecutive days
>>Follow algorithm from the top from the day of result.
 Followed with one-day session after every 2
weeks

Repeat HVL 3 months after 1st EAC if EAC has

been successful and adherence has improved.
If not successful continue with EAC.

HVL <1000copies
HVL >1000 copies/ml
 Continue current regimen
 Gather patient’s information from both
 Repeat HVL at months 6, 12, 18, etc.
 At each subsequent 6 months HVL, clinicians and counsellors
follow algorithm from the top until  Switch to second line (team decision)
breast feeding cessation

45
4.4 Tests for Monitoring Disease Progress and Treatment Safety
Table 4.1 Test for Monitoring Disease Progress and Treatment Safety
Phase of HIV management Recommended Test

Baseline investigation Retest for verification of HIV test results

TB Screening
CD4 count/percentages
HbsAg
Hematological test
Biochemistry test (ALT, RFT)
Cryptococcus antigen if CD4 count <200 cells/mm for
Adults.Screening for sexual transmitted infections
Urine for pregnant test (child bearing potential women)
During ART Hb for AZT1
Creatinine clearance for TDF2
ALT
Haematological test (FBP- Attn: Hemoglobin)
Biochemistry test (Lipids, RFT)

HVL
Suspected Treatment failure, HVL
IRIS & Adverse Effects
CD4
Haematological test
Biochemistry test
HBsAg serology
Treatment Failure HIV Drug Resistance where accessible

46
4.5 Tests for Monitoring Antiretroviral Treatment Safety (Toxicity)
Anti-retroviral drugs are known to produce short and long term side effects in some patients.
Clinical follow up is supported by laboratory investigations. Capacity for testing haematology
and clinical biochemistry will continue to be developed at all health facilities providing Care
and Treatment in the country. The frequency of monitoring depends on the ART regimen
used as summarized in table 10.4 in Chapter 10.
Furthermore, ART drug toxicity varies in severity which determines the clinical action to
take. The following tables show the grading of adverse events as a result of ARV toxicity for
adults and children.
Table 4.2 Grading Adverse Reactions in Adults

Abnormal Range of Laboratory Tests

Grade I Grade II Grade III Grade IV

Item
Toxicity Toxicity Toxicity Toxicity
Haemoglobin 8.0-9.4 g/dl 7.0-7.9 g/dl 6.5-6.9 g/dl <6.5 g/dl
Absolute 1-1.5 x 109/L 0.75–0.99 0.5-0.75 x 109/L <0.5 x 109/L
Neutrophil Count x109 /L
ALT 1.25-2.5 IU/L >2.5-5 IU/L >5.0-10 IU/L >10 IU/L
upper normal upper normal upper normal limit upper normal
limit limit limit
Triglycerides 3-4.51 mmol/L 4.52-8.48 8.49-13.56 mmol/L >13.56 mmol/L
mmol/L
Cholesterol >1.0-1.3 >1.3-1.6 >1.6-2.0 mmol/L >2.0 mmol/L
mmo/L mmol/L
upper normal limit upper normal
upper normal upper normal limit
limit limit
Management Continue ART Continue ART Consult expert
immediately
Repeat test two weeks after the Repeat test one
before stopping
initial test and re-assess week after initial
ART
test and reassess
If ALT still grade 3,
consult expert
about stopping ART

47
Table 4.3 Grading Severity of Adverse Reactions in Children
Abnormal Range of Laboratory Tests
GRADE I GRADE II GRADE III GRADE IV
ITEM
TOXICITY TOXICITY TOXICITY TOXICITY
Haemoglobin 9.0-9.9 g/dl 7.0-8.9 g/dl <7.0 g/dL Cardiac failure
secondary to
>3 months -
anaemia
< 2 yrs old
Haemoglobin 10-10.9 g/dl 7.0-9.9 g/dL <7.0 g/dL Cardiac failure
secondary to
2 yrs old
anaemia
Absolute 0.75-1.2 x 109/L 0.4-0.749 x 109/L 0.25-0.399 x 109/L <0.25 x 109/L
Neutrophil
Count
ALT (SGPT) 1.1-4.9IU/L 5.0-9.9IU/L 10.0-15.0IU/L >15IU/L
upper normal limit upper normal limit upper normal limit upper normal limit
Triglycerides - 1.54-8.46 mmol/L 8.47-13.55 >13.56 mmol//L
mmol/L
Cholesterol - 4.43-12.92 12.93-19.4 >19.4 mmol/L
mmol/L mmol/L

48
4.6 Laboratory Diagnosis for Opportunistic Infections
For laboratory diagnosis of common OIs such as TB, upper respiratory tract infections, Meningitis,
Diarrheal and Septicaemia, diagnostic protocols and SOPs are available and should be used.
Teamwork between laboratory technicians and clinical staff at the CTC is required to optimize
diagnostic capacities.
4.7 Laboratory Safety Precaution
Safety precautions in the laboratory should be adhered during all steps starting from specimen
collection, storage, transportation, processing and disposal of biohazard wastes to minimize
occupational risks. The risk of transmission of HIV, Hepatitis B virus (HBV) and other blood-borne
disease agents are minimized if laboratory personnel observe safety precautions at all times. All
specimens should carefully be handled as infectious.
4.7.1 Sample Storage and Disposal
All samples should be stored in tightly closed and well labelled tubes/ containers and kept in an
upright position during storage. Temperature should be monitored and recorded in a temperature
chart, which is provided in each equipment used for storage of specimens. All used or old
specimens should be disposed immediately by autoclaving and incineration.
4.7.2 Sample Transportation
Laboratory protocols and SOPs should be followed when transporting samples from collection
point to the hub and thereafter from the hub to the testing laboratory:
A specimen delivery checklist/ sample manifest form should be used to verify all transported
samples.
Considering the SOPs, specimens should appropriately be packed and placed in proper and safe
containers before transporting them.
Dispatch and receipt records of transported samples should be maintained.
4.8 Internal Quality Assurance
Laboratory Internal Quality Assurance (IQA) involves close monitoring and tracking processes and
procedures done in the laboratory. It involves checking that all laboratory and testing equipment are
in good working condition and perform accurately as expected; all tests done produce reliable
results and documentation is properly done for all laboratory activities and outputs.
The bottom line for a functional laboratory internal quality control scheme is having well
documented and archived laboratory activities (equipment performance and calibrations; testing
results with appropriate controls; remedial actions for occurrences and safety practices).
IQA is mandatory for all tests that are done during monitoring of HIV clients, hence involving all
areas that participate on testing and monitoring of HIV infected and AIDS clients (RCH, VCT,
Laboratory, PITC etc.). All samples for IQA testing are treated as of client’s samples. A well-
functioning internal control scheme culminates into good performance in External Quality
Assessment
4.9 External Quality Assurance
External Quality Assurance (EQA) is a system used to objectively check the laboratory
performance using an external agent or facility. Three methods are used to do EQA: Proficiency
Testing (PT), Re-testing and on-site evaluation. The benefits of doing EQA include comparing
performance among different testing sites, detection of the early warning signs for system
problems, objective evidence of testing quality, areas that need improvement and training. EQA is
mandatory for all tests done in monitoring of HIV clients, hence involving all areas that participate
on testing and monitoring of HIV and AIDS infected clients (e.g. RCH, VCT, Laboratory, and
PITC). All samples for EQA testing are treated as client’s samples.
4.9.1 Proficient Testing
Proficient Testing Schemes (PTS) are inter-laboratory comparisons that are organized regularly to
assess the performance of analytical laboratory and the competence of the analytical personnel.
4.9.2 Inter-Laboratory Comparison
Inter-Laboratory Comparison is a system whose sample testing is performed by one HF and then
re-tested at the different HF or reference laboratory for comparison of results. The samples for
interlaboratory comparison should be randomly selected.
4.9.3 On-Site Evaluation
On-site evaluation is done by an external supervisor who visits the facility to obtain a realistic
picture of the laboratory practices and provides assistance on problematic areas. This will include
re-testing of samples.
 CHAPTER 5
HIV PREVENTION
5.0 Introduction
This chapter describes the Combination Prevention approach which includes: biomedical,
behavioural and structural interventions to achieve maximum impact on reducing HIV transmission
and acquisition. Particular emphasis is given on the Positive Health, Dignity and Prevention
(PHDP) package. The chapter also includes a section on the key HIV prevention services for Key
and Vulnerable Populations (KVP).
5.1 Positive Health, Dignity and Prevention (PHDP)
PHDP focuses on improving and maintaining health and well-being of PLHIV, which, in turn,
contributes to the health and well-being of sexual partners, families and communities. Indirectly,
PHDP is in contrast to previous approaches on ‘positive prevention’, which could be interpreted as
treating people living with HIV as vectors of transmission. By focusing on the journey experienced
by PLHIV from testing to support, care and treatment, ‘‘Positive Health, Dignity and Prevention’’
positions the health and social needs and experiences of PLHIV within a human rights framework.
Promotion of high HIV risk behaviour reduction among PLHIV and non-infected individuals is
important in controlling transmission and acquisition of HIV infection.
In order for PHDP programming to be successful, it must include a synergistic combination of
interventions at three different levels.
Central Level Interventions
At this level, interventions mainly focus on changes in the policy and legal framework to alter the
environment in ways that promote and support implementation of PHDP activities and services. To
date, HIV prevention has largely focused on providing information, counselling and testing for
those who are HIV-negative. While this is an important strategy, people living with HIV have often
been left out of prevention. Recently, consensus has formed around the benefits of targeted HIV
prevention among individuals who know that they are HIV-positive. The additional strategy of
providing prevention recommendations and strategies to those who are already HIV-positive aim to
prevent the spread of HIV to their sex partners and infants born to HIV-infected mothers, as well as
to protect the health of HIV-infected individuals.
Health Facility Interventions
HIV care and treatment clinics provide an important setting for HIV infection prevention and
control for several reasons. Firstly, CTC reaches a large number of PLHIV. Secondly, it integrates
prevention strategies into care and treatment clinic ensuring comprehensive and consistent quality
of care. Thirdly, it provides an opportunity in imparting prevention messages at every visit.
Components of a comprehensive package for HIV infection prevention and control in the clinical
setting are:
 Condom distribution and promotion
 Messaging and counselling support for social and behavioural change including: sexual risk
reduction, retention in care, adherence to medications, and partner HIV testing and
counselling
 HIV testing and counselling
 ART as prevention
 Voluntary Medical Male Circumcision (VMMC)
 Screening and treatment of STIs and RTIs
 Prevention of Mother to Child Transmission (PMTCT)
 Safer pregnancy counselling and family planning services integration
 Identification of social needs, referral and linkage for community-based services

Cervical cancer screening with visual inspection using acetic acid (VIA)
Providers can impact the HIV epidemic in their communities by addressing it through offering
prevention, care and treatment services to PLHIV,
Community Level Interventions
Community level interventions are in line with the national guidelines on Community Based HIV
Services (CBHS). The following are the components of the minimum package of the CBHS:
Condom distribution and promotionMessaging and counselling support for health behaviours
including: sexual risk reduction; retention in care, adherence to medications, and partner HIV
testing and counselling
HIV testing and counselling
Screening of STI
Safer pregnancy and family planning counselling
Identification of needs for care, treatment, referral and linkage for health facility- based services
5.2 Condom promotion and distribution
Both male and female condoms are highly efficacious and cost effective in preventing sexual
transmission of HIV and other STIs. Condom use will continue to be a key component of the HIV
prevention package in Tanzania Mainland, with a focus of high-risk groups and the general
population.
The key elements to successful condom programming include easy access to condoms for those
who need them within the health care setting, provision of sufficient quantities of condoms to be
used with every sexual encounter until the next visit, provision of education and demonstrations on
consistent and proper condom use, choice options between male and female condoms, mass media
marketing and promotion of condoms in order to increase availability, accessibility and utilization.
5.3 Social and Behaviour Change Communications (SBCC)
5.3.1 Comprehensive Knowledge on HIV and ART
Social and Behaviour Change Communication is the developmental practice of enabling individual
and societal change through engaging communities to determine what changes are necessary to
address their specific challenges and identifying localized strategies to facilitate the required
change10.

Messages and behavioural drivers that contribute to social environment in which individuals grow
and live and variously constitute barriers to health and wellness. Both structural and behavioural
drivers collectively fuel the spread of the HIV and AIDS epidemic.

Table 5.1 Structural and Behavioural Drivers

Migration and mobility Stigma, discrimination, and lack
of open communication around
Disempowerment through poverty
HIV and sex
Unemployment and economic inequality
Multiple concurrent sexual
Gender inequality partnerships

Social and cultural norms Improper and inconsistent

condom use
Weak policies, laws and law enforcement
Intergenerational and
Barriers to accessing prevention and other transactional sex
services
Gender based violence
An absence of services
Alcohol and drug abuse
Source: Adapted from Situation and Response Analysis Report on SBCC for HIV and AIDS, TB and
STIs in SADC Member States. Coxswain Social Investment Plus.
Communication is an essential element for HIV prevention and treatment and care efforts. It is the
exchange of information, ideas or feelings. Communication is the core components of SBCC that
enables interactive process of engagement between SBCC practitioners and communities. This
engagement is aimed at empowering communities to change their behaviours.
SBCC interventions usually comprise a combination of advocacy, communication and social
mobilization:
 Advocacy attempts to influence leaders at all levels from community right up to national
and sometimes regional and international levels to promote enabling legislation and remove
barriers to change.
 Communication can enable and promote behavioural change that often uses multiple
channels including inter-personal (provider-client), TV, radio, print, drama, peer education,
storytelling, etc.
 Social Mobilization to or within individuals, groups and communities can encourage
grounds well support to address barriers of change.

Within the new scope of test and start, SBCC should play a lead role in raising awareness and
appropriately communicate the “test and treat” approach, especially because this approach diverts
from the previous messages on eligibility criteria for ART initiation.
Recent studies provide strong evidence for the prevention benefits of ART. PLHIV who are
adherent to ART and successfully maintain low or undetectable viral load are far less likely to
transmit HIV to their sexual partner(s). Therefore, early enrolment into care, retention, and
adherence to ART is a key component of HIV prevention.
PLHIV who are recently infected and/or are not yet on ARVs, usually look healthy and clinically
well, and continue with their normal lifestyle (including sexual behaviours). However, it is known
that HIV-positive persons who are not on ARVs and having unprotected sex may have high viral
loads and may be at a high risk of transmitting HIV to their sexual partners.
PLHIV once having being very ill but are now on ART, generally, enjoy better health and more
active lives, which may lead to a renewed desire for sexual activity, and new partners. Thus,
adherence to medication and retention in care is critical by ensuring that clients continue to receive
life-saving medicines, and risk reduction message reinforcement.
Another important benefit of ART is that it leads to a viral load suppression to undetectable levels
that decrease chances of transmitting HIV. However, it should be understood that, even if a client is
on ARTs, there is a possibility of PLHIV transmitting HIV, including drug resistant strains. So, it is
important for healthcare providers to help PLHIV understand that they can still transmit HIV and
recommend that they take precautions, and adhere to prevention measures even when they are on
treatment and HIV viral load is at undetectable level. Providers should inform clients that:-
The goal of ART is to suppress viral replication with the aim of reducing the patient’s VL to
undetectable levels.
Strict adherence will help maintain undetectable VL levels thereby preventing damage to the body’s
immune system and restoring and maintaining healthy living, as well as reducing the risk of sexual
and vertical transmission of HIV.
ART is very effective in reducing onwards HIV transmission by infected individuals and helps to
drastically reduce TB incidence.

5.3.2 Couple HIV Testing and Counselling

Healthcare providers should encourage PLHIV to bring in their partners for HIV testing and
counselling. This provides an opportunity to counsel couple(s) together, and help to identify
discordant couples.
For the discordant couple, healthcare providers should give prevention messages to help clients
reduce the risk of transmission to HIV-negative sex partners. By encouraging partners in a
discordant relationship to adopt safer sex behaviours, providers play an important role in helping
discordant couples protect the negative sexual partner from becoming HIV-infected. Additionally,
HIV-negative partners should get tested regularly. Recent evidence shows that, early initiation of
ART to the infected sexual partner reduces the chances of infecting his/her partner.
In concordant relationships where both partners are HIV-positive, a potential consequence of
unprotected sex to the HIV-infected sexual partner is that he or she may become “re-infected” with
a different strain of HIV or STIs.
5.3.3 Reducing Risk Behaviours
Persons living with HIV remain sexually active and desire a healthy sex life. One of the first steps
to providers taking a PHDP approach in clinical setting is to recognize that PLHIV have a right to
sex as one of their human rights and needs, and need ongoing education and support from their
healthcare providers on how to protect themselves and their sexual partners. PLHIV are receptive to
various risk reduction advice given by HCWs. Specifically, risk reduction messages include
reduction of concurrent sexual partners, consistent and proper condom use, disclosure and knowing
your partner’s status, and reduced alcohol consumption. Include citation.

5.4 Screening of Sexually Transmitted and Reproductive Tract Infections (STIs/RTIs)

Sexually Transmitted and Reproductive Tract Infections (STI/RTIs) remain a public health problem
of major impact in many countries. Failure to diagnose and treat STIs/RTIs at an early stage may
result into serious complications and consequences including infertility, foetal wastage, ectopic
pregnancy, ano-genital cancer, premature delivery, as well as neonatal and infant infections. STIs
are also known to enhance the spread of HIV infections in communities. On the other hand, there
are other RTIs that are caused by organisms normally present in the reproductive tract, or are
introduced during sexual contact or invasive medical procedures. These RTIs are wrongly labelled
as STIs leading to unnecessary stigmatization of women and marital disharmony.
WHO estimates that over 357 million episodes of curable and many more incurable STIs occur
each year worldwide. Non-sexually-transmitted RTIs are even more common. Tanzania is no
exception to this state of affairs. In Tanzania, 10-20% of the sexually active population contract
STIs each year. In 2011, the HIV and Syphilis surveillance among antenatal clinic attendees
showed a 2.5% overall prevalence of Syphilis). 11 Also STIs/RTIs facilitate sexual acquisition and
transmission of HIV infection as well as impacting the socio-economic status of the families.
Furthermore, STIs/RTIs affect the success of other health programs. The control of STIs/RTIs is a
public health priority. Therefore, a comprehensive STI/RTI control and prevention programme is
vital.
Syndromic management of STIs is based on the diagnosis of defined symptoms and easily
recognizable clinical signs.
Common symptoms of STIs/RTIs are painful micturation, abnormal vaginal/urethral discharge,
genital ulcerations, genital itching, and swelling of inguinal lymph nodes, scrotal swellings, lower
abdominal pain and pain during sexual act.
Each syndrome can be a result of a number of different causative agents. Table 5.1 below describes
the advantages and disadvantages of different approaches in STIs/RTIs screening.

Table 5.1 Advantages and Disadvantages of Different Approaches in STI/RTI Screening

Aetiological/ Avoids overtreatment, saves drugs Laboratory results are often

Laboratory not reliable due to lack of
Conforms to traditional clinical
quality control
training
Mixed infections are often
Satisfies clients who feel
overlooked
not properly attended
without laboratory check up Treatment delays, reluctance of
clients to wait for laboratory results
Can be extended as screening
to identify clients with High costs
asymptomatic STIs/RTIs
Laboratory services not available at
the majority of health facilities.

Aetiological/ Saves time for clients Mixed infections are often

Clinical overlooked
No need for laboratory facilities
Similar clinical features can be

11 ANC Surveillance 2012

 caused by a variety of causative
agents
Requires long term training
Does not identify asymptomatic
STI
A typical presentation in HIV
infection or mixed infections

Syndromic Saves time for clients Entails frequent overtreatment of

clients
No need for laboratory facilities
Requires special attention
Provides adequate treatment, even
to microbial drug
for mixed infections
sensitivity monitoring on regular
Easy to teach and simple to apply basis.

Cost-effective Does not identify asymptomatic

Promotes integration of services

Due to non-specificity of symptoms, stigma and social implications attached to STIs, healthcare
workers should be careful not to mislabel RTIs as STIs. The latter should be diagnosed and treated
promptly and adequately. Treatment to the sexual partners is strongly recommended, as well as
periodic screening and presumptive treatment to sex workers, as per national STI guidelines.

5.4.1 Syphilis
Syphilis in both men and women is associated with high risk rate of HIV acquisition and with
serious complications on pregnancy outcome. Co-infections of syphilis and HIV infections may
alter the clinical presentation and treatment modalities of syphilis.
Indications and Opportunities for Screening
Screening for syphilis during pregnancy should be done at the first antenatal visit, or as early as
possible. It can be repeated in the third trimester if resources permit, to detect infection acquired
during the pregnancy.
Women who do not attend antenatal clinic should be tested at delivery. Although this will not
prevent congenital syphilis, it permits early diagnosis and treatment of newborns.
Women who have had a spontaneous abortion (miscarriage) or stillbirth should also be screened for
syphilis; in many areas, identification and treatment of syphilis remove a major cause of adverse
pregnancy outcome.
Because of the serious complications of syphilis in pregnancy, the first priority should be to ensure
universal antenatal screening.
Screening for syphilis should also be done in all women with history of abortion or preterm
delivery.
Men and women with STI syndromes other than genital ulcer should be screened for syphilis.
Screening is unnecessary for clients with ulcers who should be treated syndromically for both
syphilis and Chancroid without testing.
Other opportunities for screening for syphilis include family planning, VMMC at any time, a
speculum examination is performed; and in all male partners of female with STI/RTI and vice
versa.

5.4.2 Overview of STI Syndromes

Although STIs are caused by many different organisms/agents, these organisms give rise to a
limited number of syndromes. Table 5.2 below outlines the nine common STI syndromes and their
etiologic agents.

Table 5.2 STI Syndromes and their Aetiological Agents

STI SYNDROME SEX COMMON AETIOLOGIC AGENT

Urethral Discharge Syndrome Males Chlamydia trachomatis

(UDS)
Neisseria gonorrhoeae

Painful Scrotal Swelling (PSS) Males Chlamydia trachomatis

(acute epididymoorchitis)
Neisseria gonorrhoeae

Vaginal Discharge Syndrome Females Candida albicans

(VDS)1
Chlamydia trachomatis
Gardnerella vaginali
Neisseria genorrhoeae
Trichomonas vaginalis

Pelvic Inflammatory Disease Females Anaerobic bacteria

(PID) (Lower Abdominal Pain)
Chlamydia trachomatis
Neisseria gonorrhoeae

Genital Ulcer Disease (GUD) Males Chlamydia trachomatis

 Females Haemophilus ducreyi
Herpes simplex virustype-2
Treponema pallidum
Klebsiella granulomatis

Inguinal Bubos Males Chlamydia trachomatis

Females Haemophilus ducreyi

Anorectal Syndrome Males Neisseria gonorrhoeae

Females Chlamydia trachomatis
Herpes simplex
Treponema pallidum
Human papilloma virus

Neo-natal Conjunctivitis Newborns Neisseria gonorrhoeae

(Opthalmia neonatorum)
Males and Females Chlamydia trachomatis

Oropharyngeal infection Males and Females Treponema pallidum

Neisseria gonorrhea
Chlamydia trachomatis
Klebsiella spp
Human papiloma virus (HPV)

Note: Cervical infections caused by Neisseria Gonorrhoea and Chlamydia trachomatis sometimes
present with vaginal discharge.
For management of common syndromes, see Flow Chart for Syndromic Management of
STI’s/RTI’s in the national STIs/RTIs guideline.
5.5 Cervical Cancer
Cervical cancer is the leading cause of cancer-related morbidity and mortality in Tanzanian women.
One-tenth of the estimated 72,000 new cases and 56,000 cervical cancer deaths in Sub-Saharan
countries in the year 2000 occurred in Tanzania.12 Furthermore, 80% of patients diagnosed with
cervical cancer die within five years of diagnosis. This low survival rate is mainly due to advanced
stage of disease at presentation and limited access to cervical cancer screening, diagnosis and
treatment services.
The problem is compounded by the HIV and AIDS epidemic. The association between HIV and
invasive cervical cancer is complex with several studies now clearly demonstrating an increased
risk of precancerous cervical lesions and more rapid progression to cancer among HIV-infected
women. In Tanzania women with cervical cancer are twice as likely to be HIV-infected and HIV-
positive women also develop cervical cancer 10 years earlier than HIV-negative women13.
Although about 40–90% of women in developed countries are screened for cervical cancer, less
than 5% of women in developing countries undergo cervical cancer screening.14,15
Researchers suggest that as women are living longer due to access to ART, they are at an increased
risk of contracting cervical cancer. While access to antiretroviral therapy is beginning to reduce
AIDS mortality worldwide, gynaecologic oncologists warn that women being treated for AIDS
could end up dying of cervical cancer unless they have access to appropriate screening and
treatment.
HIV-positive women require a more intensive screening schedule. It is recommended that annual
cervical cancer screening using VIA as the primary screening method or rapid HPV testing be
integrated into the national policy as part of routine care for HIV-positive women. Care and
treatment clinic (CTC) sites should be closely linked with sites providing services for cervical
cancer prevention, or ideally, provide the services themselves. In addition, amongst sexually active
girls and women, cervical cancer screening should be done at HIV diagnosis and repeat annually
regardless of previous results.
Women living with HIV are at a greater risk for developing cervical cancer because of higher rates
of co-infection with HPV which is persistent in most cases. Characteristics of HPV related lesions

12 Parkin DM, Pisani P, Ferlay J: Estimates of the worldwide incidence of 25 major cancers in 1990. Int J Cancer 1999,
80:827-841.
13 Kahesa C, Mwaiselage J, Wabinga HR, Ngoma T, Kalyango JN, Karamagi C (2008). Association between invasive

cancer of the cervix and HIV-1 infection in Tanzania: the need for dual screening. BMC Public Health 8(1):262.
14 Hakama M, Chamberlain J, Day NE, Miller AB, Prorok PC: Evaluation of screening programmes for gynaecological

cancer. Br J Cancer 1985, 52(4):669-673

15 Chirenje ZM, Rusakaniko S, Kirumbi L, Ngwalle EW, Makuta-Tlebere P, Kaggwa S, Mpanju-Shumbusho W, Makoae

L: Situation analysis for cervical cancer diagnosis and treatment in east, central and southern African countries. Bull
World Health Organ 2001, 79(2):127-132
in HIV positive women include larger precancerous lesions that are more difficult to treat,
recurrence of precancerous lesions following treatment and rapidly progressive cervical cancer.
Cervical cancer screening should therefore be integrated as part of routine care for HIV-positive
women. Annual screening using visual inspection with acetic acid (VIA) or rapid HPV testing is
recommended. Screening should be initiated at HIV diagnosis, regardless of age, once sexually
exposed. For women who have just delivered, screening can be initiated post puerperal. Refer to
the Tanzania Service Delivery Guidelines for Cervical Cancer Prevention and Control for detailed
information and guidance.

5.6 Family Planning and Safer Pregnancy Counselling Services

PLHIV have sexual desires and have the right to bear children, hence they need support from
healthcare providers to safely plan for wanted pregnancies and to avoid unwanted pregnancies.
Since many PLHIV attending CTCs do not make visits with their partners, provider assessment of
fertility desires to both male and female CTC clients is essential. Typically, family planning and
pregnancy services are directed toward women only, while within the partnership, men’s fertility
desires and expectations are equally important. HIV clinical care settings provide an opportunity to
reach out to male members of the couples and emphasize shared decision-making and open
communication about pregnancy and contraception.
One of the key strategies for ensuring that HIV positive couples have access to contraceptives and
advice about pregnancy is to provide family planning (particularly dual protection i.e. barrier and
non-barrier methods) and safer pregnancy counselling within the CTC following an integrated
model of service provision. Another strategy is through prevention of mother to child transmission
(PMTCT) services, where ART has proven to be the most efficacious treatment for prevention of
transmission to the child. Women of child bearing potential who opt to use DTG should be
counselled on the consistent use of reliable and long acting contraceptive and/or effective dual
contraception with condoms (Note: More details are available in the national SRHS/FP
guidelines).
.S

5.7 Biomedical Prevention of HIV

5.7.1 Infection Prevention and Control (IPC)
Exposure of the health service providers to the blood of those receiving care occurs mostly via
accidental injuries, from sharps such as syringe needles, scalpels, lancets, broken glass or other
objects contaminated with blood. Poor practices during patient care by HIV-infected medical staff
may also expose the patient to infection. Also, when equipment (e.g. suction) is poorly sterilized,
HIV may be passed from an HIV-infected individual to an uninfected patient within the healthcare
setting.
Protecting HSPs from occupational exposure and ensuring that they know their status and receive
HIV services is an important priority for the health sector. HIV and other Blood Borne Pathogens
(BBPs) such as Hepatitis B and Hepatitis C may be transmitted in healthcare settings from patient
to patient and patient to healthcare worker, or vice versa.
Accidental transmission can be prevented by implementing the following infection prevention and
control measures:
 Adherence to standard precautions such as hand hygiene;
 Use of Personal Protective Equipment (PPE) such as gloves;
 Proper healthcare waste management
 Processing of instruments by decontamination
 Cleaning and sterilization using High-Level Disinfectants (HLDs)
 Observing safe work practices

For effective occupational health programme facilities, managers and providers should ensure:
 A good occupational health programme aiming to identify, eliminate and control exposure
to hazards in the workplaces;
 Provision of training to health service providers in identifying and controlling hazards;
 Provision of immunization against Hepatitis B;
 Implementation of standard precautions;
 Provision of free access to post-exposure anti-retroviral prophylaxis for HIV;
 Promotion of reporting of incidents and quality control of services provided.

5.7.2 Post Exposure Prophylaxis (PEP)

Post Exposure Prophylaxis (PEP) is the immediate provision of preventive measures and
medication following exposure to potentially infected blood or other bodily fluids in order to
minimize the risk of acquiring infection. Several clinical studies have demonstrated that HIV
transmission can be reduced by 81% following immediate administration of anti-retroviral agents.
Exposure prevention is the primary strategy for reducing occupational HIV transmission, that is, the
chance of acquiring infection following exposure to blood and other bodily fluids (semen, vaginal
secretions and breast milk) from an infected person. These bodily fluids should be considered as
being infectious. Wounds and skin sites that have been in contact with blood or body fluids should
be washed with soap and water. In case of splash involving mucous membranes (e.g., eye) should
be flushed with water immediately. Sexual exposure comprises an act of unprotected voluntary or
forced sexual intercourse (rape/sexual assault), as well as in the case of slipped or torn condom
during sex with discordant partner.
Effective post-exposure management entails the following elements:
 Management of exposure Site,
 Exposure reporting,
  Assessment of infection Risk,
 Appropriate treatment,
 Follow-up and counselling.

When an exposure occurs, the circumstances and post exposure management procedure applied
should be recorded in the exposed person’s confidential form for easy follow up and care.

Evaluation of the exposed Individuals

Individuals exposed to HIV should be evaluated within two hours rather than days and no later than
72 hours. A starter pack should be initiated within two hours after exposure and before testing the
exposed person. Exposed healthcare workers should be counselled and tested for HIV at baseline in
order to establish infection status at the time of exposure. PEP should be discontinued if an exposed
healthcare worker refuses to test. To facilitate an effective choice of HIV PEP drugs, the evaluation
should include information on the type of medication the exposed person might be taking and any
current or underlying medical conditions or circumstances (such as pregnancy, breastfeeding, renal
or hepatic disease) that might influence drug selection. Vaccination against Hepatitis B should be
considered.
In addition, rape survivors should be offered counselling, crisis prevention and provision of on-
going psychosocial support so as to reduce/minimize immediate rape trauma disorder and long-term
post-traumatic stress disorder and referred to mental care, police and legal services, according to
law and regulations.

Evaluation of the Source Person

Evaluation of the source person should be performed when the exposed individual agrees to take
PEP. If the HIV, HBV and HCV status of the source person is unknown perform these tests after
obtaining consent. The exposed healthcare worker should not be involved in obtaining consent from
the source person. If the source person is unknown, evaluation will depend on other risk criteria. Do
not test discarded needles or syringes for viral contamination.

Drugs for HIV PEP

Recommended PEP Regimen: TDF+3TC/FTC+DTG for adult and adolescents once a day for four
weeks and for children (based on body weight) AZT + 3TC + LPV/r twice daily for four weeks.
Children whose weight is more than 20kg DTG can be used instead of LPV/r and maintain
AZT+3TC as backbone.
Note: If the source is using PI based regimen, then the PEP regimen should be PI based (similar to
the source’s regimen).
Follow-up of HIV Exposed Individuals
HIV antibody tests should be performed at least after 4-6 weeks’ post-exposure (i.e. at 6 & 12
weeks). HIV testing should also be performed for any exposed person who has an illness that is
compatible with an acute retroviral syndrome, irrespective of the interval since exposure.
If PEP is administered, the exposed person should be monitored for drug toxicity at baseline and 2
weeks after starting PEP. Minimally, it should include a full blood picture (FBP), renal function test
(RFT-Serum creatinine and urinalysis) and hepatic function tests (LFT- ALT).
Exposed persons should be re-evaluated within 72 hours, after additional information about the
source of exposure including serologic status, viral load, current treatment, any resistance test
results (if available) or information about factors that would modify recommendations, is obtained.
PEP should be administered for four weeks if tolerated. If not, manage symptoms accordingly and
if intolerance persists, change to more tolerable PI based regimen. If the patient seroconvert and the
exposed person becomes HIV infected, he/she should be referred to a CTC for proper care and
treatment service.

5.7.3. Pre –Exposure Prophylaxis (PrEP)

Pre-Exposure Prophylaxis (PrEP) is the use of ARV drugs daily by HIV-uninfected persons to
prevent the acquisition of HIV before the person becomes exposed to HIV. PrEP is used by people
who are at a substantial risk for HIV acquisition to lower their chances of getting HIV infection.

5.7.3.1 PrEP targeted Populations for PrEP

Targeted population for PrEP include Sex workers (female, male and transgender adults (18 years
of age and above), men who have sex with men, people who inject drugs, vulnerable adolescent
girls (15-19), young women (20-24) and HIV negative partner of Sero-discordant couples when an
HIV infected partner is not on ART or is on ART for less than six months or has not attained viral
suppression less than 50copies/ml.
5.7.3.2 Eligible clients for PrEP

• Aged 15 years and older

• HIV sero negative

• At substantial risk* of HIV infection

• No suspicion of acute HIV infection

• Creatinine clearance >60ml/min**

• Willingness to consent for and use PrEP as prescribed

Substantial risk of HIV infection means:

a) vaginal or anal sex without a condom with more than one partner or,
b) history of a new sexually transmitted infection or,
c) use of post exposure prophylaxis for sexual exposure or,
d) Has a known HIV positive sexual partner(s) who is not on ART/ on ART less than
six months or refuses to report a risk category but still requests PrEP

5.7.3.3 Clients who are not eligible for PrEP include:

 Acute HIV Infection (AHI)

 Client with eGFR* <60ml/min

 Significantly mobile persons that will not be able to attend visits as prescribed. For
example:
o clients who will not be in a region where PrEP can be provided at the next visit
o clients who do not have contact information
 Unwilling/unable to take daily medication
 Allergy or contraindication to any medication within PrEP regimen.
Comparing PrEP and PEP

Comparing PrEP (Pre-Exposure Prophylaxis)

and PEP (Post-Exposure Prophylaxis)

What’s the same?

Both are used by HIV uninfected persons
Both use ARVs to prevent HIV acquisition
Both are available from a clinical provider by prescription
Both are effective when taken correctly and consistently

What’s different?
PrEP is started BEFORE potential exposure and PEP is taken
AFTER exposure
PEP is taken for 28 days only. PrEP requires ongoing use as
long as HIV risk exists 20

Comparing PrEP and ART

 HIV treatment requires adherence to life-long therapy with consistent, fully-suppressive
dosing.
 PrEP is needed during “periods” of high HIV risk.
 Both ART and PrEP require optimal adherence.
 Individuals taking PrEP require ongoing risk assessment and PrEP can be discontinued if
they:
o Acquire HIV infection.
o Are no longer at substantial risk for HIV infection.
o Decide to use other effective prevention methods.
 Motivation for adherence is different:
• ART is taken by HIV-infected persons, who may have symptoms, so as to remain healthy
and prevent onward transmission of HIV.
• While PrEP is taken by HIV uninfected persons to prevent acquisition of infection.

ARVs Used for PrEP and Their Side Effects

The WHO recommends that oral PrEP regimens should contain tenofovir disoproxil fumarate
(TDF).
The recommended PrEP regimen in Tanzania is: Emtricitabine (FTC) 200mg/Tenofovir
Disoproxil Fumarate (TDF) 300mg (Truvada) PO Daily. For more information on minor and
adverse effects of the drugs of the PrEP regimen refer Chapter 10, Table 10.5. .

5.7.3.4. Indications for PrEP discontinuation

Individuals taking PrEP require ongoing risk assessment and PrEP can be discontinued if
individuals acquire HIV infection, are no longer at substantial risk for HIV infection or decide to
use other effective prevention methods and poor adherence.
PrEP should be provided for at least 28 days after the last possible exposure to HIV. The client
should return after completing the final prescription for an HIV test to confirm status. Refer the
client to other relevant prevention services.
5.8 Voluntary Male Medical Circumcision (VMMC)
Voluntary Medical Male Circumcision (VMMC) has been implemented in different sub-Saharan
countries in an effort to reduce the incidence of HIV infection amongst men. Three randomized
controlled trials16,17 demonstrated that medical male circumcision is an effective protective factor
against heterosexual HIV acquisition, reducing the risk of transmission from females to males by
approximately 60%. Surgical removal of the foreskin reduces male’s vulnerability to HIV in penile-
vaginal intercourse. Therefore, VMMC is an important component of comprehensive HIV
prevention in areas with a high prevalence of heterosexually-transmitted HIV infection.
In Tanzania, the national prevalence of male circumcision (medical and non-medical) is about
77.6% among male aged 15 years and older (THIS 16/17). The male circumcision rate is as low as
26% in non-circumcising communities. The coverage rate of VMMC amongst non-circumcising
communities has risen up to between 14% to 38% following implementation of National Strategy
for Scaling up Male Circumcision for HIV prevention.18
Early Infant Male Circumcision (EIMC) is another component in Tanzania’s national HIV
prevention strategy. There are significant benefits in performing EIMC in infancy (between one to
60 days of age). Procedures for EIMC are much easier to perform compared to that of adults/
adolescents. EIMC also has a lower rate of adverse events, faster healing and a lower unit cost than
VMMC.

16Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a
randomized controlled trial. Lancet. 2007;369:643–656. [PubMed]
17Citation here—the famous three studies in Kenya and Uganda Gray RH, Kigozi G, Serwadda D, et al. Male

circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 2007;369:657–666. [PubMed]
18United Republic of Tanzania MoHSW, National AIDS Control Programme,. National Strategy for Scaling Up Male Circumcision for

HIV Prevention. 2010.

5.8.1 Minimum Package for VMMC Services
All HCW offering VMMC services should:
 Educate clients on the link between VMMC and HIV prevention
 Offer HIV testing and counselling so that clients know their HIV status and refer clients
who test positive to a care and treatment clinic
 Refer clients who test HIV positive to care and treatment
 Screen for STIs and RTIs (and treatment, when indicated) since STIs increase a person’s
risk of acquiring or transmitting HIV
 Counsel on risk reduction
 Promote and distribute male and female condoms together with the promotion of their
correct and consistent use
 Provide surgical care that is safe and of high quality, in settings that are adequately
equipped and environmentally suitable for minor surgical procedures
 Provide appropriate postoperative care and care of any associated adverse events.

5.8.2 Minimum Package of Early Infant Male Circumcision (EIMC) Services

All HCW at facilities offering EIMC services for HIV prevention must:
 Provide information to parents or guardians on advantages and risks of EIMC.
 Offer of HIV testing and counselling to parents or guardians to ensure identification of HIV-
exposed infants.
 Link HIV-positive parents to HIV care and treatment services.
 Counsel on the post-operative care of circumcised infants and identification of related
complications, danger signs and where to go for follow-up care, if required.
 Provide surgical care that is safe and of high quality, in settings that are adequately
equipped and environmentally suitable for minor surgical procedures.
 Provide appropriate postoperative care and care of any associated adverse events.
 Refer clients to appropriate services such as immunization, well baby care, and HIV care
and treatment for HIV-exposed infants and/or those infants found to be HIV-positive
through Early Infant Diagnosis (EID).

5.9 Blood Safety

Unsafe blood transfusion is a well-documented mode of transmission of HIV and other infections.
Many recipients of blood and blood products are at risk of transfusion-transmissible infections,
including HIV, as a result of poor blood donor recruitment and selection practices and the use of
unscreened blood.
Access to safe blood transfusion is an essential part of quality health care. The MoHCDGEC has
established National Blood Safety Program (NBSP) to ensure the availability of safe blood and
blood products through a nationally coordinated blood transfusion service.
HCWs should ensure that clients in need of blood or blood products are transfused with safe blood
which has been appropriately screened for all transfusable pathogens using WHO criteria at the
zonal centre.

5.10 HIV Prevention Services for Key and Vulnerable Populations (KVP)
According to WHO, Key Populations (KPs): are defined groups of people who, due to specific
higher-risk behaviours, are at increased risk of HIV irrespective of the epidemic type or local
context. Also, they often have legal and social issues related to their behaviours that increase their
vulnerability to HIV. WHO guidelines focus on five key populations: 1) men who have sex with
men 2) people who inject drugs 3) people in prisons and other closed settings 4) sex workers and 5)
transgender people. The key populations are important to the dynamics of HIV transmission. They
are also essential partners in an effective response to the HIV epidemic.
Vulnerable populations (VPs): are groups of people who are particularly vulnerable to HIV
infection in certain situations or contexts. Such groups are adolescents (particularly girls in sub-
Saharan Africa), orphans, street children, people with disabilities, and migrant and mobile workers.
These populations are not affected by HIV equally across all countries and epidemics.19

Key and vulnerable populations (KVP) are therefore important to the dynamics of HIV
transmission and in an effective response to the epidemic. The groups include:
 Sex workers (SW) and their clients
 People who inject or use drugs – PWID/PWUD
 Men who have sex with men – MSM
 People in prisons and other closed settings
 Adolescent girls and young women (AGYW)
 Mobile populations (long distance truck drivers, fisher folks and fishing communities,
miners and mining communities, construction and plantation workers)
 Disabled persons in all forms
 Street living or working children and displaced people.

WHO Consolidated Guidelines on HIV prevention, diagnosis, treatment and care for key populations 2016
19
HSPs need to provide non-judgmental, non-discriminatory services to be able to identify and
address the special needs of key and vulnerable populations within and beyond the healthcare
setting. The following list summarizes the key services to be offered to KVP:
 Promote and provide male and female condoms
 Provide VMMC service
 Provide HTS
Provide ART to HIV infected individuals
Provide pre-exposure prophylaxis (PrEP)
 Screen and manage STIs, RTIs and cervical cancer
 Counsel and offer Reproductive Health Services (RHS) inclusive of family planning
services and dual protection as well as counselling and PMTCT
 Link to facility providing medication-assisted treatment (MAT) and other drug dependence
treatments (i.e. harm reduction)
 Provide behavioral change and communication service
 Screen for Hepatitis B and C and provide vaccination for Hepatitis B as appropriate
 Screen for Tuberculosis and manage accordingly
 Screen for sexual violence and provide PEP along with other interventions for gender-based
violence (GBV)
 Link with psychosocial support services through targeted campaigns in identified key and
vulnerable population settings, use community based outreach, mobile phone technologies,
social networking and develop friendly key population services at health facilities; this will
facilitate dissemination of behavioural messages, promote follow-up and referral to services,
improve adherence to treatment, and increase client participation in their own health care.
 Sensitize and educate health service providers, community health workers, CBHS, peers,
supportive staff and management on issues of specific key and vulnerable populations and
on non-discriminatory practices and eliminating stigma, using pre-service and in-service
training, job-aids, supportive supervision, and training follow up.
 Ensure confidentiality: Attention should be devoted to protecting privacy and
confidentiality, e.g. closing the consultation room door or finding a private place to talk.
Clients should be reassured of confidentiality.

Proper Linkage and referral mechanisms to community support programmes (e.g.

psychosocial support, income generating group, spiritual support and legal support etc.).

For further details on management of HIV for KVP, refer to the National Guidelines on
Comprehensive HIV Interventions for Key and Vulnerable Populations, 2017 Edition.
 CHAPTER 6
MANAGEMENT OF HIV OPPORTUNISTIC INFECTIONS AND CO-
MORBIDITIES IN ADOLESCENTS AND ADULTS
6.0 Introduction
Anti-retroviral Therapy (ART) does not provide a cure for HIV, but has drastically reduced
HIV related morbidity and mortality. This is due to the fact that ART reverses the HIV-
induced immune depletion which is responsible for occurrence of different opportunistic
Infections (OIs). Early ART initiation, whereby all HIV-infected clients are initiated anti-
retroviral therapy regardless of CD4 cells count will prevent occurrence of OIs and other co-
morbidities.
Effective use of ARVs among PLHIV has resulted into improved survival and quality of life.
On the other hand, this has led to increased risk of age related diseases including NCDs.
Raised blood levels of low density lipoprotein, total cholesterol (TC) and triglyceride,
overweight/obesity, and abnormal waist circumference, are some of the risk factors of NCDs
in PLHIV, also related to the side effects of some of ARVs20 and HIV itself. Commonest
NCDs in HIV include cardiovascular diseases, diabetes, chronic lung diseases and
malignancies.21,22 In Tanzania, the commonest NCDs reported among PLHIV are
hypertension and diabetes mellitus.
This chapter highlights clinical features and treatment of the common symptoms encountered
in persons infected with HIV, prevention, diagnosis and treatment of common opportunistic
infections, and some of the co-morbidities commonly seen among adolescents and adults
above 15 years. Provision of prophylaxis, prompt diagnosis and adequate treatment of OIs
and screening, diagnosis and management of common NCDs in HIV care and treatment
clinics are crucial in improving the quality of life in PLHIV.

6.1 Clinical Features Commonly Encountered in Patients with HIV and AIDS
6.1.1 Fever
Fever in a patient may be due to various causes. However, the associated clinical features
may inform the diagnosis. If pointing features to a diagnosis are not present, as a minimum,
the following investigations should be done:
 Rapid Diagnostic test (MRDT) for malaria followed by blood slide for malaria to
quantify parasites / Blood slide (if MRDT is not available)
 Sputum for microscopy/AFB& gene Xpert/RIF

20Nigatu,T., Integration of HIV and Noncommunicable Diseases in Health Care Delivery in Low- and Middle-
Income Countries.Prev Chronic Dis, 2012.9.
21UNAIDS, Chronic care of HIV and non-communicable diseases. How to leverage the HIV experience? Joint

United Nations Programme on HIV AND AIDS. 2011

22Kagaruki, G.B., et al., Magnitude and risk factors of non-communicable diseases among people living with HIV

in Tanzania: a cross sectional study from Mbeya and Dar es Salaam regions.BMC Public Health, 2014.14(1): p.
904.
  Chest X-ray
 Urinalysis
 FBP& ESR

Where facilities are available, and if indicated, the following tests should also be done:
 Urine culture
 Sputum culture for MTB
 Blood culture for TB and other organisms
 Stool culture for salmonella species and other organisms

6.1.2. Cough and Shortness of Breath

Persistent cough and /or shortness of breath can usually be attributed to one of the following:
 Pulmonary TB
 Bacterial pneumonia
 Pneumocystis Jiroveci Pneumonia (PJP)
 Pulmonary Kaposi’s sarcoma
 Viral pneumonia
 Disseminated pulmonary strongyloidosis
 Cardiac failure, commonly due to HIV associated cardiomyopathy
 Pleural or pericardial effusion, commonly due to TB
 Lymphocytic Interstitial Pneumonia (LIP)

Sometimes, it may be impossible to determine the underlying cause of cough and dyspnoea
on clinical history and physical examination alone. At such times, laboratory tests may be of
critical value. The recommended laboratory investigations include:
 Sputum for microscopy/AFB x 2 (can be done at all levels)
 Sputum for pyogenic culture and sensitivity
 Chest X-ray
 Bronchoscopy (consultant hospitals)
 Electrocardiogram (ECG) and Echocardiography (where available)
 FBP and ESR
 Oxygen saturation using pulse oximeter in PCP cases
 Stool analysis

6.1.3. Weight Loss

Weight loss in persons with HIV induced illnesses may be due to:
 Reduced food intake
 Difficult/painful swallowing
 Diminished gastrointestinal uptake (malabsorption, diarrhoea)
 TB (a frequent cause of rapid weight loss)
 Intestinal worms
Other concomitant debilitating conditions such as:
 Cancer
 Repeated vomiting
 HIV itself

Manage weight loss by treating the underlying cause. This includes provision of high calorie
and protein foods treatment (for further reading see Chapter 13).
6.1.4. Diarrhoea
Diarrhoea in persons with HIV induced illnesses may have various causes including:
 Salmonella or Shigella (commonest)
 Amoebiasis
 Chronic malabsorption
 Cryptosporidiosis
 Mycobacterium Avium Complex (MAC) infection
 Isosporidiosis
 Clostridium difficile infection
 Cholera.

Investigations and Management:

Examine stools for microscopy and culture for treatable causes e.g. Salmonella, Shigella, V.
cholerae, Amoeba, Mycobacterium Avium Complex (MAC) and Isospora.
Diarrhoea can be treated in the following ways:
 Rehydration with Oral Rehydration Salts (ORS) or Intravenous (IV) fluids
 Treatment of underlying causes
 Nutritional therapy (see details in Chapter 13)
 Anti-diarrhoea drugs such as Loperamide (in persistent diarrhoea among adults with
no obvious treatable causes).

Note: Starting ART is often the best treatment for persistent/resistant diarrhoea (particularly
cryptosporidiosis).
6.1.5. Persistent Generalized Lymphadenopathy (PGL)
Lymphadenopathy may be due to a number of causes including the following:
 HIV
 Mycobacterium tuberculosis infection
 Kaposi’s sarcoma
 Lymphomas
 Pyogenic bacterial infection with regional lymphadenitis
 Leukemia
 Juvenile Rheumatoid arthritis.
Investigations may include:
 Fine Needle Aspiration for Acid-Fast Bacilli (AFB)/Gram stain/cytology
 Lymph node biopsy for histological diagnosis
 Chest X-ray
 FBP and ESR

Treatment is mainly of the underlying cause.

