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"file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "d80549fd-eee5-4e06-845f-f9ff6a06a031", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "8598539134cb306365ee25c6e8f37ab061544d0b4f9fda2efa9ab5c31596e777", "class_name": "RelatedNodeInfo"}}, "text": "NATIONAL GUIDELINES\n FOR HIV PREVENTION,\nTREATMENT AND CARE\nNATIONAL AIDS AND STIs CONTROL PROGRAMMEFEDERAL MINISTRY OF HEALTH NIGERIA\n                  2020\n                        Copyright 2020.\n           Federal Ministry of Health, Abuja Nigeria\n                      ISBN: 978-978-980-273-9", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 297, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "26950c1f-67e2-453c-b319-f6de968dd2a4": {"__data__": {"id_": "26950c1f-67e2-453c-b319-f6de968dd2a4", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "e06312be-ac0d-4144-b459-d85a260aa542", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "ca5327f7040d24a115df6202cbc61f9d6788db5e67816b8ec04bedf11e6f83cb", "class_name": "RelatedNodeInfo"}}, "text": "Foreword\nOver the years, the Federal Ministry of Health has put in place several response mechanisms aimed at\nreducing the impact of HIV and AIDS and ensuring people living with HIV (PLHIV) in Nigeria\nreceive quality services by formulating national policies, protocols and standard operating\nprocedures to guide implementation.\n\nThese new 2020 National Guidelines for HIV Prevention Treatment and Care further underscores the\ngovernment's commitment to the welfare of all Nigerian children, adolescents, young persons,\npregnant women and adults living with HIV. It was developed through extensive consultations\ninvolving government, bilateral and multilateral organizations, civil society organizations, the\nacademia, and the patient community. The wellbeing of the recipients of care remained the principal\nconsideration.\n\nThese new Guidelines support evidence-based interventions that can improve efficiency and\neffectiveness despite the limited resources in the country's HIV programme. Its implementation will\nrequire increased investment and shared responsibility from all arms of government, donors and\nimplementing agencies. Implementing the guidelines fully will have an unprecedented impact on\npreventing new infections and reducing the number of people dying from HIV-related causes over\nthe coming years.\n\nThe key recommendations of these guidelines include the use of novel testing strategies for improved\ncase finding, initiating antiretroviral therapy (ART) in all HIV positive people including children,\nadolescents, adults, pregnant and breastfeeding women, regardless of clinical and immunological\nstages of the disease. Other recommendations include re-testing of patients prior to initiating ART,\nadoption of pre-exposure prophylaxis (PrEP) for individuals at high risk of acquiring the infection,\nTB/HIV co-infection management, provision of a specialized package of care for patients with\nAdvanced HIV Disease (AHD), and one-off administration of tuberculosis preventive treatment\n(TPT), differentiated service delivery models (DSD), as well as the establishment of adolescent-\nfriendly services.\n\nThese Guidelines provide all the guidance that health workers require to deliver comprehensive\npackage of high-quality HIV prevention, treatment and care interventions that addresses the needs of\nPLHIV, individuals at a high risk of acquiring HIV infection and the general population.\n\nI am optimistic that proper deployment and application of all the recommendations contained here\nwill help in effective management of HIV infections, bolster the HIV response, and ensure an\nirreversible decline of the epidemic.\n\nI therefore endorse and recommend this 2020 National Guidelines for HIV prevention, Treatment\nand Care for use across all the health facilities and service delivery points in the country and also for\nindividuals and organizations involved in the management of HIV and AIDS.\n\nDr Osagie E. Ehanire MD, FWACS\nHonourable Minister for Health\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                               i", "mimetype": "text/plain", "start_char_idx": 8, "end_char_idx": 3089, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "3654f14e-2802-4a60-be07-de284212fc51": {"__data__": {"id_": "3654f14e-2802-4a60-be07-de284212fc51", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "a73ca0a7-bd17-4c76-922c-3efb23cd6132", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "f55de4948bab1a066d4f8ccd447ac9cca2c68f6dcac8c6755493d0eb42f268f6", "class_name": "RelatedNodeInfo"}}, "text": "Acknowledgements\nThis document is the result of collaborative efforts led by the Federal Ministry of Health through\nits National HIV/AIDS, STIs & Hepatitis Control Programme (NASCP) with support from\nimplementing partners, bilaterals, multilaterals, civil society organizations and donor agencies.\n\nThe Federal Ministry of Health acknowledges with utmost gratitude, the inputs of all individuals\nwho devoted their time, amidst the COVID-19 pandemic, to review and contribute to this very\nimportant document. We also extend our appreciation to representatives of the following\norganizations who carefully reviewed the various chapters and sections of the document and\nprovided their invaluable contributions: UNICEF, UNAIDS, CDC, USAID & DOD and their\nimplementing partners and AHF.\n\nOur special thanks go to WHO, Clinton Health Access Initiative (CHAI), the academia under the\numbrella of the National Task Team on Antiretroviral Therapy, and the core editorial team for\nproviding all the needed technical and/or financial support to convene the meetings that\nculminated in the development of the 2020 National Guidelines for HIV Prevention, Treatment\nand Care.\n\nWe also appreciate the patient community for providing insight into some of the strategies and\nprogrammatic considerations that were harnessed for inclusion into this document. We are\ngrateful to the representatives of the departments of family health and hospital services, the\nNational Tuberculosis and Leprosy Control Programme of the Federal Ministry of Health, the\nNPHCDA, NAFDAC, NACA, NEPWHAN, ASWHAN, CISHAN and APYIN.\n\nFinally, I thank the Honourable Minister of Health and the entire Ministry leadership for the\ncreation of an enabling environment for the staff to work. I also commend the staff in the Office\nof the Director Public Health for the immense support to the various programmes/divisions in the\ndepartment. I appreciate the efforts of NASCP staff under the leadership of the National\nCoordinator, and especially the staff of the Treatment, Care and Support component of NASCP\nthat coordinated all the activities and meetings that ultimately led to the completion of this\ndocument in a timely manner.\n\nDr. Umo Mildred Ene-Obong\nHead/Director, Public Health Department\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         ii", "mimetype": "text/plain", "start_char_idx": 7, "end_char_idx": 2362, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "2545a562-1d03-46e3-80cf-bf6281aa84c5": {"__data__": {"id_": "2545a562-1d03-46e3-80cf-bf6281aa84c5", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "ded1af02-1f25-4283-be99-f9a75f9a5761", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "d07f6d3364c40af30992923633bee531a41bcde50e491b9cae4bc8ef803271f7", "class_name": "RelatedNodeInfo"}}, "text": "Executive Summary\nThe 2020 National Prevention, Treatment and Care Guidelines is a ten-chapter consolidated\ndocument that provides general and specific guidance on the diagnosis of HIV infection, the use\nof antiretroviral (ARV) drugs for preventing and treating HIV infection, and the care of people\nliving with HIV using a broad range of current technological innovations, interventions and\nevidence-based practices. This guideline is structured along the continuum of HIV testing,\nprevention, treatment and care.\n\nThe first chapter introduces the guidelines in general, its guiding principles, the process of\nreviewing and evaluating its implementation across service delivery points, the epidemiology of\nHIV in Nigeria, and a summary of the new inclusions into the 2020 Guidelines.\n\nChapter two provides guidance on HIV testing services (HTS), novel testing strategies including\nHIV self-testing, recency testing, use of HIV risk stratification checklists, and Nucleic acid\ntesting at birth. It also provides guidance on laboratory and clinical diagnosis of HIV infection.\n\nChapter three focuses on the use of antiretroviral therapy (ART), with emphasis on the\ncharacteristics and mechanisms of action of ARVs, criteria for initiating ART in different age\ngroups, the approved regimens for ART and management of treatment failure. It also provides\nguidance on the use of Tenofovir, Lamivudine and Dolutegravir (TLD) as the preferred first-line\nregimen for all adults and adolescents, the use of Dolutegravir in second-line ART for adults\nand adolescents, and the use of Dolutegravir based regimen as preferred first-line for children\nweighing 3kg and above. Chapter four recognizes the need to track and manage adverse drug\nreactions and provides guidance for effective pharmacovigilance in ART.\n\nIn the fifth chapter, the focus is on adherence to ART, its importance in achieving viral\nsuppression, and guidance on monitoring and improving adherence. Chapter six is dedicated to\nthe prevention of mother to child transmission (PMTCT) of HIV using ART and non-ART\ninterventions including prophylaxis for the HIV exposed infant.\n\nIn chapter seven, preventive management of HIV is presented. This chapter provides detailed\nguidance for offering pre and post-exposure prophylaxis (PrEP and PEP). Chapter eight focuses\non Advanced HIV Disease (AHD), Opportunistic infections (OIs) and the comorbidities. It\nprovides guidance on the implementation of the AHD package of care, cotrimoxazole preventive\ntherapy, tuberculosis preventive therapy, as well as the management of common opportunistic\ninfections.\n\nChapter Nine focuses on improving the efficiency of service delivery by using Differentiated\nService Delivery (DSD) models, and decentralized services. Special attention is given to\ndifferentiated service delivery based on clinical characteristics and sub-groups including key\npopulations.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                        iii", "mimetype": "text/plain", "start_char_idx": 8, "end_char_idx": 3006, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "2946096a-a280-4f43-aef4-61d179ab6621": {"__data__": {"id_": "2946096a-a280-4f43-aef4-61d179ab6621", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b2ba8c78-89d3-43c1-a10c-19eea3e287a2", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "3ea42fed9aa17964616c3bf92237463a3fb65415bec291210809558700553383", "class_name": "RelatedNodeInfo"}}, "text": "Finally, the tenth and the last chapter deals with the monitoring and evaluation of all the various\nstrategies and interventions involved in the health sector response. It also provides basic\ninformation on the strategies for monitoring the implementation of HIV services under these\nguidelines, and relevant indicators used for measuring the impact as well as the effectiveness of\nall the HIV Interventions.\n\nDr Akudo. E. Ikpeazu\nNational Coordinator\nNASCP\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         iv", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 562, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "68ee8655-3c6f-4e67-a94a-7acd725d2df1": {"__data__": {"id_": "68ee8655-3c6f-4e67-a94a-7acd725d2df1", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "350b4bee-dbca-456e-a970-d63b1b5168a6", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "68404139a0f7b6f95ecec6391ee55cfc7e04a5e033f9216d2f5a1ad4e8915f02", "class_name": "RelatedNodeInfo"}}, "text": "Editorial Team\nDr Bilkisu Jibrin                   Head Treatment, Care & Support NASCP - Coordinating Editor\nDr Nwaokenneya Peter                Assistant Director, Adult ART/TB/HIV- NASCP\nDr. Urhioke Ochuko                  Assistant Director, Childhood TB - NTBLCP\nMrs Atu Uzoma                       Assistant Director, Logistics Unit - NASCP\nProf. Sulaimon Akanmu               Chairman NTTA / Haematologist LUTH Lagos\nProf. Oche Agbaji                   Member NTTA / Physician JUTH Jos\nProf. Oliver Ezechi                 Director of Research NIMR Lagos\nDr Eugenia Ofondu                   Member NTTA / Physician FMC Owerri\nDr Damien Anweh                     Member NTTA / Physician FMC Markurdi\nDr Ali Onoja                        Member HTS Task team / CEO African Health Project\nDr Tolulope Oladele                 Assistant Director, Health Sector Response Support NACA\nDr Olufemi Oke                      Technical Advisor, Paediatric HIV treatment\n                                    and OVC Services, CRS\nEmmanuel Clifford                   National Secretary NEPWHAN\nNere Otubu                          Program Manager CHAI\nPharm Williams Eigege               Associate CHAI\nOluwakemi Sowale                    Senior Analyst CHAI\n\n            NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                      v", "mimetype": "text/plain", "start_char_idx": 7, "end_char_idx": 1353, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "f01d891d-f0ff-4e9a-b0bd-99482d52ba77": {"__data__": {"id_": "f01d891d-f0ff-4e9a-b0bd-99482d52ba77", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "0cd240db-6dbb-4e35-a825-e886db82a365", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "e7709cf8239cc1e9f8b9cdc452ab138b1dcd66e8db09c72c113588b53f8717a5", "class_name": "RelatedNodeInfo"}}, "text": "Abbreviations and Acronyms\n3TC             Lamivudine\nABC             Abacavir\nABUTH           Ahmadu Bello University Teaching Hospital\nACT             Artemisin-based Combination Therapy\nADR             Adverse Drug Reaction\nAHD             Advanced HIV disease\nAIDS            Acquired Immunodeficiency Syndrome\nAKTH            Aminu Kano University Teaching Hospital\nALP             Alkaline Phosphatase\nALT             Alanine Transaminase\nANC             Antenatal Care\nAPIN            AIDS Prevention Initiative in Nigeria\nARM             Artificial Rupture of Membrane\nART             Antiretroviral Therapy\nARV             Antiretroviral drugs\nAST             Aspartase Transaminase\nASWHAN          Association of Women Living with\n                HIV/AIDS in Nigeria\nATV/r           ritonavir boosted Atazanavir\nAUC             Area under the curve\nUATH            University of Abuja Teaching Hospital\nAZT             Zidovudine\nc-ART           Combination ART\nCD4+            Cluster of Differentiation Antigen 4\nCDC             Centres for Disease Control\nCFCC            Client and Family Centred Care\nCHAI            Clinton Health Access Initiative\n\nCHEW            Community Health Extension Worker\nCIHP            Centres for Integrated Health Programs\nCiSHAN          Civil Society for HIV/AIDS in Nigeria\nCKD             Chronic Kidney Disease\nCmax            Maximum Concentration\nCMS             Central Medical Stores Oshodi\nCMV             Cytomegalovirus\nCNS             Central Nervous System\nCOBI            Cobicistat\nCOPD            Chronic Obstructive Pulmonary Disease\nCPK             Creatinine Phospokinase\nCPT             Cotrimoxazole preventive Therapy\n\nCrAg        Cryptococcal Antigen\nCrCl        Creatinine Clearance\nCRRF        Combined Report and Requisition Form\nCS          Cesarean Section\nCSF         Cerebrospinal Fluid\nCSO         Civil Society Organization\nCT          Computed Tomography\nCTX         Cotrimoxazole\nCXR         Chest X-Ray\nD4T         Stavudine\nDAA         Directly Acting Antiviral\nDBS         Dried Blood Spot\nDdl         Didanosine\nDHOS        Department of Hospital Services\nDLV         Delavirine\nDNA         Deoxyribonucleic Acid\nDOTS        Direct Observed Treatment Short Course\nDRESS       Drug Reaction, Eosinophilia, Systemic\n            Symptoms\nDRV/r       Ritonavir boosted Darunavir\nDRTB        Drug Resistant Tuberculosis\nDTG         Dolutegravir\nED          Erectile Dysfunction\nEFV         Efavirenz\nEID         Early Infant Diagnosis\nELISA       Enzyme Linked Immunosorbent Assay\nEmtct       Elimination of Mother to child\n            transmission of HIV\nENT         Ear Nose Throat\nEPTB        Extra Pulmonary Tuberculosis\nEQA         External Quality Assurance\nESRD        End Stage Renal Disease\nETR         Etravirine\nECV         External Cephalic Version\nEVG         Elvitegravir\nFBO         Faith based Organization\nFBS         Fasting Blood Sugar\nFCT         Federal Capital Territory\nFCTA        Federal Capital Territory Administration\nFDC         Fixed Dose Combination\n\n                                   NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  vi", "mimetype": "text/plain", "start_char_idx": 7, "end_char_idx": 3172, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "19699929-2213-4357-a0f7-60e9b4624d2d": {"__data__": {"id_": "19699929-2213-4357-a0f7-60e9b4624d2d", "embedding": null, 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"a60a1b509bcfe4d22b4069008761b7ddc8feada4deabf6621bcd5351a5689e83", "class_name": "RelatedNodeInfo"}}, "text": "FETH        Federal Teaching Hospital\nFMC         Federal Medical Centre\nFMOH        Federal Ministry of Health\nFP          Family Planning\nFPV         Fosamprenavir\nFTC         Emtricitabine\n\nGFR         Glomerular Filtration Rate\nHAART       Highly Active Antiretroviral Therapy\nHb          Haemoglobin\nHbsAg       Hepatitis B surface Antigen\nHBV         Hepatitis B Virus\nHCT         HIV Counselling and Testing\nHCV         Hepatitis C Virus\nHCW         Health Care Worker\nHIV         Human Immunodeficiency Virus\nHLA         Human Leucocyte Antigen\n\nHPV         Human Papilloma Virus\nHSR         Hypersensitivity Reaction\n\nHSV         Herpes Simplex Virus\nHTS         HIV Testing Services\nHU-PACE     Howard University Pharmacy and\n            continuing Education\n\nIBBSS       Integrated Biological Behavioural\n            Sentinel Survey\nIDV         Indinavir\nIHVN        Institute of Human Virology Nigeria\nINH         Isoniazid\n\nINSTI       Integrase Strand Transfer inhibitor\nIPT         Isoniazid Preventive Therapy\nIPV         Intramuscular Polio Vaccine\nIRIS        Immune Reconstitution inflammatory\n            Syndrome\nJUTH        Jos University Teaching Hospital\nLF-LAM      Lateral Flow Lipoarabinomannan\nLGBTI       Lesbian, Gay Bisexual Transgender and\n            Intersex\nLIP         Lymphoid Interstitial Pneumonia\nLMCU        Logistic Management Coordinating Units\nLMIS        Logistic Management Information System\nLP          Lumbar Puncture\n\nLPV/r       Lopinavir/ritonavir\nLUTH         Lagos University Teaching Hospital\nM&E          Monitoring and Evaluation\nMAC          Mycobacterium Avium Complex\nMARPs        Most at Risk Populations\nMCH          Maternal and Child Health\nMLSCN        Medical Laboratory Science Council\n             of Nigeria\nMNCH         Maternal, Newborn and Child Health\nMOH          Ministry of Health\nMP           Malaria Parasites\nMTB          Multidrug Resistance TB\nMTCT         Mother to Child Transmission\nMUAC         Mid Upper Arm Circumference\nNACA         National Agency for the Control of AIDS\nNACS         Nutrition Assessment Counselling\n             and Support\nNARH         National AIDS and Reproductive\n             Health Survey\nNASCP        National AIDS and STIs Control\n             Programmed\nNAUTH        Nnamdi Azikiwe University Teaching\n             Hospital\nNBBFSW       Non-Brothel Based Female Sex Worker\nNEPWHAN      Network of People Living with HIV\n             in Nigeria\nNFV          Nelfinavir\nNIMR         Nigeria Institute of Medical Research\n\nNNRTI        Non-Nucleoside Transcriptase Inhibitors\nNPHCDA       National Primary Health Care\n             Development Agency\nNRTI         Nucleoside Reverse Transcriptase\n             Inhibitors\nNSAIDS       Non-SteroidalAnti-Inflammatory Drugs\nNTTA         National Task Team on ART\nNVP          Nevirapine\nOIs          Opportunistic infections\nPap          Papanicolaou Test for cervical\n             cancer screening\nPCR          Polymerase Chain Reaction\nPCV          Packed Cell Volume\n\nPDSA cycle   Plan, Do, Study, Act\nPEP          Post Exposure Prophylaxis\nPEPFAR       US President Emergency Plan For\n             AIDS Relief\nPHC          Primary Health Care\n\n                                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  vii", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3307, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "1d7985d4-1253-4981-8d04-7ed68942acb3": {"__data__": {"id_": "1d7985d4-1253-4981-8d04-7ed68942acb3", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "e6b20c2e-dea6-43f2-84f6-038c311a2615", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "5d72d8e62e6ad140039c2e625a28685c26329dcb35a8b1e71dd9c4b3b6412bd4", "class_name": "RelatedNodeInfo"}}, "text": "PHDP    Positive Health Dignity and Prevention\nPI      Protease Inhibitor\nPI/r    Ritonavir boosted Protease Inhibitor\nPITC    Provider Initiated HIV Testing and\n        Counselling\nPJP     Pneumocystis Jiroveci Pneumonia\nPLHIV   People Living with HIV\nPME     Programme Monitoring and Evaluation\nPMM     Patient Management and Monitoring\nPMTCT   Prevention of Mother to Child\n        Transmission\nPrEP    Pre-Exposure Prophylaxis\nQA      Quality Assurance\nQI      Quality Improvement\nRAL     Raltegravir\nRNA     Ribonucleic Acid\n        Reproductive Tract Infection\nRTI\nRVP     Rilpivirine\nSACA    State Agency for the Control of AIDS\nSQV     Saquinavir\nSTI     Sexually Transmitted Infection\ntARVp   Triple Antiretroviral Drug Prophylaxis\nTB      Tuberculosis\nTDF     Tenoforvir\nTPT     Tuberculosis Preventive Therapy\n\nTPV     Tipranavir\nTT      Tetanus Toxoid\nUBTH    University of Benin Teaching Hospital\nUCH     University College Hospital Ibadan\nUCTH    University of Calabar Teaching Hospital\nUNAIDS  Joint United Nations Programme on\n        HIV/AIDS\nUNICEF  United Nations Children Emergency Fund\nUNN     University of Nigeria\nUNTH    University of Nigeria Teaching Hospital\nUSAID   United States Agency for International\n        Development\nVIA     Visual Inspection Acetic Acid for cervical\n        cancer screening\nVL      Viral Load\nWBC     White Blood Cell\nWHO     World Health Organization\n\n                              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  viii", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1505, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "10d55b20-dc46-40b0-8f1f-52c0345328f9": {"__data__": {"id_": "10d55b20-dc46-40b0-8f1f-52c0345328f9", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "15f05621-003d-45a6-8e12-26628dd267d0", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "cc4deeb3b70e73b69eb9b5502167cd6a347ba5207329f40e12738cbf14b79a5d", "class_name": "RelatedNodeInfo"}}, "text": "Definition of Terms\nHIV-Retesting: This is a second HIV test conducted after a positive first test result. Re-testing is\nrecommended before initiation of ART.\n\nHIV sero-discordant couples: Sexual relationship in which one partner is HIV positive and the\nother HIV negative.\n\nKey populations: These are groups of individuals who bear a high burden of HIV and are\nexposed to a higher risk of acquiring the infection.\n\nARVs: These are medicines used to treat HIV.\n\nART: This is the use of a combination of three or more ARVs to treat HIV in order to achieve\nbetter viral suppression. Highly active anti-retroviral therapy (HAART) or combination Anti-\nRetroviral Therapy (cART) is used interchangeably.\n\nViral load: It is the number of HIV RNA copies in a millilitre of plasma.\n\nSustained viral suppression: This is an optimal response to ART such that the viral load\nremains below the detection threshold usually at less than 20 copies of HIV RNA/ml.\n\nStable on ART: These are PLHIV who have received ART for at least one year and have no\nadverse drug reactions that require regular monitoring, no current illnesses, have a good\nunderstanding of lifelong adherence with evidence of treatment success (i.e. two consecutive\nviral load measurements below 1000 copies/mL).\n\nClinical failure in adults and adolescents: It is the presence of new or recurrent clinical event\nindicating severe immunodeficiency (WHO clinical stage 4 condition) following 6 months of\neffective treatment.\n\nClinical failure in Children: It is the presence of new or recurrent clinical event indicating\nadvanced or severe immunodeficiency (WHO clinical stage 3 and 4 clinical condition with the\nexception of TB) after 6 months of effective treatment.\n\nImmunological failure in adults and adolescents: This is when the CD4+ cell count fall to or3\nbelow pre-treatment baseline value or persistent CD4 levels below 100 cells/mm or 50% decline\nfrom on-therapy CD4+ cell count peak level.\n\nImmunological failure in Children younger than 5 years: It is persistent CD4 levels below3\n200 cells/mm or <10%.\n\nImmunological failure in Children older than 5 years: It is persistent CD4 levels below 100\ncells/mm3\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          ix", "mimetype": "text/plain", "start_char_idx": 8, "end_char_idx": 2283, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "12466745-40c6-439d-a711-2e0265564faf": {"__data__": {"id_": "12466745-40c6-439d-a711-2e0265564faf", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "bb06734a-c023-48c6-9074-e22ae9bbe10c", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "dd3dab8eeac65e388eb06ebf32a8c08425df8408775d19fa2611cfac29c71710", "class_name": "RelatedNodeInfo"}}, "text": "Virologic failure: It is a persistently detectable viral load exceeding 1000 copies/ml (that is, 2\nconsecutive viral load measurements within a 3-month interval, with adherence support between\nmeasurements) after at least six months of using ARV drugs.\n\nPharmacovigilance in HIV: This is also known as drug safety. It is the collection, detection,\nassessment, monitoring, and prevention of adverse effects in patients on antiretroviral drugs and\nother medicines associated with the management of HIV/AIDS.\n\nAdherence to ART: It is the extent to which a PLHIV behaviour coincides with the ART\nregimen as agreed through mutual decision-making between the PLHIV and the adherence\ncounsellor.\n\nMTCT of HIV: This is mother to child transmission of HIV, which can occur in pregnancy,\nlabour and delivery, or through breastfeeding.\n\nPMTCT: Prevention of mother to child transmission of HIV is the strategy for ensuring that HIV\ninfection is not transmitted to an infant during pregnancy and lactation period\n\nHIV-exposed infants: These are infants delivered to HIV positive women.\n\nHigh-risk infants: These are infants delivered to HIV positive women with an increased risk\nof viral transmission. These women may not have had ARVs or have had less than 4 weeks of\nARV or have a viral load of greater than 1000copies/ml in the last month prior to delivery.\n\nInfant ARV prophylaxis: These are ARVs administered to all HIV exposed infants to prevent\nthem from acquiring HIV infection.\n\nEID: Early infant diagnosis of HIV is the testing of all HIV exposed babies to determine their\nHIV infection status by detecting the presence of HIV DNA using PCR.\n\nDBS: Dried blood spot testing (DBS) is a form of biosampling where blood samples are blotted\nand dried on filter paper. The dried samples can easily be shipped to an analytical laboratory and\nanalysed using various methods such as DNA amplification.\n\nPCR DNA: Polymerase chain reaction is the use of an enzyme to multiply both HIV DNA and\nRNA in blood sample.\n\nPrEP: It is the use of oral ARVs to prevent HIV infection in individuals exposed to high risk of\nacquiring HIV.\n\nPEP: It is the use of oral ARVs by individuals exposed to HIV in order to block the acquisition of\nHIV.\n\nTB Preventive Therapy: TB Preventive Therapy (TPT), previously referred to as Isoniazid\npreventive therapy (IPT) is the treatment offered to individuals who are considered to be at risk of\ndeveloping active TB disease, in order to reduce that risk. It is also referred to as the treatment of\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                            x", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2618, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d3e45770-3c25-4bc7-92a5-c00878b22913": {"__data__": {"id_": "d3e45770-3c25-4bc7-92a5-c00878b22913", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "0cf8e324-f8f2-4bab-9115-dd6143ac5401", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "9f63548509a1c609b9707a37843f3a01e84c293824fdbf37fbc7417a850f1a69", "class_name": "RelatedNodeInfo"}}, "text": "Latent TB Infection (LTBI) .\n\nCPT: Cotrimoxazole preventive therapy is the routine administration of cotrimoxazole in all\nHIV positive individuals to prevent the development of a variety of infections.\n\nCo-infection: Co-infection is the spontaneous existence of two or more infections in an\nindividual.\n\nCo-morbidity: Co-morbidity is the occurrence of one or more illnesses in an individual with a\nprimary disease.\n\nOpportunistic infection: Opportunistic infections (OIs) are infections that occur more\nfrequently and can become severe in individuals with HIV when their immune system becomes\nweakened.\n\nDifferentiated care: Differentiated care is the delivery of a minimum package of HIV/AIDS\ntreatment care and support services according to the diversity of the care needs for people living\nwith HIV.\n\nDecentralization in the context of HIV: Decentralization is the devolution of part\nresponsibility for the offer of HIV treatment and care from the tertiary and secondary level ART\ncentres to the primary level health facilities.\n\nRetention in HIV care: It is the number of individuals on ART who are retained in the same\nfacility or are transferred out to another facility offering ART services over a period of time.\n\nLinkage to HIV prevention, care, treatment and support: Proportion/number of individuals\nwho complete a medical visit within 3 months of the diagnosis of HIV\n\nTask shifting/sharing: It is a rational redistribution of tasks among health workforce teams,\nallowing a wider range of cadres to offer certain services, safely and effectively as a means of\nrapidly expanding access and improving health care.\n\nContinuum of care: it is an integrated system of care that guides and tracks clients over time,\nthrough a comprehensive range of health services starting from screening for HIV, through to\ninitiation of ART, retention in care and psychosocial support.\n\nMonitoring in HIV: Monitoring in HIV is the regular observation, recording and process of\nroutinely gathering information of activities taking place in HIV programme.\n\nEvaluation: Evaluation in HIV is a systematic assessment which focuses on expected and\nachieved accomplishments in HIV programmes.\n\nHIV Data flow: Data flow is the transmission of HIV data from source (health facilities) through\nlocal governments and states data platforms to the Federal Ministry of health as the final data\nrepository.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                        xi", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2486, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "dc02f2f1-3b29-4fd3-bd57-6052f6cfb1f3": {"__data__": {"id_": "dc02f2f1-3b29-4fd3-bd57-6052f6cfb1f3", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "beee3919-633f-4a33-85ff-c4fb845e4470", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "63f803f63ab767330b567b4543b4546ab24e7b1e428d88d59bd26c6767c24d77", "class_name": "RelatedNodeInfo"}}, "text": "HIV Data validation: Data validation is defined as the checking of all collected HIV data for\ncompleteness, thoroughness and reasonableness, and the elimination of errors.\n\nData Quality Assurance: Data Quality Assurance is a routine measure to ensure quality of data\nthrough a process of validation, reliability, precision, integrity and timeliness.\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                  xii", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 449, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "a9371335-a576-4664-9e90-c5e0a230c2be": {"__data__": {"id_": "a9371335-a576-4664-9e90-c5e0a230c2be", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "901f56e3-ee77-4bd4-88f8-2de67c9bbe49", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "22c1ecf39e9fb08b3ad11fc3fcf8baa2261aeae9aaf12837f69c347edca8bae3", "class_name": "RelatedNodeInfo"}}, "text": "Table of Contents\nForeword                                                                         i\nAcknowledgements                                                                 ii\nExecutive Summary                                                                iii\nEditorial Team                                                                   v\nAbbreviations & Acronyms                                                         vi\nDefinition of terms                                                              ix\nTable of Contents                                                                xiii\n\nCHAPTER 1 \u2013INTRODUCTION                                                          1\n1.1 Objectives of the Guidelines                                                 3\n1.2 Epidemiology of HIV in Nigeria                                               6\n    1.2.1 HIV Transmission                                                       6\n1.3 Natural History of HIV                                                       7\n    1.3.1 Adults and Children older than 5 years                                 7\n    1.3.2 HIV in Pregnancy                                                       7\n    1.3.3 HIV infection in children under 5 years                                8\nCHAPTER 2 - DIAGNOSIS OF HIV INFECTION                                           10\n2.1 Introduction                                                                 11\n2.2 HIV Testing Services                                                         11\n    2.2.1 Risk Stratification                                                    11\n    2.2.2 Pre -test services                                                     11\n    2.2.3 Post -test services                                                    11\n    2.2.4 Index Testing Services                                                 12\n    2.2.5 Social Network Testing                                                 13\n    2.2.6 Blended Index and Social Network Strategies                            13\n    2.2.7 HIV Self-testing                                                       13\n    2.2.8 Recency Testing                                                        14\n2.3 HTS in Pregnancy                                                             14\n    2.3.1 Approach to HTS in Pregnant Women                                      14\n    2.3.2 Essential Components of HTS for PMTCT                                  14\n    2.3.3 HTS for women in labour                                                15\n    2.3.4 HTS for post-partum women                                              15\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  xiii", "mimetype": "text/plain", "start_char_idx": 8, "end_char_idx": 2707, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c54c1d22-797e-4907-8c6c-24db37b60d69": {"__data__": {"id_": "c54c1d22-797e-4907-8c6c-24db37b60d69", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "a07822fb-7857-492e-9786-74f6962d3d3d", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "8f4aaad11d1a9d241062c898fa17eb38d2e0b8402889642327a08b1717b723ef", "class_name": "RelatedNodeInfo"}}, "text": "2.4 Re-testing                                                                             15\n2.5 Repeat HIV Testing                                                                     15\n2.6 Disclosure Scenarios                                                                   16\n2.7 Linkage of HTS to care and ART                                                         16\n2.8 Laboratory Diagnosis of HIV Infection                                                  17\n     2.8.1 Antibody Assays                                                                 17\n     2.8.2 Enzyme-Linked Immunosorbent Assay (ELISA) or Enzyme\n             Immunoassay (EIA) for Blood Screening                                         18\n     2.8.3 Nucleic Acid -based Testing                                                     19\n     2.8.4 HIV DNA Polymerase Chain Reaction (PCR)                                         19\n     2.8.5 Viral Load Assay - Reverse Transcriptase Polymerase Chain Reaction (RT-PCR)     19\n2.9 Laboratory Diagnosis of HIV Infection in Children by Age Group                         20\n     2.9.1 Children aged \u226418 months                                                        20\n     2.9.2 Children aged \u226518 months                                                        22\n2.10 Clinical Diagnosis and Staging of HIV Infection                                       22\nCHAPTER 3 - ANTIRETROVIRAL THERAPY                                                         26\n3.1 Introduction                                                                           27\n3.2 Classes of Antiretroviral Drugs                                                        27\n3.3. Preparation of Adults, Adolescents and Children for ART                               29\n      3.3.1 Baseline Assessment for ART                                                    29\n      3.3.2 Further Baseline Assessment                                                    29\n      3.3.3 Initiating ART in Adults                                                       30\n      3.3.4 Initiating ART in Adolescents (10-19 years of age)                             30\n      3.3.5 Initiation of ART in infants and children younger than 10 years of age         30\n      3.3.6 Recommendations for Use of ART in TB/HIV Co-infection                          30\n      3.3.7 Key considerations when treating PLHIV with TB:                                31\n      3.3.8 Recommendations for use of ART in HIV/Hepatitis Co-infection                   32\n3.4 Recommended ART Regimen for Adults, Adolescents and Children                           33\n      3.4.1 First -line ART regimens for adults and adolescents                            33\n      3.4.2 First -line ART for children                                                   33\n      3.4.3 Programming Transitioning to DTG -based regimen                                34\n3.5 Monitoring Patients on ART                                                             34\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020           xiv", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3069, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "7d8e52f3-2288-45a9-a756-038ee5a7524f": {"__data__": {"id_": "7d8e52f3-2288-45a9-a756-038ee5a7524f", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "55aa267b-200c-4cdd-bf59-9879ee07f144", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "71e34aaf5dba0a4ec160a5dbc9d463912187a1a3984f133f5ea99fbf4a2741f7", "class_name": "RelatedNodeInfo"}}, "text": "3.5.1 Monitoring and Follow-up in Adults                                   34\n     3.5.2 Monitoring Children and Adolescents on ART                           35\n3.6 Management of HIV Treatment Failure                                         37\n     3.6.1 Definitionof HIV Treatment Failure                                   37\n     3.6.2 Causes of HIV Treatment Failure                                      39\n     3.6.3 Substitution and switch of ARV drugs                                 40\n     3.6.4 Second-line ART Regimens                                             40\n3.7 Third-line ART                                                              42\n     3.7.1 Criteria for Switch to Third-Line ART                                42\n     3.7.2 Operational Guidance for Third-Line ART                              42\n3.8 Low-Level Viremia (LLV)                                                     43\n     3.8.1 Management of Low -level viremia (LLV)                               43\n3.9 ART in Special Circumstances                                                44\n     3.9.1 Kidney impairment                                                    44\n     3.9.2 Cardiomyopathy                                                       44\n     3.9.3 Osteoporosis                                                         44\nCHAPTER 4- PHARMACOVIGILANCE IN ANTIRETROVIRAL THERAPY                          47\n4.1 Introduction                                                                48\n      4.1.1 Active Pharmacovigilance                                            48\n4.2 Pregnancy Monitoring for Patients on ARVs                                   48\n4.3 HIV Drug Resistance (HIVDR)                                                 49\n4.4 Adverse drug reactions (ADRs)                                               49\n     4.4.1 Classification of Adverse Drug Reactions (ADRs)                      49\n4.5 Drug toxicity                                                               50\n     4.5.1 Laboratory monitoring of toxicity:                                   50\n4.6 Steps to Recognize ADRs                                                     54\n4.7 Who is to Report ADRs?                                                      54\n4.8 What ADRs Should be Reported?                                               54\n4.9 Pharmacovigilance Data Collection and Reporting Process                     55\n4.10 Principles of Management of Adverse Drug Reactions                         55\n     4.10.1 Management of Specific ARV Adverse Drug Reactions                   57\n4.1 1 Prevention of Adverse Drug Reactions                                      61\n4.1 2 ARV Drug Interactions                                                     62\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  xv", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 2820, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "3f4cfa8d-f0c2-4696-827b-b9d8948a23b1": {"__data__": {"id_": "3f4cfa8d-f0c2-4696-827b-b9d8948a23b1", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "7ed68513-66c4-4e72-b22c-a35b7857080a", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "48a6f285d41cfcdf6f7e7387fd9d139c8f327407bf1614c99a7b62888eccfb84", "class_name": "RelatedNodeInfo"}}, "text": "4.12.1 Interactions Between Contraceptives and Antiretroviral Drugs                  62\nCHAPTER 5 -ADHERENCE TO ANTIRETROVIRAL THERAPY                                              65\n 5.1 Introduction                                                                           66\n 5.2 Adherence Preparation for ART                                                          66\n 5.3 On-going adherence for clients on ART                                                  67\n 5.4 Monitoring of Adherence                                                                67\n      5.4.1 Factors known to improve adherence                                              68\n      5.4.2 Factors associated with poor adherence                                          68\n      5.4.3 Adherence in Specific Populations                                               69\n      5.4.4 Recommendations for improving adherence                                         70\n CHAPTER 6 -PREVENTION OF MOTHER TO CHILDTRANSMISSION OF HIV INFECTION                      72\n 6.1 Introduction                                                                           73\n 6.2 Mother-to-Child Transmission of HIV                                                    73\n      6.2.1 Prevention of MTCT                                                              74\n      6.2.2 Benefit of PMTCT                                                                77\n 6.3 Pre-ART Care for HIV-positive pregnant women                                           78\n      6.3.1 Initial evaluation of HIV pregnant women                                        78\n      6.3.2 Initial Clinical Examination of HIV Positive Pregnant Women                     78\n      6.3.3 Laboratory Investigation of HIV Positive Pregnant Women                         79\n      6.3.4 Syphilis testing for pregnant women                                             80\n 6.4 Use of Antiretroviral Therapy for PMTCT                                                80\n      6.4.1 Recommended first-line regimen for pregnant and breastfeeding women.            80\n      6.4.2 ARV prophylaxis for the HIV exposed infant                                      80\n      6.4.3 Cotrimoxazole Prophylaxis for HIV exposed infants                               81\n      6.4.4 Antenatal Care for HIV positive preg nant women                                 82\n 6.5 Management of HIV positive women in labour, delivery and within 72 hours of delivery   82\n      6.5.1 Induction of Labour                                                             83\n      6.5.2 Conduct of Delivery                                                             83\n      6.5.3 Vaginal Delivery                                                                83\n      6.5.4 Caesarean Section (CS)                                                          83\n      6.5.5 Specific Modification of Obstetric Care for HIV Positive Women                  84\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020              xvi", "mimetype": "text/plain", "start_char_idx": 7, "end_char_idx": 3040, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "2264f79a-13fc-42c9-83b9-6b349c7f6350": {"__data__": {"id_": "2264f79a-13fc-42c9-83b9-6b349c7f6350", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "1a1accbc-a4bc-4180-b303-fee8b66b9201", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "c19c7fbb38bff4fabd87e487f6b9faa7b55f39d69eceb54cd9152053633b067f", "class_name": "RelatedNodeInfo"}}, "text": "6.6 PMTCT/TB integration services                                                        84\n     6.6.1 Pregnant women with TB and HIV co-infection                                   84\n     6.6.2 Infection Control                                                             86\n     6.6.3 Management of Newborn of a Mother/ Household contacts with LTBI               86\n6.7 Care and Support of the HIV-Exposed Infant                                           86\n     6.7.1 Immediate and on-going care of the new-born of HIV positive women             86\n     6.7.2 Infant feeding in the context of HIV                                          87\n     6.7.3 Early Infant Diagnosis (EID)                                                  87\n     6.7.4 Childhood Immunizations in the Context of HIV                                 87\n6.8 Special Considerations for Adolescent and Young Women in PMTCT                       90\n6.9 Linkage of PMTCT with comprehensive HIV Treatment, Care and Support\n      Services for Mothers and Infants                                                    91\n     6.9.1 Engagement of Non-Formal Health Actors (NFHA) in the (referral and Linkage)\n           of PMTCT services                                                              91\nCHAPTER 7- PREVENTIVE MANAGEMENT IN HIV                                                   93\n7.1 Introduction                                                                          94\n     7.1.1 Combination prevention / Minimum Prevention Package Intervention (MPPI)        94\n7.2 Pre-Exposure Prophylaxis                                                              95\n     7.2.1 Criteria for PrEP initiation                                                   95\n     7.2.2 PrEP minimum package                                                           95\n     7.2.3 PrEP effectiveness                                                             95\n     7.2.4 Approved drugs for PrEP                                                        95\n     7.2.5 PrEP administration guidance                                                   96\n     7.2.6 Daily PrEP and Event -Driven PrEP                                              96\n     7.2.7 PrEP for Serodiscordant Couples                                                96\n     7.2.8 Settings where PrEP can be accessed                                            96\n     7.2.9 Contraindications for PrEP                                                     97\n     7.2.10 Client follow-up                                                              97\n     7.2.11 PrEP discontinuation                                                          99\n7.3 Post -Exposure Prophylaxis                                                            99\n     7.3.1 Post-Exposure Prophylaxis for Occupational HIV exposure                        99\n     7.3.2 Evaluation for Post-Exposure Prophylaxis                                       100\n     7.3.4 Determination of Risk and ARV drugs for PEP                                    100\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020           xvii", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3127, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c2df6a16-a379-414a-b374-131df144ab64": {"__data__": {"id_": "c2df6a16-a379-414a-b374-131df144ab64", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b3bcde75-8c51-404d-80cc-eba8b9215c9e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "73e52f9801b2a41819e60bbfef2cc694ada7f4b35e007fdb0c872149ba71a467", "class_name": "RelatedNodeInfo"}}, "text": "7.3.5 Recommendations for PEP                                                             100\n     7.3.6 Recommended Drug Combinations for PEP                                               101\n 7.4 Post-Sexual Assault Exposure Prophylaxis                                                  102\n     7.4.1 Recommendations                                                                     103\n     7.4.2 Clinical considerations                                                             103\n 7.5 Interventions for Key Populations                                                         104\n     7.5.1 Recommended comprehensive prevention package ofInterventions for key populations    104\n 7.6 Condom availability and promotion for HIV programme                                       105\n     7.6.1 Elements of Condom Programing                                                       105\n     7.6.2 Key Steps in Condom Programing                                                      106\n7.7 Gender -Based Violence                                                                     106\n     7.7.1 GBV Prevention                                                                      107\n     7.7.2 GBV Case Identification and First-line Support Recommendations                      107\n     7.7.3 GBV Clinical Response Recommendations                                               107\n7.8 Management of Sexually Transmitted Infections (STIs)                                       108\n     7.8.1 Objectives of STIs/RTIs management                                                  108\n     7.8.2 Components of syndromic management                                                  108\n     7.8.3 Prevention of STIs/RTIs                                                             108\n7.9 Prevention for Adolescent and Young Persons (AYPs)                                         109\n     7.9.1 Harm Reduction program                                                              109\n     7.9.2 Cervical Cancer Prevention                                                          110\nCHAPTER 8-ADVANCED HIV DISEASE, OPPORTUNISTIC INFECTIONS,\n                 AND CO-MORBIDITIES                                                            112\n8.1 Advanced HIV Disease                                                                       113\n     8.1.1 Introduction                                                                        113\n     8.1.2 Definition of advanced HIV disease                                                  114\n     8.1.3 Components of AHD package of care                                                   115\n     8.1.4 Diagnostics for AHD and associated OIs                                              115\n     8.1.5 Management of opportunistic infections in AHD                                       117\n     8.1.6 ART Initiation and Intensive Adherence Support for Patients with AHD                121\n     8.1.7 Vaccination for People with AHD                                                     122\n     8.1.8 Immune Reconstitution Inflammatory syndrome (IRIS)                                  123\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                 xviii", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 3226, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "90f844d2-1564-46bd-a474-98360321df68": {"__data__": {"id_": "90f844d2-1564-46bd-a474-98360321df68", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "1b71c1a5-e026-4de7-8c11-e902bc18a490", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "136686408360e40b34d533e8162e91a28bc013bae1c72c8d7452e8420c2be827", "class_name": "RelatedNodeInfo"}}, "text": "8.1.9 Management of AHD among Children less than ten years                   124\n8.2 Other Opportunistic Infections (OIs)                                         126\n8.3 Preventing Opportunistic Infections (OIs)                                    126\n    8.3.1 Cotrimoxazole Preventive Therapy (CPT)                                 127\n    8.3.2 Tuberculosis Preventive Treatment (TPT)                                128\n8.4 HIV-RELATED CO-MORBIDITIES                                                   146\n     8.5 Mental Health and HIV                                                   146\n    8.5.1 Recommendations                                                        146\n    8.5.2 Management Considerations                                              147\nCHAPTER 9 -SERVICE DELIVERY                                                      149\n9.1 Introduction                                                                 150\n9.2 Differentiated Service Delivery                                              150\n     9.2.1 Differentiated HIV Testing Service Delivery                           151\n     9.2.2 Differentiated ART Service Delivery                                   151\n     9.2.3 Differentiated Service Delivery Based on Clinical Characteristics     153\n     9.2.4 Differentiated Service Delivery based on Sub-Populations              155\n     9.2.5 Differentiated Service Delivery Based on Context                      161\n     9.2.6 Integration of Service Delivery                                       161\n     9.2.7 Family-Centred Differentiated Service Delivery                        162\n9.3 Standards for Quality HIV Service Delivery                                   163\n     9.3.1 Standards of Care                                                     163\n     9.3.2 Standard Precautions                                                  166\n9.4 Nutrition                                                                    167\n     9.4.1 Nutrition in HIV Positive Pregnant and Lactating Woman                167\n     9.4.2 Nutrition in Children Living with HIV                                 167\n     9.4.3 Nutrition and Antiretroviral Therapy                                  169\n9.5 Service Delivery for Adolescents Living with HIV                             169\n     9.5.1 Adolescent Friendly Health Service                                    169\n     9.5.2 Package of services for adolescents living with HIV                   170\n     9.5.4 Psychosocial support for adolescents living with HIV                  172\n     9.5.5 Transitioning to adult care                                           172\n     9.5.6 Peer-driven adolescent service delivery models                        174\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  xix", "mimetype": "text/plain", "start_char_idx": 4, "end_char_idx": 2803, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d2ddf457-da76-44e6-8a2e-c9c06df20412": {"__data__": {"id_": "d2ddf457-da76-44e6-8a2e-c9c06df20412", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "24daa7b2-b406-45ba-9c27-bde583364c36", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "c5e1ce429be9eeb90e68c7fd3db4a9310a006b79ee99330c36137f7c221060c9", "class_name": "RelatedNodeInfo"}}, "text": "CHAPTER 10- MONITORING & EVALUATION                                                    176\n10.1 Introduction                                                                      177\n10.2 Selection of Indicators                                                           177\n10.3 Data Management                                                                   182\n    10.3.1 Data Collection                                                             182\n10.4 HIV Data Dissemination and Use                                                    184\n10.5 Human Resource for M&E                                                            184\n10.6 HIV M&E Logistics                                                                 185\n10.7 Additional strategies in M&E                                                      185\n10.8 HIV Research                                                                      185\n10.9 Periodic monitoring of the implementation of the guidelines and content update    185\nReferences                                                                             187\nAppendix                                                                               189\n     Appendix 1: Commonly used Adult and Paediatric ARV Formulations and Dosage        190\n     Appendix 2: Mental Health Screening                                               198\n     Appendix 3: Energy and Nutritional Recommendations for PLHIV                      199\n     Appendix 4: Recommended activities for adolescent HIV service delivery            200\n     Appendix 5: Guide on Age-Appropriate Disclosure for Children and Adolescents      203\n     Appendix 6: Self-management timeline for transitioning ALHIV                      204\n     Appendix 7: Algorithm for Screening and Diagnosing TB in PLHIV                    206\n     Appendix 8: Global Standards for Quality Health-Care Services for Adolescents     210\n     Appendix 9: Pharmacovigilance or Drug and Therapeutic Committees\n     (PVC) - Terms of Reference                                                        211\n     Appendix 10: NAFDAC ADR Form                                                      212\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020         xx", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2251, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c8775f56-b0f5-4e2e-97dc-9e7fbc0a7e4d": {"__data__": {"id_": "c8775f56-b0f5-4e2e-97dc-9e7fbc0a7e4d", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "7e4683bc-a627-44f7-b658-f3506fb36d03", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "eddd59ed378ea88f1485c502149eba29f494e988a10b729ad900945113ea96aa", "class_name": "RelatedNodeInfo"}}, "text": "1. INTRODUCTION\n\nWhat\u2019s Inside:\n1.1 Objectives of the Guidelines\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026................3\n 1.1 Objectives of the Guidelines\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\n1.2 Epidemiology of HIV in Nigeria\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.......\u2026\u2026.6\n 1.2 Epidemiology of HIV in Nigeria\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\n1.3 Natural History of HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026........................7\n 1.3 Natural History of HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026", "mimetype": "text/plain", "start_char_idx": 15, "end_char_idx": 356, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "2f207758-5bda-46cb-8876-588ac83892c4": {"__data__": {"id_": "2f207758-5bda-46cb-8876-588ac83892c4", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "5b9a1e73-c41b-4a96-b45e-e4f43b34513a", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "2dc3a72e14b77aba2a14b360413bae458e7a2b10ce0b4c9c4e235da77b72a35a", "class_name": "RelatedNodeInfo"}}, "text": "The 2020 Nigeria HIV Guidelines are informed by the basic principles of equality, equity and\nsocial justice and they align strongly with the universal declarations of human rights. They\npromote universal access to comprehensive HIV prevention, treatment and care for all persons in\nNigeria. The recommendations of these guidelines are the product of careful balancing of\nscience and public health. The core principles of these guidelines include:.\n\n     1. Public Health Approach: These guidelines reinforce the objectives of the national\n          strategy for decentralization of HIV services in Nigeria. They seek to make HIV\n          prevention, treatment and care services universally available to all Nigerians\n          irrespective of socioeconomic class and creed. This approach uses simplified drug\n          formularies, fixed-dose combinations, task shifting and sharing, and simplified systems\n          for clinical mentoring.\n\n     2. Promotion of human rights and equity: Access to quality health care services\n          including HIV prevention, treatment, care and support is a basic human right which is\n          the entitlement of all people regardless of nationality, sex, sexual orientation, ethnicity,\n          race, religion or other status. These rights should be recognized as fundamental to\n          realizing the universal right to health. These guidelines will support the equitable\n          provision of quality HIV services including ART and related interventions to all the\n          people who need them; especially pregnant women, children and high-risk populations.\n          These services should be provided in an environment that minimizes stigma and\n          discrimination. Basic rights and freedom of all clients will be respected in the\n          implementation of the guidelines. For example, informed consent (for HIV testing and\n          initiation of ART) and adequate health information safeguards should be put in place to\n          ensure consent and confidentiality. Priority should be given to people who are most ill\n          and those who are already on treatment.\n\n     3. Implementation guided by in-country peculiarities: Implementation of the\n          recommendations of these guidelines will be informed by local context including; HIV\n          epidemiology, availability of resources, the organization and capacity of the health\n          systems at all levels of care. Indigenous best practices will be promoted alongside global\n          standard practices.\n\n     4. Strengthening health systems through innovation and learning: Service delivery\n          approaches recommended in these guidelines will be implemented in a manner that\n          strengthens health systems and enhances the local capacity to keep pace with the rapidly\n          evolving science of HIV medicine.\n\n     5. Increasing the effectiveness and efficiency of programmes: As the country scales-up\n          access to ART in the face of competing national priorities, efforts will be made to\n          optimize the effectiveness and efficiency of National HIV programmes through\n          provision of ART to people living with HIV and implementing strategies and\n          recommendations that are sustainable and less dependent on foreign aid.\n\n     6. Differentiation and Integration of Services: With the UNAIDS 95-95-95 targets,\n          scale-up of HIV care, treatment and support services, and differentiating ART treatment\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                             2", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3583, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c7626593-cf29-4529-aa51-05fd2393dcae": {"__data__": {"id_": "c7626593-cf29-4529-aa51-05fd2393dcae", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "5a5595fa-2b45-48fb-8182-ac124be56ea7", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "af2daab082f545f3288b0bc0ef477205e89a84eb2811b33633daf81e3d625dbe", "class_name": "RelatedNodeInfo"}}, "text": "becomes imperative for expansion and provision of patient-focused care. Strengthening\n           linkages and referrals are important components of differentiation. The integration and\n           linkage of HIV services with TB, sexual and reproductive health, maternal, newborn and\n           child health services offer opportunities for providing ART, increasing adherence and\n           reducing attrition in care.\n\n     7. The HIV Continuum of Care: These guidelines are predicated on HIV continuum of\n           care. The diagnosis of HIV should be followed with timely initiation of ART and\n           retention in care, sustained virological suppression resulting in improved quality of life.\n           As many more PLHIV live longer, stable and healthier, HIV has become a chronic health\n           condition. This requires that health systems and community interventions should be\n           modified to optimize the chronic care model.