Unit 9

Management of Comorbidities and

Other Services

Training for Clinicians on the Use of the

Namibian Guidelines for Antiretroviral

Therapy, 6th Edition

Unit 9: Slide 2

TB/HIV CO-INFECTION

Unit 9: Slide 3

World Top 10 Notification Rates; 2017

0

100

200

300

400

500

600

700

800

Sou

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Unit 9: Slide 4

Trends in case notification rates;

2007-2017

Source: ETR.net V20180222

Unit 9: Slide 5

Estimated burden of TB Disease in

Namibia; 2017

Source: WHO Global TB report 2018.

Unit 9: Slide 6

• Very high prevalence of both HIV and TB

• Most common HIV-related OI in Sub-Saharan Africa

• In 2017:

98% of TB patients knew their HIV status

36% of these patients tested HIV positive

• Intensified TB Case-finding (ICF)

Screen all PLHIV for TB at each encounter

o Symptoms

o Exposure contact

Eligible PLHIV should be offered TPT

TB/HIV Co-Infection

Source: ETR.net V20180222

Unit 9: Slide 7

TB/HIV Co-Infection (2)

• 10% lifetime risk of reactivating latent TB among HIV negative

persons

• 10% risk per year of reactivating latent TB among HIV positive

persons

HIV +

HIV -

New TB

Infection

Latent

TB

Infection

Primary

Progressive

TB Disease (children,

rare adults,

HIV+)

~ 10%

reactivate (TB disease)

each year

~ 5%

reactivate (TB disease)

2 years

till death

~5 %

reactivate (TB disease)

1-2 years

Unit 9: Slide 8

• Reduces risk of active tuberculosis by 60 - 90%

in HIV positive patients on ART

• Can be used in pregnancy

• All HIV positive patients who do not have a

contraindication should have a course of TPT

TB Preventative Therapy (TPT)

Unit 9: Slide 9

• Screen all PLHIV for TB

• If no to TB screening questions

Initiate TPT

• Assess this at every clinical visit

• Patients that have completed TB treatment

should be initiated immediately on TPT

Eligibility for TPT

Unit 9: Slide 10

• Refer to Handout 9.1 / guidelines on algorithm

for TB screening and TPT initiation.

• Symptom screening in adults

Cough (current), weight loss, night sweats, fever

• Symptom screening in children

Cough (current), poor weight gain, fever,

swellings in the neck or armpits (lymph node

enlargement), recent close contact

• If yes to any symptom screening question

Perform a bacteriological examination for TB

Algorithm for TB Screening

Unit 9: Slide 11

• Bacteriologically (preferred) Xpert MTB/RIF (GeneXpert)

o an automated molecular diagnostic test for TB .

o Detects M.tb as well as rifampicin resistance-conferring mutations

o Provides results directly from sputum in less than two hours.

o Should be the first diagnostic test for all presumptive cases including HIV + cases.

o Results can be:

− MTB Detected with Rif resistance / Rif sensitivity or Rif indeterminate (positive)

− MTB not detected (negative)

Diagnosing TB

Unit 9: Slide 12

• Bacteriologically

Line probe assays o 2nd line LPA as a follow-on test for Xpert

rifampicin resistance to screen for

resistance to fluoroquinolone and 2nd line

injectables.

o 1st line LPA to confirm resistance to

isoniazid and rifampicin, only when needed

o LPA for MOTT IDTo identify the species

when culture is positive for Mycobacterium

other than MTB.

Mycobacterial culture, when needed

Direct (smear) microscopy

o not routinely provided for diagnosis

o mainly used for confirmed TB cases, at

baseline or follow-up

Diagnosing TB (2)

Unit 9: Slide 13

• Clinically Radiologically

o CXR when − Xpert MTB/RIF is negative, or

− in emergency situations where sputum cannot be produced

− The patient is a symptomatic child being evaluated for TB.

