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Clinical guidelines across THE CONTINuUM OF CARE:

LINKING PEOPLE DIAGNOSEd WiTH hiv infection to hiv care and treatment

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6.1 Introduction 84 6.2 Good practices for linkage to care 84 6.3 General care for people living with HIV 84 6.4 Preparing people living with HIV for ART 87 6.5 What to expect in the first months of ART 88

Goal of this chapter To provide an overview of issues and interventions related to general HIV care for individuals from the time that they are diagnosed with HIV infection to the time that they are initiated on ART, including practices for linking people diagnosed with HIV infection to HIV care and treatment, the components of a general care package, and preparing individuals for starting ART.


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Consolidated guidelines on the use of antiretroviral drugs for treating and preventing hiv infection

6. Th  e continuum of care: linking people diagnosed with HIV infection to HIV care and treatment 6.1 Introduction It is critical for people living with HIV to enrol in care as early as possible. This enables both early assessment of their eligibility for ART and timely initiation of ART as well as access to interventions to prevent the further transmission of HIV, prevent other infections and comorbidities and thereby to minimize loss to follow-up. The 2012 WHO strategic HIV testing and counselling programme framework (1) especially emphasizes the importance of ensuring linkage between HIV testing and counselling programmes and prevention, treatment, care and support services.

6.2 Good practices for linkage to care Interventions to improve linkage to care need to be more rigorously evaluated. However, several systematic reviews and observational studies suggest that several good practices can improve linkage to care (2–4). These include integrating HIV testing and counselling and care services; providing on-site or immediate CD4 testing with same-day results; assisting with transport if the ART site is far from the HIV testing and counselling site; involving community outreach workers to identify the people lost to follow-up; ensuring support from peers or expert patients; and using new technologies, such as mobile phone text messaging.

6.3 General care for people living with HIV Countries should establish a package of general HIV care interventions, in addition to ART, for people living with HIV to reduce HIV transmission, prevent illness and improve their quality of life. Not all people living with HIV are eligible for ART and, of those eligible, not all will be able to access ART immediately. Others may choose to defer ART to later. Enrolment in care provides an opportunity for close clinical and laboratory monitoring and early assessment of eligibility for ART and timely initiation, and aims to minimize loss to follow-up. Many care interventions are relevant across the full continuum of care, including HIV-exposed individuals and people living with HIV before initiating, and during ART. General care includes basic HIV prevention, promoting the health of people living with HIV and the screening, prophylaxis and management of HIV-related coinfections and comorbidities. WHO has produced summary guidance on general care and prevention interventions (5–7) , and in 2008, recommended a package of 13 prevention interventions for adults and adolescents living with HIV in resource-limited settings (5). These include (1) psychosocial counselling and support; (2) disclosure and partner notification; (3) co-trimoxazole prophylaxis; (4) TB counselling, screening and preventive therapy; (5) preventing common fungal infections; (6) preventing sexually transmitted infections and supporting reproductive health needs, including prevention of and screening for cervical cancer; (7) malaria (co-trimoxazole, bed-nets and preventing malaria among pregnant women); (8) selected vaccine-preventable diseases; (9) nutrition; (10) family planning; (11) PMTCT; (12) needle and syringe programmes for people


6. The continuum of care: linking people diagnosed with HIV infection to HIV care and treatment

A general care package will vary according to the epidemic type, populations affected and prevalence of coinfections, other comorbidities and health conditions. Table 6.1 provides an overview of elements of a general care package for people living with HIV. Section 8.1 summarizes key recommendations from existing WHO guidelines on the screening, prophylaxis and timing of ART with the most common coinfections, comorbid conditions and other health conditions.

Table 6.1 Overview of key elements of general care over the continuum of HIV care for people living with HIV Service

At HIV diagnosis

At At Stable enrolment initiation while into care of ART receiving ART

At treatment failure and switching ART regimen

Comment and crossreferences

General care WHO clinical staging

Annex 1

Past and current HIVrelated conditions Pregnancy status

✓ Section 8.2.6.1

Family planning and Contraception

Sections 7.1.2 and 7.2.2

PMTCT Support for disclosure and partner notification

Section 5.1.4

Risk reduction counselling and combination HIV prevention approaches

Section 5.2.4

Screening for, preventing and managing comorbidities and noncommunicable diseases

Section 8.2.1

Screening for and managing mental health problems and substance use

Sections 8.2.2 and 8.2.3

Psychosocial counselling and support

6. The continuum of care: linking people diagnosed with HIV infection to HIV care and treatment

who inject drugs; and (13) water, sanitation and hygiene.

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Consolidated guidelines on the use of antiretroviral drugs for treating and preventing hiv infection

Table 6.1 (continued) Service

At HIV diagnosis

At At Stable enrolment initiation while into care of ART receiving ART

At treatment failure and switching ART regimen

Comment and crossreferences

Section 8.2.5

Section 8.2.4

Sections 7.1.3 and 8.2.4

General care Managing pain and symptoms Nutritional assessment and counselling Nutritional, growth and development assessment in children and adolescents

Infant and child feeding Preventing and treating coinfections Co-trimoxazole preventive therapy

Section 8.1.1

Intensified TB casefinding

Section 8.1.2

Isoniazid preventive therapy

Section 8.1.2

Screening for cryptococcal infection and fungal prophylaxis

Screening for hepatitis B and C

Section 8.1.3

Section 8.1.4

Malaria prevention (insecticide-treated bed-nets and prophylaxis)