\n\n     8. Contribution to National and Global Health Goals: These guidelines have taken into\n           consideration the letter of the 2016 United Nations General Assembly Special Session\n           (UNGASS ) Political Declaration on HIV which affirms the 2030 agenda for sustainable\n           development including the resolve of member states to end the AIDS epidemic by 2030.\n           The 2016 guideline was designed to ensure that the UNAIDS 2014 declaration of 90-90-\n           90 was achievable; however, huge gaps still exist. In particular, the 2018 National AIDS\n           Indicator and Impact Survey (NAIIS) showed that an estimated 800,000 individuals are\n           yet to be identified. As at the end of 2019, approximately 1.14 million people were on\n           treatment out of the estimated 1.9 million people living with HIV. Thus, the country is at\n           60% ART coverage. Although there are facility reports of giant strides being made\n           concerning the third 90 at tertiary institutions in Nigeria, nationwide report showed\n           widely variable suppression rates as low as 50% in some facilities to 80% in others.\n           Specifically, the current guidelines seek to contribute towards the achievement of\n           UNAIDS 95-95-95 targets. In addition, this document will contribute to achieving the\n           goals and targets articulated in the National HIV/AIDS strategic framework (NSF 2021-\n           2025).\n\n1.1 Objectives of the Guidelines\n     \u00a7     To provide updated and evidence-based clinical recommendations for the provision of\n           HIV prevention, treatment, care and support services\n     \u00a7     To provide guidance on key service delivery and operational issues needed to increase\n           the effectiveness and efficiency of HIV service delivery and strengthen the continuum of\n           HIV care through linkage and integration\n     \u00a7     To provide programmatic guidance for the effective delivery of HIV prevention,\n           treatment, care and support services at all levels of the health care system\n     These Guidelines will support;\n     \u00a7     Early HIV diagnosis and timely initiation of lifelong combination ART\n     \u00a7     Package of care for the management of PLHIV presenting with advanced HIV disease\n     \u00a7     Use of viral load testing for monitoring ART treatment success and diagnosis of\n           treatment failure\n     \u00a7     Monitoring drug toxicity in every individual on ART\n     \u00a7     ARV prophylaxis to HIV exposed infants, timely DNA PCR testing and early linkage of\n           HIV positive infants to treatment and care\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                            3", "mimetype": "text/plain", "start_char_idx": 11, "end_char_idx": 3689, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "e726f3c2-7817-4ece-a896-e500bd29d9f3": {"__data__": {"id_": "e726f3c2-7817-4ece-a896-e500bd29d9f3", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "cb58c5bb-f3f0-4a87-928e-4d1683e4e2a7", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "88d2f87e33d1015221071ca9e2c9852aafe1d318a68438329b881ea8db4245f8", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7     Prevention of new HIV infections among adults, adolescents, pregnant and\n           breastfeeding women and children\n     \u00a7     Strengthened adherence to ART and retention in care\n     \u00a7     Improved quality ART service delivery all over the country\n\nWhat is new in the 2020 National Guidelines for HIV Prevention, Treatment and Care?\nART should be initiated in all adults, adolescents, pregnant and breastfeeding women, and\nchildren with a diagnosis of HIV regardless of WHO clinical stage and CD4+ cell count. This\nrecommendation (as in the 2016 Guidelines) maintains that people who test HIV positive will be\ninitiated on ART once they are willing and ready to start ART for life.\n\nHowever, as a priority, health care workers should initiate ART in the following;\n     \u00a7     All adults and adolescents with severe or advanced HIV clinical disease ( WHO stage 3\n           or 4 )\n     \u00a7     All adults and adolescents with HIV and CD4+ cell count of less than 350 cells/mm\u0000\n     \u00a7     All HIV positive pregnant and breastfeeding women\n     \u00a7     All HIV positive children older than 5 years of age with severe or advanced disease\n           (WHO stage 3 or 4)\n     \u00a7     All HIV positive children older than 5 years of age with CD4+ cell count less than 350\n           cells/mm\u0000\n     \u00a7     All HIV positive children less than 2 years of age\n     \u00a7     All HIV positive children less than 5 years of age with CD4+ cell count of less than 750\n           cells/mm ; or CD4+ percentage less than 25%\u0000\n\nTable 1.1: List of new recommendations\n\n   Service Area                                    New update\n   HIV diagnosis                Current innovative testing strategies for improved case finding and efficient\n                                use of resources\n                                Risk stratification before HIV testing\n                                Index testing\n                                Recency testing\n                                HIV Self testing\n                                Nucleic acid testing at birth\n\n   HIV Treatment                Tenofovir+Lamivudine+Dolutegravir as preferred first-line ART for all\n                                adults and adolescents\n                                Use of Dolutegravir (DTG) in second-line ART regimen\n                                Use of DTG in Children less than 20kg\n                                Package of care for advanced HIV disease\n                                Use of long-acting injectables\n                                Use of reverse transcriptase translocator inhibitor\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                   4", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 2694, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "e658601b-7e4e-406a-9849-b9597cfe6367": {"__data__": {"id_": "e658601b-7e4e-406a-9849-b9597cfe6367", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b193fec2-808b-438d-8c4c-bc4a14557e87", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "9d91045a896be61daa8a26b2d56148d3d6ee1c3691642a2b01c0aab116dc88f3", "class_name": "RelatedNodeInfo"}}, "text": "Service Delivery            Expansion on models for Differentiated service delivery for specific\n                               populations\n                               Adolescent friendly services and models\n                               Integration of family planning service in ART\n\n   Laboratory testing          Use of point of care devices for rapid assessment of:\n                               Viral load in pregnant women presenting close to labour\n                               Early infant diagnosis in hard to reach areas\n                               Same day CD4+ cell count\n                               Diagnostics for opportunistic infections\n                               Urine Lateral Flow Lipoarabinomannan (LF-LAM) assay\n                               Stool for Xpert MTB/RIF assay in children\n                               CrAg test\n                               Histoplasma antigen test\n                               IgG/IgM Toxoplasma Antibody Test\n\n   HIV exposed infants         Nucleic acid testing at birth (NAT)\n   Prevention                  Event-driven Pre-Exposure Prophylaxis\n\nProcess of guidelines review\nThe review and development of the 2020 National Guidelines on HIV prevention, treatment, and\ncare, commenced in June 2019 when the Federal Ministry of Health established working groups\nof the National Task Team on ART. These working groups included:\n     i.   PMTCT working group\n     ii. Adult/Pediatric ART working group\n     iii. Service Delivery working group\n     iv. AHD working group\n     v.   Lab/HTS working group\n\nThe working groups were mandated to review the respective sections of the 2016 National\nguidelines for HIV Prevention, treatment and Care in line with emerging HIV management\nmodalities. The committees worked remotely and also met in person to review the guidelines and\ndevelop recommendations for inclusion in the 2020 guidelines. Following the completion of the\ntasks by the groups, the FMOH convened series of stakeholders' meetings to review the output\nfrom the working groups and integrate into a final document. Resources used for the review\nincluded the WHO Policy brief on Antiretroviral Regimens (July 2019), NAIIS 2018 Technical\nReport and the Nigerian National data repository amongst others.\n\nRecommendations contained in this document are the product of stakeholder consensus, and the\nprincipal consideration is the wellbeing of the patients. The recommendations are essentially\nguidance on HIV diagnosis, general HIV care and support, rational use of ARV drugs for treating\nand preventing HIV infection and effective delivery of services.\n\nStakeholders involved in the review and development of the 2020 national guidelines included\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          5", "mimetype": "text/plain", "start_char_idx": 3, "end_char_idx": 2827, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "3c79bb2d-bcaf-44d4-bd6a-8b9308fb6709": {"__data__": {"id_": "3c79bb2d-bcaf-44d4-bd6a-8b9308fb6709", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f470abef-19d8-43df-b56a-6bdbf18fe018", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "456bca1780bb901d6193706a6fd5858151efe634341dfc9526fa12c26fbbf4e2", "class_name": "RelatedNodeInfo"}}, "text": "representatives of the FMOH, SMOH, NPHCDA, NACA, NAFDAC, NTBLCP, CHAI,\n UNAIDS, WHO, UNICEF, PEPFAR, CDC, USAID, HIV Implementing Partners, NEPWHAN,\n CSOs, National Task Teams for ART, PMTCT and HTS, facility-level HIV service providers.\n The process was coordinated by the NASCP.\n\n Target audience\n The 2020 National Guidelines for HIV Prevention, Treatment and Care is intended primarily for\n use by HIV programme managers and service providers at all levels of HIV service delivery. The\n critical audiences for the guidelines include:\n     \u00a7    Health facility level service providers\n     \u00a7    National and State level HIV Programme Managers\n     \u00a7    National HIV treatment and prevention technical working groups\n     \u00a7    National TB programme managers\n     \u00a7    Managers of maternal, newborn and child health and reproductive health programmes\n     \u00a7    Clinicians and other health service providers in private practice\n     \u00a7    Managers of national laboratory services\n     \u00a7    Community-based organizations including People living with HIV\n     \u00a7    International and bilateral agencies and organizations\n\n 1.2 Epidemiology of HIV in Nigeria\n Nigeria reported the first case of AIDS in 1986. Since then, the National HIV prevalence\n increased exponentially from 1.8% in 1991 peaking at 5.8% in 2001 and progressively declining\n through 4.4% in 2005, 3% in 2014. Based on the report from NAIIS, the current prevalence of\n individuals aged 15 - 64 is 1.4%. As at 2019, Nigeria had an estimated HIV burden of 1.9 million\n people, the fourth largest in the world. The incidence of HIV in 2018 was estimated at 8 per\n 10,000 persons (NAIIS). The prevalence varied across Regions and States with the highest\n prevalence being in the South-South (3.1%) while the North-West had the lowest prevalence\n(0.6%). Akwa Ibom state had the highest prevalence (5.5%) while Katsina had the lowest\nprevalence (0.3%).\n\n1.2.1 HIV Transmission\nHeterosexual sex still accounts for the majority of transmissions in Nigeria. Over 90% of\ntransmissions are via unprotected sexual intercourse between heterosexual individuals.\nHowever, current data suggest that homosexuality is contributing disproportionately to the\noverall National epidemic. It is estimated that MSM constitutes only about 1% of the Nigerian\npopulation, yet this group now contributes 20% of new infections in Nigeria. This is not\nunexpected given the fact that 2018 NAIIS documented National population HIV prevalence of\n1.4% whereas the prevalence of the infection among MSM has been rising consistently from\n14% in 2007 to 17% in 2010 and 23% in 2014.\n\nAnother prominent mode of transmission of HIV is from the HIV positive mother to her child.\nMost children less than 15 years living with HIV acquire the infection through mother-to-child\ntransmission (MTCT). This can occur during pregnancy, labour and delivery or during breast-\nfeeding.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                       6", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 3001, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "fca6b7b3-b73e-4487-86e3-1093f5d792b6": {"__data__": {"id_": "fca6b7b3-b73e-4487-86e3-1093f5d792b6", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "21806729-4feb-45fb-b1b3-5f28dcaaa6e0", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "62282ddf18b2011451e7bbc1df5a568d110f3f0ad4d558a4024cbce68223e304", "class_name": "RelatedNodeInfo"}}, "text": "Other modes of transmission of HIV whose incidence rate is not well documented include\ntransmission from transfusion with infected blood and blood products, contact with sharp skin-\npiercing objects used for scarifications, tattoos, and surgical procedures.\n\n1.3 Natural History of HIV\n\n1.3.1 Adults and Children older than 5 years\nA typical HIV infection can be divided into three stages: primary infection, asymptomatic\ninfection, and symptomatic infection including AIDS. Following primary HIV infection, the\nCD4+ cell count decreases and the HIV RNA rises significantly. With sufficient exposure to viral\nantigens, cytotoxic T-lymphocyte responses are generated, and the HIV viral load typically\ndeclines to an equilibrium known as a virologic \u201cset-point\u201d within 6 to 12 weeks of infection.\nOnce this viral set-point is reached, the CD4+ cell count may rebound again marginally, although\nit does not often return to baseline values. Concurrent with these events are clinical\nmanifestations of acute HIV infection in 30% to 60% of individuals.\n\nAbout half of newly infected people experience flu-like symptoms while the rest are\nasymptomatic. Once infected, adults experience an asymptomatic clinical latency that lasts 2 to\n10 years, during which HIV is produced and removed by the immune system and CD4+ T cells\nare killed and replaced. This latency period is considerably shorter in children. During this\nasymptomatic period, the number of infected circulating CD4+ cells and free virions are\nrelatively low. Moreover, the hematopoietic system can replace most T cells that are destroyed,\nthus keeping the CD4+ cell counts in the normal range for adults and children >6 years (636-9773\ncells/mm ).\n\nA number of opportunistic infections (OIs), including recurrent oral candidiasis and tuberculosis\nare common during the early symptomatic phase of AIDS. As the CD4+ cell count declines to an\neven lower level, additional life-threatening OIs such as herpes zoster, amoebiasis,\nmicrosporidiosis, strongyloidiasis, toxoplasmosis, dermatophytosis etc. may occur with\nincreasing frequency and severity. In the later stages of symptomatic HIV infection, the viral\nload levels rise again. Quantitative PCR methods (viral load assays) demonstrate:\n     \u00a7    Continuous replication of HIV in nearly all infected individuals, although the rates of\n          virus production vary by as much as 70-fold in different individuals\n     \u00a7    The average half-life of an HIV infected cell in vivo is 2.1 days. Recent reports have\n          suggested an even faster turnover of plasma virus of 28 to 110 per minute9\n          Up to 10 \u20131010HIV particles are produced each day, and averages of 2 x 10 CD4+9\n     \u00a7\n          cells are produced each day.\n\n1.3.2 HIV in Pregnancy\nIn pregnancy, immune function is suppressed in both HIV-infected and uninfected women.\nThere is a decrease in immunoglobulin and complement levels in early pregnancy and a more\nsignificant decrease in cell-mediated immunity. Studies have shown that pregnancy may\nhowever not affect the progression of HIV or the rate of death. On the other hand, HIV infected\npregnant women are more likely to develop early pregnancy complications such as bacterial\npneumonia, urinary tract infections, spontaneous abortion, higher rates of ectopic pregnancy and\nincreased stillbirth rates, especially from areas where the epidemic has been present for a long\ntime. The risk appears to be lower in asymptomatic HIV positive pregnant women.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                       7", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3588, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "37dbc8ce-0513-42b3-b24c-8872305c85e1": {"__data__": {"id_": "37dbc8ce-0513-42b3-b24c-8872305c85e1", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "41d4cc4e-094c-46bf-9ff9-03837c7a466d", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "afbee86de356a695f62d9ecb8c2e74ffb31ad77e1ba5732bbebdab30a6e757d6", "class_name": "RelatedNodeInfo"}}, "text": "1.3.3 HIV infection in children under 5 years\nThere are critical differences between HIV progression in children and adults. Stemming largely\nfrom the lower efficiency of a child's immature immune system, these differences usually result\nin more rapid disease progression and a much shorter duration for each stage.\n\nAt birth, viral load is usually very low but within the first 2 months of life, it increases rapidly to\nvalues well above 100,000 copies/ml. Thereafter the viral load remains high until the age of 2 or\n3 years after which it declines gradually to reach the viral load set point. These viral dynamics are\nsignificantly different from the rapid increase and decrease of the viral load seen in horizontally\ninfected older children and adults.\n\nIn children, the higher viral load is associated with the level of somatic growth of the lymphatic\nsystem and the inability of their immature immune system to mount an HIV-specific response.\nWhen assessing the immune system in infants and children, it is very important to compare the\nchild's CD4+ cell count with the age-appropriate values. Lymphocyte counts are very high in\ninfancy and decline to adult levels around 6 years of age.\n\nHigher mortality in HIV-infected children may result from intercurrent infections, malnutrition,\nand lack of access to primary HIV care including delayed definitive diagnosis. With no\ninterventions, the majority of children who acquired HIV perinatally develop HIV-related\nsymptoms by 6 months of age.\n\nPerinatally infected children fit into one of three categories:\n     \u00a7    Category 1: Rapid progressors develop signs and symptoms of HIV and AIDS and die by\n          age 1 year. These children are likely to have acquired the infection in-utero or during the\n          early perinatal period (about 25 \u2013 30%)\n     \u00a7    Category 2: Children develop symptoms early in life, followed by rapid deterioration\n          and death by age 3 to 5 years (about 50 \u2013 60%)\n     \u00a7    Category 3: Long-term survivors live beyond age 8 years (5 - 25%)\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                             8", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2143, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8fbbbad6-f4dc-4c95-bc40-31f2bdbc9b76": {"__data__": {"id_": "8fbbbad6-f4dc-4c95-bc40-31f2bdbc9b76", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "ed1d9a13-ad5a-42c3-8640-261b1d667501", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "b4ebf8c6c6f11e86a7482e649859ae138266a621fed158b65042b56a7a6e15c0", "class_name": "RelatedNodeInfo"}}, "text": "List of Contributors\nDr. Umo Mildred Ene-Obong\nDr Akudo Ikpeazu\nMr Araoye Segilola\nPharm Oloyede Yekini\nDr Akpan Nsebong\nOmbudadu Obadiah A\nDr Deborah Odoh\nMrs Semlek Rachael N\nDr Nwaokenneya Peter\n\nDr Chioma Ukanwa\nMs Rahila Agwom\nDr Chinwendu Daniel\nNdukwe\nProf. Sulaimon Akanmu\nDr Damien Anweh\nDr Rita O. Oladele\nDr Charles Olomofe\nDr Oluwafunke Ilesanmi\nDr Dennis Onotu\nDr Obinna Ogbanufe\nDr Igboeline Onyeka Donald\nDr Abiye Kalio\nFolu Lufadeju\nPharm Willams Eigege\nDr Saswata Dutt\nDr Olufemi Oke\nDr Olawale Fadare\nDr Olayiwola Lanre\n                                                          Chapter 1\nHead/Director, Public Health Department FMoH\nNational Coordinator NASCP\nFormer, National Coordinator\nFormer, Director, Logistics Unit NASCP\nDeputy Director NASCP\nDeputy Director NASCP\nDeputy Director, NTTP & Performance Management NASCP\nChief Accountant NASCP\nAssistant Director, Adult ART/TB/HIV - NASCP\nSenior Medical Officer 1, NTTP & Performance Management\nNASCP\nChief Scientific Officer NASCP\nDeputy Director, Health Sector Response Support NACA\n\nChairman NTTA / Haematologist LUTH Lagos\nMember NTTA / Physician FMC, Markurdi\nMember NTTA / Microbiologist LUTH Lagos\nPublic Health Physician FETH Ido Ekiti\nTechnical Officer, HIV and Viral Hepatitis WHO\nBranch Chief, Continuum of care & treatment CDC\nSenior Program Specialist, HIV care and treatment CDC\nProgramme Manager, Treatment USAID\nProgramme Manager USAID\nDeputy Country Director CHAI\nAssociate CHAI\nSenior Technical Advisor, HIV/TB/DR -TB IHVN\nTechnical Advisor CRS\nTechnical Director TMEC/RISE Program\nSenior Technical Advisor CCFN\n\n                             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  9", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 1698, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "87ac8c22-b593-4d6d-a4c0-5dc813b024b8": {"__data__": {"id_": "87ac8c22-b593-4d6d-a4c0-5dc813b024b8", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "d0616d2d-42c9-4f68-beae-bc8c7bca793d", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "139a00f271a2724397e82d0fb751171cb357cfa73004fb687f1937d3e6a9dbdc", "class_name": "RelatedNodeInfo"}}, "text": "2. DIAGNOSIS OF HIV\n                     INFECTION\n\nWhat\u2019s Inside:\n2.1 Introduction\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..11\n 1.1 Objectives of the Guidelines\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\n2.2 HIV Testing Services\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u202611\n 1.2 Epidemiology of HIV in Nigeria\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\n2.3 HTS in Pregnancy\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u2026\u202614\n 1.3 Natural History of HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\n2.4 Re-testing\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.15\n2.5 Repeat HIV Testing\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u2026..15\n2.6 Disclosure Scenarios\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026....16\n2.7 Linkage of HTS to care and ART\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.....16\n2.8 Laboratory Diagnosis of HIV Infection\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u202617\n2.9 Laboratory Diagnosis of HIV Infection in Children\n    by Age Group \u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..20\n2.10 Clinical Diagnosis and Staging of HIV Infection\u2026\u2026\u2026\u2026\u202622", "mimetype": "text/plain", "start_char_idx": 12, "end_char_idx": 735, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "5eaa0ee8-597a-45b2-b551-78959a5741f6": {"__data__": {"id_": "5eaa0ee8-597a-45b2-b551-78959a5741f6", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "8f99ac88-9521-473d-9f09-5032ce5440f1", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "6fad3c23f49f529227a2867c0060a965ec874204409b50852b2659c9c2d9149e", "class_name": "RelatedNodeInfo"}}, "text": "2.1 Introduction\nDiagnosis of HIV infection is simply a proof of the presence of HIV in an individual, and this can\nbe achieved by demonstrating either the presence of HIV antibodies in plasma or serum (indirect\ntest) or the virus in blood (direct test). Available tests for diagnosis of HIV include antibody,\nantigen and nucleic acid tests. The antibody detection tests are suitable for the diagnosis of HIV\ninfection in adults and children 18 months and above, while the nucleic acid test is used mainly\nfor the diagnosis of HIV infection in children under 18 months. The diagnosis of HIV infection\nshould not be made without first obtaining a positive result from any of the test methods\nhighlighted above. It is recommended that before commencing ART all persons who have tested\nHIV positive should be re-tested.\n\n2.2 HIV Testing Services\nHIV Testing Services (HTS) provides a gateway to HIV prevention, treatment and care services.\nHTS consists of a range of services that include diagnosis of HIV using HIV testing methods,\ncounselling (pre-test information and post-test counselling), linkage to HIV prevention,\ntreatment and care and other clinical services, and coordination with laboratory services for\nquality assurance and the delivery of accurate results.\n\nAll forms of HTS should be voluntary and should adhere to WHO's five C's: consent,\nconfidentiality, counselling, correct test results and connections to care, treatment and\nprevention services. The WHO five C's are principles that apply to all models of HTS and in all\ncircumstances. For further information, refer to the\nNational HTS Guidelines 2017.\n\n2.2.1 Risk Stratification\nRisk stratification is a strategy that identifies those who are likely to be infected with HIV based\non their risk exposure. The HIV risk stratification tool enables service providers to determine if a\nclient presenting at the health facility or community is eligible for an HIV test or not, following\nan assessment using a set of predetermined criteria. The Risk stratification Tool (RST) has been\nuseful in aiding the programme to be more efficient in the testing of clients.\n\n2.2.2 Pre-test services\nPre-test information may be provided through individual or group information sessions and\nmedia such as posters, brochures, and short video clips shown in waiting rooms. When children\nand adolescents are receiving HTS, information should be presented to them in an age-\nappropriate manner and in a way their guardians can understand. Pre-test information sessions\nfor people receiving HIV testing should emphasize the benefits of HIV testing, the meaning of an\nHIV-positive and an HIV-negative test, and an assessment of clients' readiness for HIV testing.\nFor further information, refer to the National HTS Guidelines 2017.\n\n2.2.3 Post-test services\nPost-test information and counselling for people who test HIV negative should emphasize an\nexplanation of the test result, referral and linkage to other relevant HIV prevention services, and\nadvise to return in 4 weeks for repeat testing in the event of recent risky behaviour. For those\npeople who test HIV positive, post-test information should emphasize an explanation of the test\nresult and helping the client to cope with emotions arising from the diagnosis, clear information\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         11", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3390, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "88c664a8-8d86-41f6-b7a5-04034a9cd93c": {"__data__": {"id_": "88c664a8-8d86-41f6-b7a5-04034a9cd93c", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "0ac1df92-ea6f-49dd-8f14-c909e33db587", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "5b518c77371c233ac6e84bdf7061648e2cc21c2e8f1a3f40e70bd55687dd741a", "class_name": "RelatedNodeInfo"}}, "text": "on ART and its benefits for maintaining health and reducing the risk of HIV transmission, as well\nas proper linkage to care. For further information, refer to the National HTS Guidelines 2017.\n\n2.2.4 Index Testing Services\nIndex testing services (ITS) is a focused HTS approach in which the household, family members\n(including children) and partners of people diagnosed with HIV are offered HTS. ITS should be\noffered by a trained provider in an appropriate, safe and ethical manner. The provider should ask\npeople diagnosed with HIV (index clients) to list their sexual partners, drug-injecting partners\n(where applicable), children, and other family members. If the index client agrees, offer these\npartners and the children HIV testing services (HTS). The process is completely voluntary. Such\nservices are key to increasing HIV case finding and achieving epidemic control.\n\nImplementers need to ensure that the following minimum requirements are in place to conduct\nvoluntary safe and ethical ITS:\n     \u00a7     All providers conducting index testing must be trained and supervised on index testing\n           procedures including 5Cs, intimate partner violence (IPV) screening, adverse event\n           monitoring, and ethics (respect for the rights of clients, informed consent and 'do no\n           harm').\n     \u00a7     Strict Adherence to 5C's should be observed/assessed at least quarterly, as well as\n           provision of additional voluntary and ethical practices as detailed below:\n               \u00b7     Providers must offer clients a choice of all four partner notification strategies\n                     (client, contract, provider, dual referral) and indicate that there are both ways to\n                     notify contacts that do not involve disclosure and ways to ensure anonymity\n               \u00b7     Providers will work with clients experiencing IPV to choose a partner\n                     notification method that ensures their safety (which may be declining of index\n                     testing service\n     \u00a7     All HIV testing clients, including index clients, should be provided with all available\n           HIV prevention, care and treatment services, regardless of whether or not they provide\n           details about their contacts. Clients must NEVER be pressured into sharing the names of\n           their contacts for fear of being denied services. Services must NEVER be withheld\n           under any circumstances.\n     \u00a7     Clients should be informed of their right to decline participation in index testing services\n           throughout the process, not just during the elicitation interview .\n     \u00a7     IPV risk assessment should be conducted for each contact elicited, with referral options\n           to necessary services using SOPs (available at\n           www.humanitarianresponse.info/files/document/nigeria_sops_gbv_prevention_respo\n           nse_2019.pdf ).\n     \u00a7     Onsite provision of first-line services (Listen, Inquire, Validate, Ensure safety,\n           Support) for anyone reporting IPV, and additional services offered either onsite or as\n           referral.\n     \u00a7     A secure environment (e.g. lockable cabinets) to store patient information.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                               12", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3320, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ce5019ec-2214-4515-b11a-52807e34b9c1": {"__data__": {"id_": "ce5019ec-2214-4515-b11a-52807e34b9c1", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f07d0282-c9ef-4aa2-b9f9-b9187b97449f", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "c845cee7d56e48832aa88337d59cbd5276ca28689fa3aa25bb0fe6ddff0cbabd", "class_name": "RelatedNodeInfo"}}, "text": "See the figure below for detailed information:\n                                                    1. Monitor\n                                                         Compliance\n                                                         with minimum\n                                                         standards\n\n                        4. Quality\n                            assurance and                                     2. Obtain Informed\n                            accountability                                        consent\n                                                       Safe and\n                                                    Ethical Index\n                                                        Testing\n                                                       Services              3. Intimate Partner\n                        5. Adverse Event                                         Violence Risk\n                            Monitoring                                           Assessment and\n                                                                                 Service Provision\n\nfigure 2.1: Safe and Ethical Index Testing Services\n\n2.2.5     Social Network Testing\nSocial Network Testing (SNT) is when HIV-positive and/or high-risk HIV-negative persons,\nparticularly from key populations (KP) are enlisted as recruiters to identify individuals from\ntheir social, sexual, and drug-using networks (network associates) for HTS. Social and risk\nnetwork strategies complement traditional peer outreach by engaging previously unidentified\nKP and other high-risk populations for HIV prevention and testing. The goal is to reach hidden,\nhigh-risk networks, expand HIV case detection potential, and, as an integrated part of a\ndifferentiated model, link HIV-positive individuals to rapid treatment, and connect HIV-\nnegative individuals to services that will help them remain HIV-negative.\n\n2.2.6 Blended Index and Social Network Strategies\nIt is valuable to synergistically build upon a core foundation of index testing to introduce social\nnetwork strategies (SNS) to expand case-finding options for high-risk groups. The two strategies\ncan be used in concert to ensure that all high-risk, direct exposure contacts and social network\nmembers are tested and that HTS extends into harder-to-reach networks of undiagnosed PLHIV.\n\n2.2.7 HIV Self-testing\nHIV self-testing (HIVST) refers to a process in which a person collects his or her specimen (oral\nfluid or blood) and then performs an HIV test and interprets the result, often in a private setting,\neither alone or with someone he or she trusts. As with all approaches to HTS, HIVST should\nalways be voluntary, not coercive or mandatory. Although reported misuse and social harm are\nrare, efforts to prevent, monitor, and further mitigate related risks are essential. A reactive (HIV-\npositive) HIVST result always requires further testing and confirmation from a trained provider,\nstarting from the beginning of the validated national testing algorithm. Importantly, HIVST is a\nscreening test and should not be used to provide a definitive HIV diagnosis. Clear messages are\nessential to ensure that HIVST users understand how to perform the test, the meaning of the test\nresults, and where and how to access follow-up services following a test, including retesting,\ncare, and treatment. Linkage to HIV testing services through a facility or HTS provider is critical\nfollowing a reactive HIVST. A negative HIVST is reliable evidence of no infection and does not\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           13", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3651, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "31547a39-9822-4ea3-8453-7eb792180c43": {"__data__": {"id_": "31547a39-9822-4ea3-8453-7eb792180c43", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "15ecfd70-9c63-4d57-81b2-0901520123d1", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "55c14a3cb97634ab9bc5de0ff7255c78d24614348e6b5f75c401a8d6ea5c1e4c", "class_name": "RelatedNodeInfo"}}, "text": "require additional testing unless PrEP is planned, in which case the negative result should be\nconfirmed using the national testing algorithm before PrEP initiation. Interpretation of a non-\nreactive (HIV-negative) self-test result will also depend on the ongoing risk of HIV exposure.\nIndividuals at high ongoing risk, or who test within six weeks of possible HIV exposure, should\nbe encouraged to retest. HIVST is not recommended for users with a known HIV status who are\ntaking antiretroviral drugs, as this may lead to an incorrect self-test result (false non-reactive).\nHIVST for children 2-11 years must be caregiver assisted or health care worker assisted with\ncaregiver consent. Provisions should also be made for persons with disabilities to access\nappropriate information and educational materials about HIVST and to receive support to\nconduct the HIVST as needed. For further information, refer to the National HIVST Operational\nGuidelines 2019.\n\n2.2.8 Recency Testing\nRecency testing refers to an anti-body-based test to distinguish recent from long-term HIV\ninfection using antibody avidity (binding strength). The recency test kit is used to indicate\nwhether a person's HIV infection was recently acquired (i.e. in the last 4-6 months). This\npromises to be a useful tool for disease monitoring and surveillance. All kits for this procedure\nshould be evaluated in line with National standards before deployment or public health use after\npost-market validation. This test should be done immediately after the client tests positive using\nthe National testing algorithm.\n\n2.3 HTS in Pregnancy\nThe entry-point for PMTCT services is through HIV testing of pregnant women at the earliest\nopportunity; during antenatal care, labour and delivery including post-partum. In all settings,\nHTS should be offered to all pregnant women seeking antenatal care. Retesting for HIV in late\npregnancy and early in labour is recommended for pregnant women who tested negative in early\npregnancy.\n\n2.3.1 Approach to HTS in Pregnant Women\nHIV testing of pregnant women should be accompanied by culturally acceptable counselling\nthat highlights the benefits of knowing one's HIV status and its implications for the woman's\nhealth, pregnancy and the unborn child. The elements of effective counselling are\nconfidentiality, timeliness, acceptance, accessibility, consistency and accuracy.\n\nThe recommended approach to testing and counselling is the routine approach (also referred to\nas the PITC \u201copt-out\u201d approach) where HIV testing is offered as part of routine tests in antenatal\nclinics. The pregnant woman reserves the right to refuse the test.\n\n2.3.2 Essential Components of HTS for PMTCT\nThese include:\n     \u00a7     Pre-test information\n     \u00a7     HIV testing with same-day result\n     \u00a7     Post-test counselling\n     \u00a7     Follow-up counselling\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          14", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2946, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "0bba6380-6ad8-472f-9350-9bc633fbd647": {"__data__": {"id_": "0bba6380-6ad8-472f-9350-9bc633fbd647", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "a11473a2-bc3e-454f-a7bf-368cfb5d461f", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "8a618e9ee653c0f2813be3b9c7990a93e859a02709fd1dcbd616ecae4496d24a", "class_name": "RelatedNodeInfo"}}, "text": "Women should be encouraged to start antenatal care early (within first trimester from 14 weeks\nof pregnancy) and HTS should be provided during the first ANC visit.\n\n2.3.3 HTS for women in labour\nHIV testing in labour should be provided for all women of unknown HIV status and those who\ntested negative during pregnancy. This is because some women might not have registered in the\nantenatal clinic and are presenting for the first time in labour. Such women should be offered the\nopt-out approach and given appropriate post-test counselling in the post-partum period or pre-\ntest counselling if she had declined the test. The following steps should be taken:\n     \u00a7     Determine HIV test history\n     \u00a7     Discuss the benefits of HIV testing and ART\n     \u00a7     Explain the HIV testing process\n     \u00a7     Offer the test\n\nIf the above is not feasible at the time the woman presents, steps should be taken to offer the test\nas soon as possible after delivery.\n\n2.3.4 HTS for post-partum women\nTo reduce the number of new paediatric infections, additional efforts are required to reduce\nmother to child transmission post-partum (especially during breastfeeding). Breastfeeding\nmothers of unknown HIV status and those who tested negative during pregnancy should be\ncounselled and assessed to determine exposure and offered testing if indicated at the 6-week\ninfant immunization visit. If negative, breastfeeding mothers should be retested at 6-month\nintervals until the cessation of breastfeeding. Counselling on the HIV retesting schedule both in\npregnancy and the postpartum period should be integrated into routine ANC and postnatal\neducation.\n\n2.4 Re-testing\nWith the advent of the \u201cTest and Treat\u201d policy in Nigeria, all HIV-positive persons are now\neligible to receive ART, regardless of CD4+ cell count. To ensure that individuals are not\nneedlessly placed on life-long ART (with potential side-effects, waste of resources,\npsychological impact of misdiagnosis), all individuals should be retested to verify their HIV\nstatus before or at the time of starting ART. Misdiagnosing HIV infection, irrespective of its scale\nis of critical importance. Any incorrect diagnosis, whether false-positive or false-negative has\nsevere personal and public health consequences and should be prevented.\n\nRetesting should be conducted by a different provider using the same testing algorithm with a\nnew specimen. Retesting should be conducted at a different site, ideally, the site where the\ndecision about ART initiation will be made. Retesting according to this procedure aims to rule\nout possible technical or clerical errors, including specimen mix-up through mislabelling and\ntranscription errors, as well as random error either by the provider or of the test device.\n\n2.5 Repeat HIV Testing\nIf an antibody only test is negative, repeat HIV testing should occur at 6 weeks, 3 months and 6\nmonths following the exposure. The following scenarios are applicable for repeat HIV testing.\n     \u00a7     Window period: Post-test counselling messages should include a recommendation that\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          15", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3174, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c0abc1ff-087c-474b-b1c1-9d95f3c96067": {"__data__": {"id_": "c0abc1ff-087c-474b-b1c1-9d95f3c96067", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "be6ca9a8-624b-461b-8294-c98d4cb4f5a2", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "9d521ea7ffd70323bebbc0bcd25dc2b11d6c2bb145253ff9bd1987231e425ad9", "class_name": "RelatedNodeInfo"}}, "text": "HIV-negative persons retest in 3 months to rule out acute infection that is too early for\n          rapid HIV tests to detect\u2014in other words, the window period.\n     \u00a7    General Population: HIV-negative persons from the \u201cgeneral population\u201d with low or no\n          risk of infection should not be advised to retest after three months, but rather they should\n          be retested annually, or as indicated by their risk of exposure. Providers should help HIV-\n          negative clients feel confident in their HIV test results and support them to stay HIV-\n          negative by linking them with appropriate follow-up prevention services.\n     \u00a7    Persons with Ongoing High Risk: In some instances, HIV-negative clients will require\n          more frequent retesting. Persons who are diagnosed HIV-negative but are at ongoing\n          high risk, such as some people from key populations, may benefit from retesting every\n          three to six months. This may help ensure early HIV diagnosis and ongoing health\n          education about HIV prevention.\n\n2.6 Disclosure Scenarios\nPeople who test HIV-negative may not need assistance or support with disclosing their HIV\nstatus to others, but maintaining privacy about testing HIV-positive, and deciding whom they\nshould disclose to, are concerns for many people who test HIV-positive. Disclosure can help\nclients get emotional support to cope with a new diagnosis and can encourage access and\nadherence to ART. Providers should support clients to disclose to persons in their life who care\nabout their health and well-being.\n\nDisclosure is not mandatory, and providers should assess the risk of intimate partner violence to\ntheir clients and make referrals to appropriate services as needed.\n     \u00a7    Disclosure to partners who may be at risk of HIV and who need to be tested is also\n          important for the partner's health and well-being and should be supported through couple\n          HIV counselling and testing or partner notification services as described in the National\n          HTS Guidelines 2017.\n     \u00a7    In the event where efforts to encourage the client to disclose their HIV status fail, and if\n          the client is placing a sexual partner(s) or other persons at risk, a service provider may\n          disclose that person's HIV status to their sex partner(s) or other people at risk. However,\n          persons must be given a reasonable opportunity to disclose their HIV status to the sexual\n          partner(s) on their own before the service provider intervenes.\n     \u00a7    In some situations, a provider may disclose a client's HIV-positive results to another\n          medical provider involved in the client's care, to ensure the client receives appropriate\n          medical care. Such disclosure should respect the client's right to privacy and\n          confidentiality.\n\n2.7 Linkage of HTS to care and ART\nFollowing an HIV diagnosis, a package of support interventions should be offered to ensure\ntimely linkage to care for all PLHIV. The following interventions should be used in improving\nlinkage to care:\n     \u00a7     Enhanced linkage with case management\n     \u00a7     Support for HIV disclosure\n     \u00a7     Patient tracking for those who failed to enroll in care\n     \u00a7     Training staff to provide multiple services\n     \u00a7     Streamlined services to accelerate time to initiation\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                            16", "mimetype": "text/plain", "start_char_idx": 10, "end_char_idx": 3493, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "0e82d153-d375-4d1c-94db-0bf657a65e7e": {"__data__": {"id_": "0e82d153-d375-4d1c-94db-0bf657a65e7e", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "e3695279-7836-44e7-94d5-de6549c1c9bd", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "8d4ca6604f9bee297630a479f51bb3a7ca12ac17020f227c14917e3f4b543ab0", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7     Peer support and navigation approaches for linkage and\n    \u00a7     Quality improvement approaches using data to improve linkage\n\n2.8 Laboratory Diagnosis of HIV Infection\nLaboratory diagnosis of HIV infection is based on the demonstration of antibodies in plasma or\nserum (indirect testing) or of the viral nucleic acid in the blood (direct testing). With the\ntechnology that is available at present, HIV antibodies are usually detectable within four to six\nweeks of infection, and within 24 weeks in virtually all infected individuals. The virus can be\ndemonstrated in the blood with nucleic acid-based tests (PCR for proviral HIV DNA and RT-\nPCR for plasma viral RNA) and viral culture.\n\n2.8.1 Antibody Assays\nAntibody testing is performed with serial or parallel testing algorithms using rapid test kits\n(RTK). Screening tests include Enzyme-linked Immunosorbent Assay (ELISA), which is mainly\nused in blood banks.\n\nHIV Rapid Testing Algorithm\nSerial and parallel testing algorithms are the two HIV testing algorithms. The algorithm\nrecommended for routine HIV testing is the serial HIV testing algorithm. Rapid test kits (RTKs)\nrecommended for use under this algorithm include Determine, Unigold, Stat-Pak, Double-check\nGold, Sure-Check, and HIV Quick Check among others. HIV serological assays adopted for use\nshould have a minimum sensitivity of 99% and specificity of 98%. All test kits meeting these\nconditions should be approved by the Honorable Minister of Health following formal evaluation\nby appropriate government agencies. All groups and organizations wishing to procure test kits\nfor use in the country should adhere to the approved RTKs. Similarly, all newly procured batches\nof RTKs should undergo Post-Market Validation (PMV) duly endorsed by the national and State\nHIV Program.\n     \u00a7    Serial testing: This is the use of 2 different screening tests employed sequentially to test\n          for HIV antibody. If the initial screening is negative, no further testing is required. If the\n          initial test is positive, it is followed by a second test. The first test should be the most\n          sensitive test and the second test should be very specific and based on an antigen source\n          different from that of the first test. Samples that produce discordant results in the two\n          tests are subjected to a third test called a tiebreaker. The main advantage of the serial over\n          parallel testing is the cost-savings in testing.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                              17", "mimetype": "text/plain", "start_char_idx": 4, "end_char_idx": 2590, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "af444b99-0f38-4d6b-ab5a-67921e649d21": {"__data__": {"id_": "af444b99-0f38-4d6b-ab5a-67921e649d21", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "3b6e1b4c-a6e4-4af1-a464-7ee2e01db7d2", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "ed6285433e078b3603d6b132caa6bdd69a98414db26a112c4d5446ccddf66437", "class_name": "RelatedNodeInfo"}}, "text": "Figure 2.2 Serial Testing Algorithm\nKey:\nTest 1: Screening\nTest 2: Confirmatory\nTest 3: Tie Breaker\n\n2.8.2 Enzyme-Linked Immunosorbent Assay (ELISA) or Enzyme Immunoassay (EIA) for\nBlood Screening\nThis test detects HIV antibodies, which the body starts producing between 2-12 weeks after\nbecoming infected with HIV. Current HIV antibody test can detect antibodies as early as 3 weeks\nafter exposure. ELISA test system is grouped into 1st to 4th generation. While all can detect HIV\nantibody as early as 3 weeks, the 4th generation can detect both IgG and IgM antibodies, HIV-\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                       18", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 678, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "561e02b6-f32c-470b-bc69-dde90b925212": {"__data__": {"id_": "561e02b6-f32c-470b-bc69-dde90b925212", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "fc3303fc-ac36-4f02-9423-07ef3845a0bf", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "0457cd8d6b5246e18cd83da5c663e42cacd9b0cf88c461c683b958631ccb0201", "class_name": "RelatedNodeInfo"}}, "text": "1/HIV-2 antibodies and also p24 antigen. This makes the 4th generation more suitable for blood\ntransfusion screening for HIV.\n\n2.8.3 Nucleic Acid-based Testing\nThis consists of DNA Polymerase Chain Reaction (DNA-PCR) and Reverse Transcriptase\nPolymerase Chain Reaction (RT-PCR). These tests are not routinely used for laboratory\ndiagnosis of HIV infection in adults and adolescents. Nucleic acid tests are virologic assays that\ndetect, confirm and measure the number of viral particles in the blood. It is recommended that\nvirologic assays used for clinical diagnostic testing (usually at birth, 6-8 weeks of age and below\n18 months of age) should have a sensitivity of >95% and a specificity of >98% under quality-\nassured, standardized and validated laboratory conditions.\n\n2.8.4 HIV DNA Polymerase Chain Reaction (PCR)\nThe HIV DNA-PCR test involves the amplification of specific DNA sequences in the proviral\nDNA that has been integrated into the host cell. This test is the preferred option for diagnosing or\nconfirming HIV infection in infants less than 18 months of age. However, false-positive results\nmay occur as a result of contamination or improper specimen handling. There is a need therefore\nto always ensure quality assurance and validation procedures in the laboratory.\n\n2.8.5 Viral Load Assay- Reverse Transcriptase Polymerase Chain Reaction (RT-PCR)\nViral load RT-PCR test is used to detect and quantify the amount of HIV RNA in plasma, Dried\nBlood Spot (DBS) and plasma separation cards. The assay requires the conversion of viral RNA\nto DNA and amplification of specific sequences in the DNA produced by a process known as\nreverse transcriptase polymerase chain reaction (RT-PCR). Results are reported in copies/ml of\nplasma.\n\nSample Referral System: VL and EID samples are moved from areas without PCR laboratories\nto testing laboratories in the optimized networks and results returned by the National Integrated\nSample Referral Network (NISRN). Clinical sample types have been expanded from the\ntraditional whole blood EDTA-plasma and DBS for VL to include Plasma Separation Card\n(PSC) and Plasma Preparation Tubes (PPT) to facilitate improved viral load quantification\ntesting, equitable viral load access for both clinic and community service-points across Nigeria\nthrough ease of handling, storage and transportation. All the standard of care PCR laboratories\nshould be linked to the National Laboratory Information Management Systems (LIMS) which is\nin turn linked to Nigeria Medical Records System (NMRS) and National Data Repository (NDR)\nfor real-time reporting of patients results into the health facility records and health repository.\nPoint of Care Testing (POCT) devices are being introduced into the HIV program to further\nensure equitable viral load access to key populations: paediatrics, pregnant/breastfeeding\nmothers, MSM, FSW, PWID; hard-to-reach communities, security challenged and other settings\nto bring testing closer to the clients, enhance effective viral load coverage and quick Turnaround\nTime (TAT) of results for clinical management of patients. Capacity development and Quality\nAssurance (QA) oversight will be provided quarterly by experts supporting the standard of care\nlaboratories. All the POCT devices for viral load will participate in National EQA supported by\nthe National Reference Laboratory/National External Quality Assurance Lab. This is to ensure\nquality assured results are produced from these devices and are useful for the management of\npatients.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          19", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3621, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "9c1f1ce7-c95a-4859-b203-a51bb2d97349": {"__data__": {"id_": "9c1f1ce7-c95a-4859-b203-a51bb2d97349", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "1dcf6d9f-bb16-4026-8d6b-81d85592b973", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "8555fc0be54958e8073a0e0e1224181ffebc3fc1b7c4b435837f19d0e20f5342", "class_name": "RelatedNodeInfo"}}, "text": "2.9 Laboratory Diagnosis of HIV Infection in Children by Age Group\n\n2.9.1 Children aged \u226418 months\nNucleic Acid Amplification Testing (NAAT) or Nucleic Amplification Testing (NAT) to detect\nDNA - can be used to detect HIV infection in neonates at birth, 6-8 weeks and 9 months. Testing\nat birth will plug the gap of loss to follow up between birth and 6 months. Exposed infants are\nbrought into care as early as possible to reduce morbidity and mortality. NAAT has a specificity\nof 99.6% and sensitivity of 100% for infants infected during pregnancy or at least 4 weeks prior\nto sample collection for testing. However, there is a need for follow-up testing at 6 weeks, 9\nmonths and 6 weeks after cessation of breastfeeding at a standard of care laboratory because of\nthe possibility of a false positive or negative result.\n\nPolymerase Chain Reaction (PCR) should be used for the detection of HIV DNA in children\nbetween the ages of 6 weeks to 18 months. Standard PCR laboratories available as referral\nnetwork in the six geopolitical zones of Nigeria will support EID testing and return of results\nback to facilities through the linkage of Laboratory Information Management Systems (LIMS)\nto EMR platform.\n    \u00a7     All HIV\u2013 exposed infants should have initial DNA PCR testing at 0-3 days of age, then at\n          6-8 weeks of age (or earliest opportunity thereafter) and 6 weeks after complete\n          cessation of breastfeeding. DNA PCR test results should be provided to the clinic and\n          caregiver as soon as possible; latest within four weeks of specimen collection.\n    \u00a7     HIV- exposed children 9 -18 months of age may have circulating maternal antibodies\n          which could be from the child and/or the mother. In this case, DNA or RNA PCR is the\n          test of choice for a definitive diagnosis.\n    \u00a7     If a screening antibody test is negative, HIV-infection is excluded if the test has been\n          conducted at least 6 weeks after complete cessation of breastfeeding.\n    \u00a7     For sick children <18 months in whom HIV infection is being considered, in the absence\n          of virological tests (DNA-PCR), HIV serological testing (RTKs) and use of the\n          algorithm (WHO clinical staging) for presumptive clinical diagnosis are recommended.\n    \u00a7     In a child <18 months with an initial positive virological test result, it is recommended\n          that ART should be started immediately, while a second specimen is collected to confirm\n          the result. It is not advised to defer ART until the confirmation result is received.\n    \u00a7     HIV-exposed infants who are well should undergo HIV serological testing at 9 months of\n          age (or at the time of last immunization visit).\n    \u00a7     Infants who have reactive serological assays at 9 months should have an immediate\n          virological test to confirm HIV infection and the need for ART.\n    \u00a7     It is strongly recommended that children <18 months of age, with signs and symptoms\n          suggestive of HIV infection should undergo HIV serological testing in a setting where\n          DNA-PCR is not immediately available and if positive (reactive), do a DNA PCR test or\n          NAAT.\n    \u00a7     NAT technologies that are developed and validated for use at or near to the point of care\n          can be used for early infant HIV testing.\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          20", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3456, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "b30b542f-a844-4320-905c-0a914d0744da": {"__data__": {"id_": "b30b542f-a844-4320-905c-0a914d0744da", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "76e3e952-91cd-4ff4-a3e3-5fc02a4e0e88", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "031ced580d002ed47355a8a3493694b2de3f027a0495fadbf45db01a5ab2e138", "class_name": "RelatedNodeInfo"}}, "text": "POSITIVE                   NEGATIVE\n                           POSITIVE                   NEGATIVE\n                                           NEGATIE\n                                                                              POSITIVE\n                                                            POSITIVE            NEGATIVE\n\nFigure 2.3: Nigeria diagnostic testing protocol: HIV-exposed infants (< 18 months of age)\n\n\n\n    NEGATIVE\n\nPOSITIVE           NEGATIVE\n\n\n                                      NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  21", "mimetype": "text/plain", "start_char_idx": 27, "end_char_idx": 595, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c0d4a4d2-3d6a-4851-9d71-f712954a76ea": {"__data__": {"id_": "c0d4a4d2-3d6a-4851-9d71-f712954a76ea", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "1c484768-8672-4e11-936a-783ba08a850c", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "f24a12727ab64eb8eaece43a7e6fa3e89e418316f1f676529a5e313b3bea26f9", "class_name": "RelatedNodeInfo"}}, "text": "2.9.2 Children aged \u226518 months\n     \u00a7     Antibody detection is reliable and recommended for children \u226518 months. The\n           exception is during the window period (6-8 weeks post-exposure) where antibodies may\n           not be present at a detectable level. For children testing negative, a repeat antibody\n           testing 3 months later is recommended if the window period is suspected.\n     \u00a7     From 18 months of life, an antibody test should be performed irrespective of whether a\n           child received breast milk or replacement feeds.\n     \u00a7     If the child is receiving breast milk after 18 months of age, repeat the test 12 weeks after\n           complete cessation of breastfeeding.\n     \u00a7     Methods such as DNA/RNA PCR could be used to resolve suspected false-negative\n           result.\n\n2.10 Clinical Diagnosis and Staging of HIV Infection\nThe WHO clinical staging of HIV for adults and adolescents that are HIV positive is as shown in\nTables 2.1 and 2.2. Staging is based on the patient's clinical presentation at the time of initial\nassessment with the healthcare provider. The most advanced symptoms at the time of evaluation\nrepresent the initial clinical stage of HIV infection.\n\nTable 2.1 WHO Clinical Classification of Established HIV Infection\n\n       HIV - Associated Symptomatology                                           WHO Clinical Stage\n     Asymptomatic                                                                                1\n     Mild Symptoms                                                                               2\n     Advanced Symptoms                                                                           3\n     Severe Symptoms                                                                             4\n\nThe staging systems include.