Histopathologically (when required)

Tuberculin skin test (TST) o is useful in supporting the diagnosis of

active TB in young children.

• Other methods TB lateral flow LAM test

o The test may be used to assist in the diagnosis of TB in HIV positive adult in-patients with signs and symptoms of TB (pulmonary and/or extrapulmonary) and

− Who have a CD4 cell count of 100 cells/µl or less, or

− Who are seriously ill regardless of CD4 count.

Diagnosing TB (3)

Unit 9: Slide 14

Treating TB: Summary of anti-TB regimens

National Tuberculosis and Leprosy Programme

Regimen Indication

First line regimen for TB

(2HRZE/4HRE)

New TB patients without rifampicin resistance

Previously treated TB patients without rifampicin

resistance

Standardised DR-TB

regimen

Patients with uncomplicated rifampicin resistant

TB

Individualised DR-TB

regimens

Patients with complicated DR-TB, including

resistance to fluoroquinolone and/or second line

injectables

Unit 9: Slide 15

• Screen all PLHIV routinely for active TB

• Exclude active TB disease before initiating TPT

• It is safe to initiate ART and TPT on the same

day

• PLHIV who are close contacts of patients with

TB should receive TPT even if they have

completed a previous course of TPT.

TPT Considerations

Unit 9: Slide 16

•Signs and symptoms of TB present

• Cough, fever, night sweats, weight loss and loss of

appetite

• NB: TB-TPT should not be given to patients who are

unwell and where there is no explanation of the illness.

•History of:

• active liver disease, liver insufficiency, or jaundice (or);

• hypersensitivity to INH or any other agent used for

TPT, (or);

• exfoliative dermatitis

Contraindications for TPT

Unit 9: Slide 17

• Educate patients on possible side effects before

initiating TPT

• If side effects develop, the patient must stop

taking TPT and report immediately to the

nearest health facility for assessment.

• Health workers should always assess clients for

side effects when they come for refills.

Managing TPT associated side

effects

Unit 9: Slide 18

• Discontinue TPT after serious toxicity.

Isoniazid-induced hepatitis

Peripheral neuropathy

Rifapentine may cause orange/red discoloration

of body fluids.

Skin manifestations e.g. exfoliative demartitis

• Screen for signs/symptoms of active TB at each

visit

• Document adherence in TB-TPT register, ePMS,

patient booklet and stamp in patient passport

TPT Monthly Monitoring

Unit 9: Slide 19

Regimen Duration Considerations

INH Once daily for 6

months (6H)

(NEW)

• TPT is now given for 6 months instead of

9 months

• Patients previously prescribed 9 months

INH and has taken 6 months should be

stopped and considered as completed.

• HCWs should ensure that the outcome is

updated in the ePMS as “TPT Completed

INH and

Rifapentine

Weekly for a total

of 12 doses

(3HP)

INH and

Rifampicin

Daily for 3

months (RH)

• Consult with TB or HIV clinical mentor or

experienced physician

TPT regimens

Unit 9: Slide 20

TPT regimens with ART

ART regimen Preferred

Regimen Alternative

On Efavirenz and Raltegravir

based regimen 6H *3HP (for adults and

children >2 years)

3HR (in children only)

On DTG based regimen and

fully VL suppressed 6H *3HP (for adults and children

>2 years)

3HR (in children only)

On DTG not fully VL

suppressed or no evidence

of suppression

6H

Pregnant women 6H

Children <2 years 6H 3HR

PI based regimen 6H

*3HP should not to be used in; pregnant women, children <2 years, patients who are

on PI containing regimen and, for patients on DTG containing regimen with high VL.