6.1.6 Altered Mental Status and Persistent Severe Headaches
The following are some of the possible causes for altered mental status and severe headaches:
 Infectious Conditions
 Bacterial Meningitis
 Cryptococcus meningitis
 Tuberculous meningitis
 Toxoplasma encephalitis
 Cerebral malaria
 Cytomegalovirus encephalitis (CMV)
 Metabolic Conditions
 Severe dehydration
 Hypoglycemia
 Electrolytes imbalance
 Renal insufficient
 Diabetic Ketoacidosis
 Mental Conditions
 HIV-dementia
 Depression
 Psychotic conditions
 HIV associated neuro cognitive disorders (HAND)

Recommended investigations include:

 Blood sugar
 Blood slide for malaria parasites
 Lumbar puncture for CSF examination
 Indian ink stain for cryptoccocal meningitis
 Salmonella and syphilis serology
 Blood cultures + sensitivity studies
 Serum Biochemistry where possible
 Serum Cryptococcus Antigen test (CrAg)
 CT brain scan/MRI brains scan (where available)
6.2. Management of Opportunistic Infections in Patients with HIV and AIDS
It is very important that all efforts are made to deal with such treatable conditions in people
with HIV and AIDS, particularly because they are managed at various levels in the health
care delivery system. Emphasis should be placed on early detection, treatment and proper
referral where necessary. Table 6.1 shows recommendations on how to identify and handle
treatable causes of morbidity as a result of selected opportunistic infections in HIV infected
individuals.
Table 6.1 Management of Common Opportunistic Infections Among Adults and Adolescents
Clinical Clinical Features and Investigations Treatment
Condition
Skin conditions
Scabies Diagnosis of many skin conditions is Benzyl benzoate Emulsion 25% (twice a day applications after bath for 2-3
usually made on clinical findings. consecutive days)
Other diagnostic investigations Crusted scabies use Ivermectin 20mcg/kg once then repeated in two weeks
include: Potassium hydroxide
If secondarily infected
preparation microscopy, Skin
scrapings microscopy CAmpiclox500mg TID for 5-7 days or Erythromycin 500mg TID for 5-7 days
Pus swab for culture & sensitivity
Dermatomycoses Whitefield’s ointment
Skin biopsy
Griseofulvin tablets 15-25mg/kg once daily for 6 weeks for Tinea
Clotrimazole or Miconazole cream for Candidiasis
Terbinafine 250mg od for at least 2 weeks
Fluconazole 150mg or 200mg od for at least 2 weeks
Impetigo Localized –use topical mupirocin ointment 2% BD for 5 days
Extensive – Cloxacillin 250mg TID for 5-7 days
Erythromycin 500mg TID for 5-7 days
Papular Pruritic Antihistamine, e.g., Cetirizine 10mg once daily for 3 days or Loratidine 10mg
Eruption (PPE)
Topical steroids, e.g. hydrocortisone, Mometasone cream
Antibiotics if there is a secondary bacterial infection, e.g. Cloxacillin or
erythromycin
Seborrheic Antifungal
Dermatitis
Ketoconazole 2% lotion 2-3 times/week for 4 weeks
Systemic antifungal if severe
Topical Steroids (careful if concomitant TB is suspected)
3% salicylic acid ointment
Molluscum ART should be considered as the primary treatment of extensive and/or
Contagiosum unusually distributed molluscum contagiosum in HIV-infected patients.
Individual lesion may be treated by:
Curettage
Cryotherapy
Electro cauterization
Kaposi’s sarcoma Cutaneous biopsies using punch This depends on the extent and severity and the options include:
(KS) biopsy
Anti-retroviral therapy (preferably PI-based, especially when extensive)
Diagnosis based on clinical criteria
Referral for chemotherapy and radiotherapy.
and chest X-ray, abdominal USS in
cases of systemic KS
Viral infections
Herpes simplex Diagnosis is usually based on clinical Acyclovir 400mg orally 8 hourly for
history and physical findings. The 7 days for mild and moderate cases
classical presentation of primary HSV of HSV (e.g. cold sores)
infection includes:
Fever
Acyclovir 800mg orally, five hourly
Lymph node enlargement for 5 days for severe and recurrent
HSV(e.g. genital infection, gingivitis,
Small painful vesicles
pharengeal tonsilitis)
Painful ulcers on the mucosa and skin
Antibiotics such as Erythromycin
Pain along gluteal and upper thigh should be used when there is
muscles (Sacral radiculomyelitis) may secondary bacterial infection
occur with genital/rectal HSV
Analgesics when pain is severe
Lesions that usually resolve within 10-
21 days after primary infection. The
HSV then becomes latent in trigeminal
and sacral nuclei and may reactivate.
Herpes Zoster or Early symptoms include pain (often Acyclovir 800mg 5 hourly for 7-10
Shingles severe and radicular) and fever days for mild and moderate cases
followed by vesicular rash over
IIV/oral Acyclovir 10 mg/kg/day 8
involved dermatome(s) 2-4 days later.
hourly for 7 days for disseminated
Primary varicella-zoster virus (VZV) VZV or ophthalmic nerve
infection usually results in chicken pox. involvement
Herpes zoster in HIV infected Erythromycin or Cloxacillin 500mg 8
individuals may be more severe, with hourly for 7 days for bacterial super-
more recurrences and may involve infection
more dermatomes.
Amitriptylin 25-50mg nocte for post-
herpetic pain (neuralgia) or
The diagnosis of herpes zoster is Carbamazepine start 100mg od
usually based on findings of
Analgesics, e.g., Paracetamol,
characteristic of painful skin lesions at
Aspirin, or Diclofenac to relieve pain
different stages of evolution (e.g.
erythema, papule, vesicles, and crusts)
in a dermatomal distribution.
Note: Use of steroids (prednisolone)
in herpes zoster is not recommended.
Human Papilloma HPV is a family of viruses that cause Primary prevention of cervical cancer
Virus Infection genital warts in men and women. involves prevention of infection with
(HPV) HPV, therefore it can be achieved
HPV is also known to cause cellular
through behavioural change
changes that can lead to cancer of the
approaches and the use of biological
cervix in women and anal cancers
mechanisms, including HPV
especially in gay men.
vaccination and consistent condom
The association between HIV and use can reduce the risk of HPV
invasive cervical cancer is complex, transmission.
due to a more rapid progression of
Annual cervical cancer screening is
cancer amongst HIV-infected women.
recommended to all sexually active
women under the age of 50 years
done at Care and treatment centres
(CTC) using VIA (visual inspection
of the cervix with acetic acid).

Treatment
There is no cure for the virus (HPV)
itself. There are treatments for the
health problems that HPV can cause,
such as genital warts, cervical
changes, and cervical cancer. For
more details for the treatment of
genital warts, cervical changes and
cervical cancer, refer to treatment
guidelines.
Fungal Infections
Oral, Patients with oropharyngeal and For treatment, any of the
Oropharyngeal, oesophageal candidiasis may complain following may be used:
Oesophageal, of pain and/or difficulty in swallowing,
Fluconazole oral/IV 150mg/day or
Trachea-Bronchial which may be due to infection of the
200mg/day for 2-3 weeks (for oro-
and oesophagus with Candida. On
pharyngeal candidiasis and others)
Pulmonary examination white painless plaque
Candidiasis (“curd like”) on buccal or pharyngeal Miconazole oral gel 3-4 times/day
mucosa or tongue surface that can after meals for 7 days
easily be scrapped off will be seen.
Nystatin oral suspension 4-6mls 3-
Where available, barium swallow X- 4 times/day continue for at least
ray/oesophago-gastro duodenoscopy 2days after oral lesions have
(OGD) can be performed. disappeared
Symptoms for trachea-bronchial and Gentian violet solution
pulmonary candidiasis may include
fever, non-productive couch, dyspnoea,
and tachypnea. Investigations include Note: Treatment should be
bronchio-alveolar lavage (BAL) for continued until symptoms resolve.
microscopy and biopsy using
bronchoscopy.

Vaginal This is one of the common illnesses Clotrimazole pessaries

Candidiasis presenting with itching and curd-like
Miconazole pessaries
genital discharge.
Fluconazole taken orally (in case
of pessaries failure)
Cryptococcal Lumbar puncture-measurement of The treatment should be done in 3
meningitis Cerebral Spinal Fluid (CSF) opening phases:
pressure and demonstration of positive
Phase 1: Induction phase
CSF with Indian Ink preparation
Amphotericin B 0.7-1mg/kg/day IV
OR
+ 5 Flucytosine 100mg/kg/day
Rapid CSF cryptococcal antigen administered orally for 7 days
(CrAg) assay followed by 1 week of fluconazole
(1200 mg/day for adults, 2
OR
mg/kg/day for children and
Rapid serum CrAg adolescents, up to a maximum dose
of 800mg daily)

In the absence of Flucytosine,

alternative therapy should be:

Amphotericin B 0.7-1mg/kg/day IV
for 14 days (If liposomal
amphotericin B is available give 3-
6mg/kg iv for 10 days) and
Fluconazole 1200mg IV/ORAL
once daily for 14 days
Phase 2: Consolidation phase
Fluconazole 800mg/ day for 8
weeks or until CSF is sterile.

Phase 3: Maintenance phase

Give patient maintenance therapy
with Fluconazole 200mg per day
for 1 year. Discontinue
Maintenance treatment if CD4 ≥
100 with undetectable (<50 copies)
viral load or CD4 ≥ 200 if viral load
monitoring not available.
Note: It is recommended to initiate
ART 5 weeks after initiation of
Cryptococcal meningitis treatment
in ART naïve patient to prevent
IRIS and reduce mortality.
Pneumocystic This condition is common in Tanzania Cotrimoxazole 1920 mg 8 hourly for
Jiroveci (PJP) especially among HIV infected 21 days and in severe cases give IV
children. Patients usually present with cotrimoxazole 15–20mgTMP/75-
non-productive cough, fever, chest 100mg SMX/kg/day IV,
tightness and shortness of breath that administered 6-8hourly, may switch
has evolved over 2-4 weeks. to oral after clinical improvement.
A Chest x-ray may show increased For those allergic to sulphur, and if
diffuse and symmetrical interstitial available, give Trimethoprim 12-
markings or diffuse alveolar pattern 15mg/kg/day + Dapsone 100mg/day
with infiltrations characterized by for 21 days as well as Clindamycin
asymmetry, nodularity, or cavitations. 450mg 4 times/day or 600mg three
Normally there is a “bat’s wing’s times daily + Primaquine 30mg once
appearance”. daily for 21 days
Chest radiograph may appear normal in Adjuvant therapy with steroids may
10-30% of patients. also be beneficial in severe cases.
Give Prednisolone 40mg twice daily
Usually in clinical circumstances
for days 1 to 5, then 40mg once daily
diagnosis is based on clinical
for days 6 to 10, and then 20mg once
presentation and exclusion of other
daily for days 11 to 21
common causes of severe dyspnoea.
Protozoal conditions
Toxoplasmosis Clinical features include: Acute infection
Focal paralysis or motor Sulphadiazine tabs 1 gm 6 hourly +
weakness depending on the Pyrimethamine tabs 100mg loading dose, then
brain area affected 50mg /day + Folic acid tabs 10mg /day for 6
weeks.
Neuro-psychiatric
manifestations corresponding to Clindamycin capsules 450mg -600mg 6 hourly
the affected area in the brain + Pyrimethamine tabs 100mg loading dose, then
50mg /day for 6 weeks.
Altered mental status
(forgetfulness etc.) After six weeks of treatment
Diagnosis predominantly based Give prophylaxis therapy with Sulphadiazine
on clinical findings after tabs 500mg 6 hourly + Pyrimethamine tabs 25-
exclusion of other common 50mg /day + Folic acid tabs 10mg /day.
causes of neurological deficit. If
For those allergic to sulphur replace
available, a CT scan or MRI
Sulphadiazine tabs with Clindamycin capsules
with contrast is very useful for
450mg 6 hourly
confirmation.
Discontinue maintenance therapy when CD4
count is >200 cells/ml, initial therapy is
completed and the patient is asymptomatic.
Primary prophylaxis therapy for toxoplasmosis
can be accomplished with Trimethoprim–
Sulphamethoxazole (TMP-SMX) tabs
160/800mg administered orally/day. For those
allergic to sulphur, give Dapsone tabs 50mg/day
+ Pyrimethamine tabs 50mg per week + Folic
Acid tabs 10mg 3 times a week.

Cryptosporidiosis Cryptosporidiosis Nitazoxanide is the recommended treatment

(cryptosporidium parvum, 500mg-1000mg twice daily for 14 days +
cryptosporidium meleagridis rehydration, electrolytes replacement and
and cryptosporidium hominis) is optimized ART. Alternatively Paromomycin
the common cause of chronic 500mg PO QID for 14-21 days can be used.
diarrhoea.
•Diagnosis can be made by
microscopic examination of the
oocytes in stool or tissue with
acid-fast staining or direct
immunoflourescence for better
sensitivity.
6.3. Prophylactic Treatment of Common Opportunistic Infections in HIV and AIDS
Many opportunistic infections can be prevented by using cotrimoxazole prophylaxis,
particularly in the case of:
 Bacterial infections e.g. pneumonia,
 Skin infection
 Sepsis
 Pneumocystis Jiroveci Pneumonia (PJP)
 Malaria
 Toxoplasmosis

6.3.1. Indication for Prophylactic Treatment Using Cotrimoxazole

Prophylactic treatment using Cotrimoxazole should be provided if any of the following
criteria applies:
 Adults, adolescents, and pregnant women with CD4 cell count ≤350 cells/mm3
 Initiate CPT in all children <5 years of age regardless of CD4 and WHO clinical stage
 All HIV exposed uninfected infants (initiate in all starting 4-6 weeks after birth)
 All HIV-infected persons with active TB.

Note:
Caution should be taken when initiating Cotrimoxazole Preventive Treatment (CPT) during
the first trimester of pregnancy in women who may not have access to good nutrition and
anaemic patients, because Cotrimoxazole causes deficiency in folic acid.
Pregnant women who are receiving CPT do not need sulfadoxine pyrimethamine (SP), an
additional medication to prevent malaria.
CPT will continue to be provided to virologically suppressed patients (<50 copies/mL) with
low CD4 cell counts (immunological non-responders).
Dosage:
For adults: One double strength tablet (160/800mg) or two single strength tablets once a day
on a daily basis. For those whose weight is <60kg, see ARV dosing chart under
Cotrimoxazole dosing.
Criteria for stopping:
Occurrence of severe side effects such as severe cutaneous reactions or fixed drug reactions.
If ART is initiated and CD4 cell count is above 350 cells/ml in adults and adolescents and
virological suppression (<50 copies/mL).
If the use of antiretroviral agents causes renal and/or hepatic insufficiency or severe
haematological toxicity
Follow-up and monitoring:
Regular follow up is recommended, initially every month for the first three months, then
every three months if the medication is well tolerated.
It is mandatory to monitor for side effects and adherence. Monitoring includes assessment of
skin reactions, measurements of haemoglobin, and white blood counts every six months and
when clinically indicated.
6.3.2. Tuberculosis Preventive Therapy against TB in PLHIV
There is sufficient evidence on the benefits of Tuberculosis (INH) preventive therapy against
Mycobacterium tuberculosis for HIV infected individuals in whom active TB has been
excluded. In this category of HIV patients, Tuberculosis Preventive Therapy (TPT) can be
offered at a dosage of 300 mg of INH daily for at least six months for adults and in children
INH is given at a dose of 10mg / kg (Range 10-15mg/kg) daily for six months as well. IPT
provides up to 18 months of protection against TB. Note that TB PT for both adults and
children is given only once in lifetime (Further details on this are provided in Chapter 8).
6.3.3 Prevention of Cryptococcal Disease
Globally, cryptococcal meningitis is a leading cause of mortality among hospitalized adults
living with HIV, but is less common among children living with HIV. Pre-emptive therapy
for cryptococcal antigen–positive asymptomatic people is a key strategy to prevent
cryptococcal meningitis related mortality.
6.3.3.1 Screening for CrAg
Algorithm for Screening Cryptococcal meningitis in clients with Advanced HIV Disease

Newly diagnosed HIV infection OR Client with AHD

CD4 testing WHO clinical staging

is not
Meningitis symptoms screening
available

WHO stage 3 & 4 Baseline CD4

Serum CrAg test CD4<200 CD4≥ 200

Start ART
Positive Negative
1 Special situations:
Screen for symptoms of meningitis
-History of prior
Check for special situations 1 cryptococcal meningitis
-Pregnancy/breastfeeding
-Clinical liver disease

2Signs/symptoms of
Symptomatic 2 (client has Asymptomatic meningitis:
at least one sign/symptom) - Headache
- Stiff neck
- Confusion
URGENT lumbar - Focal neurological
puncture for CSF deficit
analysis, CrAg/India ink
test Start pre-emptive therapy with fluconazole 800
CrAg + CrAg -
mg/day x2 weeks but exclude other causes of
meningitis. Start ART after 2 weeks.

Hospitalize for treatment of

cryptococcal meningitis Taper to fluconazole 400 mg/day x8 weeks, then
200 mg/day for at least 1 year. Discontinue if
client is adherent to ART and Fluconazole and
CD4 ≥ 100 and viral load is undetectable (<50
Abbreviations: AHD- Advanced HIV Disease copies/mL) OR CD4 ≥ 200 if viral load
monitoring is not available)
Screen for serum Cryptococcal antigen for all ART-naive adults and adolescents with CD4
cell count of <200 cells/mm3 or WHO stage 3 & 4 if CD4 testing is not available.
Through “reflex” testing, laboratory personnel should conduct Cryptococcal Antigen
screening on any samples sent for CD4 count testing where CD4 is found to be <200
cells/mm3.

If serum CrAg screening test is negative in ART-naïve clients, screen for other opportunistic
infections and initiate ART. If screening test is positive (bloodstream disease) but there is no
evidence of meningitis, give pre-emptive therapy with fluconazole 800mg once daily for 2
weeks (induction phase), followed by 400mg once daily for 8 weeks (consolidation phase)
then 200mg once. Discontinue maintenance treatment if CD4 ≥ 100 cells/mm3 with
undetectable viral load (<50 copies/mL) /or CD4 ≥ 200 cells/mm3 if viral load monitoring not
available. Start ART two weeks after starting fluconazole pre-emptive therapy.
If screening test is positive with signs and symptoms of meningitis, perform Lumbar Puncture
for CSF Cryptococcal Antigen. If CSF CrAg is negative give pre-emptive therapy as above
and if the client is CSF CrAg positive give treatment as indicated in table 6.1 (management of
Common Opportunistic Infections Among Adults and Adolescents) ART should be started
after 5 weeks.
NOTE: The routine uses of antifungal primary prophylaxis for cryptococcal disease in HIV-infected
adults, adolescents and children with a CD4 count less than 200 cells/mm3 and who are CrAg-
negative or where CrAg status is unknown is not recommended prior to ART initiation.

Summary of the diagnostic approach to cryptococcal meningitis.

Lumbar puncture available No lumbar puncture available or

contraindicated

Rapid Perform CSF cryptococcal Perform serum, plasma or whole blood

cryptococcal antigen cryptococcal antigen.
antigen test
If CrAg-positive, treat immediately and
available
refer for further investigation if
indicated.

No rapid Perform CSF India ink Prompt referral for further investigation
cryptococcal
antigen test
available
Common signs and symptoms of Cryptococcal Meningitis Symptoms
Symptoms
 Headache
 Nausea with or without vomiting
 Changes in vision or hearing (such as double vision, blindness or deafness)
Signs
 Change in mental status ranging from confusion to lethargy to coma
 Papilledema
 Seizures
 Cranial nerve palsies (such as movement problems, particularly cranial nerve VI)
 Other focal neurological nervous system deficits

Table 6.1 Management of Common Opportunistic Infections Among Adults and

Adolescents
Cryptococcal Lumbar puncture-measurement of The treatment should be done in 3
meningitis Cerebral Spinal Fluid (CSF) phases:
opening pressure and demonstration
Phase 1: Induction phase
of positive CSF with Indian ink
preparation Amphotericin B 0.7-1mg/kg/day IV
+ 5-flucytosine 100mg/kg/day
OR
administered orally for 7 days
Rapid CSF cryptococcal antigen followed by 1 week of fluconazole
(CrAg) assay (1200 mg/day for adults, 2
mg/kg/day for children and
OR
adolescents, up to a maximum dose
Rapid serum CrAg of 800mg daily)
In the absence of 5-flucytosine,
alternative therapy should be:
Amphotericin B 0.7-1mg/kg/day IV
for 14 days (If liposomal
amphotericin B is available give 3-
6mg/kg iv for 10 days) and
fluconazole 1200mg IV/oral once
daily for 14 days
Phase 2: Consolidation phase
 Fluconazole 800mg/day for 8 weeks
or until CSF is sterile.
Phase 3: Maintenance phase
Give patient maintenance therapy
with fluconazole 200mg/day
(discontinue maintenance treatment
if CD4 ≥ 100 with undetectable [<50
copies/mL] viral load or CD4 ≥ 200
if viral load monitoring not
available).
Note: It is recommended to initiate
ART 5 weeks after initiation of
cryptococcal meningitis treatment in
ART-naïve patient to prevent IRIS
and reduce mortality.

Table 6.2 Amphotericin B toxicity prevention, monitoring and management

Pre-emptive hydration and electrolyte supplementation

Adults and adolescents One litre of normal saline solution with 20 mEq
of potassium chloride (KCl) over two hours
before each controlled infusion of amphotericin B
and one to two 8-mEq KCl tablets orally twice
daily. An additional 8-mEq KCl tablet twice daily
may be added during the second week. If
available, magnesium supplementation should
also be provided (two 250-mg tablets of
magnesium trisilicate or glycerophosphate twice
daily, or magnesium chloride 4 mEq twice daily).

Monitoring (adults, adolescents and children)

Serum potassium Baseline and 2–3 times weekly (especially in the

second week of amphotericin B administration)
Serum creatinine Baseline and 2–3 times weekly (especially in the
second week of amphotericin B administration)

Haemoglobin Baseline and weekly

Management (adults, adolescents and children)

Hypokalaemia If hypokalaemia is significant (K <3.3 mol/l),

increase potassium supplementation to 40 mEq
KCl by intravenous infusion and/or one to two 8-
mEq KCl tablets orally three times daily. Monitor
potassium daily.
Elevated creatinine If creatinine increases by ≥2 fold from the
baseline value, increase pre-hydration to 1 L
every eight hours and consider temporarily
omitting a dose of amphotericin B. Once
creatinine improves, restart amphotericin B at 0.7
mg/ kg/day and consider alternate-day
amphotericin B. If creatinine continues to rise,
consider discontinuing amphotericin B and
continuing with fluconazole at 1200 mg/ day,
especially if seven doses of amphotericin have
been received. Consider fluconazole dose
adjustment if significant renal impairment.
Monitor creatinine daily.

Severe anaemia Transfusion should be undertaken if possible, for

severe amphotericin B–related anaemia (anaemia
may also be a reason to discontinue amphotericin
B prematurely in the second week of a planned
two-week induction course of amphotericin B
with fluconazole)

6.3.3.2 Special Situations

If a patient is already on ART and has a positive serum CrAg result, they should continue with ART.
A history should be conducted to ascertain previous treatment. If the client has been previously
treated then they may be experiencing persistent or recurrent symptoms.
Main causes of persistent and recurrent symptoms among people with Cryptococcal meningitis

Recurrent symptoms Persistent symptoms

Raised intracranial pressure Raised intracranial pressure

Treatment failure due to suboptimal induction, Treatment failure caused by suboptimal induction
consolidation or maintenance treatment treatment

Inadequate drug regimen, dose or duration Inadequate drug regimen, dose or duration

Failure to prescribe or to adhere to fluconazole Fluconazole drug resistance (rare)

consolidation or maintenance treatment
Fluconazole drug resistance (rare) Other concomitant illness (such as viral,
bacterial, or tuberculous meningitis)

Cryptococcal immune reconstitution

inflammatory syndrome (IRIS) following ART
initiation

Other concomitant illness (such as viral, bacterial

or tuberculous meningitis)
Rule out causes of recurrent or persistent symptoms (table above). Perform a lumbar puncture for CSF
CrAg test and treat for cryptococcal meningitis if CSF is CrAg positive. If asymptomatic (or CSF
cryptococcal antigen test is negative) then start pre-emptive fluconazole dose as for ART-
naive patients.
If the client is presenting with cryptococcal meningitis relapse:
• Start or restart induction treatment according to the recommendations for induction treatment.
• Manage raised intracranial pressure with therapeutic lumbar puncture
• Reinforce adherence.
• If ART has not already started, initiate ART after 5 weeks of optimal antifungal therapy
After excluding other causes of symptoms among people who have started ART consider
cryptococcal IRIS.

Management of Cryptococcal meningitis in pregnancy and Breastfeeding

Amphotericin B monotherapy (0.7-1mg/kg/day for 2 weeks) should be used to treat

Cryptococcal meningitis in first trimester pregnancy. Fluconazole is considered category D
and is associated with human fetal teratogenic risks. It should be avoided in first trimester of
pregnancy. Clients presenting with these conditions should be referred to a specialist.

Fluconazole may be excreted in breast milk. If a Breastfeeding mother is required to use

Fluconazole, she should be educated to make an informed choice to continue breast feeding
since it is the best source of nutrients for the baby and supplementary feeding is too
expensive or not affordable. Monitor the baby’s Liver and renal Function Tests and refer to
specialist if abnormal.
Clients with Immunological failure on ART
In patients who develop immunological failure while receiving ART and where the CD4+ T-
lymphocyte count drops <200 cells/µl after secondary prophylaxis has been stopped, restart
fluconazole at 200 mg daily and refer to the above section on maintenance-phase treatment
for the duration of treatment.
Clients with clinical liver disease
If signs/symptoms of liver toxicity develop (e.g. abdominal pain), evaluate for liver
dysfunction and refer client to specialist if abnormal.

6.3.3.3 Management of Patients on Cryptococcal Treatment

Management of Increased Intracranial pressure
Patients on Cryptococcal treatment should be regularly monitored for the signs and symptoms
of increased intracranial pressure as highlighted above. For the initial two weeks of
cryptococcal treatment, clinical response including recurrence or resolution of fever,
headache and other increased intra-cranial pressure should be assessed on daily basis and
serial lumbar punctures performed if indicated.
CSF, Serum or Plasma cryptococcal antigen test is of little or no value in predicting treatment
failure or relapse among PLHIV with cryptococcal meningitis.
Management of Drug toxicity;
Drug toxicity and side-effects from amphotericin B therapy, especially hypokalaemia,
nephrotoxicity and anaemia, are barriers to optimal induction treatment, particularly in low-
and middle-income countries.
Safe administration of amphotericin B should be given priority and may require referral to a
centre with access to a minimum package of preventing, monitoring and managing toxicity. •

The routine uses of antifungal primary prophylaxis for Cryptococcal disease in HIV-infected
3
adults, adolescents and children with a CD4 count less than 200 cells/mm and who are CrAg
negative or where CrAg status is unknown is not recommended prior to ART initiation.

Managing Cryptococcal IRIS

Even after successful treatment, living or dead yeast cells remain in CSF. With early
initiation of ART and improved immunity, immune system can recognize these yeast
components leading to marked inflammation and raised intracranial pressure.Very high
intracranial pressure in response to ART and immune reconstitution may lead to death.
Symptoms and signs for IRIS as explained in Chapter 10 should be elicited regularly for
cryptococcal meningitis patients.
If a patient presents with Cryptococcal IRIS.
 Continue ART
 Promptly manage elevated intracranial pressure.
Optimize antifungal therapy, restart induction therapy while waiting on culture results
in case this might be relapsed disease.

Short-course of oral steroids (Prednisolone [PO] 1-2mg/kg daily for 5 - 7 days), although not
recommended for routine use, may be considered if the patient experiences clinical deterioration and
or and/or the development of life-threatening complications (such as intracranial space-occupying
lesions with mass effect or extracranial disease impinging on vital structures) despite use of above
measures.

1. Guidelines on the diagnosis, prevention and management of cryptococcal disease in HIV-infected adults,
adolescents and children: supplement to the 2016 consolidated guidelines on the use of antiretroviral drugs for
treating and preventing HIV infection. Geneva: World Health Organization; 2018. License: CC BY-NC-SA 3.0
IGO.
6.4 Common Non-Communicable Diseases among PLHIV
Prevention of NCDs is the mainstay of reducing the burden which can be achieved by
lifestyle modification. Screening for hypertension, diabetes and dyslipidaemias for early
identification and management of these diseases is of paramount importance in the HIV
population.
In general lifestyle modifications include the following:
 Physical exercises- 30-60 minutes of aerobic exercises 4-5 times a week
 Maintain a healthy body weight (BMI 18.5-24.9kg/m2) and waist circumference
<102cm in men and <88cm in women
 Smoking cessation
 Limit alcohol consumption (14 standard units per week for men and 9 times per week
for women)
 Dietary changes- diet emphasis should be made on fruits, vegetables, low fat dairy
products, reduce fatty foods, increase intake of whole grains and fish. Drink a
minimum of 2 litres of water daily and restrict salt intake to <2g/day.

6.4.1 Screening, Diagnosis and Management of Hypertension

 Measurement of BP should be done and recorded during every visit to care and
treatment clinic
 An elevated BP (defined as BP ≥140/90 mmHg on at least 3 different occasions) will
require treatment as per Tanzania standard treatment guidelines and essential
medicines list 2013 and lifestyle modifications.

Note: If there is persistent uncontrolled BP or development of Hypertension related

complications, the patient should be referred to appropriate level for further evaluation and
management.
6.4.2 Screening, Diagnosis and Management of Diabetes Mellitus
Baseline blood glucose (random/fasting) should be evaluated to all PLHIV during enrolment.
If blood glucose is normal at baseline, annual evaluation is recommended. Symptoms such as
polyuria, polydyspia, polyphagia and some risk factors such as family history of diabetes and
BMI> 30kg/m2 warrant screening for diabetes. Blood glucose measurement can be
categorized as:
 Normal fasting <6mmolL and random <11mmol/L
 Pre-diabetes fasting 6.1-6.9mmol/L and 2-hour post prandial 7.8-11.0mmol/L
 Diabetes fasting >7.0mmol/L and random >11.1mmol/L

Management
Regular monitoring of Fasting and Random blood sugar levels is essential where available,
monitor HgA1c (glycated haemoglobin) every 3 months for patients with confirmed
diagnosis of diabetes mellitus.
Patients should be encouraged to modify their lifestyle (such as weight loss, nutritional
support (portion sizes and low glycaemic index foods to help with control of blood sugar)
If lifestyle change does not successfully control blood sugar levels, start treatment for
diabetes as per the Standard Treatment Guidelines and Essential Medicines List 2013.
6.4.3 Screening, Diagnosis and Management of Dyslipidemias
Baseline screening of fasting lipid profile (total cholesterol, LDL and triglycerides) should be
done at baseline for all PLHIV. Diagnosis of dyslipidemia is made when fasting total
cholesterol is >5.2mmol/L, LDL>3.4mmol/L or triglycerides > 2.2mmol/L.
Management of dyslipidemias includes life style modifications for a minimum of 3 months.
For patients on ARVs known to cause or exacerbate dyslipidemia such as LPV/r, then
consider substitution to a more lipid friendly drug ATV/r before adding a lipid lowering drug.
It is important to rule out ART failure before substitutions of LPV/r with ATV/r.
6.4.4 Screening for Chronic Kidney Disease
Diagnosis:
 Serum creatinine and urinalysis for protein are essential markers for kidney disease
which can be evaluated at baseline.
 Abnormal results such as creatinine clearance <60ml/min or dipstick proteinuria ≥1
are indicatives of impaired kidney function. Repeated tests should be done to confirm
diagnosis.

The estimation of the degree of kidney damage and staging is important to guide management
and prevent further adverse outcomes of chronic kidney disease. Therefore, additional
investigations and specialist consultation may be required.
For patients on TDF based regimen, substitution to another non TDF based regimen is
recommended once chronic kidney disease is diagnosed.
Precaution should be taken to avoid nephrotoxic drugs and some ARV drugs may require
dose adjustment for kidney impairment (all NRTIs except ABC). NNRTIs, PIs, and INSTIs
do not require dose adjustments for impaired renal function.
6.5 Hepatitis B and C Co-infections
6.5.1 Hepatitis B Co-infection
Hepatitis B virus infection (HBV) shares the same routes of transmission as HIV but HBV is
about 100 times more infectious. In endemic areas of both HBV and HIV, men who have sex
with men (MSM) show higher rates of HBV and HIV co-infection than people who inject
drugs (PWIDs) or heterosexuals23. During acute HBV infection in HIV-infected individuals,
there is an increased risk of developing chronic hepatitis infection, reducing the chances of
spontaneous clearance and increased rate of HBV replication or reactivation. Such events
increase the incidence of chronic liver disease, cirrhosis and hepatocellular carcinoma.
Furthermore, HBV/HIV co-infection has been associated with a rapid HIV disease
progression, poor ART outcomes and some complications of hepatotoxicity, drug interactions
and hepatitis related immune reconstitution.
HBV screening
It is recommended that all HIV infected individuals are screened for HBV for the presence of
Hepatitis B surface antigen (HBsAg). The presence of this antigen indicates that the patient is
currently infected with HBV; its persistence for six months or longer indicates chronic
infection. Patients testing positive for HBsAg should be tested for quantitative HBV DNA
where available (giving the level of hepatitis DNA in blood).
Where available, other tests that can be done for further evaluation of HBV are:;
 Hepatitis B PCR (HBV DNA): polymerase chain reaction is a very sensitive method
used to detect Hepatitis B DNA. It is either qualitative (giving positive or negative
result) or quantitative (giving the level of Hepatitis B DNA in blood).
 Hepatitis B surface antibody (HepBsAb): If produced in large amounts (>100 IU) it
usually indicates that the patient has cleared the virus (if they have been infected) and
are now immune.
 Hepatitis B core antibody (HepBcAb): This is an antibody against Hepatitis B core
antigen. Patients who have been infected with Hepatitis B virus produce antibodies to
the core protein which is usually life-long (whether or not they clear the virus). Core
antibodies do not confer immunity and are present in patients who still have active
infection.
 Hepatitis B e antigen which is usually expressed when the virus is replicating at a
high level. It is often found in individuals having abnormal liver function tests (LFTs)
and chronic hepatitis. Presence of this e antigen indicates high infectivity.
 Hepatitis B e antibody (HepBeAb): this is the patient’s antibody that is produced to
Hepatitis B e antigen. When present, it sometimes indicates that the level of
replication of the Hepatitis B virus is lower. In patients with abnormal LFTs and
Hepatitis B e antibody present, a Hepatitis B PCR is indicated which will indicate the
true level of ongoing replication. HepBeAb fall over time in patients who have
cleared the virus and may eventually become undetectable.

23Konopnicki et al. Hepatitis B and HIV: prevalence, AIDS progression, response to highly active antiretroviral
therapy and increased mortality in the EuroSIDA cohort. AIDS, 2005, 19:593–601.
HBV evaluation and treatment
The presence or absence of clinical evidence for cirrhosis might be the key issue in defining
treatment strategy in HBV/HIV co infected patients. Physical examination should be
performed to check for signs of liver disease such as jaundice, ascites, abnormal liver on
palpation and other signs of cirrhosis. When there is evidence of chronic liver disease, close
follow up is required to monitor for hepatotoxicity and referral to a consultant hospital may
be warranted for additional evaluation and management. Laboratory measurement for liver
enzyme ALT is required and if elevated, it may indicate an active liver disease but exclusion
of other causes for elevation of ALT is important.
NOTE: Because HBV positive patients are at higher risk of hepatotoxicity, closer monitoring
of liver function (with ALT) is advised.
Emtricitabine (FTC), Lamivudine (3TC), and tenofovir disoproxil fumarate (TDF) have
activity against both HIV and HBV. Therefore, for patients co infected with HIV and HBV,
ART should be initiated with the fixed dose combination of TDF/FTC or the individual drug
combinations of TDF plus 3TC/FTC as the NRTI backbone of a fully suppressive ARV
regimen.
The recommended ART regimen in HIV/HBV co-infection is TDF +FTC/3TC +EFV
NOTE:
TDF is indicated in HIV/HBV co-infection even with creatinine clearance <50ml/min,
remember to avoid fixed dose combinations of ART to allow for renal dose adjustment.
Patients with impaired kidney function and the continuation of using TDF is importantly
required, then management from a specialist in Internal Medicine or Nephrologists is
required
Discontinuation of agents with anti-HBV activity may cause serious hepatocellular damage
resulting from reactivation of HBV; patients should be advised against stopping these
medications.
HBV prevention
HBV vaccination reduces the risk of new HBV infection in HIV-infected individuals. Also it
reduces the risk of new infections progression to chronicity. Therefore, HIV-infected infants,
children, adolescents and adults without evidence of hepatitis B infection (HBsAg negative)
should be vaccinated against hepatitis B with the standard vaccination regimen.

6.5.2 Hepatitis C and HIV co-infection

Hepatitis C infection is low in the general population and among PLHIV but higher in HIV –
infected people who inject drugs (PWID) due to the shared routes of transmission. Screening
for HCV is by HCV serology testing offered to individuals at risk of HCV infection. For
confirmation of chronic HCV, where available HCV RNA PCR is required and HCV
genotype testing for selecting appropriate Direct Acting Antivirals (DDA) regimen. Liver
enzyme ALT, if elevated, may indicate an active liver disease but remember to exclude other
causes of elevation of liver enzymes.
HCV is treated using direct acting antivirals (DAA) such as Daclatasvir (60 mg) + Sofosbuvir
(400 mg) for genotypes 1, 2 and 3 for duration of 12 weeks.

References:
1. WHO, Preventing and managing other comorbidities and chronic care for people
living with HIV. World Health Organization 2013
2. Rabkin M, N.S., Scaling up chronic care systems: Leveraging HIV programs to
support noncommunicable diseases services. J Acquir Immune Defic Syndr, 2011. 57
(Suppl2): p. S87-S90.
3. Nigatu, T., Integration of HIV and Noncommunicable Diseases in Health Care
Delivery in Low- and Middle-Income Countries. Prev Chronic Dis, 2012. 9.
4. UNAIDS, Chronic care of HIV and non-communicable diseases. How to leverage the
HIV experience. Joint United Nations Programme on HIV AND AIDS. 2011
5. Kagaruki, G.B., et al., Magnitude and risk factors of non-communicable diseases
among people living with HIV in Tanzania: a cross sectional study from Mbeya and Dar es
Salaam regions. BMC Public Health, 2014. 14(1): p. 904.
 CHAPTER 7
PAEDIATRIC AND ADOLESCENTS HIV AND AIDS-RELATED CONDITIONS
7.0 Introduction
Majority of HIV infection in children is acquired through mother to child transmission during
pregnancy, delivery or breastfeeding. Exposure to HIV continues as long as a child of an
HIV-infected mother is breastfed. HIV infected infants may not have any signs or symptoms
soon after birth but usually develop the features in the early infancy period. These features
may overlap with those of other common childhood diseases. The HIV infection progresses
more rapidly in children than in adults.
7.1 Diagnosis of HIV Infection in Children
7.1.1 Diagnosis of HIV Infection in Children below 18 Months
Infants born to HIV-infected women have antibodies to HIV passively transferred from their
mothers; these antibodies can persist until 9 to 18 months of age. Thus, a positive rapid HIV
antibody tests in infant does not confirm nor exclude HIV infection. Therefore, DNA PCR is
required in order to confirm HIV infection in children <18 months of age. PCR tests should
be done at six weeks of age or at any time < or = 9 (months) as a first test. When the child of
> 9 months is first seen by a healthcare worker, that child will be tested for HIV infection
using antibody test. If the result is positive, then DNA- PCR should be used to confirm the
HIV infection as per algorithm

Table 7.1 Summary of Diagnosis of HIV infection in children <18 Months who are being
breastfed by a mother known to be HIV Positive
Do HIV DNA-PCR at 6 weeks of age; if positive, start ART immediately while waiting for
second HIV DNA-PCR results.
All children with negative results should have HIV test at 9 months of age using DNA
PCR, and HIV antibody test at 12 weeks after complete cessation of breast feeding, and
final rapid test at 18 months of age. If the result is positive then DNA PCR is used to
confirm their status.
If the child is being breastfed by an HIV infected mother, a negative antibody test does not
exclude an HIV infection. On-going exposure to HIV through breastfeeding continues to
put the child at risk of acquiring HIV infections.
A single positive DNA- PCR test means the infant is presumably infected and should be
initiated on ART. A second DNA PCR sample should be taken immediately after receiving
a positive test result so as to confirm the first test result. NB: The second test should not
delay ART initiation.
For a child that was never breastfed: a single negative DNA PCR test after the age of 6
weeks excludes HIV infection.

15
For a child that has completely stopped breastfeeding for more than 3 months prior to
virologic (DNA PCR) testing, a negative DNA PCR test excludes HIV infection.
Children at the age of 9 months should receive HIV test using DNA -PCR.
Note: Changes in transmission dynamics as well as in policy and practice have complicated
RDT use for determining infection status at this age.
For High Risk HIV Exposed Infants Refer to Annex 11.
All positive tests should be confirmed with a DNA PCR test. However, if the child is
symptomatic; fulfilling WHO stage 3 or 4 criteria and or a DNA PCR test is not available
but HIV antibodies are present (rapid test is positive), a presumptive diagnosis should be
made and ART started.

7.1.2 Diagnosis of HIV Infection in Children <18 Months where the Mother’s HIV
Status is Unknown
Testing of a mother is the best way to ascertain HIV exposure status of her infant. If the
mother is HIV positive, testing of the infant should follow the steps for diagnosis of HIV
infection in the HIV exposed infant or child <18 months. If the mother is not available, test
the child for HIV infection using antibody test first. If the result is positive, then DNA- PCR
should be used to confirm the HIV infection.
7.1.3 Diagnosis of HIV Infection in Children <18 Months where the Mother is Not
Available
Since the mother’s HIV status is unknown, the HIV exposure status of the baby needs to be
established. The guardian or caretaker needs to be counselled for HIV testing of the child. If
rapid test is positive take sample for DNA- PCR for confirmation, initiate ART while
awaiting for the results, start the child on Cotrimoxazole prophylaxis; If DNA-PCR results
turns negative then ART and Cotrimoxazole should be interrupted.
Table 7.2 Steps for diagnosis of HIV infection in children where the mother is not available
To children with > 9months and < 18months, Do rapid HIV antibody test immediately the
child is seen at the HF to determine HIV exposure
If HIV antibody test result is positive do HIV DNA PCR. If the result is negative, re- test if
symptomatic, at 12 weeks after cessation BF or at 18 months of age (Ab test).

If rapid HIV antibody test is positive and the child has stage THREE or FOUR symptoms
(PRESUMPTIVE DIAGNOSIS), collect DBS for DNA PCR test and immediately initiate
ART.
If the child is younger than 18 months and is symptomatic, HIV DNA PCR should be taken
even if the rapid antibody test is negative.
All children with negative results should have a final rapid test at 18 months to confirm
their status.

16
Note: Exposed children should be seen monthly for the first year of life and should be
followed up as per recommendations for all children. A clinical examination to assess for
signs and symptoms of HIV infection should be performed during all visits. Failure to thrive
and neurodevelopmental delay might be signs of HIV infection.
Managing discordant results and treatment interruption in HIV Exposed Children
WHO has recommended initiating infants on ART after an initial positive Nucleic Acid Test
(NAT) / DNA-PCR, while simultaneously collecting a confirmatory sample, if the second
(confirmatory) NAT/DNA-PCR is negative; a third NAT/DNA-PCR should be performed
before considering ART interruption
The following should be considered when assessing patients for ART interruption after
discordant test results; positive then a negative result followed by a third test with a negative
result:
1. The infant in question, is ought to have no clinical signs or symptoms suggestive of
HIV infection
2. A follow-up plan should be agreed upon with family, caregiver(s) and health-care
staff. There should active follow-up to ensure that a potentially infected infant is
retained and re-initiated on treatment if virological rebound occurs;
3. Tracking information (phone, address, etc.) of the family/caregiver(s) should be
collected and confirmed.
4. Infants who develop signs and symptoms indicative of HIV infection should undergo
immediate testing
Note:
virological rebound in HIV-infected infants starting treatment early is expected to happen
within 8 months of interruption in >99% of HIV-infected infants

Follow up of an Infant with ART interruption

In settings were both EID (qualitative) and VL (quantitative) tests are available, tests should
be performed at 4 weeks, 4 months and 8 months after treatment interruption

Infants who test positive on follow-up test should be re-initiated on treatment as per current
guidelines and a confirmatory sample taken.
Follow up on ART interruption should consider the continuous risk of transmission resulting
from breastfeeding and, once the intensive follow up is completed (that is 8 months after
treatment interruption), the national infant testing schedule for HIV-exposed infants should
be applied in order to ensure an appropriate final diagnosis. If breastfeeding has stopped prior
to the end of the intensive follow up, final HIV status can be defined with NAT/DNA-PCR
performed at least 6 weeks post cessation of breastfeeding, as summarised below in “Scenario
a and or b” respectively.

17
EID and viral load at 4 weeks, 4 months, and 8 months after interruption
Scenario a: Cessation of breastfeeding occurs after completion of the follow up post ART
interruption.

Scenario b: When cessation of breastfeeding occurs before completion of the follow up post
ART interruption. 8 months NAT 1: + Start ART

NB Initiate duo prophylaxis (AZT and Nevirapine) ePNP while waiting for NAT or PCR
results

18
Fig 7.1: HIV Testing Algorithm for Infants and Young Children

Child presents at clinic

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

Positive Negative PCR Negative Ab test Positive Ab test

PCR

Retest using If not Still (or If not <18 months: ≥18 month’s
DNA-PCR: breastfed recent) breastfed Retest with confirmatory Ab
Start ART for at least breast- for at least DNA-PCR test
while waiting 12 weeks feeding 12 weeks
for
confirmatory
results

Child is not Child is If negative If positive,

Re-test:
HIV-infected not HIV- the child is child is HIV-
-If symptomatic
Re- test: infected Negative infected,
-At 9 months of
-if symptomatic start ART.
age
- At 18 months Re- test:
-12 weeks after
of Age (Ab -if
cessation BF
test) symptoma
-At 18 months of
age (Ab test) tic
- At 18
months of
age (Ab
test)

Note: If the HIV PCR results are inconclusive, repeat HIV PCR and viral load at the earliest
possible opportunity.

19
7.2 Manifestations of HIV Infection and AIDS in Children
Clinical signs and symptoms of HIV infections are useful parameters in making an HIV
diagnosis. In children, these features sometimes overlap with those of other common
childhood diseases. Children with severe or atypical clinical diseases are more likely to be
HIV-infected.
Signs and Conditions Characteristic to HIV Infection:
 Pneumocystis pneumonia
 Oesophageal candidiasis
 Extrapulmonary cryptococcosis
 Lymphoid interstitial pneumonitis
 Herpes zoster (shingles) with multi-dermatomal involvement
 Kaposi’s sarcoma
 Lymphoma
 Progressive multifocal encephalopathy
 Signs and Conditions Common in HIV-Infected Children
 Severe bacterial infections, particularly if recurrent
 Persistent or recurrent oral thrush
 Bilateral painless persistent parotid enlargement
 Generalized persistent non-inguinal lymphadenopathy
 Hepatosplenomegaly (in non-malaria endemic areas)
 Persistent and/or recurrent fever
 Neurologic dysfunction
 Herpes zoster (shingles), single dermatome
 Persistent generalized dermatitis unresponsive to treatment
 Signs and Conditions Common in both HIV-Infected and Non-Infected Children
 Chronic, recurrent otitis with ear discharge
 Persistent or recurrent diarrhoea
 Severe pneumonia
 Tuberculosis
 Failure to thrive
 Acute and chronic malnutrition

A presumptive diagnosis of severe HIV infection should be made if the child fulfils the
criteria in Table 7.3.

20
Table 7.3. Criteria for Presumptive Diagnosis of Severe HIV Infection in Infants and
Children <18 Months
A presumptive diagnosis of severe HIV should be made if:
2a. The child is symptomatic
with two or more of the
following:
Oral thrush
Severe pneumonia
Severe sepsis
A child has a positive rapid
HIV antibody test result AND OR
2b. Any child who is
fulfilling WHO stage 3 or 4
criteria

(criteria found in Annex 2,

WHO Clinical Staging for
Children)
Other finding that support the diagnosis of severe HIV infection in an HIV-infected child
include:
Recent HIV-related maternal death; or

Start ART as soon as possible while waiting for DNA PCR results.
Confirm the diagnosis of HIV infection as soon as possible with DNA PCR.

Definition of Symptoms in Table 7.3 above.

Oral thrush: Creamy white-to-yellow soft small plaques on red or normally coloured mucosa
which can often be scraped off (pseudomembranous), or red patches on the tongue, palate or
lining of the mouth, usually painful or tender.
Severe pneumonia: Cough or difficult breathing in a child with chest in drawing, stridor or
any of the IMCI general danger signs, i.e. lethargic or unconscious, not able to drink or
breastfeed, vomiting, and presence or history of convulsions during current illness;
responding to antibiotics.

21
Severe sepsis: Fever or low body temperature in young infant with any severe sign, e.g. fast
breathing, chest in drawing, bulging fontanele, lethargy, reduced movement, not feeding or
sucking breast milk, convulsions.
Note: The HIV status should be confirmed as soon as possible or at 18 months. Presumptive
diagnosis should NOT be done in children older than 18 months of age. In these children,
HIV infection must be confirmed or excluded using widely available antibody tests.

22
Diagnosis using the Integrated Management of Childhood Illnesses (IMCI).
IMCI guidelines are a useful tool at the first level health facility to screen children with
possible HIV infection who need to be referred to HIV testing or that have the test performed
and are referred to care and treatment if they test positive.
IMCI algorithm should not be used for initiation of ARVs in children rather it should be used
to refer children to further HIV evaluation and management.
Any sick child, whether or not qualifying by IMCI algorithm, should as early as possible be
offered HIV testing through PITC service to establish the infection status.
WHO Clinical Staging for Children with Confirmed HIV infection
(Refer to the Annex 2).
Clinical staging is useful for assessment at baseline (at diagnosis of HIV infection), entry into
long-term HIV care and in the follow-up of clients in care and treatment programmes. The
clinical stages have been shown to be related to survival, prognosis and progression of
clinical disease without antiretroviral therapy in adults and children.
7.3 Care and Social Support of HIV Exposed and Infected Children
7.3.1 Management of HIV Exposed Children
HIV exposed child is defined as any child born to or who is being breast-fed by an HIV
infected mother. The HIV exposure stops after complete cessation of breast-feeding.
However, child’s HIV infection can be excluded by an HIV DNA PCR test at six weeks and
at nine months of age; or by rapid HIV antibody test three months after cessation of breast-
feeding and a confirmatory test at 18 months of age.
The HIV-exposure status of all infants attending RCH services should routinely be
established and documented. The counselling of parents on care of infants born by HIV
positive mothers is an essential component of the management of HIV exposed children.
Management strategies include:
 HIV diagnostic testing for the child
 Scheduled clinic visits for care.