\n    \u00b7      Presumptive clinical diagnoses that can be made in the absence of laboratory tests\n    \u00b7      Definitive clinical criteria that require confirmatory laboratory tests\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                             22", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2092, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "7f3474f8-133c-4ba2-b629-a18c23b06a70": {"__data__": {"id_": "7f3474f8-133c-4ba2-b629-a18c23b06a70", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b41ddfc7-5cbe-426f-bfed-1046b5708ecc", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "53b5fb5449f6f44a9bbc79c9d90979f7c670e185877f9a7519f100fd11960c63", "class_name": "RelatedNodeInfo"}}, "text": "Table 2.2 WHO Clinical Staging of HIV/AIDS for Adults and Adolescents with confirmed HIV Infection\n Adults and adolescentsa                                           Children\n   Clinical stage 1\n  \u2022 Asymptomatic                                                   \u2022 Asymptomatic\n  \u2022 Persistent generalized lymphadenopathy                         \u2022 Persistent generalized lymphadenopathy\n   Clinical stage 2\n  \u2022 Moderate unexplained weight loss (<10% of                      \u2022 Unexplained persistent hepatosplenomegaly\n      presumed or measured body weight)                            \u2022 Recurrent or chronic upper respiratory tract infections\n  \u2022 Recurrent respiratory tract infections                            (otitis media, otorrhoea, sinusitis, tonsillitis)\n      (sinusitis, tonsillitis, otitis media,                       \u2022 Herpes zoster\n      pharyngitis)                                                 \u2022 Lineal gingival erythema Recurrent oral ulceration\n  \u2022 Herpes zoster Angular cheilitis                                   Papular pruritic eruption Fungal nail infections\n  \u2022 Recurrent oral ulceration Papular pruritic                        Extensive wart virus infection\n      eruption Fungal nail infections Seborrhoeic                  \u2022 Extensive molluscum contagiosum\n      dermatitis                                                   \u2022 Unexplained persistent parotid enlargement\n   Clinical stage 3\n  \u2022 Unexplained severe weight loss (>10% of                        \u2022  Unexplained moderate malnutritionb not adequately\n      presumed or measured body weight)                               responding to standard therapy\n  \u2022 Unexplained chronic diarrhoea for longer                       \u2022  Unexplained persistent diarrhoea (14 days or more)\n      than 1 month                                                 \u2022  Unexplained persistent fever (above 37.5\u00b0C,\n  \u2022 Unexplained persistent fever (intermittent or                     intermittent or constant, for longer than one 1 month)\n      constant for longer than 1 month)                            \u2022  Persistent oral candidiasis (after first six weeks of\n  \u2022 Persistent oral candidiasis Oral hairy                            life) Oral hairy leukoplakia\n      leukoplakia Pulmonary tuberculosis                           \u2022  Lymph node tuberculosis; pulmonary tuberculosis\n  \u2022 Severe bacterial infections (such as                              Severe recurrent bacterial pneumonia\n      pneumonia, empyema, pyomyositis, bone or                     \u2022  Acute necrotizing ulcerative gingivitis or\n      joint infection, meningitis, bacteraemia)                       periodontitis\n  \u2022 Acute necrotizing ulcerative stomatitis,                       \u2022  Unexplained anaemia (<8 g/dL), neutropaenia (<0.5\n      gingivitis or periodontitis                                     \u00d7 109/L) or chronic thrombocytopaenia (<50 \u00d7\n  \u2022 Unexplained anaemia (<8 g/dl),                                    109/L)\n      neutropaenia (<0.5 \u00d7                                         \u2022  Symptomatic lymphoid interstitial pneumonitis\n  \u2022 109/L) and/or chronic thrombocytopaenia                        \u2022  Chronic HIV-associated lung disease, including\n      (<50 \u00d7 109/L)                                                   bronchiectasis\n   Clinical stage 4c\n\n                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                23", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3423, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "f3e1bf24-d778-4490-b7cd-30377dcf6b4f": {"__data__": {"id_": "f3e1bf24-d778-4490-b7cd-30377dcf6b4f", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "4b26d273-248d-49c9-a26e-1ef50fecbc3b", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "730ae223071f15ce69d4562f9432466fceb13cc9f4f16a30db6b17e45209d72e", "class_name": "RelatedNodeInfo"}}, "text": "\u2022 HIV wasting syndrome                                           \u2022 Unexplained severe wasting, stunting or severe\n  \u2022 Pneumocystis (jirovecii) pneumonia                                malnutritiond not responding to standard therapy\n      Recurrent severe bacterial pneumonia                         \u2022 Pneumocystis (jirovecii) pneumonia\n  \u2022 Chronic herpes simplex infection                               \u2022 Recurrent severe bacterial infections (such as empyema,\n      (orolabial, genital or anorectal of more                        pyomyositis, bone or joint infection, meningitis, but\n      than one month in duration or visceral at                       excluding pneumonia)\n      any site)                                                    \u2022 Chronic herpes simplex infection (orolabial or cutaneous\n  \u2022 Oesophageal candidiasis (or candidiasis                           of more than 1 month\u2019s duration or visceral at any site)\n      of trachea, bronchi or lungs)                                \u2022 Oesophageal candidiasis (or candidiasis of trachea,\n  \u2022 Extrapulmonary tuberculosis Kaposi                                bronchi or lungs)\n      sarcoma                                                      \u2022 Extrapulmonary tuberculosis Kaposi sarcoma\n  \u2022 Cytomegalovirus infection (retinitis or                        \u2022 Cytomegalovirus infection (retinitis or infection of other\n      infection of other organs)                                      organs with onset at age older than one month)\n  \u2022 Central nervous system toxoplasmosis                           \u2022 Central nervous system toxoplasmosis (after the neonatal\n      HIV encephalopathy                                              period)\n  \u2022 Extrapulmonary cryptococcosis,                                 \u2022 HIV encephalopathy\n      including meningitis                                         \u2022 Extrapulmonary cryptococcosis, including meningitis\n  \u2022 Disseminated nontuberculous                                    \u2022 Disseminated nontuberculous mycobacterial infection\n      mycobacterial infection\n  \u2022 Progressive multifocal                                         \u2022 Progressive multifocal leukoencephalopathy\n      leukoencephalopathy                                          \u2022 Chronic cryptosporidiosis (with diarrhoea) Chronic\n  \u2022 Chronic cryptosporidiosis Chronic                                 isosporiasis\n      isosporiasis                                                 \u2022 Disseminated endemic mycosis (extrapulmonary\n  \u2022 Disseminated mycosis (extrapulmonary                              histoplasmosis, coccidioidomycosis, penicilliosis)\n      histoplasmosis, coccidioidomycosis)                          \u2022 Cerebral or B-cell non-Hodgkin lymphoma HIV-\n  \u2022 Lymphoma (cerebral or B-cell non-                                 associated nephropathy or cardiomyopathy\n      Hodgkin)\n  \u2022 Symptomatic HIV-associated\n      nephropathy or cardiomyopathy\n  \u2022 Recurrent septicaemia (including\n      nontyphoidal\n  \u2022 Salmonella)\n  \u2022 Invasive cervical carcinoma Atypical\n      disseminated leishmaniasis\na In the development of this table, adolescents were defined as 15 years or older. For those younger than 15 years, the clinical staging for children\nshould be used.\nb For children younger than 5 years, moderate malnutrition is defined as weight-for-height < \u20132 z-score or mid-upper arm circumference 115\nmm to <125 mm.\nc Some additional specific conditions can be included in regional classifications, such as penicilliosis in Asia, HIV-associated rectovaginal\nfistula in southern Africa and reactivation of trypanosomiasis in Latin America.\nd For children younger than five years of age, severe wasting is defined as weight-for-height < \u20133 z-score; stunting is defined as length-for-\nage/height-for-age < \u20132 z-score; and severe acute malnutrition is either weight for height < \u20133 z-score or mid-upper arm circumference <115\nmm or the presence of oedema.\nSource: Adapted from: WHO case definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-\nrelated disease in adults and children. Geneva, World Health Organization, 2007 (www.who.int/hiv/pub/guidelines/HIVstaging150307.pdf).\n\n                 NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                            24", "mimetype": "text/plain", "start_char_idx": 2, "end_char_idx": 4335, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "0cc7b718-e77a-4fa9-b575-d440736b1630": {"__data__": {"id_": "0cc7b718-e77a-4fa9-b575-d440736b1630", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "0e46b13d-06b4-47b8-aad7-967f80dcf3ac", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "ba233474e8f689108d2fc5bfc0000ac72c714a6291161dfe1b9267e19d2936b6", "class_name": "RelatedNodeInfo"}}, "text": "List of Contributors\n Mrs Grace Mfon Bassey\n Mrs Ima-Dada John\n Mrs Katherine Igbosofulu\n Mr Envuladu Ovye\n Mrs Etubi Eruona\n Okorie Uche\n Samson Omoighe\n James Yohanna\n Agba Janet C\n Dr Rex Mpazanje\n Adegoke Olufemi Dickson\n Okoye McPaul\n Dr Jerry Gwamna\n Chidozie Meribe\n Dr Aminu Suleiman\n Dr Yusuf Ahmed\n Angela Agweye\n Kingston Omo-Emmanuel\n Mrs Pamela Nenpanmwa Gado\n Jibrin Kama\n Aisha Ejigbo\n Obed Ikechukwu Nnamdi\n Chinelo Ekweremadu\n Chris Ogar\n Abutu Abraham.E.\n Mr Mark Akhigbe\n Fortune Kailo\n Dr Ali Onoja\n Mr Manason Rubainu\n                                                   Chapter 2\nAssistant.Director, Head LAB NASCP\nAssistant Director, Head HTS NASCP\nAssistant Director, ACSM NASCP\nChief Science Lab. Technologist NASCP\nACMLS, Treatment, Care and Support NASCP\nSenior Medical Laboratory Scientist NASCP\nScientific officer 1 NASCP\nScientific Officer/PDA NASCP\nAD MLS NTBS/FMOH\nHIV Adviser WHO\nLaboratory Systems Specialist CDC\nLaboratory Branch Chief/Project Officer CDC\nPrevention Branch Chief CDC\nSenior Program Specialist HTS CDC\nLab Lead US DoD\nPrevention Team Lead US DoD\nProject Management Specialist Testing and Linkages USAID\nClinical Laboratory Manager USAID\nHIV Testing Services Programme Manager USAID\nSenior Program Manager CHAI\nSenior Analyst CHAI\nLaboratory Quality Assurance/LMIS Specialist SFH\nSenior Technical Specialist CRS\nMSH\nMonitoring & Evaluation Officer NEPWHAN\nLaboratory Advisor Heartland Alliance\nNational Coordinator APYIN\nCEO African Health Project\nCEO Peak Medical Laboratories\n\n                               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  25", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1624, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "cbf4cd4a-ea76-453c-89c2-92232040c4e6": {"__data__": {"id_": "cbf4cd4a-ea76-453c-89c2-92232040c4e6", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "8cc3126d-9554-4860-b2dc-8b10a93112ff", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "767c4709ca1632c102c18f45032e9c074701d3aad1a918e0e3ca38540614537d", "class_name": "RelatedNodeInfo"}}, "text": "3. ANTIRETROVIRAL\n                      THERAPY\n\n What\u2019s Inside:\n3.1 Introduction\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u202627\n 1.1 Objectives of the Guidelines\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\n3.2 Classes of Antiretroviral Drugs\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u202627\n 1.2 Epidemiology of HIV in Nigeria\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\n3.3. Preparation of Adults, Adolescents and\n 1.3 Natural History of HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\n    Children for ART\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u2026....29\n3.4 Recommended ART Regimen for Adults,\n    Adolescents and Children\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u202623\n3.5 Monitoring Patients on ART\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u202634\n3.6 Management of HIV Treatment Failure\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.37\n3.7 Third-line ART\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.42\n3.8 Low-Level Viremia (LLV) \u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026..43\n3.9 ART in Special Circumstances\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026.....44", "mimetype": "text/plain", "start_char_idx": 13, "end_char_idx": 724, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "acf15b45-89c3-4b6c-9b22-65ac9ab5b73d": {"__data__": {"id_": "acf15b45-89c3-4b6c-9b22-65ac9ab5b73d", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "2316e695-883a-4e52-90ae-8891ccc28d27", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "c89ab81e7c936fe207c3308fbea860b73ad6452726ab31e3047574908e6ffb74", "class_name": "RelatedNodeInfo"}}, "text": "3.1 Introduction\nAntiretroviral therapy (ART) is the treatment of HIV infection using a combination of\nantiretroviral drugs (ARVs). All HIV infected persons irrespective of clinical stage and CD4+\ncell count without contraindications should be initiated the same day or within 7 days of HIV\ndiagnosis if possible. Pregnant and breastfeeding women, infants and children under 5 years, and\npatients with advanced HIV disease (AHD) should be prioritized for rapid initiation of ART.\nAntiretroviral therapy (ART) should be offered in a comprehensive manner that includes access\nto on-going adherence counselling, baseline and periodic clinical and laboratory monitoring,\nprevention and management of opportunistic infection (OIs), treatment monitoring and follow-\nup.\n\nThe goal of ART includes achievement of sustained virologic, immunologic, clinical, and\nepidemiologic control of HIV. Sustained viral suppression is necessary to prevent the\ndevelopment of ARV drug resistance, reduce morbidity from OIs and improve the quality of life\nof HIV infected individuals. In children, ART will promote and restore normal growth and\ndevelopment.\n\n3.2 Classes of Antiretroviral Drugs\nAntiretroviral drugs (ARVs) are classified according to their modes of action. Each class targets\na different step in the viral life cycle. The classes of antiretroviral drugs are:\n\nNucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs): These compete with host\nnucleotides to serve as the substrate for reverse transcriptase chain elongation. Absence of 3'OH\ngroup on sugar moiety prevents the addition of another nucleotide, resulting in chain\ntermination, abortion of viral DNA chain elongation and cessation of viral replication.\n\nNon-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): Inhibit HIV reverse\ntranscriptase by binding a hydrophobic pocket close to the active site thereby locking the site in\nan inactive conformation.\n\nProtease Inhibitors (PI): Inhibit HIV protease by binding to its active site, preventing the\ncleavage of gag and gag-pol precursor. Virions are produced but they are incomplete and non-\ninfectious.\n\nEntry Inhibitors: Block the mechanisms by which HIV gains access into the cytoplasm of\nCD4+ cell molecule bearing cell. There are 3 classes:\n     (a) Attachment inhibitors: These agents complex with glycoprotein 120 and prevent it from\n          interacting with the CD4+ molecule thus, the attachment of the virus to the cell is\n          blocked.\n     (b) Fusion inhibitors: These are agents designed to complex with the viral GP41. GP41 is\n          the viral protein that is capable of fusing with cellular membrane molecules called\n          chemokine receptors. The interaction of fusion inhibitors with GP41 blocks the fusion\n          of viral membrane with cellular membrane.\n     (c) Chemokine Receptor Antagonists: These are agents that complex with cell membrane\n          receptors that serve as fusion proteins i.e. CXCR4, CCR5.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                        27", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3064, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ece5e8f9-7b87-4fe2-8ca5-4e82a3261183": {"__data__": {"id_": "ece5e8f9-7b87-4fe2-8ca5-4e82a3261183", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "2132ff62-acf2-45ff-bf42-f5b08985ffe7", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "5422b336ac271def6ede100519d03efacf9723a37e77599fcc5aeb9765839cb8", "class_name": "RelatedNodeInfo"}}, "text": "HIV Integrase Inhibitors: Also known as Integrase Strand Transfer Inhibitors (INSTI). These\n                   inhibit DNA strand transfer into the host-cell genome and thus prevent viral integration.\n                   Integrase Inhibitors do not confer resistance to other ART classes.\n\n                   Pharmacokinetic enhancers/ PI boosters: These are drugs used in HIV treatment to increase\n                   the effectiveness of certain classes of ARV drugs. The PIs are metabolized by cytochrome P450\n                   (CYP) 3A enzymes; and intentional inhibition of these enzymes' lead to higher drug exposure,\n                   lower pill burden and simplified dosing schedules (pharmacokinetic enhancement). In HIV\n                   therapy, two pharmacokinetic enhancers or boosting agents are used: ritonavir and cobicistat.\n                   These agents inhibit CYP3A4, with cobicistat being a more specific CYP inhibitor than\n                   ritonavir. Unlike ritonavir, cobicistat does not have antiretroviral activity.\n                   Table 3.1 Classes of Antiretroviral Drugs\n\n                     Class                                              Drugs\n\n                     Nucleoside/Nucleotide Reverse                      Abacavir (ABC); Emtricitabine (FTC); Lamivudine (3TC);\n                     Transcriptase Inhibitors (NRTIs                    Tenofovir Disoproxil fumarate (TDF); Tenofovir\n                                                                        Alafenamide (TAF); Zidovudine (AZT, ZDV); Didanosine\n                                                                        (ddI) ; Stavudine (d4T)*\n\nNon-Nucleoside Reverse\nTranscriptase Inhibitors (NNRTIs)\nProtease Inhibitors (PI)\n\n\nProtease Inhibitors (PIs) boosters\nIntegrase Strand Transfer Inhibitors\n(INSTIs)\nEfavirenz (EFV); Etravirine (ETR); Nevirapine (NVP);\nRilpivirine (RPV)\nAtazanavir (ATV); Darunavir (DRV); Lopinavir (LPV);\nFosamprenavir (FPV); Indinavir (IDV); Nelfinavir\n(NFV); Saqu inavir (SQV); Tipranavir (TPV)\nRitonavir (RTV); Cobicistat (COBI)\nDolutegravir (DTG); Elvitegravir (EVG); Raltegravir\n(RAL); Cabotegravir (CAB)\n\n                     Attachment Inhibitors                              Fostemsavir; Ibalizumab; Anti CD4 adnectin\n\n                     Fusion Inhibitors                                  Enfuvirtide; Anti-GP41 Adnectin; Combinectin\n\n                     Chemokine receptor antagonists                     Maraviroc; Vicroviroc; Cenicriviroc\n\n                   Antiretroviral Drug Combination for HIV Treatment: It is recommended that combinations\n                   of a minimum of three drugs from at least two different classes of ARVs be used for ART. These\n                   ARVs are expected to act at different points of the HIV life cycle. Typically, a backbone of 2\n                   NRTIs combined with an Integrase inhibitor, an NNRTI or a PI is used. Monotherapy or dual\n                   ARV therapy for HIV infection is not recommended for treatment because of the increased risk\n                   of development of drug resistance.\n\n                                 NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                 28", "mimetype": "text/plain", "start_char_idx": 19, "end_char_idx": 3252, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "917a5744-d60e-45ee-acc2-dbe2361f5364": {"__data__": {"id_": "917a5744-d60e-45ee-acc2-dbe2361f5364", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "8a66c412-fc7f-46de-88c5-856ed3ebcc2a", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "3e3393d3e6bc38e501dd929c4d734da7aeafb35e3c09253a676130c30d62afcd", "class_name": "RelatedNodeInfo"}}, "text": "3.3. Preparation of Adults, Adolescents and Children for ART\n\n3.3.1 Baseline Assessment for ART\nThe baseline assessment and preparation of patients for ART should include:\n    \u00a7     Re-testing for HIV to verify HIV positive status\n    \u00a7     A comprehensive history and clinical examination\n    \u00a7     Assessment of patient's readiness for initiation of ART (regimen, dosage, scheduling,\n          benefits, adverse effects, follow up, monitoring visits and age-appropriate disclosure)\n    \u00a7     Development of patient-centred adherence strategy\n    \u00a7     Baseline laboratory assessment\n\nIt is noteworthy that the first few months of therapy are important especially as certain\noccurrences during the period can influence the outcome of treatment. These include Adverse\ndrug reactions, immune reconstitution inflammatory syndrome (IRIS) and opportunistic\ninfections following commencement of treatment. These may confuse healthcare workers and\npatients leading to poor adherence and treatment failure. Patients should be warned to expect\nthese complications but reassured that they are usually transient and would abate in the course of\ntreatment. The importance of adherence for positive treatment outcomes must be emphasized\nand health care workers are encouraged to develop individualized treatment adherence plans for\neach patient. Patients should be advised that poor adherence to treatment at any time following\ninitiation of ART is associated with treatment failure, rapid development of drug resistance, ill\nhealth and possibly death. HIV positive adolescents and adults who are not willing and ready to\nstart ART should receive on-going counselling and education to promote retention in care.\n\n3.3.2 Further Baseline Assessment\nFurther baseline assessment includes:\n    1.    Complete history and physical examination: Anthropometric assessment (weight,\n          height/length, OFC, chest & mid-upper arm circumference). History of comorbidities\n          (renal, cardiovascular disease), pregnancy, anaemia, STI, prior ART use - including\n          single-dose Nevirapine, prescribed medications, drug misuse (heroin, alcohol), should\n          be documented. Social and sexual history should also be determined especially for\n          adolescents.\n    2.    Screening for TB and Hepatitis (B and C) should be done. Xpert MTB/RIF assay should\n          be used for cases of presumptive TB. Where GeneXpert equipment is not accessible or\n          specimen not available for Xpert MTB/RIF assay, PLHIV with CD4+ cell count <200\n          cells/mm3 or severely ill irrespective of CD4+ cell count should receive a urine LF -\n          LAM assay for TB diagnosis.\n    3.    Determination of nutritional, psychosocial, growth and immunization status of patient\n          (including determination of BMI for adults)\n    4.    Rectal and vaginal examination (including cervical cancer screening)\n    5.    Screen for mental health issues and substance abuse\n    6.    Screen for Non-Communicable diseases\n    7.    Determination of WHO clinical stage for HIV/AIDS\n    8.    Pregnancy assessment, family planning and counselling services, where required\n    9.    Conducting baseline laboratory assessments\nThis assessment should not delay the commencement of ART.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                        29", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3371, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "a0f35305-4795-4663-aa87-28be47f77647": {"__data__": {"id_": "a0f35305-4795-4663-aa87-28be47f77647", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "d9779b34-8027-45dc-8cb2-f4f5b576e2ad", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "25210fd07175368a300df0d351c8a1754908aee79d0e3f837b95a265afdfaf53", "class_name": "RelatedNodeInfo"}}, "text": "3.3.3 Initiating ART in Adults\nART should be initiated in all adults living with HIV without contraindications, regardless of\nWHO clinical stage and CD4+ cell count. Initiating ART early in PLHIV is associated with\nreduced mortality and ill health. Untreated HIV infection may be associated with the\ndevelopment of serious co-morbidities such as cardiovascular, kidney and liver diseases, cancers\nand mental illness. Early initiation of ART serves the useful purpose of preventing the\noccurrence of these diseases. An additional advantage of early initiation of ART is that it\nsubstantially reduces the risk of sexual transmission to HIV-negative partners.\n\n3.3.4 Initiating ART in Adolescents (10-19 years of age)\nImplementation considerations\nTo ensure that adolescents (10-19 years) achieve the goals of ART, it will require developing\nadolescent-friendly health services, appropriate provider training and implementing\nprogrammes that emphasize support for age-appropriate disclosure, adherence and retention in\ncare, including peer to peer support.\n\nHealthcare providers are advised to leverage the influence that parents and caregivers exercise\non their adolescents to improve adherence to ART. Hence, parents and caregivers should be\ninvolved in developing a treatment adherence plan for their wards.\n\nRecommendations for ART initiation in adolescents (10-19 years)\n     \u00b7    It is recommended that the implementation of early ART in adolescents should be\n          prioritized to ensure that effective and age-appropriate counselling approaches are a\n          prominent component of the ART package for this age group.\n     \u00b7    ART should be initiated in all adolescents living with HIV, regardless of WHO clinical\n          stage and at any CD4+ cell count.\n     \u00b7    Use of DTG with NRTI backbone as the preferred 1st line regimen for adolescents\n          including women of childbearing age (TDF + 3TC (or FTC) + DTG). Women should\n          however be given all necessary information to enable them make informed choices.\n     \u00b7    Adolescents with severe or advanced HIV clinical disease (WHO clinical stage 3 or 4)\n          and a CD4+ cell count of <200 cells/mm3 should be given priority for ART initiation.\n\n3.3.5 Initiation of ART in infants and children younger than 10 years of age\nART should be initiated in all children with HIV, regardless of WHO clinical stage, or at any\nCD4+ cell count. Infants and young children living with HIV are more likely to die within the\nfirst two years of life from the disease in the absence of any intervention. As they grow older the\nrisk of disease progression and mortality, in the absence of treatment, falls to rates similar to\nthose of young adults.\n\nAside from preventing illness and death in very young children, earlier initiation of ART can\nmitigate the negative effects of HIV infection on growth, pubertal and nervous system\ndevelopment.\n\n3.3.6 Recommendations for Use of ART in TB/HIV Co-infection\nThere is strong evidence that initiation of ART within two weeks of TB treatment is associated\nwith a marked reduction in overall TB-related morbidity and mortality. ART should be started in\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         30", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3264, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "26353723-d481-49ef-8d3c-3ec4e208c20d": {"__data__": {"id_": "26353723-d481-49ef-8d3c-3ec4e208c20d", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "4522b624-aa17-41ed-a8ff-944314211002", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "131290362b094739547d9b64813496518fad30a451c0c9d2a31274ca72a8c7d0", "class_name": "RelatedNodeInfo"}}, "text": "all TB patients (adults, adolescents and children) living with HIV, regardless of CD4+ cell count.\nTB treatment should be initiated first, followed by ART as soon as possible within the first 2\nweeks of treatment. This strategy will:\n     \u00a7     Simplify patient management\n     \u00a7     Improve adherence\n     \u00a7     Avoid ARV and TB drug interactions\n     \u00a7     Avoid overlapping toxicities\n     \u00a7     Minimize the risk of immune reconstitution inflammatory syndrome (IRIS)\n     \u00a7     Reduces the confusion over which drug (ARV or Anti-TB) to take first\n\n3.3.7 Key considerations when treating PLHIV with TB:\n     a.    Patients on ART who develop TB should have the ARVs reviewed to accommodate the\n           use of Rifampicin in the anti-TB regimen.\n     b.    For patients on a PI-based initial or subsequent ART regimen, rifabutin should be\n           substituted for rifampicin.\n     c.    Rifampicin significantly lowers the plasma concentration of DTG therefore a double\n           dose of DTG should be used (Give DTG 50 mg twice daily if rifampicin is being used as\n           the anti-TB regimen).\n     d.    Efavirenz cannot be used with Bedaquiline (BDQ) among PLHIV with drug-resistant\n           TB (DR-TB), as it decreases the concentration of BDQ. Nevirapine or DTG is\n           considered the best option for treatment of DR-TB with BDQ - based regimen.\n     e.    In the treatment of DR-TB, Delamanid is generally considered safe to be administered\n           with all ARVs.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                        31", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1595, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "7395f8df-7217-47f6-aac4-da0c007d6fe2": {"__data__": {"id_": "7395f8df-7217-47f6-aac4-da0c007d6fe2", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "edebafe2-2439-4991-82f0-b9d98f808091", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "4bcad398f16a1eb73ebc68c192e6ad6692f3331fcecb52175316265c2555eb33", "class_name": "RelatedNodeInfo"}}, "text": "Table 3.2: Scenarios for the management of TB/HIV co-infected patients\n\n                                          Scenario                   Action\n\n                     Newly registered TB patients                    \u00b7    Start TB treatment regimen immediately\n                     diagnosed with HIV                              \u00b7    Commence ART within 2 weeks of anti TB (irrespective\n                                                                          of the CD4+ cell count)\n                                                                     \u00b7    Initiate CPT\n\nPLHIV on ART who develop TB\n\n\n\n\n\u00b7    Continue ART (Substitute N VP with E FV, if on DTG then\n     administer twice daily)\n\u00b7    Start TB treatment immediately\n\u00b7    Continue/initiate CPT\n\u00b7    Reassess for HIV treatment failure\n\nPLHIV on second -line ART who\ndevelop active TB\n\n\n\n\u00b7    Reassess for HIV treatment failure\n\u00b7    Continue ART\n\u00b7    Start TB treatment immediately, change anti-TB to single\n     drugs with rifabutin-containing regimen if on protease\n     inhibitors\n\nPregnant PLHIV on ART who\ndevelop TB\n\n\n\n\n\u00b7    Continue ART\n          o    EFV not contraindicated\n          o    Double -dose DTG\n\u00b7    Start TB treatment immediately\n\u00b7    Continue/Initiate CPT (avoid CPT in 1st trimester)\n\u00b7    Reassess for HIV treatment failure\n\n                    3.3.8 Recommendations for use of ART in HIV/Hepatitis Co-infection\n                    Antiretroviral therapy (ART) should be initiated in all HIV/Hepatitis co-infected individuals\n                    regardless of CD4+ cell count and stage of liver disease.\n                         \u00a7     HIV/HBV Coinfection: The recommended ART for HIV/HBV coinfected PLHIV is\n                               TDF + 3TC (or FTC) + DTG. This is because TDF and 3TC are active against HBV.\n                         \u00a7     HIV/HCV Coinfection: Antiretroviral therapy should be initiated first in HIV/HCV co-\n                               infected patients before commencing Direct Acting Antivirals (DAAs) for HCV\n                               treatment. Drug-drug interactions (DDIs) should be carefully considered and the\n                               appropriate ARV or hepatitis drug substitutions/dose adjustments made before\n                               commencing treatment.\n\n                                  NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                32", "mimetype": "text/plain", "start_char_idx": 20, "end_char_idx": 2450, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "0907d110-16ca-445d-b263-efbab1033aa4": {"__data__": {"id_": "0907d110-16ca-445d-b263-efbab1033aa4", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "42d90d1f-950c-4be5-9cde-6c661b7ec96d", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "713045743ebb79bf39bade1b3b915be856b66b68a45e6b86edc94c39b867f682", "class_name": "RelatedNodeInfo"}}, "text": "Healthcare workers need to note that there is a risk of IRIS associated with early initiation of ART\nin HIV/hepatitis coinfection, referred to as 'hepatitis flare' which usually occurs within the first 6\nto 12 weeks after ART initiation. (see section 8.1.8).\n\n3.4 Recommended ART Regimen for Adults, Adolescents and Children\nThe following are the recommended ART regimens for the management of HIV in Nigeria.\n\n3.4.1 First-line ART regimens for adults and adolescents\nTable 3.3 Recommended first-line ART regimens for adults, adolescents, pregnant, breastfeeding women and\nchildren\n\n  First -line ART             Preferred first-line                  Alternative first-           Special Circumstances\n                              regimen                               line regimens\n\n  Adults and                  TDF + 3TC (or FTC) +                  TDF + 3TC (or FTC)           TAF + 3TC (or FTC) + DTG\n  Adolescent s                DTG                                   + EFV 400                    ABC + 3TC + DTG\n\n                                                                                                 AZT + 3TC + EFV 400\n\n 3.4.2 First-line ART for children\nTable 3.4 Recommended First-line ART regimen for Children\n\n  Weight              Age (years)          Preferred First Line              Alternative First Line              Special\n  (Kg)                                     Regimen                           Regimen                             Circumstances\n  Neonates\n  < 3kg               < 1 month            AZT + 3TC + DTG*                  AZT + 3TC + LPV/r**                 AZT+3TC+NVP\n                                           or RAL\n  Infants & Children\n  < 20kg              < 6years             ABC +3TC + DTG                    ABC+3TC +LPV/r                      ABC + 3TC\n                                                                                                                 +EFV*+(or\n                                                                             AZT + 3TC +LPV/r\n                                                                             ABC (or AZT) +3TC+                  NVP)\n                                                                             RAL**+                              AZT + 3TC +\n                                                                                                                 EFV (or NVP)\n  20 \u2013 30kg           6-10years            ABC+3TC+DTG                       ABC+3TC +LPV/r                      AZT + 3TC +\n                                           Or                                ABC +3TC + RAL                      LPV/r (or RAL)\n                                           TDF***(TAF)****\n                                           + 3TC +DTG\n\nNote:\n*DTG 5mg and 10mg (scored/dispersible) formulations are available for use in children from 4weeks of age and weighing at least 3kg to children\n<20kg\n**LPV/r pellets or granules can be used if starting after two weeks of age\n***TDF is used for children aged 6-10 years weighing >30kg\n****TAF is used for children with weight >25kg\n*+EFV is used for children above 3years (>15kg)\n**+The use of this INSTI could be considered where available in instances of poor tolerability or administration challenges with LPV/r,\nparticularly in settings where the rapid expansion of maternal treatment could lead to infants and children at very high risk of carrying an NNRTI\nresistance virus.\n\n                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                 33", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3579, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "0432304f-161a-4617-8dac-7995249d554b": {"__data__": {"id_": "0432304f-161a-4617-8dac-7995249d554b", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "8f94e266-ff5f-46ca-a6f0-e49be3053eab", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "b64580b3104a7e65067be1f4538f3d2153277b79706f06a8cefb821911d62ed4", "class_name": "RelatedNodeInfo"}}, "text": "3.4.3 Programming Transitioning to DTG - based regimen\n The transitioning of non-DTG based first-line regimens to DTG-based regimens should be done\n in virally suppressed and stable patients. Patients failing on a non-DTG based first-line regimen\n should be switched to the preferred second-line regimen.\n\n 3.5 Monitoring Patients on ART\n\n 3.5.1 Monitoring and Follow-up in Adults\n Once a patient is initiated on ART, assessment should look out for:\n     \u00a7     Any persisting or new signs/symptoms of HIV related conditions\n     \u00a7     Potential drug toxicities\n     \u00a7     Optimal Adherence\n     \u00a7     Response to therapy (Clinical, Immunological and Virological).\n     \u00a7     Weight changes, growth and development including height in children\n     \u00a7     Abnormal Laboratory parameters\n\nTable 3.5 Recommended Schedule for Monitoring Adults on ART: Clinical Assessments\n\n                                   Pre-                   Month                 Every six              Every\n                                   Treatment              three                 months                 Scheduled\n                                   (Baseline)                                                          Clinical\n                                                                                                       Consultation\n\n  Physical exam                    X                      X                     X                      X\n  * Adherence                      X                      X                     X                      X\n    counselling\n\n  * Clinical                       X                      X                     X                      X\n    Screening for TB\n\n  Clinical screening               X                      X                     X                      X\n  for chronic care\n  & PHDP Services\n\n*Adherence counselling and clinical screening for TB should be done at every clinical or drug pick up visit\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                        34", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 2046, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d5aaf49c-63b2-4467-a196-665136c1fbcc": {"__data__": {"id_": "d5aaf49c-63b2-4467-a196-665136c1fbcc", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "163fb365-a76b-4ef3-977c-0ba4c45343a3", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "04d93c7c795cd84fb3530fb65da6274ba9303578df569dc7d899c9a6dbd29223", "class_name": "RelatedNodeInfo"}}, "text": "Table 3.6 Recommended Schedule for Monitoring Adults on ART: Laboratory Tests\n                                                                     Pre-                     Month on ART                 Every 6       Every 12\n                                                                     Treatment            1st     3rd     6th     12th     Months        Months\n                                                                     (Baseline)                                                          (Annual)\n  HIV-1 RNA (VL)                                                                                           X\u2021      X\u2021                          X\n  CD4+*                                                                     X\n  *Cryptococcal antigen test (CrAg) and\n  TB LAM if CD4+ cell count < 200 cells/mm3                                 X\n  Hb/PCV                                                                    X              X1      X                           X\n  WBC, Platelets                                                     As clinically indicated              As clinically indicated\n  ALT                                                                               X                     As clinically indicated\n  Serum Creatinine (Calculate eGFR)                                         X                      X                           X\n  HBsAg and HCV                                                             X\n  Urinalysis                                                                X                      X3                          X3\n  Syphilis test                                                      As clinically\n                                                                     indicated\n  Cervical cancer screening (VIA/Pap                                                X                      Every 3 years if a screening\n  Smear/HPV screen)                                                                                        test is negative\n  AST, ALP, FBS, Amylase, Pregnancy test,                                                      As clinically indicated\n  Lipid profile, U/E, Xpert MTB/RIF test,\n  Chest X-Rays\nX Essential\n1For patients on AZT; 2 Patients on NVP;        3 patients on TDF.\n\u2021We recommend that all adult clients on ART should have a VL test at 6 months after ART initiation; If <1000 copies/ml, then repeat testing 6\nmonths later, then repeat at least every 12 months if remains <1000 copies/ml. If the VL is \u22651000copies/ml, the patient should receive enhanced\nadherence counselling (EAC) and have a repeat VL only after three months of GOOD adherence. A repeat VL test result of \u22651000 cp/ml following\nEAC is indicative of virologic failure. Clients with persistent virologic failure despite EAC interventions may need to have their drug regimen\nswitched to second-line ART if they have been on a DTG-based regimen (e.g., TLD) for at least 1 year.\n                                                                                                                                         3\n* urine LF-LAM assay and CrAg tests should be done automatically by the laboratory on all CD4+ counts < 200 cells/mm . (CD4 test is\n                                                                                 3\nrecommended every 6 months until two consecutive values over 200 cells/mm ).\nsLaboratory monitoring tests may differ according to the level of the health care facility and should be done according to the above schedule.\n\n3.5.2 Monitoring Children and Adolescents on ART\nClinical and laboratory monitoring are essential parts of HIV and AIDS care in children and\nadolescents. However, laboratory results do not have to be available on the same day following\nHIV diagnosis to initiate ART, provided there is no evidence of TB, meningitis or renal disease.\n\n                 NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                             35", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3982, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n"}, "__type__": "1"}, "1f46ee69-3127-41bf-a026-949f116e9271": {"__data__": {"id_": "1f46ee69-3127-41bf-a026-949f116e9271", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f304db54-f2b3-4e3b-a2de-46912a556131", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "ad14c87dd45bc6f7950887ea2fb7a8b401412608448cf835059b58e2fe3e2be1", "class_name": "RelatedNodeInfo"}}, "text": "Table 3.7 Recommended Schedule for Monitoring Children and Adolescents on ART: Clinical Assessments\n                                                                              Pre-treatment                     Week on ART                      Every\n                                                                              (Baseline)                 2nd       4th       8th       12th      3months+\n   History and Physical Exam                                                            X                 X         X         X          X              X\n\n   Anthropometric Measurements (Wt, Ht, Length,\n   OFC, MUAC*,Chest circumference, BMI**)                                               X                 X         X         X          X              X\n   Nutrition (Feeding, diet)                                                            X                 X         X         X          X              X\n   Immunization status***                                                               X\n   HPV Vaccination Assessment****                                                       X\n\n   Adherence monitoring                                                                 X                 X         X         X          X              X\n   Psychosocialassessment*****                                                          X                 X         X         X          X              X\n\n   Clinical Screening for TB, Meningitis, and other                                     X                                   As indicated\n   OIs (assessment INH and CTX Prophylaxis) and\n   other infectious diseases\n                                                                          2\n*Most appropriate for children aged 1 \u2013 5 years\u2019**BMI in kg/m for adolescents, +/- grading for obesity\u2019;***Ascertain completion of\nroutine immunization, otherwise refer accordingly;****For female children and adolescents between ages 9-18 years;*****Most\nappropriate for adolescents;+More frequent clinic visits and examination may be required for unstable patients\n\nTable 3.8 Recommended Schedule for Monitoring Children and Adolescents on ART: Laboratory Tests\n                    Investigations                           Pre-Treatment                     Month on ART                   Every 6         Every 12\n                                                             (Baseline)                    1st      3rd      6th     12th     Months          Months\n                                                                                                                                              (Annual)\n  HIV-1 RNA (viral load estimation)                                                       All Children and Adolescent should have a VL test\n                                                                                          every 6-months\n  CD4+ Cell count/CD4%*                                                                                      X        X            X\n  Hb/PCV                                                                 X                 As clinically indicated\n  WBC + differentials, Platelets                             As clinically indicated\n  ALT                                                                                     As clinically indicated\n  U/E/Creatinine (Calc CrCl)                                 As clinically indicated\n  HbsAg and HCV                                              As clinically indicated\n  Urinalysis                                                             X                As clinically indicated\n  GeneXpert, Chest X-ray                                     As clinically indicated\n\n  Cervical Cancer Screening**                                            X                Every 3 years if screening test is negative\n  CrAg Test                                                              X                For adolescents 10 \u201319 years only (Not\n                                                                                          recommended for children < 10yesars)\n  AST, ALP, FBS, Amylase, Pregnancy\n  test*, LF- LAM test for TB infection                       As clinically indicated\nX Essential;1 For patients on AZT; 2 Patients on NVP;3 patients on TDF;*Most appropriate for adolescents especially where pregnancy is suspected;**\nOlder or sexually active adolescents;\u2021 Desirable: Baseline viral load can be performed especially for those with prior exposure to ARVs but is not routinely\nrecommended. We recommend that all children and Adolescents initiating ART should have viral load determined 6 months following initiation of therapy and\nevery 6 months thereafter. If the VL is \u22651000copies/ml, the patient should receive enhanced adherence counselling (EAC) and have a repeat VL only after three\nmonths of GOOD adherence. A viral load test result of >1000copies/ml following reinforced adherence counselling and support is indicative of virologic failure.\nClients with persistent virologic failure despite adherence interventions should have their drug regimen switched to second-line ART regimen.\n\n                  NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                                      36", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 5256, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n"}, "__type__": "1"}, "bdccff43-9267-49dd-973e-3969d76f7f3c": {"__data__": {"id_": "bdccff43-9267-49dd-973e-3969d76f7f3c", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "fb94fcb1-c659-4391-9b7c-96b4b17402da", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "060c3f58934cf088fd94a3b62add47da3fb40de54c600153712ae58f69b93653", "class_name": "RelatedNodeInfo"}}, "text": "3.6       Management of HIV Treatment Failure\n\n3.6.1 Definition of HIV Treatment Failure\nHIV treatment failure may be defined as sub-optimal treatment outcomes following the initiation\nof ART. Although HIV treatment failure can be classified as either virologic, immunologic or\nclinical failure (see table 3.9); virologic treatment failure is the best measurement of treatment\nfailure.\n\nVirologic failure is defined as a VL above 1000 copies/ml based on two consecutive VL\nmeasurements 3 months apart, and after an adherence intervention Non-suppressed VL (VL \u2265\n1000copies/ml) and its management. Critical to the goal of viral suppression is the return of\nresults to the clinical staff and patient, and actions for non-suppressed VL. A VL \u2265\n1000copies/ml should be considered a critical lab value and communicated to the clinical staff\nand the patient in an expedited fashion. All patients with non-suppressed VL results should\nundergo Enhanced Adherence Counseling (EAC) sessions, which involves:\n\n  Step 1              A structured assessment of ART adherence\n\n  Step 2              Exploration of specific barriers contributing to poor adherence (as well as the\n                      possibility of drug interactions, intercurrent infections, incorrect dosage in children)\n\n  Step 3              Identification of potential solutions to address barriers\n\n  Step 4              Joint development of an individualized adherence intervention plan and the follow\n                      up of patients for improved adherence\n\nA VL test should be repeated in 3 months after EAC. Review patients for ART regimen switch if\nVL is still unsuppressed. In particular, it is important to ensure that effective laboratory\ninformation management systems are in place for the prompt identification and notification of\nthe sites, HCWs and unsuppressed patients for timely management. All VL results must be\nreturned to the patient in addition to their charts.\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                     37", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2060, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "1945a469-7ca1-4b28-a2ed-98a91af8bbe8": {"__data__": {"id_": "1945a469-7ca1-4b28-a2ed-98a91af8bbe8", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "15f935d9-babb-47b7-be7f-6af1ace70582", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "65cf07402c876d15c714da7a4f183cca353d87556e3d6f47ad5dc8068ba1627e", "class_name": "RelatedNodeInfo"}}, "text": "Table 3.9 Classification of HIV Treatment Failure\n\n  Failure                   Definition                                            Comments\n\n                            Adults and adolescents                                The condition must be\n                            New or recurrent clinical event indicating            differentiated from IRIS\n                            severe immunodeficiency (WHO clinical                 occurring after initiating ART\n                            stage 4 condition) after 6 months of effective\n                            treatment.                                            For adults, certain WHO clinical\n  Clinical Failure          Children                                              stage 3 conditions (pulmonary\n                            New or recurrent clinical event indicating            TB and severe bacterial\n                            advanced or severe immunodeficiency                   infections) may also indicate\n                            (WHO clinical stage 3 and 4 clinical                  treatment failure\n                            condition with exception of TB) after 6\n                            months of effective treatment\n                            Adults and adolescents                                Without concomitant or\n  Immunological             CD4+ cell count falls to the baseline (or below)      recent infection to cause a\n                                                        Or                        transient decline in the CD4+\n  failure                   Persistent CD4+ cell count below 100 cells/mm3        cell counts.\n                                                        Or\n                            50% decline from on-therapy CD4+ cell count\n                            peak level\n                            Children\n                            Younger than 5 years\n                            Persistent CD4+ cell count below 200\n                            cells/mm\u0000 or <10%\n                            Older than 5 years                                 3\n                            Persistent CD4+ cell count below 100 cells/mm\n  Virological               Plasma viral load \u2265 1000 copies/ml 6 months           An individual must be taking\n  Failure                   after starting ART on consecutive VL                  ART for at least 12 months\n                            measurements                                          before it can be determined\n                                                                                  that a regimen has failed\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                     38", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2712, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "51e6552d-1fd9-412e-8b5d-77348f9a962c": {"__data__": {"id_": "51e6552d-1fd9-412e-8b5d-77348f9a962c", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "be0b5699-8a0c-47b7-853e-99b69258523d", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "72b8de4f750d3aef5abffcd7458ecc83771a5969bb9fb719f73b97d961fce8f8", "class_name": "RelatedNodeInfo"}}, "text": "Figure 3.1: Algorithm for Treatment Failure Evaluation in Adults, Adolescents and Children\n\n3.6.2 Causes of HIV Treatment Failure1 .Viral factors\n                                         \u00a7                    Acquired drug resistance: Patients may develop drug-resistant mutations while on\n                                                              ART if maximal adherence (\u226595%) is not maintained.\n                                         \u00a7                    Transmitted drug resistance: Patients may be infected with drug-resistant virus\n                                                              during their initial exposure or be re-infected with drug-resistant virus while on\n                                                              ART.\n                 2.                      Non-viral Factors\n                                       HIV Treatment failure may result when ARV plasma drug levels do not reach therapeutic\n                                       concentration. This may be due to:\n                                          \u00a7                  Host factors: poor adherence to ART, malnutrition and malabsorption of drugs\n                                          \u00a7                  Choice of initial ART regimen, poor potency or improper dosing\n                                          \u00a7                  Drug-drug interactions\n\n3.6.3 Substitution and switch of ARV drugs\nSubstitution is the replacement of one or two ARV drugs in a regimen with another drug of the\nsame class usually because of the following;\n\n                                                       NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                             39", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 1693, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "f6a3b39c-ed5c-4960-ba8e-98c1aef5a29c": {"__data__": {"id_": "f6a3b39c-ed5c-4960-ba8e-98c1aef5a29c", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "46025842-30da-425c-9d8f-93a1ca63afc5", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "74285a01afc9040536586fd9678d98340cc4d2e73f90682508b3e1ddf00af682", "class_name": "RelatedNodeInfo"}}, "text": "1.    Toxicity/ adverse drug reactions\n     2.    Co-morbidity\n     3.    Pregnancy\n     4.    Drug interaction\nSwitching is the replacement of two or more ARV drugs in a regimen with other drugs, including\ndrugs of a class due to treatment failure. Switching can also be referred to as changing a patient\nfrom a first-line regimen to a second-line regimen or from a second-line regimen to third-line or\nsalvage regimen.\n\nWhen to Switch to Second Line:\nThe longer an individual is maintained on a failing regimen, the longer there is ongoing viral\nreplication. This will lead to a worse clinical outcome, greater opportunity for drug resistance\nand increased risk of transmission.\nIn some patients with repeat VL >1,000 copies/ml it may be useful to consider the extent of viral\nload reduction by log scale. A reduction of >1 log per month with good adherence may suggest\nviral load suppression is achievable on the current regimen with additional time. Such patients\nshould continue the current regimen and repeat viral load in another few months to see if it has\ngone below 1,000 copies/ml.\nBefore switching to a second-line regimen, improved ART adherence should be reported and\ndetected, and treatment failure should be confirmed (repeat VL>1,000 copies/ml). Health\nfacilities should constitute a multidisciplinary Switch committee to review, track, and make\ndecisions about switching to second-line.\nIdeally, the committee should consist of a healthcare worker (medical doctor) and a nurse who\nknows the client and is conversant with his/her ART treatment history, and the adherence\ncounsellor who has provided EAC to the client and is aware of his/her barriers to adherence.\n\n3.6.4 Second-line ART Regimens\nProtease inhibitor-based regimen is recommended as the preferred ARV drug for second-line\nART among adults, adolescents and children. However, DTG may be used as an alternative\nsecond-line regimen if an individual is intolerant of LPV/r or has a contraindication to ATV/r or\nif the first-line regimen does not contain DTG.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                        40", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 2144, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "29b08aab-6d0e-4cd7-933d-1250be88337b": {"__data__": {"id_": "29b08aab-6d0e-4cd7-933d-1250be88337b", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f53ba4fb-e79c-4699-ad59-06c779df9194", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "d86777903aec4131729fd55e04633877a9b61a0ec7d01b3af6b02ea613a6fde2", "class_name": "RelatedNodeInfo"}}, "text": "Table 3.10 Preferred and Alternative Second-line ART regimens for Adult and Adolescents including Pregnant\nand Breastfeeding Women\n\n  Target Population             Failing First -line          Preferred Second -line              Alternative Second -line\n                                Regimen                      Regimen                             Regimens\n\n  Adults and                    TDF+3TC (or                  AZT+3TC (or FTC)                    AZT+3TC (or FTC)\n  Adolescents                   FTC) +DTG                    +ATV/r or LPV/r                     +DRV/r\n                                TDF+3TC (or                  AZT+3TC (or FTC)                    AZT+3TC (or FTC) +DTG\n                                FTC) +EFV                    +ATV/r or LPV/r\n                                AZT+3TC (or                  TDF+3TC (or FTC)                    TDF+3TC (or FTC) +DTG\n                                FTC) +EFV                    +ATV/r or LPV/r\n  TB/HIV Co -                   Same regimens as recommended above for adults and adolescents; however,\n  infection                     DTG should be administered at 50 mg twice daily with first -line anti -TB\n                                medicines and rifabutin substituted for rifampicin in patients receiving\n                                protease inhibitors. Alternatively, double-dose LPV/r (that is, LPV/r 800\n                                mg/200 mg twice daily) is recommended for TB/HIV co-infected patients on\n                                first -line anti -TB medicines.\n  TB/HBV Co -                   TDF + 3TC (OR FTC) + ATV/r or LPV/r\n  infection\n\nTable 3.11: Recommended Second-line ART Regimen for Neonates, Infants, and Children\n  Weight (Kg)            Age (years)         Failing First Line                        Preferred 2 ndLine Regimen\n                                             Regimen\n  Neonates\n  < 3 kg                 < 1 month           AZT + 3TC + DTG or RAL                    AZT + 3TC + LPV/r\n  Infants & Children\n  < 20kg                 < 6years            ABC +3TC + DTG                            AZT+ 3TC + LPV/r or ATV/r                ***\n                                                                                       ABC+3TC +LPV/r\n                                                                                       ABC (or AZT) +3TC+ RAL\n  20 - <30kg             6 \u2013 10years         ABC+3TC+DTG                               AZT + 3TC + LPV/r or ATV/r or\n                                                                                       DRV/r+\n                                             OR\n                                             TDF* (TAF**) + 3TC (or                    ABC +3TC + LPV/r or ATV/r\n                                                                                       DRV/r+                                    or\n                                             FTC) + *DTG\n  TB/HIV Co -            Same recommendations as for adults and adolescents. However, RAL dose\n  infection              should be doubled and administered twice daily with first -line anti -TB\n                         medicines\n *TDF is used for children aged 6-10 years weighing >30kg\n**TAF is used for children weighing > 25kg\n***ATV/r can be used as an alternative to LPV/r for children older than 3months, but limited availability of suitable formulations for children\nyounger than 6years\n+ Should not be used for children < 3years and combine with appropriate dosing of ritonavir\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                41", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3648, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "dd0e3beb-4dfc-4cbc-8f68-4f9c48677c07": {"__data__": {"id_": "dd0e3beb-4dfc-4cbc-8f68-4f9c48677c07", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "623425ad-8d44-4cdb-a113-eb4b65ecdd99", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "8fcb01fea9db8557509eb9e6ace877a4af06d7f5123cbb0cefacf781b140f9f7", "class_name": "RelatedNodeInfo"}}, "text": "3.7 Third-line ART\nThird-line therapy refers to the ART offered to PLHIV in response to the failure of second-line\ntreatment. Efforts should be made to assess and optimize adherence and rule out any significant\ndrug interactions. It is recommended that switch to third-line therapy be left in the hands of HIV\nspecialists with requisite experience and expertise in the management of treatment-experienced\nHIV patients. The choice of third-line therapy is more difficult in the absence of HIV drug\nresistance.\n\nThird-line regimens should include new drugs with minimal risk of cross-resistance to\npreviously used regimens, such as INSTIs and second or third-generation NNRTIs and PIs. The\nWHO has recommended that National ART programmes in resource-limited settings develop\npolicies for access to third-line ART, containing ritonavir-boosted darunavir, integrase\ninhibitors, and etravirine. These agents have been shown to be effective in highly treatment-\nexperienced patients in trial settings.\n\nThe FMOH has set up a third-line ART Committee to oversee the implementation of third-line\nART in Nigeria; and designated some sites spread across the six geo-political zones of the\ncountry as third-line ART sites. Also, it has developed and disseminated the criteria for the switch\nand operational guidance for third-line ART.\n\n3.7.1 Criteria for Switch to Third-Line ART\nIn the event of suspected treatment failure on second-line ART, the following criteria should be\nmet before a switch to third-line ART:\n\n     1.    The patient should be confirmed to have failed on first-line and second-line ART\n     2.    The patient should have a viral load result suggestive of treatment failure\n           (>1000copies/ml) after at least 6 months on an effective second-line ART regimen\n     3.    The patient must undergo adherence assessment, followed by 3 months of documented\n           EAC; the EAC must assess and optimize adherence and rule out any significant drug\n           interactions.\n     4.    The patient's repeat viral load at the completion of EAC must be >1000copies/ml.\n     5.    The patient's adherence during and following EAC must be >95%.\n     6.    HIV drug resistance testing (genotype or phenotype) should be done to determine the\n           ARVs that are still active.\n\n3.7.2 Operational Guidance for Third-Line ART\n     1.    Patients that meet the criteria stated above for switch to third-line ART should be referred\n           to the third-line site closest to the referring facility with a filled third-Line ART eligibility\n           form, a recent HIV viral load result (done within the last 6 months) and a result of HIV\n           drug resistance testing.\n     2.    The third-line ART site will review the third-line ART eligibility form and forward the\n           completed forms to the National third-line Committee through the\n           email: nationalthirdline@gmail.com\n     3.    Upon approval by the National third-line Committee, the patient will commence\n           treatment at the third-line site.\n     4.    Patients commenced on third-line ART should have a viral load test done 3 months after\n           the commencement of therapy.