Unit 9: Slide 21

Recommended dosages of TPT regimens

Drug

regimen

Dose per kg body

weight

Maximum

dose

Pyridoxine

INH alone,

daily for 6

months

Adults, 5 mg/kg 300 mg Adults and children 12

years and older 25

mg daily

Children, 10 mg/kg

(range, 7–15 mg)

4-6.4 kg = 50 mg

6.5-9.9 kg =100 mg

10-13.9 kg=150mg

14-19.9 kg=200mg

20-24.9 kg=250mg

>25 kgs=300mg

300 mg Children 5 to 11 years

of age 12.5mg daily

Children <5 years of

age not routinely given

Unit 9: Slide 22

Recommended dosages of TPT

regimens (2)

Drug

regimen

Dose per kg body weight Maximum

dose

Pyridoxine

Weekly

rifapentine

plus INH for

3 months

(12 doses)

Individuals aged ≥ 12 years:

INH: 15 mg/kg

Individuals aged 2–11 years:

INH: 25 mg/kg

Rifapentine: 10.0–14.0 kg

= 300 mg

14.1–25.0 kg = 450 mg

25.1–32.0 kg = 600 mg

32.1–50.0 kg = 750 mg

> 50 kg = 900 mg

INH, 900

mg

Rifapentine,

900 mg

Adults and children 12

years and older 50 mg

daily

Children 5 to 11 years

of age 25mg daily

Children <5 years of

age not routinely given

Unit 9: Slide 23

Recommended dosages of TPT

regimens (3)

Drug

regimen

Dose per kg body

weight

Maximum

dose

Pyridoxine

Daily INH

plus

rifampicin

for 3

months

INH:

Adults, 5 mg/kg

Children, 10 mg/kg

(range, 7–15 mg)

Rifampicin:

Adults, 10 mg/kg

Children, 15 mg/kg

(range, 10–20 mg)

INH, 300 mg

Rifampicin,

600 mg

Adults and children

12 years and older 25

mg daily

Children 5 to 11 years

of age 12.5mg daily

Children <5 years of

age not routinely

given

Unit 9: Slide 24

• PTB is a WHO Clinical Stage 3 disease, while EPTB is Clinical Stage 4:

Individuals with either diagnosis are eligible for ART

If not already on ART, start TB treatment first, followed by ART as soon as possible

ART must be started within 2 - 8 weeks o Do not wait until after 8 weeks!

With profound immunosuppression (e.g. CD4 <50) start ART as soon as possible within first 2 weeks

When to Start ART During TB Therapy in

Adults and Children

Unit 9: Slide 25

• No interaction with NRTI class

• Drug interactions between rifampicin and INSTIs and PIs

• INSTIs class:

Rifampicin lowers DTG levels

o Give twice daily DTG

• Protease inhibitor (PI) considerations:

Rifampicin lowers the blood levels of almost all PIs by up to 80%

Modification of PI dose required if used with rifampicin

Do not use Atazanavir with Rifampicin

TB/HIV Treatment Issues

Unit 9: Slide 26

ART for Adults with Active TB

Preferred 1st line ART

regimen

TDF + FTC (or 3TC) + DTG (at 50mg twice daily)

Alternate 1st line ART

regimen

TDF + FTC (or 3TC) + EFV (at 400mg once daily) (this is a change

from the previous guidance which recommended increasing the dose to

600mg with TB treatment).

For PLHIV on a boosted PI

regimen

Option 1: Substitute rifampicin in the TB treatment with rifabutin

Option 2: If Rifabutin is unavailable or contraindicated, maintain

rifampicin in TB treatment and use PI based regimen super boosted

with ritonavir.*

TDF or AZT + 3TC with LPV/r 400mg+ritonavir 400 mg BD (LPV/RTV)

or (LPV/r 800 +ritonavir 200mg BD)

Note: ATV/r is contraindicated in patients with TB/HIV co-infection

Preferred 1st line

ART regimen

TDF + FTC (or 3TC) + DTG (at 50mg twice daily)

Alternate 1st line

ART regimen

TDF + FTC (or 3TC) + EFV (at 400mg once

daily)