Infants of HIV infected mothers should receive prophylactic treatment against PCP and other
opportunistic infections using Cotrimoxazole from 6 weeks of age or at first encounter with
the health care system and continued until HIV infection is excluded. This should be given
orally as per required dosing (see annex 5 paediatric dosing chart).
Mothers should be counselled on the advantages of exclusive breast-feeding, with particular
attention to the risk of mixed feeding. Infants should exclusively breast-feed for the first six
months of life and then continue breast-feeding until 1 year. At six months of life, infants
should begin taking complementary foods. Infants who are HIV positive should continue
breast-feeding for at least two years.
Care for the mother of HIV-exposed children during follow up should always be addressed.
These HIV infected mothers should receive appropriate care and treatment including
psychosocial support.
23
7.3.2 Care of HIV infected children
All children should be assessed for symptoms related to HIV as well as the need for treatment
and prophylaxis for opportunistic infections and other HIV related conditions.
A complete medical and immunization history should be obtained, with particular emphasis
on the suspected mode of HIV transmission, history of ARV exposure (pre-, intra-, post-
partum, and during breast-feeding) and timing of HIV diagnosis. HIV-infected children
should receive routine paediatric care and be monitored for their HIV disease progression.
Baseline laboratory tests should be performed.
Children below the age of five (5) years are considered unstable and should be seen monthly.
Children above 5 years and adolescents should be considered stable if they meet the criteria
for stable clients. At each visit, a complete physical examination should be done, focusing on
assessment and management of intercurrent illness as well as assessment for development of
new WHO stage 3 or 4 clinical conditions, which may indicate treatment failure.
Nutrition, growth and neurodevelopment assessment should be done every visit and
documented in age appropriate monitoring tools.
Doses of prophylactic or treatment medications should be reviewed and adjusted on the basis
of the current weight, compliance and tolerability at every visit.
Medication plans (OI prophylaxis and ARV therapy) need to be discussed intensively with
parents or guardians. It is advisable that one single person in the household is identified as the
consistent care provider responsible for dispensing treatment to the child.
HIV related care needs of parents or guardians themselves need to be discussed and
appropriate referrals made accordingly.
Children using ARVs should be closely monitored at every visit for signs of toxicity (i.e.
clinical or laboratory indications) and adverse events should be properly documented and
reported to the Ministry of Health, Community Development, Gender, Elderly and Children
through adverse drug reaction (ADR) forms.
Counselling and psychosocial support should include the children and be provided in an age
appropriate fashion.

7.4 Prophylactic Treatment of Common Opportunistic Infections

7.4.1 Cotrimoxazole Prophylaxis for Infants, Children and Adolescents Living with HIV
All children younger than five years of age living with HIV should receive Cotrimoxazole
prophylaxis regardless of symptoms or CD4 percentage and should continue until the age of
five years when they can be reassessed.
After five years of age, initiation of Cotrimoxazole prophylaxis is recommended for
symptomatic children (WHO clinical stages 2, 3 or 4) and children with a CD4 cell count of
<350/ cells/mm3.

24
In children older than five years of age, discontinuation can be considered for those with CD4
count above 500/ cells/mm3 and adherent to ART.
Tuberculosis Preventative Therapy is an important component of TB prevention in children
living with HIV. (For further details refer to Chapter 6, Section 6.3.2).

7.5 Clinical Manifestations of Paediatric HIV Infection

7.5.1 Respiratory Conditions in Children with HIV Infection
Pneumonia and chronic lung diseases contribute to the increased morbidity and mortality of
HIV-infected children. The different pulmonary conditions are difficult to differentiate from
each other but are common in immune suppressed children. The most common respiratory
conditions include:
7.5.1.1 Bacterial pneumonia
The common causes of pneumonia include Streptococcus pneumoniae, Haemophilus
influenzae, Staphylococcus aureus, and gram negative bacteria such as Klebsiella pneumonia.
Recurrent bacterial pneumonia suggests immunodeficiency. Further investigations should be
done to exclude TB, LIP, and fungal infections.
Clinical Presentation
History of fever, cough and fast breathing (tachypnoea)
With or without signs of severe pneumonia (chest in drawing, cyanosis and lethargy)
On auscultation of the chest one hears unilateral or bilateral crepitation (crackles), decreased
breath sounds or bronchial breathing
When pulse oximetry is available it may demonstrate hypoxia (02 saturations less than 90% at
room air).
Diagnosis
 Diagnosis of pneumonia is mainly made by medical history and physical examination.
Other laboratory investigations may be of assistance:
 Complete blood counts; raised white blood cells (WBC) with a neutrophilia suggest
bacterial infection.
 A chest x-ray is not necessary for diagnosis of acute pneumonia but may be useful in
ruling out complications or other pulmonary conditions
 Because symptoms of pneumonia and malaria may overlap, in malaria endemic areas
remember to do a malarial smear and treat for malaria if indicated
 Blood cultures can assist in identifying the causative agent
 Sputum induction and nasopharyngeal aspirate may assist in the diagnosis of TB or
PCP

Management of pneumonia at outpatient level

Management should follow national/ IMCI guidelines but include the following:

25
  Oral Amoxicillin 40mg/kg/dose BD for 5 days.
 For children above 5 years, atypical pneumonia should be considered (e.g.
mycoplasma) give macrolides as drug of choice Azithromycin 10mg/kg orally OD 5
days or Erythromycin 12.5mg/kg orally QID for 5 days.
 Co-trimoxazole should not be used to treat pneumonia unless PCP is suspected. If
PCP is suspected, then high dose Co-trimoxazole should be used.
 Give paracetamol for fever.
 Cough syrups have no added value and are not indicated

Management of severe pneumonia

Severe pneumonia should be managed in hospital and should include both supportive and
specific therapy.
Supportive Care
 Pulse oximetry is critical for the assessment of 02 saturations and if below 90%,
oxygen should be supplemented. If pulse oximetry is not available, children
presenting with chest in drawing, cyanosis or hypoxia need supplemental oxygen.
 Ensure adequate hydration (either IV or oral depending on the severity) and monitor
for signs of dehydration or over hydration.
 Remember to give paracetamol for fever and pain.
 Ensure adequate feeding, if necessary by naso-gastric tube.

Specific therapy:
 Give Ampicillin 50 mg/kg IV or IM every 6 h for at least 7 days and Gentamicin 7.5
mg/kg IV or IM once a day for at least 7 days.
 If the child does not show signs of improvement within 48 hours switch to ceftriaxone
(80 mg/kg IV or IM once daily)
 Antibiotic therapy for HIV-infected children needs to be longer 7-14 days
 If an infant is HIV exposed or infected and suspected to have PCP add high dose
Cotrimoxazole IV or Orally 8mg/kg of Trimethoprim and 40mg/kg of
sulfamethoxazole every 8 hours for 21 days. Steroids can be prescribed in case of
severe respiratory distress.
 Children treated for PCP should continue taking CPT prophylaxis until the diagnosis
of HIV infection has been excluded and all HIV exposure has ended.
 If pneumonia is associated with typical Staphylococcal skin lesions, a positive blood
culture for Staphylococcus aureus, and poor response to 1st line antibiotics, or if the
child just had measles, consider staphylococcal pneumonia. A chest X-ray (if
available) may show pneumatoceles (very small cavities). For such children,
treatment should also include clindamycin or vancomycin.

7.5.1.2 Lymphocytic Interstitial Pneumonitis

26
Lymphocytic Interstitial Pneumonitis (LIP) usually occurs in children more than one year of
age and is often mistaken for pulmonary TB. Diagnosis is usually by exclusion. The
following are common clinical symptoms:
 Clinical signs and symptoms
 Chronic cough
 Cyanosis
Digital/finger clubbing
Difficulty in breathing
 May be associated with parotitis, generalised lymphadenopathy and
hepatosplenomegaly
 Poor response to TB therapy.
 Radiological picture (Chest X-ray)
 Diffuse bilateral reticulonodular infiltrates may appear similar to miliary TB
 May develop consolidation, cystic lesions; bilateral hilar or mediastinal lymph node
enlargement
 Particularly difficult to differentiate from TB.

Management
Management of children with LIP, after exclusion of TB, includes the following:
 Antiretroviral therapy as specific therapy
 Steroids are needed when children with LIP having respiratory distress
 Prednisone 2 mg/kg/day - initially for 2 weeks daily and then decrease the dose over 2
to 4 weeks, depending on the response to treatment. When giving steroids, monitor
closely for symptoms and signs of untreated TB as steroids can reactivate TB
 Oxygen therapy during episodes of hypoxia
 Bronchodilators such as salbutamol where there is wheezing
 Antibiotics are needed during episodes of concurrent superinfection with pneumonia
 Chest physiotherapy and postural drainage if there is secondary bronchiectasis
 Supportive care includes correction of anaemia with iron supplementation
 Consult or refer to specialist care if the child shows poor response to treatment.

7.5.1.3 Pneumocystis Jiroveci Pneumonia

Pneumocystis Jiroveci Pneumonia (PCP) is the major cause of severe pneumonia and death in
HIV infected infants. The incidence is highest during the first year of life and usually peaks at
3 to 6 months of age. Infants may be in a good nutritional state and may have no clinical
features that indicate the presence of HIV.
Clinical features
 No or low grade fever
 Marked respiratory distress (chest in drawing, cyanosis, inability to drink)

27
  On auscultation clear chest or diffuse fine crepitating
 Poor response to standard antibiotic treatment
 Severe persistent cyanosis/hypoxia (SPO2< 90%)
 They may have other signs of HIV including hepatosplenomegaly, oral thrush,
lymphadenopathy.

Investigations
The mainstay of PCP diagnosis in Tanzania is clinical therefore where there is a high index of
suspicion, clinicians should promptly initiate therapy along with treatment for bacterial
pneumonia.
 A chest x-ray may show hyperinflation, diffuse infiltrates or normal
 Sputum induction with nasopharyngeal aspirate stained with Giemsa or Silver or
immunofluorescent stains
 Bronchoalveolar lavage where available can also be used to produce a specimen for
staining.

Management of PCP
Management of PCP includes both specific and supportive treatment:
Specific:
 High dose cotrimoxazole (CTX) IV (or oral) 8mg/kg TMP-40mg/kg
sulfamethoxazole given every 8 hours for 21 days
 Prednisone at 1- 2mg/kg/day for 7-14 day (taper if given for more than 7days)
 Secondary prophylaxis using cotrimoxazole after an acute episode of PCP

Supportive:
 Oxygen therapy
 Maintain and monitor hydration
 Antipyretic if there is fever
 Continue therapy for bacterial pneumonia
 Nutrition support

7.5.2. Tuberculosis in children

HIV-infected children should be evaluated for TB disease at the time of their HIV diagnosis
and any time they present with symptoms suggestive of TB or have a history of a new contact
to an adult with TB. There is a considerable overlap of clinical and radiological findings of
PTB and other forms of HIV-related lung diseases and malnutrition. TB in children is
discussed in detail in Section 8.5 of this guideline.
7.5.3 Diarrhoea

28
Diarrhoea is one of the most common causes of under -5 mortality. Diarrhoea illness is more
frequent in HIV-infected children, it tends to be more severe and prolonged, and it is often
associated with other co-morbid conditions, including severe acute malnutrition and
pneumonia.
Causative organisms are similar to those in otherwise healthy children (i.e. Rotavirus,
Enterobacter, E. coli, Salmonella species, etc). Persistent diarrhoea (>14 days) is more
common among children with more severe immune suppression.
Acute and chronic diarrhoea with or without dehydration should be managed according to
IMCI guidelines as in all children. Rehydration with ORS is the first priority. Antibiotics
should be used where indicated. Caregivers should be counselled about the management and
hygiene (hand washing, safe water). In case of persistent diarrhoea other causes should be
excluded.
A careful feeding history is essential in the management of a child with diarrhoea. Inquiries
should also be made about: frequency of stools, number of days of diarrhoea, blood in stools,
report of a cholera outbreak in the area, recent antibiotic or other drug treatment, and attacks
of crying with pallor in an infant.
Note:
 Acute watery diarrhoea – non-bloody diarrhoea lasting <14 days
 Dysentery – diarrhoea with visible blood mixed in stools
 Persistent diarrhoea – diarrhoea lasting >14 days

Investigations
 Stool microscopy
 Stool culture/sensitivities if available
 May be particularly useful for persistent diarrhoea.

Management
 Management of diarrhoea in HIV-exposed and HIV-infected children should
generally be the same as for HIV-uninfected children
 Dehydration status should be assessed and managed according to WHO/IMCI
guidelines
 Elemental zinc supplementation is recommended for 10–14 days, with increased
fluids and continued feeding, for all children with diarrhoea (10 mg per day for
infants under six months of age, 20mg per day for infants and children over sixxx
months).
 Emphasize continued or increased feeding during and after the diarrhoea episode
 Ciprofloxacin 15mg/kg BD for three days is recommended for treatment of bloody
diarrhoea.
 Daily micronutrients and multivitamins are recommended for two weeks for all
infants and children with persistent diarrhoea.

7.5.4 Oral candidiasis

29
Oral candidiasis or thrush is a very common presentation of HIV in children, and persistent or
recurrent outside of the neonatal period is a WHO Clinical Stage III condition.
Management:
 2% Miconazole oral gel 5mls BID for two weeks
 Nystatin suspension for minimum of two weeks
 Infants –100,000 units in every six hours
 Children – 400,000 – 600,000 units in every six hours

7.5.5 Esophageal candidiasis

Clinical features
 Usually associated with extensive oral thrush
 Infants and young children - present with refusal to feed and crying during feeds
 Older children – pain with swallowing
 Vomiting

Management
 Fluconazole 3-6 mg/kg orally once daily for 2 weeks

If the child is not responding to oral formulation or unable to tolerate oral medications or at
risk of disseminated candidiasis, IV fluconazole (3-6mg/kg once daily) can be prescribed
Otitis media
Inflammatory condition of the middle ear cavity; if untreated can lead to hearing loss.
7.5.6 Acute otitis media
Purulent exudates in the middle ear cavity with or without ear discharge lasting less than 14
days.
Clinical features
 Otalgia (painful ear)
 Ear discharge
 Fever
 With an evidence of inflamed and bulging tympanic membrane on otoscopy

Investigation
If there is ear discharge: ear swab for gram stain, culture and sensitivity
Management
 Oral Amoxicilin 40mg/kg BD for 5 days or

30
  Oral Azithromycin 10mg/kg OD for three days and oral Paracetamol 15mg/kg TID
for three days.

7.5.6 Suppurative (Chronic) otitis media (draining ears)

Recurrent/persistent suppurative (draining) ears are very common presentation of HIV-
infection in children and should be an indication for HIV-testing in children with unknown
status.
Clinical features
 Ear discharge
 With an evidence of perforated tympanic membrane.

Investigation
 Ear swab for gram stain culture and sensitivity.

Management
 Ear wicking
 Ciprofloxacin 0.3% ear drops three time a day —use immediately after wicking
 Keep ear upright for 15 minutes after drops
 Give oral cefalexin 12.5mg/kg (max dose 25mg/kg) BID for 10 days.

7.5.7 Skin manifestations

Rashes and other skin problems are a common manifestation of HIV in children. Examples
include papular pruritic eruption (PPE), tinea corporis, warts and herpes zoster.
7.5.7.1 Herpes Zoster
Symptoms include pain and fever followed by vesicular rash over a dermatome. For more
details, refer to Section 6.4.1.
Management
 Acyclovir 20mg/kg/dose po or IV 6 hourly per day for 7 days
 Apply Acyclovir cream 5% to the lesions every 6 hours or apply zinc oxide 5% 12
hourly
 Give gabapentine 5mg/kg orally 8 hourly for 2 weeks
 If infected add flucloxacillin po 25mg/kg/dose 6 hourly per day for 7 days.
 Paracetamol for pain.

7.5.7.2 Kaposi sarcoma (KS)

Though not as common as in adults, children do get Kaposi sarcoma. The presentation
includes purple plaques on the skin and mucous membranes, especially the palate, nodular
skin disease, lymphatic involvement with “woody” edema, and less commonly visceral and
pulmonary presentations. However, children are also likely to present with enlargement of

31
lymph nodes and may have enlarged lymph nodes as their only presenting symptom of
Kaposi sarcoma.
Management
 Children with KS should be referred to specialty centres for chemotherapy; the
response tends to be good.
 ART should be given.

Note: KS patients can develop IRIS while on ART.

7.5.8 Malnutrition
Childhood acute malnutrition is high among HIV-infected children. Severe wasting is a
common clinical presentation of HIV infection in children. Generally, despite of their HIV
status, children with severe malnutrition are at risk for a number of life-threatening problems
and require urgent and appropriate rehabilitation. HIV-infected children with severe
malnutrition have a higher risk of mortality than uninfected children due to the frequency and
severity of OIs including TB. After their recovery from the initial rehabilitation, HIV infected
children need urgent initiation of ART. Children with an unknown HIV status, who present
with severe malnutrition, should be tested for HIV and be screened for TB.
Clinical presentation of severe malnutrition
Severe malnutrition is characterized by the presence of any of the following: weight/height z
score <-3, severe visible wasting or bilateral pitting edema. SAM is also defined by a MUAC
of <11.5cm in children of 6-59 months of age, MUAC < 13.5 cm in children 5-9 years of age
and <16.0 cm in children of 10-14 years of age.

Management of severe malnutrition

The treatment of severe malnutrition in HIV-infected children is the same as for uninfected
children. Please refer to Guidelines for Integrated Management of Severe Acute Malnutrition
and Community Based Management of Malnutrition for details.
In HIV-infected children, the initial period of stabilization may take longer due to direct
effects of HIV on the gut, appetite suppression or presence of OIs, such as TB that may be
hard to diagnose.

32
 CHAPTER 8
TB AND HIV CO-INFECTION
8.0 Introduction
TB is the most common opportunistic infection and the major cause of deaths among HIV
and AIDS patients. TB and HIV have been declared emergencies demanding global attention.
HIV increases the risk of TB reactivation and progression from TB infection to active
disease. The likelihood of developing TB in an individual who is HIV negative is 5-10%,
while for those who are HIV positive the risk is higher at 20-30%24. On the other hand, TB
increases the risk of progression from HIV to AIDS disease.

8.1 TB Management in HIV and AIDS Patients

8.1.1 Pattern of HIV-related TB
As HIV infection progresses, CD4+ T-Lymphocytes that play an important role in the body’s
defence against tubercle bacilli declines in number and function. Thus, the immune system
fails to prevent the growth and local spread of M. tuberculosis. There are two types of TB:
Pulmonary and Extra pulmonary TB (EPTB) whereby the most common type of TB in HIV
is extra pulmonary TB.
8.1.2. Pulmonary TB
Pulmonary TB (PTB) refers to any bacteriologically confirmed or clinically diagnosed case
of TB involving the lung parenchyma or the tracheobronchial tree. The suspected case can be
diagnosed if one sputum examination is positive for acid-fast bacilli (AFB) by microscopy or
gene X-pert.
AFB negative pulmonary tuberculosis is defined as the presence of at least two sputum
specimens negative for AFB by gene X-pert or microscopy, but with clinical or radiological
features consistent with active tuberculosis. Pulmonary TB can be detected by culture and
sensitivity even if it has not been detected by Gene-Expert or Microscopy.

8.1.3. Extra-pulmonary tuberculosis (EPTB)

EPTB is defined as bacteriologically or clinically confirmed tuberculosis in organs other than
the lungs proven by one specimen from an extra-pulmonary site: culture-positive for
Mycobacterium tuberculosis, AFB positive by gene X-pert or microscopy, histological or
strong clinical evidence consistent with active extra-pulmonary tuberculosis. The most
common forms of EPTB are pleural effusion, lymphadenopathy, pericardial disease, milliary
disease, meningitis, spinal TB (Pott’s disease) and disseminated TB. Other sites of the body

24 Manual for the Management of Tuberculosis and Leprosy, sixth edition, 2013

33
which may be affected by TB include bones other than spine, peripheral joints, adrenal
glands, skin, genito-urinary tract, intestines, peritoneal membrane and upper respiratory tract.
8.1.4. Tuberculosis diagnostic approaches
There are two main approaches for TB diagnosis: Clinical and laboratory.
Clinical diagnosis
Clinical diagnosis involves history taking and physical examination.
History Taking
In clinical diagnosis of TB a careful and extensive history-taking is essential. The health
provider should ask the patient about existing classical symptoms suggestive of TB disease
among adults such as cough of any duration night sweats, fever and weight loss. If coughing,
ask about sputum colour and quantity, history of TB disease and the outcome of treatment,
the presence of other immune compromising medical conditions such as diabetes mellitus,
treatment with immunosuppressants and history of TB contact(s).
The patient should also be asked about: tobacco-smoking, including frequency and duration
of smoking, history of substance abuse (drugs and alcohol) and occupational history that may
suggest exposure to silica dust, especially among miners.
Physical examination
Although no physical sign is sensitive or specific enough for TB, it is critical to assess
patients for fever, look for anaemia, exclude lymphadenopathy, and confirm the presence or
absence of chest and neurological abnormalities and hepato-splenomegaly in order to screen
for co-morbidities and rule out EPTB in all patients, including those with suspected PTB.
Furthermore, advanced HIV patients with TB may present with signs and symptoms of
septicaemia.

Laboratory diagnosis
Early identification and effective treatment of TB cases is important in TB care and control.
Diagnosis of PTB depends on the identification of tubercle bacilli either by sputum
microscopy, or culture and identification of bacterial DNA using molecular techniques (Gene
X-pert).
Sputum smear microscopy
Sputum smear examination is the cornerstone of TB diagnosis. The test is relatively quick,
easy to perform, and inexpensive. The purpose of sputum microscopy is to:
 Diagnose people with active TB in the absence of Gene-Xpert.
 Monitor the progress of treatment.
 Confirm whether cure has been achieved.

34
Sputum culture
Culture is a more sensitive method for detecting Mycobacterium than AFB microscopy and
can detect as low as 10 bacilli/ml of sputum. However, culture methods are slow and
expensive.
Molecular tests
(i)GeneXpert® MTB/RIF Assay. This is a highly sensitive and specific rapid automated
molecular test for the combined detection of TB and rifampicin resistance. WHO;
recommends the use of GeneXpert test as the initial test for PLHIV. However, due to the
limited number of GeneXpert machines and cartridges available in Tanzania it is an initial
test in only health facilities where GeneXpert machines are available. In health facilities
without GeneXpert machines, it is used as a follow-up test for smear-negative HIV-positive,
TB suspects.
(ii) Polymerase chain reaction using strip technology in Line Probe Assay (LPA) for DST.
LPA is used for rapid detection of Rifampicin and Isoniazid resistance, which can occur
within two days, hence facilitating early initiation of correct treatment or appropriate
measures to prevent transmission of MDR TB.

C) New technologies
Urine for TB Lateral Flow Lipoarabinomannan (LAM-Test)
The Lipoarabinomannan (LF-LAM) test is based on the detection component of the cell wall
of mycobacterium in urine and has the potential to be a point-of-care test for TB. It is only
sensitive to advanced HIV disease, and additional testing is needed for confirmation due to
low sensitivity and specificity. Lipoarabinomannan testing is recommended for diagnosis of
TB in HIV-positive patients with either a CD4 count of less than 200 cells/uL or who present
with one of the four danger signs: respiratory rate greater than 30 breaths/minute, temperature
exceeding 39°C, heart rate more than 120 beats/minute, and/or unable to walk unaided
irrespective of CD4 count.
Drug Susceptibility Testing (DST)
Drug susceptibility testing (DST) is the laboratory technique used to determine whether the
mycobacterium isolates from specimen (direct) or culture-based (indirect) are susceptible or
resistant to a TB drug. In Tanzania, DST is done using rapid molecular testing on GeneXpert
platforms (e.g. MTB/RIF, Ultra, and Omni); using first- and second-line LPA, polymerase
chain reaction (PCR), TaqMan™ Array Cards,25 and sequencer; or by culture using solid or
liquid medium.

35
iii) Other relevant investigations for tuberculosis in adults
 Chest X-ray
 Histological examination.

Note: For more details on TB diagnosis please refer to the current NTLP Manual.

8.1.5 Presumptive TB treatment for severely ill patients

Presumptive TB case among PLHIV is defined as individuals suspected of having TB
according to TB screening tool (Annex 7) or with any of the following danger signs:
Respiratory Rate >30 per minute, Temperature >39 degree Celsius, Heart Rate >120 per
minute and unable to walk unaided. Presumptive TB treatment is based on expert opinion
where expedited diagnosis of TB is not possible or feasible due to patient or health system
limitations, but TB investigations should be done even after presumptive TB diagnosis is
made. Treatment should be stopped only upon having proof of a negative TB test or strong
evidence of an alternative diagnosis.

8.1.6 Standard TB Treatment Regimens for adults

There are two phases of TB treatment: initial (intensive) and continual. During the
intensive phase, there is a rapid killing of the TB bacilli. Most patients with smear-
positive TB become non-infectious after about two weeks of effective treatment. During
the continual phase, the drugs kill the remaining bacteria, and prevent relapse after
completion of treatment.

All new or previously treated patients should receive a six-month regimen containing
rifampicin: 2RHZE/4RH. The regimen requires daily observed treatment by a health care
provider or other designated individual, which could include a family member or friend,
throughout the six months.
Standard regimen for previously treated adults other than MDR-TB: All previously treated
TB patients should provide a specimen for rapid molecular testing (GeneXpert MTB/RIF),
where available, and culture and DST. All patients who are rifampicin resistant should
receive MDR-TB treatment in a designated health facility.
Patients who are rifampicin susceptible should be treated with a first-line treatment regimen
containing all four drugs (2RHZE/4RH) while waiting for DST results. In the sites with no
GeneXpert, all previously treated patient specimens should be referred to the nearest facility

36
with GeneXpert. Culture and DST specimens should be submitted to the respective zonal
facility/laboratory.
Previously treated patients who failed treatment (treatment failure) should provide specimen
for Xpert MTB/RIF test and a sputum sample should be sent for culture and DST. In facilities
where a GeneXpert machine is not available, patients should be initiated on first-line TB
treatment while waiting for culture and DST results.

8.1.7 Tuberculosis associated Immune Reconstitution Syndrome

HIV positive patients may experience an occurrence of features of active TB or a temporary
exacerbation of signs and symptoms of TB with or without an aggravated radiographic
manifestation after the initiation of ART. This paradoxical reaction in HIV infected TB
patients is a result of immune reconstitution. Signs and symptoms include fever,
lymphadenopathy, central nervous system lesions and worsening of the chest X-ray
appearance. This syndrome is known as the Immune Inflammatory Reconstitution Syndrome
(IRIS).
In such cases, it is crucial that TB treatment failure is excluded before diagnosing IRIS. The
management includes continuation of both ART and anti-TB therapies, and if severe,
prednisone 1-2 mg/kg for 1-2 weeks can be given (thereafter gradually decreasing dosage).

8.2. Collaborative TB/HIV activities

The MoHCDGEC commits itself to the endeavour of dramatically reducing TB and HIV
morbidity and mortality through comprehensive collaborative TB and HIV activities. The
strategies adopted in these guidelines are in line with global efforts to combat dual TB and
HIV epidemics recommended by the WHO. The strategies take into account the key values of
effectiveness, efficiency, equity, equality, and timeliness of delivery.
The measures being implemented include: Strengthening the mechanisms of collaborations
and joint management between HIV and TB-control programmers for delivering integrated
TB and HIV services; reducing the burden of TB in PLHIV and initiate early Antiretroviral
therapy (the Three I’s for TB and HIV) and reduce the burden of HIV in patients with
presumptive and diagnosed TB. The following collaborative TB and HIV activities are
recommended to be implemented in the country by both HIV and TB programmes:
(i) Strengthen the mechanisms of collaborations and joint management between HIV and TB-
control programmes for delivering integrated TB and HIV services:
 Set up and strengthen a coordinating body for collaborative TB and HIV activities,
functional at all levels
 Determine HIV prevalence among TB patients
 Determine TB prevalence among PLHIV
 Carry out joint TB and HIV planning to integrate the delivery of TB and HIV services
 Engage NGOs and CBOs in implementation of TB and HIV activities

37
  Establish and integrate national M&E system for collaborative TB and HIV activities
that informs both NTLP and NACP annual operational plans
 Address the need of Key populations for TB and HIV

ii) Reduce the burden of TB in PLHIV and initiate early ART (the Three I’s for TB and
HIV):
 Intensify TB case-finding implemented at all HIV care and treatment clinics and all
other healthcare facility settings
 Provide high quality TB treatment for HIV infected TB patients
 Initiate TB Preventive Therapy (TPT) with Isoniazid for both adults and
children.Other alternative short regimens (Rifapentine+INH, Rifampicin+INH) will be
used when available in country.
 Initiate TB prevention through early initiation of ART as per national guidelines
 Ensure control of TB infection in health-care facilities and congregate settings.

iii) Reduce the burden of HIV in patients with presumptive and diagnosed TB:
 Provide HIV testing and counselling to patients with presumptive TB
 Provide HIV testing and counselling to patients diagnosed with drug-sensitive TB and
drug resistant TB
 Provide HIV prevention interventions for patients with presumptive and diagnosed
TB
 Provide co-trimoxazole preventive therapy for TB patients living with HIV (TB
PLHIV)
 Ensure HIV prevention interventions, treatment and care for TB patients living with
HIV
 Provide antiretroviral therapy to TB PLHIV irrespective of CD4 cell count as per
national guidelines.

Since TB is the leading opportunistic infection in HIV, all PLHIV should: be screened for TB
on every clinic visit in order to reduce morbidity and mortality; be provided with TPT to
prevent them from developing active TB depending on eligibility criteria; and observe
principles of TB infection control.
8.2.1 Intensified TB case-finding
Intensified TB case finding involves screening for symptoms and signs of TB in settings
where HIV-infected people are concentrated using standardized TB screening tools (available
for both children and adults) (Annex 7). TB screening promotes early identification of TB
among PLHIV and thus increases access to TB treatment, improves survival and quality of
life and reduces transmission of TB in the community. People with presumptive TB should
undergo diagnostic follow up using the TB diagnostic algorithm.
Furthermore, the diagnosis of childhood TB may be done clinically in the absence of
bacteriological confirmation by using the score chart (Annex 11).

38
8.2.2 TB Preventive Therapy (TPT)
TB Preventive Therapy (TPT) is an intervention that should be part of the package of care for
PLHIV. Currently, TPT involves giving Isoniazid (INH) tablets to eligible individuals in
order to prevent progression to active TB disease. Other alternative short regimens
recommended to be used when available are Rifapentine+INH weekly for 3 months and
Rifampicin+INH daily for 3 months.
Tuberculosis Preventive Therapy (TPT)
In individuals with HIV, IPT reduces the risk of developing tuberculosis for about 60% and
prolongs survival26.
Exclusion of active TB is critically important before this preventive therapy is started.
Isoniazid is given daily for six to nine months and should be given only once in a life time.
This therapy requires consideration of several steps, including identification of HIV-positive
clients, screening in order to exclude active TB, assessing eligibility for IPT and monitoring
of treatment adherence and side effects.

Eligibility for TPT among adults and adolescents

For patients with no history of TB treatment:
All HIV positive individuals who screen negative for active TB are eligible for TPT.
A tuberculin skin test should be performed to all HIV infected individuals wherever possible.
However, tuberculin test may be negative in severely immunocompromised clients due to
cutaneous anergy and should not be used as exclusion criteria for TPT.
For patients with history of TB treatment:
People living with HIV who successfully completed their TB treatment should immediately
receive TPT for six months. It has been shown that PLHIV who receive TPT immediately
after completion of TB treatment have less risk of TB recurrence and mortality.
Other exclusion criteria for TPT include:
 Alcohol abuse
 Non-adherence to long term treatment
 Current / past history of hepatitis
 Medical contra-indication to INH.

26Ayele HT, Mourik MSMv, Debray TPA, Bonten MJM (2015) Isoniazid Prophylactic Therapy for the Prevention
of Tuberculosis in HIV Infected Adults: A Systematic Review and Meta-Analysis of Randomized Trials. PLoS ONE
10(11): e0142290. doi:10.1371/journal.pone.0142290

39
TPT should only be offered in the following situations:
 Where quality supportive counselling is available
 After effective screening for active TB
 Where there is capacity for follow-up and monitoring of patients to encourage
adherence to preventive therapy.
 Where there is capacity to manage side effects and exclude active TB during IPT.

Dosage:
 Isoniazid: 300 mg daily for 6 months to complete one cycle of IPT
 IPT should only be given in one cycle in life time and no repeat cycle is needed.

Note: In case of neuropathy due to INH, Pyridoxine should be used for treatment of
neuropathy.

TPT in pregnancy
The benefits of TB preventive therapy for eligible pregnant women outweigh the risks.
Active TB during pregnancy is associated with spontaneous abortions, and adverse peri-natal
outcomes. Ten percent of maternal deaths in Africa are due to TB/HIV co-infection. TB
Preventive Therapy is not contraindicated in pregnancy and it can be given during any
trimester. TB Preventive Therapy should be completed even if the woman becomes pregnant
while on the medicine.

8.2.3 ART in HIV and TB Co-infected individuals

ART has been reported to reduce TB rates by up to 90% at the individual level, and 60% at
the population level, and also reduces TB recurrence rates by 50%27,28,29. Initiation of ART
for all those with HIV and TB co-infection, if accompanied by high levels of coverage and
ART adherence, it reduces the number of TB cases, TB mortality rates and TB transmission
at the population level.

27 Lawn SD, Myer L, Edwards D et al. Short-term and long-term risk of tuberculosis associated with CD4 cell
recovery during antiretroviral therapy in South Africa. AIDS 2009; 23:1717–25. [PMC free article[PMC free
article][PubMed][PMC free article][PubMed]
28 Gupta A, Wood R, Kaplan R et al. Tuberculosis incidence rates during 8 years of follow-up of an antiretroviral

treatment cohort in South Africa: comparison with rates in the community. PLoS One 2012; 7:e34156. [PMC
free article[PMC free article] [PubMed][PMC free article] [PubMed]
29 Van Rie A, Westreich D, Sanne I. Tuberculosis in patients receiving antiretroviral treatment: incidence, risk

factors, and prevention strategies. J Acquir Immune Defic Syndr 2011; 56:349–55. [PMC free article[PMC free
article][PubMed][PMC free article][PubMed]

40
For TBHIV co-infected individuals who are not on ART at TB diagnosis, TB treatment
should be started first, followed by ART as soon as possible, within the first 2 weeks after
starting TB treatment.
For PLHIV who are already on ART at TB diagnosis, TB treatment should be started
immediately and ART continued as instructed below:
Rifampicin and Nevirapine should not be used concurrently due to drug interactions. PLHIV
diagnosed with TB while on Nevirapine containing regimens should be switched to efavirenz
based regimens
In individuals who need TB treatment and who require an ART regimen containing a boosted
protease inhibitor (PI), it is recommended to use LPV/r double dose (i.e. LPV/r
800mg/200mg twice a day) or with an adjusted, super-boosted dose of RTV (i.e. LPV/r
400mg/ 400mg twice a day) but this is frequently associated with high levels of toxicity and
requires clinical and laboratory monitoring.
NOTE:
Consideration 1: When TB is diagnosed in patients already receiving ART, TB treatment
should be started immediately. There are two issues to consider in such cases: whether ART
needs to be modified because of drug interactions to reduce the potential for overlapping
toxicities, or the presentation of active TB in a patient on ART constitutes ART failure that
requires a change on the ART regimen.

Consideration 2: When TB is diagnosed in PLHIV who are already on ART and Medically
Assisted Therapy using Methadone, Rifampicin decreases Methadone level by 33% to 68%
and hence the Methadone dose increase may be required30.

8.3.4 TB Infection in health-care facilities and congregate settings

TB infection control should be implemented in health care facilities and congregate settings
where people with TB and HIV are frequently confined. Measures to reduce TB transmission
include administrative, environmental, and personal protection measures, which are generally
aimed at reducing exposure to M. tuberculosis among healthcare workers, prison staff, police
officers and their clients, and other persons in the congregate settings.
8.3.4.1 Administrative measures
Administrative measures should include early recognition, diagnosis, and treatment of TB
patients, particularly those with pulmonary TB, and quarantine of suspected pulmonary TB

30HIV AND AIDS Treatment and Care for Injecting drug users. Clinical Protocol for WHO European Region 2007.

41
patients until a diagnosis is confirmed or excluded. Specifically, administrative measures
include:
 Early identification of TB patients and reduction of TB transmission.
 All clients should be screened for TB as soon as they arrive at the facility to identify
those with at least one TB symptom.
 In outpatient departments, coughing patients should wait in well-ventilated areas.
 TB suspects need to be examined in a well-ventilated room.
 Have patients turn their heads and cover their mouths when they cough.
 Avoid contact between TB and HIV positive patients by separating them.

Separation of TB patients from HIV patients can be done through one of the following
modalities:
 If TB clinic is providing ART, channel PTB and HIV co-infected patients to the TB
clinic where they should receive TB and HIV care, treatment (anti TB
treatment/CPT/ART) and adherence counselling; refer them to CTC at the end the TB
treatment to ensure continuum of care (general HIV care, CPT, ARV provision, HBC,
etc)4.
 If the TB clinic is not providing ART, evaluate PTB and HIV co-infected patients at
CTC on separate days to avoid sharing the same waiting area with PLHIV.
 If volunteers living with HIV (e.g. peer educators) are working at the HF level (e.g.
CTC), they should be informed about the risk of developing TB and they should avoid
accompanying TB suspects/patients.31

Clinic operating procedure:

Patients who report at CTC for registration should be observed and be probed on coughing
and if so they should immediately be sent to the laboratory for sputum sample and return
back to CTC for registration and care.
TB infection control plan:
Every health facility needs to have TB infection plan which is to be reviewed at least once
every year. TB infection control plan should contain information regarding TB control in the
respective health facility. Moreover, every health facility needs to have TB infection focal
person to oversee implementation of TB infection control measures.
8.3.4.2 Environmental control measures
Environmental protection should include maximizing natural ventilation and direct sunlight.
This is the second line of defence for preventing the spread of TB in HIV care settings. If the

31Guidelines for Tuberculosis Infection Control in health care facilities, MOHSW Tanzania,2010

42
work practice controls are inadequate, environmental control will not eliminate the risk of TB
spread. The common control measures include:
 Open doors and windows to allow cross air ventilation.
 Waiting places and examination rooms designed in a manner that they have maximum
natural ventilation. Fans may also assist in the process of air circulation.
 Collection of sputum for TB should be done in an open environment and away from
other people, not in small rooms or other enclosed places.

8.3.4.3 Personal protective measures

Personal protective measures protect healthcare workers, patients and family members in
areas where the concentration of droplet nuclei cannot be adequately reduced by
administrative and environmental control measures. These measures prevent the spread of TB
infection and shield healthcare workers from possible exposure to TB infection.
Protection of healthcare workers:
 Respiratory protective equipment is an additional measure to protect HCWs from
inhaling infectious droplet nuclei expelled out into the air by a patient with infectious
TB disease.
 Personal protective measures should ONLY be used in situations where there is an
increased risk of transmission.
 Respirators are among the equipment and interventions used to protect personnel who
must work in environments with contaminated air. In Tanzania they are recommended
to be used when providing care to infectious MDR-TB and XDR-TB patients or
people suspected of having infectious smear positive MDR-TB or XDR-TB.
 The primary way to prevent transmission of TB to health workers and others at the
health facility is for TB patients to take their medicines regularly. By doing so, they
will become non-infectious in a week or two. Proper ventilation of the place where
treatment is provided is also very important.

In addition:
All healthcare workers should be made aware of the increased risk of developing TB when
they are HIV positive.
Those working in hospital departments where TB patients are admitted should be advised to
test for HIV. If they test positive, they should avoid contact with presumptive TB and
confirmed TB patients.
Normal masks do not protect medical staff against inhaling infected droplets and are
therefore not recommended as preventive measures for healthcare workers.

43
8.4 HIV-related TB in Children
The natural history of TB in a child infected with HIV is similar to that of an adult as it
depends on the stage of HIV disease, nutritional status and exposure to TB infections. During
early stages of HIV infection when immunity is good, the signs and symptoms of TB are
similar to those in a child without HIV infection. As HIV infection progresses and immunity
declines, dissemination of TB becomes more common and TB meningitis, miliary TB, and
widespread tuberculosis lymphadenopathy may occur.

8.3.1 Prevention of TB in children

i) BCG vaccination
In HIV positive neonates, BCG rarely causes disseminated infection of M. bovis and if it
occurs it should be treated with 2{RH} E/4RH. The WHO recommends that in countries like
Tanzania where there is a high prevalence of tuberculosis, BCG should be given to all
neonates immediately after birth, regardless of HIV status. The possible benefits of BCG
outweigh the possible disadvantages. However, BCG should not be given to children who
present with clear signs and symptoms of HIV-disease or AIDS.
TPT in children
TPT in children is achieved by administering Isoniazid in order to prevent active TB, children
should be considered for Isoniazid as follows:
 All new born without signs and symptoms of active TB disease that is born to mothers
with active TB disease
 All under 12 months HIV-infected children without signs and symptoms of active TB
disease and with a known TB contact
 All HIV-infected children who are 12 months or older with no signs and symptoms of
active TB disease.

Explain to the child (if age appropriate) and parent/caregiver that treatment with the medicine
Isoniazid is essential to prevent the child from becoming sick due to TB disease. Describe the
potential side effects and that they should return to the clinic whenever any adverse reactions
occur.
Emphasize to the parent/caregiver and/or child that:
The full duration of treatment is 6 months to complete one cycle of TPT (TPT should be
given only once in a life time and no repeat cycle is needed). The child must adhere to and
complete their treatment.
The child should return to clinic if they feel ill whilst on TPT, or if they develop TB
symptoms such as cough, fever, and poor appetite.
The parent/caregiver does not need to limit the child’s activities in any way.
Dosage:
Isoniazid: 10 mg/kg (10-15 mg/kg) daily for six months.

44
 Note: IPT should be initiated only after TB disease has been ruled out. Neuropathy due to
INH should be treated with pyridoxine.

8.4.2 Diagnosis of Tuberculosis in Children

The diagnosis of TB in children can be very difficult due to a wide range of symptoms.
Sputum can hardly be obtained from children and is often negative even on culture. Signs and
symptoms of TB in children are atypical. The diagnosis should therefore be based on at least
one of the following: clinical findings especially when there is failure to thrive or weight loss;
family history of TB contact; X-ray examination; tuberculin testing; culture results; and non-
response to broad spectrum antibiotic treatment. A score chart can help to reach the diagnosis
of tuberculosis. Older children who are able to cough up sputum should go through the same
assessment as adults using Gene-Expert as the “gold standard” test.

Treatment of TB in children
Treatment regimens for tuberculosis disease
Treatment of TB disease in children requires multidrug combination therapy. Anti-TB
drugs have a synergistic effect on each other; their combined actions produce a greater
effect than the sum of the individual medications.
In general, paediatric treatment regimens are comparable to adult regimens. Because TB
in young children can rapidly disseminate with serious sequelae, prompt initiation of
therapy is critical. Appropriate regimens, dosing, and duration are outlined in Table 8.1
and 8.2 below:
Table 8.1. Recommended treatment regimens for paediatric patients in Tanzania
Recommended regimen
TB disease category Intensive phase Continuation phase

All forms of pulmonary and 2 months of daily 4 months of daily RH

extrapulmonary TB (except TBRHZE
meningitis and TB of the spine/
bones/joints) and Previously treated
bacteriologically confirmed TB cases
(relapse, return after lost to follow-up
and treatment failure, other previously
treated )**

TB meningitis; miliary TB*; TB of 2 months of daily 10 months of daily RH

the spine/bones/joints RHZE
MDR TB See Annex 9.1 “Drug-resistant tuberculosis in
children”
E: Ethambutol; H: Isoniazid; R: Rifampicin; Z: Pyrazinamide.

45
*30 percent of children with a miliary picture on chest radiography have central nervous
system involvement and should be treated with a 12-month regimen (see “Tuberculosis
meningitis” on Section ...).
**All previously treated TB cases should be evaluated for MDR TB by sending samples
for culture and drug susceptibility testing. Relapse cases are those who have been
previously treated for TB, were declared cured or treatment completed at the end of the
most recent treatment episode, and a new diagnosed with a recurrent episode of TB
(either a true relapse or a new episode of TB caused by re-infection).
Note: If an adolescent is pregnant, refer to the section in the adult guidelines on treatment
of TB in pregnancy.
Adapted from: Graham SM et al. Desk-Guide for Diagnosis and Management of TB in
Children. Paris, France: International Union Against Tuberculosis and Lung Disease;
2010; and Definitions and reporting framework for tuberculosis – 2013 revision
(updated December 2014), WHO/HTM/TB/2013.2.

Medications and dosages

 To treat children with TB, calculate all anti-TB medicine doses by weight and use
FDC tablets. It is important to weigh the child at each visit and adjust medication
dosages as needed. Anti-TB medications, daily dose and range, maximum dose,
and potential adverse reactions are provided in Table 8.2below.
 If available, give Pyridoxine supplementation to children receiving TB treatment at
a prophylactic dosage of 1-2 mg/kg per day.

Table 8.2. Drug dosing and adverse reactions for the treatment of TB in children
Drug Daily dose Maximum Adverse reactions
and range daily dose
mg/kg
Isoniazid 10 (7-15) 300 mg Mild hepatic enzyme elevation, hepatitis,
peripheral neuritis, hypersensitivity
Rifampicin 15 (10-20) 600 mg Orange discoloration of secretions or
urine, vomiting, hepatitis, influenza-like
reaction, thrombocytopenia, pruritus
Pyrazinamide 35 (30-40) - Hepatotoxic effects, hyperuricemia,
arthralgias, gastrointestinal tract upset
Ethambutol 20 (15-25) - Optic neuritis (usually reversible),
decreased red-green colour
discrimination, gastrointestinal tract
disturbances, hypersensitivity

46
Adapted from WHO, Stop TB Department. Rapid Advice: Treatment of Tuberculosis in
Children. WHO/HTM/TB/2010.13; and WHO, 2014. Guidance for National TB
Programmes on the Management of TB in Children, 2nd Edition.

Fixed-dose combination tablets

Use FDC tablets whenever possible to facilitate adherence and simplify regimens. The
FDCs available for use in children in Tanzania include Rifampicin, Isoniazid, and
Pyrazinamide (R/H/Z, 75/50/150mg) and Rifampicin and Isoniazid (R/H, 75/50mg).
Children below 25kg body weight will need to receive Ethambutol as a separate
medication, but older children weighing 25kg and above can be treated using adult FDC
tablets of Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol (RHZE,
300/150/400/275mg). Table 8.3 lists the paediatric FDC dosage needed to achieve the
correct dose by weight in children <25kg.
Guidelines for using TB dosing charts:
 If the child is less than 25kg: use paediatric FDC dosing chart (Table 3.3)
 If the child is ≥25kg: use adult FDC dosing chart (see NTLP Manual).

Table 8.3. Weight-based dosing of anti-TB drugs for children (0-24.9kg body weight)
Intensive phase * Continuation phase
(2 months) (4 months)
RHZ (paediatric) Ethambutol RH (paediatric)
Weight (kg)
75/50/150mg 100mg 75/50mg
<4kg** For infants below 4 kg, consult a paediatric specialist, DTLC, and
RTLC for treatment advice
4-7.9kg 1 tablet 1 tablet 1 tablet
8-11.9kg 2 tablets 2 tablets 2 tablets
12-15.9kg 3 tablets 3 tablets 3 tablets
16-24.9kg 4 tablets 4 tablets 4 tablets
≥25kg use adult FDCs
H: Isoniazid; R: Rifampicin; Z: Pyrazinamide.
*WHO recommends four-drug therapy during the intensive phase for all children.
**For children <4kg, recommend referral to paediatric specialist/DTLC/RTLC to assist with
dosing and treatment in this high-risk group.
Note: For more details, refer to the National Guidelines for the Management of Tuberculosis
in Children, 2018.
8.4.4 ART in HIV infected infants and children on TB treatment

47
For HIV infected infants and children below three years old, if on NVP- based regimen,
continue NVP ensuring that dose is 200mg/m2 (optimized dose), and if on LPV/r based
regimen double the dose of LPV/r.
For HIV infected infants and children above three years old: It is recommended to give 2
NRTIs with EFV and if on LPV/r-based regimen double the dose of LPV/r.

8.5 Drug Resistant TB

This is a form of TB on which first-line anti-TB drugs have little or no effect. The diagnosis
is confirmed through DST using molecular and/or phenotypic tests of M. tuberculosis strains.
All MTB detected as rifampicin-resistant cases should have specimen sent to a zonal TB
laboratory for first- and second-line LPA, culture, and DST.
8.5.1 Identification of presumptive drug-resistant TB patients
The following patient groups are at high risk for DR-TB and should have their sputum
specimen sent immediately for molecular testing, culture, and DST:
 Treatment failure after using first-line anti-TB medicines
 Close contact of a known DR-TB case
 Patients who remain sputum smear-positive after completion of Intensive Phase of
first-line anti-TB drug regimen
 Relapse and return after loss to follow-up, without recent treatment failure
 HCWs presenting with TB symptoms
 Vulnerable groups in congregate settings (prisoners, urban poor, miners, people who
use drugs)
 Patients who have a contact who died while on DOT for TB
 Residents or migrants from high MDR-TB burden settings who presents with TB
symptoms.

Patients found to have RR-TB or MDR-TB at any point in time should be started on an
adequate second-line drug regimen. The treatment of DR-TB involves standardised and
individualised approaches consisting of intensive and continuation phases. For further details,
refer to Chapter 9 in TB and Leprosy Manual 7th Edition, 2019.