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                  42", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3292, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "862a6eb6-8144-4c6a-b3c6-35703b0fb9fb": {"__data__": {"id_": "862a6eb6-8144-4c6a-b3c6-35703b0fb9fb", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "49eac260-f2c8-471d-9bcf-1e6355305afc", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "8bc7e61b38043de2bc7f195871166624969022da83225c7cce384d4a52240d11", "class_name": "RelatedNodeInfo"}}, "text": "The following table shows the sequence of switching ART from first-line to third-line regimens:\nTable 3.12 Sequence of Switching ART from first-Line to third-Line regimens\n Target Population               First-line                 Second -line                 Third-line Regimens\n                                 Regimens                   Regimens\n Adults and Adolescents          TDF + 3TC (or              AZT + 3TC (or FTC)           TDF + 3TC (or FTC) +\n                                 FTC) + DTG                 + ATV/r or LPV/r or          DRV/r + DTG +/ - ETV\n                                                            DRV/r\n                                 TDF + 3TC (or              AZT + 3TC (or FTC)           AZT+3TC (or FTC) +\n                                 FTC) + EFV 400mg           + ATV/r or LPV/r or          DRV/r \u00b1 ETV +/ - DTG\n                                                            DTG or DRV/r\n\n Children and infants            ABC + 3TC + DTG            AZT + 3TC + LPV/r            RAL or DTG + DRV/r\n                                                            (or ATV/r)                   (children >3years) + ABC\n                                                            AZT + 3TC + DRV/r            or AZT + 3TC\n                                                            (children > 3years)\n\n                                 ABC (or AZT) +             AZT (or ABC) + 3TC\n                                 3TC + LPV/r                + DTG\n                                                            AZT (or ABC) + 3TC\n                                                            + RAL\n\n                                 ABC (or AZT) +             AZT (or ABC) + 3TC\n                                 3TC + EFV                  + DTG\n                                                            AZT (or ABC) + 3TC\n                                                            + LPV/r (or ATV/r)\n\n3.8 Low-Level Viremia (LLV)\nThe WHO recommends routine VL for individuals on ART as the preferred monitoring approach\nto confirm ART success, and defines treatment failure as a \u201cpersistently detectable VL exceeding\n1000 copies/mL after at least 6 months of starting a new ART regimen\u201d. This VL threshold,\nhowever, misclassifies PLHIV who harbour drug-resistant viruses. Data have shown that low-\nlevel viremia (LLV), defined variably as an intermittent or persistent VL between 200 - 999\ncopies/ml is associated with drug resistance mutations (DRMs) and/or treatment failure, with an\nincidence of virologic failure (VF) among PLHIV with persistent LLV <500 copies/mL\nestimated to be about 4-8%. Persistent higher-range LLV (e.g. \u2265400 copies/ml) is associated\nwith clinical disease progression and/or mortality.\n\n3.8.1 Management of Low-level viremia (LLV)\n     \u00a7    All clients with low-level viremia (VL 200 - 999 copies/ml) should undergo a thorough\n          assessment of the cause of the elevated VL and specifically consider the possibility of\n          (ABCDE):\n          \u2022    Adherence problems\n          \u2022    Bugs (Intercurrent infections)\n          \u2022    In-Correct ART dosage\n          \u2022    Drug Interactions\n          \u2022    REsistance.\n     \u00a7    Implement interventions to re-suppress the VL, including EAC (1-3)\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                     43", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3367, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "dfa8d842-7c48-4f9a-9e84-e6dc64aa5515": {"__data__": {"id_": "dfa8d842-7c48-4f9a-9e84-e6dc64aa5515", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "2a7267b6-b273-4a20-a20c-fefb4dee9771", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "d77b4e4d01ebdaa599454cf3715b3d941a26ddf31845e7fc3d37823c4d7ac0bf", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7     Repeat VL after three months of GOOD ADHERENCE\n    \u00a7     If the current regimen is TLE or TDF/3TC/NVP, switch to TLD.\n\n3.9 ART in Special Circumstances\nA number of non-communicable diseases (NCDs) adversely affect the outcome of ART in\nPLHIV. These NCDs must be taken into consideration as dose adjustment helps significantly to\nlimit the complications of ART in these settings. The most common NCD in HIV infection is\nkidney impairment. Many patients also have drug-induced or disease-related cardio-myopathy.\nOsteoporosis is also becoming a common complication being reported among older women on\nTDF-containing ART.\n\n3.9.1 Kidney impairment\nExperience from Nigeria has shown that 23.8% [2] of newly diagnosed HIV infected patients\npresent with evidence of kidney impairment. Long term follow-up of about 5,000 patients on\nTDF containing regimen in another study from Jos, Nigeria [3] showed that 10% of patients\nwithout baseline evidence of kidney impairment develop laboratory features of kidney\nimpairment by week 24 of follow up. This proportion increased to 45% by week 144. The\nauthors concluded that ART regimens in Nigeria need to be reviewed concerning the use of TDF.\nThey suggested an alternative regimen such as ABC or TAF. There is also the need to dose adjust\n3TC as this drug is 80 - 90% eliminated by the kidney.\n\n3.9.2 Cardiomyopathy\nThere is no current published national data regarding HIV and ARV related cardiomyopathy.\nHowever, anecdotal reports from high volume sites in Nigeria suggest that a significant number\nof HIV infected Nigerians are now developing hypertension and electrocardiographic and\nechocardiographic features of cardiomyopathy. Research is ongoing in Nigeria to study and\nreport this phenomenon. While awaiting this report, present knowledge suggests that\ncardiomyopathy is more associated with the use of ABC. Other studies have established a\nrelationship between ABC and increased hyperactivity of platelets. The platelet endothelial cell\ninteraction is suggested to be a major factor predisposing to cardiovascular diseases in HIV\ninfected population.\n\n3.9.3 Osteoporosis\nDecreased bone mineral density has been reported as a long-term complication of TDF. This is\nthe reason why paediatricians do not recommend the use of TDF in children in order not to limit\ngrowth potential. In adults, however, particularly post-menopausal females, decreased bone\nmineral density associated with post-menopausal age may become complicated with long term\nuse of TDF. Presently, we do not have in-country data to support the magnitude of this problem.\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                       44", "mimetype": "text/plain", "start_char_idx": 4, "end_char_idx": 2695, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "a6d9f97d-5c5a-47e6-8499-14af5f7eca16": {"__data__": {"id_": "a6d9f97d-5c5a-47e6-8499-14af5f7eca16", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "058cf569-4498-4431-bc93-e8129f9968aa", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "f3c52aa94ca703203bb4a2c8eb4bc50db47fff199212a6f4e91b7594569968d7", "class_name": "RelatedNodeInfo"}}, "text": "Table 3.13. Recommendations for ART in special circumstances\n\n        Special circumstance                         Problems                           Recommendations\n\n        Kidney impairment                            TDF toxicity                 Replace TDF 300mg with ABC\n                                                                                  600mg*\n                                                                                  OR replace with TAF 25mg\n                                                     3TC toxicity                 Dose adjustment based on eGFR\n                                                                                  eGFR>50, no adjustment, 300mg\n                                                                                  daily\n                                                                                  eGFR 30           \u2013 49ml/min, 150mg\n                                                                                  daily\n                                                                                  eGFR 15-29ml/min, 75mg daily\n                                                                                  eGFR <15ml/min or dialysis\n                                                                                  dependent, 75mg alternate days\n\n        Cardiomyopathy                               ABC toxicity                 Refer the patient for cardiology\n                                                                                  review and HIV specialist\n                                                                                  opinion\n        Osteoporosis                                 TDF toxicity                  Replace with TAF\n\n*eGFR >50ml/min, recommended regimen is ABC+3TC+DTG, 600/300/50mg daily\neGFR 30-49ml/min, recommended regimen is ABC/3TC/DTG, 600/150/50mg daily\neGFR 15-29ml/min, recommended regimen is ABC/3TC/DTG, 600/75/50mg daily\neGFR <15ml/min or on renal dialysis, recommended regimen is ABC/3TC/DTG, 600 daily, 75mg alternate days (or 37.5mg daily), 50mg daily\nCreatinine Clearance (eGFR) can be calculated using Cockcroft -Gault equation below\n(140-age(yrs) x weight(kg)/Plasma Creatinine (mg/dl) x72\nFor Females, the result should be multiplied by 8\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                   45", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2411, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "f2b83be5-4173-43e6-9550-bff513d8d17a": {"__data__": {"id_": "f2b83be5-4173-43e6-9550-bff513d8d17a", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "df39f982-8864-4fdb-8bae-ba0df1408fcc", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "7f8d8a82acec289512caa4c379cda9b5ce8e127c5d5a5cd9b681eef108d00e62", "class_name": "RelatedNodeInfo"}}, "text": "List of Contributors\nDr Bilikisu Jibrin\n\nDr Etiobhio Ehimen\n\nDr. Urhioke Ochuko\nChika-Onyiah Ogechukwu\nProf. Oche Agbaji\nProf. Augustine Omoigberale\nProf. Stephen Oguche\nDr Sunny Ochigbo\nDr Abiola Davies\nDr Omoniyi Amos Fadare\nDr Andrew Abutu\nDr Fagbamigbe Omodele Johnson\nAdemola Oladapo\nDr Adegbenga Olarinoye\nDr Ismail Lawal\nDr Chux Anago\nDr Nere Otubu\nDr Iboro Nta\nDr Emerenini Franklin Chime\nDr Olanrewaju Olaiya\nMrs Aisha Nantim Dadi\nDr Rosemary Adu\nDr Plang Jwanle\nDr Echey Ijezie\nIkechukwu Ezekpeazu\nDr Austin Azihaiwe-Justine\nDr Pius Nwaokoro\nDr Felicia Mairiga\nPrince Gambo\nEmmanuel Clifford\nDr Ugwuike, Joseph Eze\n\nChike Anyachor\n\nDr Valentine Uche\n                                                  Chapter 3\nAssistant Director, Head Treatment, Care and Support\nNASCP\nSenior Medical Officer, Treatment, Care and Support\nNASCP\nAssistant Director, Childhood TB - NTBLCP\nSenior Scientific Officer I NASCP\nMember NTTA / Physician JUTH Jos\nMember NTTA / Paediatrician UBTH Benin\nMember NTTA / Paediatrician JUTH Jos\nMember NTTA / Paediatrician UCTH Calabar\nHealth Manager UNICEF\nNational Professional Officer TB/HIV WHO\nART Program Manager CDC\nSenior Program Specialist, HIV Care and Treatment CDC\nSenior Progam specialist SI CDC\nSenior Program Specialist - Pediatric Treatment US DoD\nLead for HIV Care and Treatment US DoD\nProgram Manager CHAI\nProgram Manager CHAI\nAssociate CHAI\nPaediatrics PMTCT Lead ICAP\nProject Director, Pro-Health International\nProject Manager SFH\nHead of Programmes (GF HIV) SFH\nAssociate Director APIN\nCountry Program Director AHF\nAPIN\nSenior Technical Advisor FHI360\nDeputy Director Technical FHI360\nFHI360\nDeputy Coordinator NEPWHAN\nNEPWHAN\nTreatment Advisor Heartland Alliance\nAccess Manager, Johnson & Johnson Global Public\nHealth\nMedical Affairs Manager, Johnson & Johnson Global\nPublic Health\n\n                                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  46", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1930, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "e536ea9b-dc57-47ae-999f-160902315304": {"__data__": {"id_": "e536ea9b-dc57-47ae-999f-160902315304", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "dea7f3fc-97d5-4d31-9496-a69bce9331d0", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "e7a0dba65922e44d3eb04421cae73357f1ede804ddfa8862ddf16328f2f3f2f2", "class_name": "RelatedNodeInfo"}}, "text": "4. PHARMACOVIGILANCE\n       IN ANTIRETROVIRAL\n                    THERAPY\n\n What\u2019s Inside:\n4.1 Introduction\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u202648\n 1.1 Objectives of the Guidelines\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\n4.2 Pregnancy Monitoring for Patients on ARVs\u2026\u2026\u2026\u2026\u2026\u2026.....48\n 1.2 Epidemiology of HIV in Nigeria\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\n4.3 HIV Drug Resistance (HIVDR)\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026...49\n 1.3 Natural History of HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\n4.4 Adverse drug reactions (ADRs)\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026...49\n4.5 Drug toxicity\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026....46\n4.6 Steps to Recognize ADRs\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026....54\n4.7 Who is to Report ADRs?\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026..54\n4.8 What ADRs Should be Reported\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026........54\n4.9 Pharmacovigilance Data Collection\n    and Reporting Process \u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026.....55\n4.10 Principles of Management of Adverse\n     Drug Reactions \u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026..\u2026\u202655\n4.11 Prevention of Adverse Drug Reactions \u2026\u2026\u2026\u2026\u2026\u2026...........61\n4.12 ARV Drug Interactions\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026...........62", "mimetype": "text/plain", "start_char_idx": 2, "end_char_idx": 911, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "46aba6b9-4e3a-44e6-b0bd-9c501b394e9e": {"__data__": {"id_": "46aba6b9-4e3a-44e6-b0bd-9c501b394e9e", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f871030b-f243-42da-bb51-2b94d3d7e9c2", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "0fdab719dc6e4c3a05723303e6cbe93fb677bc431d4eb63696e6cfec01eec448", "class_name": "RelatedNodeInfo"}}, "text": "4.1 Introduction\nPharmacovigilance (PV) is defined as the science and activities relating to the detection,\nassessment, understanding, and prevention of adverse effects or any other drug-related problem\nincluding medication errors, drug misuse, and abuse. Pharmacovigilance is an arm of patient\ncare that aims at making the best use of medicines for the treatment or prevention of disease.\nGood pharmacovigilance practise will identify the risks and the risk factors in the shortest\npossible time so that harm can be avoided or minimized.\nThere are two methods of pharmacovigilance:\n    \u00a7     Active pharmacovigilance\n    \u00a7     Passive pharmacovigilance\n\nMonitoring and reporting of drug therapy problems including adverse drug reactions (ADRs)\nand medication errors should be an integral part of clinical practice for ensuring patient safety\nand optimal treatment outcomes. All healthcare providers (doctors, pharmacists, nurses, and\ncounsellors, etc.) at various service delivery points should, therefore, assess patients for ADRs at\nevery encounter and report all suspected adverse events using the NAFDAC ADR form (Yellow\nform). All facilities should establish a functional hospital-based pharmacovigilance committee\nin all ART/PMTCT centres to coordinate ARV clinical pharmacovigilance. This committee is\nvery vital to the success of pharmacovigilance and management of ADRs in a clinical setting.\n\n4.1.1 Active Pharmacovigilance\nActive (or proactive) safety surveillance means that active measures are taken to detect adverse\nevents. This is managed by active follow-up after treatment and the events may be detected by\nasking patients directly or screening patient records. It is based on structured procedures to\nobtain detailed information about patient populations, thereby allowing consideration of\nmodifying factors such as polypharmacy, comorbidity, and socio-demographic characteristics.\nIn addition, it enables targeted monitoring of specific drugs and adverse reactions to optimize the\nquality and quantity of reports as well as quantifying the frequency and severity of both expected\nand unanticipated adverse drug reactions. This surveillance is best done prospectively. Active\npharmacovigilance is sometimes descriptively referred to as hot 'pursuit'. The most\ncomprehensive method of active pharmacovigilance is Cohort Event Monitoring (CEM). It is an\nadaptable and powerful method of getting good comprehensive data. Other methods of active\nmonitoring include the use of registers, record linkage and screening of laboratory results in\nmedical laboratories.\n\nActive pharmacovigilance is compulsory for all new drugs imported or manufactured for use\nwithin the country. It may be initiated, managed or financed by the Market Authorization\nHolder/PHP voluntarily or pursuant to an obligation imposed by the National Agency for Foods\nand Drugs Administration and Control (NAFDAC). In any case, the process must be done in\ncollaboration with NAFDAC.\n\n4.2 Pregnancy Monitoring for Patients on ARVs\nIt is strongly recommended that all women who are known to be pregnant on ART should be\nfollowed up to find out the outcome of the pregnancy and the health status of the infant. Health\ncare providers should collect data on all ARV drug exposure during pregnancy using an\nappropriate data collection tool. Data collected should include:\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          48", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3455, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "e66f562b-fac7-441e-801e-4c8d252fb3ad": {"__data__": {"id_": "e66f562b-fac7-441e-801e-4c8d252fb3ad", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "3de5c659-67f4-4438-a111-3bd691e28eff", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "6e2195f8fa9d1ec4508e1f3b7ea782fb9ee5d533738a6f4d82dc79a7b0c525ca", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7    Baseline information on the pregnancy; What ARV is the woman on?, Did the woman\n          get pregnant while on ART?, or Was ART initiated during pregnancy?\n     \u00a7    Details on any pregnancy-related problems in the woman, foetal death and or\n          abnormalities observed when the infant is examined at birth or postnatally\n\n4.3 HIV Drug Resistance (HIVDR)\nThe global risk of further increases in HIVDR is heightened by the implementation of WHO\nguidelines recommending \"Treat All\" and pre-exposure prophylaxis, and many more people\ninitiating HIV treatment. While concerns about resistance should not stop the provision of\nantiretroviral therapy (ART) to all in need, the long-term implications of earlier initiation on\nadherence and drug resistance need to be closely monitored and responded to.\n\nIf not properly controlled, HIVDR can reduce the durability of the current first-line regimen for a\nsignificant proportion of patients. These patients would have to be switched to more expensive\nsecond-line or even third-line regimens. With higher levels of HIVDR, more resources would be\nneeded to treat the same number of patients, or more likely, fewer patients could be treated with\nthe same resources.\n\nTherefore, surveillance of HIVDR and implementation of effective responses are key to\npreserving the effectiveness of first-line ART which is the goal of any ART programme.\n\n4.4 Adverse drug reactions (ADRs)\nAn adverse drug reaction (ADR) is defined by WHO as \u201ca response to a drug which is noxious\nand unintended, and which occurs at doses normally used in man for the prophylaxis, diagnosis,\nor therapy of disease, or the modification of physiological function.\u201d Side Effect refers to the\nunintended effect of a health product occurring at doses normally used in man which is related to\nthe pharmacological properties of the drug.\n\nThe therapeutic benefits of ARV use far outweigh the risk, thus despite the ADRs and toxicities\nencountered with ARV use, they are still essential inpatient management. ARVs resulting in\nADRs that pose a serious threat to the health and well-being should be discontinued without\ndelay and necessary consultations made regarding the next line of actions.\n\n4.4.1 Classification of Adverse Drug Reactions (ADRs)\nThe WHO classifies ADRs into four categories based on severity. Severity is a subjective\nassessment made by the healthcare provider and/or patients. Despite being subjective, it is useful\nin identifying adverse reactions that may affect adherence or further harm that needs prompt\nintervention.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         49", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 2663, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "564eb76e-282a-440c-8f3f-2542b0bdc9bb": {"__data__": {"id_": "564eb76e-282a-440c-8f3f-2542b0bdc9bb", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "bed4a432-cc84-4d34-acf4-229a811f255c", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "fc096d59613c7c27ab8b63d926d9d8922ac78ccfe298739d7935e82ed176bfa5", "class_name": "RelatedNodeInfo"}}, "text": "Table 4.1: WHO Severity Grading of ADR\n\n  Severity Grade                                          Characteristics\n  1 \u2013 Mild ADR                                       \u00b7    Transient or mild discomfort (<48 hours)\n                                                     \u00b7    No limitation of activity\n                                                     \u00b7    No medical intervention or therapy required\n  2 \u2013 Moderate ADR                                   \u00b7    Mild to moderate limitation of activity\n                                                     \u00b7    Some assistance may be needed\n                                                     \u00b7    No or minimal medical intervention required\n  3 \u2013 Severe ADR                                     \u00b7    Marked limitation of activity\n                                                     \u00b7    Some assistance usually required\n                                                     \u00b7    Medical intervention or therapy required\n                                                     \u00b7    Hospitalization possible\n  4 \u2013 Life-Threatening ADR                           \u00b7    Extreme limitation of activity\n                                                     \u00b7    Significant assistance required\n                                                     \u00b7    Significant medical intervention or therapy required\n                                                     \u00b7    Hospitalization or hospice care probable.\n\n In the event of severe/life-threatening ADRs, the offending drug(s) must be discontinued and\n changed to another drug from within its class.\n\n 4.5 Drug toxicity\n This is the unwanted effect of drugs resulting from administration in excess of the required\n therapeutic dose, or accumulation of drugs in the body due to inefficient absorption, distribution,\n metabolism, or excretion. Some clinical conditions e.g. renal impairment and chronic liver\n disease may also predispose patients to drug toxicity. Drug toxicity can be detected clinically\n (history and clinical examination) and/or through laboratory testing (table 4.2).\n\n In the event of drug toxicity, dose adjustment is recommended where feasible; otherwise, the\n offending drug should be discontinued and changed to another drug from within its class.\n\n 4.5.1 Laboratory monitoring of toxicity:\n Laboratory monitoring of patients receiving ARVs for either HIV treatment or prophylaxis is\n very important for early detection and prevention of some ADRs. Abnormal laboratory values\n may be early warning signals preceding the clinical manifestations of some ADRs in patients\n receiving antiretroviral drugs. Symptom-related monitoring is useful and there are also several\n laboratory tests (but not routinely required) for assessing the safety and toxicity of ART,\n especially in high-risk clients.\n\n The table below shows the ARV drug class, clinical abnormality, and the laboratory test that\n could be used for its monitoring.\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                   50", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3043, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "06ffd5cf-14b6-4351-a619-69626d138beb": {"__data__": {"id_": "06ffd5cf-14b6-4351-a619-69626d138beb", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "de7b1f5b-e522-460a-8229-3890647ffb60", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "4fbc7a54b05ff96b36faf293ac5a4320bf5ebd99e55d15be9215f30fec9e91ea", "class_name": "RelatedNodeInfo"}}, "text": "Table 4.2 Common ADRs associated with ARV drugs and necessary laboratory tests\n\n Drug class Drug                      Common ADRs                       Risk factors                       Laboratory Tests\n NRTI            Abacavir             Hypersensitivity                  Presence of HLA-B*5701\n                                                                        gene                               CPK,\n                 (ABC)                Hepatotoxicity                                                       Liver enzymes\n\n                 Emtricitabine        Hepatotoxicity                                                       Liver enzymes\n                 (FTC)\n\n                 Lamivudine           Cough, diarrhoea, fatigue,                                           Non-specific\n                 (3TC)                malaria, headache,\n                                      lethargy, Nausea,\n                                      vomiting and pancreatitis\n                                      (in children\n                 Tenofovir            Renal Toxicity                    Underlying renal disease;          Creatinine,\n                 Disoproxil                                             Age >50 years old;                 Urinalysis\n                 Fumarate                                               BMI <18.5 or low body\n                 (TDF)                                                  weight (<50 kg), diabetes,\n                                                                        hypertension Concomitant\n                                                                        use of nephrotoxic drugs\n                                                                        or a boosted PI\n                                      Decreases in bone                 History of osteomalacia\n                                      mineral density                   (in adults) and rickets (in\n                                                                        children) and pathological\n                                                                        fracture Risk factors for\n                                                                        osteoporosis or bone\n                                                                        mineral density loss,\n                                                                        Vitamin D deficiency\n                 Zidovudine           Anaemia, leukopenia,              Baseline anaemia or                Full blood count\n                 (AZT)                neutropenia,                      neutropenia CD4+ cell 3            E/U/Cr\n                                                                        count of \u2264200 cells/mm             CPK\n                                      Lactic acidosis, severe           BMI >25 (or bodyweight\n                                      hepatomegaly with                 >75 kg) Prolonged\n                                      Myopathy                          exposure to NRTIs\n\n NNRTI           Efavirenz            CNS manifestations                Depression or other mental\n                 (EFV)                                                  disorder (previous or at           Liver enzymes\n                                                                        baseline), Daytime dosing Serum cholesterol\n                                      Hepatotoxicity                    Underlying HBV and HCV\n                                                                        co-infection, Concomitant\n                                                                        use of hepatotoxic drugs\n                                      Hypercholesterolemia              Risk factor(s) unknown\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                               51", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3884, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d48c8ee5-532b-4ee6-b396-91ad5cd6dc53": {"__data__": {"id_": "d48c8ee5-532b-4ee6-b396-91ad5cd6dc53", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "a062f72c-2684-4d5d-9054-7ecf04b56a57", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "aaa6e717af8412e6662af767e977d9772d9f4a5c9ca883e149a7ff2f9accb2d4", "class_name": "RelatedNodeInfo"}}, "text": "Drug class Drug                      Common ADRs                      Risk factors                       Laboratory Tests\n                                     Gynaecomastia                    Riskfactor(s) unknown\n                Nevirapine           Hepatotoxicity                   Underlying hepatic disease\n                                                                      HBV and HCV co-infection Liver enzymes\n                (NVP)\n\n                                     Severe skin rash and             High baseline CD4+ cell\n                                     hypersensitivity reaction,       count\n                                     including Stevens-\n                                     Johnson syndrome\nPI              Atazanavir/rito      Electrocardiographic             Pre-existing conduction            ECG\n                navir(ATV/r)         abnormalities (PR and            system disease\n                                     QRS interval                     Concomitant use of drugs\n                                     prolongation)                    which may prolong the PR\n                                                                      or QRS intervals\n                                                                      Congenital long QT\n                                                                      syndrome\n                                     Indirect                         Presence of UDP\n                                     hyperbilirubinemia               Glucuronyl transferase\n                                     (clinical jaundice)              1A1*28 (UGT1A1*28)\n                                                                      gene\n                                     Nephrolithiasis                  Previous history\n                Darunavir/riton      Hepatotoxicity                   Underlying hepatic                 Liver enzymes\n                avir(DRV/r)                                           disease, Concomitant use\n                                                                      of hepatotoxic drugs\n                                     Severe skin and\n                                     hypersensitivity reactions\n                Lopinavir            Hepatotoxicity                  Underlying hepatic disease          Liver enzymes\n                /ritonavir                                           HBV and HCV co-infection            Serum amylase\n                (LPV/r)                                              Concomitant use of\n                                                                     hepatotoxic drugs                   ECG\n                                     Pancreatitis                     Advanced HIV disease,              Lipid profile\n                                                                      alcohol\n\n                                     Arrhythmias                      People with pre-existing\n                                                                      conduction system disease\n\n                                     Dyslipidaemia                    Cardiovascular risk factors\n                                                                      as obesity and diabetes\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                             52", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3355, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "412b6170-56f2-4110-b46b-ea2a8243efdf": {"__data__": {"id_": "412b6170-56f2-4110-b46b-ea2a8243efdf", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b660ab5e-0cae-4cfc-b45b-cdfe638e5c7a", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "9a032a6b4518337b980c6f7b1cf2584d7bb0b59defa79d0c12ba4aaec1f7ad47", "class_name": "RelatedNodeInfo"}}, "text": "Drug class Drug\n\n               Ritonavir\n               (RTV)\n\n\n\nIntegrase      Dolutegravir\ninhibitors     (DTG)\n\n\n\n\n\n               Raltegravir\n               (RAL)\n\n\n\n\n\n\nCommon ADRs                      Risk factors                      Laboratory Tests\nDiarrhoea                        Riskfactor(s) unknown\nHepatotoxicity                   Underlying hepatic disease         Liver enzymes\nHyperglycaemia                   HBV and HCV co-infection Urinalysis, BSL-\nHyperlipidemia                                                      blood sugar level\n                                                                    Serum lipids\n                                                                    CPK, Uric acid\nHepatotoxicity                   Underlying hepatic                 Liver enzymes\n                                 disease, Concomitant use\n                                 of hepatotoxic drugs\nHypersensitivity reactions Risk factor(s) unknown\nInsomnia                         Risk factor(s) unknown\nIRIS, Neural Tube                PLHIV with AHD\nDefects (NTDs)\nRhabdomyolysis,                  Concomitant use of other           CPK\nmyopathy, myalgia.               drugs that increase the risk\n                                 of myopathy and\n                                 rhabdomyolysis, including.         Liver enzymes\n                                 statin\nHepatotoxicity,                  Risk factor(s) unknown\nSevere skin rash and\nhypersensitivity reaction\n\n                    Table 4.3: Common ADRs associated with drugs used in the management of Ois\n\n                      Drug                        Common ADRs                                                Laboratory\n                                                                                                             Tests\n\n                      Cotrimoxazole               Hypersensitivity, Steven Johnson\u2019s Syndrome, Anaemia and   CBC and Liver\n                                                  Liver problems                                             function test\n\n                      Isoniazid                   Liver problems, Musculoskeletal symptoms and GI symptoms   LFT\n\n                      Fluconazole                 CNS and GI symptoms\n\n                      Amphotericin B              Injection site reactions, hypersensitivity reactions, GI   E/U/Cr\n                                                  symptoms, musculoskeletal symptoms, respiratory symptoms,\n                                                  CNS symptoms, vision changes, low potassium, and dysuria\n\n                      Flucytosine                 Hypersensitivity, Hepatic disorders, Haematological,       LFT, E/U/Cr,\n                                                  Respiratory, Renal, GI and CNS disorders                   CBC & RBS\n\n                                   NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         53", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2954, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "bc0c97aa-a04a-47cc-a805-66382154f492": {"__data__": {"id_": "bc0c97aa-a04a-47cc-a805-66382154f492", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "61215856-3ddd-403b-8304-cb85383ea587", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "ff96da5c934b38a35b0b1367340fc45c418432cd58947f5ab05bde2b018c1bac", "class_name": "RelatedNodeInfo"}}, "text": "The severity grading of laboratory test abnormalities may guide prompt intervention and\nprevent the negative consequences of ADR.\n\n4.6 Steps to Recognize ADRs\n      1. Take adequate history and do a thorough physical examination of the patient\n      2. Establish time relationships, between start of therapy to the time of onset of the\n           suspected reaction.\n      3. Carry out appropriate laboratory investigations, where indicated\n      4. Check the pharmacological properties of the suspected drugs if required\n\n4.7 Who is to Report ADRs?\nAdverse drug reactions (ADRs) should be reported by Physicians, Pharmacists, Nurses,\nMedical laboratory scientists, other health and community health care workers, caregivers, and\npatients. The original copy should be sent to NAFDAC by the facility pharmacovigilance focal\nstaff, while the duplicate copy should remain in the patient's folder. The third copy should\nremain in the booklet at the Service Delivery Point. All completed booklets should be sent to the\npharmacovigilance focal staff for safekeeping.\n Table 4.4: Reporting Timelines\n\n  Type of ADR Report                                                                  Time frame for Reporting\n\n  Serious (expected and unexpected)                                                   15 days\n\n  Non-serious(unexpected)                                                             15 days\n\n  Non-serious (expected)                                                              Within 90 days\n\n  Foreign report (Spontaneous/published/study)                                        Within 90 days\n\n  Notification of change in nature, severity or frequency or risk factor 15 days\n\n  New information impacting on benefits \u2013 risk profile of product                     3 days\n  including international regulatory decisions\n\n 4.8 What ADRs Should be Reported\n     1.    All serious reactions (expected or unexpected) that one suspects for established or\n           well-known drugs\n     2.    All suspected reactions, including minor ones for new drugs\n     3.    If an increased frequency of a given reaction is observed\n     4.    All suspected adverse reactions associated with drug-drug, drug-food, or drug-food\n           supplement interactions and drug-disease interactions.\n     5.    ADRs during pregnancy and lactation\n     6.    ADRs occurring from an overdose or medication error\n     7.    Lack of efficacy of a medication, or when suspected pharmaceutical defects are\n           observed\n     8.    Reactions suspected of causing death, danger to life, admission to hospital,\n           prolongation of hospitalization, or birth defects.\n     9.    When in doubt whether the suspected adverse event/reaction is an ADR or not, you\n           must report to the National Pharmacovigilance Centre.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                    54", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2922, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "90eaa9ff-45b8-42fe-a21b-f90a50485759": {"__data__": {"id_": "90eaa9ff-45b8-42fe-a21b-f90a50485759", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "00a70fa1-3a19-4d4a-b79a-93ff9dc63b29", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "7607ad25fae1df3996a491f2deb771e637eaadb2b633a2676f033c5046a6f31d", "class_name": "RelatedNodeInfo"}}, "text": "4.9 Pharmacovigilance Data Collection and Reporting Process\nAll ADRs should be reported to the National Pharmacovigilance Centre using the NAFDAC\nADR form (yellow form). The following steps should be taken:\n\nFigure 4.1 Pharmacovigilance Reporting\n\nRefer to the NAFDAC website for all reported ADRs (https://www.nafdac.gov.ng/)\n\n4.10 Principles of Management of Adverse Drug Reactions\nEnsure strict adherence to the standard procedures outlined below for detecting, evaluating and\nreporting ADRs in ART/PMTCT Clinical Settings\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                      55", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 626, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d6462b09-8739-424d-a1f0-f7d7ec6fe987": {"__data__": {"id_": "d6462b09-8739-424d-a1f0-f7d7ec6fe987", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "4be95891-6fea-4401-9457-31c177535094", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "2258503b4d64be4bbbfe8f2637da303e88f8a6da40b9478c0de1b6a55b449aa4", "class_name": "RelatedNodeInfo"}}, "text": "Figure 4.2: Management of Adverse Drug Reactions\n\n                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  56", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 132, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ad42d765-1e7b-4ff6-8a26-70fa3b6b1448": {"__data__": {"id_": "ad42d765-1e7b-4ff6-8a26-70fa3b6b1448", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "32daecc7-b917-48b7-8049-1ac5b47f8b33", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "94ff47d43b4cb6e944e2309df5dcb3b506d89125a8536d85a689cb615ed61def", "class_name": "RelatedNodeInfo"}}, "text": "4.10.1 Management of Specific ARV Adverse Drug Reactions\nAdverse reactions associated with ARV drugs usually have a class similarity; however certain\ndrugs in each of the classes present more severe forms of adverse reactions than others. In the\nmanagement of adverse events, special attention should, therefore, be paid to drug-specific\nadverse reactions. For example, Zidovudine is implicated in ARV-induced anaemia more than\nany other ARV in the same class, just as Efavirenz is more likely to cause CNS toxicity than the\nother ARV drugs in the same class.\n    a)    Nucleoside Reverse Transcriptase Inhibitors (NRTIs): All NRTIs are capable of\n         inhibiting mitochondria DNA (mtDNA) gamma polymerase enzyme resulting in\n         mitochondrial toxicity. As NRTIs inhibit DNA polymerase, all tissues that have DNA\n         can be affected. The manifestation of NRTI adverse drug reaction is dependent on the\n         organ involved; there can be myopathy presenting with muscle weakness, bone marrow\n         disorders causing depression of haemopoiesis and leading to anaemia, leucopenia and\n         thrombocytopenia; lipolysis resulting in fat atrophy (lipoatrophy). It can cause\n         myelotoxicity and neuropathy when it affects peripheral neurons, thus precipitating\n         peripheral neuropathy. Though rare, prolonged usage of NRTIs may also affect\n         myocardial cells resulting in cardiomyopathy. Others include hepatitis, pancreatitis, and\n         lactic acidosis.\n    b) Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): They increase the3\n         incidence of severe hepatotoxicity in women with CD4+ cell count > 250cells/mm and3\n         men with CD4+ cell count > 400cells/mm . Other common reactions include skin rash\n         and CNS disorders.\n    c) Protease Inhibitors (Pis): PIs are potent CYP3A4 inhibitors hence many drug-drug\n         interactions can occur on co-administration with other drugs. ADRs due to PIs can be\n         severe. These include acute effects of diarrhoea, vomiting and hepatotoxicity; and long-\n         term toxicity which includes peripheral loss of subcutaneous fat (lipoatrophy), fat\n         accumulation within the abdominal cavity (protease paunch or crix-belly), fat\n         accumulation in the upper back (dorsocervical pad or buffalo hump), gynecomastia in\n         males, fat accumulation in the breast in females and fat accumulation in subcutaneous\n         tissue (peripheral lipomatosis). Management of acute ADRs includes reassurance and\n         symptomatic treatment as it clears within 4-6 weeks of therapy.\n    d)    Integrase Inhibitors: Neuropsychiatric (NP) symptoms have been reported with all\n         INSTIs, and their onset is usually described during the first few weeks after introduction.\n         Symptoms include headaches, reduced concentration, anxiety, irritability, dizziness,\n         insomnia, altered dreams, depression, unexplained pain, and more recently, mood\n         changes.\n\nAll INSTIs have been associated with mild increases in creatinine levels, usually without clinical\nsignificance, but caution is needed in patients with low eGFR (<30mls/min), when using other\nnephrotoxic drugs, such as TDF. There is also a potential risk of weight gain associated with\nDTG. Some of the following approaches may be helpful for patients on DTG:\n    \u00a7    Clinicians should avoid DTG for patients with a history of severe Neuro-Psychiatric\n         symptoms.\n    \u00a7    DTG should also not be given at the same time as supplements containing\n         Magnesium (Mg), or Zinc (Zn). These may be in multivitamins, certain laxatives,\n         or antacids, it is therefore important to know what other tablets your patients are taking\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           57", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3845, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "4deee8b6-f12f-4cfa-8afb-e31e731b2927": {"__data__": {"id_": "4deee8b6-f12f-4cfa-8afb-e31e731b2927", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "aca10965-e5f0-4bfe-a683-23ddfc07a07e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "7f03d0ca055df54d6fea283120a56b36fb6406f4e31e71ad7c2bb07aa52baea4", "class_name": "RelatedNodeInfo"}}, "text": "\u2022     If your patients are taking any of these, advise them to take their ARVs at least 2\n                 hours before or at least 6 hours afterwards\n     \u00a7     DTG may be given with calcium (Ca) or Iron (Fe) supplements if taken with food\n     \u00a7     Clinicians should monitor the body weight and BMI of patients.\n\nTable 4.3 Adverse drug reactions associated with the use of specific ARV drugs and their management\n\n Antiretrovira        Primary toxicities                            Minor                 Monitoring/Management\n l Drug                                                             toxicities\n\n Zidovudine           Anaemia, neutropenia, myopathy,               Blue to black         For anaemia:\n (AZT)                lipoatrophy or lipodystrophy [Risk            discolouration        \u00b7 Change to TDF and/or transfuse\n                      factors include -Baseline anaemia             of nails, nausea,\n                      or neutropenia; CD4+ cell count\n                      \u2264200 cells/mm3]                               and headache          \u00b7 Do not use AZT if Hb < 8.0 g/dl(PCV <24%)\n                      Lactic acidosis or severe                                           For myopathy, discontinue if CPK\n                      hepatomegaly with steatosis [Risk                                   rises. If AZT is being used in first-\n                      factors include -BMI >25 (or                                        line ART, substitute with TDF or\n                      bodyweight >75 kg); Prolonged                                       ABC. If AZT is being used in\n                      exposure to nucleoside analogues]                                   second-line ART, substitute with\n                                                                                          ABC\n\n Lamivudine           Pancreatitis, Liver toxicity                  Skin rash,            Discontinue if serum amylase\n (3TC)                Mild peripheral neuropathy                    headache              elevated. Restart when resolved or\n                                                                                          change to ABC\n\n Emitricitabine       Similar to lamivudine                         Occasional\n (FTC)                                                              hyperpigmentat\n                                                                    ion of skin\n                                                                    (palms/ soles)\n\n Tenofovir            Tubular renal dysfunction,                    Occasional GI         If creatinine clearance declines,\n Disoproxil           Fanconi syndrome [Risk factors:               intolerance           substitute with non-nephrotoxic\n Fumarate             Underlying renal disease; Older                                     drugs such as ABC or adjust the\n (TDF)                age; BMI <18.5 (or bodyweight                                       dosage. (See section on co-\n                      <50 kg); Untreated diabetes                                         morbidities)\n                      mellitus; Untreated hypertension;                                   If TDF is being used in first-line\n                      Concomitant use of nephrotoxic                                      ART, substitute with AZT or ABC.\n                      drugs or a boosted PI]                                              If TDF is being used in second-line\n                      Decreases in bone mineral                                           ART (after AZT use in first-line\n                      Density [Risk factors: History of                                   ART), substitute with ABC.\n                      osteomalacia and pathological\n                      fracture; risk factors for\n                      osteoporosis or bone loss]\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                58", "mimetype": "text/plain", "start_char_idx": 11, "end_char_idx": 3987, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "2049938f-f391-4b3b-93de-823d99929371": {"__data__": {"id_": "2049938f-f391-4b3b-93de-823d99929371", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "4f0832ef-abbd-4c06-94dd-f185435ddbb4", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "405bf357239f878a9a3aae3259d7420db633eebe7f7fecd364cd86c41706bed3", "class_name": "RelatedNodeInfo"}}, "text": "Lactic acidosis or severe\nhepatomegaly with steatosis [Risk\nfactors: Prolonged exposure to\nnucleoside analogues; Obesity]\nExacerbation of hepatitis B\n(hepatic flares) [Risk factors:\nDiscontinuation of TDF due to\ntoxicity]\n\n\n\n\n\nUse an alternative drug for hepatitis\nB treatment.\n\n\n                          Abacavir          Life-threatening hypersensitivity                          Discontinue therapy if\n                          (ABC)             reaction may occur in 3-9% of                              hypersensitivity develops. Abacavir\n                                            patients [Risk factors- the presence                       should never be used in that\n                                            of HLA-B*5701 Gene]                                        individual again.\n                                            Lactic acidosis may also occur                             If ABC is being used in first-line\n                                            with/without hepatic steatosis                             ART, substitute with TDF or AZT.\n                                                                                                       If ABC is being used in second-line\n                                                                                                       ART, substitute with TDF\n\n                       Nevirapine           Life-threatening skin rash and                             Low dose over first 2 weeks\n                       (NVP)                hypersensitivity reaction (Stevens-                        minimizes rash occurrence. If mild\n                                            Johnson syndrome) which occurs                             or moderate (Grade 1/2) continue\n                                            in less than 5% of patients and                            cautiously or substitute with EFV.\n                                            usually within 8 weeks of treatment                        If severe discontinue NVP and\n                                            DRESS syndrome (drug rash,                                 permanently if hepatitis confirmed.\n                                            eosinophilia, and systemic\n                                            symptoms) manifesting as fever,                            Change to EFV.If the person cannot\n                                            arthralgia, etc.                                           tolerate either NNRTI, use boosted\n                                            Hepatotoxicity [Risk factors:                              PIs\n                                            Underlying hepatic disease; HBV\n                                            and HCV co-infection;\n                                            Concomitant use of hepatotoxic\n                                            drugs; CD4 + cell count>250\n                                            cells/mm3 in women; CD4+ cell\n                                            count >400 cells/mm3for men; First\n                                            month oftherapy (if lead-in dose is\n                                            not used)\n\n                        Efavirenz          Persistent central nervous system                Dizziness  Rash i n 10% but rarely severe in\n                        (EFV)              toxicity (such as abnormal dreams,                          <1%; CNS symptoms often resolve\n                                           hallucination, insomnia, amnesia,                           2-4 weeks.\n                                           depression or mental confusion).                            EFV is contraindicated in patients\n                                           CNS side effects occur in about                             who already have psychiatric\n                                           50% of pati       ents (usually self-                       manifestations.\n                                           limiting) [Risk factors: Depression\n                                           or other mental disorder (previous                          Change to NVP. If the person\n                                           or at baseline); Daytime dosing]                            cannot tolerate either NNRTI, use\n                                           Hepatotoxicity [Risk factors:                               boosted PIs\n                                           Underlying hepatic disease- HBV\n                                           and HCV co-infection,\n                                           Concomitant use of hepatotoxic\n                                           drug]\n\n                                     NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                       59", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 4828, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8882f48e-056c-4b16-84f1-858eed3485a0": {"__data__": {"id_": "8882f48e-056c-4b16-84f1-858eed3485a0", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "08ac72bf-393c-4f59-84cb-e2a19687dabc", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "7664d4c0a4d430c656a0b0c51cde709cd475e156c273ec69b496ab61951f6ba8", "class_name": "RelatedNodeInfo"}}, "text": "Convulsions[Risk factor: History\n                     of seizure]\n                     Hypersensitivity reaction, Stevens-\n                     Johnson syndrome. Mobiliform\n                     rash may appear but usually not\n                     life-threatening\n                     Potential risk of neural tube birth\n                     defects (very low risk in humans)\n                     Male gynecomastia.\n\nEtravirine           Severe skin rash; hypersensitivity           GI Intolerance,   Monitor liver enzymes and lipids.\n(ETR)                reactions (Stevens-Johnson                   rash              Rarely discontinue (<2%) due to\n                     syndrome), Erythema multiforme,                                adversereaction.\n                     hepatotoxicity, lipid abnormality                              Limitedoptions are available\n                     and psychiatric disorders\nAtazanavir/          Electrocardiographic abnormalities           Nausea and       Clinical jaundice is cosmetic and\nritonavir            (PR interval prolongation) [Risk             diarrhoea, skin   not related to hepatitis or liver\n(ATV/r)              factors: Pre-existing conduction             rash              damage. Substitute only if\n                     disease; Concomitant use of other                              adherence is compromised\n                     drugs that may prolong the PR                                  Monitor liver enzymes\n                     interval]\n                     Indirect hyperbilirubinaemia                                   Change to LPV/r or DRV/r. If\n                     (clinical jaundice) [Risk factors:                             boosted PIs are contraindicated\n                     Underlying hepatic disease HBV                                 and NNRTIs have failed in\n                     and HCV co-infection;                                          first-line ART, consider integrase\n                     Concomitant use of hepatotoxic                                 inhibitors\n                     drugs]\n                     Nephrolithiasis and risk of\n                     prematurity [Risk factor unknown]\n\nLopinavir/rito       Electrocardiographic                         Headache,         Diarrhoea is rarely severe should\nnavir (LPV/r)        abnormalities (PR and                        weakness,         be managed with antispasmodics-\n                     QT interval prolongation,                    nausea,           usually resolves after weeks to\n                                                                  vomiting,         months of therapy.\n                     torsades de pointes) [Risk factors:          diarrhoea and\n                     People with pre-existing                     skin rash\n                     conduction system disease;                                     If LPV/r isused in first-line ART\n                     Concomitant use of other drugs                                 for children, use an age-\n                     that may prolong the PR interval]                              appropriate NNRTI (NVP for\n                     QT interval prolongation [Risk                                 children younger than 3 years and\n                     factors: Congenital long QT                                    EFV for children 3 years and\n                     syndrome; Hypokalaemia;                                        older). ATV can be used for\n                     Concomitant use of drugs that                                  children older than 6 years\n                     may prolong the QT interval]                                   If LPV/r is used in second-line\n                     Hepatotoxicity [Risk factors:                                  ART for adults, use ATV/r or\n                     Underlying hepatic disease;                                    DRV/r. If boosted PIs are\n                     HBV and HCV co-infection;                                      contraindicated and the person\n                     Concomitant use of hepatotoxic                                 has failed on treatment with\n                     drugs]                                                         NNRTI in first-line ART,\n                                                                                    consider integrase inhibitors\n                     Pancreatitis [Risk factors:\n                     Advanced HIV disease]\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                            60", "mimetype": "text/plain", "start_char_idx": 21, "end_char_idx": 4618, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8691d04a-9db0-4ecc-9d0c-758b6ee5260b": {"__data__": {"id_": "8691d04a-9db0-4ecc-9d0c-758b6ee5260b", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "3a99e139-e729-4e22-a611-e8305b38869c", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "db003dc859cfb905eb37c77787836f506dd018b668e88ea0f687af8d7bb5ef06", "class_name": "RelatedNodeInfo"}}, "text": "Risk of prematurity, lipoatrophy or\n                                          metabolic syndrome,\n                                          dyslipidaemia or severe diarrhoea\n                                          [Risk factors unknown]\n\nDarunavir/rito      Hepatotoxicity [Risk factors:\nnavir (DRV/r)       Underlying hepatic disease HBV\n                    and HCV co-infection,\n                    Concomitant use of hepatotoxic\n                    drugs]\nDarunavir/rito      Hepatotoxicity [Risk factors:\nnavir (DRV/r)       Underlying hepatic disease HBV\n                    and HCV co-infection,\n                    Concomitant use of hepatotoxic\n                    drugs]\n                    Severe skin and hypersensitivity\n                    reactions [Risk factors:\n                    Sulfonamide allergy]\nIf DRV/r is being used in second-\nline ART, substituting with ATV/r\nor LPV/r can be considered.\nWhen it is used in third-line ART,\nlimited options are available\nIf DRV/r is being used in second-\nline ART, substituting with ATV/r\nor LPV/r can be considered.\nWhen it is used in third-line ART,\nlimited options are available\n\n\n\n\nRaltegravir         Rare, -hypersensitivity, acute\n(RAL)               renal failure\n\n\n\n\nMyopathy,            Limited options are available\nmyalgia, mild\nto moderate\nnausea,\nheadache and\ndiarrhoea\n\n                      Dolutegravir        Hepatotoxicity                               Insomnia,            Monitor liver function and toxicity\n                      (DTG)               Severe allergic reactions                    headache             may worsen with existing hepatitis\n                                          (hypersensitivity)                                                B or C\n                                                                                                            Patient should be advised to take\n                                                                                                            drugs in the morning\n\n                     4.11 Prevention of Adverse Drug Reactions\n                     Applying the principles of rational use of medicines can prevent most ADRs, some of the\n                     principles include the following:\n                         \u00a7     Use of few drugs, whenever possible\n                          \u00a7    Use drugs that you are familiar with\n                          \u00a7    Do not change therapy from known drugs to unfamiliar ones without good reason\n                          \u00a7    All patients commencing ARV should be properly counselled on the ADRs related to the\n                               medications, preventive measures, where applicable, and what to do when it occurs or is\n                               suspected. The healthcare provider should be very knowledgeable about this\n                          \u00a7    Be vigilant and look out for these adverse effects when initiating therapy and during\n                               follow-up.\n                          \u00a7    Encourage patients to be actively involved in ADR reporting. ADR monitoring tools can\n                               be made available for patients to document ADRs they are experiencing while on ART;\n                               and this can be validated by the HCW during clinic visits.\n\n                                   NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                             61", "mimetype": "text/plain", "start_char_idx": 42, "end_char_idx": 3499, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "a96499cd-fceb-4763-99a1-75b5a586b424": {"__data__": {"id_": "a96499cd-fceb-4763-99a1-75b5a586b424", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "829886fb-154c-42c1-b723-38838df7fc81", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "993701f576b6cae91dd721a6028c93d3c4c750c5df4b5719d9f6457534145936", "class_name": "RelatedNodeInfo"}}, "text": "4.12 ARV Drug Interactions\nDrug interaction refers to the modification of the action of one drug by another, and can be\nuseful, of no consequence, or harmful. Multiple drug use (polypharmacy) is extremely common\nin ART/PMTCT settings, so the potential for drug interaction is enormous. Adverse interactions\nmay be catastrophic but are often avoidable. Patients receiving care for HIV infection have the\nlikelihood of experiencing various drug interactions because of the drugs in ART combinations,\nco-administered drugs for OIs, and co-administered drugs for other concurrent ailments. There\nare two major groups of ARV drug interactions:\n     \u00a7     Non-ARV vs. ARV Drug Interactions\n     \u00a7     ARV vs. ARV Drug Interactions\nAs a rule of thumb, most ARV drugs are metabolized by the Cytochrome P450 3A4 isoenzyme\nin the liver. Many other drugs are also metabolized by this enzyme and ARV drugs will either\nraise or lower these other drug levels and either be increased or decreased themselves by these\ninteractions. All PIs, as well as all current clinically used NNRTIs, are metabolized by CYP 450\nenzyme cascade (particularly CYP 3A4) which can be induced and/or inhibited by several drugs\nthus the possibilities of many drug/drug interactions.\n\nTable 4.4 Important ARV drug interactions\n  Drug             Interaction                               Action\n\n  EFV; NVP         Decreased level of Atazanavir             Avoid the combination or consider increase LPV/r\n                   and LPV/r significantly occur             dose to 533mg/133mg twice daily in PI-experienced\n                   when used concomitantly with              patients.