For PLHIV on a

boosted PI

regimen

Option 1: Substitute rifampicin in the TB

treatment with rifabutin

Option 2: If Rifabutin is unavailable or

contraindicated, maintain rifampicin in TB

treatment and use PI based regimen super

boosted with ritonavir.*

Unit 9: Slide 27

Child or adolescent with TB and is

not yet on ART

<4 weeks old • Seek advice

4 weeks to <3

years old or

weight <10

kg

• ABC/3TC + DTG bd

• If DTG not available:

• ABC + 3TC + RAL or

• ABC + 3TC + super-boosted

lopinavir/ritonavir (LPV/r + R)*

• NB: Switch to standard ART regimen two

weeks after competing rifampicin-based

TB treatment

Unit 9: Slide 28

3 years old and

weight 10 kg to

<20 kg

• ABC + 3TC + DTG bd

• NO previous eMTCT/PMTCT NVP exposure:

ABC+ 3TC + EFV

• if DTG not available and the child has had

previous eMTCT/PMTCT NVP exposure:

• ABC + 3TC + RAL

• or

• ABC + 3TC + super-boosted lopinavir/ritonavir

(LPV/r + R) *

• NB: two weeks after TB treatment is completed,

change to the standard ART regimens

Child or adolescent with TB and is

not yet on ART (2)

Unit 9: Slide 29

Child or adolescent with TB and is

not yet on ART (3)

Adolescents 20

to <30 kg

• ABC + 3TC + DTG bd

• if no DTG available,

• And If the child has had NO previous

eMTCT/PMTCT NVP exposure

• ABC+ 3TC + EFV

• ABC + 3TC + RAL (if RAL available)

• ABC + 3TC + super-boosted lopinavir/ritonavir

(LPV/r + R)*

≥30 kg and at

least 10 years

old:

• TDF + 3TC + DTG bd

• If DTG not available, TDF + 3TC + EFV

Unit 9: Slide 30

• Bacteriological confirmation is crucial for TB

diagnosis.

• All PLWA should be screened for TB at every

visit.

• All PLWA with no S/S of TB should receive at

least one course of TPT.

• INH for TPT is now given on the same day as

ART initiation and is only for 6 months.

• A course of TPT should be repeated after TB

treatment or after exposure to TB from a close

contact.

Key Messages

Unit 9: Slide 31

CRYPTOCOCCAL MENINGITIS

Unit 9: Slide 32

Cryptococcal Meningitis

• Clinical presentation:

Occurs most commonly when CD4 < 200

Characterized by subacute meningitis

Acute confusional state

Nausea and vomiting

Stiff neck is absent in 70% of cases

Cranial nerve abnormalities common with

increased intracranial pressure from

communicating hydrocephalus

Unit 9: Slide 33

Cryptococcal Meningitis (2)

• CSF findings:

Clear or turbid appearance

Pressure commonly raised

CSF cell count may be normal or slightly elevated

Protein may be raised

Glucose may be low

CSF India ink yield (75%)

Ask lab to do CSF CrAg if India ink negative

CSF culture is diagnostic (95 – 100%)

• Blood culture may be positive

Unit 9: Slide 34

CSF of Patient with Cryptococcal

Meningitis

CSF India Ink

Source: https://i.pinimg.com/originals/4d/50/3b/4d503b74a7b026f2e9a3a0464c12aa12.jpg

Unit 9: Slide 35

Treatment of Cryptococcal

Meningitis: Induction

• Amphotericin B 1 mg/kg/day (given with pre-

emptive hydration and electrolyte

supplementation)

plus

• Fluconazole 1,200mg daily for adults and

12mg/kg daily (up to maximum of 800mg daily)

for children and adolescents 2 weeks in hospital

Source: WHO Rapid Advice, Diagnosis, Prevention and Management of Cryotococcal

Diseases in Adults, Adolescents and Children, December 2011.