48
CHAPTER 9: PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV
9.0 Introduction
The Prevention of Mother to Child Transmission of HIV (PMTCT) services have been
implemented in the country since 2000. In 2012, Tanzania adopted the global plan for
elimination of HIV infection among children born to HIV-infected mothers and keeping their
mothers alive. The goal of the national elimination of Mother to Child Transmission of HIV
(e-MTCT) plan was to reduce vertical transmission rate from 26% in 2010 to 4% by the end
of 2015. To further expedite progress towards the set target, in 2013, Tanzania adopted the
WHO recommendation of providing Life Long ART to pregnant and Lactating women living
with HIV (LLAPLa), using a fixed dose combination regimen of one pill once per day (also
known as Option B+). By December 2014, countrywide LLAPLa rollout was achieved.
Ostensibly, the programme will contribute towards achieving the 90, 90, 90 goal by 2030.
Moreover, there has been emerging evidences resulting into various WHO recommendations
that are geared to help programmes deliver services closer to people; integrate HIV treatment
in RMNCAH, Tuberculosis and other services; and use a wide range of health workers to
administer treatment and follow up care.
The programme is keen at adapting or adopting guidance that keep up with the latest
scientific evidence and enables services to be delivered equitably and sustainably to all
populations across the country.
Tanzania has a policy of screening all pregnant women for HIV and syphilis at the first
antenatal care visit. Of recent, WHO recommended the HIV/Syphilis Duo test for countries
committed to eliminate mother to child transmission (e-MTCT) of HIV and Syphilis. The
country is planning to start implementing Duo test in phases using the experience gained
from a pilot carried out in Shinyanga region. The implementation will involve altering the
National testing algorithm, procurement of kits revisions of the capacity building materials,
and the feasibility assessment
In addition, the country plans to introduce gradually the PCR test at birth for HIV exposed
infants who are identified as high risk. This will go hand in hand with the scale up of Point of
Care (POC) testing technologies in order to expand HIV early testing within districts with
high volume of HIV+ pregnant women and/or districts with logistical challenges for
conventional HIV testing technologies. Health facilities with at least 30 HIV+ pregnant
women in a year will be targeted and perform PCR at birth to HIV exposed infants who have
identified as high risk. This is expected to capture more children who need ART much earlier
and put them on care.
9.1 Basic facts about mother-to-child transmission of HIV
Mother-to-child transmission (MTCT) of HIV refers to the transmission of HIV infections
from HIV-infected mothers to their infants. MTCT can occur during pregnancy, labour and
delivery, and breast-feeding. Without intervention, the overall risk of MTCT is approximately
20% to 45%. Transmission of HIV from mother to her child accounts for over 90% (find
current data) of all HIV infections in children aged below 15 years.

49
Figure 9.1: Estimated HIV outcomes for infants born to mothers living with HIV

55–80 infants
100 infants born to HIV-infected
will NOT be
mothers who breastfeed
HIV-infected

10-15 10-15 5-20

infants infants
infants
infected
infected during infected
labour during
during
and breast-
pregnancy delivery
feeding

25-50 infants will be HIV-infected

There are multiple risk factors that increase the chance of a mother in transmitting HIV to her
child:
 High maternal viral load and low CD4 cell count, which occurs in newly infected
individuals, individuals with suboptimal HIV treatment adherence or response and in
advanced stages of HIV disease (AIDS).
 Virulence of viral subtypes and strains impacts MTCT, rates are higher with HIV-1
than with HIV-2 infections.

Obstetric and neonatal risk factors, as outlined in Table 9.1 below:

Table 9.1: Viral factors, maternal conditions, and obstetric interventions that may increase the
risk of HIV transmission
During Pregnancy During Labour and delivery When Breast-feeding

50
High maternal viral load High maternal viral load and High maternal viral load and low
and low CD4 cell count low CD4 cell count CD4 cell count
Viral, bacterial or Chorioamnionitis (from Oral disease in the infant (e.g.
parasitic placental untreated STIs or other mouth sores)
infections (e.g. Malaria) infections)
Breast abscesses, nipple fissures,
Sexually transmitted Rupture of membranes for and mastitis
Infections (STIs) more than 4 hours before
Duration of breast-feeding
delivery
Mixed feeding (i.e. breast-feeding
Prolonged labour
combined with other foods or
fluids) before 6 months of age

9.2 Goal of Tanzania’s PMTCT programme

The goal of the PMTCT programme is to attain virtual elimination of MTCT of HIV while
improving care for infected parents and children, hence contributing towards the 90, 90, 90,
Goal by 2030. The programme has the following objectives:
 Increase the proportion of pregnant women and breast-feeding mothers who know
their HIV status
 Increase the proportion of HIV positive pregnant and breast-feeding women who
receive ARVs
 Ensure access to care and treatment for mothers and babies living with HIV
 Improve child survival among HIV posed and infected children.

Note: Virtual elimination refers to 90% reduction in estimated number of new infections in
infants; and an MTCT rate of <5%, which is associated with at least 90% of all the HIV
exposed infants being alive and uninfected with the virus at the age of two years.
9.3 Four elements of a comprehensive approach to PMTCT
A comprehensive approach to PMTCT consists of four elements that guide interventions:
Four elements of a comprehensive approach
1. Primary prevention of HIV among women of childbearing age and their partners
2. Prevention of unintended pregnancies amongst women living with HIV
3. Prevention of vertical transmission of HIV from mothers to their infants
4. Provision of treatment, care and support to women living with HIV and their partners,
infants, and families.

51
9.3.1. Primary prevention of HIV among women and their partners
Primary prevention is the most effective means to control the spread of HIV and minimize its
impact on individuals, families, and communities. Preventing HIV infection in women of
childbearing age is the best way to prevent MTCT.

Practice Points
1 Healthcare workers at RCH clinics should ensure that HIV testing and counselling is
integrated and offered to all women of childbearing age, their partners, and children whose
mothers are HIV positive or mothers with unknown status.
2 Sexually active women and men should be encouraged to use safer sex practices including
barrier methods such as condom use, reduce the number of sexual partners, and stay faithful
to their sexual partners.
3 All health care providers should emphasize early diagnosis and treatment of STIs in their
practices.

Preventing and treating STIs is an important component in HIV prevention. Co-infection with
an STI increases risk of HIV acquisition significantly. All healthcare providers should
emphasize early diagnosis and treatment of STIs in their practices. Young people should be
provided with information about and access to HIV prevention services and should be
encouraged to abstain from sexual activity until they can make responsible decisions.
Treating HIV-infected individuals with ARVs can also help prevent transmission of the virus
to their partners or spouses.
Another basic effort in HIV prevention involves preventing the spread of HIV in health care
settings. All facilities in Tanzania should use Standard Precautions to prevent transmission of
HIV.
9.3.2. Prevention of unintended pregnancies among women infected with HIV
Family planning is part of a comprehensive public health strategy to prevent MTCT. All
women living with HIV and their partners should receive family planning counselling and
should be empowered to access and utilize effective contraceptive methods in order to avoid
unplanned pregnancies. A woman’s/couple’s choice of contraceptive methods should be
based on her health status and personal preference. The contraceptive option of her/their
choice should be provided on site or through referral to the nearest facility when the method
of choice is not available.
Dual protection is the simultaneous prevention of Sexual transmitted infections (including
HIV) and unwanted pregnancy). For example, the use of condoms alone (male or female) or
condom with any other method of contraception would provide dual protection.
9.3.3. Interventions to prevent HIV transmission from mothers to their Infants
The PMTCT program offers a range of services and interventions that can reduce the risk of
MTCT. These include HIV education, testing and counselling for pregnant and breast-feeding
women and their partners, antiretroviral treatment (ART) and prophylaxis to HIV exposed
infants, safer delivery practices, and counselling on safer infant feeding and care of the HIV-
exposed infant.

52
 9.3.4. Treatment, care and support for HIV-infected women and their families
Providing HIV treatment, care and support is critical for enabling pregnant women living
with HIV to address their health needs and ensure the well-being of their children and
families. The PMTCT programme should strive to provide comprehensive HIV care and
treatment services, and when this cannot be provided in RCH clinics it is important to
strengthen coordinated referral systems to ensure that women and their families have access
to comprehensive HIV care services at appropriate clinics.
In the context of treat all, lifelong ART is recommended for all pregnant women living with
HIV and breast-feeding women regardless of their CD4 cell count or WHO clinical stage or
gestational age. However, all women diagnosed with HIV infections should have their blood
viral load, CD4 cell count checked and clinically evaluated to monitor their progress as they
start ART. It is important that viral suppression is attained before delivery to ensure maximal
reduction of MTCT; hence the need of frequent HVL monitoring. Care and treatment services
to pregnant and breast-feeding women living with HIV should be provided in RCH settings
or by referral when care and treatment services cannot be provided in RCH clinics. Infants
born to mothers living with HIV will require close follow-up and monitoring of the
following: growth and development, immunizations, prophylaxis against HIV infections and
opportunistic infections (ARVs and CPT), early testing for HIV and nutritional counselling
and support services. All HIV-infected infants should be provided with comprehensive
paediatric HIV care and treatment services.
Table 9.2: Services that contribute to a comprehensive approach to PMTCT

PMTCT services How these services contribute to a comprehensive

approach

Routine HIV testing and counselling  Identifies women/couples living with HIV so that
they can receive PMTCT services and HIV care,
treatment and support

 Identifies women who are currently negative but at

high risk for acquiring infections during pregnancy
and or breast-feeding period. Women/couples should
be encouraged to continue using protective
interventions

 Consider PrEP for HIV negative pregnant and

breastfeeding women in case of discordant couples It
should be given following the general guidelines.
PrEP should continue until exposure of HIV to the
baby ceases

53
Comprehensive antenatal  Monitors pregnancy progress, early detection and
treatment of pregnancy-related complications such
care (ANC)
as STIs and anaemia

 Provides prevention of malaria and TB

 Counsels mothers on optimal nutrition

 Provides preventative methods such as (CPT) for

PCP, IPT and malaria

Lifelong ART for HIV positive  Improves maternal health, which in turn improves
pregnant and breast-feeding women child’s survival chances

 Reduces maternal viral load, which in turn reduces

infant exposure to the virus and risk of MTCT

ARV prophylaxis for HIV exposed Reduces the chance of the HIV-exposed infant from
infants getting infected with HIV from the mother during the
postpartum period
Safer delivery practices Reduces likelihood of labour and delivery complications
and infant exposure to HIV during labour and delivery
Counselling for safer infant Promotes safer infant feeding options to improve child
nutrition and survival and reduces infant exposure to the
feeding practices
virus, hence reducing MTCT
Postpartum care for the mother Supports mother’s health and nutrition status and
addresses woman’s family planning needs
Early infant HIV diagnosis, and  Identifies infants infected with HIV and initiates
treatment them on ART to improve their survival

 Monitors and manages signs and symptoms of

infection in children exposed to HIV

 Ensures HIV early infant diagnosis (HEID) and CPT

for infants starting at six weeks of age

 Ensures infant testing three months after cessation of

breast-feeding and a confirmatory testing at 18
months of age

 Facilitates early initiation of ART for HIV infected

children

Partner and family involvement  Identifies the partner who is HIV infected or who is
at risk of being infected (discordant)

54
  Identifies and facilitates children and other family
members to receive HIV care, treatment and support

Family planning Reduces risk of unintended pregnancy by giving proper

contraception choice to both partners, preferably dual
protection

9.4 Integrating PMTCT into routine Reproductive and Child Health Services
Integration of PMTCT into ANC services, will contribute to enable the National health care
programs to improve care and pregnancy outcomes for all clients. The National policy for
HIV testing requires all pregnant women to be tested for HIV once they start attending the
ANC services. The service for women living with HIV includes the same basic services
provided for all pregnant women. However, obstetric and medical care should be expanded to
address the specific needs of women living with HIV.

Practice Point
 Pregnant women living with HIV should attend ANC clinic every month during pregnancy
to be provided with adherence and medication support to ensure close follow-up and
monitoring.
 Pregnant women should be advised to book early for ANC services, starting from ≤12
weeks of gestation.
 Adolescents and young mothers should be given special attention to address their needs
during ANC.

Table 9.3 Essential package of Integrated ANC services for pregnant women living with
HIV infection
Client and family Collect routine information as guided by the Tanzania obstetric
history record, including medical, surgical, obstetric, and family planning
Understanding Assess and help client identify special needs given their
Client’s Context circumstance, e.g. psychosocial support, mental health needs, or
tailored scheduling of visits
Disease Screening Assess the current signs or symptoms of illnesses including HIV,
(History and TB, malaria, cervix cancer and STIs
Physical
Examination)

55
 Laboratory testing Conduct routine tests and HIV-specific laboratory tests:
 Syphilis

 Confirmatory HIV testing (if indicated)

 Urinalysis

  Full Blood Picture (FBP)

HIV staging  Conduct clinical and immunological staging according to the
WHO clinical staging system
Treatment  Assess readiness to start ART. Support client to formulate
Readiness and strategies for treatment adherence and support including
support disclosure

 Plan for continuous treatment support.

Antiretroviral  Provide life-long ART to all HIV positive pregnant women

Treatment (ART) regardless of CD4 cell count, WHO clinical stage or gestational
age

Tuberculosis  Screen for signs and symptoms of TB disease at every visit.

(TB) Evaluate for TB disease if symptomatic.

 Initiate IPT for eligible pregnant and lactating women

Opportunistic  Cotrimoxazole preventive therapy (CPT) should be provided to

pregnant women with CD4 cell count ≤350 cells/mm3
infection (OI)
prophylaxis
Malaria  Support and monitor adherence to CPT. Women on CPT do not
need Sulfadoxine - pyrimethamine prophylaxis for malaria

 Identify acute cases of malaria; treat promptly according to the

STI prevention  national guidelines
Assess risk, diagnose and treat STIs according to the national
guidelines.
and treatment
 Counsel on preventing STIs. Always recommend the use of
condom throughout pregnancy and breastfeeding

56
 Adherence to  Provide counselling and education on healthy pregnancy, HIV
ART, CPT and TPT care and treatment and PMTCT

Ensure knowledge and understanding of the rationale for ART

and infant ARV prophylaxis and the risks of non-adherence to
ART, CPT and TPT

   Ensure accurate knowledge of maternal ART and infant

Nutrition  Conduct nutritional and dietary assessment and provide
counselling and supportive services.

 Give iron, folic acid and multivitamin supplements according to

national guidelines.

Planning Delivery  Explain that interventions for PMTCT — including the

provision of ARVs to the mother and infant — are critical
during the labour and delivery period

 Plan in advance with the client on the mode and place of

delivery
Tetanus Toxoid Administer immunization according to national guidelines.
Safe Instruct her to immediately return to the clinic/hospital if she
experiences symptoms of pregnancy complications such as
Motherhood
bleeding, fever, signs and symptoms of pre-eclampsia, severe
pallor or abdominal pain.
HIV-exposed  Educate about infant ARV prophylaxis
Infant  Explain that infant prophylaxis is most effective when initiated
as soon as possible (preferably within 6–12 hours) after
delivery. Infants who have not received ARV prophylaxis soon
after birth should receive prophylaxis immediately thereafter up
to six weeks of age. For high risk HIV exposed infants ARV
prophylaxis should be given for up to 12 weeks of age.

 Inform about infant HIV testing and emphasize the importance

of early diagnostic testing

 All HIV exposed infant should be tested for HIV infection (see
Section 4.1.3 Diagnosing HIV infection in children under 18
months)

 Explain that all infants should initiate CPT at the age of 6

weeks. This should continue until HIV infection has been ruled
out and the infant is no longer at risk (is no longer breast-
feeding)

57
 Infant feeding  Support the mother to breast-feed exclusively for the first 6
months of life, followed by the introduction of complementary
feeding with continued breast-feeding until 12 months of age

 At 12 months of age, encourage cessation of breast-feeding

over the course o f abo ut one month
Signs or Provide information and instructions on seeking healthcare for
symptoms of HIV disease progression, such as frequent and
symptoms
recurrent illnesses, chronic persistent diarrhoea, oral and
related to HIV oesophageal candidiasis, fever, severe weight loss or signs of any
opportunistic infection. Refer women to a CTC when appropriate.


Mental health, Assess and address needs for mental health, psychological and
Psychological social support
and social  Refer for further mental healthcare if need be
support
 Refer to community-based psychosocial support networks or
organizations where available

 Encourage partners to undergo testing and counsel them on

disclosure

 Assess need to test other children in the family, even if they are
asymptomatic

Effective  Counsel about consistent use of condoms during pregnancy, as

family well as throughout the breast-feeding period to avoid new HIV
infection, re-infection and further transmission
planning and
 Include long-term family planning with partner involvement
safer sex
when possible. Discuss dual protection (dual protection refers
to the use of condoms in addition to the chosen method of
contraception)

9.4.2 HIV Testing and Counselling for Pregnant and Breast-feeding women
All pregnant women and their partners (unless known to be HIV positive) should be
counselled and tested for HIV during their first ANC visit. For those who are HIV negative,
repeat test should be conducted during the third trimester (between 32 weeks and 36 weeks
gestational age). A pregnant woman, who did not appear for testing at third trimester, will
have an opportunity to test during labour and delivery. If testing at labour and delivery did
not happen, then the test will be provided at six weeks immunization /postnatal visit. A
second repeat test will be done at 6 months post-partum during Vitamin A supplementation
and thereafter as per general population.

58
All breast-feeding mothers, unless known to be HIV positive, should be counselled and tested
during breast-feeding. For those whom were tested during third trimester or at labour and
delivery, a repeat HIV test should be offered at 6thmonth after the first test and thereafter as
per general population.
9.4.3 Categories of status of PMTCT clients according to risk of vertical HIV
transmission
After HIV diagnosis, pregnant and lactating women living with HIV can be further
categorized into two groups depending on the risk of vertical HIV transmission to their
children.
High risk group: these are the ones with increased risk of transmission, it includes all
women diagnosed to be living with HIV during pregnancy or breastfeeding period. Also,
women known to be HIV positive but not yet on ART or already on ART but with high viral
load (≥50/UL of blood).
Low risk group: these are the ones already on ART, and have achieved viral load of <50/UL
according to VL results within three months diagnosis of pregnancy.
High risk is a fixed categorization throughout the follow-up of index mother-child pair, while
low risk status can downgrade to high risk. Once downgrading occurs the high-risk status is
maintained to the end of follow-up.

Summary of care tailored by risk category

59
9.4.3 Care of HIV-infected women during labour and delivery
All labour and delivery services should include interventions to prevent MTCT such as:
HIV testing for women whose HIV status is unknown and women with initial
negative tests that were not retested at third trimester (32 to 36 weeks of gestation)
 Administration of ART to HIV positive pregnant women and ARV prophylaxis to
infants
 Implementation of safer obstetric practices
 Labour and delivery care

The Management of labour should follow obstetric best practices and all HCWs must use
Standard Precautions during labour and delivery as outlined in Table 9.4 below:
Table 9.4 Safer obstetric practices to reduce MTCT
Safer Obstetrical Practice Description
Use Standard Use protective gear, safely use and dispose of sharps, use sterilized
Precautions (good equipment and safe disposal of contaminated materials
infection prevention
practices) for all
patient’s care
Minimize vaginal Perform vaginal examinations only when necessary, using sterile
examinations technique

60
 Avoid prolonged  Use a partograph to monitor the progress of labour, and record all
labour medications used during labour, including ART.

 Consider use of oxytocic medications to shorten labour when

appropriate

 Use non-invasive foetal monitoring to assess need for early

intervention

Avoid artificial Avoid early rupture of membranes (before 7cm dilation) unless
rupture of necessitates
membranes
Avoid unnecessary  Avoid invasive procedures, including scalp electrodes or scalp
trauma during sampling
delivery
 Avoid routine episiotomy

 Minimise the use of instrumental vaginal delivery such as forceps

or vacuum delivery

Minimize the risk  Carefully manage all stages of labour to prevent infections and
of postpartum avoid prolonged labour
haemorrhage
 Actively manage the third stage of labour by using recommended
uterotonic medicines and controlled cord traction

 Perform uterine massage

 Repair genital tract lacerations

 Carefully remove all products of conception

Use safe transfusion  Minimise the use of blood transfusions

practices
 Use only blood screened for blood borne infections such as HIV,
hepatitis B and C also, when available, syphilis and malaria

Provide support and Emotional support during labour is important particularly for women
reassurance living with HIV. Whenever possible, women living with HIV should
have a companion of their choice present during labour (preferably
companions aware of their HIV status).

9.4.4 Special labour and delivery considerations

Obstetric care in the home delivery setting
Healthcare workers should strongly encourage all women to give birth at health facilities
where skilled HCWs can address potential complications and provide specialized care to

61
reduce the risk of MTCT. In the interest of women who give birth at home, pregnant women
and home birth attendants should have basic knowledge on PMTCT interventions. All
pregnant women benefit when home birth attendants are knowledgeable about the signs and
symptoms of complications during birth and know when and how to refer women to
healthcare facilities. Home birth attendants should receive information on:
 How HIV is transmitted from mother to child
 Risk factors for MTCT
 Safer delivery practices to reduce the risk of MTCT
 Standard Precautions

Practice Point
All infants delivered at home should be brought to the health facility as soon as possible,
preferably within 6 hours after delivery. HIV exposed infants should be provided with
prophylaxis regimen.

9.4.5. Care after a spontaneous abortion (miscarriage)

Women living with HIV who are symptomatic may be at higher risk of spontaneous abortion
(miscarriage). In some cases, the HIV status of the woman may be unknown. For women who
have a spontaneous abortion, HCWs should:
 Provide HIV testing and counselling, if not tested
 Assess for signs and symptoms of HIV infections
 Provide comprehensive post-abortion care
 Remove the conception products and uterine contents
 Use of uterotonics, such as misoprostol or oxytocin
 Provide post-abortion contraception counselling and support
 Provide the client with preferred method of the contraception options available for
post abortion contraception

9.4.6. Immediate post-delivery care of HIV-exposed infants

Regardless of the mother’s HIV status, all infants should be kept warm after birth and dried
carefully. Infants should be handled with gloved hands until maternal blood and secretions
have been washed off. In caring for new-borns, HCWs should observe standard precautions.
Prophylaxis for HIV Exposed Infants
 Administer NVP syrup immediately after birth to all HIV exposed infants and
continue until six weeks of age
 In case a high-risk infant is identified, give enhanced postnatal prophylaxis (ePNP)
for a total of 12 weeks as described in the table below.

Table xxxx : Enhanced postnatal prophylaxis (ePNP) for high risk HEI.

62
Dosage forms
Fixed Dose Combination Dose 0-6 weeks Dose 6-12 weeks
AZT/3TC/NVP (60/30/50
¼ tab twice daily NVP - once daily
mg)

If Fixed Dose Combination AZT + 3TC (60/30mg); ¼ NVP - once daily

AZT/3TC/NVP is not tab twice daily and NVP
available. syrup Once daily.

High-risk infants:
Are those who are: Born to women diagnosed to be living with HIV during pregnancy or
breast-feeding period. Also, women known to be HIV positive but not yet on ART or already
on ART but with high viral load (≥50/UL of blood).
Infant prophylaxis is most effective when given as soon as possible after birth, preferably
within 6 to 12 hours
Infants identified beyond the age of four weeks should not be given ARV prophylaxis
Table 9.5 Infant NVP dosing

Infant NVP dosing recommendations

Infant age NVP daily dosing
Birth to 6 weeks
Birth weight 2000–2499g 10mg once daily
Birth weight ≥2500g 15mg once daily
Based on the dosing required to sustain exposure in the infant of >100 ng/mL with the fewest
dose changes
Low birth weight infants <2000g should receive mg/kg dosing; suggested starting dose is
2mg/kg once daily.

Practice Point
Infants who are diagnosed with HIV infection should be initiated on ART by a trained
clinician or nurse at CTC or RCH.
 For High risk HIV exposed infants; Health care worker can use a fixed dose
combination tablet to provide the prophylaxis as shown below:

 When administering the FDC tablet, remember to tell the mother that she should keep
the remaining quarter of a tablet for the evening dose
Perinatal care for HIV-exposed infants should be geared to minimize trauma to the new-born
and reduce the time that the new-born is exposed to the mother’s blood and body Secretions.

63
9.4.7. Management of HIV-infected women and their infants in the immediate postpartum
period
Immediate post-delivery care:
Healthcare workers should use Standard Precautions when assessing vaginal bleeding and
should safely dispose the blood-stained linens and pads.

Practice Point
 Clamp the cord immediately after birth, and avoid milking the cord (avoid squeezing it
towards the infant). Cover the cord with gloved hands or gauze before cutting to avoid
splash of cord blood.
 Use suction only when the infant shows signs of distress or aspiration. Use either mechanical
suction at less than 100mm Hg pressure or bulb suction, rather than mouth-operation
suction.
 Place the infant immediately on the mother’s breast if she is going to breast-feed;
preferably within one hour after delivery. If she is using replacement feeding, place
the infant on her body for skin-to-skin contact and provide help with the first feed
 Administer ARV prophylaxis as soon as possible following birth.
 Administer Bacillus Calmette-Guérin (BCG) and polio vaccines according to national
guidelines.
 For non- breast-fed infants, administer vitamin A 50,000 IUs at birth or within 6 months.

Postpartum care for women with unknown HIV status

Women whose status is unknown and those with negative results from previous tests should
strongly be encouraged to test for HIV and advised to breastfeed exclusively as per National
recommendation. Partners and other siblings of HIV exposed infants should be
encouraged to receive pre-test information, counselling and HIV testing.

HIV testing and counselling:

Women who received HIV testing during labour and delivery should receive additional HIV
Post-test counselling postpartum. Women of unknown HIV status should receive pre-test
information, counselling and HIV testing (unless they decline), so that their infants can
receive ARV prophylaxis if needed. Partners and other siblings of HIV-infected women
should be encouraged to receive pre-test information, counselling and HIV testing.

Counselling about safer infant feeding:

 All women, regardless of HIV status, should receive infant feeding counselling during
postpartum care according to the guidelines
 Mothers should receive support to exclusively breastfeed

64
  Healthcare workers should encourage and provide counselling about exclusive
breastfeeding or provide counselling on replacement feeding for women who choose
to do so, before the women and their infants leave the facility or hospital
 Mothers should demonstrate chosen infant feeding method and HCWs should observe
the mother implementing proper feeding technique before discharge
 Healthcare workers should discuss with the mother on how to cope with possible
stigmatization if she chooses not to breastfeed and advise her on the suppression of
lactation.

ARV treatment for mother and ARV prophylaxis for the infant:
All mothers living with HIV need to be informed on the importance of adherence and the
correct way to take their ARVs and how to administer ARV prophylaxis to their infants.
Vitamin A supplementation:
Before discharge, HCWs should administer vitamin A 200,000 IUs to the mother.
Counselling about infant HIV testing and CPT:
Women with HIV must be counselled on the importance of infant testing and be scheduled
for testing prior to discharge. HIV-exposed infants should have an initial HIV test at the age
of 6 weeks or as soon as possible thereafter. Infants who test HIV-negative will need a repeat
HIV testing at 9 months using DNA PCR of age; 3 months after complete cessation of
breastfeeding and a confirmation test at the age of 18 months using antibody test.
For HIV exposed infants who are identified as high risk, Nucleic Acid Test (NAT), DNA –
PCR will be performed at birth. For infants who become HIV + at birth, initiate them on ART
while taking another DBS for repeat HIV test using DNAPCR. For those who are HIV
negative they should receive a second test at 6 weeks of age; at 9 months of age and 3 months
after cessation of breastfeeding. A final test should be performed at the age of 18 months
(Refer Infant testing algorithm)
In addition, all HIV-exposed infants should begin CPT at the age of six weeks.

65
Counselling about postpartum family planning:
Women living with HIV should receive counselling on preventing unintended pregnancies.
Dual protection should be discussed in order to prevent HIV re-infection and pregnancy. In
addition, all HIV-exposed infants should begin CPT at the age of six weeks.
Comprehensive care visits schedule for the mother and infant:
Mothers with HIV and their families will need uninterrupted HIV care, treatment and support
services. Healthcare workers should prepare a follow up plan together with the client and
ensure the mother knows the time, location, contact person and purpose of all follow-up
appointments.

66
In case, the services required are not available at the health facility, healthcare worker should
facilitate successful referrals and linkages to HIV treatment, care and support services

Practice Points
Standard of care, mother-child follow-up in RCH will continue until the child attains the age of
2 years.

 All postpartum follow-up appointments for the mother and the infant, including infant
HIV testing and immunizations, should be scheduled before discharge.
 Women should be instructed on the amount, time, frequency and duration of their ART
medication. They should receive information about the importance of adhering to ART.
Women should receive information about the importance of observing time for infant
HIV testing and adherence on ARV and CPT prophylaxis for their infants.
 Women living with HIV should return for postpartum care at seven, 28 and 42 days
postpartum like other women in the general population.
 Where HIV care and treatment services are not available at the RCH clinic, they should
immediately be referred to a nearby CTC.
 All infants should have their HIV exposure status recorded on their RCH cards/Booklet
and should be followed monthly at Under-Five clinics until the child attains the age of
5 years. However, the PMTCT care and follow up will end at the age of 18 months
after confirmation of the final HIV status
 When shifting the mother from PMTCT to CTC the HCWs should educate the
mother/care giver on the importance of continuing protecting her child from HIV
infection.

Postpartum assessment of healing and routine physical assessment

During the mother’s postpartum visits, HCWs should conduct the following activities to
monitor the mother:
 Measure blood pressure and temperature
 Monitor uterine involution (shrinking)
 Check healing of any repaired genital/perineal lacerations or episiotomy
Examine the vulva and perineum for signs of infection, redness, tears, swelling or pus.
Confirm cessation of postpartum bleeding (check sanitary pad for the amount of
bleeding).
 Check for signs of infections
 Check for signs of anaemia (e.g. pallor) and ask about fatigue.

67
9.5. Use of antiretroviral (ARV) drugs during pregnancy and lactation
ARV drugs are used for pregnant and lactating mothers with HIV primarily for the mother’s
health and to prevent the exposed child from becoming infected. It may also offer benefits for
preventing the sexual transmission of HIV.
9.5.1. Prevention of Mother to Child Transmission
The pregnant or breast-feeding women with HIV should be started on lifelong ART for their
own health at the time of diagnosis. The recommended first line regimen is once a day fixed
dose regimen of Tenofovir (TDF) +Lamivudine (3TC) + Dolutegravir (DTG), although
Tenofovir (TDF)+Lamivudine (3TC) + Efavirenz (EFV) may be an option for use during the
pre-conception period through the first eight weeks of pregnancy to avoid potential risk of
neural tube defects. TLD should be continued postpartum and women should receive on-
going counselling support to continuing HIV care and treatment in order to maintain good
health and to reduce the risk of HIV transmission on others.

Practice point
Always
1. Discuss benefits of lifelong ART: health benefits, prevention of MTCT and
prevention of onward HIV transmission to others
2. Discuss and make sure the client understands and comprehends all possible side
effects of ARVs
3. Work with clients to find motivation to remain adherent to ART, and devise strategies to
overcome threats against adherence (e.g. Multi months prescription, and longer interval
between visits only when absolutely necessary)
For clients on 2nd and 3rd line ART regimens should continue with their current regimens.

The WHO guidelines released in July 2018 put forward a women-centred approach stating:
Key considerations:
 Women living with HIV receiving ART who present for pregnancy care should
continue their ART during pregnancy, provided the regimen is tolerated & effective in
suppressing viral replication
 The WHO guidelines highlight that DTG is safe in 2nd and 3rd trimester, and results
from the DOLPHIN 2 study show a significantly greater proportion of women
achieved undetectable viral load starting a DTG-based regimen late in pregnancy,
compared with EFV.[1,2]
 Clinicians should assess the risks of changing treatment during pregnancy and
decisions made according to the stage at which pregnancy is diagnosed, due to risks
of viral load fluctuations when changing regimens.
WHO recommends an EFV-based regimen as a safe and effective first line (1L)
regimen that women of childbearing potential can use during the period of potential

68
 risk for developing neural tube defects (at conception and up to eight weeks after
conception)
 Women of childbearing potential who do not currently want to become pregnant can
receive DTG together with consistent & reliable contraception; hormonal
contraception and DTG have no drug–drug interactions.
 A women-centred approach will be adopted and women of child bearing potential
including those who are using long term effective contraception to be given adequate
information to enable them make informed decision and informed choice consent to
using DTG
 Women of child bearing potential who are not on long term effective contraception
and choose to use DTG MUST sign a consent form
 Women who expect to become pregnant and choose not to take DTG should be given
options to use TLE
 On spot Pregnancy testing using UPT
 All pregnant women should routinely receive high dose Folic acid (5mg) pre-
conception and during pregnancy. Clients with DTG intolerance such as severe liver
diseases should not be given DTG containing regimens.

NOTE: For women of child bearing potential they will be informed that while remaining
on DTG, it is strongly recommended that they use an effective contraceptive method
such as tubal-ligation, hormonal implant, Intra Uterine Device (IUD), injectable
contraceptives, or oral contraceptive pills. Also, they will be informed that they can be
given an alternative drug combination that is equally effective (TLE) if they don’t opt for
TLD. Even if they don’t want to use contraceptive, they can still get TLD if she makes the
informed decision to do so.

9.5.2. Monitoring PMTCT clients

Successful ART results in viral load decrease, immune recovery and therefore an increase in
the number of CD4 cells/mm3. This results into lower transmission risks, improved maternal
survival and therefore improved HIV free survival for her baby.
In settings where routine HIV Viral Load monitoring is available, CD4 Tlymphocytes count
should be done at baseline to determine immunological stage and establish need for CPT. For
clients with CD4 count of <350 cell/mm3, the test should be repeated every 6 months and
when CD4 >350 cell/mm3, stop CD4 monitoring and continue with HIV VL monitoring.
Refer Chapter 4: Table 4. Viral Load Monitoring during Pregnancy and Breastfeeding

69
CHAPTER 10: ANTIRETROVIRAL THERAPY FOR ADOLESCENTS AND
ADULTS
10.0 Introduction
 Antiretroviral therapy (ART) for the treatment of HIV infection has improved steadily
since the advent of potent combination therapy. With advancement in treatment for
HIV, there has been significant improvement in the safety and tolerability of
regimens. ART has dramatically reduced HIV-associated morbidity and mortality and
has transformed HIV disease into a chronic, manageable condition. The pill burden
and dosing frequency for ARVs have been reduced and adverse events minimized; all
of which have contributed to the success rates in initial treatment. In addition,
treatment of HIV-infected individuals with ART is highly effective at preventing
transmission to sexual partners.

These benefits are maximal when treatment is initiated soon after the HIV diagnosis is made
and patients are virologically suppressed. Therefore, the lag time between an HIV diagnosis
and treatment should be reduced drastically through early testing of asymptomatic individuals
and early linkage to care and antiretroviral treatment. Antiretroviral drugs are effective and
safe in suppressing viral replication when used in combination.

70
This chapter gives a general overview of ART and specific recommendations on managing
adolescents and adults aged 15 years and above.

10.1 Types of Antiretroviral Drugs

 The recommended antiretroviral drugs to be used in these guidelines fall into the
following five main categories:
 a) Nucleotide reverse transcriptase inhibitors (NtRTIs)
 b) Nucleoside reverse transcriptase inhibitors (NRTIs)
 c) Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
 d) Protease inhibitors (Pls)
 e) Integrase strand transfer inhibitors (INSTI)/ Integrase inhibitors


 Other antiretroviral drugs used elsewhere include:
 f) Fusion inhibitors e.g. Enfuvirtide (ENF)
 g) Chemokine receptor inhibitors/ CCR5 inhibitors e.g. Maraviroc

10.1.1 Nucleotide Reverse Transcriptase Inhibitors (NtRTIs)

Nucleotide analogues resemble nucleoside analogues (NRTI’s). The mechanism of action
involves selectively inhibiting viral reverse transcriptase enzyme. Examples of these
antiretroviral drugs include:
 Tenofovir disoproxil fumarate (TDF)
 Tenofovir alafenamide (TAF)

10.1.2 Nucleoside Reverse Transcriptase Inhibitors (NRTIs)

 This group of drugs is the mainstay of antiretroviral therapy in the country. The
primary mechanism of action of this class is inhibition of viral RNA-dependent DNA
polymerase (reverse transcriptase) enzyme. The drugs that are available in Tanzania
for this class include:
 Zidovudine (AZT)
 Lamivudine (3TC)
 Emtricitabine (FTC)
 Abacavir (ABC)

10.1.3 Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)

Similar to the NRTIs, NNRTIs also act by disrupting the reverse transcription of viral RNA
into DNA that is then incorporated in the cell’s nucleus. However, unlike the NRTIs, they are

71
not directly incorporated into the viral DNA; instead they inhibit replication directly by bind-
ing to the enzyme reverse transcriptase. Resistance to these drugs develops rapidly, especially
when used alone due to low genetic barrier. There are two groups of NNRTIs, 1st and 2nd
generation, the latter has an advantage of having a better resistance profile and a higher
genetic barrier to the development of resistance. The 2nd generation of NNRTs may be
effective after the failure of the first generation of NNRTI-based regimen due to resistance.
Drugs under this class that are recommended in this guideline include:
a) 1st generation NNRTIs
 Nevirapine (NVP)
 Efavirenz (EFV)
b) 2nd generation NNRTIs
 Etravirine (ETR)


10.1.4 Protease Inhibitors (PIs)
PIs competitively inhibit the HIV protease enzyme whose activity is critical for the terminal
maturation of infectious virions. This inhibition prevents the maturation of virions capable of
infecting other cells. Such drugs are usually boosted with a small dose of ritonavir (also a PI)
to enhance therapeutic drug concentration and hence increase efficacy of the drug, reduce
food restrictions, dose and frequency of administration. Boosted PIs have a high genetic
barrier to resistance. The newer PIs such as Darunavir have an advantage of having a better
resistance profile, a higher genetic barrier to the development of resistance and a broad
spectrum of activity against PI resistant viruses. They are therefore effective after failure of a
first generation PI-based regimen due to resistance. Drugs under this class that are
recommended in this guideline include:
a) 1st generation currently available Protease Inhibitors (PIs)
 Atazanavir (ATV).
 Lopinavir (LPV),
 Ritonavir (usually used as a booster with other PIs)
b) 2nd generation currently available Protease Inhibitors (PIs)
 Darunavir (DRV)

10.1.5 Integrase Strand Transfer Inhibitors (INSTI)/ Integrase inhibitors

This group of drugs acts by inhibiting integrase enzyme which facilitates integration of viral
pro-DNA into the host cell. Drugs under this class that are recommended in Tanzania
include:
a) Dolutegravir (DTG)
b) Raltegravir (RAL)

72
10.2 Goals of Antiretroviral Therapy
The principal aim of antiretroviral therapy is to prevent morbidity and mortality in people
with HIV and AIDS by durably suppressing viremia to undetectable levels, and thereby
reconstituting and maintaining the immune capacity.
HIV and AIDS cannot be cured by using currently available ARV regimens because during
the acute phase of HIV infection some viruses hide in some tissues (sanctuaries), where they
stay dormant or with a very minimal replication for a life time. Early initiation of ART limits
the number and reduces the size of sanctuaries, with subsequent reduction in the number of
circulating viruses in the blood. The sanctuaries can last for a lifetime, therefore, once
patients are initiated on ART, they need to be maintained on it indefinitely to prevent viral
rebound.
The primary goals of combination antiretroviral therapy are:
1. Maximal and durable suppression of viral load to <50 copies/ml.
2. Restoration and/or preservation of immunologic function by attainment of CD4
recovery to normal thresholds ≥500 cells/mm³.
4. 3. Reduction of HIV-related morbidity and mortality. Improvement of survival and
quality of life.
Secondary goals are to reduce:
 The pool of individuals who are virologically not suppressed, hence infectious and
thus reduce the risk of HIV transmission in the community. The pool of pregnant and
lactating mothers who are virologically not suppressed, hence infectious and thus
reduce the risk of HIV transmission from mother to child and
 Transmission among discordant couples.

10.3 Rationale for early initiation of ART

Early initiation of combination antiretroviral treatment (ART) is associated with health
benefits in terms of reduced morbidity and mortality in all age groups. In addition, ART is
effective in prevention of HIV transmission and also helps to drastically reduce TB
incidences.
Therefore, the Ministry of Health has adopted the Treat All approach where all individuals
who are infected with HIV are started on ART regardless of CD4 cell count and clinical
stage.

10.3.1 Evaluation to be done before initiating ART

From the moment a patient tests HIV-positive, he/she should be linked to the Care and
Treatment Clinic (CTC). In health facilities where ART is being initiated at RCH and TB
clinics, patients can be managed at those clinics. Mobile outreach clinics can also be used

73
where there are no nearby health facilities to provide ART services. For KVP ART can be
initiated in the community (for ART services to KVP refer Chapter 2).
Before initiating any patient on ART, a complete assessment of the patient should be
performed starting with in-depth medical history followed by a head-to-toe physical
examination including WHO clinical staging. However, the WHO clinical staging should be
used to provide baseline clinical information but it should not be used to determine eligibility
for ART. In addition, the TB screening questionnaire should be administered. Patient data
should be recorded in the CTC2 cards and in the patient file. For the baseline laboratory test
before initiation of ART, refer to Table 4.1in Chapter 4. Treatment decisions should be based
on HIV status, readiness of the patient and a solid adherence support plan.

10.3.2 When to start ART in Adolescents and adults

.

A. Clients related Considerations

Before the client is initiated on ART, the following psychosocial conditions should be
met:
i. They should be willing and ready to adhere to lifelong ART
ii. Commits him/herself to attend clinics as per schedule.
iii. The clients is not abusing alcohol and if he/she does is willing to stop it
iv. HIV infected PWID clients should be willing to attend medically assisted therapy e.g.
methadone replacement therapy if services are available.
Note: The client should be encouraged to disclose his/her HIV sero-status to a treatment
assistant and or a self-chosen family member.

B. Health Services Delivery Settings Considerations

i. The client, his/her treatment assistant and other family members (with clients'
consent) should be educated on HIV and AIDS to ensure adequate ART literacy
on the importance of optimal adherence, consequences of non-adherence, self-
assessment of clinical red flags for seeking unscheduled clinic visits.
ii. Develop together with the client, his/her treatment assistant and other family members
an adherence plan for his/her treatment.
iii. Provide general orientation to the client, his/her treatment assistant and other family
members on the following:
 whom to call and where to get refills,
 whom to call and where to go when clinical problems arise,
 whom to call/where to go for assistance on social, spiritual and legal
problems and other community support services to ensure adherence,
comprehensive service delivery and support services.
iv. Link the client to a PLHIV support group
v. Provide depression treatment and support for depressed clients
vi. Provide MAT for PWID and other support services
vii. Ensure friendly services for adolescents and young people.
74
10.4 First Line ART
10.4.1 Introduction
Antiretroviral therapy, both in naïve clients and those who have received treatment before,
involves the use of a combination of antiretroviral drugs. Triple therapy consists of 2 NRTI +
1 INSTI or 2 NRTI + 1 NNRTI or 2 NRTI + 1 PI. It is important to remember that there is no
single combination that is best for every client and/or that can be tolerated by all clients. It is
stressed that for both initial and subsequent ART lines the aim is to attain undetectable viral
load (<50 copies /ml) and regain CD4 cell count to normal thresholds (≥500 cells /mm3).
Prescriptions of ARV regimens should be recommended on the basis of a client's clinical
condition, co-morbidities, co-administered drugs, age, pregnancy status, convenience, and
ability to tolerate the regimen.

10.4.2 First line ARV combination regimens

ARVs should be used according to indications and contraindications that govern the use of
ARVs to minimize side effects and drug-drug interactions. The following recommended
ARV drug combinations are currently available as first line treatment for adults and
adolescents:

a) DTG based regimens:

 TDF + 3TC + DTG (Default first Line regimen)
 ABC + 3TC+ DTG
 AZT+ 3TC+ DTG
b) EFV based regimens:
 TDF + 3TC + EFV600 or EFV400
 TDF+FTC+EFV600 or EFV400
c) NVP based regimens:
 AZT+3TC+NVP

The following 1st line ARV drug combinations will be systematically phased out when the
new ARVs regimens are available:
 TDF+FTC+EFV600
 ABC/3TC+EFV600
 AZT /3TC+ EFV600
 AZT+3TC+NVP
Note: The following ARV drugs are in fixed drug combinations (FDC):
 TDF/3TC/DTG (TLD)
 ABC/3TC/DTG (ALD)
 TDF/3TC/EFV600 (TLE)
 TDF/3TC/EFV400 (TLE)
 TDF/FTC/EFV600 (ATRIPLA)

75
  TDF/3TC
 TDF/FTC (Truvada)
 ABC/3TC
 AZT/3TC/NVP (Duovir-N)
 AZT/3TC (Combivir)
Table 10.1 Recommended first line regimens for adults and adolescents
RECOMENDED FIRST LINE REGIMENS FOR ADULTS AND ADOLESCENTS
Patient group Preferred (Default) Alternative Regimen
Regimen
Adults and adolescents (>15 years), TDF +3TC +DTG (TLD) ABC + 3TC+ DTG
Pregnant/lactating mothers TDF + 3TC +EFV (TLE600
or TLE400)

Special situations:
AZT + 3TC + DTG

HIV and TB co-infections TDF + 3TC +DTG TDF + 3TC +EFV (TLE600)
(Double dosage of DTG)
ABC + 3TC+ DTG (Double
dosage of DTG)

Special situations:
AZT + 3TC + DTG (Double
dosage of DTG)
People who Inject Drugs (PWID) TDF + 3TC +DTG ABC + 3TC+ DTG

TDF + FTC +ATV/r

NOTE:
 Clients with TB and HIV co-infection who cannot tolerate DTG and pregnant women
who will opt not to use DTG will continue to use TLE (EFV600) until evidence to
support use of TLE (EFV400) is available.
 For clients with TB and HIV co-infection consider using a PI based regimen if
EFV600 is not available.
 The TDF+3TC+DTG combination is the default combination to be prescribed to all
adult and adolescent clients if there is no any contraindication. The regimen can also
be used in patients with TB and HIV, HIV and HBV co-infection and PWID.
 TLD is more efficacious compared to other available options with NRTI backbones,
causing rapid decline in viral load of up to 50 RNA copies per milliliter in 12 weeks
where as the optimal suppression occurs at 24 weeks when using Efavirenz containing
formulations. Furthermore, TLD causes robust CD4 recovery in both early and
76
 advanced disease; it is suitable for late presenters or those with advanced disease and
more appropriate for pregnant women booking late at Antenatal Clinics.
 TLD has less side effects and few important drug-drug interactions hence well
tolerated compared to previously use first line regimen. There are safety concerns for
use of TLD in pregnant women but the pharmacokinetics studies do not show any
difference between TLD and TLE.
 Higher genetic barrier of DTG means patients are less likely to develop resistance and
do not shortly require switching to more expensive second-line treatment options.
 DTG does not interact with methadone; therefore it is a suitable drug for regimens in
PWID.
 DTG dosing is 50mg OD but it should be administered at a dose of 50mg twice a day
for patients on Rifampicin based treatment because Rifampicin reduces DTG drug
levels in the blood.
 TLE600 should be used as an alternative first line to clients on anti TB Rifampicin to
offset increased metabolism of EFV by Rifampicin
 TDF 300mg based regimens should not be initiated to patients with weight less than
30kg
 EFV600 should not be initiated for children aged <3 years or weighing <10kg.
 For pregnant women, TLE600 should be used as an alternative to TLE 400 due to
increased volume of distribution during pregnancy.

Caution: ARV drugs have the potential to decrease the bioavailability in hormonal
contraceptives especially with oral contraceptives. Dual contraception with condoms and
injectable contraceptives is therefore recommended.
The major concern with Tenofovir (TDF) based treatment is renal toxicity. Tenofovir (TDF)
associated nephrotoxicity is more common in patients with pre-existing renal dysfunction or
those receiving other concomitant nephrotoxic medications cleared through the kidney, low
birth weight, advanced age and lower CD4 cell counts. Otherwise, the overall rate of
discontinuation for renal events is extremely low. TDF nephrotoxicity risk is also increased
in patients with co–morbidities which may also be associated with renal dysfunction such as
HIV Associated Nephropathy (HIVAN), hypertension and diabetes mellitus. It is
recommended that for patients on TDF based regimens, routine renal toxicity monitoring by
proteinuria and blood creatinine determination should be done at baseline and after every six
months. Therefore, clients with high risk of nephrotoxicity or with pre-existing renal
dysfunction should be kept on Abacavir based regimens.

10.4.3 ART in women of childbearing potential or pregnant women

The recommended first-line regimen for this patient subgroup is: TDF + 3TC + DTG.
Alternative regimens for this group are the same as in adolescents and adults (see Table 10.1
above).
 Pregnant women, breastfeeding women and women of childbearing potential should
be given adequate information to make informed choices about their treatment
options.

77
  All women of child bearing potential should be tested urine for pregnancy (UPT)
before ART initiation, especially if DTG is to be initiated.
 DTG can be used in pregnant and women of child bearing potential; however, there is
a potential risk for neural tube defects for children born by mothers on DTG during
conception and first trimester. All pregnant women and those who wish to conceive
should be given Folic acid supplements.
 TLD (fixed-dose combination of TDF + 3TC + DTG) could be considered for
pregnant women identified as receiving or starting ART later in the pregnancy
(second and third trimester), although the switch to TLE (fixed-dose combination of
TDF + 3TC (or FTC) + EFV) should be ensured after delivery in case the woman
does not have access to reliable contraception.
 Pregnant women, who do not wish to use DTG, should be prescribed with TLE
throughout the first trimester, and they will be switched to a DTG-based regimen
thereafter.
 For women of child bearing potential who would not wish to conceive and use TLD,
should be advised to use long acting contraceptive and/or effective dual contraception
with condoms.
 For a woman of child bearing potential who wish to conceive should be advised to use
TLE throughout the first trimester then be switched back to DTG thereafter.
NOTE: Effective contraception is defined as correct use of the following methods:
Contraceptive intrauterine device (IUD) or intrauterine system (IUS); Subdermal
contraceptive implant or Progestogen injections. Male or female condom use is
recommended with all contraceptive methods for dual protection against pregnancy and
to avoid transmission of HIV and other sexually transmitted infections.