\n                   EFV or NVP\n\n  TDF              Concomitant use with ATV:                 Dose: ATV/r (300/100 mg) daily co-administered\n                   TDF level is increased by 24%-            with TDF 300 mg daily. Avoid concomitant use\n                   37% and Atazanavir level is               without RTV. If using TDF and H2 receptor\n                   decreased by 25%                          antagonist in ART-experienced patients, use ATV/r\n                                                             (400 mg/100 mg) daily. Monitor for TDF-associated\n                                                             toxicity.\n\n Abacavir (ABC) is not currently associated with any clinically significant pharmacokinetic drug\ninteractions. However, a large dose of ethanol (>0.7g/kg body weight) increases ABC plasma\nAUC by 41% as well as prolongs ABC elimination half-life by 26%. Patients must therefore be\ncautioned on alcohol use during ABC therapy.\n\n4.12.1 Interactions Between Contraceptives and Antiretroviral Drugs\nIn line with standard recommendations, ALHIV can use all available contraceptive methods,\nincluding hormonal contraceptives, implantable devices, intrauterine devices, the transdermal\npatch, and vaginal ring.\n\nMany PIs and NNRTIs alter the metabolism of oral contraceptives and may reduce the efficacy\nof oral contraceptive agents or increase the risk of estrogen \u2013 or progestin \u2013 related adverse\neffects. Integrase strand transfer inhibitors (specifically raltegravir) appear to have no\ninteraction with estrogen-based contraceptives. Dolutegravir (DTG) has been found safe and\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                    62", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3381, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "2391d76b-7176-4234-8795-d79529734513": {"__data__": {"id_": "2391d76b-7176-4234-8795-d79529734513", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "288b233a-0ab6-4bbf-ae49-2426baf85a8b", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "ba20957ccabf7e4e0c053343f542b46fa9a18b08e45c0518dab7a34253d85519", "class_name": "RelatedNodeInfo"}}, "text": "effective to use with hormonal contraceptives among women living with HIV.Unless there is\nclinical evidence or concern of bone fragility, providers may use depot medroxyprogesterone\nacetate (DMPA) with or without ART (specifically TDF), as an effective long-term\ncontraceptive.\n\nAdditional resources for other possible drug interactions can be found in the following sites:\nwww.hiv-druginteractions.org\nwww.hiv-interactionslite.org\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                    63", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 531, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "f9739e48-e043-4d18-95af-627f6d9acd5d": {"__data__": {"id_": "f9739e48-e043-4d18-95af-627f6d9acd5d", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "9ede276c-b433-4e3b-ac80-42315c89b1d9", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "7121cbf2beea7d23e3b71da03d87aa4d88285f17f60eca4b18a372dfc8eaded7", "class_name": "RelatedNodeInfo"}}, "text": "List of Contributors\nPharm. Ologun Taiye Joseph\nPharm. Atu Uzoma\nPharm. Chidi OKorie\nTuraki Abdul\nMr Ogbeke Geoffrey Ighowho\nDr Fatimah Jajere\nProf. Ebun Adejuyigbe\nDr Hadiza Khamofu\nOluwakemi Sowale\nDr Opeyemi Abudiore\nPharm Anthonia Ibeme\nNkiru Anonyuo\nMr Batholomew Igwe\nTimothy Yakubu\nPharm. Adebanjo Adeyemi Olowu\nDr Kenneth Anene Agu\nOmeh Idoko Onuche\nPharm. (Dr) Peter Agada\nPharm. Agboola Oguntonade\nPharm Usman Ismail\nNkem Chukwuemeka\n                                                     Chapter 4\nDirector, Logistics Unit NASCP\nAssistant Director, Logistics Unit NASCP\nPrincipal Pharmacist NASCP\nPrincipal Pharmacist Technician NASCP\nSenior Scientific Officer NASCP\nACRO NAFDAC\nMember NTTA / Paediatrician OAUTH, Ile Ife\nChief of Party FHI360\nSenior Analyst CHAI\nSenior Analyst CHAI\nForecasting & Supply Planning Manager GHSC-PSM\nPlan and Source Director GHSC-PSM\nHealth System Strengthening and Logistics Specialist FHI360\nSenior Laboratory Advisor ICAP\nSupply Chain Lead JHPIEGO\nAssociate Director, Howard University Pace Center\nAssociate Director, Howard University Pace Center\nState Program Manager, Howard University Pace Center\nPharmacy Advisor Heartland Alliance\nIntern NAFDAC\nSouth-South Deputy ASWHAN\n\n                               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  64", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 1319, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "960b0915-b8ce-4265-84a2-f19008a46fd0": {"__data__": {"id_": "960b0915-b8ce-4265-84a2-f19008a46fd0", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "aa9f7bb3-6c91-414f-92d2-f3af1d44163e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "bfd8fef7bda87b1540a3ebbc37b87012f0575ee8877b662c967b99ab349f004d", "class_name": "RelatedNodeInfo"}}, "text": "5. ADHERENCE TO\n         ANTIRETROVIRAL\n                  THERAPY\n\nWhat\u2019s Inside:\n5.1 Introduction\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u202666\n 1.1 Objectives of the Guidelines\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\n5.2 Adherence Preparation for ART\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026...66\n 1.2 Epidemiology of HIV in Nigeria\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\n5.3 On-going adherence for clients on ART\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.67\n 1.3 Natural History of HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\n5.4 Monitoring of Adherence\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026.67", "mimetype": "text/plain", "start_char_idx": 9, "end_char_idx": 416, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "408a2dd0-b4c7-4ee2-a0e3-cc7825ba3f3b": {"__data__": {"id_": "408a2dd0-b4c7-4ee2-a0e3-cc7825ba3f3b", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "d24f9f2b-9c09-470c-9809-e2bd05d63366", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "09a274c3c807c28030fa2224b0959d1e409b4b8d71cb28d5e40438ae6c8267e1", "class_name": "RelatedNodeInfo"}}, "text": "5.1 Introduction\nAdherence is the patients' behaviour of taking drugs correctly based on mutual agreement\nbetween the patient and health care provider. It is the act of taking the right drugs, at the right\ndose, at the right frequency, and at the right time.\n\nAdherence to ART is necessary for achieving sustained suppression, delaying the onset of drug\nresistance, enhancing immune recovery, and improving the overall health and quality of life of\nthe individual. Poor or non-adherence to ART results in suboptimal viral suppression which may\nlead to the emergence of drug resistance and loss of future treatment options.\n\nAll persons on ART should receive adherence support which could be face-to-face and/or virtual.\nFace-to-face and virtual adherence support may be provided by health workers, family, friends,\ntreatment partners, and support groups. Adherence support IEC materials in the form of posters\nand patient information leaflets are also essential.\n\n5.2 Adherence Preparation for ART\nAdherence counselling and support has become even more important with the advent of the test\nand treat policy. This is because we have asymptomatic persons initiated on ART. It is\nrecommended that patients should undergo adherence preparation before they commence ART.\nIt is also recommended that adherence preparation should be implemented as an ongoing\nmultidisciplinary task that involves as many relevant health workers as possible that are involved\nin the care of the patient including the doctor, pharmacists, laboratory scientists, nurses, and the\nofficer officially designated as adherence counsellor.\n\nHealth workers should note that the success of any adherence strategy adopted depends on:\n     \u00b7    Information and education provided to clients before the initiation of ART\n     \u00b7    Assessing their understanding of the information provided\n     \u00b7    Willingness and readiness for the client to commence treatment\n     \u00b7    Assessing and addressing barriers to initiating ART\n\nAdherence counselling is central to any adherence strategy and should:\n     \u00b7    Provide basic information on HIV and its manifestations.\n     \u00b7    Provide information on ARV medication which should include dosing, frequency,\n          duration, and adverse effects of ARV medications including how the medications should\n          be taken and what to do in case of missed dose.\n     \u00b7    Provide information on ART and the benefits of early initiation.\n     \u00b7    Highlight the importance of 100% adherence, which implies not missing any dose.\n          Emphasize that non-adherence is the single most important factor that can lead to the\n          development of drug resistance.\n     \u00b7    Provide information to the patient in whom ART initiation will be delayed due to AHD\n          (e.g. information on the increased risk of mortality when patients with AHD are\n          commenced on certain ARVs such as DTG etc.).\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           66", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3016, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "328023d9-9dda-4b54-b343-992b402c667b": {"__data__": {"id_": "328023d9-9dda-4b54-b343-992b402c667b", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "dacb2b81-a024-4641-92dc-c50462e62f41", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "de1ff65c89dc0d33d92596978892c6ded5cb9bf30ae3466ad8407d9fa490b911", "class_name": "RelatedNodeInfo"}}, "text": "5.3 On-going adherence for clients on ART\nContinuous adherence counselling is essential in ART and should be accessible to every patient\non ART. This should include adherence assessments and documentation at every clinic visit;\nemphasis should be on the importance of continued adherence, good nutrition, and involvement\nof support systems (relatives, friends, peers and/or community support personnel). Ongoing\nadherence support should be face-face or virtual. When provided by health workers, the checklist\nmust be used to document the interaction, and this should be filed in the client's folder. Barriers\nto adherence should also be assessed and addressed.\n\n5.4 Monitoring of Adherence\nSustained viral suppression is dependent on adherence to ARVs. Adherence monitoring provides\nan opportunity to reinforce the positive behaviour of the adherent patient, and to flag patients that\nrequire support to improve adherence. Adherence in many studies is measured by expressing the\nnumber of doses taken as a percentage of the number of doses prescribed. For example, if 20\ndoses are prescribed and 19 doses are taken, adherence is 95%. This translates to missing one\ndose in ten days on a twice-daily regimen.\n\nEffective monitoring of adherence involves a combination of approaches based on resource\ncapacity (human/ financial), acceptability by client and providers, and comprehension of the\nlocal context. These include:\n     a.   Viral load monitoring: This is considered the gold standard for monitoring adherence\n          and treatment success. Where the viral load is not effectively suppressed an adherence\n          intervention should precede a repeat viral load test. Viral load monitoring has a high\n           likelihood to motivate adherence by engaging clients in the process of monitoring their\n          own results and understanding the meaning of their results.\n     b.   Pharmacy refill records: These records document the dates a client collected their\n          ARVs. Irregular collection may indicate adherence challenges. As with other adherence\n          assessment methods, pharmacy refill records may over-estimate adherence, as\n          collecting ARVs does not guarantee that they are being taken or taken correctly. This is\n          however an acceptable proxy.\n     c.   Self-reporting: This is a quick and inexpensive approach to adherence monitoring. It is\n          easily carried out in clinical settings and frequently used in routine care; however, it is\n          subject to recall bias.\n     d.   Pill counts: This involves a physical count of the remaining pills at each pharmacy refill\n          visit. It is used to compare the actual to the expected consumption of ARVs for a given\n          period. The effectiveness of pill counting is limited by the fact that some clients may\n          discard tablets not taken before their routine clinic visits leading to over-estimated\n          adherence. Additionally, the time required by health providers to conduct pill counts may\n          not be available, especially in resource-limited settings. Other approaches may include\n          electronic methods e.g. Medication Event Monitoring System (MEMSCap). This\n          involves the use of an electronic device that monitors the dates and time the pill bottle is\n          opened. The bottle opening represents medicine intake. Another method that can be used\n          is the quantification of drug levels in body fluids (plasma, urine, saliva) of clients.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                            67", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3608, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ad951af6-e7d6-458d-8e1c-71a45eeb3170": {"__data__": {"id_": "ad951af6-e7d6-458d-8e1c-71a45eeb3170", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "411fe102-d94f-4a4b-8592-293dc7c80182", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "825b0c582cb10f59fc13c8e066c37b98d36263d2ccc2f83cfa61a74700019934", "class_name": "RelatedNodeInfo"}}, "text": "5.4.1 Factors known to improve adherence\nThe following factors have been associated with high adherence rates:\n     \u00a7      Increased access to ART.\n     \u00a7      Individual patients, family, peers, and friends, community members, or treatment-\n            supporter engagement in adherence education and support.\n     \u00a7      Family-centred care when more than one family member is infected with HIV\n     \u00a7      Continuous and effective adherence counselling, which includes knowledge and\n            understanding of HIV infection, course of treatment, and expected adverse reactions and\n            what to do in the event of an adverse reaction occurring.\n     \u00a7      Drug regimen simplicity e.g. Fixed Drug Combination (low pill burden)\n     \u00a7      The use of drugs with fewer adverse effects.\n5.4.2 Factors associated with poor adherence\n\n                Patient factors                             Treatment Factors                         Patient-Provider\n             Self-efficacy (belief in                     Drug toxicity                                  Relationship\n             one\u2019s ability to succeed)                    High pill burden                           Poor patient-caregiver\n             regarding adherence.                         Long duration of                           relationship\n             Substance abuse e.g.                         treatment                                  Lack of trust\n             Active drug or alcohol                       Complexity of the                          Poor conception of\n             use                                          treatment                                  maintenance of client\u2019s\n              Lack of social support                      Medication side effects                    confidentiality\n             Incarceration                                                                           Lack of empathy/\n             Pregnancy-related                                                                       warmth\n             conditions                                                                              Poor communication\n             Inability of patients to                     Clinical Environment                       skills\n             identify their medications                   Distance to facility                       Stigma and\n             Lack of patient                              Poor quality of adherence                  discrimination\n             education.                                   counselling                                Lack of client\u2019s\n             Forgetfulness                                Clinic staff attitude                      openness/ cooperation\n             Stressful life events                         Cost of treatment\n             Self-stigmatization                          Perceived benefits versus\n                                                          barriers e.g.\n             Health status e.g. severe                    discrimination and\n             illness, dementia, mental                    stigmatization\n             health                                       Perceived lack of\n                                                          confidentiality\n                                                          Unpleasant past\n                                                          experiences\n                                                          Long waiting time\n\nFigure 5.1: Factors associated with poor Adherence\n\n                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                68", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3650, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "25eb9292-1d8f-4b0d-9b2c-5ebc8b414c17": {"__data__": {"id_": "25eb9292-1d8f-4b0d-9b2c-5ebc8b414c17", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "95a4dc29-15e1-460c-a82c-bdcbaa259275", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "15a6c4c81a54f8e7d80eb9a83a7d0ef43b49cc52c00bf5f0b7c4e47d23ec1bc4", "class_name": "RelatedNodeInfo"}}, "text": "5.4.3 Adherence in Specific Populations\nWhile stigma, discrimination and health facility challenges are cross-cutting issues affecting\nadherence, some factors are peculiar to specific populations:\n\nTable 5.1: Adherence in specific populations\n\n  Population                        Factors affecting adherence\n\n  Infants and young                 \u00b7 Poor taste and large volumes of liquid formulations\n  children                          \u00b7  Large pill size, pill burden, and difficulty in swallowing pills.\n                                    \u00b7  Changing dosage requirement in relation to weight gain\n                                    \u00b7  Inadequate nutrition\n                                    \u00b7  Identification of responsible caregivers and a family-centred approach\n                                       would improve adherence               .\n  Adolescents                       \u00b7 Psychosocial factors such as peer pressure\n                                    \u00b7  Limited adolescent-friendly health services including skilled health\n                                       workforce\n                                    \u00b7  The transition from paediatric to adolescent care\n                                    \u00b7  Limited adolescent-tailored treatment literacy and adherence training tools\n                                    \u00b7  Disclosure issues\n\n  Pregnant and                      \u00b7 Nausea and vomiting\n  postpartum women                  \u00b7  Post-partum depression\n                                    \u00b7  Non-disclosure to significant persons\n                                    \u00b7  Inadequate awareness and knowledge of HIV and PMTCT\n\n  People with                       \u00b7 Use of alcohol and substances abuse can lead to forgetfulness\n  substance use and                 \u00b7  Poor comprehension of treatment plans\n  mental health                     \u00b7  Drug interaction and ADRs\n  conditions\n  Key populations                   \u00b7 Stigma and discrimination\n  including prisoners               \u00b7  Poor access to health services\n                                    \u00b7  Absence of health care which targets their specific needs\n                                    \u00b7  Risk of drug-drug interaction\n\n  Persons with                      \u00b7 Poor access to health facilities\n  disability                        \u00b7  Lack of appropriate patient education channels (e.g. for visually and\n                                       hearing impaired)\n\nHealth workers are required to take note of the adherence challenges peculiar to each of the\ngroups and design for each patient an individualized adherence plan that adjusts for their\nlifestyle, work, and social environment.\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                       69", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2774, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6b224616-5935-4159-b18e-8a8471f44854": {"__data__": {"id_": "6b224616-5935-4159-b18e-8a8471f44854", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "c26dcb6a-0101-4115-aacc-a83af3ce0c1d", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "38c78a7778a71495882b1ee28b93bc8a3d9d0f669dba6b0142c3c9321cf95ba7", "class_name": "RelatedNodeInfo"}}, "text": "5.4.4 Recommendations for improving adherence\nThe following can be useful to improve patient adherence to ART:\n     \u00a7     Treatment education for patients and treatment supporters\n     \u00a7     Treatment-supporter involvement\n     \u00a7     Peer health education/peer counsellors\n     \u00a7     Routine assessment and reinforcement of adherence during follow up\n     \u00a7     The use of Fixed-Dose Combination (FDC) and drugs with lower dosing frequency\n     \u00a7     Reminders and patient engagement tools (e.g. a cell phone, SMS text messages, alarm\n           clock, calendars, social media platforms etc.)\n     \u00a7     Convenient ARV packs\n     \u00a7     Follow up visits before ARV supplies are exhausted\n     \u00a7     Positive feedback on health improvements\n     \u00a7     Nutritional assessment, care, and support\n     \u00a7     Prevent and/or adequately manage ADR\n     \u00a7     Address lifestyle factors e.g. alcohol abuse\n     \u00a7     Adapting therapy to the client's lifestyl\n     \u00a7     Minimizing out-of-pocket payments at the point of care as much as possible\n     \u00a7     Encourage participation in support groups\n     \u00a7     Improved social support\n     \u00a7     Directly Observed Therapy \u2013where possible\n     \u00a7     Cognitive-behavioral therapy and behavioral skill training\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                    70", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1345, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "5fa6d07e-2207-4164-8cac-d5529fddefea": {"__data__": {"id_": "5fa6d07e-2207-4164-8cac-d5529fddefea", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "097a82c5-a184-4dea-be84-8e1cf6734d96", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "795db1344fa02b19c241e35f63d1def2a950b26277e53e699e4657ae9d1f466e", "class_name": "RelatedNodeInfo"}}, "text": "List of Contributors\nPharm. Ologun Taiye Joseph\nPharm. Atu Uzoma\nPharm. Chidi OKorie\nTuraki Abdul\nMr Ogbeke Geoffrey Ighowho\nDr Fatimah Jajere\nProf. Ebun Adejuyigbe\nDr Hadiza Khamofu\nOluwakemi Sowale\nDr Opeyemi Abudiore\nPharm Anthonia Ibeme\nNkiru Anonyuo\nMr Batholomew Igwe\nTimothy Yakubu\nPharm. Adebanjo Adeyemi Olowu\nDr Kenneth Anene Agu\nOmeh Idoko Onuche\nPharm. (Dr) Peter Agada\nPharm. Agboola Oguntonade\nPharm Usman Ismail\nNkem Chukwuemeka\n                                                     Chapter 5\nDirector, Logistics Unit NASCP\nAssistant Director, Logistics Unit NASCP\nPrincipal Pharmacist NASCP\nPrincipal Pharmacist Technician NASCP\nSenior Scientific Officer NASCP\nACRO NAFDAC\nMember NTTA / Paediatrician OAUTH, Ile Ife\nChief of Party FHI360\nSenior Analyst CHAI\nSenior Analyst CHAI\nForecasting & Supply Planning Manager GHSC-PSM\nPlan and Source Director GHSC-PSM\nHealth System Strengthening and Logistics Specialist FHI360\nSenior Laboratory Advisor ICAP\nSupply Chain Lead JHPIEGO\nAssociate Director, Howard University Pace Center\nAssociate Director, Howard University Pace Center\nState Program Manager, Howard University Pace Center\nPharmacy Advisor Heartland Alliance\nIntern NAFDAC\nSouth-South Deputy ASWHAN\n\n                               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  71", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 1319, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "fa861445-8f3b-42e4-9894-649649799d13": {"__data__": {"id_": "fa861445-8f3b-42e4-9894-649649799d13", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "0763e7f4-f513-4e9f-b368-f75ce9df57f4", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "6f5f12d28d87fa43d269f7d83bab09a3a2fcc86de8b74a74856b38fdd24aa2ca", "class_name": "RelatedNodeInfo"}}, "text": "6. PREVENTION OF MOTHER\n        TO CHILD TRANSMISSION\n               OF HIV INFECTION\n\nWhat\u2019s Inside:\n6.1 Introduction \u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026...73\n 1.1 Objectives of the Guidelines\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\n6.2 Mother-to-Child Transmission of HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026...73\n 1.2 Epidemiology of HIV in Nigeria\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\n6.3 Pre-ART Care for HIV-positive pregnant women\u2026\u2026\u2026\u2026\u2026.78\n 1.3 Natural History of HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\n6.4 Use of Antiretroviral Therapy for PMTCT\u2026\u2026\u2026\u2026\u2026\u2026\u2026....80\n6.5 Management of HIV positive women in labour,\n    delivery and within 72 hours of delivery\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026...82\n6.6 PMTCT/TB integration services\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026......84\n6.7 Care and Support of the HIV-Exposed Infant\u2026\u2026\u2026\u2026\u2026\u2026....86\n6.8 Special Considerations for Adolescent and\n    Young Women in PMTCT\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026.......90\n6.9 Linkage of PMTCT with comprehensive\n    HIV Treatment, Care and Support Services\n    for Mothers and Infants\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026....91", "mimetype": "text/plain", "start_char_idx": 6, "end_char_idx": 897, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "df2bcbc9-d92a-45e4-b23e-2809e45cab81": {"__data__": {"id_": "df2bcbc9-d92a-45e4-b23e-2809e45cab81", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "0c345946-9b78-4886-8358-15366638611c", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "7b4d14338c018164f17ed6f9f5a47c07aeb5838cbe29d5d1a3ddd771e2dfcc80", "class_name": "RelatedNodeInfo"}}, "text": "6.1 Introduction\nHIV can be transmitted from an infected mother to her child during pregnancy and delivery, and\nsubsequently through breastfeeding. This mother-to-child transmission of HIV (MTCT) is also\nreferred to as vertical transmission while measures to prevent its occurrence are the Prevention\nof Mother-to-Child Transmission (PMTCT). Given the successes recorded in the PMTCT, the\nglobal community is moving towards the elimination of Mother to Child Transmission of HIV\n(eMTCT).\n\n6.2 Mother-to-Child Transmission of HIV\nIn the absence of any preventive measures, the rate of occurrence of MTCT is about 25-40%\n(Figure 6.1). This mode of HIV transmission is responsible for most HIV infections in children.\nThe following factors have been associated with increased risk of MTCT in any population, high\nprevalence of HIV among women of reproductive age and their partners, low contraceptive use\nresulting in unintended pregnancies among HIV positive women. Increased risk of MTCT in a\nHIV positive woman during pregnancy, labour, delivery and breastfeeding has been associated\nwith high maternal viral load (from new or re-infection, advanced disease or treatment failure);\nwide range of infections, including STIs and those of the genital tract and maternal malnutrition.\nObstetric factors such as antepartum haemorrhage, external cephalic version, early rupture of\nmembrane exceeding four hours before delivery, chorioamnionitis, prolonged labour, invasive\ndelivery procedures including use of forceps and episiotomy have also been observed to\nincrease MTCT of HIV. Other risk factors include; preterm birth, first infant in multiple births,\nbreastfeeding and extended duration of breastfeeding, early mixed feeding, breast abscesses,\nnipple fissure, mastitis, and oral disease in the infant.\n     100 infants bom to HIV infected women who breastfeed                                        60 to 75 infants will not\n      without any interventions                                                                  be HIV-infected\n                 5-10 infants                               About 15                               5-15infants\n                   infected                                  infauts                                 infected\n                    during                                  infected                                  during\n                 pregnancy                              during labour                             breastfeeding\n                                                          and delivery\n                                            25-40 iufants will be HIV-infected\nFigure 6.1: The Pattern of Mother-to-Child Transmission of HIV (MTCT) during Pregnancy, Delivery and\nBreastfeeding in Untreated Women Living with HIV.\nAlthough the current HIV prevalence of 1.4% in Nigerian adults and 0.2% among children\n(NAIIS 2018) suggest a low MTCT, two findings in the report have an ominous outcome;\n    a) Women (1.3%) have almost 4 times the prevalence of men (0.4%) in the same age group.\n    b) This gender disparity was greatest among females of age 20-24 years, the age when most\n          Nigerian women bear children.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                        73", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3298, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ed87b6ed-1a3c-4449-94e8-b192ed012e32": {"__data__": {"id_": "ed87b6ed-1a3c-4449-94e8-b192ed012e32", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "03546f0a-8e6a-4b14-946c-4352a86ef080", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "920fd42dfd3c201020f377646c6045cacad51592a7f64d7bf54335b827e94b37", "class_name": "RelatedNodeInfo"}}, "text": "35.0\n      30.0      28.6        26.3       25.6\n      25.0                                                                                              20.6     21.0\n                                                   19.7                   18.0                   19.4\n      20.0                                                    16.9                   16.5\n                14.4        13.2\n      15.0                             12.5                                                            11.2      11.4\n                                                   8.8                    9.1         8.8        10.3\n      10.0                                                     7.5\n       5.0\n       0.0\n                2010       2011        2012       2013        2014        2015       2016        2017  2018      2019\n                                               At six weeks          At final transmission\nFigure 6.2: Trends in Estimated Pattern of MTCT in Nigeria\n\n6.2.1 Prevention of MTCT\nTo stop the vertical transmission of HIV, WHO introduced a set of interrelated public health\ninterventions designed to prevent transmission of the virus from an HIV positive mother to her\nchild during the period of pregnancy, delivery and breastfeeding. Prevention of MTCT is the\npackage of care given to pregnant women, their families and communities, aimed at preventing\ntransmission of HIV from infected mothers to their babies (vertical transmission). It operates on\n4 pillars:\n\n Pillar 1              Primary prevention of HIV infection in women of reproductive age (WRA)\n                       & their partners\n\n Pillar 2              Prevention of unintended pregnancy among HIV- positive women\n Pillar 3              Prevention of HIV transmission from HIV positive mothers to their infants\n\n Pillar 4              Provision of appropriate treatment, care and support to HIV Positive mothers,\n                       their infants & families\n\nPillar 1:\nPrimary prevention of HIV infection in women of reproductive age and their partners include the\nfollowing:\n     \u00a7     Use of the \u201cABC\u201d approach to enhance safer and responsible sexual behaviour and\n           practices. This involves:\n           \u2022 A = Abstinence from having sexual intercourse\n           \u2022 B = Be faithful to a faithful partner\n           \u2022 C = Condom use correctly and consistently\n     \u00a7     Safe and responsible sexual practices include:\n           \u2022 Delaying the onset of sexual activity until marriage\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                 74", "mimetype": "text/plain", "start_char_idx": 6, "end_char_idx": 2598, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8f8ed3d7-45e2-4ded-9938-f088bf4a615c": {"__data__": {"id_": "8f8ed3d7-45e2-4ded-9938-f088bf4a615c", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "bd113c6d-4ca8-4e3d-80fb-800db1f24172", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "c53b3f36f271924a9777d90591e55f2936abd4f8affcc5bf7bf35eccaee1f810", "class_name": "RelatedNodeInfo"}}, "text": "\u2022 Reducing the number of sexual partners\n           \u2022 Consistent and correct use of condoms.\n      \u00a7    Provision of early diagnosis and treatment of STIs: The early diagnosis and treatment of\n           STIs can reduce the incidence of HIV in the general population by about 40%.\n           Comprehensive STI treatment services present an opportunity to provide information on\n           HIV infection, MTCT and referral to HIV testing services (HTS). Making HIV testing\n           services widely available especially to women attending antenatal clinic ensures that\n           they know their HIV status. All HIV pregnant women should be linked to PMTCT\n           services on-site or by referral.\n      \u00a7    Provision of appropriate counselling for women who are HIV negative: Counselling\n           provides an opportunity for a woman who is HIV negative to better understand how to\n           protect herself and her infant from HIV infection. It also serves as motivation to adopt\n           safer sex, family planning practices and encourages partner testing.\n\n Pillar 2:\n Prevention of unintended pregnancy among HIV positive women improves the lives of these\nwomen and their children and is essential for eliminating mother-to-child transmission of HIV.\nNigeria has an unmet need for family planning of 19% (NDHS 2018). The unintended pregnancy\nrate among women living with HIV reaches an estimated 51-90% in some settings, accounting\nfor 27% of maternal death, which can be prevented by meeting the unmet need for family\nplanning.\n\nIt is the responsibility of health services to provide HIV positive women and their partners with\ncomprehensive information and education about the risks associated with childbearing as part of\nroutine public information about HIV and AIDS. This is to ensure that HIV positive women and\ntheir partners have informed choices of action and to respect and support the decisions they reach\nas this is their sexual and reproductive rights. This implies:\n     \u00a7     Providing good quality, user-friendly, and easily accessible family planning services to\n           HIV positive women that can prevent unwanted pregnancy.\n     \u00a7     Providing and promoting consistent condom (male/female) use combined with a more\n           effective method of contraception (dual method) for dual protection from HIV and other\n           STIs and from unplanned pregnancies.\n     \u00a7     Integrating dual protection messages into family planning counselling services\n     \u00a7     Offering contraception including emergency contraception to all HIV positive mothers\n           in the immediate postpartum period to prevent unintended pregnancy. Lactational\n           amenorrhoea does not guarantee adequate contraception even in women who\n           exclusively breastfeed. (Refer to medical eligibility criteria for contraceptive use in HIV\n           positive women).\n\nPillar 3:\nPrevention of HIV transmission from HIV Positive mothers to their infants includes;\n     \u00a7     HIV testing services\n     \u00a7     HIV and Infant feeding counselling\n     \u00a7     Modification of obstetric practices\n     \u00a7     Administration of ART to all HIV positive pregnant women irrespective of their WHO\n           clinical stage and CD4+ cell count\n     \u00a7     Administration of single or dual ARV prophylaxis to all infants delivered to HIV\n           positive women.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                            75", "mimetype": "text/plain", "start_char_idx": 11, "end_char_idx": 3485, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "56153e17-6584-47e4-94eb-0d61edadce71": {"__data__": {"id_": "56153e17-6584-47e4-94eb-0d61edadce71", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "0242014e-ecee-4e60-814f-396398913fc2", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "2941d7a7de740c736cd8bf77f5fe6e45e01b0043b0a1a2c98c3900f6dd969d55", "class_name": "RelatedNodeInfo"}}, "text": "Pillar 4:\n                     Provision of appropriate treatment, care and support to HIV Positive mothers, their infants and family\n\nPackage of services for mothers\n\u00a7     ART for all HIV positive women\n\u00a7     Cotrimoxazole prophylaxis\n\u00a7     TB screening, prophylaxis and treatment\n\u00a7     Continued infant feeding counselling\n      and support\n\u00a7     Nutritional counselling and support\n\u00a7     Sexual and reproductive health\n      services including family planning\n\n\u00a7     Cervical cancer screening\n\u00a7     Psychosocial support.\n\u00a7     Partner counselling and testing\n\u00a7     Pre-Exposure Prophylaxis (PrEP) for\n      serodiscordant couples\n\n\n\n\n\n\n\n\n\n\n\nPackage of services for HIV exposed children\n\u00a7    ARV prophylaxis\n\u00a7    Routine immunization and growth monitoring\n     and support\n\u00a7    Cotrimoxazole prophylaxis starting at 6 weeks\n     HIV diagnostic testing using DBS for DNA-PCR\n     or NAT at birth (when available), 6 to 8 weeks\n     of age and 6 weeks after breastfeeding has ended.\n     HIV antibody test can be used for HIV screening\n     for children older than 9 months where virologic\n     test is not available. HIV antibody test is the\n     recommended diagnostic testing for children\n     older than 18 months.\n\u00a7    HIV antibody tests should primarily be used fo\n     screening of infants and children less than 18 of age\n     months, so as to establish exposure status where\n     the mother has not herself been tested for HIV or\n     is not willing to be tested\n\u00a7    Ongoing infant feeding counselling and support\n\u00a7    Screening and management of tuberculosis\n\u00a7    Prevention and treatment of malaria\n\u00a7    Nutritional care and support\n\u00a7    Psychosocial care and support\n\u00a7    Antiretroviral therapy for all HIV infected\n     children (see Chapter 3)\n\u00a7    Symptom management and palliative care if needed\n\n                      To achieve effective PMTCT across Nigeria, the following challenges should be addressed\n                      (Table 6.1)\n\n                                     NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          76", "mimetype": "text/plain", "start_char_idx": 21, "end_char_idx": 2107, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ab4207e4-f6bc-4cde-887a-36a6fa234ffa": {"__data__": {"id_": "ab4207e4-f6bc-4cde-887a-36a6fa234ffa", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "167f1e0f-55f9-4cdc-9258-7bf6ee291c10", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "f5c8c9ca4973a7df347ee3609897bd2c737ed1d6808a6fdcaa2f125da89a2332", "class_name": "RelatedNodeInfo"}}, "text": "Table 6.2 Challenges and Strategies to achieve effective PMTCT in Nigeria\n                              Challenges\n  Only 46% WRA (45% of Males) have comprehensive\n  knowledge of HIV Transmission & Prevention*\n  Only 57% WRA (52% Males) know MTCT*\n  1% WRA (13% Males) have 2= sexual partners*\n  Only 12% of married women use modern contraceptive*\n  High PMTCT Cascade gaps & MTCT of 5% at 2months\n  (NASCP)\n  Dwindling funding for supporting PMTCT programmes\n  High out-of-pocket expenses for PLHIV\n*NDHS 2018\n\n  Strategies to Achieve Effective PMTCT\nPrimary prevention of HIV in WRA &\nPartners\n\n\nPrevention of unintended pregnancy in PLHIV\nPrevention of MTCT in pregnant PLHIV\n\nTreatment, care & support to HIV Positive\nmothers, children & families\n\n\n                    6.2.2 Benefit of PMTCT\n                    The benefits of PMTCT is not limited to the baby alone, a successful PMTCT intervention\n                    benefits the mother, the family, community and health system as outlined in table 6.2\n                     Table 6.2 Challenges and Strategies to achieve effective PMTCT in Nigeria\n\n                                                                          Benefits of PMTCT\n                                                      \u00b7    Identification of HIV positive mothers for targeted interventions to\n                                                           reduce risk of transmission of infection to their infants and to access\n                                                           treatment, care and support services\n                                                      \u00b7    Promotion of positive behaviour change and reduction in risk of HIV\n                      Mother                               transmission\n                                                      \u00b7    Increase the use of dual protection methods of family planning and STI\n                                                           prevention\n                                                      \u00b7    Promotion of optimal infant feeding practices and support\n                                                      \u00b7    Promotion of access to early preventive and medical care\n                                                      \u00b7    Prevention of HIV transmission to infants\n                      Infant                          \u00b7    Promotion of early diagnosis and intervention for the HIV exposed\n                                                           infants including linkage to care for HIV positive infants\n                                                      \u00b7    Improvement of child health and survival\n                                                      \u00b7    Promotion of communication between couples and testing of both\n                                                           partners\n                                                      \u00b7    Reduction in the risk of sexual transmission to sero-discordant partners\n                      Family                          \u00b7    Provision of opportunity for testing other family members\n                                                      \u00b7    Access to reproductive health services\n                                                      \u00b7    Contribution to reduction of stigma and discrimination\n                                                      \u00b7    Provision of infant feeding support.\n\n                                    NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                   77", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3512, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "f8049a54-37ba-46a7-bcf7-53752847e8de": {"__data__": {"id_": "f8049a54-37ba-46a7-bcf7-53752847e8de", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "e756844c-03ea-4056-b728-1452d036a9ec", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "7fa641a3ab913fad4a506ea6ba1b0d0b687654f1c2e87c0d20978b272d205cdb", "class_name": "RelatedNodeInfo"}}, "text": "\u00b7    Promotion of the understanding of the HIV and AIDS epidemic among\n                                     those living with HIV and AIDS within the community thereby\n                                     strengthening community support structures\n  Community                     \u00b7    Promotion of uptake of risk reduction practices\n                                \u00b7    Promotion of acceptance and uptake of HIV testing services\n                                \u00b7    Contribution to reduction of stigma and discrimination\n                                \u00b7    Provision of infant feeding support\n  Health System                 \u00b7    Provision of opportunity to strengthen the health system\n\n 6.3 Pre-ART Care for HIV-positive pregnant women\n\n 6.3.1 Initial evaluation of HIV pregnant women\n All HIV- positive pregnant women should have a full physical examination. In addition to\n routine antenatal services, special focus should be placed on HIV-related illnesses including\n symptoms and signs of opportunistic infections (OIs) especially tuberculosis. Special attention\n should also be paid to the following:\n     \u00a7     Anaemia\n     \u00a7     Persistent diarrhoea\n     \u00a7     Respiratory infections: TB and other bacterial respiratory infections are common OIs in\n           HIV positive women\n     \u00a7     Oral and vaginal candidiasis\n     \u00a7     Lymphadenopathy\n     \u00a7     Herpes zoster (chronic/recurrent) is a common presenting sign of HIV infection,\n           occurring early in the disease, often before there is much immune suppression\n     \u00a7     Other skin conditions such as candidiasis, vaginal wart, and others\n     \u00a7     Other sexually transmitted infections\n     \u00a7     Weight gain or loss\nFurthermore, pregnant women found to have Advanced HIV Disease (AHD) should be managed\naccordingly (see chapter 8).\n\n6.3.2 Initial Clinical Examination of HIV Positive Pregnant Women\nThe initial examination of the HIV positive pregnant woman is done to identify possible\nproblems and complications that might be present. This examination should be done in a way\nthat respects clients' privacy and rights. All pregnant women should be counselled and told why\nit is important to conduct clinical examinations. A complete physical examination should be\nperformed and care taken to maintain all safety precautions. The examination should be holistic.\nHowever, special attention should be paid to HIV related\nsigns of OIs;\n     \u00a7     Palor: anaemia is common in pregnancy and can also occur as a result of ARV related\n           side effect (AZT) and OIs.\n     \u00a7     Dehydration: this could occur as a result of persistent diarrhoea.\n     \u00a7     Abnormal chest finding: respiratory infections, especially TB, are common OIs among\n           HIV positive women.\n     \u00a7     Oral, oesophagal and vaginal candidiasis: candidiasis is common and may be recurrent\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                            78", "mimetype": "text/plain", "start_char_idx": 32, "end_char_idx": 2985, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "b87e123e-5744-4e18-b66e-dde781b8aaee": {"__data__": {"id_": "b87e123e-5744-4e18-b66e-dde781b8aaee", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "0da1961f-0945-4f8b-b3da-f33f2d57bb2b", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "f1b6763c3864763906b8ff0edfa48ce1c037a6db768ccbff84c4f1533042e581", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7     Other skin conditions: such as pityriasis versicolor, vaginal warts, Kaposi sarcoma,\n           herpes zoster etc may also be found. It is therefore important to look out for these skin\n           conditions.\n     \u00a7     Signs of other STIs: HIV positive women may have other STIs. It is therefore important\n           to look out for these signs (see the section on STIs).\n\n6.3.3 Laboratory Investigation of HIV Positive Pregnant Women\nHIV positive pregnant women should have all routine laboratory investigations conducted for\npregnant women. They should have additional tests performed to monitor the progression of\ntheir clinical condition. They should have haemoglobin or hematocrit estimation at least four\ntimes during the pregnancy and urinalysis done at every clinic visit. The following investigations\nare recommended. (See table 6.3 for appropriate laboratory investigation).\nTable 6.3 Recommended laboratory investigation of HIV positive pregnant women\n   Laboratory Investigations                 At Booking/          2nd visit (26-        3rd visit (30-32        4thvisit (34-36\n                                             Presentation           28 weeks)                weeks)                  weeks)\n  Routine for all pregnant women\n  PCV or FBC where available                        X                     X                     X                        X\n  Blood Group                                       X\n  Haemoglobin Genotype                              X\n  Cervical Cancer Screening                         X             This screening should be done at least once during\n                                                                  pregnancy\n  HBsAg and HCV                                     X\n  Syphilis test                                     X\n  Urinalysis                                        X                     X                     X                        X\n  MP                                       As clinically indicated\n  Specific for HIV positive\n  CD4+                                              X                                                                    X\n  Viral load                               At 3months after the commencement of ART                                      X\n  LFT                                      As clinically indicated\n  E/U/Cr                                   As recommended by chapter 3\n  Lipid Profile                            As clinically indicated\n\n*Hepatitis B at booking; If negative, she should be offered HBV vaccination. When positive, ART regimen containing TDF+ 3TC or FTC should\nbe used.\n**Newly diagnosed HIV positive women enrolled into care, should have at least one viral load test at a gestational age of 32 to 36 weeks.\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                               79", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 2874, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "3decf4c1-4d1d-47e3-89e4-969884f8887d": {"__data__": {"id_": "3decf4c1-4d1d-47e3-89e4-969884f8887d", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "6aa5b7cb-ff60-46c7-8de7-631e9a719280", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "02f1b6101de61fa640294bd100e319b14fbe6b54df1d5a7749580a3ec68a1655", "class_name": "RelatedNodeInfo"}}, "text": "6.3.4 Syphilis testing for pregnant women\nSyphilis has devastating effects on the unborn baby and mother. Untreated syphilis increases the\nrisk of spontaneous miscarriage and congenital infection which has lifelong impact. Syphilis is\nan opportunistic infection whose presence if not treated increases the risk of MTCT of HIV\nduring pregnancy. The spirochete has been documented to bore through the placental barrier\nthereby promoting MTCT of HIV. All pregnant women should be screened for syphilis using\navailable Treponema pallidum- based test.\n\n6.4 Use of Antiretroviral Therapy for PMTCT\nPregnancy in HIV positive women is an absolute indication for ART. ART should be initiated in\nall HIV pregnant and breast-feeding women regardless of gestational age, WHO clinical stage\nand at any CD4+ cell count and continued for life.\n\nART should be initiated urgently in all pregnant and breastfeeding women, even if they are\nidentified late in pregnancy or postpartum. This is the most effective way to prevent MTCT of\nHIV through the reduction of maternal viral load. Same day initiation of ART is preferred except\nin patients with AHD (see chapter 8).\n\n6.4.1 Recommended first-line regimen for pregnant and breastfeeding women\nIn line with National recommendations, DTG- based regimen is the preferred first-line ART for\nHIV positive pregnant women.\nTable 6.4 Recommended first-line ART Regimen in Pregnant and Breast-Feeding Women\n  Target Population              Preferred first-line                  Alternative first-line regimens\n                                 regimens\n\n Pregnant or                     TDF + 3TC + DTG                       TDF + 3TC (or FTC) + EFV400\n breastfeeding women                                                   AZT + 3TC + EFV400\n                                                                       TDF + 3TC (or FTC) + EFV400\n                                                                       AZT + 3TC + NVP\n                                                                       TDF + 3TC (or FTC) + NVP\n                                                                       ABC + 3TC + DTG.\n                                             st\nIn order to serve this preferred 1 line regimen, all women of reproductive age who canst\npotentially be on DTG- based regimen during the 1 trimester of pregnancy should receive\nintensive counselling on the benefits and potential risks. This includes those already on the\nDTG-based regimen and those newly diagnosed.\n6.4.2 ARV prophylaxis for the HIV exposed infant\nAll HIV exposed infants should receive ARV prophylaxis. Infants at low risk of acquiring HIV\nfrom their mothers should receive NVP only once daily for 6 weeks. While infants born to\nmothers with HIV who are at high risk of acquiring HIV should receive dual prophylaxis with\nAZT (twice daily) and NVP (once daily) for the first 12 weeks of life, whether they are breastfed\nor formula-fed. Antiretroviral prophylaxis should commence within 72 hours of birth.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                            80", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3112, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "b2f66bb7-f7b2-4d4a-8acc-f0e8f0419421": {"__data__": {"id_": "b2f66bb7-f7b2-4d4a-8acc-f0e8f0419421", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "4b72de71-3c13-4c2d-ac27-c7e36b61bd0e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "0e14c3038c0ed40997242dc66c37c47ca7062bab686cddde77ef819027212e7c", "class_name": "RelatedNodeInfo"}}, "text": "Table 6.5 ARV Prophylaxis for Low-Risk Infants with NVP\n\n  Infant Age                                                      Daily Dosing\n\n  Birth to 6 weeks:\n  Birth weight <2.5kg                                             10 mg (1 ml) once daily\n  Birth weight =2.5kg                                             15 mg (1.5 ml) once daily\n\nARV prophylaxis for high-risk Infants\n\nHigh-risk infants are defined as those:\n     \u00a7     Born to women with established HIV infection who have received less than four weeks\n           of ART at the time of delivery\n                                                              OR\n     \u00a7     Born to women with established HIV infection with viral load >1000 copies/mL in the\n           four weeks before delivery;\n                                                              OR\n     \u00a7     Born to women with incident HIV infection during pregnancy (this includes women\n           diagnosed in labour) or breastfeeding;\n                                                              OR\n     \u00a7     Identified for the first time during the postpartum period, with or without a negative HIV\n           test prenatally.\n\nTable 6.6 ARV prophylaxis for High-risk Infants with NVP and AZT\n\n   Infant Age                                          Nevirapine daily dosing              Zidovudine daily dosing\n\n    Birth to 6 weeks (dual prophylaxis):\n    Birth weight <2.5kg                              10mg (1ml) once daily                 10mg (1ml) twice daily\n    Birth weight >2.5kg                              15mg (1.5ml) once daily               15mg (1.5ml) twice daily\n\n    6 weeks to 12 weeks                              20mg (2ml) once daily                  60 mg (6ml) twice daily\n\n6.4.3 Cotrimoxazole Prophylaxis for HIV exposed infants\nCotrimoxazole prophylaxis is recommended for HIV-exposed infants from 6 weeks of age and\nshould be continued until HIV infection has been excluded by an age-appropriate HIV test 8-12\nweeks after complete cessation of breastfeeding.\nTable 6.7 Dosing for Cotrimoxazole Prophylaxis in HIV-Exposed Infants and HIV-Infected Children\n\n  SN         Infant Age / Weight                                                        Dosage\n  1           For infants below 6 months or < 5 kg                                     120mg daily\n\n  2           For children 6 months - 5 years or 5 -15 kg                               240 mg daily\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                         81", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2530, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ce6358f5-943d-44b1-9322-c091ff9d078b": {"__data__": {"id_": "ce6358f5-943d-44b1-9322-c091ff9d078b", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "2b81146a-2587-44ea-addb-852c130b8b6b", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "fdc5a1b27af8f35f717371760d18b0c4fa9fb3f2798a774e6046363a775cfd66", "class_name": "RelatedNodeInfo"}}, "text": "6.4.4 Antenatal Care for HIV positive pregnant women\nWhen a woman is known to be HIV positive or is diagnosed as HIV positive during pregnancy,\nher obstetric and medical care will need to be strengthened and modified. Post-test counselling\nfor HIV positive pregnant women should include information on the following:\n    \u00a7     Disclosure, partner notification and testing\n    \u00a7     Benefits of PMTCT intervention\n    \u00a7     ART\n    \u00a7     Nutrition\n    \u00a7     Delivery\n    \u00a7     Infant feeding and infant testing\n    \u00a7     Importance of testing other children and benefits of paediatric ART\n    \u00a7     The need for follow-up and adherence\n    \u00a7     Continuous screening for active TB infections and TB Preventive Therapy (TPT) for\n          those who do not have the infection (see NTBLCP guidelines)\n\nAll HIV positive pregnant women should be given optimal health care to ensure their safe\ndelivery*. In a situation where the life of the woman is being threatened by the continuation of\nthe pregnancy, consideration of termination of pregnancy should be in accordance with the\nprovisions of the law. (see National Guidelines on the termination of pregnancy for legal\nindications 2018).\n\n6.5 Management of HIV positive women in labour, delivery and within 72 hours of delivery\nThe current use of very efficacious ARVs, such as DTG assures that most women should be\nvirologically       suppressed by the time their delivery is due. Nonetheless, viral load estimation is\nrecommended between 32-36 weeks of gestation to confirm this and enhance the preference of\nvaginal delivery. The management of Labour should therefore follow standard obstetric practice\n(see National obstetric protocol). Analgesia should be given in labour if required and epidural\nanalgesia is not contraindicated (See Table 6.8 Interventions for safe vaginal delivery).\n\nHIV positive women should not be isolated or treated differently from other women in labour.\nSupportive measures, empathy and caring attitudes by the health care provider are important for\nall women, particularly for HIV positive women who are concerned about their condition and\nrisks of HIV transmission to their children. HIV positive pregnant women should not be\nstigmatized nor discriminated against by medical staff including those who may not have\ndisclosed their status to their partner or family members.\n\nWhenever possible, during labour, HIV positive women should have the option to have a\ncompanion of their choice who can provide supportive companionship. Where this is not\npossible, labour ward staff must be sensitive to the fears and concerns of the HIV positive\nmother.\n\n*Note\n    \u00a7     Avoid invasive procedures such as chorionic villous sampling, amniocentesis or cordocentesis\n    \u00a7     External cephalic version (ECV) may carry a risk of HIV transmission to the foetus and should therefore be avoided\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                       82", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2978, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "df10a722-e931-479e-bb50-e4b2c6123336": {"__data__": {"id_": "df10a722-e931-479e-bb50-e4b2c6123336", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "164a1210-15fc-4973-81b2-849c24d59b46", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "082fe5541dabf679ddc712e2fdaa2a02f7bb076a4f2c91becb9705e3d34dda21", "class_name": "RelatedNodeInfo"}}, "text": "Table 6.8 Intervention for Safe Vaginal Delivery and Baby Care at Delivery\n\n                    Interventions during labour/delivery                            Care of the baby at delivery\n\n\u00a7  Perform vaginal cleansing with warm (0.25%)\n   chlorhexidine solution to prevent genital\n   infections\n\u00a7  Avoid the following:\n   -    Frequent vaginal examinations\n   -    Episiotomies (unless absolutely necessary)\n   -    Instrumental delivery (unless\n        when necessary)\n\n   -    Milking the cord before clamping\n   -    Clamp cord immediately after the baby is\n        delivered and cut, under cover of wrapped\n        gauze swab to avoid blood spurting.\n\u00a7  Wipe baby\u2019s mouth and nostrils with gauze at\n   the delivery of the head.\n\u00a7  Handle all babies with gloves regardless of the\n   mother\u2019s HIV status until blood and secretions\n   are washed off\n\u00a7  Keep all babies warm soon after delivery\n\u00a7  Where suctioning is indicated, a mechanical\n   suction unit (at a pressure below\n   100mmHg) or bulb suction should be used;\n   mouth operated suction should be avoided\n\u00a7  Place the baby on the mother\u2019s body for\n   skin-to-skin contact soon after delivery\n\n\n                  6.5.1 Induction of Labour\n                  As prolonged rupture of membranes is associated with increased risk of MTCT, careful\n                  assessment of the desirability of Caesarean Section (CS) rather than induction of labour is\n                  necessary. The use of prostaglandins or its analogues (misoprostol) can be considered.\n\n                  6.5.2 Conduct of Delivery\n                  Delivery should be conducted using standard practices and aseptic techniques while avoiding\n                  unnecessary trauma or prolongation of the second stage.\n\n                  6.5.3 Vaginal Delivery\n                  HIV positive women who are on ART should be allowed to deliver vaginally where there is no\n                  obstetric contraindication. Vaginal delivery remains the primary delivery mode of choice.\n\n                  6.5.4 Caesarean Section (CS)\n                  HIV infection on its own is not an indication for CS. Available evidence shows that elective CS\n                  for women on ART who have achieved viral suppression has no added advantage over vaginal\n                  delivery. Every pregnant woman including adolescents should be monitored closely.\n\n                  Elective CS can be considered for HIV positive women before the onset of labour or rupture of\n                  membranes in cases where the woman is not on ART and/or where the maternal viral load is\n                  known to be high (> 1000copies/ml). Available evidence shows that when elective CS is\n                  performed before the onset of labour or rupture of membranes, it reduces the risk of MTCT by\n                  greater than 50% as compared to vaginal delivery among women not on ART or with high viral\n                  load. These guidelines, however, do not recommend routine offer of elective CS for any group of\n                  HIV positive pregnant women.\n\n                                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                     83", "mimetype": "text/plain", "start_char_idx": 18, "end_char_idx": 3217, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "bbabf9ec-1068-4071-b0d3-4dc42e6cc0bd": {"__data__": {"id_": "bbabf9ec-1068-4071-b0d3-4dc42e6cc0bd", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "11d5c898-7a51-4824-b9fe-d6d1536e2878", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "0dd82d8a7f4b99af1bc1ec41d77dcdcc9bc9fd4d4b26b4319ba87c58cde991ae", "class_name": "RelatedNodeInfo"}}, "text": "Where CS is performed (elective or emergency) in HIV positive women, they should receive\nprophylactic antibiotics. If CS is performed after prolonged labour or prolonged rupture of\nmembranes a longer course of antibiotics is recommended.