Unit 9: Slide 36

Treatment of Cryptococcal

Meningitis (2)

• Consolidation:

Fluconazole 800 mg daily for adults and 6-12mg/kg daily (maximum 800mg daily) for children and adolescents 2 months

• Maintenance (secondary prophylaxis):

Then 200 mg daily for adults and 6mg/kg daily for children and adolescents.

• Continue Fluconazole for minimum 1 year in total and discontinue when patient has had 2 CD4 counts > 200 cells/mm3 taken at least 6 months apart

Unit 9: Slide 37

RENAL INSUFFICIENCY

Unit 9: Slide 38

• Causes of renal insufficiency among HIV positive patients, e.g.:

Acute:

o Dehydration

o Malaria

o Heart failure

Chronic:

o HIV-associated nephropathy

o Hypertension

o Diabetes

o Renal Artery Stenosis

Renal Insufficiency and HIV

Unit 9: Slide 39

• Prior to starting ART

Calculate estimated creatinine clearance (CrCl)

Adjust ART dosage as needed if alternatives are

not available

• For patients on TDF, monitor:

CrCl at week 6, month 6 and12 then every 12

months thereafter

o Monitor at least once every month in patients with

chronic renal insufficiency

Renal Insufficiency and ART

Unit 9: Slide 40

• Formula for calculation of CrCl in adults uses the

patient’s age, weight and serum creatinine:

(140-age) x weight (kg) x 1,22 serum creatinine (μmol/l)

For women, multiply above result by 0.85

Calculation of CrCl in adults

Unit 9: Slide 41

• CrCl calculation for adults is not applicable to

children < 18 years old, use Schwartz equation

• It uses child’s length/height and serum

creatinine:

length (cm) x k x 88.4 serum creatinine (μmol/l)

k = 0.45 for infants 1 - 52 weeks

k = 0.55 for children 1 - 13 years old

k = 0.55 for adolescent females 13 - 18 years

k = 0.7 for adolescent males 13 – 18 years

SCHWARTZ Equation for Children

Source: Schwartz, GL et. al. A simple estimate of glomerular filtration rate in children

derived from body length and plasma creatinine. Pediatrics 1976, 58:259-263

Unit 9: Slide 42

• NRTIs (except Abacavir)

Excreted through the kidneys

Require dosage reduction in renal impairment

TAF given in CrCl 30 -50 without dose adjustments

• NNRTIs and PIs are

Excreted through the liver

No dosage adjustment needed

• Cotrimoxazole:

Can also cause nephrotoxicity

Require Dosage Adjustment

o CrCl is 15-30 ml/minute decrease CTX dose by 50%

o < 15ml/min do not give CTX

Dosage Adjustment of Meds in Renal

Insufficiency

Unit 9: Slide 43

Dosage Adjustment of TDF/TAF in Renal

Insufficiency

Creatinine

Clearance

(ml/min)

Recommended Dosing of

TDF 300 mg

Dosing of

TAF/FTC/DTG

≥50 Every 24 hours Every 24 hours

30-49 Every 48 hours Every 24 hours

10-29 Twice a week Not recommended

< 10 No recommendation available

owing to a lack of

pharmacokinetic data in this

population

Haemodialysis

patients

Every 7 days or after a total of 12

hours of dialysis (administer

following completion of dialysis)

Unit 9: Slide 44

IMMUNE RECONSTITUTION

INFLAMMATORY SYNDROME (IRIS)

Unit 9: Slide 45

• A dramatic increase in the inflammatory

response to antigens from previous, partially

treated or latent infections in HIV patients shortly

after initiating ART

• It usually occurs in the first few weeks after a

patient starts therapy

Immune Reconstitution

Inflammatory Syndrome (IRIS)

Unit 9: Slide 46

• Common risk factors for IRIS;

Rapid decline in viral load (especially in the first

three months after ART initiation)

Low baseline CD4 count (especially <50

cells/mm3) and rapid increase after initiating ART

Initiation of ART soon after initiation of treatment

for opportunistic infection (OI)