Source; WHO July 2018 Interim Guidance on ARVs

10.4.4 Antiretroviral drugs for people who inject drugs (PWID) on medical assisted
therapy
Drug use and addiction do not preclude successful ARV treatment. ART is as effective for
HIV positive PWID as it is for other people with HIV and AIDS. Given appropriate support,
former and active PWID can adhere just as well as others and should have equal access to
ART. Special attention should be paid to the particular needs of former and active PWID
when administering ART, including those related to substance dependence, co-morbidities
and co-infections. ART services should be integrated into Medically Assisted Therapy
(MAT) Clinics. For the ART naïve clients ART should be initiated when the client has been
stabilised and his /her methadone dosage has been determined. This usually takes between 2-

78
3 months after starting MAT. The previously used NNRTIs, NVP and EFV and to a less
extent Lopinavir and Ritonavir induce metabolism of methadone through cytochrome CYP
450 3A with a net effect of reducing serum concentration of Methadone. EFV for example,
decreases methadone plasma concentration for up to 50% overtime. Use of combined TDF
backbone with preferably DTG or alternatively use of ATV/r is recommended. These are not
associated with significant decreases of methadone plasma concentration.
Thus the preferred regimen for PWID is TDF+ 3TC +DTG.
During the course of treatment, all treatment experienced PWID on regimens other than
ATV/r or DTG should be switched to a DTG based regimens.
10.5 Second line ART
10.5.1 Second-line antiretroviral therapy in adults and adolescents

The second line NRTI choice for adults and adolescents depends on the first line regimen.
For patients on TDF based regimens in first line, the preferred second line option is AZT plus
3TC combined with a ritonavir-boosted PI, preferably ATV/r because it is dosed once daily
and has fewer metabolic complications and side effects. The same NRTIs, with exception of
3TC and FTC used in previous regimen should not be used in subsequent regimens during
switching due to treatment failure. LPV/r can be used as an alternative to ATV/r in patients
using anti-TB drugs (with ritonavir super boosting) and children below six years. Also,
ATV/r (300/100mg) cannot be used in children below 30kg.
For patients who were on AZT and had never used TDF regimen, the default second line
option will be TDF or ABC based regimen combined with a boosted PI (TDF+FTC+ATV/r).
For patients who were introduced to TDF in first line due to AZT toxicity, the default second
line option is to use ABC plus 3TC combined with a ritonavir-boosted PI ATV/r or LPV/r.
(ABC + 3TC + LPV/r or ATV/r). However, ABC may be rendered ineffective due to cross
resistance with TDF associated resistance mutations. Doses for these drugs are shown in
Annex 7.
Note that ATV/r, LPV/r, ABC/3TC and TDF/FTC are currently available as FDC
formulations which simplify dosing and administration.

79
 Table 10.2 Recommended second line regimens for adults and adolescents
RECOMMENDED SECOND LINE REGIMENS FOR ADULTS AND ADOLESCENTS

Patient group Preferred (Default) Regimen Alternative Regimen

Adults, adolescents (>15 years) AZT/3TC+ATV/r: if TDF was
and Pregnant women / used in first-line
breastfeeding mothers ABC/3TC+ATV/r
TDF/FTC+ATV/r: if AZT was ABC/3TC+LPV/r
used in first-line TDF/FTC+LPV/r

AZT + 3TC + DTG (For

patients who did not use
DTG in the first-line)

HIV and TB co-infection AZT/3TC+LPV/r ABC/3TC+LPV/ra

TDF/FTC+LPV/r a
Note: double dosage of
LPV/r to 800/200mg for
Rifampicin based TB
treatment

People Who Inject Drugs (PWID) AZT/3TC + DTG AZT + 3TC+ ATV/r
ABC + 3TC +ATV/r
Note: Delayed diagnosis of treatment failure by using non-virological criteria results into
accumulation of resistance associated mutations (RAMs). These RAMs compromise efficacy
of drugs with similar resistance pattern (TDF and ABC) for future use. In case of previous
AZT use, the accumulation of multiple Thymidine Associated Mutations (TAMs)
compromise efficacy of all NRTIs and NtRTIs. AZT associated mutations limit future
treatment options making future use of ABC and TDF ineffective.

10.6 Third-line Antiretroviral Therapy

Patients failing 2nd line regimens may have extensive NRTI and NNRTIs associated
resistance mutations (RAMS) which limit their use in third line regimens. Therefore, 3 rd line
regimens, in order to have at least two or preferably three effective drugs, their regimens need
to be constructed using other new classes of drugs or second generation formulations of
previous drugs which have minimal resistance. These second generation drugs have a higher
genetic barrier to resistance and their efficacy is not compromised by RAMs associated with
the first generation formulations. For example, Darunavir (DRV) does not have cross
resistance to PIs used in the second line.
ETR is a second generation NNRTI with minimal cross resistance to First generation
NNRTIs (EFV and NVP) however, it has many drug-drug interactions and is contraindicated
to use with many commonly used drugs such as Rifampin, Artemether/Lumefantrine,
Carbamazepine, Prazquantel, fluconazole, amiodarone, digoxin etc.
Third-line regimens recommended in this guideline include:
a) Integrase Strand Transfer Inhibitors (INSTIs) or Integrase Inhibitors: Dolutegravir (DTG)
and Raltegravir (RAL).

80
 b) Second generation PI: Boosted Darunavir (DRV/r)
HIV Drug Resistance Testing and Third line ARV Regimens:
Before switching to third line ARV regimens, genotypic HIV drug resistance should be done
to rule cross resistance between 1st and 2nd generation drugs and assist in the determination if
treatment failure is due to HIV drug resistance. Genotyping will also inform on the possibility
of recycling drugs used in previous regimens i.e. some drugs used in first or second regimens
may still be effective in third line.

Table 10.3: Recommended third line regimens for adults and adolescents
RECOMMENDED THIRD LINE REGIMENS FOR ADULTS AND ADOLESCENTS
Patient group Preferred (Default) Regimen Alternative Regimen

Adults, adolescents (>15 years) DTG+DRV/r+ AZT/3TC RAL + DRV/r + AZT/3TC

Pregnant women/breastfeeding (DTG or RAL)+DRV/r+ DTG + DRV/r (AZT/3TC)

mothers AZT/3TC

HIV and TB co-infection DTG (BD) + LPV/r+ (AZT/3TC RAL+(AZT/3TC or

or TDF/FTC) TDF/FTC)+LPV/r

People Who Inject Drugs DTG+DRV/r+ AZT/3TC DTG+ATV/r+ AZT/3TC

(PWID)
Note: (1) DTG in third line regimen should be given twice daily for clients who were previously
exposed to INSTIs.

(2) For TB and HIV co-infected patients on LPV/r should be switched to DRV/r after completion of TB
treatment

(3) For second and third line regimens which are non TDF based, in case of new Hepatitis B co -
infection TDF with FTC should be added to the new regimen as treatment of Hepatitis B.

10.7 Changing Antiretroviral Therapy

There are multiple reasons that may prompt the need to change antiretroviral therapy. These
can be grouped into two major categories:
 Drug specific adverse events (toxicity)
 Treatment failure

When changing treatment, the following should be observed:

If changing due to toxicity
o Change only the drug suspected to be causing the problem.
If changing due to treatment failure
o Never change to monotherapy
o Change at least two drugs, preferably change all three drugs
81
 o When selecting drugs, choose drugs that have not been used before, drugs
which do not have cross-resistance/or no overlapping toxicities or drug-drug
interactions
o Lamivudine has advantage of decreasing viral fitness and increasing
susceptibility to AZT and therefore it may be retained when changing the
failing regimen.
10.7.1 Changing antiretroviral therapy due to toxicity
From a clinical perspective, it is generally recommended that when changing a client`s
regimen due to toxicity, only the toxic drug(s) should be replaced, wherever possible, by a
drug without overlapping toxicities. Table 10.4 below shows types of toxicities and risk
factors associated with first, second and third-line ARV drugs and suggested management

Figure 10.1: Substitution within First Line Antiretroviral Regimens

10.7.1.1 Severity of adverse events due to ARVs

All adverse events shall be recorded in the adverse effects forms (TFDA Yellow Form). Side
effects or toxicities caused by ARVs can be classified into three broad categories:
First category: Symptoms are mild and transient and often require patient assurance that
these symptoms are common and usually decrease over time. Symptomatic relief may be
offered, such as paracetamol for headaches. ARV interruption is rarely indicated in this
situation.
Second category: Symptoms are somewhat more severe and often respond to some medical
intervention. They include more severe gastric upset with nausea and vomiting, more severe
headaches and mild peripheral neuropathy that does not incapacitate or interfere with a
patient’s lifestyle. These symptoms can often be successfully treated with anti-emetics, anti-
diarrhoea medicines, analgesics, neuroleptics (e.g. Amitriptyline) and other medicines. ARV
interruption is usually not indicated in this situation and often symptomatic treatment is only
temporary.
Third category: Symptoms are severe such that ARV drugs must be stopped and replaced by
an alternative drug. These include anaemia (haemoglobin <7.5 gm/dl or a falling
haemoglobin, that often drops by 2gm/dl) as can occur with the use of AZT. Severe
symptoms noted in the first two categories can sometimes lead to the stopping of ARV due to
severe toxicities such as nausea with severe discomfort and minimal intake for three or more
days, vomiting all intakes in 24 hours or dehydration due to vomiting, severe headaches not
82
responsive to non-narcotic analgesics, or fatigue reducing activity by more than 50%. In such
situations, one or more ARVs should be replaced by another drug.
10.7.1.2 ABC (Abacavir) hypersensitivity
ABC hypersensitivity is genetically predetermined with a marker HLA-B5701 allele. It
occurs in between 3% to 5% of all people, being less common amongst individuals of African
descent. It commonly occurs within the first six weeks of treatment; it rarely occurs after
months of treatment. If clinical worsening occurs, after months of ABC treatment, other
causes of clinical deterioration should be ruled out first. Hypersensitivity symptoms include:
flu symptoms, shortness of breath, cough, fever, aches and pains, a general ill feeling,
fatigue/tiredness, swelling, abdominal pain, diarrhoea, nausea, muscle or joint pains,
numbness, sore throat or rash. ABC will be stopped immediately and not re-started if this
occurs, because re-challenging can be fatal. Abacavir hypersensitivity should be suspected in
case of clinical worsening during the course of treatment.

Table 10.4: Types of toxicities associated with First, Second and Third-line ARV drugs
ARV Major types of toxicity Risk factors Suggested management
TDF Tubular renal dysfunction,  Underlying renal disease
Fanconi syndrome  Older age  If TDF is being used in
 BMI <18.5 (or body first-line ART,
weight <50kg) substitute it with ABC
 Untreated diabetes
mellitus  If TDF is being used in
 Untreated hypertension second-line ART,
 Concomitant use of substitute it with AZT
nephrotoxic drugs or a or ABC.
boosted PI
Decreases in bone mineral  History of osteomalacia
density and pathological fracture
Risk factors for
osteoporosis or bone loss
Lactic acidosis or severe Prolonged exposure to
hepatomegaly with steatosis nucleoside analogues
 Obesity
Exacerbation of hepatitis B Discontinuation of TDF due No available alternative
(hepatic flares) to toxicity drug in the country for
treatment of hepatitis B
e.g. Entecavir
ABC Hypersensitivity reaction Genetic predisposition If ABC is being used in
(HLA-B 5701 gene) first or second-line ART,
substitute with TDF or
AZT
AZT Anaemia, neutropaenia,  Baseline anaemia or
myopathy, lipoatrophy or Neutropaenia If AZT is being used in
lipodystrophy  CD4 cell count ≤200 second-line ART,
3
cells/mm substitute it with ABC
Lactic acidosis or severe  BMI >25 (or body
hepatomegaly with steatosis
83
 weight >75 kg)
Prolonged exposure to
nucleoside analogues
EFV Persistent central nervous  Depression or other For central nervous system
system toxicity (such as mental symptoms, dosing at
dizziness, insomnia and disorder (previous or at bedtime. Consider using
abnormal dreams) or baseline) EFV at a lower dose (400
mental symptoms (anxiety, mg/day or an integrase
depression and mental  Daytime dosing inhibitor (DTG) if EFV
confusion) 400 mg is not effective in
reducing symptoms.
Convulsions History of seizure
Hepatotoxicity  Underlying hepatic For severe hepatotoxicity
disease or hypersensitivity
 Coinfection with reactions, substitute with
hepatitis B or C another therapeutic class
 Concomitant use of (integrase inhibitors or
hepatotoxic drugs boosted PIs).
Severe skin and
hypersensitivity reactions Risk factors unknown
Gynaecomastia Substitute with another
Risk factors unknown therapeutic class (integrase
inhibitors or boosted PIs).
NVP  Hepatotoxicity  Underlying hepatic  If hepatotoxicity is
disease mild, consider
 Severe skin rash and substituting with EFV,
Hypersensitivity reaction,  Coinfection with including for children
including Stevens- hepatitis B or C three years and older.
Johnson syndrome
 Concomitant use of  For severe
hepatotoxic drugs hepatotoxicity
and hypersensitivity,
 High baseline CD4 cell and for children
count younger than three
(CD4 count >250 years, substitute with
cells/mm3 another therapeutic
for women or >400 class (integrase
cells/mm3 inhibitors or boosted
for men) PIs).
Hepatotoxicity  Underlying hepatic
disease Replace it with ATV/r
 HBV and HCV co-
infection
LPV/r  Concomitant use of
hepatotoxic drugs
Pancreatitis Advanced HIV disease
Lipoatrophy or metabolic Risk factors unknown
syndrome dyslipidaemia,

84
 severe diarrhea and risk of
prematurity
ATV/ Indirect hyperbilirubinaemia  Underlying hepatic Indirect hyperbilirunemia
r (clinical jaundice) disease is usually transient and
 HBV and HCV co- ATV/r can be continued,
infection however, if severe
 Concomitant use of jaundice develops and is
hepatotoxic drugs associated with
significantly raised
transaminases, then ATV/r
should be replaced with
LPV/r
Nephrolithiasis and risk of Risk factors unknown Replace it with LPV/r
prematurity
DTG Increase in cholesterol History of dyslipidemia,  Monitor cholesterol
levels; mild elevated liver diabetes, hypertension levels; monitor Liver
enzymes; significant rises in function especially in
creatinine levels; Insomnia HBV and HCV.
and headache may also be  Provide symptomatic
experienced treatment
ETR Common: Skin rash, allergic No known risk factors  Monitor severity
reactions, Nausea, increased and occurrence of
low density Lipids, fever and other
Gastrointestinal disorders symptoms.
and Fatigue  Provide
Rare: Severe skin rash, symptomatic
Peripheral neuropathy and treatment
renal failure
RAL Increased Cholesterol levels, History of dyslipidemia, In case of severe adverse
Glucose, Aspartate Amino diabetes, hypertension effects, switch to DTG if
Transferase (AST), Bilirubin. patient is >12 years old
Rash, Cough, Fatigue,
dizziness and insomnia
DRV/ Increased Cholesterol levels, History of dyslipidemia  Monitor severity and
r triglycerides; Diarrhea, occurrence of fever
Headache, Rash, Abdominal and other symptoms.
pain and Nausea  Provide symptomatic
treatment

10.7.2 Changing antiretroviral therapy due to treatment failure

Monitoring individuals receiving ART is important to ensure successful treatment, identify
adherence problems and determine whether and which ART regimens should be switched in
case of treatment failure. Treatment failure can be virological, immunologic and/or clinical. It
results from failure to suppress viral replication with the development of viral resistance. It is
recommended that treatment failure diagnosis should be based on virological criteria because
it is the earliest marker of treatment failure. The advantage of early diagnosis of treatment
failure is that it is associated with less resistance associated mutations (RAMS) and hence
preserves future treatment options. In contrast late diagnosis of treatment failure using

85
immunological (CD4) or clinical criteria is associated with accumulations of RAMS which
reduce future treatment options.

Table 10.6: WHO definitions of treatment failure in chronological order of occurrence:

virological, immunological and clinical failure for the decision to switch ART regimens.

Failure Definition Comments

Virological Plasma viral load above 1000 An individual must be taking ART for
copies/ml with a log drop <0.5 at least six months before it can be
based on two consecutive viral determined that a regimen has failed.
load measurements after three
months, with enhanced adherence
support

Immunological Fall of CD4 from the baselineWithout concomitant or recent

or Persistent CD4 cell count infection or steroid use to cause a
levels below 100 cells/mm3 transient decline in the CD4 cell count
Immunological and clinical
characteristics of treatment failure
develop much later after virological
failure. Immunological and clinical
criteria of treatment failure may also
misclassify treatment failure and lead
to unnecessary ARV switch to
subsequent (line of treatment) regimen

Clinical New or recurrent clinical event The condition must be differentiated

indicating severe from IRIS
immunodeficiency (WHO clinical
stage 4 conditions) after six
months of effective treatment.

Transient rises in viral load are called viral blips and are not due to treatment failure. A
diagnosis of treatment failure requires two consecutive viral load levels after six months of
treatment with HVL above 1000 copies/mL tested within an interval of three months after
enhanced adherence counselling.
Treatment failure should be distinguished from IRIS in which case the viral load will be low
and the CD4 cell count will be high.

10.7.3 Switching to third line ARV regimens

It is crucial that before a regimen is declared to have failed, a multidisplinary switch team is
convened to rule out non-adherence which is the commonest cause of reduced CD4 cell count
and a VL rise, but is often not associated with HIV drug resistance. This team will also plan
for enhanced adherence and support, for a period of three months before a second VL test. In

86
case of non-adherence, these measures will lower the VL, increase CD4 cell count and avert a
switch to a subsequent regimen.
Before switching to third line ARV regimens, genotypic HIV drug resistance is
recommended to rule cross resistance between 1st and 2nd generation drugs and also assist in
the determination of whether treatment failure is from non-adherence. Genotyping will also
inform possibility of recycling drugs used in previous regimens i.e. some drugs used in first
or second regimens may still be effective in third line.
10.7.3.1 Criteria for changing clients to Third-line ARV
10.7.3.1.1 Failing any Second-line regimen
Referral to specialist care is recommended where third-line regimen can be chosen according
to genotype resistance testing and managed by an expert panel at tertiary care facilities.
The criteria for diagnosing second-line failure are the same as those used for diagnosing first-
line failure. In the event of treatment failure, a comprehensive evaluation to ascertain the
cause of failure should be conducted. Efforts must be made to assess and optimize adherence
and rule out any significant drug interactions. When this has been done and there is still
evidence of failure, patients should have a regimen change that will include at least two
active agents.
Viral load testing should be the gold standard for diagnosing treatment failure and the
resistance test should be used to determine the third-line regimen.
10.7.3.1.2 Eligibility for Third-Line Evaluation
All clients should have undergone an Enhanced Adherence Counselling
 Failing 2nd line regimens
 Documented virologic failure (VL >1000) on a PI regimen; except children below
three years
 Steps to refer client to 3rd line review committee:
1- Client suspected to have second-line failure from dispensary or health centre is
referred to the hospital
2- At the hospital, the client is reviewed by clinicians working in CTC, the checklist
is completed and only the checklist is sent to the review committee at the tertiary
care facility/zonal referral hospital
3- At the zonal level, the review committee reviews the checklist and recommends
which clients should be referred for evaluation including genotype resistance
testing and decision
4- Zonal level review committee communicates the decision back to the referring
hospital within a month.

10.8 Monitoring Patients on ART

Monitoring of clients on ART is based on clinical and laboratory parameters.

Clinical Monitoring:
It is expected that, treatment success is associated with weight gain and reduced morbidity
from opportunistic infections and improvement in the quality of life. At each clinic visit,
thorough history and physical examination should be done and recorded in the patient file.
Appearance of new or persisting opportunistic infections, or lack of weight gain, can indicate
treatment failure, hence, it should require further evaluation to determine fulfilment of criteria
for treatment failure. Switching to subsequent regimens should be based on virological

87
criteria; however, in settings where there is a limited access to HVL, immunological criteria
should be used.

Laboratory Monitoring:
Initiation of ART is done irrespective of CD4 cell count levels. The CD4 cell count should
nevertheless be determined from baseline to monitor immunological response. For patients
with CD4 cell count less than 350 cell/mm3 at baseline, the CD4+ T lymphocyte count should
be repeated after six months, until the patient is stable (CD4+ T lymphocyte count more than
350cell/mm3). However, in cases of suspected IRIS or treatment failure, CD4 can be tested at
intervals less than six months. As HIV viral load testing is scaled up, then there will be less
need to use CD4 levels for monitoring.

Viral load (VL) testing is the gold standard or most preferred monitoring approach to
diagnose and confirm treatment failure. It provides an early and more accurate indication of
treatment failure and the need to switch to subsequent ART line regimens, thereby reducing
accumulation of drug resistance mutations. This improves clinical outcomes and preserves
future ART line options. All health facilities should have access to viral load testing as per
national HVL testing algorithm. Treatment should be considered successful if the viral load is
<1000 copies/mL, but defined as "stable" with low risk of transmission at VL<50 copies/mL.

Discordant viral load and CD4 cell count response to ARV

Usually, concordant HIV viral load and CD4 response to ARV is when the client optimally
suppressed HIV viral load (<50 copies/ml) and robust CD4 cell count gain. A discordant
response occurs when there is optimal HIV viral load suppression without an associated
robust CD4 cell count gain. This type of response is associated with increased morbidity and
mortality. Risk factors for immuno-virological discordance response include: age more than
50 years at ART initiation, co-morbidities such as Hepatitis B, CMV, TB, high viral load at
treatment initiation, low baseline CD4 cell count and late treatment initiation of WHO
clinical stage 3 and 4. This also occurs more often in highly treatment-experienced patients
with drug-resistant HIV.
In such scenario a HCW should first, make certain the patient is receiving appropriate
prophylaxis for OIs; examine the patient's medication list for medications that can suppress
bone marrow e.g consider switching from an AZT-containing regimen to a regimen that does
not contain AZT; evaluate for any clinical manifestations, such as systemic symptoms or
pancytopenia, which suggest a marrow infiltrative process and lastly continue ART, even if
the patient has do not have a good CD4 cell count response.

10.8.1 Clinical and laboratory monitoring of clients on First and Second-line ART
regimen

(i) Scheduled visits

The first six months of ART

Clients should attend the appropriate clinic (CTC, RCH, TB, MAT) monthly for the first six
months for clinical and laboratory evaluation and drug refills.
Six months after starting ART
88
After six months of ART, if the client is clinically stable (Refer Chapter 2), with good
adherence for at least six months to ART regimen, and no history of drug toxicity or recurrent
OI, he/she may be given clinical appointment of six months and three months ARV refill
based on client's preferred ARV refill model. . The client should be given two ARV
prescriptions of three months each. During this period (before a clinical visit), the client will
report to the health facility any clinical warning sign for earlier clinical review.
Six months prescription and dispensing
Clients who continued to be stable after receiving two consecutive three months prescriptions
should receive six monthly prescriptions and dispensing of ARVs.
(ii) Unscheduled visits
Apart from scheduled visits, it is also important for the clients to present themselves to the
clinic for clinical review if they develop any unexpected/warning symptoms and/or
complications. Clinical review will determine the appropriate management required and the
need for stability re-categorization.
(iii) In case of loss to follow up

Proactive follow-up is needed by clinic team members in collaboration with home based
care providers to follow up patients who do not turn up for their scheduled visits. It is
important to institute and maintain system triggers for this throughout follow-up. Use of
reminders list, promised to come diaries, appointment blocks and patient healthcare provider
ties which have shown to improve adherence. Also, the appointment and tracking registers
should be used effectively to identify and track loss to follow up clients. A good referral
mechanism with community service directory should therefore be established between the
clinic and other levels of healthcare delivery.
Table 10.7: Summary of Laboratory Monitoring of Adolescent and adult on First and
Second-Line ART Regimens

Regimens Monitoring Tests Frequency Rationale

HVL (All Clients) For HVL monitoring, ART monitoring

refer to HVL
algorithm
TDF+3TC+DTG
ABC+3TC+DTG CD4 (All clients) Baseline (All) ART monitoring

AZT+3TC+(EFV or After every six

NVP) months if CD4 is
<350 cells/ml
TDF+FTC+(EFVor
NVP) FBP/Hb (All Baseline, week 4, Anaemia
clients) thereafter six monthly monitoring
If a client has Hb
<8.5g/dl avoid
AZT

89
 Serum Creatinine Baseline, and after Screening for early
(For patients on every six months and renal toxicity
TDF) whenever
symptomatic

ALT (For patients Baseline, one month, Liver toxicity

on DTG or NVP) after every six
months and whenever
symptomatic

AZT/3TC+ATV/r Bilirubin (For all Baseline, 6 months or Indirect hyper-

clients on ATV/r) whenever bilirubinemia
TDF/FTC+ATV/r
symptomatic
ABC/3TC+LPV/r or
DTG

Note: - Frequent laboratory tests will determined by clinical evaluation outcome.

-The frequency of CD4 and viral load monitoring may be less than six months when IRIS
or treatment failure is suspected (See Chapter 4 for more details on criteria and schedule
of CD4 and HVL testing).

Laboratory Monitoring of Adolescent and adult on First and Second-Line ART

Regimens
 FBC: at baseline, then monthly for three months, then after every six months with
CD4 and viral load
 Fasting cholesterol and triglyceride: at baseline, six months and thereafter every
12 months
 Liver function tests (ALT): at baseline, six monthly
 Fasting glucose: every 12 months
 Urinalysis: at baseline and after every three months
 Serum creatinine: at baseline and once a year.

10.9 Immune Reconstitution Inflammatory Syndrome (IRIS)

IRIS is a phenomenon associated with the occurrence or worsening of opportunistic
infections/malignancies which can occur early after initiation of ART or at later (several
months to years) during the course of ART. There is an increased risk for occurrence of IRIS
in the following situations:
 Treatment naïve patients
 Patients with advanced HIV disease with CD4 cell count <50 cells/mm3
 Patients with undiagnosed and untreated opportunistic conditions

90
  Patients who have been introduced on ART before or shortly after initiation of
treatment of opportunistic infection/malignancy
 In the advent of DTG use, there is increased likelihood for IRIS because of
rapid HIV viral load suppression.
NB: Any OI, malignancy and autoimmune diseases may present as IRIS
For clients with TB, this syndrome has been reported to occur in as many as 30% of patients
in the developed world. The syndrome is characterized by fever, lymphadenopathy,
worsening pulmonary lesions and expanding central nervous system (CNS) lesions. These
reactions are typically self-limiting although they may require the use of a brief course of
corticosteroids to reduce inflammation for CNS or severe respiratory symptoms.
Initiation of ART can also unmask previously undiagnosed infections such as hepatitis B or C
viral infections as it improves the inflammatory response while repairing the immune system.
In general, ART should not be stopped when immune reconstitution syndromes occur except
in life threatening situations in which ART should be temporarily stopped. However, where
there is doubt, the opinion of a senior HIV physician should be sought.
The criteria for making a diagnosis of IRIS are delineated in Table 10.8 below:
Table 10.8: Immune Reconstitution Inflammatory Syndrome

Diagnosis of IRIS would require:

Both major (A plus B) criteria or Criterion A plus 2 minor criteria

Major criteria
A. A typical presentation of “opportunistic infections or tumours” in patients
responding to anti-retroviral therapy (ART) includes:
 Localized disease e.g. lymph nodes, liver, spleen
 Exaggerated inflammatory reaction e.g. severe fever, with exclusion of other
causes of painful lesions
 Atypical inflammatory response in affected tissues e.g. granulomas,
suppuration, necrosis, perivascular lymphocytic inflammatory cell infiltrate
 Progression of organ dysfunction or enlargement of pre-existing lesions after
definite, clinical improvement with pathogen specific therapy prior to
commencement of ART and exclusion of treatment toxicity and new
diagnoses
 Development or enlargement of cerebral space occupying lesions after
treatment for cerebral
Cryptococcus or toxoplasmosis
 Progressive pneumonitis or the development of organizing pneumonia after
treatment of pulmonary-TB or PCP
 New onset or worsening of uveitis/vitritis after resolution of CMV retinitis
 Fever and cytopenia after treatment for disseminated Mycobacterium avium
complex (MAC) disease

91
 Enlargement of Kaposi’s sarcoma lesions and subsequent resolution or
partial regression without
 Commencement of radiotherapy, systemic chemotherapy or intralesional
therapy
B. Decrease in plasma HIV-RNA level by >1 log base ten copies/ml (1 log drop
= 9/10 of Baseline VL copies). This applies in settings where baseline VL is
performed.

Minor criteria
 Increased blood CD4+ cell count after initiation of ART
 Increase in immune response specific to the relevant pathogen e.g. delayed
type hypersensitivity to mycobacterial antigens (PPD conversion)
 Spontaneous resolution of disease without specific antimicrobial therapy or
tumour chemotherapy with continuation of anti-retroviral therapy.

Management of IRIS
Mild to moderate forms:
 Reassure the patient
 Do not stop ART
 Provide specific treatment for the opportunistic infections/malignancies or other
diseases
Severe life threatening IRIS
 Reassure the patient
 Stop ART temporarily
 Provide high doses of Prednisolone 1mg/kg for 4 weeks then taper down the dose. In
case of severe cryptococcal meningitis IRIS, short course of Steroid may be
prescribed (Refer cryptococcal meningitismanagement, on Chapter 6).
NOTE: When using high dose steroids, it is important to rule out Strogyloides stecolaris
infection to avoid disseminated strongylodiasis.
 Provide other appropriate supportive measures such as management of fever, oxygen
therapy, i.e. fluids
 Restart ART when the patient stabilizes

92
 CHAPTER 11:
ANTIRETROVIRAL THERAPY IN CHILDREN AND ADOLESCENTS LIVING
WITH HIV
11.0 Introduction
ART in children and adolescents has been proven to increase survival and decrease HIV-
related morbidity and mortality. Children and adolescents should be started on ART as soon
they are diagnosed including those with presumptive diagnosis. This chapter discusses ART
for children and adolescents living with HIV and AIDS (C/ALHIV) below 15 years of age.
11.1 Goals of Antiretroviral Therapy in Children and Adolescents
The goals of antiretroviral therapy for children and adolescents are to suppress HIV
replication and therefore prevent disease progression, preserve, enhance, or reconstitute the
immune system and therefore reduce opportunistic infections, reduce morbidity, promote
optimal growth and development and long life prolong the survival of C/ALHIV and improve
their quality of life. In most children, viral load decline is followed by rising CD4 cell counts
after ART initiation. Generally, CD4 cell count increases over the course of the first year of
treatment reaches a plateau and then continues to rise further over the second year. However,
in some children, severe immunosuppression may persist. The lower the CD4 cell counts at
the start of ART the slower the recovery. Persistent failure of CD4 cell count response should
alert the clinician to potential adherence problems or non-response to ART. Undetectable
viral loads of <50 copies/ml should be achieved and sustained.

In order to achieve these goals, the following strategies should be used:

 Identify barriers (e.g. Non-disclosure, suboptimal dosage, adherence to frequency of
drug prescribed) to adherence and implement supportive strategies for caregivers and
clients to maximize adherence to the antiretroviral regimens
 Adequate counseling of the parent/caregiver and of children an age appropriate way
 Rational sequencing of drugs for the preservation of future treatment options
 Monitoring of drug resistance
 Monitoring of toxicities and adverse drug reactions.

11.2 When to start ART in children and adolescents under 15 years

It is important that prescribers are clear about when to start antiretroviral drugs. They also
need to know which drugs to use, in which order, when to change therapy, and which
alternative drugs to use when changing therapy.
11.2.1 Initiation of ART for children and adolescents under 15 years
Among children and adolescents under 15 years, there are three groups for eligibility to begin
treatment:
All children and adolescents <15 years of age who have a confirmed diagnosis of HIV,
regardless of WHO clinical stage or CD4 cell count

93
Children <18 months of age with a positive DNA /RNA PCR test who should start ART and
repeat the DNA /RNA PCR test for confirmation
Presumptive HIV infection: HIV exposed children below 18 months with a presumptive HIV
infection without a DNA /RNA PCR test result, (see criteria for presumptive diagnosis of
severe HIV infection in infants and children <18 months in Chapter 7) should start ART and
do a confirmatory DNA /RNA PCR test as soon as possible.

Table 11.1: When to start ART in children and adolescents under 15 years

Age When you start

Children 0-15 years Treat all of them regardless of WHO

clinical stage or CD4 cell count

Children below 18 months old who Start ART while are waiting for DNA-
qualify for presumptive diagnosis PCR confirmation test results.

Children <18 months of age with a Start ART while waiting for the second
positive DNA/RNA DNA/RNAPCR test result
PCR test

11.2.2 First-Line ARV Regimens in Infants and Children under 15 years

The first-line regimen for children under 15 years is as shown in Table 11.2 below:

Table 11.2 Summary of first line ART Regimen for children under 15 years old
Patient group Preferred 1stLine Justification Alternatives Comments
Regimen
Infants and ABC/3TC+LPV/r Higher genetic AZT/3TC+LPV/r LPV/r is available
Children resistance in three
weighing barrier formulations
<20kg AZT/3TC+DTG (syrup, granules
Avoids NNRTI
(25mg or 10mg and tablets)
transmitted
DTG if available)
resistance from -LPV/r oral
mother during solutions for
PMTCT younger infants
until they are able
Potential for
to take granules
malaria
prevention -LPV/r granules
for infants and
Spares AZT
younger children

94
 for second-line -LPV/r
100mg/25mg heat
stable tablets for
children 10kg and
above and able to
swallow whole
tablets

Children and ABC + 3TC + -Lowers HIV ABC+3TC+LPV/

adolescents DTG viral load very r
ABC/3TC
weighing fast
Dispensable Tablet
≥20kg
-Has high 120/60 mg plus
genetic barriers DTG tablet 50mg
to resistance
compared to
both PIs and
NNRTIs
-Spares AZT
for second-line

Children and TDF + 3TC + Higher genetic ABC+3TC+DTG TLD Fixed Dose
Adolescents DTG resistance Combination
TDF+3TC+EFV6
weighing ≥30 barrier
00 or EFV400
kg
Avoids NNRTI
transmitted
resistance from
mother during
PMTCT
Possibility of
malaria
prevention
Spares AZT
for second-line

For TB and ABC/3TC+LPV/r Continue with ABC/3TC+LPV/r

HIV co- ABC/3TC+LP in the morning and
infected V/r but the onlyLPV/r in the
children dose of LPV/r evening
already on should be
LPV/r based doubled due to

95
regimen the interaction
between
ritonavir and
rifampicin
For TB and ABC/3TC+DTG For children ABC/3TC+DTG
HIV co- 20-25 kg in the morning and
infected who get only DTG in the
children TB/HIV co- evening
already on infection it is
DTG based advisable to
regimen give them
ABC/3TC/EF
V for the time
of the TB
treatment then
revert to
ABC/3TC/DT
G after
completion of
TB Treatment
For children >
25 kg
Continue with
ABC/3TC+DT
G but the dose
of DTG should
be doubled due
to the
interaction
between
ritonavir and
rifampicin

For TB and TDF+3TC+DTG For children TLD in the

HIV co- 20-25 kg who morning and only
infected on get TB/HIV DTG (50mg ) in
TLD co-infection it the evening
is advisable to
give them
TDF/3TC/EFV
for the time of
the TB
treatment then
revert to
TDF/3TC/DT

96
 G after
completion of
TB Treatment
For children >
25 kg
Continue with
the same
regimen,
Double dose of
DTG

For dosing of ARV regimens see Annex 8, Paediatric Antiretroviral Dosing

NOTE: Children with weight above 30kg can use 300mg TDF as a fixed dose combination
with 3TC.
Special Considerations for LPV/r syrup, granules and tablets:
LPV/r (80mg/20mg/mL) oral solution for infants with HIV infection who are unable to
safely swallow LPV/r pellets or granules. Infants will typically use oral solution until 3-6
months of age (typical upper weight limit of 6 kg), before transitioning to pellets or granules.

The LPV/r syrup requires a cold chain during storage at the facility only. After dispensing,
the syrup is stable at room temperature for one month so patients should be given a maximum
of one month supply.
LPV/r granules: to be used for CLHIV who are able to safely swallow LPV/r granules but
who are unable to swallow LPV/r tablets whole. LPV/r granules are appropriate for many
infants who weigh 3-5.9kg, all infants 6-9.9kg, and some children in the 10-13.9 kg weight
band who cannot yet swallow small tablets whole
LPV/r tablet is heat stable but must be swallowed whole and should not be split or crushed as
it loses effectiveness and LPV/r has shown protection benefit against malaria32.
LPV/r 100mg/25mg tablets for CLHIV who are able to swallow tablet whole without
splitting or crushing. Transition to LPV/r tablets should occur as early and as safely as
possible. This will require a proactive approach to teaching young children how to swallow
tablets whole. These tablets are smaller and easier to swallow than LPV/r 200mg/50mg used
in older children and adults. This formulation is appropriate for some children in the 10-13.9

32Achan J et al. antiretroviral agents and prevention of malaria in HIV infected Ugandan Children. New England
Journal of Medicine 2012, 367:2110-2118.

97
kg band and most children in the 14 kg-19.9 kg weight band. Transitioning younger children
from pellets or granules to tablets is better for patients and caregivers as it greatly simplifies
administration.

11.3 Changing ARV Therapy in children and adolescents under 15 years

11.3.1 Drug toxicity
The principles for changing ARVs and the managing drug toxicity in children and
adolescents are similar to those applied to adults. When toxicity is related to an identifiable
drug in the regimen, the offending drug should be replaced with another drug that does not
have the same side effects.

11.3.2 Treatment failure

11.3.2.1 Virological treatment failure
Viral load is the most reliable method to detect early treatment failure. Virological treatment
failure is recognized if the child or the adolescent is adherent to the current ART regimen, for
six months or more and has two consecutive viral load measurements over 1000 copies/ml at
three months apart. For more details on routine HVL see Chapter 4, Section 4.4.

Changing a child or an adolescent from first to second-line ARV is a decision that should
only be undertaken after consultation with an expert. Second-line treatment is generally used
following treatment failure, as reflected by a HVL greater than 1000 copies/ml despite good
adherence. General considerations prior to defining treatment failure:
 Allow reasonable trial on therapy with good adherence (at least 12 – 24 weeks) before
concluding that a regimen is failing. (Calculate HVL drop from previous
measurement using 0.5 log thresholds for children above 2 years and 0.7 log for
children below 2 years)
 Monitor closely the adherence during this time
 Always attempt to improve adherence before switching regimens, as poor adherence
to treatment is the most common cause of virological failure.

11.3.2.2 Immunological treatment failure

If adherence is good, immunological criteria indicating that a change to second-line therapy is
warranted where/when HVL test is not available includes the following:
Table 11.3: CD4 criteria suggesting immunological failure a
Immunological failure is recognized as developing or returning to the following age-related
immunological thresholds after at least six months on ART, in a treatment-adherent child:

98
<5 years of age CD4 count of <200 cells/mm3 or CD4 <10%
≥5 years of age CD4 count of <100 cells/mm3
a
Preferably, at least two CD4 measurements should be available
Use of percentage CD4 in children <5 years and absolute CD4 cell counts in those ≥5 years
of age is preferred.
If serial CD4 values are available, the rate of CD4 cell count declines from the peak, CD4
cell count reached should be taken into consideration.
Note: CD4 cell percentage should not be measured during an inter-current infection but can
be determined when the child has recovered.
If there is a modest decline in CD4 cell count or percentage (<5%); and if there is no failure
to thrive do not change medication, instead maintain close monitoring.

11.3.3 Clinical treatment failure

Clinical treatment failure is a new or recurrent clinical event indicating advanced or severe
immunodeficiency (WHO clinical stage 3 and 4 with exception TB) after six months of
effective treatment.
Clinical conditions indicating that a change to second-line therapy is warranted include:
Poor growth (failure to gain weight, declining or stagnant weight) over a six-month period,
after excluding other causes, such as TB, feeding problems and food insecurity, no
improvement of neuro-developmental milestones, development of HIV encephalopathy,
recurrent infections, such as oral candidiasis, persistent diarrhoea, recurrent severe bacterial
pneumonia and advancement from one clinical stage to another or new evidence of new
WHO stage 3 or 4 disease (see Paediatric WHO Clinical Staging).
Note:
 Short inter-current episodes of pneumonia, LRTI and gastroenteritis should not be
regarded as clinical failure.
 Pulmonary or lymph node TB, which are clinical stage 3 conditions, are not
indications of treatment failure, and thus may not require consideration of second-line
therapy
 The response to TB therapy should be used to evaluate the need for switching therapy
 Before an ARV regimen is thought to be failing based on clinical criteria, the child
and the adolescent should have received the regimen for at least six months.
 The condition must be differentiated from immune reconstitution inflammatory
syndrome.

11.4 Laboratory parameters for monitoring children and adolescents under 15 years at
baseline, before and during ART
Table 11.4: Laboratory parameters for monitoring infants and children under 15 years at

99
baseline, before and during ART
Laboratory tests for diagnosis and Baseline At initiation Every six As required
monitoring (at entry of first-line or months or symptom-
into care) second-line directed
ART regimen
HIV diagnostic testing √
Haemoglobin √ √ √
WBC and differential count √ √
%CD4+ or absolute CD4 cell count √ √b √
Pregnancy testing in adolescent girls √ √
Full chemistry (including, but not √ √e √
restricted to, liver enzymes, renal
function, glucose, lipids, amylase,
lipase and serum electrolytes)e
HIV VL measurement √d √
OI screening (where possible) √ √ √ √
a. HIV re-testing for verification before ART initiation, re-testing is not indicated when
switching to 2nd or 3rd line

b. For children of <5years continue CD4 monitoring every six months

c. CD4 cell count should be taken on emergence of WHO stage 3 or 4 disease

d. Viral load monitoring is done annually if the first two VL results 6th month apart are
<1000 copies/mL

e. Regular monitoring (every six months) of full chemistry, particularly lipid levels, liver
enzymes and renal functions, should be considered for infants and children on ART.

11.5 Assessment of infants and children receiving ARV therapy

Important clinical signs of response to ARV therapy in children include improvement in
growth and development and decreased frequency of infections (bacterial infections, oral
thrush, and/or other opportunistic infections). Clinical monitoring of ARV treatment in
children should consist of feeding practice and nutritional status, growth monitoring: weight,
height, MUAC (mid-upper arm circumference), head circumference should be monitored in
children under 3 years old, neurologic symptoms and developmental milestones,
cotrimoxazole prophylaxis taken daily, adjustment of ARV dose based on weight, WHO

100
disease clinical staging, immunization status, other medical conditions, screening for malaria
and TB and drugs side effects

11.6 Recommended Second-Line ARV Therapy for Infants and Children under 15 years
Optimized NRTIs backbone should be used: AZT following TDF or ABC failure and vice
versa.
For children and adolescents less than 20kgs whose first-line regimen was EFV or NVP
based, then switched to LPV/r based regimen and maintain PIs. Measures to improve
adherence should be taken, (since PIs have high genetic barrier for mutation) for
improvement of virological suppression.
For children and adolescents whose 1st regimen was EFV or NVP based, then switched to
DTG based regimen and were not previously exposed to PIs, their preferred 2 nd line regimen
is PIs based. However, DTG can be re-cycled in the second line due to its high genetic
barrier.
Note: Infants and children take longer time to attain adequate viral suppression. Before
confirming treatment failure, calculate drop in VL (using 0.5 log for two years and above, 0.7
log below two years - for further details on how to convert VL into numbers see Annex 06).
Table 11.5: Recommended second-line ART regimens for children and adolescents under 15
years
Patient group If is on the Preferred 2L Comments
following first line
Children and ABC+3TC+LPV/r Maintain PI -Higher genetic
adolescents <20kg resistance barrier
whose 1st regimen was
-Spare INSTI for
EFV or NVP based, AZT+3TC+LPV/r AZT+3TC+LPV/r
third-line
then transitioned to
LPV/r based regimen

Children and ABC+3TC+DTG AZT+3TC+ATV/r Maintain DTG in

adolescents ≥20kg the 2L due to
st AZT/3TC+DTG
whose 1 regimen was higher genetic
EFV or NVP based, AZT+3TC+DTG ABC+3TC+DTG barrier than PIs.
then transitioned to (for those who
DTG based regimen cannot tolerate
AZT)

101
Children and TDF+3TC+DTG AZT+3TC+ATV/r
adolescents weighing
ABC+3TC+ATV/r
≥30kg

For dosing of ARV regimens see Annex 8, Paediatric Antiretroviral Dosing

Note:
 ATV/r can be used as an alternative to LPV/r in children above six years old if
pediatric formulation is available but adolescents >30kg can take adult formulation.

11.7 Third Line ARV regimens in children and adolscents under 15 years
With the roll out of routine HIV viral load monitoring in the programme, early and accurate
confirmation of treatment failure will be determined. This will prevent accumulation of drug
resistant mutants and thereby improving clinical outcomes. Similarly, improvement in
diagnosis of second line ART failure will go hand in hand with the scale up of HIV viral load
monitoring.
Clients failing 2nd line regimen have extensive NRTI and NNRTIs associated resistance
mutations which minimise their use in third line regimens. Third line regimen is constructed
using new classes of drugs or second generation formulations, in order to have at least two or
three effective drugs. For examples, Darunavir (DRV) is a second generation PI without cross
resistance to Lopinavir/r used in the previous regimens. New classes of drugs include
Integrase Strand Transfer Inhibitors (INSTIs) or Integrase Inhibitors such as Dolutegravir
(DTG) and Raltegravir (RAL). The other groups include Fusion Inhibitors such as
Enfuvirtide (ENF) and Chemokine Inhibitors (CCR5 Inhibitors) such as Maraviroc. The
disadvantages of the last two groups are the currently available fusion inhibitor requires
parenteral administration while the CCR5 Inhibitor Maraviroc requires prior determination of
HIV tropism, a test which is not yet available in Tanzania.
Therefore, this guideline recommends the use of Integrase Inhibitors DTG and RAL, Second
generation PIs (DRV/r) as third line

11.7.1 Criteria for Change to Third-line

Failing any 2nd line regimen
The criteria for diagnosing second-line failure are the same as those used for diagnosing first-
line failure. In the event of treatment failure, a comprehensive evaluation to ascertain the
cause of failure should be conducted. Efforts must be made to assess and optimize adherence
and rule out any significant drug interactions. When this has been done and there is still
evidence of failure, patients should have a regimen change that will include at least two
active agents.

102
Viral load testing should be the gold standard for diagnosing treatment failure and the
resistance test should be used to determine the third line regimen. Referral to specialist care is
recommended where third line regimen can be chosen according to genotype resistance
testing and managed by an expert panel at tertiary care facilities.

Eligibility for Third Line Evaluation:

All clients Failing 2nd line regimens who have undergone an Enhanced Adherence
Counselling and documented HIV virologic failure (VL >1000) on a PI regimen; except
children below 3 years.
Steps to refer client to 3rd line review committee
1. Client suspected to have second line failure from dispensary or health centre is
referred to the hospital
2. At the hospital, the client is reviewed by clinicians working in CTC, the checklist is
completed and only the checklist is sent to the review committee at the tertiary care
facility/zonal referral hospital.

At the zonal level, the review committee reviews the checklist and recommends which clients
should be referred for evaluation including genotype resistance testing and decision.
Zonal level review committee communicates the decision back to the referring hospital
within a month.
Selection of third-line regimen should consider genotype resistance test results as well as
treatment history.
Table 11.6. Third-line regimens paediatrics and adolescents

Patient group 3L Options Justification

Children <20kg DRV/r -High genetic barrier,

Effective for patients with
RAL + DRV/r + AZT/3TC
resistance to LPVr and ATVr,
cannot be used in children <3
Children >20kg and years of age
above
DTG + DRV/r + AZT/3TC RAL-Can be used for children <20
kg
DTG-Can be used for children >20
kg

103
11.8 Adverse reactions in children and adolescents
Drug-related adverse reactions while on ART can occur immediately (soon after a drug has
been administered), early (within the first days or weeks of treatment) or late (after months of
treatment).
Adverse reactions can vary in severity from mild to severe to life-threatening and may be
specific to the drug or general to the class of drugs in use.
Table 11.7 Major Types of ARV Toxicity in Children and adolescents
ABC ABC is associated with hypersensitivity reactions. Patients may have
severe skin rashes or other non-specific symptoms such as fever,
arthralgias and lymphnode enlargement

AZT AZT is associated with risk of haematological toxicity which can

include anemia neutropenia and thrombocytopenia. Measuring
hemoglobin is recommended before initiating ART among children and
adolescents with low body weight, low CD4 cell counts and advanced
HIV disease. Patients with severe anemia at baseline (haemoglobin <7.5
g/dL) should avoid AZT as first line therapy

TDF TDF is associated with nephrotoxicity. Nephrotoxicity is more common

in elderly patients but it also occurs in children and adolescents,
especially if co-administered with PI based therapy. Monitoring of
creatinine clearance is recommended.
EFV EFV’s main type of toxicity is central nervous system side effects,
which typically resolve after a few weeks. However, in some cases, they
can persist for months or never resolve at all.
NVP NVP’s major toxicities include severe skin rash and hypersensitivity
reaction (Steven’s Johnson syndrome) and hepatotoxicity. Because of
the risk of potentially life-threatening hepatotoxicity associated with
NVP, hepatic dysfunction of any aetiology in a child and an adolescent
on NVP requires careful consideration of whether NVP should be
continued.
LPV/r LPV/r’s major toxicity includes hepatotoxicity, pancreatitis, diarrhoea
and lipoatrophy. The risk of hepatotoxicity is increased in patients with
underlying hepatic disease and the risk of pancreatitis is increased in
patients with advanced HIV disease. Electro-cardiac abnormalities are
also possible; patients with pre-existing conduction system disease are
at an increased risk

104
ATV/r Toxicities of ATV/r are similar to those of LPV/r. ATV/r can cause
jaundice (indirect hyperbilirubinemia). Jaundice (indirect
hyperbilirubinemia) is usually transient and ATV/r can be continued. If
severe jaundice develops and there are significantly raised
transaminases, then ATV/r should be replaced with LPV/r

DRV/r DRV/r’s major toxicity is hepatotoxicity. Patients with underlying

hepatic disease, hepatitis B or C co-infection or who are taking other
hepatotoxic drugs are at a higher risk. The other side effect is severe
skin and hypersensitivity reactions. Patients with sulfonamide allergy
are at a higher risk
RAL RAL’s potential toxicity includes rhabdomyolysis, myopathy and
myalgias as well as hepatitis and hepatic failure and severe skin rash and
DTG hypersensitivity
DTG reactions.
major toxicity is hepatotoxicity and hypersensitivity reactions.
Patients with underlying liver disease or hepatitis B or C co-infection
are at a higher risk.

Principles in the management of ARV drug toxicity:

 Determine the seriousness of the toxicity
 Evaluate concurrent medications and establish whether the toxicity is attributable to
ARV drug or non-ARV medication taken at the same time
 Consider other disease processes (e.g. viral hepatitis in a child (or an adolescent) on
ARV drugs who develops jaundice). Not all problems that arise during treatment are
caused by ARV drugs.
 Manage the adverse reactions according to its severity.