\n\n6.5.5 Specific Modification of Obstetric Care for HIV Positive Women\n     \u00a7    Care should be individualized in special circumstances such as premature rupture of\n          membranes (preterm and term) and ante-partum haemorrhage\n     \u00a7    Use of the partograph: proper and consistent use of the partograph in monitoring the\n          progress of labour will improve the management and reduce the risk of prolonged labour\n          in all women\n     \u00a7    Artificial rupture of membranes (ARM) is practised routinely in many settings although\n          it should be reserved for women with abnormal progress of labour. Rupture of\n          membranes of more than four (4) hours duration is associated with an increased risk of\n          HIV transmission. Therefore, early ARM should be reserved for those with foetal\n          distress or abnormal progress. ARM can be done if cervical dilatation is 7 cm or more.\n     \u00a7    Instrumental delivery: forceps and vacuum delivery should be avoided as they have been\n          shown to be associated with increased risk of MTCT. If it has to be done, vacuum with\n          silastic cup is preferred\n     \u00a7    Vaginal cleansing with chlorhexidine (0.25% solution) reduces the risk of puerperal and\n          neonatal sepsis. It may also have some effect on HIV transmission where membranes are\n          ruptured for more than 4 hours. The number of vaginal examinations should be kept to a\n          minimum.\n     \u00a7    Routine episiotomy has been shown to have no obstetric benefit; it should be used only\n          for specific obstetric indications\n\n6.6 PMTCT/TB integration services\n\n6.6.1 Pregnant women with TB and HIV co-infection\nNigeria has the highest TB burden in Africa and the sixth highest in the world . TB causes one in\nthree deaths among PLHIV, and co-morbidity of TB and HIV in pregnancy causes up to 40%\nmortality. These are the reasons why continuous screening of HIV positive pregnant women\nshould be conducted throughout pregnancy to identify women who have active TB disease.\nThose with the disease should be given immediate access to TB treatment according to the\nNTBLCP Guidelines. Those without the disease should be placed on TB Preventive Therapy\n(TPT) irrespective of the duration of pregnancy.\n\nEvery ANC provider should be prepared and equipped to screen every pregnant woman for TB\ndisease at each clinic visit, whether they are HIV positive or not. The screening of those who are\nHIV positive is even more important because not detecting the co-infection of HIV and TB in\npregnancy is a leading cause of death among them.\n\nAt every ANC visit, the HIV positive pregnant woman should be asked if she has any of the\nmajor symptoms of TB; cough, fever, weight loss or night sweats (especially drenching type).\nRefer to Appendix 7 for Algorithm for Screening Adults and Adolescents Living with HIV for\nTPT.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                        84", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3219, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8335158d-efb6-4dd7-a532-53765d1659c7": {"__data__": {"id_": "8335158d-efb6-4dd7-a532-53765d1659c7", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "8612a10c-9c3e-44a0-badd-99b49033629b", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "786334f4c7227421f1e7581483e0ab17156c44de72c16bd98c84ce68200b49f5", "class_name": "RelatedNodeInfo"}}, "text": "At each visit, the pregnant or breastfeeding HIV positive woman should be identified to belong to\nany of the following three categories:\n     1)    Has no cough but has other symptoms of TB \u2013 the patient should be referred to the\n           medical officer to exclude TB (according to NTBLCP Guidelines); or\n     2)    Has cough with other symptoms of TB \u2013 the patient is likely to have TB disease that\n           requires confirmation with Xpert MTB/RIF assay, and subsequent management\n           according to NTBLCP Guidelines; or\n     3)    Has none of the four symptoms \u2013 the patient should be counselled and started on TPT\n           irrespective of the gestational age of the pregnancy.\n\nTuberculosis Preventive Therapy (TPT) involves the administration of medicines (e.g. Isoniazid\n300mg daily) for a minimum period of six months to a pregnant/breastfeeding PLHIV who does\nnot have active TB disease. It is purposed to protect her from developing active TB disease.\n     Triple pill combination of Isoniazid + Cotrimoxazole + Pyridoxine is available and a good option for\n    TPT among pregnant and postpartum women with HIV.\n\n Management of Newborn of a Mother/ Household contacts with active TB\n Infants born to mothers with active TB disease may become infected with TB. When infected,\n the infant may be asymptomatic or present with acute symptoms that are often non-specific.\n Management depends on the peculiar situation, but evaluation should be at a referral centre\n Some possible scenarios regarding infant born to mothers with TB include:\n\n     i.    If a mother is diagnosed with TB before the third trimester of pregnancy and taking TB\n           medications with good adherence and is improving:\n           \u00a7    Examine the new born\n                o    If symptoms and signs of TB are not present administer BCG\n                o    If symptoms and signs of TB are present, evaluate further for TB disease\n                o    If symptoms and signs suggest other disease(s), manage/refer as appropriate\n           \u00a7    Perform maternal HIV screening (if not done in ANC)\n           \u00a7    Refer all other household contacts for TB evaluation\n     ii.   If a mother is diagnosed with TB in the third trimester or shortly after delivery:\n           \u00a7    Evaluate for maternal PTB or EPTB disease including uterine TB\n           \u00a7    Perform maternal HIV screening (if not done in ANC)\n           \u00a7    Defer BCG vaccine administration for the newborn\n           \u00a7    Evaluate infant for congenital TB if the newborn is symptomatic or where mother is\n                AFB positive or has untreated disseminated or partially treated TB/poor adherence.\n           \u00a7    Evaluate infant if mother is diagnosed with endometrial TB regardless of treatment\n                status with:\n                o    CXR\n                o    Gastric aspirates for Xpert MTB/Rif and culture of 3 consecutive samples\n                o    Abdominal ultrasound\n           \u00a7    Lumbar puncture for CSF Xpert MTB/Rif, LPA and cultures.\n           \u00a7    If TB disease is confirmed in the newborn, initiate TB therapy promptly in\n                consultation with a paediatrician where available.\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                              85", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3296, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "cd10c5c0-b8b9-4672-84f2-48fb6652ed8c": {"__data__": {"id_": "cd10c5c0-b8b9-4672-84f2-48fb6652ed8c", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "94074aac-7b35-4582-a34c-27d1a0feb8b7", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "5ae691fad378ef968b76ce90c74565b168e8c79706cee23f879854c1bb30c1e0", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7     If congenital TB is excluded, administer TPT for LTBI until age of 6 months\n          Perform Mantoux or IGRA test and if positive, reassess for active TB\n    \u00a7     If active disease is ruled out, give TPT for LTBI\n    \u00a7     If the Mantoux/IGRA is negative and TB disease is ruled out and mother/household\n          contact becomes smear-negative, stop INH and administer BCG vaccine two weeks\n          after stopping TPT\n    \u00a7     Follow-up infant monthly.\n    \u00a7     Refer all other household contacts for TB evaluation\n\n6.6.2 Infection Control\n    \u00a7     Separate the newborn from any active TB case in the household including the mother\n          during the evaluation period\n    \u00a7     Newborn should receive expressed breastmilk during period of isolation\n    \u00a7     Mother/adult contact should wear a facemask while handling the baby\n    \u00a7     Follow isolation precautions\n    \u00a7     Once the baby is on INH and the mother or adult source is on continuation phase of\n          treatment, no need to separate the baby, and the mother can again breastfeed the baby\n\n6.6.3 Management of Newborn of a Mother/ Household contacts with LTBI\nIn a newborn whose mother or other household contact has LTBI:\n    \u00a7     Treat the mother or household contact for LTBI (if mother or household contact are\n          contacts of an infectious TB index case)\n    \u00a7     Perform maternal HIV screening (if not done in ANC)\n    \u00a7     Since a positive Mantoux/IGRA result is a marker for an unrecognised case of active TB\n          in the household, evaluate all other household members for TB disease/LTBI.\n    \u00a7     The newborn needs no special evaluation\n    \u00a7     Administer BCG vaccine if no active case of TB is detected in the household\n\n6.7 Care and Support of the HIV-Exposed Infant\n\n6.7.1 Immediate and on-going care of the new-born of HIV positive women\nThe immediate care of the new-born follows standard practice regardless of the mothers' HIV\nstatus. At delivery all newborns should:\n    \u00a7     Be handled with latex gloves until maternal blood and secretions are washed off\n    \u00a7     Have their mouths and nostrils wiped with sterile gauze after delivery of the head\n    \u00a7     Have the cord clamped immediately after the baby is delivered and avoid milking the\n          cord\n    \u00a7     Have the cord cut under cover of a lightly wrapped gauze swab to avoid blood spurting\n    \u00a7     Be kept warm\n    \u00a7     Be suctioned if indicated using a mechanical/electrical suction unit at a pressure below\n          100mmHg or bulb suction. Mouth operated suction is contraindicated\n    \u00a7     Be cleaned with warm chlorhexidine solution or wiped dry with a towel or surgical cloth\n          to remove maternal body fluids\n    \u00a7     Place the baby on the mother's chest for skin to skin contact soon after delivery. In this\n          position, the baby will latch on to one of the mother's breasts to initiate feeding unless the\n          mother opted for an alternative feeding method\n    \u00a7     Have vitamin K administered, ensuring injection safety\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                              86", "mimetype": "text/plain", "start_char_idx": 4, "end_char_idx": 3152, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "0f7dfd70-ba56-40ef-a14b-71f791d3680e": {"__data__": {"id_": "0f7dfd70-ba56-40ef-a14b-71f791d3680e", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "c9a63a30-baa2-4db5-bc47-dd46c7b548be", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "ffd2c643482f419daac78b5313f0fa2761d92dd352edefd82b5fe8bcf8567113", "class_name": "RelatedNodeInfo"}}, "text": "6.7.2 Infant feeding in the context of HIV\nAppropriate infant feeding is critical to child survival because the natural food for infants is\nbreast milk. In the context of maternal HIV infection, infant feeding can become complex. HIV\ninfection may be transmitted through breast milk from mother to child and this risk approaches\n5%-15% in the absence of any intervention. Breast milk substitute has the benefit of zero HIV\ntransmission but carries with it the risk of increased morbidity and mortality from malnutrition,\ndiarrhoea and pneumonia.\n    \u00a7     It is recommended that mothers of HIV exposed infants breastfeed their babies\n          exclusively for the first six (6) months of life.\n    \u00a7     Adequate complementary feeds should be introduced at 6 months in addition to breast\n          milk\n    \u00a7     Breastfeeding complemented by adequate complementary and household foods should\n          be continued till 12 months of age.\nMothers who breastfeed should be aware that:\n    \u00a7     Mixed feeding (breast milk plus substitutes or foods) increases the risk of MTCT of\n          HIV.\n    \u00a7     ARV provided during labour and to the mother/infant pair throughout breastfeeding\n          protects the infant from MTCT of HIV\n    \u00a7     The risk of transmitting HIV to her infant during breastfeeding is higher in certain\n          conditions such as:\n          o    When the woman is severely ill (by clinical or laboratory measures)\n          o    When she has mastitis, breast abscess, or other similar conditions\n          o    When the child has ulcers in the mouth\n          o    When breastfeeding is prolonged beyond 12 months of age\n\nBreast milk substitute: Breast milk substitute means feeding infants who are receiving no\nbreast milk with correctly prepared commercial infant formula that provides most of the\nnutrients' infants need until the age at which they can be fully fed on family foods. Unlike\nbreastfeeding, it does not protect against infections. During the first 6 months of life, breast milk\nsubstitutes should be with a suitable commercial infant formula prepared hygienically. After 6\nmonths the suitable commercial formula should be complemented with other foods.\n\n6.7.3 Early Infant Diagnosis (EID)\nAll HIV-exposed infants should have DNA PCR testing or NAT at birth, 6 \u2013 8 weeks of age, 9\nmonths and 8-12 weeks after complete cessation of breastfeeding. If the baby is not being\nbreastfed, DNA PCR testing should be done at birth and 6 weeks [ Refer to figure 2.3].\n\n6.7.4 Childhood Immunizations in the Context of HIV\nHIV-exposed infants, children and adolescents with HIV should receive all vaccines under\nroutine vaccination according to recommended national immunization schedule (NPI) as shown\non Table 6.9. The WHO recommends that the certain situations require special considerations\nfor HIV exposed and infected neonates, infants and children as outlined below.\n\n6.7.4.1 Considerations for BCG vaccine\n    \u00a7     Neonates born to women of unknown HIV status should be vaccinated as the benefits of\n          BCG vaccination outweigh the risks\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                            87", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3190, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "42969f5a-e5ed-4bb6-b1ff-2e6ba07db0fb": {"__data__": {"id_": "42969f5a-e5ed-4bb6-b1ff-2e6ba07db0fb", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "27cf2791-cf3c-43db-8ca7-2dd817047ada", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "c95208b304bfbf5645bfe0b067ee6bb4d0657c064bc440bab5d448808c130dec", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7     Neonates of unknown HIV status born to HIV infected women should be vaccinated if\n          they have no clinical evidence suggestive of HIV disease, regardless of whether the\n          mother is receiving ART\n    \u00a7     Neonates with HIV infection confirmed by early virological testing, BCG vaccination\n          should be delayed until ART has been started and the infant confirmed to be\n          immunologically stable (CD4>25%)\n    \u00a7     HIV-infected children on ART, those clinically and immunologically stable (Cd4%\n          >25% for <5 years or CD4 count \u2265200 for >5 years) should be vaccinated with BCG.\n\n6.7.4.2 Considerations for Pneumococcal vaccines\n    \u00a7     HIV-positive infants and pre-term neonates who have received their 3 primary vaccine\n          doses before 12 months of age may benefit from a booster dose in the second year of life.\n    \u00a7     Unvaccinated children aged 1\u20135 years at high risk for pneumococcal infection due to\n          underlying conditions, such as HIV infection or sickle-cell disease, should receive at\n          least 2 doses separated by at least 8 weeks.\n\n6.7.4.3 Considerations for Measles vaccines\nIn the following situations, a supplementary dose of MCV should be given to infants from 6\nmonths of age:\n    \u00a7     Measles vaccine should be routinely administered to potentially susceptible,\n          asymptomatic HIV infected children and adults, given the severe course of measles in\n          patients with advanced HIV disease (AHD).\n    \u00a7     Vaccination may be considered for those with symptomatic HIV infection if they are not\n          severely immunosuppressed.\n    \u00a7     Where there is a high incidence of both HIV infection and measles, an initial dose of\n          Measles vaccine may be offered as early as age 6 months (recorded as MCV0).\n    \u00a7     The 2 routine doses of Measles vaccines (MCV1 and MCV2) should then be\n          administered to these children according to NPI schedule.\n    \u00a7     An additional dose of Measles vaccine should be administered to HIV-infected children\n          receiving HAART following immune reconstitution.\n    \u00a7     If CD4+ counts are monitored, an additional dose of MCV should be administered when\n          immune reconstitution has been achieved, e.g. when the CD4+ count reaches 20\u201325%.\n    \u00a7     Where CD4+ monitoring is not available, children should receive an additional dose at\n          6\u201312 months after initiation of HAART.\n    \u00a7     A supplementary dose (recorded as MCV0) should be considered for infants known to\n          be exposed (i.e. born to an HIV-infected woman) or soon after diagnosis of HIV\n          infection in children older than 6 months who are not receiving HAART and for whom\n          the risk of measles is high, with the aim of providing partial protection until they are\n          revaccinated after immune reconstitution with HAART.\n\n6.7.4.4 Considerations for Human Papillomavirus vaccine\n    \u00a7     A 3-dose schedule (0, 1-2, 6 months) should be used for all vaccinations initiated \u226515\n          years of age, including in girls <15 years known to be immunocompromised and/or HIV\n          infected (regardless of whether they on HAART or not.\n    \u00a7     It is not necessary to screen for HPV infection or HIV infection prior to HPV\n          vaccination.\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          88", "mimetype": "text/plain", "start_char_idx": 4, "end_char_idx": 3414, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "f4581f14-f3bf-4dbd-9070-d193c65d0c9a": {"__data__": {"id_": "f4581f14-f3bf-4dbd-9070-d193c65d0c9a", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b8bc1ccb-cdc9-4b1f-a81c-0a365d8f5bec", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "fae974a0b70688aedbaf97a13fbab52cea9fe85ac862d9b91c7ecb49fc425821", "class_name": "RelatedNodeInfo"}}, "text": "Table 6.9 National Routine Immunization Schedule\n\n  Minimum              Vaccine                     Dosage         Route of       Site of administration\n  Target age                                                      delivery\n  At Birth             BCG                         0.05ml         Intradermal    Left upper arm\n                       OPV0                        2 drops        Oral           Mouth\n                       Hep B                       0.5ml          Intramuscular  Right thigh (antero-lateral\n                                                                                 aspect)\n  6 Weeks              Pentavalent (DPT,                                         Left thigh (antero-lateral\n                       Hep B, Hib) 1               0.5ml          Intramuscular  aspect)\n                       Pneumococcal                                              Left thigh (antero-lateral\n                       Conjugate Vaccine           0.5ml          Intramuscular  aspect)\n                       (PCV) 1\n                       OPV1                        2 drops        Oral           Mouth\n                       Rota 1                      1ml            Oral           Mouth\n  10 Weeks             Pentavalent (DPT,                                         Left thigh (antero-lateral\n                       Hep B, Hib) 2               0.5ml          Intramuscular  aspect)\n                       Pneumococcal                                              Right thigh (antero-lateral\n                       Conjugate Vaccine           0.5ml          Intramuscular  aspect)\n                       (PCV) 2\n                       OPV2                        2 drops        Oral           Mouth\n                       Rota 2                      1ml            Oral           Mouth\n  14 Weeks             Pentavalent (DPT,           0.5ml          Intramuscular  Left thigh (antero-lateral aspect)\n                       Hep B, Hib) 3\n                       Pneumococcal\n                      Conjugate Vaccine            0.5ml          Intramuscular  Right thigh (antero-lateral aspect)\n                      (PCV) 3\n                      OPV3                         2 drops        Oral           Mouth\n                      IPV                          0.5ml          Intramuscular  -Right thigh (anterolateral aspect,\n                                                                                 25cm away from PCV3 site)\n  6 Months             Vitamin A                   100,000        Oral           Mouth\n                                                   IU\n  9 Months             Measles (MCV0)              0.5ml          Subcutaneous   Left upper arm\n                       Yellow fever                0.5ml          Subcutaneous   Right upper arm\n                       Meningitis                  0.5ml          Intramuscular  Left thigh (antero-lateral aspect)\n  15 Months            Vitamin A                   100,000        Oral           Mouth\n                                                   IU\n                       Measles (MCV1)              0.5ml          Subcutaneous   Left upper arm\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                   89", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3258, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "e8b993ed-b3cb-4a52-a45a-61c3e0086b05": {"__data__": {"id_": "e8b993ed-b3cb-4a52-a45a-61c3e0086b05", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "82ec9b35-315a-4da3-9794-4bea1e5c89fa", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "58419a87e372078d7c5412b2dec1141b035a463d49fa6a212fa58145a17c19c1", "class_name": "RelatedNodeInfo"}}, "text": "6.8 Special Considerations for Adolescent and Young Women in PMTCT\nIn Nigeria, an estimated 23% of women aged 15-19 years begun childbearing, of which 17%\nhave had their first child and 5% are pregnant for their first child [4].\n\nTo achieve eMTCT in Nigeria, it is therefore very important to pay special attention to any\nadolescent girl presenting with pregnancy in a health facility. Efforts should be made to seek out\nthe many pregnant adolescents in the community that do not present to health facilities for ANC\nand delivery. The needs of Adolescent Girls and Young Women (AGYW) in eMTCT are like\nthose of an adult woman, the major difference is the fact that their vulnerabilities are heightened\nphysiologically, emotionally and socially. Service delivery thus needs to be responsive to their\nneeds across the 4 pillars of PMTCT as below:\n\nPillar 1:\nKey concerns for AGYW include:\n     \u00a7    Low knowledge of HIV transmission\n     \u00a7    Low-risk perception\n     \u00a7    Lack of awareness of prevention options/methods to reduce risks and/or skills to use\n          them\n     \u00a7    Late start of ANC\nPMTCT programmes should make provision for integration of HIV prevention\nmessages/information targeting AGYW at the community level and through women groups,\nmobile services, social media platforms, peer-groups, youth centres etc. Provider-facilitated\nscreening, lay or peer counsellor, self-assessment (considering sexual risk, risky relationships,\nlifestyle risk and situational risk) are additional considerations required.\n\nPillar 2:\nConsidering the high rates of unintended pregnancies in AGYW, unsafe abortion among\nadolescents contributes to maternal mortality for this age group. The specific challenges faced\nby pregnant AGYW living with HIV include lack of knowledge of contraceptive options, life\nskills and self-efficacy, inaccessible and non-friendly services, lack of support for dual\nprotection and limited access to contraceptives beyond condoms.\nSpecific considerations required include:\n     \u00a7    FP/SRH information and life skills tailored for Adolescents living with HIV (ALHIV)\n     \u00a7    Contraception and dual protection tailored to their needs integrated within HIV care,\n          safe conception and pregnancy planning\n     \u00a7    Support group-based approaches\n     \u00a7    Community-based distribution and activities to optimize contraceptive options\n          available to ALHIV\n\nPillar 3:\nThe major risk factors associated with vertical transmission in pregnant AGYW living with HIV\nare late start of ANC, delayed HIV testing and treatment initiation leading to suboptimal\ntreatment outcomes.\nSpecial considerations to be offered to AGYW include;\n     \u00a7    Tailored approaches to case finding, earlier pregnancy testing, and early initiation on\n          treatment for young mothers\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         90", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2910, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6dcb8458-3c6c-41d9-b8a1-3ed09294135b": {"__data__": {"id_": "6dcb8458-3c6c-41d9-b8a1-3ed09294135b", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b24c18fe-b6e9-4888-88f4-17131be8f70f", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "50fdf1129b7b1b966c0071e7996a489395f0fca81b59498eff62811344c64868", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7    Active (facilitated) treatment referrals\n     \u00a7    Facility and out-of-facility based models specifically serving young mothers\n\nPillar 4:\nThe major concern for AGYW living with HIV postpartum (post EID) is treatment continuity.\nOther concerns include SRH needs, age of young mother and spacing of children. The PMTCT\nprogram should ensure young mothers living with HIV receive:\n     \u00a7    Longer-term care and support focused on retaining young mothers and children in care\n     \u00a7    Integrated delivery of ARV, SRHR, FP\n     \u00a7    Care involving men\n     \u00a7    Family-based care\n     \u00a7    Mental health screening and intervention approaches in the context of HIV care\n     \u00a7    Integrated case management systems\n\n6.9 Linkage of PMTCT with comprehensive HIV Treatment, Care and Support Services\nfor Mothers and Infants\nThe follow-up treatment, care and support for HIV-positive mothers after delivery, the care of\ntheir HIV exposed infant and other children is important as part of the continuum of care\npackage. A family-focused care should be the standard, this is designed to identify, engage and\ncare for all HIV-positive family members, prevent new infections among family members at\nrisk, raise family support and awareness within the HIV department at a health facility\ndepending on the PMTCT service model.\nPMTCT services can be offered in both public and private health facilities. Mother-infant pairs\nfrom health facilities with no capacity for comprehensive HIV care should be referred to\ncomprehensive health services that provide HIV treatment, care and support by 6 weeks after\ndelivery or at the earliest possible time thereafter. This is because it is important that treatment\nand care extend beyond the prevention of MTCT for women, infants, and family members at risk\nfor or infected with HIV.\n\n6.9.1 Engagement of Non-Formal Health Actors (NFHA) in the (referral and Linkage) of\nPMTCT services\nThere are human resource gaps in the health sector in Nigeria, while the implementation of the\ntask shifting policy is ongoing, there is a need for a medium-term intervention in the form of\nengagement of the non-formal health actors in the delivery of PMTCT services in Nigeria.\n\nNon-formal health actors play a critical role in maternal and child health care response. Their\nrole in PMTCT will include the following:\n    1.    Community sensitization and awareness creation\n    2.    Community mobilization\n    3.    HIV case identification\n    4.    Peer influence for PMTCT service uptake\n    5.    Referral and linkage including EID and immunization services\n    6.    Tracking and contact tracing\n    7.    Non-clinical care and support\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          91", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 2769, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "fe0a4216-a134-4080-9389-0ce534f52052": {"__data__": {"id_": "fe0a4216-a134-4080-9389-0ce534f52052", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "1e4fc864-ba85-43cc-b3c0-3b97b2c53829", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "a84fe57169ccab92598ce8313a4b37aebda704fdab6c238714d8fd7dc191ee9c", "class_name": "RelatedNodeInfo"}}, "text": "List of Contributors\nDr Adesigbin Clement\nDr Ijaodola Olugbenga\nTaiwo Olakunle\nZainab E. Abdullahi\nDr Adeyinka Adewemimo\nDr Benson Udu\nMrs. Hidayat Bukola Yahaya\nDr Gideon Sorochi Okorie\nProf. Oladapo Shittu\nProf. Solomon Sagay\nProf Anteinette Ofili\nProf. Oliver Ezechi\nDr Idowu Adebara\nDr Stephen B. Bature\nDr Chinyere Ukamaka Onubogu\nDr Benjamin Aiwondagbon\nDr Ochola-Odonga Dorothy\nDr Victoria Isiramen\nDr Idayat Uthman\nDr. Efuntoye Adeola Tim\nBennett Okechukwu Urama\nDr Chris Obanubi\nLilian Anomnachi\nDr Andrew Etsetsowaghan\nDr Omoregie Godpower\nDr Amalachukwu Ukaere\nHalima Ibrahim\nMrs Ehi Adejo-Ogiri\nOgochukwu Ginigeme\nDr Helen Omuh\nRuth Dauda Akolo\nChinwe Aganekwu\nAbang Roger\nMwoltu Nanribet Gabriel\nAkanji Michael O\n                                                              Chapter 6\nDeputy Director, Head of Prevention NASCP\nAssistant Director, National Officer PMTCT NASCP\nChief Scientific Officer NASCP\nPopulation Programme Officer I NASCP\nSenior Medical Officer I NASCP\nSASPC, FCT\nProgramme Officer Health Sector Response Support NACA\nAssistant Chief program officer/ PMTCT/HTS Focal Officer NACA\nChairman, PMTCT Task Team / OBY/GYNAE ABUTH Zaria\nMember PMTCT Task team / OBY/GYNAE JUTH Jos\nPublic Health Physician, UBTH Benin\nDirector of Research, NIMR Lagos\nConsultant OBY/GYN, FTH Ido Ekiti\nMember PMTCT Task Team / OBY/GYN, BDTH/KASU Kaduna\nPaediatrician, NAUTH, Nnewi\nWHO\nHealth & HIV Section UNICEF\nHealth Manager UNICEF\nNational Program Officer UNAIDS\nSenior Specialist PMTCT, CDC\nForecasting and Supply Planning Advisor GHSC-PSM\nProgramme Manager USAID\nDeputy Program Director CHAI\nTechnical Director FHI360\nHead/Practice Lead, HIV and TB SFH\nProgram Director SFH\nProgram Manager SFH\nGender Officer/POC JHPIEGO\nICAP\nDeputy Director IHVN\nWelfare - Deputy ASWHAN\nCoordinator, FGI CISHAN\nDirector of Programs Heartland Alliance\nMental Health Technical Advisor Heartland Alliance\nKey Populations Advisor Heartland Alliance\n\n                               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  92", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 2044, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "a321530f-1a62-4901-ab77-f24c7c7ef4cc": {"__data__": {"id_": "a321530f-1a62-4901-ab77-f24c7c7ef4cc", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "89978ecf-b3dc-44c9-ba00-117b7fde0769", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "81d89329045406826db761b46f43b0c5236aa62ee25a1f3877a5d4a3a8bd2a4b", "class_name": "RelatedNodeInfo"}}, "text": "7. PREVENTIVE\n           MANAGEMENT IN HIV\n\nWhat\u2019s Inside:\n7.1 Introduction\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026......94\n 1.1 Objectives of the Guidelines\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\n7.2 Pre-Exposure Prophylaxis\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026.....95\n 1.2 Epidemiology of HIV in Nigeria\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\n7.3 Post-Exposure Prophylaxis\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026...99\n 1.3 Natural History of HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\n7.4 Post-Sexual Assault Exposure Prophylaxis\u2026\u2026\u2026\u2026\u2026\u2026\u2026.102\n7.5 Interventions for Key Populations\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026...104\n7.6 Condom availability and promotion for\n   HIV programme\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026\u2026\u2026\u2026......105\n7.7 Gender-Based Violence\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026.......106\n7.8 Management of Sexually\n   Transmitted Infections (STIs)\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026....108\n7.9 Prevention for Adolescent and Young\n   Persons (AYPs)\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026..\u2026\u2026.........109", "mimetype": "text/plain", "start_char_idx": 18, "end_char_idx": 766, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d8afb92e-b0a5-487d-a9f3-2dcb12636e47": {"__data__": {"id_": "d8afb92e-b0a5-487d-a9f3-2dcb12636e47", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "a4ab4b2c-9d85-4407-8acb-f5f76d83e829", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "5b34eb1d0730727f7ff9a6fa6f5269ac1463bd5a53837706de0e1684eff70412", "class_name": "RelatedNodeInfo"}}, "text": "7.1 Introduction\nPreventive management of HIV is a broad term for different interventions that protect\nindividuals from contracting/transmitting HIV infection. It also includes interventions that\nprotect the HIV positive individual from common opportunistic infections (OIs) including\ntuberculosis. It is recommended that all persons who come in contact with health services should\nbe allowed access to any combination of HIV prevention interventions most suitable to their\nneeds. The necessity for the simultaneous employment of different approaches and intervention\ntypes for the prevention of HIV infection has led to the concept of combination prevention.\n\n7.1.1 Combination prevention / Minimum Prevention Package Intervention (MPPI)\nThe National Prevention Plan (NPP) 2010-2012 introduced the combination prevention\napproach, locally called the \u201cMinimum Prevention Package Intervention\u201d (MPPI), which are\ndefined prevention intervention packages that address the drivers of the epidemic. The package\nemphasized dosage and intensity and promoted ownership and sustainability. The MPPI is\ndefined as, \u201cthe strategic, simultaneous use of different classes of prevention activities\n(biomedical, behavioural, structural) that operate on multiple levels (individual, community and\nstructural), to respond to the specific needs of particular audiences and modes of HIV\ntransmission, and to make efficient use of resources through prioritization, partnership, and\nengagement of affected communities\u201d (UNAIDS Prevention Reference Group Definition).\n\nBehavioural interventions include a range of behaviour change communication activities\ndesigned to promote HIV risk-reducing and protective behaviours. These activities span, and\noften combine, mass media, community mobilization, advocacy and interpersonal\ncommunication (IPC) such as one-to-one or one-to-group educational activities. Social media\nand mobile technology are important tools that should be integrated into HIV prevention\nprogrammes and is particularly critical in informing about and providing prevention services to\nkey populations.\n\nBiomedical interventions include several medical interventions that can prevent HIV infection,\nreduce transmission, and/or reduce the risk of infection. These are interventions that directly\ninfluence the biological systems through which the virus infects a new host, such as preventing\ninfection (e.g., male and female condoms), reducing transmission (e.g., ART as prevention), or\nreducing acquisition/infection risk. These interventions include correct and consistent use of\nmale and female condoms and lubricants, HIV testing and counselling, PMTCT, STI diagnosis\nand treatment, ARV for PrEP and PEP, microbicides, and vaccines.\n\nStructural interventions are strategies recommended for change in social, legal, political and\neconomic factors that increase vulnerability to HIV. These interventions address stigma and\ndiscrimination, legal and human rights violations, gender-based violence and inequality. They\nare also designed to support income-generating activities, promote the integration referral,\nadherence and retention in health services.\n\nEffective implementation of combination prevention in the country will require political\ncommitment and leadership, programme coordination and management, partnerships and\ncollaboration, adequate HR, advocacy, community and social mobilization, functional\ncommodity supply management systems, M&E and research.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                      94", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3562, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "66ff19b7-adb9-4a43-af40-09a3681f7fb7": {"__data__": {"id_": "66ff19b7-adb9-4a43-af40-09a3681f7fb7", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "029784e1-bd59-4afa-abbb-1c021e43671e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "167acc11ca64d579cc8a3316c347da51dfe12eede46580ee7ca97d7bc871adaf", "class_name": "RelatedNodeInfo"}}, "text": "7.2 Pre-Exposure Prophylaxis\nPre-exposure prophylaxis (PrEP) is the pre-emptive use of ARVs to reduce the probability of\nHIV negative individuals acquiring HIV infection, especially in persons who are deemed at\nsubstantial risk.\n\nRationale: A systematic review and meta-analysis of oral PrEP trials using TDF-based ARV\ndrug combinations demonstrated that daily oral PrEP is effective in reducing the risk of acquiring\nHIV infection. The level of protection did not differ by age, sex, mode of acquiring HIV (rectal,\npenile or vaginal exposure).\n\n7.2.1 Criteria for PrEP initiation\nThe criteria for PrEP initiation are as follow:\n      \u00a7    HIV seronegative\n      \u00a7    No suspicion of acute HIV infection\n      \u00a7    A substantial risk of HIV infection\n      \u00a7    Urinalysis to rule out proteinuria\n      \u00a7    Willingness to use PrEP as prescribed\n\n7.2.2 PrEP minimum package\nThe PrEP minimum package of services includes:\n      1.   HIV testing and counselling, including index testing, self-testing and couple testing\n      2.   eGFR* and monitoring of kidney function\n      3.   Hepatitis screening\n      4.   Comprehensive HIV prevention including risk-reduction counselling and\n           condom/lubricant distribution\n      5.   Assessment of need for contraceptives and/or pregnancy testing\n      6.   Sexually Transmitted Infection screening, diagnosis and treatment\n      7.   Screening for NCDs, such as diabetes mellitus and hypertension\n      8.   Referral for services for gender-based violence, legal aid services, or mental health\n           issues identified during counselling\n      9.   Adherence assessment and counselling, help identify possible barriers to good\n           adherence\n\n7.2.3 PrEP effectiveness\nWhen used as directed, PrEP can reduce the risk of HIV among at-risk individuals by more than\n90%. PrEP can be more effective if it is combined with other HIV prevention mechanisms such\nas condom use, drug abuse treatment and harm reduction services for people living with HIV.\n\n7.2.4 Approved drugs for PrEP\nThe preferred drug regimen for PrEP is the combination of daily TDF + FTC / TDF + 3TC. The\nalternate regimen for PrEP is a daily dose of TDF.\n\n * Urinalysis should be offered as baseline screening when eGFR results are delayed, or when eGFR is not available in the health care facility.\n Waiting for eGFR result should not delay initiation of PrEP. However, if urinalysis is not normal, PrEP initiation should be delayed until\n creatinine results come back. eGFR should be performed at 6 months, followed by annual screening.\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                             95", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2688, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "da9a1793-389a-4499-a9c4-0bffd2ae98e1": {"__data__": {"id_": "da9a1793-389a-4499-a9c4-0bffd2ae98e1", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "a1ce6a4a-240d-46ee-b8ab-a940925efe42", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "f635b9202141d920218097b0f884315d528c5e3ba10e4504bfe50850ef04fd5d", "class_name": "RelatedNodeInfo"}}, "text": "7.2.5 PrEP administration guidance\nPrEP must be prescribed by a healthcare professional who has completed training on the\nNational Guidelines for the use of ARVs for PrEP. Daily PrEP should be used during periods of\nsubstantial risk of HIV acquisition and can be stopped during periods of low or no risk. The\ncategory of individuals prioritized for PrEP are listed below;\n     1.    Sero-discordant couples/partners\n     2.    Sex workers\n     3.    People who inject drugs (PWID)\n     4.    Individuals who engage in anal sex on a prolonged and regular basis\n     5.    Sexually exposed adolescents and young people\n\n7.2.6 Daily PrEP and Event-Driven PrEP\nThere are two options for the dosing frequency of PrEP: daily dosing and event-driven dosing.\nDaily dosing is recommended for men, women and transgender people. Event driven PrEP is\nONLY recommended for MSM.\n\nDaily dosing is the provision of PrEP given as 1 tablet daily. People must take their PrEP for 7\nconsecutive days before drug levels are high enough to prevent HIV infection. Daily dosing with\na single pill should be sustained throughout the period of HIV risk for as long as substantial risk is\nongoing. Those wanting to stop PrEP should continue taking the single pill daily dose for 28 days\nafter the last HIV exposureas\n\nEvent-driven PrEP (ED-PrEP) is only recommended for men who have with men. The first dose\nof 2 pills (TDF/FTC or TDF/3TC), called the loading dose, should be taken between 2 and 24\nhours prior to exposure. The second dose (after sex) is a single pill taken 24 hours after the first\ndose. The third dose is a single pill taken 24 hours after the second dose. ED-PrEP has been\ndescribed as \u201c2+1+1\u201d dosing. This 2+1+1 dosing is the only ED-PrEP regimen that has been\ndemonstrated to be effective. The 2+1+1 dosing describes ED-PrEP when an isolated act of sex is\ninvolved. If more sex acts take place over the following days, a single PrEP pill can be continued\ndaily for as long as sex continues, with a single daily pill taken for the next two days after the last\nsex act.\n\n7.2.7 PrEP for Serodiscordant Couples\nHIV transmission occurs among sero-discordant couples. Where additional HIV prevention\nchoices are needed for sero-discordant couples, daily oral PrEP may be considered as a possible\nadditional intervention for the uninfected partner. PrEP can be discontinued by the uninfected\npartner when the infected partner has achieved viral load suppression and are adhering to their\nARVs.\n\n7.2.8 Settings Where PrEP can be Accessed\nPrEP implementation can be integrated into any setting that meets the conditions for initial\nevaluation and initiation including:\n     \u00a7     One-Stop-Shop (OSS) for KPs (including community and facility settings)\n     \u00a7     HIV clinics\n     \u00a7     ANC/MNCH/RH and STI clinics\n     \u00a7     Community settings meeting the criteria for initial client assessment and evaluation e.g.\n           integrated prevention centres\n     \u00a7     Adolescent and youth-friendly outlets.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                             96", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3100, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "a23652c1-ea03-400d-8bf6-bf07fb7e3096": {"__data__": {"id_": "a23652c1-ea03-400d-8bf6-bf07fb7e3096", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b442d6b7-9232-4c94-be77-cf63e264cc16", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "7fb2e6881e0b229ff39912802397c8d3fd46a4958005bd3a1ea7febb285d4de9", "class_name": "RelatedNodeInfo"}}, "text": "Table 7.1: Services provided by cadre\n\n                         Human resource cadre                          Services Provided\n\n                       Doctors                                         Risk screening, clinical eligibility assessment, counselling,\n                                                                       initiation, prescriptions and follow up reviews\n\n                       Nurses                                          Counselling and refills\n\n                       Pharmacists                                     Dispensing PrEP drugs, counselling on adherence and side effects\n\n                       Laboratory Scientists/Technicians               Conducting laboratory tests and providing results\n\n                       HTS Counsellors                                 Counselling and risk screening, laboratory samples (if trained as a\n                                                                       phlebotomist)\n\n                       Community and facility support                  Demand creation, health education, counselling and risk\n                       cadres (i.e. expert clients, Outreach           screening, appointment reminders and follow up\n                       Workers, peer educators)\n\n7.2.9 Contraindications for PrEP\nPrEP should NOT be provided to people with:\n     \u00a7     HIV positive test on the day of PrEP initiation using\n           the Nigeria national HIV testing algorithm\n     \u00a7     Known exposure to HIV in the past 72 hours\n           (requires PEP)\n     \u00a7     Signs of Acute HIV Infection (AHI) (Box 7.1)\n           (Defer PrEP and consider PEP counselling for\n           clients with a history of high-risk unprotected sex in\n           the past three days, even in the absence of symptoms\n           of AHI).\n     \u00a7     A client unable to commit to PrEP adherence, and to\n           attend scheduled PrEP visits\n     \u00a7     Drug allergy to TDF or FTC\n     \u00a7     eGFR < 60 ml/min\n     \u00a7     Concurrent nephrotoxic medication\n\nBox 7.1. Sign and symptoms of AHI\n\n     Fever 38.38'C or 101 F\n     Swollen lymph glands\n    Fatigue/Malaise\n    Skin rash\n    Headache\n     Sore throat\n     Muscle or joint pains\n     Nausea or vomiting\n     Diarrhoea\n     Sweats\n\n\n\n\n                     7.2.10 Client follow-up\n                     Once on PrEP, clients should return after one month to assess and confirm HIV-negative test\n                     status, assess for early side effects, discuss any difficulties with medication adherence, and any\n                     other client concerns. Follow-up should be every 3 months from the initiation visit. Table 7.2\n                     outlines the procedures for each of the follow-up visits.\n\n                                   NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                           97", "mimetype": "text/plain", "start_char_idx": 20, "end_char_idx": 2880, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "70d35e42-d502-4b84-a88d-50a7d143a71b": {"__data__": {"id_": "70d35e42-d502-4b84-a88d-50a7d143a71b", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "99ee7f82-26be-458b-b73c-cff5f7baf9f9", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "952874ad136e06659e635888c552ee3480aecf0c5b0d79688ea4f5cb071f8216", "class_name": "RelatedNodeInfo"}}, "text": "Table 7.2. Follow-up visits procedures\n\n               Visit                                                            Procedure\n\n  Visit 2 (Month 1)                    \u00b7    Safety monitoring clinical assessment\n  Counsellor/Clinician                 \u00b7    HIV testing and counselling\n  Visit                                \u00b7    Adherence and risk reduction counselling\n                                       \u00b7    Offer HBV vaccination if available and HBsA gnegative (follow\n                                            HBV vaccination schedule complete series)\n\n  Visits for Months 3, 9,            \u00b7     HIV testing and counselling\n  15                                 \u00b7     HIV risk assessment for PrEP continuation\n                                     \u00b7     Adherence and risk reduction counselling\n                                     \u00b7     Assess for adverse drug reactions\n\n  Visits for      Months 6,          \u00b7     HIV testing and counselling\n  12, 18, 24, 36                     \u00b7     Creatinine and eGFR *\n                                     \u00b7     HIV risk review and assessment for PrEP continuation\n                                     \u00b7     Adherence and risk reduction counselling\n                                     \u00b7     Assess for adverse drug reactions\n  Unscheduled visits: as             \u00b7     Determine if the reason for the visit is PrEP related or not e.g adverse\n  per need.                                events\n                                     \u00b7     Assess and manage the reason for the unscheduled visit according to\n                                           national guidelines e.g. acute or chronicillnesses, worsening existing\n                                           conditions\n                                     \u00b7     Provide HIV risk reduction and PrEP adherence counselling\n                                     \u00b7     Agree on follow up schedule\n\n  During every visit\n  Remind PrEP users on the dosage of PrEP needed to achieve adequate levels of the ARVs in tissues to be\n  effective and importance of adherence. During these window periods, safer sex practices should be\n  encouraged (including abstinence and condoms).\n\n  Management of clients with inconclusive HIV test result during follow-up visits\n  For non-pregnant or lactating clients:\n       \u00b7    Discontinue PrEP\n       \u00b7    Follow the national HIV testing algorithm for clients with an inconclusive result.\n       \u00b7    Only after a confirmed HIV negative result, can the client continuewith PrEP\n       \u00b7    Offer risk reduction counselling and strongly emphasize the importance of condom use during the\n            period with inconclusive HIV test results (e.g. new infection is highly infectious)\n*creatinine clearance should be performed at 6 months, followed by annual screening.\n\n                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                       98", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2913, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n"}, "__type__": "1"}, "6e14e2ad-1fbe-4dff-b9e8-6c29c33d0b58": {"__data__": {"id_": "6e14e2ad-1fbe-4dff-b9e8-6c29c33d0b58", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b8f2d8e5-aee8-447b-af1c-ce37062942d1", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "82483ed7777e2ea48f2b14474f11d25cae2e060681f952b4aa08921ec8d841a3", "class_name": "RelatedNodeInfo"}}, "text": "7.2.11 PrEP discontinuation\n Ideally, clients should inform their service provider when they want to discontinue PrEP. Health\n care workers should discuss the options of when to discontinue PrEP with their clients. PrEP can\n be stopped for the following reasons:\n     \u00a7     Client request\n     \u00a7     Positive HIV test (clients who seroconvert while on PrEP should be linked to care and\n           initiated on ART in line with national guidelines)\n     \u00a7     Safety concerns, such as eGFR <60mls/min\n     \u00a7     No longer at substantial risk\n     \u00a7     Persistent side effects\n Documentation for persons on PrEP should be as rigorous as for person who are on ART. Upon\n discontinuation of PrEP, the following information should be documented:\n     \u00a7     HIV status at the time of discontinuation\n     \u00a7     Reasons for discontinuation\n\n 7.3 Post-Exposure Prophylaxis\n Post-Exposure Prophylaxis (PEP) is the short-term use of ARVs to prevent HIV infection in\n persons accidentally exposed to a potential risk of acquiring HIV infection. This applies usually\n to accidental exposure to HIV either in the course of legitimate work as could occur among\n health workers who are vulnerable to needle stick injuries or contact with infectious body fluids.\n It also applies to sexual assault victims especially in cases where the HIV status of the perpetrator\n cannot be readily determined.\n\n It is recommended that PEP for HIV infection should be offered and initiated as early as possible\n in all individuals with an exposure that has the potential for HIV transmission, as soon as\n possible within 72 hours.\n\n 7.3.1 Post-Exposure Prophylaxis for Occupational HIV exposure\n Needlestick injuries are major risks for HIV transmission in the workplace. The risk of\n transmission is greatly increased if associated with deep injury, visible blood on the sharp\n instrument, procedures involving a needle placed in the source patient's blood vessel, virally\n unsuppressed patients and terminal illness in the source patient.\nThe following types of exposures may pose the risk of HIV transmission for health workers and\nshould be considered for PEP:\n     \u00a7     Needlestick injury or injury with a sharp object that has been used on an HIV positive\n           patient\n     \u00a7     Mucosal exposure of the mouth, eye, or nose by splashing infectious body fluids\n     \u00a7     Broken skin exposed to blood, blood stained body fluids, or other infectious body fluids\n           (breast milk, genital secretions, cerebrospinal, amniotic, peritoneal, synovial,\n           pericardial and pleural fluids).\n\nSteps to take following a needle-stick injury or mucosal exposure:\nIn the event of an injury with a sharp object such as a needle or scalpel that has been used on a\npatient or in the event of a mucous surface being in contact with blood or secretions from a\npatient, the following steps should be followed:\n     \u00a7      Do not squeeze, suck or rub the injury site\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           99", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 3052, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "885973c4-3d7c-4091-9146-89d6702f082e": {"__data__": {"id_": "885973c4-3d7c-4091-9146-89d6702f082e", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "bfd062d5-3acf-4266-be8f-54e6b4128cf9", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "1193a61d20b21261f1484e822c3b7a17a5c6cbfbd6992315954701e298929051", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7     Allow blood or secretion to flow freely\n                         \u00a7    Wash exposed area well immediately with soap and running water or antiseptic solutions\n                              such as 2% polyhexidine or 70% glutaryladehyde.\n                         \u00a7    After a splash to the eye or any other mucous surface, irrigate/rinse the exposed area\n                              immediately with water (preferably running water) or normal saline\n                         \u00a7    Report the exposure to a senior member of staff, supervisor or the PEP officer\n                         \u00a7    If eligible, give ARV drugs recommended for PEP immediately possibly within 1 hour\n                              and at the latest within 72 hours of the exposure (persons presenting after 72 hours of the\n                              exposure should also be considered for PEP).\n\n                    7.3.2 Evaluation for Post-Exposure Prophylaxis\n                    Evaluating exposed person's eligibility for HIV PEP involves assessing the following:\n                         \u00a7    Timing of the potential exposure\n                         \u00a7    HIV status of exposed person\n                         \u00a7    The nature and risk of the exposure\n                         \u00a7    HIV status of the source of the potential exposure\n\n                    7.3.4 Determination of Risk and ARV drugs for PEP\n                    The exposure should be classified as \u201clow risk\u201d or \u201chigh risk\u201d for HIV infection as below:\n\nLow Risk:\n\u00a7    Solid needle or superficial exposure on\n     intact skin\n\u00a7    Small volume (drops of blood) on mucous\n     membrane or non -intact skin exposures\n\u00a7    Source is asymptomatic or viral load <1000\n     copies/ml\n\nHigh Risk:\n\u00a7    Large bore needle, deep injury, visible blood\n     on device, needle in patient artery/vein\n\u00a7    Large volume (major blood splash on mucous\n     membrane or non -intact skin exposures)\n\u00a7    Source patient is symptomatic, in acute\n     seroconversion and has high viral load (>\n     1000 copies/ml)\n\n                    7.3.5 Recommendations for PEP\n                         \u00a7     Immediately after exposure to HIV, all exposed individuals should take a 3drug ARV\n                               combination for PEP.\n                        \u00a7      The chosen regimen should be continued for 28 days or until the result of the HIV test for\n                               the source patient is known to be negative.\n                        \u00a7      Enhanced adherence counselling and support (psychosocial, mental, etc.) should be\n                               provided for PEP users\n                        \u00a7      If the preferred regimen is not available, it is better to administer an alternative regimen\n                               than to wait.\n\n                                  NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                             100", "mimetype": "text/plain", "start_char_idx": 25, "end_char_idx": 2943, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "060c3c93-52d6-43c6-9f4a-a3519911294e": {"__data__": {"id_": "060c3c93-52d6-43c6-9f4a-a3519911294e", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f8503a96-c99e-4b16-b780-455d3159de95", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "f51098f0e625dd93150f714158d668c3e75d6848567e2f8ec51b7652b943f569", "class_name": "RelatedNodeInfo"}}, "text": "Table 7.3 Recommended actions following HIV testing in PEP\n                      If the source person is HIV negative                    \u00a7 No PEP is necessary for the exposed health worker\n                                                                                 unless there is suspicion that the source is newly infected\n                                                                                 and in the window period.\n                      If the exposed health worker is HIV                     \u00a7 No PEP is necessary\n                      positive\n                                                                              \u00a7 The health worker should be referred for further\n                                                                                 counselling and initiation of ART/ long - term management\n\nIf the health worker is HIV negative\nand the source patient is HIV positive\n\n\n\n\n\u00a7 Give ARV drugs for four weeks;\n\u00a7 Repeat health worker\u2019s HIV test at 3 and 6 months after\n   the initial test.\n\u00a7 Should the health worker seroconvert during this period,\n   provide appropriate care and counselling; refer for expert\n   opinion and long-term management.\n\n                      If it is not possible to determine the                  \u00a7 Assume that the source patient is positive and proceed\n                      HIV status of the source patient                           according to the guidelines above\n\n                     7.3.6 Recommended Drug Combinations for PEP\n                     It is recommended that a three-drug ARV regimen should be used for PEP. TDF + 3TC (or FTC)\n                     is recommended as the preferred backbone regimen for HIV PEP for adults and adolescents.\n                     DTG or EFV are recommended as the preferred third drug for HIV PEP for adults and\n                     adolescents. However, where available, LPV/r, RAL, or DRV/r, can be considered as alternative\n                     options. If the source person is known to be on a second-line regimen or has failed first-line\n                     regimen, the preferred prophylaxis regimen should be \u201ca second-line regimen\u201d. If the source\n                     person on the second-line regimen has a detectable viral load, the prophylaxis should be a third-\n                     line regimen Children above 30kg should receive TDF/3TC/DTG or EFV. In children <10 years\n                     or less than 30kg, AZT + 3TC is recommended as the preferred backbone regimen for HIV PEP.\n                     Alternative backbone regimen for this age category will include ABC + 3TC or TDF + 3TC (or\n                     FTC). DTG is recommended as the preferred third drug for HIV PEP for children < 10 years. An\n                     age-appropriate alternative regimen can be identified from LPV/r, ATV/r, RAL, DRV/r.\n                    Table 7.4 Recommended Drug Combinations for Post-Exposure Prophylaxis\n\n                      Recommended 3-Drug ARV Combinations\n\n                           1. TDF/3TC/DTG (Preferred)\n                           2. TDF/3TC/EFV orAZT/3TC + EFV\n                      Nevirapine should never be used for PEP as the risk of fatal hepatotoxicity outweighs the risk of HIV\n                      infection.\n                      Where DTG and EFV is contraindicated, either of the 2drug combinations may be combined with LPV/r,\n                      RAL, or DRV/r\n                     Note:\n                     \u0178 NVP should not be used in children above the age of 2 years.\n                     \u0178 A 28-day prescription of antiretroviral drugs should be provided for HIV PEP following initial risk assessment.\n                     \u0178 Enhanced adherence counselling is suggested for individuals initiating HIV PEP\n\n                                    NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                            101", "mimetype": "text/plain", "start_char_idx": 21, "end_char_idx": 3938, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "38726e7b-c162-45f3-a9c6-566dbc75914a": {"__data__": {"id_": "38726e7b-c162-45f3-a9c6-566dbc75914a", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "e4009003-7fc7-4be5-ae29-50db53dfacda", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "9c626f5660691197fae154904d7969efa49c94d060921e48440d2ed0601c400d", "class_name": "RelatedNodeInfo"}}, "text": "In areas of high HIV incidence, a significant number of HIV positive individuals may be in the\n'window period' of acute infection and test antibody negative. A high level of suspicion for acute\nHIV infection should therefore be maintained and PEP continued if there is suspicion that the\nsource patient has recently been infected with HIV.\n\nGuidance should be given on risk reduction measures until the exposed person is known to be\nHIV negative. It is important to consider the risk of exposure to viral hepatitis when evaluating\npersons for post-exposure management.