Disseminated versus localized OI

ART-naïve patient

IRIS (2)

Unit 9: Slide 47

• Although patients with IRIS appear as though ART is failing (clinical deterioration), these patients are actually undergoing robust improvements in their immune systems

• Examples of infections or conditions which have been associated with IRIS:

Tuberculosis

MAC

Cryptococcal meningitis

Herpes zoster

Kaposi Sarcoma

IRIS (3)

Unit 9: Slide 48

NON-COMMUNICABLE

DISEASES

Unit 9: Slide 49

• These diseases include hypertension, diabetes

mellitus, and ischaemic and rheumatic valvular

heart disease.

• Cardiovascular conditions particularly

pericarditis and dilated cardiomyopathies may

be HIV, OI, or medication-related.

• Some ARVs, especially PIs, may cause

hypercholesterolemia and in the long term could

result in premature onset of coronary artery

disease or stroke.

Cardiovascular Diseases

Unit 9: Slide 50

• Increased vasculitic events have been noted

in HIV patients leading to strokes, peripheral

arterial occlusions and other vaso-occlusive

events.

• Risk reduction for cardiovascular diseases by:

Weight measurements and BMI

Blood pressure

Blood glucose levels every 6 months for those at

risk

Blood cholesterol every year

Cardiovascular Diseases (2)

Unit 9: Slide 51

• PLHIV are at high risk of mental, neurological

and substance-use disorders

• Depression is one of the commonest mental

health problems among PLHIV including

adolescents LHIV

• Screen for all patients with poor adherence and

high viral load for depression

• Use the PHQ – 9 – Refer to Handout 9.2

Depression

Unit 9: Slide 52

FAMILY PLANNING

Unit 9: Slide 53

WHO medical eligibility criteria

categories for contraceptives .

Medical eligibility Description criteria category Use of medical eligibility criteria categories in clinical practice

With clinical judgement With limited clinical judgement

1 A condition for which there is no

restriction for the use of the

contraceptive method

Use method in any circumstances Yes

(use the method)

2 A condition in which the advantages

for using the method generally

outweigh the theoretical or proven

risks

Generally use the method; some follow-

up may be needed

3 A condition in which the theoretical or

proven risks usually outweigh the

advantages of using the method

Use of the method not usually

recommended unless other more

appropriate methods are not available

or not acceptable; clinical judgement

and continuing access to clinical

services are required for use

No

(do not use the method)

4 A condition that represents an

unacceptable health risk if the

contraceptive method is used

The method should not be used

Unit 9: Slide 54

WHO MEDICAL ELIGIBILITY CRITERIA CATEGORY SUMMARY TABLE FOR

CONTRACEPTION, ARV DRUGS AND TB MEDICATIONS.

CHC a POP DMPA/ NET-

EN LNG/ETG

implants

LNG-IUD

initiation

LNG-IUD

continuation

NRTIs

ABC, TDF, AZT, 3TC, ddI, FTC, d4T 1 1 1 1 2/3b 2

NNRTIs

EFV, NVP 2 2 1 2 2/3b 2

EFV, rilpivirine 1 1 1 1 2/3b 2

Protease inhibitors (PIs)

ATV/r, LPV/r, DRV/r, RTV 2 2 1 2 2/3b 2

Integrase inhibitors

Raltegravir 1 1 1 1 2/3b 2

TB medications

Rifampicin or rifabutin c 3d 3 DMPA=1

NET-EN=2 2 1 1

a. CHC: Combined Hormonal contraceptive includes the combined oral contraceptive pill, the combined

contraceptive vaginal ring, the combined contraceptive patch and the CIC.

b. No drug–drug interactions but depends on clinical disease status.

c. 3HP and 1HP used for TB preventive therapy contain rifapentine.

d. CIC is WHO medical eligibility criterion 2 for concomitant rifampicin or rifabutin therapy

Unit 9: Slide 55

Woman centered approach !!!!