In general:
Severe life-threatening reactions: Immediately discontinue all ARV drugs, manage the
medical event (i.e. provide symptomatic and supportive therapy) and reintroduce ARV drugs
using a modified regimen (i.e. with an ARV substitution for the offending drug) when the
patient is stabilized.
Severe reactions: Substitute the offending drug without stopping ART.
Moderate reactions: Consider continuation of ART as long as it is feasible. If the patient does
not improve on symptomatic therapy, consider single-drug substitution.
Mild reactions: Reassure a child (or an adolescent) and the caregiver that while the reaction
may be bothersome, it does not require a change in therapy; provide counselling and support
to mitigate adverse reactions.
Emphasize on the maintenance of adherence despite mild and moderate reactions.
Table 11.8: Severe toxicities of ARVs in infants and children, and potential drug
substitutions

105
Toxicity events Responsible Suggested first-line ARV
ARV drug substitution
Acute symptomatic hepatitis NVP EFV
If the patient cannot tolerate
either NNRTI, use boosted PI
Severe or life-threatening rash boosted PI
(Stevens-Johnson syndrome)
Hypersensitivity reaction ABC AZT
Lipoatrophy/metabolic syndrome LPV/r If LPV/r is used in first line
ART for children and
adolescents, use an age
appropriate NNRTI (NVP for
children below 3 years and
EFV for children and
adolescents with 3 years and
above)

ATV/r can be used for

children and adolescents
above 6 years
Severe anaemia or neutropenia AZT Substitute with ABC if < 35
kg
Severe gastrointestinal intolerance

Substitute with TDF if > 35

kg
Persistent and severe central EFV NVP
nervous system toxicity
Tubular renal dysfunction TDF If TDF is being used in first
line ART, substitute with
AZT or ABC
If TDF is being used in
second line ART, substitute
with ABC

Patients on third-line ARV regimen who develop toxicities should be managed by a

specialist.

106
 CHAPTER 12:
ADHERENCE TO ART AND RETENTION ACROSS CONTINUUM OF CARE
12.0 Introduction
Adherence means sticking firmly to treatment regimen by taking the right medicine, with the
right dose, at the right time, in the right frequency, in the right way every day and exactly as
agreed between healthcare providers, clients and care givers. High level of sustainable
adherence is crucial for achieving viral suppression needed for attainment of ART benefits
which include immune restoration, prolonged survival, reduced resistance, improved quality
of life and treatment as prevention. This chapter explains factors and strategies that influence
adherence counselling and monitoring among children, adolescents, youth and adults.
12.1 Factors and Strategies that Influence Adherence to ART
Adherence level of >95% is needed to maximize the benefits of ART. However, achieving
such high rates over a long period of time is a challenge. Therefore, to improve adherence,
different approaches should be sought and tailored to the patient’s lifestyle through proper
counselling and health education.
12.1.1 Factors that Influence Adherence
The following are predictors of good adherence to ART:
 Client’s self-commitment
 Availability of emotional and practical life support
 Clients’ ability to fit the medications into their daily routine
 Uninterrupted availability of ARVs
 Accessibility to CTC services
 Good tolerability of ARVs.

12.1.2 Factors that Enhance Adherence

Factors that enhance adherence are categorized as follows:
(i) Client related factors
 Disclosure of HIV status
 Readiness to be on life-long medication
 The understanding that the first-line ART regimen has the best chance of long-term
success
 The understanding on the advantages and disadvantages of adhering to ARVs
 Involvement of a treatment supporter/family member
 Readiness to participate in Couple/Family counselling.

107
(ii) Health service providers related factors include:
 Agreement between a client and HSPs on the treatment plan
 Building a trusting relationship with the clients
 Supportive, non-judgmental attitudes and behaviours of the HSPs
 Health education to clients at every clinical encounter with emphasis on adherence
and possible side effects associated with ART
 Linkages to community support services
 Teamwork approach by HSPs.

(iii) Regimen-related factors

 Use of fixed drug combinations to reduce pill burden
 Minimise Drug interactions and side effects through rational drug selection
 Observe ARVs medication requirements (e.g. with food, without food, etc.).

Adherence Counselling for Treatment in Adults in the context of ‘‘Treat All’’

For achieving optimal and sustained adherence in the context of ‘‘Treat All’’, clients should
be educated on, the benefits of early treatment regardless of CD4 cell count or clinical stage.
These benefits include much prolonged survival, better clinical outcomes, early restoration of
immunity, community prevention of TB and new HIV infections.

12.2.1 Sessions on Adherence Counselling for Adults

i) First session of adherence counselling
Review:
 CTC 1 card and ensure client’s information filled out is complete and accurate
 CTC 2 card to understand client’s socio-demographic data
 Use the checklist for counselling session I and document the information in CTC2
card, provide enough time for questions and respond accordingly
 Review client’s basic knowledge on HIV infection, AIDS progression and correct any
misconceptions
 Provide information on early lifelong treatment of ARVs
 Discuss with the client on how ARVs inhibit HIV replication
 Discuss with the client on importance of treatment adherence and the consequences of
failing to take ARV as prescribed
 Provide information on the role of CD4 cell count and viral load in monitoring
treatment outcome
 Discuss potential barriers and lifestyles that might influence adherence to ART and
assist the client to make a plan to overcome the barriers (See Table 12.2 below)
 Discuss with the client on Positive Health, Dignity and Prevention (PHDP)

108
  Refer the client for treatment and prophylaxis in case of any OIs
 Discuss and link to community based health services Assess client’s willingness and
readiness to start ART
 Schedule the client on early appointment for the 2nd counselling session if the client is
not willing and ready to start ART.

(ii) Second Session of Adherence Counselling for Adults

 Review the previous counselling session and answer client’s questions appropriately
 Use counselling session II checklist and document the information in CTC2 card,
provide enough time for questions and respond accordingly
 Discuss potential barriers and lifestyles that might influence ARVs adherence and
assist the client to make a plan to overcome the barriers (See Table 12.2)
 Assess client’s willingness and readiness to start ART. Schedule the client on early
appointment for the 3rd counselling session if s/he is not willing and ready to start
ART.

(iii) Third Session of Adherence Counselling for Adults

 Confirm the client’s readiness to start ART and initiate treatment
 Use counselling session III checklist and document the information in CTC2 card,
provide enough time for questions and respond accordingly
 Assess barriers to adherence and address them
 Involve the client to change (if needed) treatment plan
 Review adherence to risk reduction behaviours, lifestyles, and use of traditional herbs
 Document successes and revisions in plans
 Let the client paraphrase instruction on how to take ARVs
 Encourage the client to return to the clinic as early as possible when he/she
experiences side effects before deciding to stop ARV
 Identify appropriate adherence helpers such as alarm clocks, cell phone alarms, pill
boxes and dose schedule cards and advise the client accordingly
 Encourage the client to have two or more adherence helpers
 Provide time for questions, respond and refer the client accordingly
 Emphasize on the importance of adherence to care and on ART
 Schedule the client for the next appointment
 Remind the client to bring the remaining pills when attending the scheduled visit.
 Follow-up Visits after Initiating ART
 Use the checklist and document follow–up visits after ARV drug initiation

Review with the client on the following:

109
  Proposed treatment adherence plan
 Understanding of the prescribed treatment regimen
 Assess client’s understanding on the importance of correct use of prescribed ARVs
 Assess adherence from self-report and pills’ count and explore about missed doses
since the last visit
 If adherence is <95% with or without viral, immunological or clinical failure, then re-
educate the client. If adherence is >95%, encourage the client to adhere to treatment
 Discuss the current (positive as well as negative) experiences about medications
 Discuss the strategies to minimize side effects
 Explore the factors that might prevent correct use of drugs
 Discuss about storage of drugs at home
 Discuss on how to ensure adequate supply of drugs in the event of unexpected travel
 Schedule with the client on the next appointment.

12.2.2 Monitoring Adherence

Optimal adherence requires full participation by the healthcare team as every client’s
interaction represents an opportunity for reinforcement. It is also important to have close
linkages between CTC based and community based HIV services to ensure a strong client
tracking system that will help to understand and mitigate any reasons for missed visits and
loss to follow up for both clients on ARV drugs. The following are important considerations
for care and treatment team members:
 All care and treatment team members shall provide continual monitoring for
adherence and timely response to adverse events or interim illnesses
 Adherence support must be intensified when some negative changes are noted, by
investigating barriers, scheduling appropriate visits, linking with home-based services
and assessing support of family/friends
 All team members should provide consistent messages related to adherence to clients
and their adherence assistants
 Clients and/or treatment assistants or care providers should be reminded to bring their
drug stocks with them at every visit
 Pharmacy staff should monitor adherence using self-reporting
 Specific training regarding ART and adherence should be offered and updated
periodically for all healthcare team members
 Systems shall be in place to adequately document indicators for levels of ARV drug
adherence for individual clients as well as using collected information to assess
performance at site level.

Note: Clients who take <80% of their pill doses are unlikely to have any durable viral
suppression. When available, HIV viral load measurement should be used to determine
whether clients are targeted for enhanced adherence counselling.

110
Formula for Calculating % Adherence:
% of pills missed = No. of pills remaining x 100
Total No. of pills prescribed

% adherence = 100 - % of pills missed

Table 12.2: Barriers to Adult Treatment Adherence and How to alleviate them
Key Barrier to adherence Suggestions to Alleviate
Social economic problems e.g.  Refer /Link to support groups for assistance
transportation, food insecurity
 Refer to organizations for economic support
e.g. Income Generating Activities (IGA)

 Identify nearby CTC sites

 Involve other family members

No disclosure  Counsel on benefits of disclosure

Travels frequently  Carry pills

 Collect pills in advance for longer period

 Walk with your CTC 1 card

 Visit any nearby health facility for required

services

 Counsel to stop or reduce alcohol intake

Behavioural barriers e.g.
 Involve other family members for support
Drinking alcohol regularly, not
planning refill for travels or not  Plan for drug refill
having a reminder
 Address the use of reminders

Emotional barriers e.g.  Counsel for psychosocial support

Depression or Mental illness
 Refer to clinician for treatment

 Involve other family members for support

ARVs issues e.g. side effects,  Discuss effectiveness and safety of drugs
pill burden

111
  Discuss issues of misconception

 Discuss drugs side effects and resistance

 Carry pills to hospital

Unexpected hospital admissions  Inform healthcare staff that you are on ARV
treatment

Stigma and Discrimination  Link patients with support groups

 Create awareness in the communities

 Refer to CBHS

 Provide health education on HIV and AIDS

Cultural Beliefs  Provide Health Education on HIV and AIDS

 Create awareness in the communities

including religious leaders and traditional
healers

Gender Based Violence  Provide couple and family counselling

 Link clients to Human Rights and Legal

issues organizations for support

Communication Problems  Use colours, symbols and pictures for

elaboration

 Usage of sign language

 Use simple language

 Use treatment supporter

 Have adequate preparation before treatment

initiation

12.3 Adherence Counselling in Children and Adolescents

12.3.1 Factors that Influence Adherence in Children
The HSPs should inquire to find out the factors that affect child’s adherence:
Child related factors

112
Child related factors include the child’s living environment, age, the complexity of the drug
regimen, HIV disclosure status and the health status. Include other medications the child is
also taking.
Family/ caregiver related factors
They include reliability, education and socioeconomic status of the caregiver, family cultural
beliefs and practices, the HIV status of the parents and caregivers and the relationship
between the caregiver and the child and ability of parents/caregiver to disclose.
System related factors
These include the relationship between the caregiver and the clinician, stock outs of
medications and contradicting information from HSPs regarding medication regimen.

12.3.2 How to Prepare for Adherence in Children

The health service provider should:
 Identify a primary committed parent/ caretaker and counsel them fully
 Discuss with parent/ caretaker on disclosure of HIV status of a child/ adolescent
 Confirm availability of support services
 Assess for stability of family environment
 Assess caregiver and child’s readiness to start ARV
 Have an agreement with a caregiver/ child that medicines should be taken as
prescribed
 Address the key barriers to adherence and suggest how to alleviate them
 Disclose child’s status and need for lifelong treatment to parents/ caregiver
 Support parent/caregiver to disclose HIV status to the child
 Identify responsible person for daily drug administration
 Family centred approach is recommended
 Conduct demonstration sessions on drug dosages and administration
 Ensure access to primary care for nutrition counseling and support.

12.3.3 Considerations for Readiness to Start Treatment for Children

Before starting medications, the HSPs should consider the following:
 Parent/caregiver understands the importance of clinic visits and maintaining CTC 1
card
 Understand roles of different household members in drug administration
 If the caregiver is ready to start ART to the child, initiate it on the same clinic day.

113
12.3.4 Strategies for Successful Adherence among Children
 Assess for readiness to treatment
 Identify and address all potential barriers to treatment
 For adherence, focus on strategies that are household or family oriented

Adherence counselling is an ongoing process and it takes time and commitment

 Ensure the use of relevant checklist and SOPs
 Address on adherence at every client’s visit
 review regularly, the strategies to meet the changing needs of the growing child
 HSPs should work as a team – doctors, nurses, pharmacists, counsellors to reinforce
adherence
 Identify one household caregiver who gives medication to the child and attends to the
clinic with the child.

Table 12.3. Common Challenges and Strategies to Improve Adherence in Children

CHALLENGE STRATEGIES
Child not taking medications  Obtain a detailed history aimed at identification of the
specific causes of his/her broad complaint

 Explore with the parent/caregiver on ways to convince

the child to take the medications

 Teach the parent/caregiver on the importance of

adherence for the child’s survival

 Simplify adherence information to ensure the

parent/caregiver understands the treatment regimen

2. Medicines make a child  Administer medications with food

sick e.g. nausea and vomiting
 Administer medications with liquid to help reduce
gastric irritation

 Reassure the caregiver/parent that most nausea and

vomiting will resolve

 If symptoms are severe, seek expert advice on regimen

change and timing of medication.

114
3. Fear of ART harming the  Ensure that the child is taking the correct dose
child e.g. the child is
clinically deteriorating despite  Examine the child for other opportunistic infections
good adherence
 Examine the child for side effects of the regimen

 Encourage the caregiver/parent to continue the regimen

unless the child has severe side effects, in which case
seek an expert advice about changing the regimen

 Utilize visiting nurses/HBC providers to assist with

adherence assessments and follow up home visits.

4. Regimen dosing confusing  Provide the caregiver/parent with a written schedule/

to a caregiver/parent illustration of medications

 A written calendar could include symbols for the times

of the day to aid with understanding, or utilize colour-
coded labels to match with drug regimen colour- coded
calendar

Where possible, elicit additional support from another

family member or other community resource person.

Parent/caregiver is ill or  Treat the ill parent/caregiver

absent and other family
members cannot give  Probe and promote disclosure
medications to the child
 Identify another treatment supporter

 Address stigma and discrimination; provide health

education to dispel myths on HIV and AIDS. Refer to
CBHS.

Complexity of measuring  Provide the parent/caregiver with a written

pediatric formulations e.g. schedule/illustration of medication
LPV/r syrup
 Demonstrate procedures; if possible seek additional
support from other family members or other community
resource persons.

12.3.6 Consequences of Poor Adherence in Children

Consequences of poor adherence to ART in children include treatment failure, HIV drug
resistance, increased morbidity and mortality as well as growth and developmental faltering.

115
12.4 Adherence among Adolescents and Youths
Adolescents and youths living with HIV are subject to stigma related with chronic illness,
challenges of parental authority and therefore, they may wish to have their own friendly
services. Adolescents and youths are susceptible to default a regimen if they encounter any
difficulties.
Favourable circumstances for adherence:
 Dedicated adolescents and youth friendly services/clinics
 Adequate support from caregiver, family, and friends
 Stability in one’s life so that they are able to obtain basic needs as well as play and
attend school like other children
 Beneficial and early disclosure leading to increased participation in their treatment
 Change in health status or laboratory parameters, encourages continuation of
treatment
 Familiarity with people responding well to similar therapies encourages the
adolescent to adhere to treatment. It is essential that they get a chance to share
experiences with peers having similar experiences
 Familiarity with someone who is sick or who may have recently died due to non-drug
adherence encourages the adolescent to avoid a similar fate, so s/he will adhere to the
regimen
 Access to a supportive clinician may also provide discussing options. Adolescents are
curious and should be given as much information by the HCP.
 Supportive community that do not stigmatize HIV clients
 Adequate support during transition from paediatric/adolescent to adult clinics.

Factors affecting drug adherence among adolescents:

 Unstable living conditions where s/he moves from one guardian to another or if living
in the streets
 Lack of support from guardian, family, friends and school teachers
 Lack of readiness and refusal to initiate/continue ART
 Limited access to adolescent friendly services
 Depression and other mental issues
 Substance use makes it difficult for individuals to adhere to treatment
 Alcoholism increases the risk of ARV drug toxicity
 Suicidal ideation

Strategies for enhancing ARV drug adherence among adolescents:

 Consider practicing drug adherence with vitamin pills, IPT and Cotrimoxazole-
prophylaxis
 Involve the adolescent when discussing treatment options

116
  Explore with the adolescents challenges they experience in taking the drugs and work
out strategies to address them. Family members and teachers may assist in the
adherence plans
 Provide adolescent friendly services
 The members of the testing and counselling team with the best relation to the
adolescent should take the lead in the counselling and support of the adolescent
 Regimens should fit into the adolescent’s life as much as possible. Remind the
adolescents that they need to continue taking the drugs even when they are feeling
unwell or feeling well.
 Use of simplified regimens, preferably ARV taken once daily
 Positive approach to treatment that nurtures the adolescent’s belief in their success,
this task should be taken by the adolescents themselves as well as their family, friends
and the care providers
 Information should be given proactively, in appropriate simple and understandable
language and in writing
 Use real life examples to illustrate issues as adolescents often think in concrete terms
 Explain to adolescents what to expect while on therapy and how to manage potential
positive and negative side effects and adherence problems
 Adolescents should be encouraged to discuss and disclose their problems with their
care providers or person whom they trust.

How to help the adolescents develop an individual strategy for drug adherence:
 Encourage the adolescent to establish a schedule for taking drugs
 Keep the drugs where they can see them in the morning and evening
 Take the ARV drugs at the fixed time every morning and evening
 Write notes and stickers to remind them to take the drugs. If they have an alarm or
phone, they can put it on as a reminder
 Keep a diary of how they are taking their drugs and to review it with the care
provider. The diary will also help them to see the changes in health as well as any
diverse changes in the body
 Plan ahead to carry ART with them when they are away from home
 Plan for sudden events that may change their normal schedule, and therefore always
they should have a few tablets with them
 Identify a treatment supporter – this strategy has been found to be very successful in
adults. Adolescents who are living alone may find it difficult to find a treatment
supporter
 Provide a dedicated adolescent and youth friendly services.

12.5 Adherence Issues among Pregnant and Breastfeeding Women

Pregnancy and lactation periods present significant biological, social and economic
challenges that may affect treatment adherence. It is estimated that around a quarter of
pregnant women have inadequate ART adherence, and this is higher during the lactation
period. Pregnancy-related conditions such as nausea and vomiting may negatively affect
117
treatment adherence. Other individual factors include suboptimal understanding of HIV, ART
and PMTCT, lack of partner disclosure and support, and fear of stigma and discrimination.
Service delivery barriers include poor-quality clinical practices, gaps in provider knowledge
and training, poor access to services and health worker attitudes.
All these should be taken into consideration when counselling pregnant and lactating women
to avoid vertical transmission.
12.6 Adherence among Key and Vulnerable Populations
In many settings, key vulnerable populations face multiple challenges related to stigma and
discrimination that can affect access to health services, all of which may impact negatively on
adherence.
Key factors to consider when providing services to key and vulnerable populations:
Assuring access: Create demand for HIV testing and counselling and prevention services
through targeted campaigns in identified key and vulnerable population settings, use
community-based outreach, mobile phone technologies, social networking and develop
friendly key population services at health facilities; this will facilitate dissemination of
behavioural messages, promote follow-up and referral to services, improve adherence to
treatment, and increase client participation in their own healthcare.
Sensitize and educate health service providers, community health workers, CBHS, peers,
supportive staff and management on issues of specific key and vulnerable populations and on
non-discriminatory practices and eliminating stigma, using pre-service and in-service
training, job-aids, supportive supervision, and training follow up.
Ensure confidentiality: Attention should be devoted to protecting privacy and confidentiality,
e.g. closing the consultation room door or finding a private place to talk. Clients should be
reassured of confidentiality.

12.7 Management of ART Experienced Clients

The CTC team should review treatment of clients who have been previously exposed to
antiretroviral therapy.
Those who stopped for reasons other than treatment failure and for whom failure is not
suspected should restart the original regimen.
Those known or suspected to have failed the previous regimen should be given an enhanced
adherence counselling and later be started on drugs they have not been exposed to before as
appropriate.
12.8 Adherence Counselling Follow-up
Evidence shows that adherence to preventive therapies such as IPT, CPT and balanced diet,
TB treatment and ART is an important factor to ensure better health outcome of clients on
long term therapy.

118
During a visit to the CTC, each client will be screened for TB and be provided with relevant
prophylaxis if s/he deserves. In addition, adherence probing through a checklist will be used
to identify possible lapses of adherence and reinforce key practices related to optimal
management.
Patients also receive information and counselling on various PHDP elements such
transmission risk reduction, nutritional and family planning advice, and adverse event
management. Other psychosocial needs such as social or legal support, disclosure of HIV
status, mental health, referrals to home based care services and facilitation for joining PLHIV
support groups will also be addressed.
Note: Adherence assessment checklist is described in specific codes within the CTC2 card.
12.9 Enhanced Adherence Counselling (EAC)
Treatment failure should be suspected whenever a patient has been on ART for at last six
months and has an HIV viral load more than 1000 copies/ml, declining in CD4 cell count, or
developing a stage 3 or 4 disease condition. Poor adherence is often the most important factor
in developing treatment failure, though there can be other causes.
Enhanced Adherence Counselling (EAC) is recommended when treatment failure is
suspected. EAC is usually conducted in three sessions within eight weeks. An intensive
counselling session is provided to overcome factors contributing to treatment failure. It is
recorded into log form in which the sessions are documented. After the third session, another
HVL test is done. When the results come back and the HVL is above 1000 copies, treatment
failure is confirmed and the treatment regimen should be changed to a second or third-line. If
it is below 1000 copies/ml, the client is regarded as adherent and continues with the same
regimen.
12.9.1 Assessment of adherence
As soon as treatment failure is suspected, it should be discussed by the facility multi-
disciplinary team and thereafter develop a plan for assessing barriers to adherence (including
scheduling a home visit) and assessing other potential causes of treatment failure (e.g.
inadequate dosing/dose adjustment, drug-drug interactions, impaired absorption drug food
interactions). All clients who are confirmed to have treatment failure should have thorough
assessment of potential barriers to adherence.
12.9.2 The goal of enhanced adherence counselling
The goal of EAC is to assess possible barriers to adherence in a non-judgmental way and help
the client construct an adherence plan with concrete objectives. It is important not to focus
solely on knowledge of HIV and ART but also to review psychological, emotional and socio-
economic factors that may contribute to poor adherence. In addition, exploring the client’s
motivation for taking medication often highlights the reasons for poor adherence.
A minimum of three sessions are recommended for enhanced adherence counselling. If the
adherence is adequately evaluated, a repeat HIV viral load should be done after three months
of good adherence and another enhanced adherence counselling is conducted to discuss the
HIV viral load results. It is preferable to have the patient go through all adherence

119
counselling sessions with the same counsellor in order to provide continuity and adequately
document it to ensure follow-up of all issues identified.
Table 12.3 Components of Sessions for Enhance Adherence Counselling

Enhanced Adherence Counselling Sessions: Overview

Review understanding of viral load (VL) and discuss why the patient’s VL is
high
Review cognitive, behavioural, emotional and socio-economic barriers to
adherence:

Session 1 Treatment literacy

Medications: dosage, timing, storage
Side effects
Discuss risk reduction (e.g. for substance abuse)
Motivation
Review adherence plan from the first session and discuss any challenges
Identify other possible gaps and emerging issues
Session 2
Referrals and networking
Assist patient to modify the adherence plan to address the identified issues

Review adherence plan from the first and second session and discuss any
challenges
Identify other possible gaps and emerging issues
Assist the patient to modify the adherence plan to address the identified issues

Session 3 Decision on repeat VL based on current adherence:

If the adherence is good: plan repeat VL testing after three months of good
adherence and explain possible ways forward, emphasizing the role of the patient
and the health facility
If adherence challenges persist: plan for further Enhanced Adherence
Counselling sessions before repeating the HVL.

Discuss the result of the second HVL test

Session to
Plan the way forward:
Discuss
If HVL now is <1,000 copies/ml: continue with the current regimen with
Repeat Viral
enhanced adherence, repeat VL after six months
Load
If HVL ≥1,000 copies/ml: prepare the patient for the change of regimen.

120
 CHAPTER 13:
MENTAL HEALTH CONDITIONS IN HIV AND AIDS
13.0 Introduction
Mental health conditions are more common in HIV infected than in non-infected people. In
some instances, this is due to (i) mental conditions existing prior to the HIV infection (ii)
mental health condition as a psychological consequence of chronic HIV infection (iii)
presence of the HIV virus in the brain. It is important to be aware that HIV individuals have
an increased risk for developing mood, anxiety, and cognitive disorders.
The common groups of mental health conditions among people living with HIV are:
 Organic Disorders (Delirium and Dementia)
 Mood Disorders (i.e. Depression and Mania) mania, adjustment disorders, post-
traumatic stress disorders
 Anxiety Disorders (i.e. adjustment disorders, panic disorders, generalized anxiety
disorders, post-traumatic stress disorders, HIV and AIDS related phobia)
 Psychotic Disorders (i.e. schizophrenia, schizoaffective disorders)
 Alcohol and other substance use disorder (i.e. cannabis, heroin and cocaine)
 Social difficulties faced as a result of stigma and discrimination
 Exacerbation of a pre-existing mental disorders, depression, mania anxiety disorders
and substance abuse may be related to the stress of living with HIV and AIDS.

Other mental disorders may be secondary to neurological complications of HIV,

opportunistic infections or side effects of ARV drugs. Pre-existing mental disorders are
associated with increased risk of acquiring HIV infection and drug use. PLHIV who present
mental conditions often come to care and treatment services with special management needs.
13.1. Mental disorders secondary to neurological complication of HIV, OIs, and side
effects of ARVs
13.1.1 Delirium
Definition: Delirium is a state of acute onset of impaired consciousness marked by anxiety,
disorganized speech, disorientation and hallucinations. The distinguishing features include
drowsiness, lethargy and a changing level of consciousness. All these symptoms usually
develop over hours or days and the presentation fluctuates. Delirium is a medical emergency
and may be life threatening, hence it requires immediate medical attention.
.
Risk Factors: Risk factors for developing delirium include:
 Advanced stages of immune suppression
 Substance use/intoxication
 Head/brain injuries
 Previous episodes of delirium
 HIV-associated dementia or infections and malignancies of the CNS

121
  Drug interactions in AIDS patients taking multiple medications
 Drug overdose (accidental or deliberate)
 High fever from any cause
 Intoxication from any cause.

In children and adolescents, the common causes of delirium are medications or substance use.
Common differentials of delirium include:
 Cryptococcus meningitis
 Toxoplasmosis
 Space occupying lesions e.g. Primary cerebral lymphoma
 Cerebral tuberculosis
 Brain abscess
 Bacterial and fungal meningitis
 Alcohol withdrawal syndrome
 Psychoactive substance abuse

Management: The appropriate treatment of delirium involves identifying and correcting its
underlying causes.
.
13.1.2 HIV Associated Dementia (HAD)
Definition: HAD is an acquired impairment of intellectual/cognitive abilities in a sufficient
degree of severity to interfere with social or occupational functioning where memory
impairment is a predominant feature. Other cognitive functions (such as attention, learning,
information processing, language, reasoning, judgment) are also affected. There is no
clouding of consciousness in HAD.
Clinical Manifestations: Affective impairment is usually in the form of apathy, irritability
and sometimes manic symptoms. Other common clinical features of late stage HAD are
seizures, global cognitive deterioration, mutism, incontinence, and severe confusion.
Clinicians should exclude other treatable, reversible causes of change in mental status such as
CNS opportunistic infections and malignancies before any diagnosis of HAD is made.
Diagnostic Tests: A lumbar puncture may be necessary to rule out acute infection, such as
bacterial meningitis, TB- meningitis, Cryptococcal meningitis, and toxoplasmosis.
Management:
Continue with or start ART
If there are other causes treat them accordingly
Give haloperidol 1.5mg per day with slow increase in the dosage depending on the response
to control agitation and hallucination.
If available, atypical antipsychotic agents such as olanzapine and respiridone can be used
starting with low doses.

122
Involve family members /treatment supporters in the management of the client.
Note:
Avoid benzodiazepines, which tend to increase confusion and decrease concentration.
PIs and NNRTIs induce or inhibit liver enzymes and therefore tend to decrease or increase
the levels of Psychotropic drugs.
13.1.3. HIV-Related Mania
Definition and Characteristic Features: AIDS related mania is secondary to HIV CNS
involvement. It is characterized by loss of the ability to control mood, and it presents with
elated or irritable moods, increased activity and energy regardless of the physical status,
decreased need for sleep and an exaggerated sense of self-importance. The condition occurs
with more advanced immunosuppression.
Management:
 Continue with ART treatment because it relieves the symptoms of AIDS related
mania.
 Sodium valproate is useful for the control of acute symptoms in patients who are on
ART
 Carbamazepine and lamotrigine can be used as mood stabilizers.

Note: Carbamazepine induces liver enzymes and increases its own metabolism as well as
ART drugs. If possible, avoid in patients on ART.
13.2 Primary Mental Health Complications
In the absence of focal neurological deficits or meningitis, primary mental health
complications should be considered when changes in mental status occur. The most common
primary mental health complications that can occur at any CD4 level are adjustment disorder,
depression, mixed depression and anxiety, and anxiety disorders.
13.2.1 Adjustment Disorder:
This condition occurs predominantly at the time of HIV disease diagnosis. These responses
include fear of discrimination and imminent death, guilt over infecting others, exacerbation of
existing mental health conditions and acute suicidal ideation. The nature of the adaptation
response influences the client’s ability to:
 Disclose HIV sero-status to others
 HIV-related self-stigmatization
 Adjustment disorder is a major barrier to sharing test results and hence limiting access
to social support.

Management: Supportive medical/clinical counselling is the mainstay of more positive

adaptive responses to HIV diagnosis.

123
13.2.2 Anxiety Disorders
Definition: Patients with HIV infection may have any of the anxiety disorders, but
generalized anxiety, post-traumatic stress, and obsessive – compulsive disorders are
particularly common. Symptoms of anxiety disorders are both psychological and physical.
The physical manifestations include: shortness of breath, chest pain, increase of heart beats,
dizziness and gastrointestinal disturbances. These symptoms may overlap with symptoms of
other common medical disorders. In addition, the clients present with fear, worry, insomnia,
impaired concentration and memory, diminished appetite, compulsive rituals and avoidance
of situations that make them anxious.
Management:
 Re-assurance, psychoeducation and supportive counselling are effective when the
level of anxiety does not interfere significantly with social or occupational
functioning
 Medications can be used when anxiety interferes significantly with sleep or daily
functioning. The clients may benefit from low doses of antidepressants like Tricyclic
Anti depressant and Selective serotonin re-uptake inhibitors (SSRIs) (e.g.
Amitriptyline and fluoxetine respectively) e.g. start with low doses of Amitriptyline
12.5mg daily to alleviate the symptoms
 Short acting benzodiazepines can be used but there is a risk of dependence
 Encourage the client to join psychosocial support groups.

13.2.3. Major Depressive Disorder

This is a mental disorder that affects the mind and the body, presenting with both
psychological and physical symptoms. Behavioural changes that may alert a physician about
possible depression include: change in treatment adherence, inability to make life/medical
care choices, preoccupation with minor problems, change in functioning, social isolation,
interpersonal problems, difficult behavior in the medical setting, or initiation/return to
substance use.
Diagnostic Challenges
 Misconception that depression in HIV is normal
 Overlapping symptoms such as fatigue, weight loss and insomnia may be due to
depression or physical illness, such as HIV
 Chronic pain and chronic physical syndromes co-morbid with mood disorders
 Medication related depression and anxiety
 Substance use (may be associated with depression).

Management:
 Reassurance, psychoeducation and supportive counselling are effective in offering
services to clients with depression
 Always initiate treatment with low doses to minimize risk of serious side effects

124
  Tricyclic antidepressants (TCAs) like amitryptylline (25-75mg per day) and
imipramine can be used
 Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine and fluvoxamine
are recommended because they have fewer side effects
 Ensure adequate doses and duration (maintenance drug treatment provided at
therapeutic dose for six months after resolution of symptoms), combined with
supportive counselling
 Adolescents with depression respond well with SSRIs compared to TCAs
 If depressive symptoms are not resolved within four weeks of initiating drug
treatment, refer the client to a mental health facility.

Care should be taken for possible interactions between antidepressants and ARTs as shown in
Table 13.1 below:
Table 13:1 Antidepressant dosage and possible ART interactions
Drug groups of Specific drugs Dose range Interactions with
antidepressants registered in (mg)
ARVs
Tanzania

1. Tricyclic Antidepressant Amitriptyline 25mg–75mg Lopinavir/r & ritonavir

increase antidepressant
Imipramine per day
levels in serum
2. Selective Serotonin re- Fluoxetine 10mg–20mg Nevirapine decreases
uptake inhibitors) level; AD increases
per day
levels of Amprenavir,
Recommended in patients
Citalopram 10mg - Delavidine, Efavirenz,
on ART
40mg per Indinavir, LPV/r,
day Ritonavir, Saquinavir

13.3. Loss, Bereavement and Crisis

Definition: Bereavement is defined as the state of perceived loss that often results from
knowing that one has HIV. Adjusting to the new status of living with HIV is often very
stressful.
Assessing for Loss, Bereavement and Crisis: this involves exploring the losses that the
PLHIV have experienced. There are six stages of bereavement. These are: shock, denial,
anger, bargaining, depression and acceptance. Among PLHIV the spectrum of loss often
begins with the knowledge of their HIV positive diagnosis and consequent loss of their
health, certainty, future hopes, relationships, lifestyles, and loss of hopes for children. PLHIV
are also more likely to experience the loss of loved ones such as partners and their own
children from AIDS defining conditions.
A crisis is a situation in which a person is unable to use his/her normal problem solving
techniques to resolve a problem. When a crisis occurs it is overwhelming for the individual

125
both emotionally and cognitively. In case of HIV and AIDS, the triggers that lead to crisis
might be death of another PLHIV, emergence of new symptoms, treatment failure or
anything that is perceived by the patient as a severe life event.
Management: is through supportive counselling.

126
 CHAPTER 14:
NUTRITION IN HIV AND AIDS
14.0 Introduction
Malnutrition and HIV are related and aggravate one another in a vicious cycle. HIV infection
can lead to undernutrition, and malnutrition affects HIV transmission and disease
progression. HIV infection impairs the body immune system and thereby increasing
vulnerability to infections. Infections lead to increased loss of nutrients which, if not
replenished, may lead to malnutrition. Malnutrition, on the other hand leads to immune
impairment. Further, when a malnourished person acquires HIV, the progression to AIDS is
rapid as the immune system is already too weak to fight off infections. On the contrary, a
well-nourished individual has strong immune system which delays the progression of HIV to
AIDS. HIV and AIDS have direct and indirect effects on nutrition. The direct effects include
reduced food intake, poor absorption of nutrients and increased utilization and loss of
nutrients. The indirect effects are those which lead to household food insecurity related to
inability to engage in food production activities.
This vicious circle contributes to repeated illnesses, deterioration of the health and eventual
death of the infected individual. Timely improvement of nutrition can help strengthen the
immune system, prevent weight loss and delay the disease progression.
14.1 Relationship between good nutrition and protection from Infections
Good nutrition enables persons with HIV and AIDS to strengthen their immune system
manage HIV-related complications and increase protection to infections. The specific
benefits of good nutrition in protection of infections are illustrated in Figure 14:1 below:
Figure 14:1. The Cycle of Good Nutrition and protection from infections in Context of HIV
and AIDS

Good Nutrition (good food

intake, maintenance of
weight and muscle tissue,
good micronutrient status)

Management of HIV- Strengthening of the

related Complications Immune system
(e.g. malabsorption, (ability to fight HIV and
diarrhoea, lack of other infections)
appetite, weight loss)

Increased protection from

Infections (e.g. diarrhoea,
tuberculosis, respiratory
infections)

127
14.1.1 Nutritional consideration at different stages of HIV infection
At different stages of HIV infection, some health problems such as mouth sores (ulcerations),
sore throat and diarrhoea, may be experienced. Infections increase the body requirements for
energy and may cause deficiency of nutrients and further burdens the already weakened
immune system. Table 14.1 below shows Nutrition, Care and Support Priorities by stages.
Table 14.1 Nutritional, care and support priorities by WHO HIV stages
HIV stage Features Nutritional Advice
Early Stage Asymptomatic or mild Counsel on healthy diet and healthy lifestyle
(stage 1 & 2 of symptoms weight loss under
WHO clinical 10% of presumed or
staging) measurable body weight

Middle Stage  Weight loss over 10% of  Counsel to minimize consequences

(stage 3 of WHO presumed or measurable
clinical staging) body weight  Counsel to maintain dietary intake during
illness
 Opportunistic infections
 Advise increased nutrient intake to recover
and gain weight

 Counsel on healthy lifestyle

 Advise on food safety and hygiene

 Advise on nutritional implication of ARV

drugs

 Provide therapeutic food when severely

malnourished

Late stage (stage Weight loss  Advise on treating opportunistic infections

4 of WHO
Symptomatic  Counsel to modify diet according to
clinical staging)
symptoms

 Counsel on healthy lifestyle

 Advise on food safety and hygiene

 Advise on nutritional implication of ARV

drugs

 Provide therapeutic food when severely

malnourished

128
14.2 Healthy eating for People Living with HIV
14.2.1 Recommendations on healthy eating for PLHIV
People living with HIV are encouraged to include foods from different food groups at each
meal.
Variety-Recommend choosing different types of food within each food group whenever
possible.
Balance - Recommend choosing foods from all food groups according to the
recommended amounts.
Moderation – Recommend controlling portion size so that balance and variety are possible.
This is essential to avoid over-nutrition or under-nutrition.

The main food groups are:

 Cereals, roots, tubers and bananas: these include maize, millet, rice, sorghum,
cassava, yams, potatoes and cooked bananas
 Legumes, nuts and foods of animal origin: these include groundnuts, cashew nuts,
beans, peas, meat and products, sea food, milk and products, poultry, eggs and edible
insects such as senene and kumbikumbi
 Fruits: these include all types of fruits commercial and indigenous such as mangoes,
oranges, guava, tangerines, bananas, baobab fruit (ubuyu), tamarind (ukwaju),
mabungo etc. They are good sources of vitamins and minerals
 Vegetables: all types i.e. exotic and indigenous vegetables such as sweet potato
leaves, pumpkin leaves, tomatoes, amaranth, okra, carrots, pumpkins, (mlenda), hare
lettuce, (figiri), wild spinach (mnavu). The foods in this group provide vitamins and
minerals.
 Sugar, honey, fats and oils, these are needed in small amounts; they include ghee,
lard, butter, margarine, coconut oil, sunflower, sugars like honey etc. Such foods are
very rich in energy.

Note:
A balanced meal is therefore defined as a meal which contains all food groups: cereals, green
bananas, roots (cassava, ming’oko, etc.) and tubers (yams, potatoes, etc.) pulses, animal-
source food, fruits, vegetables, sugar, honey, fats and oils. Sugar, honey, fats and oils are
among food items which can be added in a meal to improve taste and also provide energy.
Although water is not part of the food groups it is important for life and is necessary every
day. Water aids digestion, absorption and transportation of nutrients in the body. It is
recommended that a person should drink at least eight glasses (1.5 litres) of water a day.

129
There is no single food that contains all the nutrients that the body needs, except breast milk
for infants up to six months of age. For a balanced meal use at least one type of food from
each food group.
14.2.2 Tips for health and nutritious lifestyle for PLHIV
 Eat variety of foods emphasized on nutrient-dense foods
 Eat small meals frequently (especially for a very sick person)
 Drink clean and safe water
 Be physically active
 Avoid alcohol, avoid smoking
 Add nutrient-dense foods (nuts, oil, fat, milk, oil seeds)
 Use spices for appetite and absorption: ginger, garlic, cardamom, lemon
 Germination and sprouting; fermentation (increases nutrient content and improves digestions and
absorption)
 Manage stress
 Observe food safety, improve cooking methods and hygiene principles
 Manage specific disease symptoms promptly (e.g., nausea, vomiting, diarrhoea and constipation).

1
14.3.1 Energy requirements
The HIV infected person has additional energy needs because of:
 Increased and altered metabolism
 Nutrient malabsorption.

14.3.1.1 HIV asymptomatic children and adults

In the absence of symptoms (WHO Stage 1), HIV-infected persons should increase energy
intake by 10% over the level of energy intake recommended for HIV uninfected persons of
the same age, sex and physical activity level.

HIV asymptomatic child:

A child should continue with breast feeding and eat a balanced meal.
With exception of fruits, fats/oils and sugar, an additional of 2 tea spoons of
margarine/butter/oil should be added to each meal.
For this group, it is recommended that:
 A balanced meal should be eaten three times per day
 In addition, a child should eat any healthy snack (e.g. a cup of milk, a slice of bread
with peanut butter) between meals i.e. two times per day.

Note: A child should eat five or more times per day.

130
HIV asymptomatic Adult
 An adult person should eat a balanced meal.
 With exception of fruits, fats/oils and sugar additional of 2 tea spoons of
margarine/butter/oil should be added to each meal. If the prepared food is porridge,
add 1 tea spoon of margarine/butter/oil and 1 teaspoon of sugar.

For this group it is recommended that:

 A balanced meal should be eaten three times per day

In addition, a person should eat any of the following healthy snacks:

 1 mug (250mls) of porridge with milk/sugar
 2 medium sweet potatoes
 2–3 large cups (250mls) of boiled full cream milk
 Healthy snacks should be given to a person two times per day (in between meals).

14.3.1.2 HIV symptomatic children and adults

In the presence of symptoms (WHO Stage 2 and above), HIV-infected persons, including
those taking ARVs, should increase energy intake by 20-30% over the level of energy intake
recommended for HIV uninfected persons of the same age, sex and physical activity level.

HIV symptomatic child:

 A child should continue with breastfeeding and eat a balanced meal.
 With exception of fruits, fats/oils and sugar, an additional of 2 tea spoons of
margarine/butter/oil should be added to each meal. If the prepared food is porridge
add 1 tea spoon of margarine/butter/oil and 1 teaspoon of sugar.

For this group it is recommended that:

 A balanced meal should be eaten three times per day.

In addition, a child should eat any of the following healthy snacks:

 1 slice of bread with groundnut paste
 1 cooked mashed banana added grinded groundnuts/pumpkins seeds
 1 cup (100mls) of boiled full cream milk and for children aged six months to be given
2–3 tablespoons and for 7–8 months old: to be given 3–4 tablespoons
 Healthy snacks should be given to a child two times per day (in between meals).

Note:
If a child is on exclusive breast-feeding should continue up to six months

131
Amount of food needed for other age groups (above eight months), further research needs to
be done, however it is advised to increase the amount of food according to the age of a child.

HIV symptomatic adult:

 An adult should eat a balanced meal.
 With exception of fruits, fats/oils and sugar an additional of 2 tea spoons of
margarine/butter/oil should be added to each meal. If the prepared food is porridge
add 1 tea spoon of margarine/butter/oil and 1 teaspoon of sugar.

For this group it is recommended that:

 A balanced meal should be eaten three times per day.

In addition, a person should eat any of the following healthy snacks:

 2 mugs (500mls) of porridge with milk / 2 teaspoon of sugar
 4 medium sweet potatoes
 2-3 large cups (250mls) of boiled full cream milk
 Healthy snacks should be given to a person two times per day (in between meals).

14.2.3 Protein requirements

HIV-infected persons do not require more protein than the level recommended for HIV
uninfected persons of the same age, sex and physical activities level.
14.2.4 Micronutrient requirements
HIV infected individuals are encouraged to include a variety of foods in the diet to prevent
deficiency. There is an evidence that some micronutrient supplements such as vitamin A, zinc
and iron at higher doses may produce adverse outcomes in HIV-infected persons (see also
Annex 8,. The Role and Sources of Selected Micronutrients for additional information). Do
not give high dose of Vitamin A if the clients with SAM are already receiving F75, F100 or
RUTF which already have sufficient Vitamin A. (only give to those who are not provided
F75, F100 or RUTF).
People infected with HIV may take several medications, including antibiotics, ARVs, anti-
malarial, anti-helminths, anti-fungal, etc. Foods and medications can interact in 4 major
ways. These are as shown in Table 14.2 below:
Table 14.2: Relationship between foods and medications

1. FOOD MEDICATION ABSORPTION,

(Affects) METABOLISM, DISTRIBUTION,
EXCRETION

2. MEDICATION NUTRIENT ABSORPTION,

(Affects) METABOLISM, DISTRIBUTION,

132
 EXCRETION
3. MEDICATION SIDE FOOD CONSUMPTION,
EFFECTS (Affects) NUTRIENT ABSORPTION

4. MEDICATION + SIDE EFFECTS

CERTAIN FOODS (Creates)

14.3.3 Relationship between medication and feeding/dietary patterns

Medications have to be managed correctly in order to ensure that the prescribed drug
combination improves drug efficacy, decrease side effects, and does not affect the nutritional
status.
Annex 9 lists some of the medications used in Tanzania. The table shows their purposes,
potential side effects and nutritional recommendations (more details are in Annex 10).
Proper dietary management can help to manage some side effects. The following are
examples:
• Changes in taste: The protease inhibitors such as Ritonavir cause changes in taste and can
cause food to taste metallic, sweeter, sourer, or too salty, which, in turn, may cause an
individual to consume less food. This can be addressed by using flavour enhancers such as
salt, sugar, spices, vinegar, or lemon to stimulate the taste buds, increase taste acuity, and
mask any unpleasant flavour. Adding spices like onions to soup will boost flavour and can
help to improve intake.
• Anorexia: Several medications, such as Isoniazid and the ARVs lamivudine may cause
anorexia and lead to reduced food intake. The dietary management of anorexia requires
eating small and frequent meals and favourite foods. PLHIV that experience anorexia should
eat five to six small meals a day and should include energy and nutrient-dense foods at each
meal to ensure adequate nutrient intake. It is also important to maintain as much physical
activity as possible, such as walking in fresh air, which also helps to stimulate appetite.
Some ARVs e.g. Tenofovir have been associated with increased risk of osteoporosis and
weakening of bones that may require medical and dietary responses. For osteoporosis, a
balanced diet with high calcium foods, such as milk, yoghurt, cheese, and vitamin D
supplement, is recommended along with medical care.
Note: Some side effects of ARVs are similar to symptoms of opportunistic infections, such as
diarrhoea e.g. Tenofovir, Ritonavir, Lopinavir. Therefore, the health worker must continue to
be alert to recognize symptoms of infections and treat these infections appropriately.

133
14.3.4 Nutritional advice in relation to multiple medications
Patients who are on multiple medications such as HIV and TB require taking many pills on a
daily basis, which can make it difficult to maintain food intake. Multiple medications have
diverse food-drug implications and side effects that necessitate specific selection of foods and
timing of medications Health workers should counsel clients and parents/caregivers on the
dietary management.
Table 14.3 Isoniazid: Relationship of food and side effects

Medication Dietary interactions and the Dietary advise

Medication Side Effects

Isoniazid TB Food reduces absorption of Do not take Isoniazid with food. Take one
treatment Isoniazid hour before or two hours after meals
May affect vitamin B6 Daily consumption of food sources of
vitamin B6 such as white beans, maize
Metabolism
avocado, meat, and fish, or vitamin B6
(25 to 50mg daily) supplementation is
recommended
Increased risk of hepatitis when Avoid alcohol
combined with alcohol
Anorexia (i.e. loss of appetite) Eat small and frequent meals. Eat
favourite foods
Diarrhoea Drink plenty of fluids and eat energy- and
nutrient rich foods. Avoid fried foods.

14.4 Monitoring of nutritional status

Monitoring of nutritional status is an important aspect of nutritional care and support for
PLHIV. This includes a comprehensive assessment by medical, psychosocial, dietary, review
of patient file for biochemical results and anthropometry.
Medical history
Many diseases such as malaria or tuberculosis can affect an individual’s nutritional status;
hence, it is important to find out the past and present health status of the patient. It is also
important to evaluate interactions between food and medications, as medications may
interfere with nutrient absorption or increase the excretion of nutrients. Vitamin, mineral, and
herbal supplementation can also affect nutritional balance.
Medical history should also be used to detect signs and symptoms associated with
malnutrition including diet related opportunistic infections. The physical appearance of the
hair, skin, and nails can assist in identifying nutritional deficiencies. For example, spoon-
shaped, pale, and brittle fingernails may indicate iron deficiency. Opportunistic infections
such as oral thrush or sore throat can affect a person’s ability to eat and increase risk of

134
complications, such as wasting or weight loss. A person's weight history, such as rapid
weight loss, can be an indicator of a nutritional problem.
PLHIV who are on ART need appropriate and adequate nutrition to achieve the full benefits
of ART. Dietary intake should be modified to manage symptoms, by making the meal soft,
mincing, boiling and use of herbs.
Psychosocial history
A psychosocial assessment includes reviewing a person's economic status, cultural
background, living situation, education level, occupation, mental status, and access to
adequate food sources to maintain good health. Each of these components plays a role in
determining a person's ability to follow through on specific dietary plans.
Dietary history
A dietary history includes an assessment of a person's usual dietary intake. This can be done
using a twenty-four-hour recall of food eaten. Reviewing food preparation methods is helpful
in determining the amount of salt and oil/fat which when taken in excess is harmful to health.
The frequency of meals eaten out is an important indicator of whether a person has access to
cooking, or just prefers to eat out instead of cooking. These factors play a role in determining
the details of a dietary counselling plan.
Biochemical assessment
Biochemical assessment of nutritional status is done in the laboratory where nutrient
deficiencies are detected. Where available test for blood protein (e.g. Serum albumin),
micronutrients (e.g. iron) and Lipid (e.g. Cholesterol), can be used to monitor nutritional
status of PLHIV. Hemoglobin level is one of the indicators used to monitor anemia.
Anthropometry assessment
Anthropometry assessment includes recording of age, sex and anthropometric measurements
(Mid Upper Arm Circumference, height, weight).
Patients who have a weight and height measured are plotted on a growth curve and
designated low/high weight for height Z score (for children) or BMI Z score (older children),
or BMI (adults). MUAC tapes are also used.
One can monitor weight loss by using body mass index (BMI) calculated as = Weight (kg)
divided by height (m2). A normal BMI is 18.5 – 24.9kg/m2. A BMI <18.5 denotes
underweight; that between 25.0 and 29.9kg/m2 is overweight, and >30.0kg/m2 is obesity. For
patients with BMI <18.5 nutritional education is required and food supplementation to be
recommended if any.
It should be noted though that even without using BMI, unintended weight loss of between 6-
7kg in one month is not a good sign. Therefore, the weight of PLHIV needs to be closely
monitored to ensure they do not lose a lot of weight due to disease progression and that
appropriate nutritional intervention is made and in a timely manner.