\nTable 7.5 Recommended schedules of investigations following HIV exposure\n Period                                     Recommended Investigations\n\n Baseline                                      HIV, HBV, HCV screening, FBC, LFT, Renal function test\n\n Two weeks                                     FBC, Liver function test, Renal function test\n\n Six weeks                                     HIV screening\n\n 3 months                                      HIV screening\n\n 6 months                                      HIV screening\n\n7.4 Post-Sexual Assault Exposure Prophylaxis\nThe possibility of HIV exposure from sexual assault should be assessed at the time of the post-\nassault examination. The benefit of PEP in the prevention of HIV infection should be discussed\nwith the assault survivors if the risk of HIV exposure exists. The likelihood of the assailant being\nHIV infected, the time that elapsed after the event and any exposure characteristics that might\nincrease the risk for HIV transmission will impact the medical recommendation for PEP and the\nassault survivor's acceptance of the recommendation. When an assailant's HIV status is\nunknown, the following factors should be considered in evaluating the level of risk:\n    \u00a7     Occurrence of vaginal or anal penetration\n    \u00a7     Occurrence of ejaculation on mucous membranes\n    \u00a7     Involvement of multiple assailants\n    \u00a7     Presence of mucosal lesions on the assailant or survivor\n    \u00a7     Other characteristics of the assault, survivor, or assailant that might increase the risk for\n          HIV transmission\nIf PEP is offered, the following should be discussed with the patient:\n    \u00a7     Benefits and known toxicities of ARV;\n    \u00a7     Follow-up that will be necessary\n    \u00a7     Benefit of adherence to recommended ARV dosing\n    \u00a7     Early initiation of PEP to optimize potential benefits (as soon as possible after and\n          preferably within 72 hours after the assault)\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                             102", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2627, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8d316c08-e0b2-4fad-b127-17450061d197": {"__data__": {"id_": "8d316c08-e0b2-4fad-b127-17450061d197", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "717f297d-0fbc-4dd0-8428-a3dad3e26f83", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "3498930a908b35cbe7edadbde00a20510e61d6c7d007717f196121fb8900a61b", "class_name": "RelatedNodeInfo"}}, "text": "7.4.1 Recommendations\n    \u00a7    A three-drug ARV regimen should be used for post-sexual exposure PEP (see ART\n         Section)\n    \u00a7    As with all cases of sexual assault, it is important to arrange for continuous counselling\n         and support (psychosocial, mental and legal, etc.) for the survivor\n    \u00a7    Emergency contraception should also be provided if indicated\n\n7.4.2 Clinical considerations\n    \u00a7    Assessment of HBV infection status should not be a precondition for offering TDF-,\n         3TC- or FTC- based PEP, but people with established chronic HBV infection should be\n\u0178        monitored for hepatic flare after PEP discontinuation. Among people with unknown\n         HBV status and where HBV testing is readily available, people started on TDF-, 3TC- or\n         FTC-based PEP should be tested for HBV to detect active HBV infection and the need\n         for ongoing HBV therapy after discontinuing PEP\n    \u00a7    NVP should not be used for PEP among adults, adolescents and older children because of\n         the risk of life-threatening adverse events associated with HIV-negative adults using this\n         drug\n    \u00a7    DTG or EFV is widely available as a third agent, as this drug is used as part of the\n         preferred first-line ART regimen. EFV is well tolerated for treatment but has limited\n         acceptability for use as PEP, as there are concerns about giving a drug associated with\n         early neuropsychiatric adverse events to HIV-negative people who may have anxiety\n         related to HIV exposure\n    \u00a7    NVP has been widely used to prevent the transmission of HIV from mothers to HIV\n         uninfected infants and should be used for preterm babies or infants younger than two\n         weeks of age where LPV/r oral liquid cannot be used. However, because the NV\n         toxicity profile beyond infancy remains unclear, its use should be avoided in children\n         older than 2 years of age\n    \u00a7    Flow chart for the provision of care for a sexually assaulted child is shown in figure 7.1\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         103", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2150, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "245fbea4-f282-4975-8a5a-7b0b87282748": {"__data__": {"id_": "245fbea4-f282-4975-8a5a-7b0b87282748", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "983205ff-63cc-4f3c-9b29-b9611d1e4dbd", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "471108417b538f34ab7f04f621d68cc3f44fc2f6de05cb4ae4d706727619439a", "class_name": "RelatedNodeInfo"}}, "text": "Figure7.1. Algorithm for screening of sexual assault in children\n\n7.5 Interventions for Key Populations\nKey Populations (KPs) are defined groups who, due to specific high-risk behaviours, are at\nincreased risk of HIV irrespective of the epidemic type or local context. Also, they often have\nlegal and psycho-social issues related to their behaviours that increase their vulnerability to HIV.\nThe KPs are important to the dynamics of HIV transmission. In Nigeria, the various KPs makeup\nonly 3.4% of the population, yet account for around 32% of new HIV infections. Without\naddressing the needs of key populations, a sustainable response to HIV will not be achieved.\n\n7.5.1 Recommended comprehensive prevention package of Interventions for key\npopulations\nA combination of interventions is required to respond effectively to HIV among KPs. The\nfollowing comprehensive package of interventions is recommended to assist programming for\nHIV prevention among KPs.\n      1. HIV prevention\n           \u00a7    Provision of condom for correct and consistent use with compatible lubricants.\n           \u00a7    PrEP should be offered as an additional prevention choice (see PrEP section for\n                guidance).\n           \u00a7    PEP should be available to all eligible people (see PEP section for guidance).\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          104", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 1403, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "f95cde35-4ddc-4bed-8efb-139a5fdd2b3d": {"__data__": {"id_": "f95cde35-4ddc-4bed-8efb-139a5fdd2b3d", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "47d88f37-d26f-4235-afec-7162bb658e69", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "68be41442cf012199ece2eed35d5fa6e8781f80a2c46f5c35da894180ca7caab", "class_name": "RelatedNodeInfo"}}, "text": "2.    HIV Testing Services\n          \u00a7     HTS including HIVST and index testing should be routinely offered to all Kps.\n     3. Treatment as Prevention\n          \u00a7     Key populations living with HIV should have the same access to antiretroviral\n                therapy (ART) as achieving viral suppression is also key to HIV prevention.\n          \u00a7     All pregnant women from KPs should have access to PMTCT services (see PMTCT\n                section for guidance)\n     4. Prevention, diagnoses and treatment of TB, viral hepatitis, cervical cancer screening,\n          STIs etc. (see the relevant sections for guidance)\n     5. Routine screening and management of mental health disorders should be provided to\n          KPs\n     6. Harm reduction for PWID: These include;\n          \u00a7     Improving access to sterile injecting equipment through needle and syringe\n                programme\n          \u00a7     Ensuring that KPs dependent on opioids should be offered and have access to\n                Opioid Substitution Therapy (OST)\n          \u00a7     Community distribution of Naloxone for overdoes management\n          \u00a7     Ensuring that KPs using harmful alcohol or other substance should have access to\n                evidence-based interventions\n\n7.6 Condom availability and promotion for HIV programme\nUniversally, condoms are pivotal in stemming the tide of the spread of HIV and STIs among any\npopulation. This is because they are the only known device that protects against STIs including\nHIV. Condom programming for key and general populations with latex condoms, compatible\nwith lubricants, substantially reduces the risk of HIV infection by 94% provided the condoms are\nused correctly and consistently. Condoms have in addition, contraceptive benefits hence their\npopularity as a product for dual protection (against unintended pregnancies and STIs including\nHIV).\n\nHowever, challenges with affordability, accessibility, availability, acceptability, perception\nincluding breakage and consistent and correct usage, have created a gap between the number of\ncondoms distributed and the amount needed for populations to protect themselves from HIV and\nSTIs. Improved condom programming can help close the gap in condom supply and use to\nreduce the spread of HIV and other STIs.\n\n7.6.1 Elements of Condom Programing\nCondom programming is a strategic approach to ensure that sexually active persons at risk of\nHIV and STIs are motivated to use condoms, have access to quality condoms, and can use them\nconsistently and correctly. Thus, condom programming must address both the supply of and\ndemand (see figure 7.2) for good quality condoms as well as the environment, which is the\ncritical operating framework through which access to and use of condoms is ensured.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                      105", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 2880, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d50eefab-886b-42e1-a55d-48b13ccaeafa": {"__data__": {"id_": "d50eefab-886b-42e1-a55d-48b13ccaeafa", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "252ca5a3-dd7a-4ffe-9a6b-e15188118b0b", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "a2da9bd51d2db7a459bbf228ff3ac65c0235c3a6b0b937eef58356dd93abfd1c", "class_name": "RelatedNodeInfo"}}, "text": "DEMAND\n                               Target specific client groups\n\n                           Identify barriers to access            CONDOM\n                            and use.                                 USE\n                          Use counselling and\n                          educational materials to\n                          promote condoms at\n                          distribution points\n\n                                Build community, social,\n                                 and political support for\n                                    condom use.\nFigure 7.2. Elements of condom programming\n       SUPPLY\n Select products that appeal\n to clients and meet their needs_\n    Forecast condom needs\n     Procure high-quality condoms\n    Manage inventory and use\n    accepted standards to store\n    and transport condoms_\n\nDistribute condoms through\n multiple channels\n and outlets\n\n\n\n                      7.6.2 Key Steps in Condom Programing\n                      The goal of condom programming is to ensure that the sexually active persons at risk of STIs are\n                      motivated to use condoms, have easy access to quality condoms and can use them consistently\n                      and correctly. It addresses the supply of and demand for condoms as well as the political, socio-\n                      cultural, and economic environment. (see figure 7.3 below for the key steps)\n                                                                             Understand condom clients\n                                                                                                      1111111111\n                                                                              and the environment:\n                                                                                               2 Assess programme\n                                                          Monitor programme progress               andplan . create action\n                                                             and ovaluate oucomes\n                                                      6 Promote condoms at Ihe community;            Procure high-quality condoms and 5\n                                                           district and nationa levels.                manage the pipeline:\n                                                                    5     Promole condoms at\n                                                                          distribution points.      Expand distribution systems:\n                     Figure 7.3. Seven steps for condom programming for HIV prevention\n\n                     7.7 Gender-Based Violence\n                     Gender-Based Violence (GBV), is a problem throughout the world, occurring in every society,\n                     country and region. When individuals or groups do not \u201cfit\u201d established gender\n                     expectations/norms they often face stigma, discriminatory practices or social exclusion \u2013 all of\n                     which adversely affect health and increase vulnerability to HIV.\n\n                                     NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                      106", "mimetype": "text/plain", "start_char_idx": 40, "end_char_idx": 3259, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ab8a6eee-8f4c-4b56-b242-391a16e67357": {"__data__": {"id_": "ab8a6eee-8f4c-4b56-b242-391a16e67357", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "d232c9fa-a397-4c59-8740-bfe750e54c8d", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "dfee5b63203768f3ced06abfd5c7b2601d6bdd422283e889fbc614b0da3c6cd1", "class_name": "RelatedNodeInfo"}}, "text": "Ignoring gender-related barriers and its integration into HIV programs can negatively affect\nprevention efforts, service utilization, adherence and health outcomes for everyone. In line with\nthis, all health care service providers should ensure the following is implemented in health care\nsettings:\n\n7.7.1 GBV Prevention\n     \u00a7    Prevent risk before it begins by using evidence-based and age-appropriate approaches to\n          prevent sexual violence and any form of coercive/forced/non-consensual sex, prevent\n          early sexual debut, and support for healthy choices.\n     \u00a7    Implement activities to prevent Intimate Partner Violence (IPV), sexual violence, and\n          provide training of HCWs to deliver evidence-based violence prevention and how to\n          respond should participants in GBV prevention activities disclose an experience of\n          violence.\n\n7.7.2 GBV Case Identification and First-line Support Recommendations\nConduct routine clinical inquiry to actively identify cases of GBV in the following settings:\n     \u00a7    Care & Treatment,\n     \u00a7    ANC/PMTCT,\n     \u00a7    Adolescent friendly services\n     \u00a7    PrEP and PEP services\n     \u00a7    HTS\n\n7.7.3 GBV Clinical Response Recommendations\nProvide comprehensive and age-appropriate clinical post-GBV care that meets the expressed\nneed of survivors. Clinical care should include the following:\n     \u00a7    Providers identify survivors via routine and/or clinical enquiry during ART initiation and\n          routine clinical care.\n     \u00a7    Survivors offered support and provided with or referred to GBV clinical care\n          interventions that help improve the mental health and psychosocial functioning of\n          survivors.\n     \u00a7    Ensure that all sites delivering post-violence clinical care services provide the full\n          minimum package of post-violence care, including:\n          o     Treatment of injuries\n          o     Rapid HIV testing and counselling with linkage to treatment as needed\n          o     STI testing/screening and treatment\n          o     Post-exposure prophylaxis (PEP)\n          o     Emergency contraception\n          o     Counselling (first-line support)\n          o     Referral to non-clinical GBV response services, such as longer-term psychosocial\n                support, child protection, police, legal aid, shelter, economic empowerment, etc.\n     \u00a7    Improve the quality of post-violence clinical care services in care and treatment sites by\n          strengthening HIV/GBV health systems and service delivery\n\nGBV considerations: Providers only ask about violence in a private setting, ensuring\nconfidentiality, which requires space, thus an audio-visual private room/space should be\nconsidered and provided accordingly.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          107", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2859, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "27eec0de-872e-4709-9f96-7410862c3f9e": {"__data__": {"id_": "27eec0de-872e-4709-9f96-7410862c3f9e", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "3a146d8b-bf96-4380-9b31-69bb77dc23fe", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "c95b839425524a0c744cc8bc2da7bfc466966fc3995ca68c28f2d71b08d1e636", "class_name": "RelatedNodeInfo"}}, "text": "7.8 Management of Sexually Transmitted Infections (STIs)\nGlobally, STIs / Reproductive Tract Infections (RTIs) remain a very important public health\nchallenge, and with the emergence of the HIV pandemic, it has become imperative for a more\ncoordinated approach to reduce its burden.\n\nA syndromic approach to the management of STIs/RTIs makes treatment accessible and\naffordable to a majority of the population because trained workers at all levels can use it as this\napproach does not require the use of sophisticated equipment, but a flow chart of symptoms\npresented by the patient and signs elicited by the health care provider is used for treatment.\n\nThe goal of STIs/RTIs syndromic management is not only to cure the patient but also to break the\nchain of transmission, avoid complications, patient education, partner treatment, provision of\ncondoms, diagnosis and prescription.\n\n7.8.1 Objectives of STIs/RTIs management\n     \u00a7    To make a correct diagnosis based on appropriate clinical assessment\n     \u00a7    To provide proper antimicrobial therapy, obtain cure, decrease infectivity and avoid\n           complications.\n     \u00a7    To reduce and prevent future high-risk behaviour\n     \u00a7    To treat sexual partners in order to break the transmission chain.\n\n7.8.2 Components of syndromic management\n     \u00a7    Building the capacity of the health care provider\n     \u00a7    Provision of counselling for STIs/RTIs\n     \u00a7    Identifying /treating all STIs/RTIs syndromes\n     \u00a7    Conducting risk assessment\n     \u00a7    Specific antimicrobial therapy\n     \u00a7    Partner notification\n     \u00a7    Prevention of ophthalmia neonatorum\n     \u00a7    Prevention of mother-to-child transmission of HIV\n     \u00a7    Referral to secondary/tertiary Healthcare levels for further management.\n     \u00a7    Data collection/management\n\n7.8.3 Prevention of STIs/RTIs\nSexually transmitted infections (STIs) and RTIs can be prevented by the following measures:\n     \u00a7    Primary preventive measures: abstinence, faithful sexual relationships, correct and\n          consistent use of condoms and vaccination\n     \u00a7    Secondary preventive measures: encouraging STI care-seeking behaviour, rapid and\n          effective treatment and case finding\n     \u00a7    Tertiary preventive measures: limitation of disability and rehabilitation including\n          psychosocial support\n\nThere is the risk assessment for all patients presenting with symptoms of STIs and anyone who\nfalls into two or more of the categories listed in the assessment is considered to be \u201crisk\nassessment positive\u201d and is assessed based on the flow charts that fits his/her symptoms. Below\nare flow charts that describe the steps to be taken in managing a patient with STI using the\nsyndromic approach.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         108", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2836, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "64ca8f89-3772-4b07-8b7b-9544afe033ef": {"__data__": {"id_": "64ca8f89-3772-4b07-8b7b-9544afe033ef", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "133862c2-9581-48fc-b5d6-ad86a63c464b", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "b7a71da405a6a7f20496499da11375dc02f920f46b02a5e515569a6da11d7140", "class_name": "RelatedNodeInfo"}}, "text": "7.9 Prevention for Adolescent and Young Persons (AYPs)\nAdolescents and young people are persons between 10 and 24 years of age. This age is\ncharacterized by rapid physical growth and development as well as sexual maturation. It is a\nperiod that can be marked by the need to try out new things such as sex, experiment with\ninjectable drugs as well as other drug types. As a result of engaging in these high-risk behaviours,\nthere has been an upsurge in the prevalence of HIV and other STIs in AYPs. The low social and\neconomic status of most AYPs complicates the situation.\n\nAYPs make up 31% of the entire population of Nigeria. Data from the Nigeria AIDS Control\nAgency (NACA) put the prevalence of HIV at 4.2% for young people aged 15 to 24. Forty\npercent of all reported new cases of HIV occur in young persons aged 15 to 24 which is the\nhighest when compared to other age groups.\n\nIn Nigeria, there are social and contextual factors that make AYP vulnerable to HIV infection.\nIdentification of the prevailing sociocultural factors in a particular community and designing\ninterventions to address them is key to success. The drivers of the epidemic pertinent to Nigerian\nAYP include multiple and concurrent sexual partnerships, intergenerational sex, sexual\ncoercion, low-risk perception, and transactional sex. Married adolescents and young women\nmay also be exposed to increased risk of HIV infections from their husbands. Exacerbating high-\nrisk behaviours are socioeconomic conditions like pervasive gender inequalities and gender-\nbased violence, poverty, unemployment or underemployment, and widespread HIV-related\nstigma and discrimination. There are also a number of traditional, religious, and cultural factors\nthat increase the risk of HIV infection and other sexual and reproductive health (SRH)\nmorbidities among young women and girls such as child and forced marriage, female genital\nmutilation, and widow inheritance. In addition, ineffective STI programming, poor integration\nof HIV and SRH services are other factors [5].\n\nHIV program for AYPs in Nigeria has a goal to reduce new HIV infections and should be\ndelivered as a package of interventions for AYP in line with Minimum Prevention Package\nIntervention (MPPI).\n\n7.9.1 Harm Reduction program\nHarm Reduction (HR) is a range of public health policies and practices that are designed to lessen\nthe negative psychosocial and/or physical consequences associated with various human\nbehaviours, both legal and illegal. As relates to HIV, drug-related harms include overdose, drug-\nrelated deaths, blood-borne infections such as HIV, HCV, HBV and bacteremia/sepsis. HR\nprogramming in Nigeria include services such as:\n    \u00a7     Needle and syringe programmes (NSPs).\n    \u00a7     Opioid substitution therapy (OST) and other evidence-based drug dependence\n          prevention services\n    \u00a7     Use of own snorting straws and crack pipes\n    \u00a7     Peer interventions to reduce the incidence of viral hepatitis and HIV\n    \u00a7     Use of motivational techniques to increase behavioural change\n    \u00a7     Distribution of condoms and lubricants\n    \u00a7     IEC materials for PWID\n    \u00a7     Testing and management of STI, HIV, HCV, HBV\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           109", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3295, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "4095cf91-89d3-48b9-bbc3-0d3cc76f314c": {"__data__": {"id_": "4095cf91-89d3-48b9-bbc3-0d3cc76f314c", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b90afd06-d6d3-43ee-b2c5-7c2f8fb7c716", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "63895af87372fc6050eba22ef21dc38a5c67f4fa3bc1ab40a301ec128fe7d1cf", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7     Vaccination, diagnosis and treatment of viral hepatitis\n     \u00a7     Prevention, diagnosis and treatment of other opportunistic infections (including HIV\n           and tuberculosis).\nIf scaled -up, these evidence-based harm reduction-oriented practices are known to reduce\ntransmission of blood-borne illnesses and injection related infections among PLHIV, as well as\nprevent fatal drug-related overdose and other harm associated with risky behaviours.\n\n7.9.2 Cervical Cancer Prevention\nCervical cancer is preventable and curable if diagnosed and treated early. The most effective\nstrategy available for primary prevention of cervical cancer is the vaccination against the HPV\naetiologic agent of cervical cancer. HPV vaccines are indicated for pre-pubertal girls and offer\nmost hope to effectively stop cervical cancer epidemic in Nigeria. HIV positive children can also\nreceive HPV vaccination because available evidence has shown that they develop sufficient\nimmune response.\n\nWomen living with HIV (WLHIV) have a higher risk of pre-cancer and invasive cervical cancer.\nThe risk and persistence of HPV infection increases with low CD4+ cell count and high HIV viral\nload. Cervical cancer screening leads to early detection of precancerous and cancerous cervical\nlesions that will prevent serious morbidity and mortality. WLHIV should be screened every three\nyears for evidence of precancerous changes in the cervix, regardless of whether they are taking\nART or their CD4+ cell count or viral load. All WLHIV should be screened for cervical cancer\nregardless of age. Immediate management for precancerous and cancerous lesions should be\nprovided. For further detail, refer to the National Cervical Cancer Prevention and Control Policy.\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                       110", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 1852, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c1f188b6-bb81-49f9-834d-8c4ac70037ad": {"__data__": {"id_": "c1f188b6-bb81-49f9-834d-8c4ac70037ad", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "086168cb-c11b-4538-bed6-9a64429ce045", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "07d1d81f6355c281b4d288da02f21c1ba75af52a3d698d0fd7bbf35eda517ede", "class_name": "RelatedNodeInfo"}}, "text": "List of Contributors\nDr Adesigbin Clement\nDr Ijaodola Olugbenga\nTaiwo Olakunle\nZainab E. Abdullahi\nDr Adeyinka Adewemimo\nDr Benson Udu\nMrs. Hidayat Bukola Yahaya\nDr Gideon Sorochi Okorie\nProf. Oladapo Shittu\nProf. Solomon Sagay\nProf Anteinette Ofili\nProf. Oliver Ezechi\nDr Idowu Adebara\nDr Stephen B. Bature\nDr Chinyere Ukamaka Onubogu\nDr Benjamin Aiwondagbon\nDr Ochola-Odonga Dorothy\nDr Victoria Isiramen\nDr Idayat Uthman\nDr. Efuntoye Adeola Tim\nBennett Okechukwu Urama\nDr Chris Obanubi\nLilian Anomnachi\nDr Andrew Etsetsowaghan\nDr Omoregie Godpower\nDr Amalachukwu Ukaere\nHalima Ibrahim\nMrs Ehi Adejo-Ogiri\nOgochukwu Ginigeme\nDr Helen Omuh\nRuth Dauda Akolo\nChinwe Aganekwu\nAbang Roger\nMwoltu Nanribet Gabriel\nAkanji Michael O\n                                                              Chapter 7\nDeputy Director, Head of Prevention NASCP\nAssistant Director, National Officer PMTCT NASCP\nChief Scientific Officer NASCP\nPopulation Programme Officer I NASCP\nSenior Medical Officer I NASCP\nSASPC, FCT\nProgramme Officer Health Sector Response Support NACA\nAssistant Chief program officer/ PMTCT/HTS Focal Officer NACA\nChairman, PMTCT Task Team / OBY/GYNAE ABUTH Zaria\nMember PMTCT Task team / OBY/GYNAE JUTH Jos\nPublic Health Physician, UBTH Benin\nDirector of Research, NIMR Lagos\nConsultant OBY/GYN, FTH Ido Ekiti\nMember PMTCT Task Team / OBY/GYN, BDTH/KASU Kaduna\nPaediatrician, NAUTH, Nnewi\nWHO\nHealth & HIV Section UNICEF\nHealth Manager UNICEF\nNational Program Officer UNAIDS\nSenior Specialist PMTCT, CDC\nForecasting and Supply Planning Advisor GHSC-PSM\nProgramme Manager USAID\nDeputy Program Director CHAI\nTechnical Director FHI360\nHead/Practice Lead, HIV and TB SFH\nProgram Director SFH\nProgram Manager SFH\nGender Officer/POC JHPIEGO\nICAP\nDeputy Director IHVN\nWelfare - Deputy ASWHAN\nCoordinator, FGI CISHAN\nDirector of Programs Heartland Alliance\nMental Health Technical Advisor Heartland Alliance\nKey Populations Advisor Heartland Alliance\n\n                               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  111", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 2045, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6e9a1819-382e-4d3e-a485-3e799a170df9": {"__data__": {"id_": "6e9a1819-382e-4d3e-a485-3e799a170df9", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f1b6d642-9133-4ac5-82f5-a56b7f795709", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "f86e6bb372b42c68c0d8df46bb2a14bc246d493c274bc099e4355c503b65edfe", "class_name": "RelatedNodeInfo"}}, "text": "8. ADVANCED HIV DISEASE,\n   OPPORTUNISTIC INFECTIONS,\n          AND CO-MORBIDITIES\n\nWhat\u2019s Inside:\n8.1 Advanced HIV Disease\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026.......113\n 1.1 Objectives of the Guidelines\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\n8.2 Other Opportunistic Infections (OIs)\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.......126\n 1.2 Epidemiology of HIV in Nigeria\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\n8.3 Preventing Opportunistic Infections (OIs)\u2026\u2026\u2026\u2026\u2026\u2026.......126\n 1.3 Natural History of HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\n8.4 HIV-Related Co-Morbidities\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026.......146\n8.5 Mental Health and HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026.......146", "mimetype": "text/plain", "start_char_idx": 6, "end_char_idx": 511, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "feb17d4c-6918-45e5-88c2-17dac1a7c7ac": {"__data__": {"id_": "feb17d4c-6918-45e5-88c2-17dac1a7c7ac", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b0409017-ee0d-4b8c-b80b-6c998b72c30f", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "1990b7a628736bf27f035cdc3418c335565b1d1a27da4aacbd558059bed4e22d", "class_name": "RelatedNodeInfo"}}, "text": "8.1 Advanced HIV Disease\n\n8.1.1 Introduction\nThe morbidity and mortality associated with HIV infection have decreased over the past decade\nas access to ART has increased. Worldwide, AIDS-related deaths rose to 1.7 million in 2004 but\nhave been on a steady decline to 770,000 as at 2018 [6]. In Nigeria, there were 94,000 AIDS death\nin 2003, but declined to 53,000 in 2018 [6]. Notwithstanding this progress, the decline in AIDS-\nrelated deaths appears to have plateaued in recent years. This is largely due to the persistent\nchallenge of Advanced HIV Disease (AHD) [8]. Globally, the proportion of people presenting\nwith AHD has remained largely unchanged during the past five years although the number of\npeople receiving ART in low- and middle-income countries (LMIC) has more than doubled over\nthis period. Recent estimates suggest that about 30\u201340% of people living with HIV starting ART3\nin LMIC have a CD4+ cell count of < 200 cells/mm and 20% have a CD4+ cell count <1003\ncells/mm [9]. In some settings, up to 50% of people present to care with advanced HIV disease\n[9]. In Nigeria, 32% of patients that commenced ART in 2018 presented with advanced HIV\ndisease [9]. Similarly, data from six high volume ART sites in the country suggests that the\nburden of AHD ranges from 16% - 50% [11].\n\nHIV infects the CD4+ cells leading to their destruction. The resultant immunosuppression\npredisposes the individual to severe opportunistic infections. These opportunistic infections\ninclude Tuberculosis, Cryptococcal meningitis, Oro-esophageal candidiasis, Toxoplasmosis,\nPneumocystis jiroveci pneumonia, histoplasmosis and septicemia [9]. Nigeria has the first and\nsixth highest TB burden in Africa and globally respectively [4]. Cryptococcus and\nHistoplasmosis, initially thought not to be prevalent, are now becoming increasingly endemic in\nNigeria with more than 25,000 cases of Cryptococcus reported annually [9] and about 124 cases\nof Histoplasmosis also reported in Nigeria. These infections account for significant morbidity\nand mortality in the AHD population. Thus, the Nigerian government is committed to focusing\nefforts to ensure that those infected with HIV achieve virological suppression, minimize the risk\nof HIV transmission, prevent and treat co-morbidities, improve survival rate and ultimately\nmove Nigeria closer to ending the HIV epidemic.\n\nDifferentiated service delivery (DSD) is an approach that simplifies and adapts HIV services to\nbetter serve the needs of PLHIV and reduce unnecessary burdens on the health system. Under a\nDSD approach, people who are stable on treatment would have a reduced frequency of clinical\nconsultations and drug refills three monthly and in exceptional circumstances six monthly. This\nallows health service resources to focus on care for patients who are ill and need intensive\nclinical follow-up. Management of AHD is one of the DSD models which the country has now\nadopted to control the HIV epidemic.\n\nThe 2017 WHO guidelines on the management of AHD recommend a package of care for\nscreening, prophylaxis, rapid ART initiation and intensified adherence interventions. These are\noffered to everyone living with HIV presenting with advanced disease. The guidelines include\nan algorithm to support decision making for providing care for people with AHD. Even though\nthe 2016 Nigeria treatment guidelines also highlighted the need to provide a differentiated\npackage of care for OIs, the entity AHD was not clearly defined.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                       113", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3581, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6dffe547-21ea-4630-b234-ce852991673d": {"__data__": {"id_": "6dffe547-21ea-4630-b234-ce852991673d", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "8e499d68-275f-4484-9a86-e00e5743ec0f", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "29dfe8cd13f32c943a3cba1b618b2d142b571e078dd86dd0f69411791b94832b", "class_name": "RelatedNodeInfo"}}, "text": "8.1.2 Definition of advanced HIV disease\nWHO defines AHD in adults, adolescents and children older than five years as CD4+ cell count3\n<200cells/mm or WHO stage 3 or 4 event. All children younger than five years of age with HIV\nare considered as having AHD. The appearance of OIs is directly related to the extent of immune\ndeficiency; the lower the CD4+ cell count, the higher the likelihood of the appearance of OIs\n[12]. The common OIs associated with AHD include the following:\n    \u00a7     Tuberculosis: Tuberculosis is the leading cause of morbidity and mortality among\n          PLHIV, accounting for one-third of the estimated 1.1 million people dying from AIDS-\n          related causes one-third of the estimated 1.1 million people dying from AIDS-related\n          causesglobally in 2015 [9]. Most of these TB-associated deaths (200,000 cases) occurred\n          among men [9]. TB also remains a leading cause of HIV-associated hospitalization\n          among adults and children living with HIV worldwide. In 2017, the number of AIDS-\n          related deaths reported in Nigeria was 51,000, and 35,000 (68%) were associated with\n          TB [6]. Furthermore, 11% (12,521) out of the diagnosed 120,266 TB cases in Nigeria in\n          2019 were co-infected with HIV [13]. Factors responsible for the persistent high burden\n          of TB among PLHIV include low ART coverage, low uptake of Tuberculosis Preventive\n          Therapy (TPT) and sub-optimal diagnosis of active TB.\n\n    \u00a7     Cryptococcal meningitis: the incidence of cryptococcal meningitis remains substantial\n          despite the scale-up of ART [9]. A recent review estimated that there were 223,100\n          incident cryptococcal meningitis cases globally in 2014, with73% of the cases occurring\n          in sub-Saharan Africa; the annual global deaths from cryptococcal meningitis were\n          estimated to be 181,100. Cryptococcal meningitis is a leading cause of mortality among\n          hospitalized adults living with HIV, accounting for 15\u201320% of adult deaths but is less\n          common among children living with HIV [14]. An average global cryptococcal3\n          antigenemia of 6% is reported among people with CD4+ cell count of < 100 cells/mm\n          [14]. In Nigeria, there is an estimated 25,000 cases of Cryptococcosis annually [9].\n          Several studies from Nigeria have revealed rates of 2% 12.9% of Cryptococcus with\n          geographical variations [15]. An earlier study on cryptococcal meningitis revealed a\n          36% hospital-based frequency amongst patients presenting with neurological symptoms\n          at Jos University Teaching Hospital [16]. The 2018 WHO guidelines on the diagnosis,\n          prevention and treatment of cryptococcal disease among adults, adolescents and children\n          summarizes the recommendations for the prevention, diagnosis and treatment of\n          cryptococcal meningitis. Pre-emptive therapy for cryptococcal antigen-positive\n          asymptomatic people is a key strategy to prevent cryptococcal meningitis.\n\n    \u00a7     Toxoplasmosis: Cerebral toxoplasmosis is the most frequent cause of meningo-\n          encephalitis among adults living with HIV not receiving co-trimoxazole. Toxoplasmosis\n          is a common protozoan infection among people with HIV. The prevalence of co-\n          infection is especially high in sub-Saharan Africa (45%), Latin America, the Caribbean\n          (49%), North Africa and the Middle East (61%) [9]. People with latent toxoplasmosis\n          infection are at risk of developing cerebral toxoplasmosis when their CD4+ cell count3\n          <200 cells/mm . About 15% of hospitalized adults living with HIV died from AIDS-\n          related illnesses were associated with cerebral toxoplasmosis [9]. The diagnosis of\n          cerebral toxoplasmosis requires imaging techniques, such as computed tomography\n          scans. In 2005, a study from JUTH revealed 32% prevalence of Toxoplasmosis among\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                        114", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 4098, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "bbe2dfd7-0947-4821-aa1f-e726f287c26b": {"__data__": {"id_": "bbe2dfd7-0947-4821-aa1f-e726f287c26b", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "ca402467-c04a-43f1-9591-f10713ebe711", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "2cd4ae8b166832af7cd458e25c99a23094b94c0080284dda3913849d3fff265a", "class_name": "RelatedNodeInfo"}}, "text": "HIV infected patients [17]. However, diagnosis was made using serological\n          technique.\n    \u00a7     Pneumocystis jiroveci pneumonia: Pneumocystis jiroveci pneumonia (PJP) is a\n          leading cause of mortality among hospitalized adults (13%) and children (29%) living\n          with HIV [18]. However, the global burden of morbidity and mortality attributable to PJP\n          is poorly characterized because appropriate diagnostic facilities are lacking in most\n          LMIC. This highlights the need for more accurate and feasible diagnostic approaches\n          and improved access to co-trimoxazole and ART. A study from Calabar revealed a 7.4%\n          prevalence of PJP among 272 known symptomatic HIV infected patients [19].\n    \u00a7     Histoplasmosis: Histoplasmosis is an AIDS-defining infection that is endemic and\n          commonly misdiagnosed as TB. The condition has been severally reported in Africa and\n          particularly in Nigeria. A recent review article revealed 470 documented cases in Africa.\n          HIV infected patients accounted for 38% of               the cases and Nigeria accounted for the\n          highest number of reported cases (124) [20]. However, most cases from Nigeria were\n          among HIV negative patient with only 4 documented cases in HIV positive Nigerian-\n          emigrant in Europe. A recent multicenter skin sensitivity screening revealed a 4.4%\n          prevalence rate of prior subclinical histoplasmosis with wide geographical variations\n    \u00a7     Severe bacterial infections: People with AHD frequently have severe bacterial\n          infections in the bloodstream, respiratory, central nervous and gastrointestinal\n          systems.The burden of mortality and morbidity attributable to severe bacterial infections\n          is poorly characterized largely because appropriate diagnostic facilities are limited.\n          Severe bacterial infections are estimated to cause more than one-third of\n          hospitalizations among adults and children living with HIV worldwide. It has been\n          reported that there is a 12.9% prevalence of bacterial bloodstream infection among\n          PLHIV with coagulase negative staphylococcus accounting for 58% of the patients [22].\n          Another study from Lagos revealed 33% of bacterial bloodstream infections in HIV\n          infected population with non-typhoidal salmonella species accounting for 45.5%\n          followed by coagulase negative staphylococcus [23]. Co-trimoxazole prophylaxis\n          provides protection against some but not all severe bacterial infections.\n\n8.1.3 Components of AHD package of care\n    1.    Diagnostics for AHD and associated OIs\n    2.    Prophylaxis against associated OIs with AHD\n    3.    Pre-emptive treatment for OIs associated with AHD\n    4.    Treatment of confirmed OIs associated with AHD\n    5.    ART initiation in the setting of AHD\n    6.    Intensive adherence counselling and monitoring\n    7.    Vaccination\n\n8.1.4 Diagnostics for AHD and associated OIs\nThese include CD4+ cell count test required to diagnose AHD and specific tests to diagnose the\ncountry defined AHD associated OIs.\n\n8.1.4.1 Role of CD4+ cell count testing in the diagnosis of AHD\nThe 2016 National treatment guidelines recommended starting ART regardless of CD4+ cell\ncount and that it should be done at baseline and every six months in addition to routine VL\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                 115", "mimetype": "text/plain", "start_char_idx": 10, "end_char_idx": 3536, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "4119764f-fbe2-4b83-8216-32f683ea182b": {"__data__": {"id_": "4119764f-fbe2-4b83-8216-32f683ea182b", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "83708622-d11e-4fbf-8ffe-948792f212d0", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "79867f7b194c17d4c7de031ab2944c45141a212fecd453cb7797f55183fb65a2", "class_name": "RelatedNodeInfo"}}, "text": "monitoring. Relying on clinical staging alone risks missing substantial numbers of PLHIV with\n                    severe immunosuppression [24] . In a study from Zimbabwe, Uganda, Kenya and Malawi, close3\n                    to half the people with CD4+ cell count <100 cells/mm were classified as having WHO clinical\n                    stage 1 or 2 disease [24]. A five year (2005- 2010) retrospective cohort study involving over\n                    14,000 patients revealed that 63% of PLHIV presented withAHD in Nigeria [25]. Despite the\n                    implementation of the 'test and treat' strategy, data from the national treatment program revealed\n                    that 32% of PLHIV presented with AHD in 2018. Consequently, it is imperative that all newly\n                    diagnosed PLHIV and those returning to care should have a baseline CD4+ cell count and same-\n                    day results obtained.\n                   Table 8.1: Diagnostics for associated opportunistic infections in AHD\n\nAssociated OIs Screening &                        Required Sample CD4+ Cell\n                      diagnosis                                             Count\nTuberculosis          Xpert MTB/RIF               Sputum                    Any\n                      assay as the first test\n                      for TB diagnosis in\n                      symptomatic patients\n                      AFB, Xpert                  Sputum/non\n                      MTB/RIF assay               sputum (stool, CSF\n                                                  and Cold Abscess)\nAdults &         Children\nAdolescents\nYes              Yes\n\n\n\nYes              Yes\n\n\n\n                                           LF-LAM                      Urine                     Urine LF-           Yes  Yes*\n                                                                                                 LAM assay for\n                                                                                                 patients with\n                                                                                                 CD4+ cell\n                                                                                                 count <200\n                                                                                                 cells/mm3\n                     Cryptococcosis Cryptococcal antigen               Serum, plasma or          <200\n                                                                                                 cells/mm3           Yes  No\n                                           (CrAg) screening            whole blood\n                     Histoplasmosis Histoplasma urinary                Urine                     <200\n                                                                                                 cells/mm3           Yes  Yes\n                                           antigen screening\n                     Pneumocystis          Giemsa stain,               Bronchial aspirate <200cells/mm3              Yes  Yes\n                      jiroveci             Grocott Methenamine\n                     pneumonia (PJP)       Silver stain\n\n                    Adapted from WHO advanced HIV disease package of care 2018\n                    * Limited data available for children\n\n                                  NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                            116", "mimetype": "text/plain", "start_char_idx": 20, "end_char_idx": 3472, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c82bbc72-ab05-4600-8bce-dffc7b6bef80": {"__data__": {"id_": "c82bbc72-ab05-4600-8bce-dffc7b6bef80", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "2fa49852-f213-49c9-8ba1-f87139c0d78f", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "3d34e3c1bb28f637ae7ba4a923b6024d964a582b4bb1a9aef8358d600cd783c6", "class_name": "RelatedNodeInfo"}}, "text": "Table 8.2: Prophylaxis for AHD associated OIs\n\n  Disease             Prophylactic         Pre-emptive             Criteria for Prophylaxis &         Target\n                      Intervention         Treatment               Pre-emptive Treatment              Population\n  Tuberculosis        Yes (TPT)            No                      Any CD4+ cell count value.         Adult and children\n\n  Pneumocystis        Yes                  No                      \u00b7 CD4+ cell count \u2264500             Adult and children\n  jiroveci                                                             cells/mm or WHO3\n  pneumonia           (CPT)                                            clinical stage 3 or 4 event.\n  (PJP)                                                            \u00b7    Any CD4+ cell count\n                                                                        value in settings with\n                                                                        high prevalence of\n                                                                        malaria and/or severe\n                                                                        bacterial infections\n\n  Cryptococcal        No                   Yes (Fluconazole        AHD                                Adult and\n  Meningitis                               pre-emptive                                                adolescent\n                                           therapy for CrAg\n                                           positive patients\n                                           without evidence of\n                                           meningitis)\n\n 8.1.5 Management of opportunistic infections in AHD\n\n 8.1.5.1 Tuberculosis\n Diagnosis\n     \u00a7     Xpert MTB/RIF assay and TB-LF LAM are the recommended diagnostic tests for\n           PLHIV presenting with AHD\n     \u00a7     Where the above tests are not available, AFB microscopy can be used, or representative\n           samples referred to sites where Xpert MTB/RIF assay or TB-LF LAM is available\n WHO strongly recommends the use of LF-LAM to assist in diagnosing active TB among\n children and Adolescent living with HIV,\n     \u00a7     with signs and symptoms of TB (pulmonary and/or extrapulmonary)\n     \u00a7     with advanced HIV disease or who are seriously ill, regardless of signs and symptoms of3\n           TB and with a CD4+ count <200 cells/ mm ;\n Prophylaxis & Treatment\n     \u00a7     Manage as in the national TB guidelines.\n ART Initiation\n     \u00a7     Immediate ART initiation is not recommended for adults, adolescents and children\n           living with HIV who have TB, because of the risk of increased mortality and should be\n           deferred by 2 weeks (if CD4+ cell count is < 50), or 4 weeks (if CD4+ cell count is > 503\n           cells/mm ) after the initiation of anti-TB drugs.\n\n 8.1.5.2 Cryptococcal Meningitis\n Diagnosis\n For adults, adolescents and children living with HIV suspected of having a first episode of\n cryptococcal meningitis, prompt lumbar puncture with measurement of cerebrospinal fluid\n (CSF) opening pressure and rapid cryptococcal antigen assay is recommended as the preferred\n diagnostic approach.\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                      117", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3286, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "225088fc-5b2a-4537-adf4-1f47d7d7abd1": {"__data__": {"id_": "225088fc-5b2a-4537-adf4-1f47d7d7abd1", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "57802baa-70e2-41bc-9a20-d210ba140618", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "0f835b599f4b16a5710d301d51ebe7bba6f5b8e0ef5b2a004786b67154abfc25", "class_name": "RelatedNodeInfo"}}, "text": "The following diagnostic approaches are recommended, according to the context:\n     a.    In settings with ready access to and no contraindication for lumbar puncture:\n           i.    If both access to a cryptococcal antigen assay (either lateral flow assay or latex\n                 agglutination assay) and rapid results (<24 hours) are available, proceed with\n                 Lumbar puncture (LP) for a rapid CSF cryptococcal antigen assay as the preferred\n                 diagnostic approach\n           ii. If access to a cryptococcal antigen assay is not available and/or rapid results are not\n                 available, proceed with LP with CSF India ink test as the preferred diagnostic\n           In settings without immediate access to LP or when LP is clinically contraindicatedaapproach\n     b.\n           i.    If both access to a cryptococcal antigen assay and rapid results are available within <\n                 24 hours, proceed with rapid serum, plasma or whole-blood cryptococcal antigen\n                 assays as the preferred diagnostic approaches\n           ii. If a cryptococcal antigen assay is not available and/or rapid access to results is not\n                 ensured, prompt referral for further investigation and treatment is required\nProphylaxis\nScreening for cryptococcal antigenb followed by pre-emptive antifungal therapy among\ncryptococcal antigen-positive people to prevent the development of invasive cryptococcal\ndisease is recommended before initiating or reinitiating ART for adults and adolescents living\nwith HIV who have a CD4+ cell count < 200 cells/mm\u0000.\n\nFluconazole 800 mg/day for two weeks, then 400 mg/day for eight weeks and continued\nmaintenance with fluconazole 200 mg/day is recommended for pre-emptive antifungal therapy.\nWhen cryptococcal antigen screening is not available, fluconazole primary prophylaxis should3\nbe given to adults and adolescents living with HIV who have a CD4+ cell count < 200 cells/mm .\nFluconazole 100mg daily for 8 weeks is recommended. Screening and primary prophylaxis are\nnot recommended for children, given the low incidence of cryptococcal meningitis in this age\ngroup.\n\nInduction\n     \u00a7     The following is recommended as the preferred induction regimen: For adults,\n           adolescents and children, a short-course (one-week) induction regimen with liposomal\n           amphotericin B (3.0 mg/kg/day) and flucytosine (100 mg/kg/day, divided into four doses\n           per day), followed by 1 week of fluconazole (1200mg/day for adults, 12 mg/kg/day for\n           children and adolescents, up to a maximum dose of 800mg daily)\nThe following induction regimens are recommended as alternative options depending on drug\navailability:\na Contraindications include significant coagulopathy or suspected space-occupying lesion based on focal nervous system signs (excluding\ncranial nerve VI palsy) or recurrent seizures and, where possible, confirmed by computed tomography. Raised intracranial pressure does not\ncontraindicate LP in (suspected) cryptococcal meningitis. Other contraindications include major spinal deformity and patient refusal despite\nadequate counselling.\nb Good practice principle: All PLHIV with a positive cryptococcal antigen result on screening should be carefully evaluated for signs and\nsymptoms of meningitis and undergo an LP if feasible with CSF examination and cryptococcal antigen assay (or India ink if cryptococcal antigen\nassay is not available) to exclude active cryptococcal disease.\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                              118", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3636, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "29c366a2-fa27-4db9-a58c-6b1855c243b5": {"__data__": {"id_": "29c366a2-fa27-4db9-a58c-6b1855c243b5", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "6c99a7e5-8e69-4b55-bf47-006f78799b87", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "5a40e0bdd574e7c8d6f6300f6df995ac8141060743bdec3707d20c1f29ec0084", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7     Two weeks of fluconazole (1200 mg daily for adults, 12 mg/kg/day for children and\n           adolescents) + flucytosine (100 mg/kg/day, divided into four doses per day)\n     \u00a7     Two weeks of amphotericin B deoxycholate (1.0 mg/kg/day) + fluconazole (1200 mg\n           daily for adults, 12 mg/kg/day for children and adolescents up to a maximum of 800 mg\n           daily).\n Consolidation\n     \u00a7     Fluconazole (800 mg daily for adults, 6\u201312 mg/kg/day for children and adolescents up to\n           a maximum of 800 mg daily) is recommended for the consolidation phase (for eight\n           weeks following the induction phase)\n Maintenance\n     \u00a7     Fluconazole (200 mg daily for adults, 6mg/kg/day for adolescents and children) is\n           recommended for the maintenance phase\n     \u00a7     Discontinuation of maintenance therapy should be done when the patient is stable on and\n           adherent to ART and has had antifungal maintenance treatment for at least one year and3\n           has a CD4+ cell count \u2265200 cells/mm and a fully suppressed VL\n Therapeutic Lumbar Puncture\n Using drugs (mannitol, acetazolamide, furosemide or steroids) for managing raised intracranial\n pressure is not being recommended because there is no evidence that these drugs improve\n     \u00a7     Outcomes in managing cryptococcal meningitis\u2013associated raised intracranial pressure;\n           and available evidence suggests their utilization may be harmful [3]\n     \u00a7     Initial measurement of intracranial pressure and management of raised intracranial\n           pressure is an essential part of cryptococcal meningitis management to prevent death and\n           serious nervous system complications\n     \u00a7     Reduction of raised CSF pressure is associated with clinical improvement and survival\n           benefit, regardless of initial opening pressure. Conversely, failure to reduce CSF\n           pressure is associated with poor nervous system outcome and increased mortality\n     \u00a7     Pressure should be relieved by draining a volume sufficient to reduce the CSF pressure to\n           < 20cm H20 or halving the baseline pressure if extremely high**\n     \u00a7     For people with initial intracranial pressure of 20cmH 0 or more or subsequent2\n           development or recurrence of symptoms or signs of raised intracranial pressure, repeat\n           therapeutic LP should be carried out\n ART Initiation\n Immediate ART initiation is not recommended for PLHIV who have cryptococcal meningitis\n because of the risk of increased mortality and should be deferred by 4\u20136 weeks from the\n initiation of antifungal\n treatment.\n\nNote: A minimum package of pre-emptive hydration, electrolyte replacement, toxicity monitoring and management should be provided to\nminimize toxicity related to amphotericin B and flucytosine.\n** Ensure manometers are available\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                        119", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 2976, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "eab9d172-45c0-4313-8da0-1786ee33420f": {"__data__": {"id_": "eab9d172-45c0-4313-8da0-1786ee33420f", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "2375af5c-ca01-4890-8b42-d50340a49959", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "9b55c91f960d606df4b0d5337d4e8ec49341b7297a41f87794eabaa16d2baef0", "class_name": "RelatedNodeInfo"}}, "text": "8.1.5.3 Oro-oesophagal candidiasis\nDiagnosis\n     \u00a7    Clinically diagnosed by retrosternal chest pain (heartburn), pain or discomfort on\n          swallowing and features of candidiasis (pseudo membranous, erythematous lesions and\n          angular cheilitis) in the mouth or throat\n     \u00a7    Laboratory: Wet mount microscopy using KOH preparation\n     \u00a7    Endoscopy should be conducted for the patient if no response to antifungal therapy and\n          collect a representative sample for testing.\nTreatment\nAdult:\n     \u00a7    Fluconazole \u2013 oral 200mg on day 1, then 100 mg daily; doses up to 400 mg/day may be\n          used based on patient's response. Treat for a minimum of 3 weeks and at least 2 weeks\n          after resolution of symptoms\n                                                           or\n     \u00a7    Itraconazole \u2013 oral 200mg daily for at least 2 weeks after resolution of symptoms\n                                                           or\n     \u00a7    Oral Nystatin 400,000 \u2013 600,000 IU qds for at least 2 weeks after resolution of\n          symptoms\n\nPaediatric:\n     \u00a7    Fluconazole \u2013 oral, 6mg/kg stat on day 1, then 3mg/kg/day for 14-21 days.\n                                                           or\n     \u00a7    Oral Nystatin 100,000 \u2013 200,000 IU qds for at least 2 weeks after resolution of symptoms\n\n8.1.5.4 Toxoplasmosis\nDiagnosis\n     \u00a7    Symptoms include fever, reduced alertness, headache, focal neurological deficits,\n          seizures, chorio-retinitis\n     \u00a7    The following diagnostic tool can be used on CSF sample: Dye test, indirect fluorescent\n          antibody test (IFA), enzyme immunoassays (ELISA, immunoblots), agglutination test,\n          avidity test\n\nProphylaxis                                                                                         3\n     \u00a7    Cotrimoxazole until CD4+ cell levels increase to more than 200 cell/mm for more than 3\n          months\n     \u00a7    Alternatively, dapsone \u2013 pyrimethamine plus leucovorin\n\nTreatment\n     \u00a7    Pyrimethamine 100mg stat and 50mg daily with folinic acid 10-25mg daily plus\n          clindamycin 300mg given qds for 6 weeks followed by life-long suppressive therapy\n          until full immunological recovery.\n                                                           or\n     \u00a7    Cotrimoxazole (Trimethoprim 10mg/kg/day + Sulphamethoxazole 50mg/kg/day) for 4\n          weeks if there is clinical and radiological improvement. Longer therapy may be\n          necessary if a response is incomplete at 6 weeks\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           120", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2629, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "46a6519d-2ea8-4a8e-9c99-b28111308170": {"__data__": {"id_": "46a6519d-2ea8-4a8e-9c99-b28111308170", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "38034635-1526-4cf5-a9a3-a61461d02315", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "cdcab13680cda77087e2b6a06b9f165e586c9a49588833d200ff6f5f28e47cab", "class_name": "RelatedNodeInfo"}}, "text": "8.1.5.5 Pneumocystis jiroveci pneumonia (PJP)\nDiagnosis\n    \u00a7     Acute/sub-acute nonproductive cough with difficulty in breathing. Oxygen saturation of\n          <92% at rest on room air\n    \u00a7     Sample types: bronchoalveolar lavage (BAL), induced and expectorated sputum,\n          nasopharyngeal aspirates and oral washing\n    \u00a7     Giemsa stain or GMS stain can be used for identification\nProphylaxis\n    \u00a7     Cotrimoxazole in adult and children (Children 6-8mg/kg/day PO, Adults 960mg daily)\n    \u00a7     Alternatively, Dapsone (100mg daily) or Dapsone plus pyrimethamine (50mg) plus\n          folinic acid 10mg weekly can be used.\nTreatment\n    \u00a7     For Moderate to severe PJP: IV Cotrimoxazole (TMP 15\u2013 20 mg and SMX 75\u2013 100 mg) /\n          kg/ day given qds or tds (switch to PO after clinical improvement for 21 days).\n    \u00a7     For Mild PJP: Cotrimoxazole: (TMP 15\u2013 20 mg/ kg/ day and SMX 75\u2013 100 mg/ kg/ day),\n          given PO in 3 divided doses for 21 days\nAlternative:\n    \u00a7     Moderate to Severe PJP: Primaquine 30 mg (base) PO once daily + clindamycin [IV 600\n          qds or 900 mg tds] or [PO 300 mg q6h or 450 mg q8h], Or Pentamidine 4 mg/ kg IV once\n          daily infused over at least 60 minutes, may reduce the dose to 3mg/kg IV once daily\n          because of toxicities\n    \u00a7     For Mild PJP: Dapsone 100 mg PO daily + TMP 15 mg/kg/day PO (3 divided doses),\n          OR Primaquine 30 mg (base) PO daily + clindamycin PO (300 mg q6h or 450 mg q8h)\n\n8.1.5.6 Histoplasmosis\nDiagnosis\n    \u00a7     Symptoms are non-specific mimicking TB (pulmonary or extrapulmonary)\n    \u00a7     Histoplasma urinary antigen screening\n    \u00a7     Tissue diagnosis will require histology of representative sample\nTreatment\n    \u00a7     Liposomal amphotericin B (3.0 \u2013 5.0 mg/kg daily intravenously for 1 -2 weeks) followed\n          by itraconazole (200mg 3 times daily for 3 days and then 200mg twice daily, for a total\n          of 12 weeks) is the preferred therapy for disseminated Histoplasmosis\n    \u00a7     For mild to moderate disease, itraconazole (200mg 3 times daily for 3 days and then\n          twice daily for at least 12 months is recommended).\n\n8.1.6 ART Initiation and Intensive Adherence Support for Patients with AHD\nThese Guidelines recommend that;\n    \u00a7     People who have no clinical signs and symptoms of TB or other OIs and whose CrAg test\n          is negative should initiate ART the same day in combination with their package of\n          prophylaxis outlined above.\n    \u00a7     In settings where CrAg testing is not available; ART should be initiated, and fluconazole\n          prophylaxis may be considered for people with AHD and be monitored with CD4+ cell\n          count test until immunological recovery is achieved.\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          121", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2850, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "4bc516f6-c3c8-469a-be2a-be72454f31c7": {"__data__": {"id_": "4bc516f6-c3c8-469a-be2a-be72454f31c7", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "8425a81f-1e45-4587-831b-b2bbe0f5dd0d", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "5f3f2ac37742fb3407bac0a98365f65ef0a075c405c5b4b21dcc1e7ef8e314b6", "class_name": "RelatedNodeInfo"}}, "text": "8.1.6.1 Intensive Follow-Up for Patients with AHD\nPeople with AHD require closer follow-up during the initial period of receiving ART to monitor\nthe response to ART and to identify signs and symptoms of possible IRIS. The guidelines\nrecommend that;\n     \u00a7     Weekly telephone calls or home visits be provided during the first month on ART.\n     \u00a7     Intensive follow-up may be required after discharge for AHD.\n     \u00a7     People missing appointments should also be actively tracked by phone or through home\n           visits.\n     \u00a7     Where face-to-face contact is not feasible; distance contact through telephone\n           consultation, mHealth, text messaging or other mobile interventions, or visits through a\n           community health worker or home-based caregiver should be considered, with the\n           consent of the client.\n\n8.1.6.2 Initiating ART in Patients with AHD\nPeople presenting for the first time or those returning to care should undergo history and clinical\nexamination to evaluate for significant OIs (such as signs and symptoms of TB and signs and\nsymptoms suggesting meningitis) before rapid ART initiation is offered. Baseline CD4+ cell\ncount testing should be performed to determine whether the patient has AHD before initiating on\nART.\n\nPeople who have no clinical signs and symptoms of TB or other OIs and whose cryptococcal\nantigen test is negative may initiate ART the same day in combination with their package of3\nprophylaxis outlined in Chapter 3. For people with CD4+ cell count <100 cells/mm in settings\nwhere cryptococcal antigen testing result is not available on the same day, consideration could be\ngiven to starting fluconazole prophylaxis and discontinuing if a cryptococcal antigen screening\nresult is negative.\nTable 8.3: ART Initiation and Intensive Adherence Support for Patients with AHD\n   Package         Intervention                                               CD4+ cell       Adults and   Children\n                                                                              count           adolescents\n   ART             Rapid ART initiation                                       Any             Yes          Yes\n   initiation\n                   Defer ART initiation if clinical signs and                 Any             Yes          Yes\n                   symptoms are suggestive of TB or\n                   cryptococcal meningitis\n\n   Intensive       Tailored counselling to ensure optimal                     < 200\n                                                                              cells/mm3       Yes          Yes\n   adherence       adherence to advance disease care package,\n   support         including home visits if feasible.