• Comprehensive counselling and informed choice should

be provided to women and adolescent girls in making

decisions about a contraceptive method that suits their life

stage and fertility intentions.

• At all times, the decision must be based on: the client’s

values, needs and preferences and the medical eligibility

for the contraceptive options for that particular client

Unit 9: Slide 56

Contraception Recommendations for

PLHIV

• Dual protection should be encouraged:

Correct and consistent use of condoms with another

contraceptive method

ARTs be can safely used COCs, progestin-only pills,

injectables and IUCD

o Minimum of 30mcg ethinyl estradiol when COC is

chosen

• PLHIV who are clinically well, can safely undergo

voluntary male vasectomy or female sterilization

Unit 9: Slide 57

Contraception Recommendations for

PLHIV

Hormonal methods

Intrauterine Device

(IUD)

Intrauterine Contraceptive Device

(IUCDs)

Progestin only

Methods

Progesterone Only Injectables (POIs)

Contraceptive Implants

Progestin Only Pills (POPs)

Combined hormonal

contraceptives

Combined Oral Contraceptives

Combined Contraceptive Patch

Unit 9: Slide 58

Contraception Recommendations

for PLHIV (2)

Non hormonal methods

Intrauterine Device (IUD) Copper IUD

Sterilization (Voluntary

Surgical Contraception)

Vasectomy (Male Sterilization)

Bilateral Tubal Ligation (Femalesterilization)

Non-hormonal methods

(barrier methods)

Male Condom

Female Condom

Natural Family Planning

(NFP) Methods

Abstinence

Coitus Interruptus/ Withdrawal

Lactational Amenorrhea Method (LAM)

Fertility Awareness Methods (FAM)

Unit 9: Slide 59

• NNRTIs and PIs decrease the therapeutic levels

of estrogen:

However, no clinical outcomes of increased

pregnancy rates have been documented

• Depo medoxyprogesterone has no known drug

interactions with ARVs:

Counsel patients about amenorrhea

• Note: Estrogen levels decreased by rifampicin

for TB patients

Contraceptives: Drug-Drug Interactions

Unit 9: Slide 60

DTG and hormonal contraceptive

• No reported or expected drug–drug interactions that would reduce the effectiveness of the hormonal contraceptive methods,

• Pharmacokinetic and other data are limited.

• DTG can likely be used with the full range of contraceptive methods without compromising their effectiveness.

• The WHO medical eligibility criteria do not provide specific recommendations for DTG and hormonal contraception.

• USA, The United States medical eligibility criterion 1 (medical eligibility criteria for the United States from 2016).

Unit 9: Slide 61

NUTRITION

Unit 9: Slide 62

• Always promote and encourage optimal nutrition intake with a variety of foods every day.

• Discuss ART and food interactions with the client before they begin treatment.

• Use the Food and Medication Intake Form to assist in counselling the client on the importance of food intake with ART.

• Identify medications that have special food interactions

• Identify potential nutrition-related side-effects with ART and provide counselling on management of side-effects.

• Promote and encourage optimal nutrition as part of HIV care.

Nutrition

Unit 9: Slide 63

• Traditional therapies and remedies for PLHIV should

be discouraged.

• Considerations when discussing supplements with

clients should include:

Multi-vitamins should be used as prescribed by a

health worker.

• Other supplements including traditional herbs and

remedies that claim to boost the immune system or

cure disease should be discouraged as they have

potential adverse medicine interactions with ARVs.

Nutrition (2)

Unit 9: Slide 64

• HIV positive patients are susceptible to

developing OIs such as TB, cryptococcol

meningitis, Hep B and PJP.

• PLHIV must be assessed and prophylaxis and

treatment be given appropriately

• Several ARVs are affected when renal function

is impaired

Dose adjustment may be required

• Family planning should be considered and

integrated in HIV care and management

Key Points