135
14.5 Therapeutic foods for management of Acute Malnutrition
After the assessment of nutritional status, children below five years of age who will be
categorized as severely malnourished, and have no medical complication (i.e. no other
disease), will be given nutrition education and supplied with Ready to Use Therapeutic Food
(RUTF) e.g. Plumpy nuts. Those with medical complications should not be given RUTF;
instead they should be referred for in-patient treatment. Children under-five who are severely
malnourished with acute or persistent diarrhoea in the rehabilitation phase, can be given or
continue with RUTF both for in-patient or out-patient treatment. Severely malnourished
children aged above five years and adult can be given RUTF if they are not severely sick and
those who are severely sick should be referred for in-patient treatment. Moderately
malnourished clients who have no medical complication will be given dietary counselling and
those who have severe medical complications should be referred for further management.

For Prescription criteria refer national guidelines for management of acute malnutrition.
Table 14.4 Indicators for acute malnutrition
Group Moderate Severe
Category
Children 6-59 months old MUAC: 11.5cm to MUAC: <11.5cm
<12.5cm
W/H < -3 SD
W/H -3 SD to <-2 SD
W/H -3 Z-scores to <-2
Children 5 - 9 years MUAC 13.5 to <14.5cm MUAC < 13.5cm
W/H -3 SD to <-2 SD W/H <-3 SD

Children 10 - MUAC 16cm to <18.5cm MUAC <16.0cm

14 years W/H -3 SD to <-2 SD W/H <-3 SD
Adolescents MUAC 18.5cm to MUAC <18.5cm
22.0cm
(15 years and above) and BMI <16.0
adults BMI 16 to <18.5

Pregnant women and women MUAC: 19cm to MUAC <19.0cm

within the period of six <23.0cm
months after delivery

Note:
 BMI is not used to assess nutritional status of pregnant women and women within the
period of six months after delivery.
 Visual assessment is not recommended as the primary method for screening or
nutritional assessment.

136
 MUAC is recommended as the primary method for screening or nutritional assessment
for pregnant women
 Consideration for PLHIV with normal nutritional status; overweight or obese e.g.
recommendations for reducing intake of sweetened foods and drinks, and increase
regular physical activities.

137
 CHAPTER 15:
COMMUNITY BASED HIV AND AIDS SERVICES
15.0 Introduction
This chapter describes Community Based HIV and AIDS services which is part of the
comprehensive continuum of HIV care services. In this chapter, the role of CBHS providers
in providing prevention, care, treatment and support is explained in relation to the facility
based services. The chapter identifies and describes needs of people suffering from chronic
illnesses and their family members, including those taking lifelong medications such as ARV
drugs.

15.1 The Overall Goal, Objectives and Scope of Community Based Health Services
15.1.1 Goal:
People living with HIV in all councils have access to quality comprehensive Community
Based HIV Services integrated with other services.
The objectives of the CBHS services are to:
 Intensify early identification of HIV positive clients and their index clients
 Promptly link HIV positive clients to care and treatment clinics
 Facilitate effective community and facility referral and linkages as well as other
services such as psychosocial, legal, spiritual, food and nutrition support
 Track the clients who have missed appointments as well as Lost to follow up
 Support ART adherence and retention
 Participate and facilitate effective implementation of ART outreach refilling option
for stable clients coming from hard to reach areas.

15.1.2 Scope of CBHS

PLHIV and their affected families and households have a variety of needs beyond mere
clinical needs. Such needs include psychological, spiritual, nutritional, educational, economic
and legal care and support. It is the CBHS that cater for these needs of PLHIV and the
surrounding community.
In Tanzania, CBHS was formally introduced by the MoHCDGEC formerly known as
MoHSW as Home Based Care Services, mainly for bedridden patients. Due to the
advancement in the management of HIV and AIDS, the scope of HBC changed significantly,
from taking care of bedridden clients to ambulatory
CBHS ensures the continuity of care provided to the PLHIV clients at the health facility
through the continuum of care. This is a set of comprehensive and linked care, treatment, and
support services provided at all levels: from health facility to community to home. Services
are provided by the government, NGOs, Community-Based Organizations (CBOs), Faith-
Based Organizations (FBOs), community members and by PLHIV and their family members.
Furthermore, Care and support programmes are developed as a response to these

138
psychological, social, nutritional, economic, legal, clinical, and nursing-care needs and
demands.
15.1.3 Target group
Community Based HIV and AIDS services target all HIV positive clients including HIV
positive adults, paediatrics, exposed children, pregnant women, People Who Inject drugs
(PWIDs), Sex Workers (SWs) as primary target groups and chronically ill clients as
secondary target groups.
15.1.4 4 Community Based HIV Services Provider (CBHSP)
For many years, Community Based HIV Services Providers have been given different names
by different HIV implementers, these included: Home Based Care (HBC) Providers, Peer
Educators, Liaison Person, Client Tracking Person, Volunteers Community Based Distributor
(CBD), etc. In addition to these, different community based HIV services providers were
assigned different roles and responsibilities which in one way or another caused confusion
and sometimes even conflicts among themselves.
This guideline recognizes the contribution of community members supporting HIV and AIDS
services at community as well as at health facility, and sets standard for harmonized
provision of Community Based HIV Services both at facility and in the community. In this
regard, all providers volunteering to HIV and AIDS services are known as Community Based
HIV and AIDS Services Providers. Also, currently, a new cadre has been introduced by the
Ministry that will be providing all health services including HIV services at community level.
This person who is permanently employed will be known as Community Health Worker. The
Community Health Worker will work hand in hand with Community Based HIV and AIDS
Service providers to achieve the goals set by the National Health Sector HIV and AIDS
Strategic Plan.
15.1.5 Selection criteria
Community Based HIV and AIDS providers work under difficult conditions and for long
hours, and they have access to sensitive and confidential information while performing their
duties. This brings them to be selected using the following criteria:
 A community member with sound integrity who can maintain confidentiality
 He/she should know how to read and write
 Based in the communities they are going to serve
 Accepted and trusted by community members
 Capable of building good interpersonal relationships
 Interested in caring for sick people
 Willing to volunteer
 Reliable
 Possess coping skills.

Community Health Workers (CHW) will be selected according to NACTE endorsed criteria.

139
15.1.6 Training
All CBHS Providers are trained using the CBHS training curriculum, developed by the
MoHCDGEC through the NACP, while CHW are trained for one year using the curriculum
developed by NACTE.
15.2 Roles and responsibilities of CBHS Providers
Following the evolution of clinical management of HIV infection, CBHS providers have
added up new roles and responsibilities so as to ensure continuity in quality ART service
provision. New roles of CBHS providers include the following:
 to provide health education to all pregnant women with HIV infection
 to provide adherence counselling of ART to HIV positive pregnant women and adults
who are enrolled in care and treatment/PMTCT
 to initiate and facilitate HIV Post Test Clubs/Support groups at the community and
supporting them to have leadership, group constitution and registration
 to identify and refer all pregnant women to RCH clinics, or Health facilities at their
catchment areas and then make follow-up
 to identify and refer all key and vulnerable population (e.g. PWIDs, and sex workers)
to heath facilities for further management
 To track and refer back to PMTCT/RCH/Health facilities of the catchment areas all
mothers who have delivered and have not come back for DBS results of their children
 To track all loss to follow up clients (adults and children) who were on care and
treatment.

CBHS providers shall provide patients with the following services, including those listed
above:
 Nursing care
 Feeding
 Nutritional care and support (education, counselling, nutritional assessments, and
attention to household food security)
 Alleviation of pain and other distressing symptoms
 Spiritual and emotional support
 Prevention of OIs
 Detection of complications and danger signs
 Linkages to healthcare facilities and other relevant services in the community
 Support for adherence to medication and clinic visit schedules
 Facilitate provision of financial and technical support for post-test clubs to engage in
income generating activities
 Provide education on use of contraceptives, condoms, disclosure, GBV, TB and STIs

140
15.3 Contribution of CBHS in Care and Treatment services
The establishment of Community Based HIV and AIDS Services programmes by the
MoHCDGEC is among the Ministry’s strategies to compliment the initiatives of the
government to combat HIV and AIDS. The following are the key areas that the CBHS are
contributing in the HIV care and treatment services:
Early case identification and enrolment
The ultimate purpose of care and treatment programme in the context of ‘Treat All’ is to make
sure that all HIV positive clients are enrolled into care and, are started on ART within two
weeks. In order to achieve that, CBHS providers should:
 Identify and link clients to HIV testing services
 Identify and enrol KVPs to nearby KVP services and peer groups
 Provide pre-test information to the clients to facilitate HIV counselling and testing at
home by the trained counsellors
 Enrol clients on ART and ensure that they regularly attend their clinics and support
group meetings
 Ensure that all pregnant women, mothers and their exposed children return to the health
facility for follow up. After enrolment to CBHS, the CBHS provider will ensure that the
clients reach their first referral point (CTC/PMTCT/Paediatric HIV Clinics/TB Clinics,
HIV post-test clubs).
 Facilitate referral services to care and treatment clinics for those who test positive in the
community
 Retention of clients into care and treatment services.

ART is a lifelong treatment, and its success depends very much on how the clients adhere to
the prescribed treatment regimen. For a patient to get the desired treatment results, they need to
continue with ART throughout their lives. Achieving such results is a challenge; therefore,
different approaches to improving adherence were established by the MoHCDGEC. These
require the CBHS provider to:
 conduct community visits to provide adherence counselling and health education to the
clients who are on treatment to stay on treatment.
 utilize CTC Desk for tracing miss appointment, Lost to follow, referral and linkages
 assist the client in choosing a primary care giver who is his/her relative to help by
reminding or assisting him/her in taking medication.
 link HIV positive clients and those who are already on treatment to PLHIV support
groups. This is a platform for PLHIV peer education, psychosocial support, and
economic strengthening through income generating activities. Through these groups,
the newly diagnosed clients will get experience and testimonies from other clients who
are on treatment for a long time hence help them with adherence and acceptance of HIV
status which will eventually help them in status disclosure.
 help adolescents in engagement to care and treatment. Also, to increase the level of
retention among clients already on ART, to care and treatment clinic
 track Loss to follow up clients from CTC/PMTCT and TB clinics.

141
CBHS has a very important role to play in ensuring that clients who are loss to follow up are
tracked back to the health facility. After identification of missed appointments and loss to
follow up clients from appointment register by the health facilities, CBHS providers of the
catchment areas should therefore:
 collect list of clients who have missed their appointments as well as lost to follow up
 follow up clients by phone calls or by physically visiting their households
 provide report/feedback through the recommended system.

In tracking loss to follow up clients, CBHS have increased efforts to those HIV positive
mothers who have delivered and have not returned back with their children for DBS results of
their children.

Referral and networking

CBHS services are part and parcel of the continuum of care and the provision of support at
different levels. An effective continuum of care requires that a functional network and referral
system are in place to improve access to appropriate services for all PLHIVs and chronically ill
patients at all times. Through an effective and functioning referral system, these patients will
continue to receive relevant services within their respective communities and homes after being
discharged from healthcare facilities, and they can revert back to facility care as and when
needed.
In order to strengthen this system, service providers will ensure that the national CBHS referral
forms are used in all referrals. The CBHS provider should:
 fill in and issue a referral form to the client
 ensure that the feedback portion is completed in and returned to the referral provider
 refer the CBHS clients depending on what their needs are and what is available to them
in their communities by way of spiritual, legal, income, nutrition and food, and
socioeconomic support
 develop and regularly update the referral services directory within their location.

142
 CHAPTER 16
SUPPLY CHAIN MANAGEMENT AND RATIONAL USE OF HIV AND AIDS
COMMODITIES
16.0 Introduction
A comprehensive HIV and AIDS programme requires a wide range of commodities supporting
a range of interventions that encompass prevention, care and treatment. Supply chain
management of HIV and AIDS commodities is critical to support the national policy and to
ensure adequate and continuous availability of quality and affordable essential medicines,
diagnostics and other consumables at service delivery sites in the right quantities, at lowest
possible cost and in timely manner. These commodities are relatively expensive and therefore
they require proper handling to ensure effective use.
Since all people living with HIV will be initiated on ART, resources and strong Procurement
and Supply Management (PSM) should be available at all levels of health system. Procurement
and ART programme managers need to work together to ensure that the national supply system
is functioning properly i.e. forecasting, procuring and distributing the quantities of ARV drug
and other health commodities required to meet the increasing national demand and the 90–90–
90 target.
The key components of procurement and supply management cycle include: (i) product
selection (ii) forecasting and supply planning (iii) procurement (iv) storage and distribution (v)
Logistics Management Information System (LMIS) (vi) Use or serving customers (vii) Quality
monitoring, and (viii) Policy. Management support is integral to each component. It includes a
variety of activities at all levels of the healthcare delivery system from the national programme
level down to where medicines are dispensed and diagnostics are used. The main activities
include managing the information system (LMIS), ensuring timely information flow between
stakeholders at different levels and securing financial and other resources for procurement,
storage and distribution of medicines and diagnostics needed for the programme.
16.1 Rational Use of Medicines (RUM)
Rational use of medicines requires medications to be appropriate to the patient’s clinical needs,
doses meet the patient’s own individual requirements, and medications are given for an
adequate period of time and at the lowest cost to the patient and his or her community.
ART is a complex undertaking that involves a large variety and quantity of drugs. It is a
lifelong treatment that is in constant development. It is therefore very important to use
medicines rationally since irrational medicine use (especially in the context of ART) may have
unwanted consequences at both the individual and the population levels. These may include:
 Treatment failure
 Rapid development of drug resistance
 An increase in the risk of toxicity
 Increase cost for treatment due to the need to use expensive medication after failure of
first line regimen
 Spread of new HIV infection.

143
Figure16. 1. Medicine Use Process

Aspects of Irrational Use of Medicines

Diagnosis:
 Inadequate examination of a patient
 Incomplete communication between a patient and the doctor
 Lack of documented medical history
 Inadequate laboratory Resources.

Prescribing:
Irrational prescribing is observed when there is:
 Incorrect prescribing
 Diagnosis is inadequate

144
  Inappropriate medicines are prescribed
 Under prescribing
 Needed medications are not prescribed
 Dosage is inadequate
 Inadequate duration of treatment
 Over prescribing
 Prescribing inappropriate length of course
 Prescribing very high dose
 Extravagant prescribing
 Prescribing a more expensive branded medicines when there is a less expensive generic
medicines
 Treating symptoms instead of treating the disease
 Multiple prescribing
 Two or more medications are prescribed when fewer would achieve the same effect.

Dispensing:
Incorrect interpretation of the prescription
 The dispenser does not pick up errors or the dispenser sees the error but does nothing
about it
 Incorrect calculation of dosage
 Retrieval of wrong medicines
 Inaccurate counting
 Inadequate labelling
 Unsanitary procedures
 Inability to effectively communicate with patients on how to use the prescribed
medicines and adherence to dose schedules.

Patient aspects of Irrational Use of Medicines

This occurs when:
 The patient demands prescription of more medicines than required
 Not following given instructions
 Sharing medicines with others
 Medicine misinformation
 Lack of patient readiness
 There is stigma
 Conflict between cultural values and therapy
 Misleading beliefs about HIV and AIDS
 Patients’ misunderstandings about the medicines and their uses
 Patient concerns about side effects and ADRs.

16.1.1 Prescriptions

145
Only trained and authorized prescribers in certified healthcare facilities are allowed to
prescribe ARVs. The prescription for ARVs should clearly indicate the name/Patient ID No.,
age, sex of the patient, body weight, medicines, dosage, and should include the name, signature
and prescriber’s code (where applicable).
16.1.2 Dispensing
Antiretroviral drugs are prescription-only medicines. They should only be dispensed to
treatment-ready patients with clear instructions and advice. The dispenser should ensure that
the prescription is appropriately written and signed by an authorized prescriber before
dispensing. ARVs should only be given to the named patient or appointed adherence assistant.
Adequate time should be scheduled for antiretroviral dispensing and counselling.
The pharmacist/dispenser should make sure that the patient understands the dosage and drug
intake schedule as well as instructions regarding the storage and food requirements. The
pharmacist/dispenser should also caution patients about possible side effects and drug-drug
interactions and respond to specific questions and problems related to ARV treatment
encountered by patients. It is also imperative for the dispenser to advice patients on measures
to be taken to reduce the side effects, including immediate return to the clinic when they
experience unwanted effects.
16.1.3 Patient Identification Cards
Each patient must be issued with a patient identification card (CTC1) for tracking the type of
regimens given and scheduling next appointment visits for refill. Patients (or appointed
adherence assistants where patients cannot collect the medication themselves) must present the
cards to the dispenser every time they collect medicines and all medications received must be
recorded on the card.
16.2 Supply Chain Management
16.2.1 Serving the customers
The ultimate purpose of public health supply chain systems is to serve the customers with
appropriate commodities at the right quantity, time, place and cost. In the context of HIV and
AIDS programmes, this purpose means ensuring an uninterrupted supply of HIV and AIDS
commodities to all people living with HIV and AIDS (PLHIV) whenever they need them. The
ARVs need to be available all the time at service delivery points (Health facilities) for
resupplying patients. This is because more than 95 percent adherence to ART is required for
treatment regimens to be effective over the long term. Thus to implement and maintain a
supply chain that is focused on the ultimate customer, the MOHCDGEC through NACP has
designed supply chain systems and procedures and prioritize interventions around the concept
of uninterrupted availability of the ARV drugs.
16.2.2 Selection of Pharmaceuticals and Diagnostics
The World Health Organization (WHO) has developed and updated guidelines for Scaling up
Antiretroviral Therapy in Resource-Limited Settings. The treatment Guidelines for a Public
Health Approach act as guidance for countries to facilitate the proper management and scale up
of antiretroviral therapy (ART). The public health approach is geared towards universal access,
standardization, and simplification of antiretroviral (ARV) drug regimens to support the

146
implementation of treatment programmes in resource-limited settings and to ensure that
treatment programmes are using ARV drugs based on scientific evidence. The goal is to avoid
the use of substandard treatment protocols and to reduce the potential for the emergence of
drug-resistant virus strains.
The MOHCDGEC through NACP has updated the national ART guideline and medicine lists
to include newly recommended ARV drug regimens and formulations and diagnostics that are
appropriate to our settings. The process included extensive discussions during the clinical
subcommittee meeting before quantification and in the workshops to review the guidelines. For
example, the detailed national ART guidelines provide recommendations for managing toxicity
or treatment failure and recommended formulations for weight and age that can help to
standardize prescribing and dispensing practices and facilitate forecasting for ARV drugs.
Selection of ARV drugs, regimens, formulations and packaging will affect procurement,
forecasting, and distribution, and these relevant supply chain issues should be considered in the
process of selecting ARV drugs. Standard Treatment Guidelines (STGs) for ART should
provide clear criteria for first, second, and third-line regimens, for the management of patients
experiencing toxicity or failing treatment, and for the treatment of specific subgroups, such as
patients with tuberculosis, pregnant women, children, and health workers who require post-
exposure prophylaxis.
16.2.4 Forecasting and Supply planning (Quantification)
Programme managers must prepare medium term forecasts to be able to coordinate funding and
procurement among the Government of Tanzania and multiple donors and to ensure
uninterrupted supplies of HIV and AIDS commodities. Medium-term forecasts, which
normally cover two years period can be prepared using Morbidity data (targeted numbers of
patients identified for treatment in national strategies over a specific period of time or by using
most current numbers of patients or number of new patients being initiated on treatment).
These can then be combined with informed assumptions from key stakeholders and
implementers.
The forecasts and procurement plans will need to be revised frequently with accordance to
SOPs (after every six months) to allow for adjustments in the supply plan as experience with
acceptability, tolerability, and efficacy of ART is gained and as supply chain and services data
are more available. This will enable programmes to rapidly keep up with changing demands
and requirements for ARVs.
16.2.5 Procurement
A uniform and harmonized procurement system is required to efficiently procure quality
assured, affordable HIV and AIDS commodities (ARV drugs diagnostics and Lab
consumables). Procurement should be based on selection of appropriate products and
forecasted needs, considering consumption, expanding services, phasing in and phasing out of
formulations and implementing new WHO recommendations.
The procurement of HIV and AIDS commodities will be done by the Medical Stores
Department, which is also responsible for storage and distribution of the commodities to all
health facilities across the country.

147
Transparent procedures should be adopted to achieve best-value procurement and a quality
assurance system implemented to procure, store and distribute high-quality HIV and AIDS
commodities.
Procurement systems should:
Procure the most effective, heat-stable, fixed-dose quality-assured ARV drug
formulations in the right quantities at the lowest possible cost and in a timely manner
 Request that the partners supporting the national HIV programme consolidate and
harmonize ARV drugs and diagnostics procurement and supply management systems
and pool demands for ARV drugs and diagnostics, exploring options for pooling under
a common tender system
 Use a publicly accessible database to facilitate access to information about prices and
support competition
 Follow the principles described in the United Nations interagency guidelines for
donated drugs.

16.2.6 Inventory Management

16.2.6.1 Ordering and Receiving HIV and AIDS commodities
HIV and AIDS commodities and related supplies should be ordered to MSD on quarterly basis
through electronic Logistics Management Information System (eLMIS)
 Obtain stock on hand data from actual quantities of available commodities after
conducting physical inventory at the end of the month and quarter
 Obtain consumption and usage data from dispensing register/pharmacy database and
national HIV/Log book, respectively
 Prepare order by filling quarterly report and request forms (R & R’s) for ARVs, Lab
commodities and related supplies by 5th day of the ordering month of the next quarter
according to the ordering schedule (ABC groups) and then enter the logistics data in
the eLMIS
 Electronic reports and orders should be submitted electronically to MSD after being
endorsed and approved by the Hospital In charge and DMOs, respectively.

Health Facilities with CTC and PMTCT services:

 PMTCT will collect ARVs and RTK’s from CTC and Lab, respectively
 PMTCT will submit Monthly ARV consumption report (completed form A3) to CTC
for refilling ARVs
 PMTCT will also submit Monthly Summary Report Form for HIV tests Kits to
Laboratory for refill RTKs.
 Stand-alone PMTCT sites will follow ILS to order PMTCT commodities along with
essential medicines from MSD.
 Ordering of other commodities (RTK‘s, Laboratory supplies, contraceptives, etc.) will
follow the same system (ILS).

148
MSD will review orders, process and deliver the medicines and related supplies direct (DD) to
the health facility
Upon receiving of HIV and AIDS commodities at the facility, the receiving officer will ensure
that the following particulars of commodities and related supplies on the delivery note and
invoice match with the delivered items in the following areas:
 Strength and dosage form
 Pack size(s)
 Batch numbers
 Expiry dates (remaining shelf life should at least be 8 months)
 Specifications
 Quantities delivered
 Condition of the commodities (not damaged).

After ensuring that all the areas are satisfactory, the receiving officer should sign, stamp and
date the Invoice and Delivery Note. If not satisfied with any of the above, the officer should not
receive or accept the item(s) that are in dispute; but sign against each disputed item(s) on the
Delivery Note and write “item not accepted” and immediately record all discrepancies on the
verification and Claims form (Form 7). The completed form number 7 should be submitted
accordingly i.e. to the supplier and copied to the facility for records.

16.2.6.2 Storage and Distribution

Facilities should have adequate storage space with conducive storage conditions, trained
personnel, and the logistics tools (store’s ledger-paper based/electronic system) to manage
supplies effectively. Stock must be kept in a high security storage area with single Pharmacist /
Pharmaceutical technician / Laboratory personnel (at any one time) responsible for receipts and
issues. Commodities must be stored according to the first-to-expire first-out (FEFO) procedure
of stock management. Accurate inventory records should be maintained and a system created
to track products that enter and leave the supply system along with a running balance and
ledgers maintained for each item.
At the end of each month, physical inventory shall be conducted and the available stock shall
be checked against the stock records. The information from the physical inventory report must
be entered into the store Ledger/bin cards-paper based and/or electronic system. Stocks that
have short shelf life that cannot be used before their expiry dates shall be redistributed
accordingly to facilities in need using a redistribution form.
Damaged and expired commodities should be immediately separated from usable ones in the
inventory, recorded on suspensory ledger and disposed using the laid out procedures.
16.2.6.3 Assessing Stock status
Adequate stock levels of Max-Min of 6/3 (For ordering site) and 2/1 (For non-ordering site)
Months of stock for each item for all required commodities shall be maintained at all times. If
the stock level for a particular item is falling below the emergency order point (1.5 months of
stock for ordering sites and two weeks stock level for non-ordering sites), an emergency order

149
shall be made to bring the stock to maximum level even if it is before the end of the review
period (end of quarter or month for ordering and non-ordering sites, respectively).
HCP’s should determine on monthly basis, the number of months (Months of Stock) HIV
commodities will last based on present consumption/usage rate. The formula below should be
used to determine Months of Stocks (MoS).

Months of Stocks (MoS) = Stock on Hand (SoH) ÷ Average Monthly Consumption (AMC) .

The result of this calculation (Months of Stock-MoS) will guide HCP’s to make decisions
based on the standardized national stock levels as mentioned above.
16.2.6.4. Record keeping
In order to facilitate efficient administration and management of HIV commodities, all
information regarding ARVs and OI medicine dispensed should be recorded in a dedicated
register book (dispensing registers/ or in the pharmacy database) and ART patient card
(CTC1).

All information regarding usage of RTK’s and other Laboratory diagnostics should be recorded
on National HIV Log book and Laboratory register, respectively.
At the store, all HIV commodity transactions should be recorded in the paper based store
ledger and/or in the Pharmacy Module database.

Close monitoring of the consumption/usage data and stock levels of HIV and AIDS
commodities is important for supplying the correct quantity and quality medicines, for
responding to changes in demand, for managing increased volumes of commodities, and for
minimizing pilferage and misuse.
Reports on HIV and AIDS commodities consumption and stocks should be kept and tracked by
health facilities. Health facilities should use this information’s to forecast and quantify their
needs. On quarterly basis, these reports should be sent to MSD through the DMOs for
programme decision making.
16.3. Logistics Management Information System (LMIS)
Logistics management information system (LMIS) collects processes and reports the supply
chain information. A well-functioning LMIS provides decision makers throughout a supply
chain with accurate, timely, and appropriate logistics data. The LMIS can be manual (paper
based), or electronic (pharmacy data base). There are three essential LMIS data which are:
 Stock on Hand
 Losses and adjustment
 Consumption data

150
16.3.1. Logistics management tools used in HIV and AIDS commodities Logistics system
The tools are used for recording information about supplies in storage, reporting & requesting
(R & R) commodities, issuing and receiving commodities. These tools include:
 Store’s Ledger (and suspensory ledger for expired commodities)
 Form A1: ARV Daily Dispensing register
 National HIV Log book
 Laboratory register
 Reporting and Requesting (R & R) forms: Form A3 (Monthly) and Form A2
(Quarterly)
 Monthly summary report form for HIV test Kits
 Requisition and issue voucher
 Form 4: MSD sales invoice
 Form 6: Goods Received Note
 Form 7: Claim and Verification for Redistribution form.

Health facilities should ensure these tools are available and properly completed in timely
manner.
16.4. Supply Chain Monitoring
Monitoring and evaluation is a cross-cutting function that is needed for all programmes and
functions to ensure commodity security. National programmes and their constituent functions
must be capable of measuring progress and outcomes if they are to ensure that targets are being
met and to determine the corrective actions to be taken.
M & E of logistics activities should be done regularly to assess progress, identify and solve
problems. This will ensure:
 Availability of commodities and quality of service provided to patients
 Planned logistics activities are carried out according to the schedule
 Proper record keeping, Logistics data collection, analysis, reporting in timely manner
for decision-making and hence a way foward plan.
 Supply chain monitoring should be done regularly through supportive supervision and
On the Job Training (OJT). Logistics Mentoring then follows to Health Facilities
observed with problems in some areas of logistics activities.

Monitoring of supply chain management will also be done through the effective use of early
warning indicators for monitoring and evaluations of procurement and supply management
systems to prevent stock-outs and overstocks leading to expiry.
R/CHMT, LMU, MSD, NACP in collaboration with IP’s should conduct quarterly review
meeting supply chain management.
Procurement, storage, distribution and dispensing procedures and records, and stock on hand
will be subject to internal and external audit. Given the cost and complexities of handling
ARVs, frequent auditing is anticipated.

151
16.5. Pharmacovigilance

WHO defines pharmacovigilance (PV) as the science and activities relating to the detection,
assessment, understanding and prevention of adverse effects or any other drug-related
problems. Monitoring and reporting of adverse drug events should be done according to the
Tanzania Food and Drug Authority (TFDA) guidelines. Adverse drug reactions reporting forms
(yellow forms) will be distributed to facilities that have been certified to deliver ART. It is
important for the health facilities to record the adverse drug reactions and report the
information to TFDA. Reporting will be done through yellow forms/ or electronic reporting
system by using smartphones or ADR Report Tool)

Furthermore, facilities are encouraged to use the information to monitor patients and switch
regimens where necessary e.g. Patients experiencing drug induced nephrotoxicity should be
switched to ABC based regimens and those experiencing DTG induced severe Hepatotoxicity
should be switched to PIs (Refer to the diagram on Chapter 10).

In case the client became pregnant while on DTG based regimen and booked for antenatal
clinic past the first trimester, the healthcare provider should maintain the client with high dose
folic acid (5mg), also check the alpha fetal protein where available and at 20 weeks the client
should do abdominal ultrasound and continue monitoring pregnancy outcome during
pregnancy (miscarriage, intra uterine fetal demise) and after delivery (malformation –neural
defect). Healthcare provider should document all this information during follow up of such
kind of client using TFDA yellow form and also follow surveillance protocol.
16.6. Collaborating with Clinical Staff
The Pharmacist shall work closely with the clinical staff to ensure appropriate prescribing
especially on dosage and appropriate ARV combinations (ARV regimens). Good collaboration
will ensure correct estimates of the number of new patients to be initiated treatment for proper
ordering of their medicines.
The Pharmacist and the Laboratory technologist/any HCWs dealing with supply chain issues
within the health facility also needs to keep clinical staff informed of the current stock levels of
ARVs, diagnostics and Laboratory consumables particularly of items nearing stock-out and
those in excess and at risk of expiry.
In the event of nationwide supply shortage, Pharmacist/ Laboratory technologist/HCP dealing
with supply chain within the facility should communicate this information to the clinical staff
so that they can pursue the best course of action.
In addition to logistics related collaborative activities, the Pharmacist is expected to keep
abreast of new information and changes in ARV regimens and act as a resource to clinicians
and other healthcare workers in advising on possible drug related side effects, changes in
formulations or regimens and informing clinicians on available formulations and drug
combinations (ARV regimens).

152
 CHAPTER 17
MONITORING AND EVALUATION
17.0 Introduction
Monitoring is a routine tracking of HIV and AIDS programme interventions through collecting,
analysing, and reporting of data to assess progress against set plans. Monitoring aims at
establishing trends, patterns, adaptation of strategies and inform decisions for programme
management.
Evaluation is an assessment of an ongoing or completed project, programme or policy, its
design, implementation and results. The aim of evaluating HIV and AIDS programme is to
determine the relevance and fulfilment of objectives, developmental efficiency, effectiveness,
impact and sustainability.
Indicators and targets have to be f formulated and targets set to track and assess progression of
the implementation of HIV and AIDS interventions. Monitoring and evaluation generate
information needed for decision-making at different levels of management of HIV and AIDS
services.
Quality Data: Quality data are data that are reliably and accurately representing the measure it
was intended to present. It also refers to the totality of features and characteristics of data that
bears on its ability to satisfy a purpose for which the data was collected for. Data are
considered to be of high quality when they are complete, accurate, consistent, relevant and
timely reported. HSPs should strive to produce data of high quality. In order for the HFs to
produce high quality data, Data Quality Assessments (DQAs) should routinely be conducted at
all levels by using DQA tools that are approved by the MoHCDGEC.

17.1 Key Components of Monitoring and Evaluation

17.1.1 Data Recording
Collection of data on HIV and AIDS interventions is done by HSPs and community health
workers at the HF and community levels using standardized tools and coordinated by DACCs
and RACCs. Reporting is done on monthly and for some data on quarterly basis from the
community and HF levels to the council level where it is posted to the DHIS2. From the
DHIS2, data can be accessed by different authorities without necessarily contacting the
national level.
The national level, through the NACP compiles HF and council data, which are then reported
to other stakeholders within and outside the country.
Tools for Recording:
Recording of the data for the HIV and AIDS services uses the following tools:
a) Patient Identification Card (CTC1): This is a card with a unique patient identification
number. It is issued at the registration section of the HF during the first visit of the client to the
care and treatment clinic. It is then kept and used by the client for identification purposes when
he/ she visit at the CTC.

153
b) Patient encounters’ Record Form (CTC2): This is a form initiated when an HIV positive
person attends for the first visit at the CTC. It is used for recording the management and
monitoring of client’s clinical outcome. The form has a client’s unique ID number, as in the
Patient Identification Card. CTC2 is kept in the client’s file and retained at the HF registry or
dedicated HIV and AIDS care and treatment cabinet.
c) Registers
There are five types of registers used at the CTC:
Appointment register
Tracking register
Pre ART register
ART register
Cohort Analysis Register
Appointment register
The standardized appointment register has been designed to help monitor clinic attendances for
all clients who are enrolled into HIV care and treatment clinic, regardless of their being on
ART or not.
Tracking register
This is a register that is used mostly by the community based HSPs to track back to care those
clients who have missed their appointments and those who are confirmed as lost to follow up.
It records how many clients have been tracked and returned to CTC, transferred out, or stopped
using services.
Pre ART Register
This register records all clients who are attending to the CTC and are not yet started on ART.
The ART Register
A tool used for recording all patients who are attending at the CTC clinic and are started on
ART.
The Cohort Analysis register
This register uses information from the ART register to compile reports for specific clients’
cohorts at 6, 12, 24, 36, 48, 60 and 72 months.
d) Patient Referral Form
This is a form that is used when a client is transferred from one CTC to another to enable him/
her carry to the next HF the relevant information about care and/ or treatment given.
17.1.2 Data Storage
Data collected from clients receiving HIV and AIDS care and treatment services shall be stored
either electronically through the CTC2, pharmacy module and the CTC3 macro database or on

154
hard copies of the tools used for data collecting purposes. The electronic means of data storage
must be secured by passwords while hard copies must be kept in rooms where confidentiality
will be ensured.
17.1.3 Data Analysis
Analysis of data on HIV and AIDS services is done from the HF to the national level. In high
volume HFs data are entered into the CTC2 (HF based) database, which aggregates
automatically and links them directly to DHIS2 database at the council level. Small volume
HFs aggregate data manually and send reports to the office of the DMO for entry in to the
DHIS2. Two forms of data analyses are done; indicator based and cascade analyses.
17.1.4 Data Reporting
Reporting of data for HIV and AIDS services is done either on monthly or quarterly basis. For
HFs that use electronic system, its reports are generated automatically and thereafter directly
linked to DHIS. For HFs that use paper base system, they aggregate data and submit to the
office of the DMO by the 7th day of the following month. Data are reported from HFs to the
council, region and finally to the national level.
17.1.5 Data Presentation:
Depending on the needs of the intended audience, presentation of the analysed outputs is done
in the form of:
Notes
Tables
Graphs
Maps
Charts
Data should be presented in simple, interpretable and actionable form to facilitate its
understanding and utilization.
17.1.6 Data Dissemination
After the data are presented in the different forms as shown above, they need to be
disseminated so as to reach a greater number of the audience for them to use the data.
Dissemination of the data is done by posting them on the notice boards that are placed in public
places as well as through conferences.
11.1.7 Data Use
It is expected that data will be reported and presented/ disseminated on monthly and or
quarterly basis. Data will be used at different levels by stakeholders for the purposes of
planning and improvement of the delivery of HIV and AIDS services.
17.2 Roles and Responsibilities of Each Level in Relation to M&E
Activities for Monitoring and Evaluation of HIV and AIDS services are carried out at HFs,
council, region and national levels. Each level has its roles and responsibilities as follows:

155
17.2.1 National Level (NACP)
Prepares and coordinates implementation of M&E framework for HIV and AIDS services
including preparation of M&E guidelines and SOPs for C&T
Guides in the preparation, revision, printing and distribution of recording and reporting tools
for HIV and AIDS care and treatment services
Coordinates supportive supervision, mentoring and data quality assessment activities for C&T
services
Manages a national CTC 2 database in line with health sector data management guidance
Advocates for use of electronic database at HFs that provide C&T services
Coordinates capacity building to HSPs in electronic data management
Coordinates and guides dissemination of C&T output data at all levels
Guides sub-national levels on data management especially on analysis and dissemination; and
advocate for data use
Provides feedback on the quality of reports generated by the lower levels
17.2.3 Regional and District Levels
There is a slight variation on the roles and responsibilities between the regional and council
levels. Those which are specific for the regional level include:
Building capacity of the council and primary HFs on the management of the data
Support the HFs in the region and the council on the recording and reporting of HIV and AIDS
services
Coordinate capacity building of the HSPs at the HFs on the M&E system of the HIV and AIDS
services
Mobilize resources for strengthening M& E system of the C&T services
Coordinate the quarterly meetings on review of data
Disseminate HIV and AIDS C&T data at region and council levels
Strengthen communication with national level on all HIV and AIDS M&E matters at regional
and council levels
Provide feedback on the quality of reports generated by the lower levels.
Health Facility Level
Ensures availability and effective use of the recording and reporting tools for HIV and AIDS
care and treatment services
Ensures timely submission of the care and treatment reports to the council’s office
Reports to the DMO on all challenges faced by the HF on all HIV and AIDS M&E system
Conducts on quarterly basis an internal data quality assessment and data review.
156
17.2.5 HIV and AIDS Implementing Partners
Comply with the national M&E system for HIV and AIDS care and treatment services
Support regions and councils to implement the care and treatment M&E system
Support regions and councils on analysis, dissemination and use of quality data reviews.

17.3 Supportive Supervision and Mentoring of the HIV and AIDS Services
A Manual on Comprehensive supportive supervision and mentoring of the HIV and AIDS
services describes ‘supportive supervision’ as a “process of helping HSPs improve their work
performance continuously.” It is carried out in a respectful and non-authoritarian way to
promote quality outcomes through strengthening communication, identifying and solving
problems, facilitating teamwork, and providing leadership and support.
Mentorship is described as a process of practical training and consultation that fosters on-going
professional development to yield sustainable high quality health outcomes.
It is crucial that all levels of health service delivery adhere to the implementation of the
supportive supervision and mentoring of HIV and AIDS services as stipulated in the Manual of
the Comprehensive Supportive Supervision and Mentoring of the HIV and AIDS Services
(2017 Edition).

157
Annexes
Annex 1: List of acknowledged Organizations and insititution.
AMREF Health Tanzania
Baylor International Pediatric AIDS Initiatives (BIPAI)
Benjamini Mkapa Hospital (BMH)
Bugando Medical Centre (BMC)
Catholic University of Health and Allied Sciences- Bugando (CUHAS)
Centers for Disease Control and Prevention- Tanzania (CDC-TZ)
Centres for Disease Control and Prevention (CDC)
Clinton Health Access Initiative (CHAI)
DED- Temeke
Deloitte- BoreshaAfya
Department of Defense – USG (DOD)
Elizabeth Glazer Pediatric AIDS Foundation (EGPAF)
Henry Jackson Foundation Medical Research International (HJFMR/Walter Reed)
International Training and Education Centre for Health (I-TECH)
Johns Hopkins Program for International Education in Gynaecology and Obstetrics
(JHPIEGO) - SAUTI Project
Kilimanjaro Christian Medical Centre (KCMC)
Lugalo General Military Hospital
Management for Development and Health (MDH)
Mbeya Zonal Referral Hospital (MZRH)
Muhimbili National Hospital (MNH)
National AIDS Control Programme (NACP)
National TB and Leprosy Programme (NTLP)
Njombe-RAS
President’s Office Regional Administration and Local Government (PORALG)
Ruvuma- RAS
Songea Regional Referral Hospital
Tanzania Food and Nutrition Centre (TFNC)
Tanzania Health Promotion Support (THPS)
University of Maryland Baltimore (UMB)
US Agency for International Development (USAID)
World Health Organisations (WHO)

158
Annex 2: WHO Clinical Staging of HIV Disease in Adults and Adolescents
Stage I Stage II
• Asymptomatic • Moderate unexplained weight loss (< 10% of

• Persistent generalized presumed or measured body weight)

lymphadenopathy • Minor mucocutaneous manifestations
(PGL) (seborrheic dermatitis, popular pruritic
Unexplained, asymptomatic eruptions, fungal nail infections, recurrent oral
ulcerations, angular cheilitis)
hepatosplenomegaly
• Herpes zoster
• Recurrent upper respiratory tract infections
(sinusitis, tonsillitis, bronchitis, otitis media,
pharyngitis)

Stage III Stage IV

• Unexplained severe weight loss Conditions where a presumptive diagnosis can be
(over 10% of presumed or made using clinical signs or simple investigations:
measured body weight) • HIV wasting syndrome
• Unexplained chronic diarrhoea • Pneumocystis jirovecipneumonia (PCP)
for longer than one month • Recurrent severe bacterial pneumonia (≥ 2
• Unexplained persistent fever episodes within 1 year)
(intermittent or constant for • Cryptococcal meningitis
longer than one month) • Toxoplasmosis of the brain
• Persistent oral candidiasis
• Chronic orolabial, genital or ano-rectal herpes
• Oral hairy leukoplakia simplex infection for > 1 month
• Pulmonary tuberculosis • Kaposi’s sarcoma (KS)
• Severe bacterial infections (e.g. • HIV encephalopathy
pneumonia, empyema, • Extra pulmonary tuberculosis (EPTB)
pyomyositis, bone or joint
infection, meningitis, Conditions where confirmatory diagnostic testing is
bacteraemia) necessary:
• Acute necrotizing ulcerative • Cryptosporidiosis, with diarrhoea > 1 month
stomatitis, gingivitis or • Isosporiasis
periodontitis
• Cryptococcosis (extra pulmonary)
• Unexplained anaemia (below 8
• Disseminated non-tuberculous mycobacterial
g/dl ), neutropenia (below 0.5 x
109/l) and/or chronic infection
thrombocytopenia (below 50 x • Cytomegalovirus (CMV) retinitis or infection of

109 /l) the organs (other than liver, spleen, or lymph

nodes)
• Progressive multifocal leucoencephalopathy
(PML)
• Any disseminated mycosis (e.g. histoplasmosis,
coccidiomycosis)
• Candidiasis of the oesophagus or airways

• Non-typhoid salmonella (NTS) septicaemia

• Lymphoma cerebral or B cell Non-Hodgkin’s

Lymphoma

159
 • Invasive cervical cancer
• Visceral leishmaniasis
• Symptomatic HIV-associated nephropathy or
HIV associated cardiomyopathy

Annex 3: WHO Clinical Staging of HIV/AIDS for children with confirmed HIV infection

Stage I Stage II
• Asymptomatic • Papular pruritic eruptions (PPE)

• Persistent generalized • Seborrheic dermatitis

lymphadenopathy • Fungal nail infections

(PGL) • Angular cheilitis

Unexplained, asymptomatic • Linear gingival erythema
hepatosplenomegaly • Extensive HPV or molluscum infection
(>5% of body area/face)
• Recurrent oral ulcerations (>2 episodes/ in

6 months)
• Parotid enlargement

• Herpes zoster (>1 episode/12 months)

• Recurrent or chronic upper respiratory

infection (URI): otitis media, otorrhoea,

sinusitis (>2 episodes/6 months)

Stage III Stage IV

• Unexplained moderate malnutrition (- • Unexplained severe wasting or severe
2SD or Z score) not responding to malnutrition (-3 SD or Z score) not
standard therapy responding to standard therapy
• Unexplained persistent diarrhoea (>14 • Pneumocystis pneumonia
days) • Recurrent severe bacterial infections (>2
• Unexplained persistent fever episodes/12 months, excluding pneumonia)
(intermittent or constant, > 1 mo.) • Chronic orolabial or cutaneous HSV
• Oral candidiasis (outside neonatal (lasting > 1 mo)
period) • Extra-pulmonary tuberculosis
• Oral hairy Leucoplakia
• Kaposi’s sarcoma
• Pulmonary tuberculosis
• Oesophageal candidiasis
• Severe recurrent presumed bacterial
• CNS toxoplasmosis
pneumonia (>2 episodes/12 months) • Cryptococcal meningitis
• Acute necrotizing ulcerative gingivitis/
• Any disseminated endemic mycosis
periodontitis
• Cryptosporidiosis or Isosporiasis (with
• Lymphoid interstitial pneumonitis
diarrhoea > 1 month)
(LIP)
• CMV infection of organ other than liver,
• Unexplained anaemia (<8g/dL),
spleen, lymph nodes (and onset age >1
neutropenia (<1000/mm3), or month)
thrombocytopenia (<30,000/mm3) for
• Disseminated mycobacterial disease other
>1 mo.
160
 • HIV-related cardiomyopathy than tuberculosis
• HIV-related nephropathy • Candida of trachea, bronchi or lungs
• Acquired recto-vesicular fistula
• Cerebral or B-cell non-Hodgkin’s
lymphoma
• Progressive multifocal
leucoencephalopathy (PML)
• HIV encephalopathy

Ref: http://www.who.int/hiv/pub/guidelines/HIVstaging150307.pdf

Annex 4:. Roles and Responsibilities of CTC Staff

CTC staff Roles and responsibilities

CTC in-charge The CTC In-charge will report to the OPD In-charge and will perform the
following duties:
• Monitor all CTC related activities, supervise, support and mentor all CTC
staff
• Coordinate linkage of CTC services with HTC, STI, RCH, PMTCT, TB
clinics, IPD, FP, OPD services, PLHIVs support groups and CBHS programs
• Conduct weekly and monthly CTC staff meetings and ensure minutes are
documented and disseminated
• Coordinate Work Improvement Teams and participate in Facility Quality
Improvement activities
• Participate in the facility monthly meetings where all other units (OPD, IPD,
RCH, TB/STI /Skin/ Dental clinics are represented.
• Ensure availability of ARVs, OI medicines and other essential medical
supplies by collaborating with relevant sections.
• Ensure availability of HIV and AIDS service delivery guidelines, SOPs, job
aids and protocols
• Ensure proper documentation and timely reporting of data.
• Ensure appointments and lost to follow up tracking system are functional
• Conduct data analysis and utilize the findings for planning and
implementation
• Ensure implementation of infection prevention control plan
CTC • Sort client files and open file for new clients
receptionist • Ensure all relevant client cards/forms are attached in client file e.g.
Continuation forms and TB screening tool, Investigations forms etc.
• Ensure referral forms for all referred clients are attached in the files
• Fill demographic information of the clients
• Manage patient files systematically for easy and quick retrieve

161
 • Direct clients to a respective area of services
• Direct all new clients without referral forms or relevant information to
counselor
Keep appointment register and alert the CBHS contact person on missed
appointments for follow up
• Conduct initial client assessment (weight, Height, vital signs) and record in
CTC cards and other relevant forms
Triage nurse • Identify serious sick clients from the waiting area and immediately refer to
relevant units/staff at the clinic for treatment
• Direct clients to respective clinicians or appropriate/required services
Clinician • Perform detailed clinical assessment (screen for OIs) and monitoring of clients
• Provide comprehensive prevention, treatment and care.
• Record all client information into the CTC1, CTC2 and clinical sheets
• Fill in the feedback section of the referral forms
• Identify and document referral needs for clients
• Consult/refer complicated cases to specialized services
• Identify and manage treatment failure
• Fill in prescription for ARVs and OIs for clients
• Order required Laboratory and Radiological investigation appropriately
Nurse • Assess individual client treatment readiness using adherence counselling
counsellor check list
• Provide adherence counselling and other aspects of PHDP at every clinic
visit
• Record all required information into CTC2 and adherence counselling
checklist
• Link the client to other support services according to the need.
• Identify and document referral needs for clients
• Fill in prescription for ARVs for clients as needed/indicated
CBHS provider • Link clients to other services and support groups for People Living with HIV
and AIDS (PLHIV)
• Maintain and update directory of referral and support services
• Ensure early identification of missed appointment and lost to follow up
clients are traced back
• Supervise and mentor community based HIV service providers
Pharmaceutical • Ensure continuous availability of HIV commodities through appropriate
personnel record keeping, ordering and receiving process
• Store commodities in spacious room under appropriate condition
• Handle prescription, dispense ARVs and OI medicines, and counsel the
client on appropriate use of medicines
• Assess adherence to medicine, occurrence of side effects, and take
appropriate measures

162
Data Clerk • Check CTC 2 card for completeness and correctness
• Enter CTC2 data in the database
• Perform data cleaning and provide regular reports to monitor progress
towards achieving performance targets.
• Participate in the facility monthly meetings where all other units (OPD, IPD,
RCH, TB/STI /Skin/ Dental clinics are represented.
CTC exit staff • Check if laboratory investigations were done and ARVs were correctly
administered
• Check, discuss and agree with client on the next clinic visit date, time, and
record it in appointment register
• Fill in daily appointment summary report forms, analyze missed appointment
and report them to CBHS contact person
• Link and refer clients to CBHS provider and other support services
Medical • Keep CTC clean at all times
attendant • Escort client to and from relevant units when necessary e.g. laboratory,
pharmacy, RCH, TB clinic, IPD wards, FP, PMTCT
• Assist with sorting of files and follow up laboratory results
• Perform general cleanliness of the clinic

163
Annex 5. Health Facilities Accreditation for initiation of ART

THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND CHILDREN

ASSESSMENT TOOL FOR HEALTH FACILITY TO PROVIDE HIV CARE AND

TREATMENT SERVICES

Minimum Criteria for a Health Centre and Dispensary

164
Name of health facility: Type of facility ………………….
District:
Region:

Date of assessment:
Baseline visit re-assessment visit
Instruction
1. Theanswerstotheminimumcriteriashould be derivedfromthehealthcenter and
Dispensary assessmenttool(version3,October 2015).
2. Thenumbersinbracketsrefertothequestion numbersinthe Health center and
Dispensary Assessment tool.
3. Circle the appropriate response (yes/no) as recorded in the assessment tools
4. If the response is yes, circle the appropriate score
5. Sum all circled yes score to make a total of minimum score
6. Cut of point
 If the facilit y scored 60% and above with consultation room, at
least three staff (Clinician, nurse and other health worker) t he
facilit y qualif y for initiation.
 If the facilit y scored below 60% action plan for improvement
should be in place before 2 n d assessment.

