National Consolidated Guidelines - Knowledge Hub

1 National Published: February 2020 FOR THE MANAGEMENT OF HIV IN ADULTS, ADOLESCENTS, CHILDREN AND INFANTS AND PREVENTION OF MOTHER-TO-CHILD TRANSMISSION South African National Department of HealthCONSOLIDATEDGUIDELINESBN ational Consolidated Guidelines iNational Consolidated Guidelines CONTENTList of Tables ..ivForeword ..vAbbreviations ..viiIntroduction ..ixBackground and Rationale ..ixTarget Audience ..xScope and Content ..xSection 1 The Minimum Package of HIV Prevention, Care and Treatment Services ..2 Section 2 HIV Testing Services and Linkage to Care.

2 10 HIV Testing Services ..10 Key guiding principles for HTS ..10 Consent for HTS in children ..10 The Basic Package of HTS services ..11 HTS approaches and settings: when, where, who, and what ..11 Frequency of Testing in Different Populations ..13 Types of tests to use in different age groups ..13 The HIV testing algorithm for all adults, adolescents, and children older than 2 years ..14 HIV Self Screening Algorithm ..14 HIV Index Testing Algorithm ..15 Linkage to Care ..18 Interventions to improve linkage to care ..18 Section 3 ART Initiation and Achieving Virological Suppression.

3 20 ART Eligibility ..20An overview of the ART initiation Initiation Step 1: Determine the timeframe for ART initiation ..20 Baseline Clinical Evaluation for Adults and Adolescents, Pregnant Women, and Children ..21 Baseline Laboratory Evaluation for Adults and Adolescents, Pregnant Women, and Children ..23 Assessing renal function ..24 Medical indications to defer ART ..25 ART Initiation Step 2: Determine if the client should be on first- or second-line ART ..26Re-initiating ART in Clients who have Interrupted Treatment.

4 26 ART Initiation Step 3: Choose the drugs in the regimen ..27 Overview of preferred ART regimens per age group ..27 dolutegravir ..28 dolutegravir Overview ..28 Drug Interactions with dolutegravir ..29 Using DTG in women of childbearing potential ..30 Algorithm for recommending ART regimens in women and girls ..31 ART Initiation in Special Populations ..31 Dual Treatment of HIV and Active TB in Neonates, Infants, Children, Adolescents, and Adults ..32 ART Dosages, Substitutions, and Side-Effects ..33 ART Initiation Step 4: Interventions to support adherence to ART and retention in care.

5 33iiNational Consolidated Guidelines Key Adherence Messages ( National Adherence Guideline) ..34 Managing a Client on ART ..35 Summary of the Care Continuum for Adult Clients on ART ..35 Summary of the Visit Frequency for Children and Adolescents Clients on ART ..36 Monitoring a Client on ART ..36 Principles of Viral Load Monitoring ..37 Assessing a Client with an elevated adults and adolescents who are on first-line NNRTI-based adult regimens to DTG-containing regimens (single drug substitution) ..40 Transitioning children and adolescents on first-line paediatric regimens to DTG-containing regimens (single drug substitution).

6 41 Management of Viral Load Results in Infants, Children, Adolescents, and Adults ..42 Clients with a repeat VL of between 50 and 999 c/mL ..43 Second- and Third-line ART Regimens for Clients with Confirmed Virological Failure ..44 Resistance Testing ..45 Indications for resistance testing in adults and adolescents ..45 Indications for resistance testing in infants and children ..45 Third-line review committee ..45 Important considerations before doing a resistance test ..45 ART Side Effects ..46 Prevention, Screening, and Management of Common Co-infections and Co-morbidities.

7 49Co-trimoxazole Prophylaxis (CPT) ..49TB Preventive Therapy ..50 Tuberculosis (TB)..51 Cryptococcal Disease ..54 Management of Hepatitis B and C Coinfection ..55 Sexually Transmitted Infections (STIs) ..55 Cervical Cancer ..56 Management of Non-Communicable Disease and Other Conditions ..57 National Pharmacovigilance Programme ..58 Section 4 PMTCT ..64 Overview of the Structure of Section 4 for Part One: Introduction and Overview of PMTCT of HIV ..65 PMTCT Part Two: Prevention ..66 Prevention of HIV ..66 Prevention of Unintended Pregnancies and Safe Conception in Women.

8 67 PMTCT Part Three: Charts per Service Delivery Clinic ..68 Labour and Delivery ..70 Care of The Mother after Birth ..72 Care of the HIV-Exposed Infant after Birth ..73 Care offered in the Community Setting ..74iiiNational Consolidated Guidelines PMTCT Part Four: Algorithms and Decision Tools ..75 ART Initiation in a Pregnant Women ..75 DTG-use in Pregnant and Breastfeeding Women ..76 Summary of First-line ART Regimens for Women of Childbearing Potential ..76CD4 Count and Toxicity Monitoring in the Pregnant or Breastfeeding Women.

9 77VL Monitoring in Pregnant and Breastfeeding Women ..77 Management of the Women with an Elevated VL ..79 The Pregnant Adolescent ..80 Prophylaxis for the HIV-Exposed Infant at Birth ..81 Principles for Infant Prophylaxis: ..81 Prophylaxis for the HIV-exposed Infant during Breastfeeding ..82 Summary of the Indications for High- and Low-risk Infant Prophylaxis ..82 Managing the Mother-Infant Pair with an Elevated VL after Delivery ..83 Breastfeeding ..84 Breastfeeding in a Women with an Elevated VL ..85 Stopping Breastfeeding.

10 85 Management of Indeterminate PCR Results and The Abandoned Infant ..86TB Screening and TPT During Pregnancy, Labour, and the Breastfeeding Period ..87 Management of the TB-Exposed Neonate ..88 Care of the HIV-Exposed but Uninfected Infant ..89 Syphilis ..90 Syphilis in Pregnancy ..91 Data Management in PMTCT ..92 Annexure 1 Summary of dosages, common side effects, and substitutions associated with first- and second-line ART in adults and adolescents ..93 Annexure 2 Antiretroviral Drug Dosing Chart for Children ..94 Annexure 3: Practical Advice on Administration of ART Medications.