Section 8.1.5

Screening for sexually transmitted infections

Section 8.1.6

Section 8.1.7

Prevention of and screening for cervical cancer


6. The continuum of care: linking people diagnosed with HIV infection to HIV care and treatment

Service

At HIV diagnosis

At At Stable enrolment initiation while into care of ART receiving ART

At treatment failure and switching ART regimen

Comment and crossreferences

Assessing for vaccine-preventable diseases

Section 8.1.7

Preparing people for ART Preparing, assessing and supporting adherence Current medications

Section 6.4

Sections 6.4 and 9.2

See section 7.4.6

6.4 Preparing people living with HIV for ART Before people start ART, it is important to have a detailed discussion with them about their willingness and readiness to initiate ART, the ARV regimen, dosage and scheduling, the likely benefits and possible adverse effects and the required follow-up and monitoring visits. For children with HIV, this conversation should directly involve the carer and include discussion about disclosing their HIV status (see Chapter 5). Retesting all people living with HIV before initiating ART is good practice to ensure correct diagnosis of HIV infection. Initiation of ART should always consider nutritional status, any comorbidities and potentially interacting medications for possible contraindications or dose adjustment. The choice to accept or decline ART ultimately lies with the individual person or his or her caretaker, and if they choose to defer initiation, ART can be offered again at subsequent visits. If there are mental health, substance use or other problems that are major barriers to adherence, appropriate support should be provided, and readiness to initiate ART should be reassessed at regular intervals. A wide range of patient information materials as well as community and peer support can help the person’s readiness and decision to start therapy. People starting treatment and carers should understand that the first ART regimen offers the best opportunity for effective viral suppression and immune recovery, and that successful ART requires them to take the medications exactly as prescribed. They should be advised that many adverse effects are temporary or may be treated, or that substitutions can often be made for problematic ARV drugs. (See section 9.2 for strategies to support adherence to an ART regimen.) People receiving ART and carers should also be asked regularly about any other medications they take, including herbal remedies and nutritional supplements. People receiving ART should understand that, while the ARV drugs reduce the risk of HIV transmission, they cannot be relied on to prevent other people from acquiring infection. They should be given advice on safer sex (including condom use) and avoidance of other high-risk activities, such as sharing of injecting equipment, to prevent transmitting HIV to other people.

6.4 Preparing people living with HIV for ART

Table 6.1 (continued)

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6.5 What to expect in the first months of ART Although taking ART is a lifelong commitment, the first six months of therapy are especially important. Clinical and immunological improvement and viral suppression are expected when individuals adhere to ART, but opportunistic infections and/or immune reconstitution inflammatory syndrome (IRIS) may develop, as well as early adverse drug reactions, such as drug hypersensitivity, especially in the first three months of ART. ART significantly decreases mortality overall, but death rates are also highest in the first three months of ART. These complications are commonest when the people starting ART already have advanced HIV disease with severe immunodeficiency and existing coinfections and/or comorbidities, severely low haemoglobin, low body mass index and very low CD4 counts or are severely malnourished (8,9) .

CD4 recovery In most adults and children, CD4 cell counts rise when ART is initiated and immune recovery starts. Generally, this increase occurs during the first year of treatment, plateaus, and then continues to rise further during the second year (10) . However, severe immunosuppression may persist in some individuals who do not experience a significant rise in CD4 cell count with treatment, especially those with a very low CD4 cell count when initiating ART. Failure to achieve some CD4 recovery should alert the health care provider to potential adherence problems or primary non-response to ART, and consideration should be given to continue prophylaxis for opportunistic infections such as co-trimoxazole preventive therapy.

Immune reconstitution inflammatory syndrome (IRIS) IRIS is a spectrum of clinical signs and symptoms thought to be associated with immune recovery brought about by a response to ART. It is a widely recognized phenomenon that occurs among 10–30% of the people initiating ART, usually within the first 4–8 weeks after initiating therapy (11,12). It may present in two different ways: paradoxical IRIS, when an opportunistic infection or tumour diagnosed before ART initially responds to treatment but then deteriorates after ART starts; or unmasking IRIS, in which initiating ART triggers disease that is not clinically apparent before ART. It should be considered only when the presentation cannot be explained by a new infection, expected course of a known infection or drug toxicity. The clinical spectrum is diverse, and IRIS has been reported for many different infections, tumours and non-infectious conditions (11,12). The most serious and life-threatening forms of paradoxical IRIS are for TB, cryptococcosis, Kaposi’s sarcoma and herpes zoster. BCG vaccine–associated IRIS (localized and systemic) may occur in infants infected with HIV in settings where BCG immunization is routine. A low CD4 + cell count (<50 cells/mm3 ) at ART initiation, disseminated opportunistic infections or tumours and a shorter duration of therapy for opportunistic infections before ART starts are the main risk factors (11,12). IRIS is generally self-limiting, and interruption of ART is rarely indicated, but people may need to be reassured in the face of protracted symptoms to prevent discontinuation of or poor adherence to ART. The most important steps to reduce the development of IRIS include: earlier HIV diagnosis and initiation of ART before a decline to below 200 CD4 cells/mm3 ; improved screening for opportunistic infections before ART, especially TB and Cryptococcus ; and optimal management of opportunistic infections before initiating ART. Timing of ART in people with opportunistic infections requires balancing a greater risk of IRIS after early initiation against continuing high mortality if ART is delayed. Chapter 8 summarizes existing WHO recommendations for the optimal timing of ART among people with TB (see section 8.1.2) and cryptococcal disease (see section 8.1.3) based on evidence from randomized clinical trials.


WHO Consolidated ARV guidelines 2013: chapter 6