165
1 Organization of HIV and AIDS care services within facility

1.a One or more confidential consultation rooms Score

One clinical consultation rooms available (4.2.1) yes no 3

Consultation rooms with visual privacy (4.2.4) yes no 3

Consultation rooms with Auditory privacy (4.2.5) yes no 2

1.b Space/room and register for registration of HIV and

AIDS patients(1.8.1and1.8.2=yes, seen) yes no 3

2 Human resource capacity and training

2.a Atleast one clinician ( ACO,CO, AMO, MO)(2.3.1) yes no 8
2.b At least one nurse (EN,RN) (2.3.3) yes no 8
2.c At least one other health worker(2.3.4,2.3.5,2.3.6or
yes no 8
2.3.7)
2.d At least two staff (Clinicians and Nurse) trained on yes no 8
National Curriculum on ART (CTC/PMTCT)(2.2)

3 HIV Testing and Counselling services

3.a One confidential room for testing and
counselling3.2.1�1and3.2.3+3.2.4=yes, observed) Sco
One confidential room for testing and Counselling re
(3.2.1) yes no 2
Testing & Counselling rooms with visual privacy (3.2.2) 2

Testing & Counselling rooms with Auditory privacy (3.2.3) yes no 2

yes no

3.b At least one HTC provider (PITC/CITC) (3.3.3) yes

n4

4 Clinical HIV and AIDS care and treatment services

4.a Availability of PMTCT services (4.8.1) yes no
8
166
 5 Patient records and reporting systems

5.a An established and working medical record system

yes no 2
(5.1.1-5.1.5,=yes)
5.b Locked area for medical records with limited access
yes no 3
(5.2.1=yes)

6 Continuum of Care
6.a Availability of CBHS (at least one = 6.2.1 &
6.2.2) yes no 5
6.b Functional system for patients tracking (5.5.2)
yes no 5

7 Laboratory

7.a Adequate laboratory space(7.2.1=yes,7.2.3=yes), 2

least oner oom
7.b HIV testing (rapid) 2
7.c Basic blood tests 2
7.6
7.d Malaria blood test 2
7.e TB sputum smears (ZNstain)+STItest(Gram 2
(7.4.13
7.f Routine testing of stool and urine(7.4.12 2
7.g Pregnancy Test 2

8 Pharmacyservices

8.a Secure storage space large enough for 6 months supply yes no 5
ofARVs (8.6.1=yes,seen)
8.b Refrigerator in pharmacy(8.6.2) yes no 5

167
 THE UNITED REPUBLIC OF TANZANIA
MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND CHILDREN

Name of Health Facility: Type of

…………………………….. facility:
Health Centre Dispensary
Address: Governme Private FBO
……………………………..
P.O.Box:…………………………… nt
Other(speci te
……………………...... fy: City/Town
/Village:
…………
…………
…………
…….
Ward: ….…………………………………. Health Service
Population: ……..….……….…………
District: ………………………………………………... Nearest referral
facility: ……………………………
Telephone number: …………………………….. and is:
Hospital Health Centre
Fax number: ……………………………..
E-mail: …………………………….. CTC NACP Code
number:………………..…………..

Key contact person:…………………………………....

Function:………………….…Mobile:………………………

Name of medical staff member in charge of HF:

…………………………………....
Date of assessment (dd/mm/yy):
……..…../……..……/……..……/
Assessment team members (name, organisation, expertise):
1.…………………………………....
2.…………………………………....
3.…………………………………....

168
4. RHMT Member:…………………………………....
5. CHMT Member:…………………………………...

General Information

6. IMPLEMENTIG PARTNER…………………….

Objectives of the assessment visit are to:

• d e t e r m i n e the availability and quality of the essential elements of the facility.
• assess the current capacity of the health facility for provision of HIV care and
treatment
• identify are as for strengthening and improvement to upgrade the health facility to be
able to provide comprehensive care and support to Persons Living with HIV/AIDS
• Issue certification to health facilities to enable them to support ART, once they have
met a standard set of criteria
Procedure
1. Complete this assessment tool by visiting the relevant health centre or dispensary;
conduct an interview with the in-charge/ representative of the facility, observe and
assess the infrastructure and equipment/supplies.
2. If the facility provides already HIV/AIDS Care and Treatment services, all the
questions in the tool need to be asked and the answers filled in as completely as
possible.
3. If these services are not yet provided, you can skip the sections.
4. Try to be brief when writing comments. Use if possible only keywords. If this pace to
write comments is not enough, write on the back of the previous page.
5. Compile and analyse the data, using the Minimum Criteria and the Assessment
Report.
6. Develop, with the facility, a Strengthening Plan and discuss the plan with the heads of
units and the in-charge at the health facility.
7. Fill the tool in duplicate and let the i.c .of the HF and team members sign these.
Provide a copy of the tool to the facility at the end of the visit.
8. Send copies of the assessment tool, the minimum criteria, the assessment
report and strengthening plan to
a. The higher level health facility linked to this
facility, by the DMO,

b. the RMO,

169
 c. the supporting partner in the region and

d. NACP.

9. Based on the results of the assessment visit, the NACP may certify the facility.
10. ANY questions regarding drug shipments, training, laboratory equipment, etc.
Should be directed to the Health Centre in-charge or District Medical Officer.

Signatures of facility staff who have provided information:

The person in charge of the HF or her/his representative:

Name: Title:

Signature: Date:

Name: Title:

Signature: Date:

Signatures of assessors:

Name: Area(s) of expertise:

Signature: Date:

Name: Area(s) of expertise:

Signature: Date:

Name: Area(s) of expertise:

Signature: Date:

Name: Area(s) of expertise:

Signature: Date:

170
Signatures of additional members of the assessment team:

Name: Area(s) of expertise:

Signature: Date:

Name: Area(s) of expertise:

Signature: Date:

Name: Area(s) of expertise:

Signature: Date:

171
Organization of HIV and AIDS Services

1.1 General

1.1.1 How many OPD patients seen in the last reporting month? Patients
1.1.2 How many OPD patients in the last reporting year? Patients
1.1.3 How many under 5 patients attended OPD in the last reporting year? Patients
1.1.4 How many patients have been admitted in the last reporting month? Patients
1.1.5 How many in-patients have been admitted in the last reporting year? Patients
1.1.6 How many under 5 patients have been admitted in the last reporting Patients
year? Jan-Dec
1.1.7 What is the farthest distance in Kilometres in your catchment area? Km
1.1.8 Is public transport available to reach your facility from the farthest Yes No
distant area?
1.1.9 Does the area have special accessibility difficulties? Yes No

At
Reporte nearb Not
Observe
1.2 HIV services d not y availabl
d
seen referr e
al
1.2.1 HIV testing &Counselling
1.2.2 Care, treatment &support
for PLHIV
1.2.3 Collaborative TB/HIV
servi
1.2.4cesCommunity Based HIV
services
1.2.5 PMTCT services
1.2.6 Reproductive and Child
Health
1.2.7 Adolescent youth friendly
reproductive health services
1.2.8 STI diagnosis and treatment
1.2.9 Nutrition assessment,
Counselling and support
1.2.10 Orphans and Vulnerable
Children services (OVC)
Initiation site
1.2.11 If ART provided the HF is

172
1.3 Functional plan for patient flow

1.3.1 Is there a clearly described patient flow plan for the facility
Yes No
in general?
1.3.2 Assess the patient flow plan, with an emphasis on C&T
P Score:
services

1.4 Supportive Supervision

1.4.1 Does the CHMT supervise your health facility (HF) Yes No
quarterly?
1.4.1.1 If yes, how many months ago was the last visit? Months
1.4.1.2 Is there a written report of this CHMT visit in the HF? Yes No
1.4.2 Does your HF receive comprehensive supportive
Yes No
supervision, mentorship or coaching services?
1.4.2.1 If yes, how many months ago was the last visit? Months
1.4.2.2 Is there a written report on comprehensive supportive
Yes No
supervision, mentorship or coaching?
1.4.3 Does the region or district provide laboratory support to your Yes No
facility?
1.4.3.1 If yes, is the visit aimed for lab supervision? Yes No
1.4.3.2 Is the visit for repair and maintenance/? Yes No
1.4.3.3 Is the visit meant to bring supplies? Yes No
1.4.3.4 Is the visit for another purpose? (if yes specify: ) Yes No

1.5 Infrastructural capacity

1.5.1 Does the Dispensary / Health Centre have the following rooms:
1.5.1.1 Reception and medical records room* Y N
1.5.1.2 Consultation room (if > 1 room, see 1.5.3) es Y o n
1.5.1.3 Laboratory room (main working room) es Y o n
1.5.1.4 Dressing room es Y o n
1.5.1.5 Injection room es Y o n
1.5.1.6 Dispensing room with drug store es Y o n
1.5.1.7 Store es Y o n
1.5.1.8 Reproductive Child Health Care (RCHC) room es Y o n
1.5.1.9 Delivery room (with waiting beds(s) and post- es o
Y n
delivery beds es o

173
1.5.2 Does the Health Centre have the following additional rooms/services:
1.5.2.1 Functioning Minor theatre Y n
1.5.2.2 Functioning major theatre es Y o n
1.5.2.3 RCHC room es Y o n
1.5.2.4 Female wards es Y o n
1.5.2.5 Male wards es Y o n
1.5.2.6 Delivery room with maternity ward es Y o n
1.5.2.7 X-ray block es Y o n
es Y o n
1.5.2.8 Office of i/c health centre
es o
1.5.2.9 Office of i/c nursing service Y n
1.5.3 How many consultation rooms are available at the facility? es o Rooms
1.5.4 How many service providers share a consultation room? clinicia
ns

1.6 CTC in charge & AIDS services

1.6.1 Is a CTC in charge/ appointed to coordinate the
HIV & AIDS care and treatment services at the facility (member Yes No
of the Care and Treatment team, see next paragraph Human
Resources)?
1.6.2 Name: Cadre

1.7 Referral and linkage to CTC

1.7.1 Does the HF have referral and networking system? Y N
1.7.2 Does the facility refer PLHIV to a nearby (referral) HF with es Y o N
a CTC? o
1.7.3 What is the distance in km from the nearest referral HF es Kms
with a CTC? Y N
1.7.4 Is public transport available to reach the referral facility?
1.7.5 How many referrals to the referral CTC took place in the es o Referral
last quarter? s

1.8 Space for registration of HIV & AIDS patients

1.8.1 Is there separate room for reception and
Yes, seen Yes, not seen No
registration of PLHIV attending the HF for C&T?
1.8.3 Assess the registration process and location P Score:

174
1.9 Medical waste disposal and
1.9.1 Do consultation rooms and HTC rooms No
ha ve sharps disposal co ntain ers?
Yes,seen Yes, not seen
1.9.2 Does the HF segregate non infection and Yes, not seen No
infectious wastes? Yes, Seen
1.9.3 Does the facility have a functioning Yes, seen Yes, not seen No
1.9.4 Does the HF have functional toilets or Yes, seen Yes, not seen No
1.9.5 Does the HF have reliable sources of water? Yes, seen Yes, not seen No
1.9.6 Is there any hand washing water (running)? Yes, seen Yes, not seen No
1.9.7 Is the sewage system operational? Yes, seen Yes, not seen No
1.9.8 Assess sanitation, incinerator and medical waste disposal in P Score:

1.10 Bio-safety at health facility

1.10.1 Waiting area for CTC adequate space and well Yes, seen yes, not No
ventilated? seen
1.10.2 Waiting area for OPD adequate space and well Yes, seen yes, not No
ventilated? seen
1.10.3 Does the HF have an Infection Control Plan Yes, seen yes, not No
1.10.4 Is there an adequate space and well ventilated Yes, seen yes, not No
waiting area for lab? seen
1.10.5 Are personal protective equipment (gloves, Yes, seen yes, not No
boots, apron, mask) available in sufficient quantity? seen
1.10.6 Is the laboratory well ventilated? Yes, seen yes, not No
1.10.7 Does the lab have a safety cabinet (hood)? Yes, seen yes, not No
1.10.9 Are (Hepa) masks for lab staff or for infective
MDR-TB Patients available? Yes,seen yes,notseen No
1.10.10 Assess the overall bio-safety status at HF P Score:

1.11 Information
1.11.1 Does the facility have a functional computer
for CTC2 and pharmacy module database entry
related to care and treatm ent? yes, seen yes, not No
seen
1.11.2 Are CTC data entered and analyzed yes,seen yes,not seen No
1.11.3 Does the HF have access to internet? yes, seen yes, not No
1.11.4 Assess the overall IT capacity of the HF P Score:

175
1.12 Power

1.12.1 Does the facility have Electrical power supply? yes, seen yes, not No
1.12.2 Does the HF have a functional backup power? yes, seen yes, not No
1.12.3 Does the HF has one or more
functioning refrigerators (if there Is no
Tanesco or working generator) yes, seen yes, not No
seen
1.12.4 Assess the overall availability of power A
Score:

176
2. Human Resource capacity and Training

2.1 Staff currently Staff Actual Number of Total working

employed at facility establishment number staffs hours per week
and their currently working at for this category
involvement in C&T employed PMTCT/CT of staff at
HOSP H/C. DISP.
1. Medical Officer Hours
2. Assistant Medical Hours
3. Clinical Assistant Hours
4. Clinical Officer Hours
5. Public Health Nurse Hours
6. Registered Nurse Hours
7. Enrolled nurse Hours
8. Laboratory Hours
9. Laboratory Technician Hours
10. Laboratory Assistant Hours
11. Pharmacist Hours
12. Pharmacy Technician Hours
14. Pharmacy assistant Hours
15. Radiographer Hours
16. Data clerk for Hours
17. HTC providers Hours
18. HBC staff Hours
19. Admin/finance staff Hours
20. Medical records staff Hours
21. IT staff-Other Data Hours
22. Medical Attendants Hours
23. Nutritionist Hours
23. Other Hours

3. HIV Testing and Counselling Services

2.3 Dedicated Care and Treatment team

2.3.1 assessing/ prescribing clinician (CA, CO AMO or MO ) Yes No

2.3.2 triage nurse Yes No
2.3.3 At least one nurse ) Yes No
2.3.4 laboratory technologist/laboratory technician/lab assistant Yes No
2.3.5 pharmaceutical technician/assistant Yes No
2.3.6 data clerk (ARV data-entry) Yes No
2.3.7 CBHC provider Yes No

177
 Yes
2.4 Guidelines available and easily accessible for use seen Not seen No
2.4.1 National guidelines for the management of HIVAIDS(2015)
2.4..2 National comprehensive guidelines for HIV Testing and
counselling(2013)
2.4..3 National guidelines on PMTCT(2013)
2.4..4 National guidelines on CBHS (2018)
2.4..5 National standard guidelines for health laboratory
2.4..7 National TB/HIV guidelines
2.4..8 Pocket handbook for HF Infection Prevention & Control in
Tanzania (MoHSW2007)
2.4..9 National TB/Leprosy Manual(NTLP)
2.4..10 National STI guidelines
2.4..11 HIV care primary booklets(acute, chronic, palliative,
2.4.5.12 SOP for HIV Testing and counselling manual
2.4.13 Other(mention):
2.4.14 Assess the overall availability of relevant guidelines A

3.2 Client Initiated Counselling and Testing (CITC) services

Does the facility:

3.2.1 Provide CITC services? If no go to 3.1.4 yes No

3.2.2 Provide pre-test counselling? yes No

3.2.3 Provide post-test counselling? yes No

3.2.4 Refer persons or patients for counselling and testing to yes No

another site?
How many referrals took place:

3.2.5 from the CITC services to the CTC within the last reported Referrals
quarter?
3.2.6 Assess the CITC capacity of the facility in general P
score:

178
3.2 Counselling room

3.2.1 Number of separate rooms available for Rooms

coun selling
Observed Reported available, Not available
but not seen
3.2.2 Means of visual privacy of rooms
3.2.3 Means of auditory privacy of
rooms
3.2.4 Is furniture present and
comfortable?
3.2.5 Is the room well ventilated?
3.2.6 Assess the overall quality of the counselling A Score:
room(s)

3.4 CITC counsellor

3.4.1 How many counsellors were trained according to the national Counsellors
CITC curriculum?

3.4.2 How many counsellors received CITC training using different Counsellors
curriculum? Mention organization and duration of training

3.4.3 How many trained CITC counsellors are actually working as Counsellors
CITC
Counsellors?

3.4.4 How many counselors are practicing without training on CITC? Counsellors

3.4.5 Assess the overall availability of counsellors and their training P

status Score:

179
3.5 Provider Initiated Testing and Counselling (PITC)

3.5.1 Is PITC practiced at this Health Facility? Yes No

3.5.2 Is PITC provided at:
OPD Yes No
IPD Yes No
RCH Yes No
CTC Yes No
TB clinic Yes No
STI clinic Yes No
Family planning clinic Yes No
Others mention…….
3.5.3 How many patients were referred for C&T after
undergoing PITC during the last reported quarter? Patients
3.5.4 How many Health Workers received the 5 days PITC HCW
training?
3.5.5 Assess the practice of PITC in general P Score:

4. Clinical care

4.1 Staffing currently working at the CTC Number NO. Category

4.1.1 Medical Officers(MO) MO
4.1.2 Assistant Medical Officers(AMO) AMO
4.1.3 Clinical Officers(CO) CO
4.1.4 Clinical Assistant (CA) CA
4.1.4 Adherence Counsellors(C) C
4.1.5 Nurses N
4.1.6 Others (CBHS providers) O

4.2 Consultation room Number Category

4.2.1 How many clinical consultation rooms are available in the Rooms
4.2.2 How many clinicians share one room at the same time? Clinicians
4.2.3 How many dedicated rooms for C&T activities only? Rooms
Reporte Not
Privacy and outfit of consultation rooms Observed d, not available
seen
4.2.4 Means of visual privacy in consultation rooms?
4.2.5 Means of Auditory privacy in consultation rooms?
4.2.6 Water and hand cleaning utensils available?

180
4.2.7 Weighing scale and height measure present?
4.2.8 Assess capacity and quality of examination rooms A

Reporte Not
d, available
4.3 HIV Testing Observed notseen
4.3.1 Rapid HIV test algorithm 2019 available?
st
4.3.2 1 test SD Bioline HIV 1-2. 3.0
4.3.3 2nd test Uni-Gold HIV
4.3.4 Internal Quality Control system for rapid algorithm
4.3.6 External Quality Assessment system for rapid
4.3.7 Does the HF use R&R system for ordering HIV test
4.3.8 Does the HF receive the HIV test orders as Yes No
4.3.9 Did the HF experience stock outs of any of the Yes No
test kits in the past 6 months?
4.3.9 Assess the status of HIV test supply A Score:

4.4 Referral & linkage betwe en inpatients and CTC

4.4.1 How many patients diagnosed with HIV at the ward were Referrals
registered at the CTC within the last 3 months
4.4.2 Does HF have referral forms? yes No
4.4.3 Does the HF uses referral forms? Yes No
4.4.4 Is there feedback mechanism for referrals made? Yes No

4.4.5 Assess the referral and registration system between the ward and P Score:
the C&T and vice versa

4.5 Opportunistic Infections and TB diagnosis and

yes No
4.5.1 can the HF provide OIs prophylaxis (CPT, IPT)to HIV positive
clien
4.5.2tsIs the HF able to diagnosis and manages common OIs? yes No
4.5.3 Does the HF provide collaborative TB/HIV services? yes No
4.5.4 Is this a TB diagnosis (AFB) and treatment (DOTS) health yes No
4.5.5 Is this a TB treatment only (DOTS) health facility? yes No
4.5.6 Is there an active TB/HIV coordination structure (e.g. committee) yes No
4.5.7Assess over all status of OI and TB diagnosis & treatment at P Score:

4.6 Referral pattern between TB and CTC/PMTCT

4.6.1 How many successful referrals took place from the TB services to
the CTC (in the HF or at the referral HF for CTC) within the last referrals
4.6.2 How many successful referrals took place from CTC to the TB referrals
services (in the HF or at the referral HF for CTC) within the last
181
4.6.3 Are all identified PLHIV at C&T site and at CITC sites screened yes No
4.6.4 Assess overall status of TB/HIV collaborative activities in HF P Score:

4.7 STI diagnosis and

4.7.1 Does the facility provide STI diagnosis? yes No

4.7.2 Does the facility provide STI treatment? yes No
4.7.3 How many referrals for STI cases diagnosed with HIV took place
from the STI-services to the CTC (in the HF or at the referral HF for referrals
CTC ) within the last reported quarter?
4.7.4 Assess overall status of STI services in HF P Score:

4.8 PMTCT services

4.8.1 Does the facility provide PMTCT services? yes No

4.8.2 What is a total number of pregnant and lactating mothers received Number
HIV testing at this HF for the last one year?
4.8.3 How many HIV positive Pregnant and lactating mother received Number
ART services for the last one year?
4.8.4 How many male partners were tested for HIV for the last one year? Number
4.8.5 Does HF have referral mechanism for infants, HIV positive yes No
pregnant and breast feeding mothers between PMTCT and CTC services?
4.8.6 Does the HF provide EID services? yes No
4.8.7 Did the HF experience any stock out of DBS Kits in the past 3 yes No
months?
4.8.8 What is a turnaround time for DBS results at this HF? Days
4.8.9 Assess the implementation status of PMTCT P
Score:

Reported Not
4.9 Post Exposure Prophylaxis (PEP) available, availabl
Observe notseen e
4.9.1 Is a PEP protocol available at the HF?
4.9.2 Does the HF regularly updated PEP
4.9.3 Assess PEP practice P
5. Patients Records and Administration

5.1 Medical records system

5.1.1 Does the facility keep medical records
(chart, files ystem) for all patients?
Yes, Yes, not No
5.1.2 Does the facility keep DBS results records?
Yes, Yes, not No
5.1.3 Does the facility use ILS/MTUHA for the
facility re cord?
Yes, Yes, not No

182
5.1.4 Does the HF keep clinical records for
C&T/PMTCT patients? Yes, Yes, not No
5.1.5 Are these records computerized at the HF seen seen
5.1.6 Assess completeness/correctness and management Ye ,
of sthese Yes,PScore:
not No

5.2 Accessibility of medical records

5.2.1 Are medical records stored in a place that can be locked? yes No
5.2.2 Assess how medical records are kept (locked area, access, filing P Score:

5.3 Current number of PLHA registered at the

5.3.1 Start date of ART at the facility l l

5.3.2 Number of HIV-positive persons registered for care
5.3.3 Number of HIV-positive persons who are eligible for ART, but did not start
5.3.4 Number of patients to date who ever started ART
5.3.5 Number of patients who started ART, who visited at least once during the
last quarter and were on treatment during the last vis it date
5.3.6 Assess data recording process at C&T Clinic P Score:

5.4 Current number of PLHIV registered at the PMTCT/PEDIATRIC ART

5.4.1 Start date of ART at the facility l l

5.4.2 Number of partners tested HIV positive enrolled in care
5.4.3 Number of children under 15 yrs diagnosed
5.4.4 Number of HIV exposed infants registered at the facility
5.4.5 Number of HIV-positive persons including partners who are eligible for ART
but did not started
5.4.6Number of patients ever started on ART at this facility to date
5.4.7 Assess data recording process at C&T Clinic P Score:

5.5 System for patient

5.5.1 Is appointments register available and in Yes in use Yes not in No
use?
5.5.2 Is tracking register available and is used? use
5.5.3 Assess system for patient follow-up and P Score:

183
 6. Continuum of Care

6.1 Referral system and linkage with community, NGOs, FBOs and
community based

6.1.1 Partnerships:Are there any formal partnerships (any correspondence, MOU,

meeting minutes, etc.) with NGOs, CBOs, FBOs, patient support groups etc.
Please indicate below with whom:

Specify name of Organization type Supported services Documentation

(spiritual, material, on partnership
organization: (NGO, CBO, and education, seen
FBO etc.) nutrition, IGAs,
legal) yes No
yes No
yes No
yes No
yes No
yes No
6.1.2 Indicate whether it is formal(written)referral yes No
6.1.3 In case referral system is formalized, documentation/referral slips yes No
6.1.4 Do FBO, NGO, CBO provides information about care, yes No
services and how to access these services?
6.1.5 Does the facility work with a ward or a council AIDS Committee? Month
6.1.6 Assess the referral system P Score:

6.2 Community Based HIV and AIDS Services (CBHS)

6.2.1 Is there a CBHS supervisor at the facility? Yes No

6.2.2 Is there a CBHS provider? Yes No
6.2.3 How many PLHIV were visited in the last reporting month? Yes No
6.2.4 How many LTFU clients were tracked and linked back to the Yes No
healt h facili ty during the previous quarter?
6.2.5 Does the CBHS provider receive transport support? (If yes Yes No
mention type o f support such as bicycle or transport
money)? …………………………..

6.2.6 Assess the Community Based HIV and AIDS Services (CBHS) P Score:

184
7. Laboratory

7.1
7.1.1 How many laboratory technologists, lab technicians, lab Technologis
assistants and lab attendants work in the labor atory?
Technicians
Assistants
Attendants

7.2 Laboratory space

7.2.1 How many rooms does the laboratory have? Rooms

7.2.2 Is there a separate section/room for specimen collection? yes No
7.2.3 Is the available space sufficient to carry out the lab work? yes No
7.2.4 Assess general condition of laboratory building AScore:

7.3 Laboratory record management and storage

7.3.1 Is there a lockable room or cabinet for record storage? Yes No

7.3.2 Assess status of laboratory record management P Score:

If not available,
referred to
7.4 Test capacity of laboratory Available where?
7.4.1 HIV testing (rapid) Yes No
7.4. 2 CD 4 count Yes No
7.4.3 Viral load Yes No
7.4.4 Syphilis screening Yes No
7.4.5 Haemoglobin Yes No
7.4.6 WBC-total Yes No
7.4.7 WBC-differential Yes No
7.4.8 Blood sugar Yes No
7.4.9 Urinalysis (glucose, proteins, sediment) Yes No
7.4.10 Pregnancy testing Yes No
7.4.11 Is there a working microscope in the Yes No
lab(if No, go to 7.3.14)
7.4.11 Stool (direct microscopy for Yes No
organisms, worm eggs, occult
blood)
7.4.12 Sputum smears(TB) Yes No
7.4.14 Malaria blood smear/rapid test Yes No
7.4.15 Does the lab have a method for Yes No
preservation and temporarily storage of
7.3.16 specimens
Is a functioning mechanism for Yes No
transportation of specimens to
another/referral CTC in place?
7.3.17 If other tests are available, specify:

185
7.5

Available?
Class of equipment Remark
Operating s
Not
? seen
yes
yes no
7.5.1 Manual haematology + diff.
Haematology 7.5.2Automatedhaematologycounter
7.5.3 Is the availability of supplies for haematology equipment regular? yes no
7.5.4 Stock-out for haematology supplies in the past 6 months seen? yes no
7.5.5 Assess the status of haematology equipment and supply chain A
7.6

Available?
Class of equipment Not Remark
Operating seen s
?
yes
yes no
Blood 7.6.1 Manual (spectrophotometer)
Chemistry 7.6.2 Automated chemistry analyzer
7.6.3 Water bath
7.6.4 Is the availability of supplies for biochemistry equipment regular? yes No
7.6.5 Stock-out for biochemistry supplies in the past 6 months seen? yes No
7.6.6 Assess the status of biochemistry equipment and supply chain A

7.7

Class of equipment Remark

Operating
Not s
? seen
yes
yes no
7.7.1 Routine testing
7.7.2 Routine test urine (manual
7.7.3 Malaria blood smears
Urine, 7.7.4 TB sputum (microscopy)
stool,
malaria, 7.7.5 Pregnancy testing (manual
TB
7.6.6 Is the availability of supplies for yes No
7.6.7 Stock-out for microbiology/parasitology supplies in the past 6 yes No
7.6.8 Assess status of microbiology/ parasitology equipment and A

186
 7.8 Refrigeration and storage

7.8.1 4oC refrigerator with a compartment for yes, seen yes, not No
7.8.2 4oC refrigerator &freezer compartment for yes, seen Yes ,not No
7.8.3 Are thermometers in place and temperature logs yes, seen yes, not No
kept Lockable store? seen
7.8.4 Is an Itemized inventory of the store available? yes, seen yes, not No
7.8.5 Assess refrigeration and storage capacity P Score:

7.9 Laboratory Quality

7.9.1 Does the laboratory have and use Standard
Operating Procedures for all the tests yes,seen yes,notseen No
performed?
7.9.2Are any internal quality control arrangements in yes, seen yes, not No
If yes, specify: monthly weekly Daily
7.9.2.1 HIV-tests:
7.9.2.2 Haematology:
7.9.2.3 Biochemistry:
7.9.3 Are any external quality control arrangements
and/or assessments in place? yes,notseen No
yes,seen
Ifyes,specify: From How often per year:
7.9.3.1 HIV-tests:
7.9.3.2 Haematology:
7.9.3.3 Biochemistry:
7.9.4 Assess QA system for lab P Score:

7.10 Back-up capacity for

7.10.1 Emergency water reserve (1000litre) for lab? yes, seen yes, not No
seen
yes, no
7.10.2 Electricity power back-up (generator/solar)? yes, seen tseen No
A
7.10.3 Assess back-up capacity for lab

8.1

Pharmacist
8.1.1 How many pharmacists, pharma ceu tical Pharmacy technician
technicians, assistants and attendants work in the
pharmacy? Pharmacy attendant
Nurse
Medical attendant
Other staff
8.1.2 Assess the staff situation at the pharmacy A

187
8.2 Functional ARV tracking system
8.2.1 Is dispensing register for ARV & OIs Not observed
available and used?
observed N
8.2.2 Is ledger book for ARVs & OIs available and observed Not N
8.2.3 Are bin cards available and updated? observed Not observed N
8.2.4 Is there a first in first out (FIFO) &FEFO observed Not N
8.2.5 Is there a system to manage nearly expired observed Not N
ARVs & OI drugs? observed o
8.2.6 Assess the pharmacy ARV& OI drugs management system P Score:

8.3 Dispensing
8.3.1 Do pharmacy staffs provide information on observed Not No
the use of medicines to the patient? observed
8.3.2 D o pharmacy staffs verify/asses observed Not No
prescriptions provided, if they adhere observed
to Rational use of Medicine and current
National Guidelines
8.33 Does Pharmacy staffs have forms to
report ADRs (Adverse Drug
Reactions) Yellow Forms & Green
8.3.3 A r e ARVs dispensed by a pharmacy staff at observed Not No
CTC pharmacy? observed
8.3.4 Are ARVs dispensed at the observed Not No
8.3.5 If pharmacy dispenses ARVs, assess the practice P Score:

8.4 Pharmacy Supplies

Did the facility in the last half year have stock-out so far of the following drugs?

(NBtickinthe1stcolumn if this drug is part of the essential drugs list for the facility)

8.4.1 Cotrimoxazole syrup yes No

8.4.2 Cotrimoxazole tabs yes No
8.4.5 Isoniazid yes No
8.4.6 RHEZ(Rifampicin/Isoniazid/Ethambutol/Pyrazinamide) yes no
FDCTB
8.5.7 RH (Rifampicin/Isoniazid) FDC for continuation phase TB yes no
8.4.9ARVs for standard1stline treatment TLE yes no
8.4.10 Nevirapine syrup yes no
8.4.11Assesstheeffectivenessofthesupplychainsystem P
Score:

188
8.5 Guidelines and SOPs

8.5.1Arethere Guidelines and SOPs available? yes, seen yes, not seen n
o
8.5.2 Does the pharmacy have and use national ARV
Pharmacy instructions? yes, seen yes, not seen n
o
8.5.3 Assess the status and quality of SOPs and policy P Score:
8.6 Storagecapacityfor6months’supplyofARVs

8.6.1 I s therestoragespacefora6- yes, seen yes, not seen N

months’supplyofARVs? o
8.6.2 Does the storage room have a refrigerator? yes, seen yes, not seen N
8.6.3 Is the storage room cool, well ventilated? yes, seen yes, not seen N
8.6.4 Assess storage capacity for ARs in the facility A Score:

9.1 Budget earmarked for strengthening clinical HIV and AIDS

9.1.1 Does the facility have a budget which has been
earmarked for strengthening activities for HIV and
AIDS services? Yes No

189
 THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH AND SOCIAL WELFARE

NATIONALHIV/AIDSCAREANDTREATMENTPLAN

Assessment Report for Health Centers and Dispensaries

Version3, October 2015

Name of health facility:

City/Town:
District:
Region:
Date of assessment:
Names of assessors:

Enclosures
Completed assessment tool: Completed minimum criteria checklist:

Fill in the strengths and weaknesses. Do not attempt to identify perse 3 of each. If
less than 3 identified, present these. If more than 3 identified, prioritize or write in
additional space.

Summary:
A summary on location (rural, urban) and structure of the facility

190
1. Organization of HIV/AIDS services within facility, infrastructure
Strengths:
1.
2.
3.

Weaknesses:
1.
2.
3.
2. Human resource capacity and training
Strengths:
1.
2.
3.

Weaknesses:
1.
2.
3.

3. Counseling and Testing services

Strengths:
1.
2.
3.

Weaknesses:
1.
2.
3.

4. Clinical HIV/AIDS care and treatment services

Strengths:
1.
2.
3.

Weaknesses:
1.
2.
3.
5. Patient records and administration
Strengths:
1.
2.

191
3.
Weaknesses:
1.
2.
3.
6. Continuum of Care
Strengths:
1.
2.
3.
Weaknesses:
1.
2.
3.
7. Laboratory services
Strengths:
1.
2.
3.
Weaknesses:
1.
2.
3.
8. Pharmacy services
Strengths:
1.
2.
3.
Weaknesses:
1.
2.
3.
9. Financial & legal issues
Strengths:
1.
2.
Weaknesses:

192
Table2.Strengthening Plan (minimum criteria): Enter the items to *The responsible person for the strengthening, and for obtaining
strengthen in the table below resources should be a representative from the health facility
The minimum criteria have been defined as the minimum conditions itself (not NACP/MOH).
needed to initiate, refill or outreach ART. However, other items to **Indicate whether funds are available (Yes),N(No),NR(Not
strengthenresultingfromtheassessmenttoolcanbeadded.Foreachitemto Required).
***Name the source of funding (health facility budget,
strengthen; enter the minimum criterion number in the 2nd column. CHMT budget, PEPFAR organization, Global Fund, etc.).

193
Item to strengthen and action to be Min Responsible Require Funds Name of Responsible Date to
taken . person(s) d available source of person(s) to be
Crit (name)*,including budget ? funding* obtain complet
(includingpossiblecomments/explanatio position Y/N/NR ** resources* ed
Actio
2.
Actio
3.
Actio
4.
Actio
5.
Actio
6.
Actio
7.
Actio
8.
Actio
9.
Actio
10.
Actio
11.
Actio

Comments:

194
Participants during this visit

Assistant Medical Officer / Clinical Officer in Char Name:

of Health Facility
Function:
Name:
Signature:
Signature:
Date:
Date:

Assessment Coach: District Representative:

Name: Name:

Function: Function:

Signature: Signature:

Date: Date:

Regional Representative: Third party / Partner Organization

Name: Name:

Function: Function:

Signature: Signature:

Date: Date:

195
Annex 6: Viral load – converting log values to numbers
The range of viral load is so wide that results are often given as results from a logarithmic
(log) scale.
This is an easier way to deal with very large and very small numbers at the same time. Below
50 copies/mL for most people on treatment is 1.7 logs. In very early infection, a viral load of
10 million copies is 7.0 logs.
Log value is a measurement used to describe HIV and expresses the viral load values as a
power of ten (written log10). The scale is used because large changes can only be captured on
graphs or diagrams by using a log scale. This turns large numbers of copies/mL into
‘manageable’ figures.

Table: HIV RNA viral load log value–number conversion

Log10 copies/mL

0.1 1 1.1 13 2.1 126

0.2 2 1.2 16 2.2 158

0.3 2 1.3 20 2.3 200

0.4 3 1.4 25 2.4 251

0.5 3 1.5 32 2.5 316

0.6 4 1.6 40 2.6 398

0.7 5 1.7 50 2.7 501

0.8 6 1.8 63 2.8 632

0.9 8 1.9 79 2.9 794

1.0 10 2.0 100 3.0 1,000

2.1 126 3.1 1,259 4.1 12,589

2.2 158 3.2 1,585 4.2 15,849

2.3 200 3.3 1,995 4.3 19,953

2.4 251 3.4 2,512 4.4 25,119

2.5 316 3.5 3,162 4.5 31,623

2.6 398 3.6 3,981 4.6 39,811

2.7 501 3.7 5,012 4.7 50,119

2.8 632 3.8 6,310 4.8 63,096

2.9 794 3.9 7,943 4.9 79,433

196
3.0 04.0 10,000 5.0 100,000
1,0
5.1 36.1 1,258,925
125,8
5.2 96.2 1,584,893
158,4
5.3 66.3 1,995,262
199,5
5.4 96.4 2,511,886
251,1
5.5 86.5 3,162,278
316,2
5.6 76.6 3,981,072
398,1
5.7 76.7 5,011,872
501,1
5.8 76.8 6,309,573
630,9
5.9 86.9
7,943,282
794,3
6.0 1,000,000
7 10,00 ,000
0

197
Annex 7: Dosages of Antiretroviral Drugs for Adults and Adolescents

Generic Name Strength and Dose

NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIs)
Abacavir (ABC) 300 mg twice daily or 600 mg once daily
Zidovudine (AZT) 300 mg twice daily
Emtricitabine (FTC) 200mg once daily
Lamivudine (3TC) 150 gm twice daily or 300mg once daily
NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NtRTIs)
Tenofovir (TDF) 300 mg once daily
NON – NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIs)
Efavirenz (EFV) 400 - 600 mg once daily
Nevirapine (NVP) 200 mg once daily for 14 days, followed by200 mg twice
200
dailymg twice daily
Etravirine (ETV)
PROTEASES INHIBITORS (PIs)
Atazanavir + ritonavir (ATV/r 300 mg + 100 mg once daily
Lopinavir/ritonavir (LPV/r) 400 mg/100 mg twice daily
Considerations for individuals receiving TB therapy
In the presence of rifabutin, no dose adjustment required.
In the presence of rifampicin, adjusted dose of LPV/r:
(LPV 800 mg + RTV 200 mg twice daily or LPV 400 mg +
RTV 400 mg twice daily) with close monitoring.
Darunavir + ritonavir (DRV/r) 800 mg + 100 mg once dailya or 600 mg + 100 mg twice
b
dailyINHIBITORS (INSTIS)
INTEGRASE STRAND TRANSFER
Dolutegravir (DTG) 50 mg once daily
Raltegravir (RAL) 400 mg twice daily
a For individuals with no previous use of protease inhibitors.
b For individuals with previous use of protease inhibitors

198
Annex 8: Paediatric Antiretroviral Dosing
Chart 1

Weig Weig
TLE
ht Combi Combi Duovi Duovi Lamivud Abacavi Efavire Nevirapi ht
Abacavir/ Abacavir/ or Truva
rang vir vir r N r ine r nz ne rang
3TC Adult 3TC Baby Atripl da
e Adult Baby Adult Baby (3TC) (ABC) (EFV) (NVP) e
a
(kg) (kg)
Dose
is Dose is ONCE
Dose Dose ONC ONCE 4 8 daily 160-200
Dose is Dose is Dose is Dose is is is E daily mg/kg/d mg/kg/d for mg/m2/d
ONCE TWICE TWIC TWIC TWIC TWI daily (TDF2 ose ose childre ose
daily daily E daily E daily E CE (TDF 08 TWICE TWICE n TWICE
daily daily 208 mg/m2 daily daily > 3 daily
mg/m ) years
2)
300 60 mg 300 300 mg
mg AZT/ mg TDF/3
AZT/ 30 mg TDF/2 00 mg
300 mg 60 mg
600 mg 60 mg 150 3TC/ 00 mg 3TC 50, 200
AZT/ AZT/ 10
ABC/300 ABC/ 30 mg 50 mg FTC (or 200 150 mg 300 mg and
150 mg 30 mg mg/ml
mg 3TC mg 3TC 3TC/2 NVP (used mg tablets tablets 600 mg
3TC 3TC syrup
tablet tablet 00 mg tablet with FTC)/6 tablets
tablet tablet
NVP NNRT 00 mg
tablet I or EFV
PI)
1 tab 1 tab
3-4.9 1 tab BD 5 ml BD 3-4.9
BD BD

199
 1 tab 1 tab
5-5.9 1 tab BD 6 ml BD 5-5.9
BD BD
1.5
1.5 tab
6-6.9 1.5 tab BD tab 7 ml BD 6-6.9
BD
BD
1.5
1.5 tab
7-7.9 1.5 tab BD tab 8 ml BD 7-7.9
BD
BD
1.5
1.5 tab
8-8.9 1.5 tab BD tab 9 ml BD 8-8.9
BD
BD
1.5
1.5 tab
9-9.9 1.5 tab BD tab 9 ml BD 9-9.9
BD
BD
10- 2 tab 2 tab 200 mg 10 ml 10-
2 tab BD
10.9 BD BD OD BD 10.9
11- 2 tab 2 tab 0.5 tab 200 mg 10 ml 11-
2 tab BD
11.9 BD BD BD OD BD 11.9
12- 2 tab 2 tab 0.5 tab 0.5 tab 200 mg 11 ml 12-
2 tab BD
13.9 BD BD BD BD OD BD 13.9
200 mg
2.5
14- 0.5 tab 2.5 tab 0.5 tab 0.5 tab + 14-
2.5 tab BD tab
16.9 BD BD BD BD 50 mg 16.9
BD
OD
200 mg
2.5
17- 0.5 tab 2.5 tab 0.5 tab 0.5 tab + 17-
2.5 tab BD tab
19.9 BD BD BD BD 50 mg 19.9
BD
OD

200
 1 tab 1 tab
1 tab
20- AM, 3 tab 3 tab AM, 300 mg 20-
3 tab BD AM, 0.5
24.9 0.5 tab BD BD 0.5 tab OD 24.9
tab PM
PM PM
1 tab 300 mg
25- AM, 1 tab 1 tab + 25-
1 tab OD 1 tab BD
29.9 0.5 tab BD BD 50 mg 29.9
PM OD
400 mg
30- 1 tab 1 tab 1 tab (200 30-
1 tab OD 1 tab BD
34.9 BD BD BD mg x 2) 34.9
OD
400 mg
35- 1 tab 1 tab 1 tab 1 tab 1 tab (200 35-
1 tab OD 1 tab BD
39.9 BD BD OD OD BD mg x 2) 39.9
OD

Chart 2

201
 Atazanavir/
Abacavir + Abacavir +
Weight ritonavir Tenofovir/ Weight
Lopinavir/ritonavir Lamivudine Lamivudine Abacavir
range (Anzavir- emtricitabine range
(Kaletra®, Aluvia® – LPV/r) (ABC/3TC (ABC/3TC (ABC)
(kg) R® – (Truvada®) (kg)
Pediatric) Adult)
ATV/r)
8
Dose is Dose is
208mg/m2/dose Dose is mg/kg/dose
10-16 mg/kg/dose TWICE daily ONCE TWICE
ONCE daily ONCE daily TWICE
daily daily
daily
ADULT
PEDIATRIC 300mg
SYRUP 200 mg
100 mg ATV/ 300mg 600 mg
80 mg LPV/50 60 mg ABC/ 300 mg
LPV/25 mg 100mg TDF/200mg ABC/
LPV/20 mg mg 30 mg 3TC tablets
ritonavir ritonavir emtricitabine 300 mg 3TC
ritonavir/mL ritonavir
tabs
tabs
3-4.9 0.5mL BD 1 tab BD 3-4.9
5-5.9 1 ml BD 1 tab BD 5-5.9
6-6.9 1.5 ml BD 1.5 tab BD 6-6.9
7-7.9 1.5 ml BD 1 tab BD 1.5 tab BD 7-7.9
8-8.9 2 ml BD 1 tab BD 1.5 tab BD 8-8.9
9-9.9 2 ml BD 1 tab BD 1.5 tab BD 9-9.9
10-10.9 2 ml BD 2 tabs BD 2 tabs BD 10-10.9
11-11.9 2 ml BD 2 tabs BD 2 tabs BD 0.5 tab BD 11-11.9
12-13.9 2 ml BD 2 tabs BD 1 tab BD 2 tabs BD 0.5 tab BD 12-13.9
14-16.9 2 ml BD 2 tabs BD 1 tab BD 2.5 tabs BD 0.5 tab BD 14-16.9
17-19.9 2.5 ml BD 2 tabs BD 1 tab BD 2.5 tabs BD 0.5 tab BD 17-19.9
1 tab in
20-24.9 3 ml BD 2 tabs BD 1 tab BD 3 tabs BD AM, 0.5 20-24.9
tab in PM

202
 2 tabs in
AM,
25-29.9 3.5 ml BD 3 tabs BD 1 tab OD 1 tab BD 25-29.9
1 tab in
PM
2 tabs
30-34.9 4 ml BD 3 tabs BD 1 tab OD 1 tab BD 30-34.9
BD
2 tabs
35-39.9 5 ml BD 4 tabs BD 1 tab OD 1 tab OD 1 tab OD 1 tab BD 35-39.9
BD

203
294

Annex 9: Third line Paediatric Formulation Dosing

Drug Pediatric Number of tablets by weight- Adult Adult

Formulation band morning and evening (kg) formulat Tablets
ion
3-5.9 6-9.9 10-13.9 14-19.9 20-24.9 25-34.9
am pm am pm am pm am pm am pm am pm

RAL Chewable 3 3 4 4 6 6 400 mg 1 1

tablet 25
Chewable 1 1 1.5 400 mg 1 1
tablet 100 1.5
Granules 0.25 0.25 0.5 0.5 400 mg 1 1
100
DRV/r a Tablet 75 3 3 5 5 5 5 600 mg + 1 1
mg 100 mg
Syrup 2.5 3.5 3.5 600 mg + 1 1
100 2.5 ml ml ml 100 mg
DTGb 50 mg 1
ETVc Tablet 25 mg, 100 100 125 125 200 mg 200 200
100 mg, 200mg mgd mgd mg mg mg mge
e

a
DRV/r must be administered with 0.5 ml of RTV mg/mL oral suspension if the child weighs
less than 15 kg and with RTF 50 mg solid formulation for children weighing 15-30 mg.
DRV/r should not be used in children younger than 3 years of age
b
DTG is currently approved for patients 12 years and above.
c
ETV is not recommended in patients less than 6 years of age or less than 16 kg. Dosing
reference for ETV comes from Etravirine. In Lexicomp Online Database in Up To Date.
Hudson (OH): Lexicomp Inc.: 2017.
d
Dose of ETV for 16 kg to < 20 kg is 100 mg twice daily
e
Dose of ETV for 25 kg to < 30 mg: 150 mg twice daily; >30 kg is 200 mg twice daily
Consult pharmacist for locally available formulations.

204
Annex 10. Modern Medications and Recommended Food Intakes and Side Effects
Medication Purpose Nutrition Foods/Bever Potential Side
Recommendatio ages/Herbs Effects
ns to Avoid
Sulfonamides: Antibiotic Take with food Nausea, vomiting,
Sulfamethoxazol for treating abdominal
e, pneumonia Pain
Cotrimoxazole and
toxoplasmosi
s
Rifampin Treatment of On an empty Alcohol Nausea, vomiting,
TB stomach one diarrhoea, loss
hour before or of appetite
two hours after
meals
Treatment of One hour before Alcohol Anorexia,
Isoniazid TB or two hours diarrhoea; may
after meals cause possible
reactions with
Supplement with foods such as
10 mg vitamin bananas, beer,
B6 avocados, liver,
daily smoked or pickled
fish, yeast, yogurt;
may interfere with
vitamin B6
metabolism,
therefore will
require vitamin B6
supplement to
prevent peripheral
neuropathy and
anaemia
Quinine Treatment of With food Abdominal or
Malaria stomach pain,
diarrhoea, nausea,
vomiting; lower
blood sugar
Sulfadoxine and Treatment of With food and Nausea, vomiting,
Pyrimethamine Malaria consume large taste loss and
(Fansidar ®) Pyrimethami quantities of diarrhoea; not
ne water recommended if
is also used Supplement folate deficient;
to treat daily with folinic not recommended
toxoplasmosi acid for breastfeeding
s (leucovorin), the women

205
 active form of
folate (5-10 mg/
day)

Fluconazole Treatment of With food Nausea, vomiting,

thrush diarrhoea; can be
used during
breastfeeding
Nystatin ® Treatment of With food Infrequent
thrush occurrence of
diarrhoea,
vomiting, nausea
Antiretroviral drugs
Abacavir (ABC) ARV Can be taken Nausea, vomiting,
NNRTI without regard to fever, allergic
food reaction, anorexia,
abdominal pain,
diarrhoea,
anaemia, rash,
hypotension,
pancreatitis,
dyspnea, weakness
and insomnia,
cough, headache
Lamivudine ARV Can be taken Alcohol Nausea, vomiting,
(3TC) without regard to headache,
NNRTI food dizziness,
diarrhoea,
abdominal pain,
nasal symptoms,
cough, fatigue,
pancreatitis,
anaemia, insomnia,
muscle pain, and
rash
Zidovudine ARV Can be taken Alcohol Anorexia, anaemia,
(AZT) with nausea, vomiting,
NNRTI food, but do not bone marrow
take with a high suppression,
fat meal headache, fatigue,
constipation, fever
dizziness, dyspnea,
insomnia, muscle
pain, rash
Efavirenz ARV Can be taken Alcohol Elevated blood

206
NRTI with cholesterol
food, but do not levels, elevated
take with a high triglycerides
fat meal levels, rash,
dizziness,
anorexia, nausea,
vomiting,
diarrhoea,
dyspepsia,
abdominal pain,
flatulence
Nevirapine ARV Can be taken St John’s Nausea, vomiting
(NVP) without regard to wort rash, fever,
NRTI food headache, skin
reactions, fatigue,
stomatitis,
abdominal pain,
drowsiness,
paresthesia; high
hepatoxicity
Lopinavir ARV Can be taken St John’s Abdominal pain,
PI without regard to wort diarrhoea,
food headaches,
headache,
weakness, nausea;
may increase the
risk of
lipodystrophy and
or diabetes
Nelfinavir ARV Take with meal St John’s Diarrhoea,
PI or wort flatulence, nausea,
light snack abdominal pain,
rash; may increase
the risk of
lipodystrophy
Ritonavir ARV Take with meal St John’s Nausea, vomiting,
PI if wort diarrhoea,
possible hepatitis, jaundice,
weakness,
anorexia,
abdominal pain,
fever, diabetes,
headache,
dizziness; may
increase the risk of
lipodystrophy

207
Saquinavir ARV Take with meal St John’s Mouth ulceration,
PI or wort taste changes,
light snack; take nausea, vomiting,
within two hours abdominal pain,
of a high fat diarrhoea,
meal constipation,
and high calcium flatulence,
meal garlic weakness rash,
supplements headache; may
increase the risk
of lipodystrophy

208
Annex 11. TB Screening tools for HIV/AIDS Patients