\n\n 8.1.7 Vaccination for People with AHD\nProviding vaccinations to PLHIV does not appear to accelerate HIV disease progression and is\nrecommended as an important part of the HIV care package. However, people with severe\nimmunosuppression may be at higher risk of complications from some live attenuated vaccines,\nand the response to other inactivated vaccines may be less effective because of the degree of\nimmunosuppression. Additional doses or revaccination after immune reconstitution on ART\nmay therefore be required.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                  122", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3342, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "a2743755-31a2-458b-930b-1e62455c963d": {"__data__": {"id_": "a2743755-31a2-458b-930b-1e62455c963d", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "85db2887-fb1e-483c-a174-01a98dadb64e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "cc2558231197fe7d2d066297f27bc597103f03ab4996431edefa9b658ed0694c", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7    Human papillomavirus: Due to increased risk of cervical cancer, vaccine schedule for\n         HPV as recommended by National Cervical Cancer Prevention and Control Policy\n         o     A three-dose schedule (0, 1\u20132 and 6 months) should be used if HPV vaccination is\n               initiated between the ages of 9 to 13 year and up to 26 years if not sexually exposed\n    \u00a7    Measles:\n         o     Children and adults with HIV infection are at increased risk of measles. However,\n               live vaccine should not be used for those with severe immunosuppression (CD4+3\n               cell count <50 cells/mm )\n         o     Vaccination should be routinely administered to potentially susceptible,\n               asymptomatic children and adults living with HIV and should be considered for\n               those with symptomatic HIV infection if they are not severely immunosuppressed\n    \u00a7    Meningococcal vaccination:\n         o     Meningococcal vaccination should be offered to everyone with\n               immunodeficiency, including those patients with AHD\n    \u00a7    Polio vaccine: Polio vaccine is live attenuated and its use in patients with AHD\n         should be in line with WHO recommendation as indicated below.\n         o     Inactivated polio vaccine or bivalent OPV may be administered safely to\n               asymptomatic infants living with HIV. HIV testing is not a prerequisite for\n               vaccination.\n         o     Bivalent OPV is contraindicated among severely immunocompromised people\n               with known underlying conditions such as primary immunodeficiencies, thymus\n               disorders, symptomatic HIV infection or low CD4+ cell count; these populations\n               can safely receive inactivated polio vaccine Vaccines not currently recommended\n               for people with AHD include BCG, Rotavirus, Yellow Fever. This is because the\n               safety and immunogenicity of these vaccines in individuals with CD4+ cell count3\n               less than 200 cell/mm ; is not certain.\n\n8.1.8 Immune Reconstitution Inflammatory syndrome (IRIS)\nAHD package of care is designed to ensure that early initiation of ART in severely\nimmunocompromised individuals does not precipitate immune reconstitution inflammatory\nsyndrome (IRIS) particularly in the setting of the use of highly potent DTG based first-line\nregimens. The package of care recommends that individuals with AHD initiate ART\nimmediately if the AHD defining OIs have been excluded. Despite this recommendation, other\nOIs that are associated with IRIS but whose management are not included in the package of care\nfor AHD may still occur when severely immunocompromised individuals initiate ART.\nConsequently, clinicians should be familiar with the risk factors associated with the\ndevelopment of IRIS, its diagnosis and management.\nThe risk factors for IRIS include:\n    \u00a7    High baseline viral load (>100,000 copies/ml)3\n    \u00a7    Low CD4+ cell count (\u2264200 cells/mm ) at ART initiation\n    \u00a7    Disseminated OIs or malignancies\n    \u00a7    Shorter duration of therapy for OIs before ART initiation\n    \u00a7    A potent ART regimen e.g TDF/3TC/DTG\nThe management of IRIS involves prompt and effective treatment of any co-infections,\nreassurance of the patient to prevent discontinuation or poor adherence and supportive\nmanagement. The prevention of IRIS includes:\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           123", "mimetype": "text/plain", "start_char_idx": 4, "end_char_idx": 3497, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ef9dd79c-c84d-4046-8ad5-0a4932a43b96": {"__data__": {"id_": "ef9dd79c-c84d-4046-8ad5-0a4932a43b96", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "915ee6f6-e99a-4b03-8ac9-c2e0a07a5e10", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "12ddbfa07f68f07e6a3f4dc98b9fbd52f23e1f772c7dcd5be09072f25cfcddec", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7    Appropriate screening and treatment of OIs before initiation of ART; with the exception\n          of TB and cryptococcal meningitis, outcomes are improved with early ART in patients\n          with OIs.\n          o    TB: Start ART 2 weeks after initiating TB treatment. However, if the patient has TB\n               Meningitis, ART initiation should be started after 4 weeks of starting TB treatment.\n          o    Cryptococcal meningitis (CCM): Start ART 4 - 6 weeks after initiating CCM\n               treatment\nIt is important for healthcare workers to exercise a high index of suspicion for IRIS in PLHIV\ncommencing ART.\n\n8.1.9 Management of AHD among Children less than ten years\nAll children less than 5 years are considered to have AHD. This is based on the rationale that\nmost children younger than five years usually present for care with advanced\nimmunosuppression, younger children have an increased risk of disease progression and\nmortality regardless of clinical and immune condition. Thus, varying age dependent CD4+ cell\ncount definitions for advanced immunosuppression among children younger than five years\nmake definitions based on CD4+ cell count difficult to implement. Children under 5 years\ndiagnosed with HIV should immediately be offered the requisite screening tests, and where\napplicable, provided with prophylaxis, treatment and vaccination for the major OIs based on the\noutcome of the screening. For children between 5 and 9 years of age, a positive HIV test should\nbe followed with a CD4+ test and clinical evaluation. If diagnosed with AHD, the child should\nreceive the applicable package of care that involves screening, prevention and treatment of OIs\nand comorbid conditions, and optimized care.\n    \u00a7     Screen: In addition to clinical screening using signs and symptoms of common OIs, HIV\n          positive children with AHD less than 10 years should be screened for TB using available\n          laboratory tools such as urine LF-LAM assay, Xpert MTB/RIF, and AFB Microscopy.\n    \u00a7     Treat: The major OIs and co-morbidity associated with AHD in children <10 years are;\n          TB, severe pneumonia, severe bacterial infections and malnutrition. Refer to table 8.4\n          and the section on management of OIs for the recommended treatment options for these\n          conditions.\n    \u00a7     Prevent: The care package for children on AHD should include; TPT and CPT.\n          Screening and primary prophylaxis of cryptococcal meningitis are not recommended\n          for children younger than 10 years, given the low incidence of cryptococcal meningitis\n          in this age group.\n          Live vaccines should be avoided in children with advanced HIV disease, however,\n          vaccination is recommended for some of the OIs as the benefits outweigh the risk. Some\n          of the vaccines include BCG, measles, catch up pneumococcal vaccine, and HPV\n          (mainly for adolescent female). Neonates with confirmed HIV infection should delay\n          BCG vaccination until ART has started and they are confirmed to be immunologically\n          stable (CD4% >25%). See table 8.4 for details on the screening, diagnosis, prevention\n          and treatment components of the AHD package of care for children under 10 years.\n          Recommendations for adolescents are similar to what obtains for adults.\n    \u00a7     Optimize: Although rapid ART initiation within seven days of diagnosis is a priority,\n          children with AHD who present with severe acute malnutrition or TB or other illnesses\n          that require hospitalization need to be stabilized first. However, initiating ART is\n          encouraged as part of the child's hospital admission to minimize loss to follow-up and\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          124", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 3854, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6b583b7c-5dbc-429b-8f49-fae2a720b4ba": {"__data__": {"id_": "6b583b7c-5dbc-429b-8f49-fae2a720b4ba", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "8113cf86-db41-472f-b2f4-cfc851805bca", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "4e068a5178ff1141163128e02fb26e428e3551f05b24dd5b6706c0f02e9fe7aa", "class_name": "RelatedNodeInfo"}}, "text": "failure to initiate ART after discharge. Similarly, ensuring linkage to the facility\n              where the child will receive ongoing HIV care upon discharge is critical. In addition,\n              intensive counselling and follow up should be provided to caregivers of children with\n              AHD.\nTable 8.4: Components of the Package of Care for Children with AHD\n   Intervention Component\n\n\n\n\n\n< 5 years         5 \u2013 9 years\n\n                                              Screen for TB using clinical algorithm followed by X-ray                                Yes               Yes\n                                              when indicated and if available\n                                              Xpert\u00ae MTB/RIF or Xpert\u00ae Ultra assay as the first test\n                         Screening            (Induced or expectorated) sputum, gastric aspirate, stool or\n                         and                  nasopharyngeal aspirate or other extrapulmonary specimens\n                         diagnosis\n                                              LF-LAM assay                                                                            Yes\n                                                                                                                                      Noa               Yes\n                                                                                                                                                        Noa\n                                              Cryptococcal antigen screening using serum, plasma, or\n                                              whole blood specimen\n                                              Pneumococcal conjugate vaccine (catch-up)\n                                              Human Papilloma Vaccine (HPV)b                                                          Yes               No\n                                                                                                                                      No                No\n                                              Measles                                                                                 Yes               Noc\n                                              BCG\n                                              Co-trimoxazoled                                                                         Yes               No\n                                                                                                                                      Yes               Yes\n                         Prevention,          TB preventive treatmente\n                         prophylaxis                                                                                                  Yes               Yes\n                         and pre          -   TPT options include\n                         emptive\n                         treatment            \u00b7     INH for 6 months\n                                              \u00b7     Daily rifampicin and isoniazid for three months (3HR)\n                                              \u00b7     Weekly rifapentine and isoniazid for three months (3HP)\n                                                    could be used from two years of age\n                                              Fluconazole pre-emptive therapy for cryptococcal antigen                                Not               Not\n                                              positive without evidence of meningitise                                                Applicable        Applicable\n                                              Tuberculosis                                                                            Yes               Yes\n                                              \u00b7     based on current TB guidelines\n                                              Severe Pneumonia (if diagnosed)                                                         Yes               Yes\n                                              \u00b7     for children less than one, empirical treatment with\n                                                    Cotrimoxazole\n                         Treatment            \u00b7     for children between one and five, treat according to\n                                                    laboratory findings\n                                              Severe bacterial infection                                                              Yes               Yes\n                                              \u00b7     treat according tothe confirmed organism\n                                              Malnutrition treatment                                                                  Yes               Yes\n                       a Screening and primary prophylaxis of cryptococcal meningitis are not recommended for children younger than 10 years given the low incidence\n                       of cryptococcal meningitis in this age group; although this guideline does not recommend routine screening of children with AHD for\n                       cryptococcal infection because of the rarity of this condition in children, studies are appearing in literature reporting cases among children. As\n                       such, clinicians are encouraged to use their clinical judgement and screen their pediatric patients for cryptococcal infections and cryptococcal\n                       meningitis when clinical features are suggestive.\n                       b Evidence indicates that adolescent females living with perinatally-acquired HIV have a higher prevalence of high-risk HPV and abnormal\n                       cervical cytology than uninfected adolescents. WHO recommends a three-dose series (0, 1\u20132 and 6 months) for females older than nine years\n                       living with HIV rather than the standard two-dose series;\n                       c only if the child missed birth and early childhood dose;\n                       d To be discontinued when CD4+ cell count >350 and viral load suppressed for at least 6 months;\n                       e TB preventive treatment is currently not recommended for infants living with HIV younger than 12 months of age unless they have a household\n                       contact of a TB case;\n\n                                        NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                         125", "mimetype": "text/plain", "start_char_idx": 14, "end_char_idx": 6434, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "9a8b8bcf-48d1-47f7-b287-d20cd0cb6368": {"__data__": {"id_": "9a8b8bcf-48d1-47f7-b287-d20cd0cb6368", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "978c800d-9248-4e77-9399-db7a8d7e4201", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "96ddc29ce83440d808fe3dd513a042c9b72220642527aca37ff3720924c0bebf", "class_name": "RelatedNodeInfo"}}, "text": "8.2 Other Opportunistic Infections (OIs)\nPersons living with HIV (PLHIV) are more prone to developing infections than persons not\ninfected with the virus largely because of the immune system damage associated with HIV\ninfection. Most of the infections that occur in PLHIVs are called OIs because they depend on a\ncompromised immune system. The appearance of OIs in PLHIV is directly related to the extent\nof immune deficiency that is the degree of depletion of CD4+cells. The lower the CD4+ cell\ncount, the higher the likelihood of the appearance of OIs. Most OIs in PLHIV begin to appear at3\nCD4+ cell counts of <350cells/mm ; and many of the OIs are useful for staging the severity of\n\nHIV disease.\nOpportunistic infections (OIs) associated with HIV fall into four broad categories namely,\nbacterial, viral, fungal and protozoal infections. The infections affect all major systems of the\nbody including the; nervous, gastrointestinal, respiratory, skin, musculoskeletal, eyes, ear, nose\nand throat. When OIs occur among PLHIV they should be treated immediately since they can\ncause considerable damage to the immune system and lead to a rapid increase in viral replication\nand disease progression and death.\n\nXpert MTB/RIF has enhanced the diagnosis of TB in HIV positive patients and its widespread\nuse in the country should improve health outcomes for HIV/TB co-infected patients.\nChronic non-communicable diseases (NCDs), including cardiovascular disease (CVD),\nhypertension, diabetes, chronic obstructive pulmonary disease (COPD), kidney disease and\nmental health illnesses present important considerations in adults and adolescents living with\nHIV and requires early assessment and management. Pre-disposing factors such as lack of\nphysical activities, smoking, and unhealthy dietary habits should be addressed.\nEarly initiation of ART, appropriate treatment of identified OIs and comorbidities, lead to a\nreversal of immune system damage with reconstitution and prevention of AIDS-related death.\n\n8.3 Preventing Opportunistic Infections (OIs)\nThe relationship between HIV and OIs is bi-directional; HIV depresses the immunity of an\nindividual thereby increasing predisposition to OIs, while OIs and other similar infections may\nlead to an acceleration of HIV disease progression.\n\nIt is therefore important that health workers have a good understanding of the role of\nchemotherapy in the prevention and treatment of OIs because while chemoprophylaxis directly\nprevent pathogen-specific morbidity and mortality, they also contribute to a reduced rate of\nprogression of HIV disease.\n\nFor instance, there is evidence that chemoprophylaxis with trimethoprim-sulfamethoxazole can\nboth decrease OI-related morbidity and improve survival. The reduced progression of HIV\ninfection would reduce the risk of subsequent OIs.\n\nThere are currently two main strategies for the prevention of OIs; CPT, which provides\nprotection to a wide range of bacterial infections and TPT, which is useful for treating latent\ntuberculosis.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                        126", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3124, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "125af0f3-3eef-48c5-9f49-c7a57187ae57": {"__data__": {"id_": "125af0f3-3eef-48c5-9f49-c7a57187ae57", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "666c1b9a-e3ab-4cf9-866a-6b91aa26a999", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "06ada7b88ed5902a2bb0867ed4785cb498c8fca7070c7a1eb710e0560e8acfdc", "class_name": "RelatedNodeInfo"}}, "text": "8.3.1 Cotrimoxazole Preventive Therapy (CPT)\nCotrimoxazole Preventive Therapy (CPT) is a fixed-dose combination of two antimicrobial\nagents (sulfamethoxazole and trimethoprim) used for the prevention of some AIDS-associated\nOIs (Pneumocystis jirovecii pneumonia [PCP] and toxoplasmosis) and the reduction of HIV-\nassociated mortality in people with low CD4+ cell counts. CPT is also used to treat a variety of\nbacterial, fungal and protozoan infections.\n\n8.3.1.1 Cotrimoxazole prophylaxis for adults\nCotrimoxazole (CTX) prophylaxis is recommended for adults (including pregnant women) with\nsevere or advanced HIV clinical disease (WHO stage 3 or 4) and/or with a CD4+ cell count \u22645003\ncells/mm ;.\n    \u00a7     Due to the high prevalence of malaria and severe bacterial infections in Nigeria,\n          Cotrimoxazole prophylaxis should be initiated regardless of CD4+ cell count or WHO\n          stage. Priority should be given to adults (including pregnant women) with severe or\n          advanced HIV clinical disease (WHO stage 3 or 4) and/or with a CD4+ cell count <500\n          cells/mm3\n    \u00a7     Routine cotrimoxazole prophylaxis should be given to all HIV-infected patients with\n          active TB disease regardless of CD4+ cell count\n    \u00a7     Cotrimoxazole prophylaxis may be discontinued in adults (including pregnant women)\n          with HIV who are clinically stable on ART, with evidence of immune recovery and\n          virological suppression\n\n8.3.1.2 Cotrimoxazole prophylaxis for HIV-infected infants, children and Adolescents\nCotrimoxazole prophylaxis is recommended\n    \u00a7     For infants, children and adolescents with HIV, irrespective of clinical and immune\n          conditions. Priority should be given to all children younger than 5 years old regardless of\n          CD4+ cell count or clinical stage, and children with severe or advanced HIV clinical\n          disease (WHO clinical stage 3 or 4) and/or those with a CD4+ cell count \u2264500 cells/mm3\n    \u00a7     Should be continued until adulthood, irrespective of whether ART is provided\n    \u00a7     For HIV-exposed infants 6 weeks of age and should be continued until HIV infection has\n          been excluded by an age-appropriate HIV test to establish a final diagnosis after\n          complete cessation of breastfeeding\n    \u00a7     In all persons with active TB regardless of CD4+ cell count and continued until criteria\n          for discontinuation in adults and children is met\nIn HIV positive individuals who have ADR to cotrimoxazole, options for prophylaxis of PJP\ninclude dapsone, dapsone plus pyrimethamine plus folinic acid and atovaquone. For those who\nwill be started on dapsone, do a G6PD deficiency test. Dapsone should be avoided in individuals\nwith G6PD deficiency.\n\n8.3.1.3 Starting Patients on CPT\nBefore commencing a client on CPT the health worker should undertake the following actions:\n    \u00a7     Verify HIV status\n    \u00a7     Take medical history\n    \u00a7     Conduct physical examination\n    \u00a7     Counsel on OIs in HIV infection\n    \u00a7     Treat pre-existing OIs\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           127", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3161, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "556f18a4-c845-463c-8b49-dd5eea8277ac": {"__data__": {"id_": "556f18a4-c845-463c-8b49-dd5eea8277ac", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "142d927d-a792-4b0e-a598-359eed608bc7", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "7b51d9c7108cb5a5d623a33fde3bff8d091ee4c58b89996a4c18b64db7dc6c95", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7     Screen for contraindications to CPT: e.g. known allergy to Sulphur-containing drugs,\n           first trimester pregnancy, kidney or liver disease\nIn addition, the patient should be counselled for drug adherence and given detailed information\nof the likely side effects of cotrimoxazole and action to take in the event of the occurrence of\nany. Common side effects associated with CPT include skin eruptions, which may be severe\n(Stevens Johnson syndrome), nephritis, hepatitis, anaemia and hyperkalaemia.\nTable 8.5: Dosage of Cotrimoxazole for CPT\n\n  Adult                                           Children\n\n  \u2265 14 years or >30 kg: 960 mg daily              Infants <6 months or < 5 kg: 120mg daily\n                                                  Children 6 months \u20135 years or 5 -15 kg: 240 mg daily\n                                                  Children 6 \u201314 years old or 15 \u201330 kg: 480 mg daily\n\n 8.3.2 Tuberculosis Preventive Treatment (TPT)\n Tuberculosis Preventive Treatment (TPT), previously referred to as Isoniazid preventive\n therapy (IPT) is the treatment offered to individuals who are considered to be at risk of\n developing TB disease, in order to reduce that risk. It is also referred to as the treatment of TB\n infection or LTBI treatment. TB is a disease that is driven by HIIV and so it is frequently\n associated with HIV and a common cause of illness and death among PLHIV.\n\n TPT is effective in preventing the development of active TB in HIV positive individuals.\n However, it is not a treatment for active TB, therefore this should be excluded before\n commencing a patient on TPT.\n For a patient to benefit from TPT, he/she must:\n     1.    Be HIV positive\n     2.    Not have active TB\n     3.    Be counselled and motivated to adhere to treatment\n\n 8.3.2.1 Recommendations for TPT\n     \u00a7     Adults and adolescents living with HIV\n           o    Adults and adolescents living with HIV should be screened with a clinical\n                algorithm; those who do not report any one of the symptoms of current cough, fever,\n                weight loss or night sweats are unlikely to have active TB and should be offered TPT\n           o    Adults and adolescents living with HIV who are unlikely to have active TB or in\n                whom active TB has been safely ruled out should receive TPT as part of a\n                comprehensive package of HIV care. TPT should be given to such individuals\n                regardless of the degree of immunosuppression, and also to those on ART, those who\n                have previously been treated for TB and pregnant women\n\n     \u00a7     Children\n           o    Children living with HIV who do not have poor weight gain, fever or current cough\n                are unlikely to have active TB. Children living with HIV who have poor weight gain,\n                fever or current cough or contact history with a TB case may have TB and should be\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                            128", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 3036, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "5587087c-9306-413d-99ab-1130581b51a2": {"__data__": {"id_": "5587087c-9306-413d-99ab-1130581b51a2", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "e3dfeb77-c63c-4d71-a084-d289c3ee1a6f", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "2590747bd3351c8d47fd0420f77e877bc1604230e21cb2b1752602ccee71107f", "class_name": "RelatedNodeInfo"}}, "text": "evaluated for TB and other conditions. If the evaluation shows no TB, they should be\n               offered TPT regardless of their age\n          o    Children living with HIV who are \u2265 12 months of age and who are unlikely to have\n               active TB on symptom-based screening and have no contact with a TB case should\n               receive six months of TPT (Isoniazid 10 mg/kg/day) but not more than 300mg/day as\n               part of a comprehensive package of HIV prevention and care if they live in a setting\n               with high TB transmission, regardless of contact with TB\n          o    In children living with HIV who are < 12 months of age, only those who have contact\n               with a TB case and who are evaluated for TB (using standard lab investigations)\n               should receive 6 months of TPT if the evaluation shows no TB disease\n          o    All children living with HIV, after successful completion of treatment for TB, should\n               receive TPT for an additional 6 months\n          o    Children aged < 5 years who are household contacts of people with confirmed\n               pulmonary TB and who are found not to have active TB on an appropriate clinical\n               evaluation or according to national guidelines should be given TPT even if LTBI\n               testing is unavailable\n          o    Children aged \u2265 5 years, adolescents and adults who are household contacts of\n               people with confirmed pulmonary TB who are found not to have active TB by an\n               appropriate clinical evaluation or according to national guidelines may be given\n               TPT\n\n8.3.2.2 Commencing TPT\nIt is recommended that health workers should undertake the following actions before initiating\npatients on TPT;\n    1.    Verify/Confirm HIV Status\n    2.    Counsel clients on TB/HIV interactions\n    3.    Exclude active TB by asking the client about:\n          a.    Ask the patients about cough, weight loss, fever and night sweats\n          b.    Check for lymph node enlargement\n          c.    For patients who answer no to (a) and (b) above, assess for contraindications to TPT,\n                counsel on adherence, and commence TPT\n          d.    For those with symptoms/signs in (a) and (b) above:\n                \u00b7 Xpert MTB/RIF should be done\n                \u00b7 If positive refer/commence short-course chemotherapy for TB (DOTS,\n                   preferably)\n                \u00b7 Those with negative results should be referred to medical officers for\n                   confirmation of diagnosis.\n                \u00b7 If signs and symptoms are absent, do a chest x-ray\n                \u00b7 If no active TB is confirmed, assess for contraindications to TPT, counsel on\n                   adherence, and commence TPT.\n    4. Counsel patient/caregiver on:\n          a.    Importance of Treatment adherence\n          b.    Side effects of INH: peripheral neuropathy, jaundice, rash and what is expected in\n                such circumstances\n          c.    Immediate recognition and reporting of signs and symptoms of active TB If a patient\n                develops active TB during the course of TPT, discontinue TPT and refer/\n                commence anti-TB treatment (DOTS)\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           129", "mimetype": "text/plain", "start_char_idx": 15, "end_char_idx": 3372, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "fd947d7c-9494-4684-8dc8-676e0dba7cbf": {"__data__": {"id_": "fd947d7c-9494-4684-8dc8-676e0dba7cbf", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "77caa77d-b8cb-4d6d-8e19-47065d38d4ec", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "1d8aad5676e04b8ea03209d5a704d30c87acff0152d464f8b82def2748e9cdc7", "class_name": "RelatedNodeInfo"}}, "text": "5.   During the monthly visit, monitor the patients for:\n          a.    Signs and symptoms of active TB\n          b.    Side effects. The most common side effect is peripheral neuropathy\n                (numbness/tingling sensation of extremities). In addition, allergic skin eruptions\n                and jaundice can occur. Since INH is co formulated with Pyridoxine,\n                Complications such as numbness/tingling/burning sensation are not expected.\n                However, if jaundice develops, discontinue TPT and refer to the clinician for\n                assessment\n\n8.3.2.3 TPT options\nThe following options are recommended for the treatment of LTBI regardless of HIV status:\n     \u00a7    6 or 9 months of daily isoniazid\n     \u00a7    3-month regimen of weekly rifapentine plus isoniazid (3HP)\n     \u00a7    3-month regimen of daily isoniazid plus rifampicin. (3HR)\n     \u00a7    1-month of daily Isoniazid and Rifapentine (1HP)\nHarmonize dispensing schedule with that of ARVs and emphasize the importance of adherence\nat each visit. Complete necessary INH prophylaxis register and INH appointment card.\n\n8.3.2.4 Dosages of the Different TPT Regimens\nThe recommended dosages of medicines used for treatment of LTBI is as shown in Table 8.6\nbelow.\nTable 8.6: Recommended Dosages of Medicines used for Treatment of LTBI\n\n  TPT regimen                        Dose per kg body weight in children                         Maximum dose\n  Isoniazid alone daily for          10mg (range:7-15mg)                                         300mg\n  6 months (6H)\n  Weekly Rifapentine plus            Isoniazid:                                                  Isoniazid - 900mg\n  Isoniazid for 3 months-            Individuals aged \u2265 12 years -15mg                           Rifapentine - 900mg\n  12 doses (3HP)                     Individuals aged 2 -11 years -25mg\n                                     Rifapentine:\n                                     10.0 - 14.0 kg = 300mg\n                                     14.1 - 25.0 kg = 450mg\n                                     25.1 - 32.0 kg = 600mg\n                                     32.1 -50.0 kg = 750mg\n                                     > 50 kg = 900mg\n  Daily Isoniazid plus               Rifampicin:                                                 Rifampicin - 600mg\n  Rifampicin for 3 months            Age < 10 years = 15mg (range: 10\u201320mg)                      Isoniazid - 300mg\n  (3HR)                              Age \u2265 10 years = 10mg\n                                     Isoniazid:\n                                     Age < 10 years = 10mg (range: 7\u201315mg)\n                                     Age \u2265 10 years = 5mg\n\n  Daily Isoniazid and                Age \u2265 13 years (regardless of weight band)                  Isoniazid \u2013300mg\n  Rifapentine for 1 month            Isoniazid 300 mg/day                                        Rifapentine - 600mg\n                                     Rifapentine 600 mg/day\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                         130", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 3088, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "32e58363-bd68-4546-b893-666d704140a9": {"__data__": {"id_": "32e58363-bd68-4546-b893-666d704140a9", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "93d3b5e8-fa4e-434c-b405-f22c6aa91253", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "e464eca4dc4f72125d0efa96e264affe2ec95b5fe9ede4c9c230bb889c91cefc", "class_name": "RelatedNodeInfo"}}, "text": "Dosage of INH for TPT\n      i.    Dosage of INH for TPT in children: INH is administered daily for TPT in children for a\n            total duration of 6 months as stated in Table 8.7 below\n      ii.   The dosage of INH for TPT in adults is 300mg daily for 6 months.\nTable 8.7: Dosage of INH for TPT in Children\n\n       Weight in kg                        INH dosages in mg/day                                      INH in Tablet/day\n             <2.5                                        25                                           \u00bc of 100mg tablet\n          2.5 - 5.9                                      50                                           \u00bd of 100mg tablet\n         6.0 - 10.9                                      100                                           1 of 100mg tablet\n         11.0 - 25.0                                     150                                          1\u00bd of 100mg tablet\n\nDosage of 3HP for TPT\n      i.    Dosages of 3HP in children: The Dosages of 3HP in children.is as stated in Table 8.8\n            below.\nTable 8.8: TPT Dosage of 3HP for Children Aged 2 - 14 years*\n           Weight                   Rifapentine** (150mg tablets)                             Isoniazid (100mg tablets)\n                                          Dose                   Tablets                     Dose                        Tablets\n         10 - 15 kg                     300mg                        2                      300mg                            3\n         16 - 23 kg                     450mg                        3                      500mg                            5\n         24 - 30kg                      600mg                        4                      600mg                            6\n           > 31kg                       750mg                        5                      700mg                            7\n*Patient aged 15 years and older should receive adult dosing\n**Rifapentine has a bitter taste. For young children who cannot swallow, crush the tablet and mix with small amount of multivitamin syrup\n\n     ii.    Dosages of 3HP in adults: The Dosages of 3HP in adults is as stated in Table 8.9 below\nTable 8.9: TPT Dosage of 3HP for greater than 14 years old\n                                                                       Weight bands for patients >14 years\n       Medicine                Formulation             30 - 35kg        36 - 45kg       46 - 55kg        56 - 70kg          > 70kg\n        Isoniazid                   300mg                    3               3                3                 3                  3\n      Rifapentine                   150mg                    6               6                6                 6                  6\n\nDosage of 3HR for TPT\nThe dosage of fixed dose combination of 3HR for TPT in both children and adults is as stated in\nTable 8.10\n\nNote: A triple pill combination containing isoniazid 300 mg + pyridoxine 25 mg + sulfamethoxazole 800 mg + trimethoprim 160 mg (scored) is\navailable (1 pill daily for adults, half pill for children 5 years and older of age and quarter for children < 5 years of age).\n\n                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                     131", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3266, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "e6f4eced-f09d-426f-ac16-1a0e99bf2a55": {"__data__": {"id_": "e6f4eced-f09d-426f-ac16-1a0e99bf2a55", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f1c5fb89-b422-4039-96a5-292b2da0441f", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "6e6a380b3145462a3b4354c9c078668b6326327501c97b51ab054326cdeedf02", "class_name": "RelatedNodeInfo"}}, "text": "Table 8.10: Dosage of Fixed Dose Combination of 3HR for TPT\n                      Children                                                           Adult\n         Strength: RH* 75mg/50mg FDC**                                   Strength: RH 150mg/75mg FDC\n       Weight Band                     RH Tablets                  Weight Band                      RH Tablets\n           4 - 7 kg                          1                                                             2\n           8 - 11kg                          2                       25 - 37 kg\n          12 - 15kg                          3\n          16 - 24kg                          4                       38 - 54 kg                            3\n             \u2265 25                  Use adult Regimen                     \u2265 55                              4\n\n*INH and 3HR are available in child - friendly and dispersible forms\n**FDC \u2013 Fixed Dose Combination\n\n8.3.2.5 General Contraindications to TPT\n     \u00a7    Active hepatitis (acute or chronic)\n     \u00a7    Active TB\n     \u00a7    Regular and heavy alcohol consumption\n     \u00a7    Symptoms of peripheral neuropathy\n     \u00a7    Allergy to TPT medicines.\n\n8.3.2.6 Contraindications to the use of Rifapentine plus INH\n     \u00a7    Individuals taking medications that may have drug interactions that are difficult to\n          manage with the regimen (e.g. PLHIV on Protease Inhibitors and NVP)\n     \u00a7    Persons presumed infected with MTB resistant to INH and RIF\n     \u00a7    Pregnant women or women planning to become pregnant during treatment.\n     \u00a7    Individuals who have had prior adverse events or hypersensitivity to INH or Rifapentine\n     \u00a7    Known pre-existing liver damage\n     \u00a7    Children under two years (no dosing for children < 2 years) [26]\n\n   \u00a7      In patients with severe malaria (impaired consciousness, low blood glucose, jaundice,\n          kidney failure, anaemia and parasitaemia >10%), stop 3HP, treat malaria urgently.\n          Restart 3HP once the episode of Malaria is resolved, to avoid drug - drug interactions\n   \u00a7      Supplement with Pyridoxine 25mg daily for six months if available when INH is given\n          for 6 months. However, lack of pyridoxine should not become a barrier to commencing\n          TPT.\n   \u00a7      3HP is recommended for PLHIV on ART that have acceptable drug-drug interactions\n          with Rifapentine such as efavirenz as well as DTG and RAL in adults. 3HP is NOT\n          recommended for PLHIVs on PI or NVP based ART. In cases where 3HP is\n          contraindicated or cannot be administered, use Isoniazid for 6 months.\n   \u00a7      INH is the preferred regimen in HIV positive children on LPV/r, NVP, DTG or RAL\n         [27]\n   \u00a7      In view of test and treat policy as well as significant virological suppression from DTG\n          containing regimens, repeat TPT after 2 years of completion is no longer\n          recommended\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                    132", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3011, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "cf531b2b-1b7d-4709-b144-9a3d8f51eefb": {"__data__": {"id_": "cf531b2b-1b7d-4709-b144-9a3d8f51eefb", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "9b87c4d9-083b-461a-9e4f-8b06ee2513d0", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "d881fbd3138368e0d5e92d89437231e46e78048eacc8d6a350f870800ecd31ed", "class_name": "RelatedNodeInfo"}}, "text": "8.3.2.6 Monitoring of Patients on TPT\nDuring monthly drug refills, monitor patient for:\n     \u00a7     Development of active TB (clinical assessment of signs and symptoms of active TB).\n     \u00a7     Development of side-effects; e.g. peripheral neuropathy (numbness/tingling sensation\n           of extremities). If present give Pyridoxine 50 - 75 mg daily.\n     \u00a7     Check for jaundice (yellowish eyes), abdominal pain, nausea, vomiting and yellowish\n           urine. If present, stop TPT and refer to medical officer to rule out active liver disease.\n     \u00a7     Check for allergic skin eruptions. If present stop treatment and refer to the medical\n           officer.\n     \u00a7     Evaluate adherence and counsel appropriately.\n     \u00a7     Any client who did not come a week after his/her TPT appointment day should be\n           tracked and managed appropriately.\nIf patient develops symptoms suggestive of active TB during the course of TPT:\n     \u00a7     Discontinue TPT\n     \u00a7     Assess for active TB\n     \u00a7     Commence DOTS if confirmed or refer to medical officer\n     \u00a7     Assess for ART/re-assess for ART failure\n\n8.3.2.7 Management of children and adults whose TPT is interrupted\nInterrupted treatment or incomplete TB preventive treatment is defined as the loss of at least one-\nthird of the intended LTBI treatment regimen (a lapse in treatment that lasted at least 1 or 2\nmonths consecutively depending on the TPT regimen employed).\nFor any client who misses appointment:\n     \u00a7     Trace the client/care giver\n     \u00a7     Find out the reason for missed appointment and address as appropriate\n     \u00a7     Offer adherence counseling\n     \u00a7     Evaluate to rule out active TB disease\n     \u00a7     Prolong treatment to compensate for the missed doses\nRefer to Table 8.11 below on management of IPT interruption\nTable 8.11: Management of interruption of TPT\n       TPT             Length of                                              Next Step\n    Regimen           Interruption\n   3HR, 6H            Less than           a.  Resume preventive treatment immediately upon return\n                      2 weeks             b.  Add the number of days of missed doses to the total treatment\n                                              duration.\n                      More than           a. If treatment interruption occurred after more than 80% of doses\n                       2 weeks                expected in the regimen were taken\n                                             \u00b7 No action is required.\n                                             \u00b7 Continue and complete the remaining treatment as per-original\n                                                plan.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                  133", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2777, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c1f4dddd-2a21-4bd1-9525-d793f881a79b": {"__data__": {"id_": "c1f4dddd-2a21-4bd1-9525-d793f881a79b", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "c7a3f57c-fa8c-4164-b41e-c92edafb6606", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "a736111d46f53511235a622f1c3f584306fe8bdf18a92b8ad22c68479c37e8cb", "class_name": "RelatedNodeInfo"}}, "text": "TPT               Length of                                                   Next Step\n    Regimen            Interruption\n\n   3HR, 6H              More than            b. If less than 80% of doses expected in the regimen were taken, and\n                        2 weeks                   the treatment course can still be completed within the expected time\n                                                  for completion, i.e. treatment duration + 33% additional time.\n                                               \u00b7 No action is required.\n                                               \u00b7 Continue and complete the remaining treatment as per original plan.\n                                             c. If less than 80% of doses expected in the regimen were taken, and\n                                                  the treatment course cannot be completed within the expected time\n                                                  for completion\n                                               \u00b7 Restart the full TPT course.\n   3HP                  Weekly               a. If the missed dose is remembered within the next 2 days\n                        schedule of            \u00b7 Take the dose immediately.\n                        one dose               \u00b7 Continue the schedule as originally planned\n                        missed\n                                             b. If the missed dose is remembered more than 2 days later.\n                                               \u00b7  Take the missed dose immediately and change the schedule for\n                                                  weekly intake to the day the missed dose was taken until treatment\n                                                  completion.\n                        More than            a. If between 1-3 weekly doses are missed.\n                        1 weekly               \u00b7 Treatment is continued until all 12 doses are taken, thus prolonging\n                        doses of 3HP               the treatment duration to a maximum of 16 weeks\n                        missed               b. If 4 or more weekly doses are missed, restart the full TPT course.\n   1HP                  Less than 1          a. If more than 80% (23) of doses expected in the regimen were taken.\n                        week                   \u00b7 No action is required, complete the remaining doses\n                                             b. If less than 80% (23) of doses expected in the regimen were taken.\n                                               \u00b7 Resume treatment immediately upon return\n                                               \u00b7 Add the missed doses to the total treatment duration to complete the\n                                                 course within a maximum of 6 weeks.\n                        More than            a. If more than 7 consecutive doses were missed.\n                        1 week                 \u00b7 Consider restarting the complete course of 1HP regimen.\n                                             b. If more than 7 doses were missed intermittently.\n                                               \u00b7 Resume preventive treatment immediately upon return\n                                               \u00b7 Add the missed doses to the total treatment duration to complete the\n                                                   course within a maximum of 8 weeks\n                                             c. If adherence to 1HP is not possible\n                                               \u00b7 consider discontinuing it and offering an alternative daily regimen\n                                                   or 3HP\n\n* If attempt to complete LTBI treatment fails after 3 attempts, no further effort should be made.\n\n                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                          134", "mimetype": "text/plain", "start_char_idx": 7, "end_char_idx": 3866, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "9c02e798-6a87-4127-828a-e6d962b64be5": {"__data__": {"id_": "9c02e798-6a87-4127-828a-e6d962b64be5", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "8ec93846-e460-4c93-92ef-3f16bf83b488", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "bf238858f6d0cd5540186725419f98ae07f47c4419903d220c2ee8255e4fe55c", "class_name": "RelatedNodeInfo"}}, "text": "8.3.2.8 Outcomes of TPT\nHealth care workers (HCW) should ensure that all children started on TPT are evaluated after\ncompleting their treatment and assigned a treatment outcome which should be documented in\nthe recording and reporting tools. The following are the possible treatment outcomes:\n     1.    Completed treatment\n     2.    Loss to follow-up\n     3.    Not evaluated\n     4.    Died\n     5.    Developed active TB\n\nRefer to appendix 7 for algorithms on screening and diagnosing children and adults living with\nHIV for TB.\n\nFor further information on TPT, refer to the National TB Guidelines and the National Guidelines\non Programmatic Management of Latent TB Infection in Nigeria.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                     135", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 793, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "a93c47f0-b8d0-44e3-b6fe-ff2c05036670": {"__data__": {"id_": "a93c47f0-b8d0-44e3-b6fe-ff2c05036670", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "5fec111b-851f-479b-92a3-2346cebac384", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "58801c702dee59f7b01f6d16479c5cbac3b96fcbfae981e61666e825b6754817", "class_name": "RelatedNodeInfo"}}, "text": "Table 8.12: Common HIV-Related Opportunistic Infections (OIs): Clinical Features, Treatment, and Prophylaxis\nInfection/CausativeSymptoms andDiagnosisTreatment and Prophylaxis Comments\nConditionsorganismssigns\n1. HBsAg quantification ifHepatitisHepatitis BThere may be noScreen for HBsAg. IfThe regimen should includeavailable\nVirussigns andpositive, screen for theTDF and 3TC, and where2. Liver biopsy if necessarysymptoms exceptfollowing;TDF is contraindicated,\n3. Baseline alpha feto-proteinas in chronic liver1. HBsAgsubstitute for TDF and add(AFP) if possible\ndisease.2. Anti HBeAgEntecavir3. Anti HBcAgRefer for specialist care if\n4. Anti HCVcomplicated.\n5. HBV-DNASome may require Peg-Interferon6. LFT\ntreatment7. Abdominal ultrasound\nBaseline AFP if possible\n1. Anti HCVThere may be noDirect-acting antiviral2. LFTsigns and(DAA);\nHepatitis C3. Abdominal ultrasound.symptoms exceptVirusThe Guideline Recommends4. HCV RNA (Refer ifas in chronic liver\nthe pangenotypic regimenpositive)disease.consisting of Sofosbuvir-\n5. FBCDaclatasvir\nRefer for specialist care for\ncomplicated cases.\nAcute watery- Viruses:- Bacteria:Frequent watery stoolsClinicalRehydrateProvide andDiarrhoea(SSS, ORS ormaintain\n- Rotavirus- EnterobacteriaeLaboratory:Resomal asadequate\n- Stool m/c/s- Enteroviruses- E. Colirequired)nutrition\nOther virusesC. jejuniSerologyZincE,U,Cr is usefulsupplementto monitor renal\n20mg daily forcomplications\n10-14 days forpaediatric\npatients\n\n                                     NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                       136", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1598, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6b48c63c-f551-4561-afca-9f065c3d8895": {"__data__": {"id_": "6b48c63c-f551-4561-afca-9f065c3d8895", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "ebc781e4-36b9-4ba6-b7cd-3f834301f101", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "6bfcee1e3641aaa34644fa9190786f1ae0f8f92775f81d139d886c33559033b8", "class_name": "RelatedNodeInfo"}}, "text": "Infection/CausativeSymptoms andDiagnosisTreatment and Prophylaxis CommentsConditionsorganismssigns\nDysenteryFrequent watery stools,ClinicalOralProvide and- E. hystoliticaabdominal cramps bloodymaintainrehydration\n- G. Lamblia- C. jejuniLaboratory:stools, fever, nausea andadequateCyclosporaIf antibiotics\n- Stool m/c/s- Isospora bellivomiting,dehydrationnutritionrequired:- Microsporidia\n- CryptosporidiaSerology, e.g. Widal testE, U. Creatinine- Ciprofloxacin- C. albicansis useful to\n- Salmonella spp.- Metronidazolemonitor renal- M. avium complexShigellaand CTXcomplications\n- S. StercoralisFor\nStrongyloidiasis:Clostridium deficile\n- AlbendazoleOral Zinc\ntherapy\nTinea corporisMalassaeziaItchy circularClinicalTopical application:Extra caution for possible NVPfurfurlesions with raisedinteractions with ketoconazole\nLaboratory: skin scrapings-Whitfield\u2019s ointment appliededges, fine scaly(see the section on drugstained with KOHb.d. for 3-5 weeks\nTinea capitisarea in the centre,interactions)Trichophytonloss of hair- 2% Miconazole cream b.dInternationally ketoconazole\nrubrumto the skin for 3-5 weeksrelativelycontraindicated since\nOral therapy: itraconazole/2013 due to increased\nfluconazoleidiosyncratic reactions\nSeborrhoeicAllergicreactionGreasy scales overSelenium sulphide shampoo,Secondary bacterial infectionClinical\ndermatitisto yeastscalp and rednessormay be common.infectionof cheek and\nTar shampoo followed by(Pityrosporum)flexural aspectssulphur salicylic acid cream\nor 1% hydrocortisone, or\nKetoconazole cream\n\n                                    NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                               137", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1678, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "f0014efe-7cbf-4561-b783-07cc6c185581": {"__data__": {"id_": "f0014efe-7cbf-4561-b783-07cc6c185581", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f69658b6-71d5-48f0-976d-3ccc6b0e7c4c", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "32df483cc6110063bf086005c6a3cffe9319722111e25e3dcce119ad8b662e33", "class_name": "RelatedNodeInfo"}}, "text": "Infection/CausativeSymptoms andDiagnosisTreatment and ProphylaxisComments\nConditionsorganismssigns\nHerpes zosterVaricella zosterPainful vesicularClinicalAdult:Refer intractable cases for(Shingles)viruslesions in aspecialist care.\nAcyclovir: 800mg 5dermatomaltimes/day for 7 daysRefer cases of herpes zosterdistribution, on the\ninvolving the eye and ear forface and trunk+ amitriptyline 25mg noctespecialist care.\nOR\n- 10 mg/kg IV q8hr for 7days\n- Analgesics\u2013 NSAIDS,carbamazepine,\namitriptyline\n- Local application ofcalamine lotion;\n- Topical application ofAcyclovir cream\n- For painful vesicularunilateral lesions on face\nor trunk.- Add gentian violet topical\napplication, tab pregabalin75mg BD (adult) 7 to 10\ndays,\nPaediatrics: Tab Acyclovir\n30mg/kg/day tds x 7 days\nHerpes simplexHerpes simplexBlisters or painfulAcyclovir Tab 400mg tdsClinicalGenitalisvirus-(HSV)sores on or aroundfor 7 \u201314 days\nthe genitals,OR 200mg 5 times dailyrectum\nfor 7 -14 days\n\n                                    NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                  138", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1095, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6c21379d-932b-4195-ba29-b337aa85540c": {"__data__": {"id_": "6c21379d-932b-4195-ba29-b337aa85540c", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "bf7cc2dd-efbd-4b78-a8d5-3a1855382398", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "ba66107a176c8c61a89f68d2167255831570fb7e39ef62efa3cf1e78de33181e", "class_name": "RelatedNodeInfo"}}, "text": "Infection/CausativeSymptoms andDiagnosisTreatment and Prophylaxis CommentsConditionsorganismssigns\nHerpes virusHerpes simplexFever, alteredIncreased CSF: serumIV AcyclovirNausea, vomiting, diarrhoea,\nencephalitisvirus 1 and 2consciousness,HSV antibody ratioheadache, malaise, rash, seizures,Paediatrics: 20mg/kg tid xconvulsions \u00b1 focalrenal dysfunction\nViral isolation21daysneurological signs\nAdult: 10-15 mg/kg IV q8hrfor 14-21 days\nCytomegaloviruCytomegaloviruEnterocolitis:ClinicalGanciclovir 5mg/kg IV bid x\ns:s (CMV)Fever, cramps,2-3 weeks;Laboratory:dysphagia,\nEnteritisFoscarnet IV 40-60mg/kg 8Biopsyodynophagia,hrly x 2-3 weeks\n(intracellular inclusions)Colitisdiarrhoea \u00b1 blood;\nRetinitis\u2013 OphthalmologicalSerologyCNSCNS: Delirium,examination; same drug\ninvolvementlethargy, headache,Skull X-raytherapy as above.malaise\nCT Scandisorientation, neck\nstiffness,CMV in CSFphotophobia,\ncranial nerve palsy,blurred vision or\n\u201cfloaters\u201d\nMeaslesMeasles virusFever, cough, redClinicalSupportive therapyHighly contagious;eyes, kerato-\nAntipyreticsRefer Complications; Nutritionconjunctivitis,support\ncoryza, maculo-Vitamin A, antibiotics aspapular rash;indicated, adequate\nhydrationComplications:\nPneumonia,diarrhoeal disease,\nmalnutrition.\n\n                                   NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                              139", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1388, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ea68465e-94c1-41c7-86ed-1f97213307ca": {"__data__": {"id_": "ea68465e-94c1-41c7-86ed-1f97213307ca", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "1ae7723d-8a5a-4b6c-88d2-471132832dfd", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "656f1943d35c8c76a2ae6c54d98a460f827439afa7010948d8f3c0548a6e9cf2", "class_name": "RelatedNodeInfo"}}, "text": "Infection/CausativeSymptoms andDiagnosisTreatment and Prophylaxis Comments\nConditionsorganismssigns\nHerpes virusHerpes simplexFever, alteredIncreased CSF: serumNausea, vomiting, diarrhoea,IV Acyclovir\nencephalitisvirus 1 and 2consciousness,HSV antibody ratioheadache, malaise, rash, seizures,Paediatrics: 20mg/kg tid xconvulsions \u00b1 focalrenal dysfunction\nViral isolation21daysneurological signs\nAdult: 10-15 mg/kg IV q8hrfor 14-21 days\nCytomegaloviruCytomegaloviruEnterocolitis:Ganciclovir 5mg/kg IV bid xClinical\ns:s (CMV)Fever, cramps,2-3 weeks;Laboratory:Biopsydysphagia,\nEnteritis(intracellular inclusions)Foscarnet IV 40-60mg/kg 8odynophagia,hrly x 2-3 weeks\nColitisSerologydiarrhoea \u00b1 blood;Retinitis\u2013 Ophthalmological\nCNSCNS: Delirium,Skull X-rayexamination; same druginvolvementlethargy, headache,\nCT Scantherapy as above.malaise\nCMV in CSFdisorientation, neck\nstiffness,photophobia,\ncranial nerve palsy,blurred vision or\n\u201cfloaters\u201d\nMeaslesMeasles virusFever, cough, redClinicalSupportive therapyHighly contagious;eyes, kerato-\nRefer Complications; NutritionAntipyreticsconjunctivitis,support\ncoryza, maculo-Vitamin A, antibiotics asindicated, adequate hydrationpapular rash;\nComplications:Pneumonia,\ndiarrhoeal disease,malnutrition.\n\n                                   NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                              140", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1389, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "da2fbfc8-3ed4-459f-9081-2787bb93e972": {"__data__": {"id_": "da2fbfc8-3ed4-459f-9081-2787bb93e972", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "c57cec0e-0087-437e-bfe5-22639275596d", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "44841029ce5ec559fe80384522e2b10047241fd3f1b550b09f76b415e1af4575", "class_name": "RelatedNodeInfo"}}, "text": "Infection/CausativeSymptoms andDiagnosisTreatment and ProphylaxisComments\nConditionsorganismssigns\nPneumoniaRespiratoryFever, chills, coughClinicalViral pneumonia is self-For severe pneumonia in children\nvirusesand pleuritic chestlimiting \u2013 requires only<12 months old treat PJPLaboratory: blood culture.pain, difficulty/ fastsupportive carepresumptively with CTX.\nBacteria:breathing.Chest x-rayBacterial:If facilities to exclude PJPS. pneumoniae\nCrepitations,-sputum examinationinfections are not available or ifa- Out-patient therapy withH. influenzabronchial breathchild on CPT develops bacterial\nCTX orsoundspneumonia do not treat with CTXS. aureusAmoxicillin orbut refer.\nM. catarhalisAmoxicillin/clavulanic acid.Quinolones are a 2nd line anti TB\nKl. pneumoniaFor in-patient therapy:drug hence rule out TB before\nusing quinolones(levofloxacin)P. aeruginosa- 2nd and 3rd generation\ncephalosporin as 2nd line.\no(Azithromycin or\nclarithromycin).oRespiratory quinolones\n(levofloxacin) in adults.\nAcuteRespiratoryFever, cough,ClinicalAmoxicillin or Amoxicillin/\nPharyngo\u2013virusesvomiting, refusal ofclavulanic acid.Laboratory:tonsillitisfeeds, drooling of\nBacteria:2nd generation cephalosporinsaliva, inflamed- Throat swab for m/c/s\n3rd and 4th generation- Strep.tonsils/ pharynx.\npneumoniaecephalosporin, and\nrespiratory quinolones- H. influenza(levofloxacin)\n- MoxerellaCatarhalis\n- Klebs.\npneumoniae\n\n                                      NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                      141", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1560, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "eee4733c-d52d-41b6-9e6b-cf5e26349aa5": {"__data__": {"id_": "eee4733c-d52d-41b6-9e6b-cf5e26349aa5", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "a3a7f5df-ceb7-4dcb-b3a5-50bd041bbc99", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "6be91b576c6648c9719fec868e56ba1db830958cf96e84278b276cd86ead5675", "class_name": "RelatedNodeInfo"}}, "text": "Infection/CausativeSymptoms andDiagnosisTreatment and ProphylaxisComments\nConditionsorganismssigns\nAcute otitisRespiratoryFever, vomiting,ClinicalAmoxicillin ormediavirusescough, ear-Amoxicillin/ clavulanic\nLaboratory:tugging;acidBacteria:- Ear swab for m/c/s\nHyperaemic2nd generation- Strep.tympaniccephalosporinpneumoniae\nmembrane,3rd and 4th generation- H. influenzapurulent earcephalosporin, and\ndischarge- Staph.respiratory quinolonesAureus\n(levofloxacin)- Moraxella\ncatarhalis\n- Klebs.pneumoniae\nChronic-S. pneumoniaeEar dischargeClinicalRefer to ENT specialistHearing loss is a complicationsuppurativelasting >14 days\nLaboratory:-H. influenzaotitis media\n-S. Aureus- Ear swab for m/c/s\nX-ray of mastoid-M. Catarhalis\n-Kl. pneumoniae\n-P. aeruginosa\nImpetigo-StreptococcusSkin pustulesClinicalClean sore with antisepticsspp,crusts,\nDrain pus if fluctuantFever (rarely)-Staph. AureusAmpicillin/cloxacillin\nCefuroxime, cefixime,amoxicillin-clavulanic\nacid and flucloxacillin.\nTopical agents such asMupirocin or Retapamulin\n\n                                  NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                            142", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1154, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "91880464-70c9-43be-9698-4780e31d6e24": {"__data__": {"id_": "91880464-70c9-43be-9698-4780e31d6e24", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "cea717c2-33c7-4418-80e1-822913d1a2b1", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "2a6765ab3c9272b9e04c7627d7e04c3490c048acc0254ecd1152beb5835be344", "class_name": "RelatedNodeInfo"}}, "text": "Infection/CausativeSymptoms andDiagnosisTreatment and Prophylaxis CommentsConditionsorganismssigns\nUncomplicated:MalariaMainly P.Fever, chills andClinicalRefer to a higher-levelArtemisinin-basedrigour, headache,falciparumfacility if complicated\nLaboratory: malariaCombination Therapynausea andparasite in blood film\nvomitingComplicated:RDT.\u00b7 Injectable Artesunate\nAvoid ACT containing- amodiaquine inThere is an increased risk of\npatients takingneutropenia with AZT andzidovudine or EFV.increased risk of hepatotoxicity\nwith EFV.- Avoid ACT\ncontaining sulfado-\nxine-pyrimethamine\ncombination if apatient is on CPT.\n- Avoid IntermittentPreventive Treatment\n(IPT) for malaria inpregnancy if the\npatient is on CPT.\nWhile awaiting m/c/sSepsis-S. pneumoniaeFeverClinical assessmentRefer to a tertiary facility inecessaryresults, either:\n-H. influenzaeShockLaboratory:-Penicillin + GentamycinIf in shock, provide supportive\n-Salmonella- FBCtherapy-Amoxicillin/clavulanic\n- Blood culture-N. meningitidesacid + genticin\n--Staph aureus- Urine cultureMetronidazole for\nanaerobes 2nd or 3rd- Organ-specific-Gram-negativesgeneratio(e.g. E. coli)signs/focus of\ncephalosporin andinfection determines-Anaerobesamoxicillin-clavulanic acidthe needed test(s).\nwith/out other antibiotics-depending on the focus of\ninfection\n\n                                  NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                          143", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1447, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "da208a73-cf64-46d6-a79f-5c9d455add81": {"__data__": {"id_": "da208a73-cf64-46d6-a79f-5c9d455add81", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "efe0d527-8698-46e2-a73a-7c449521a374", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "564e5c307e773ab47a02b5ef2c53942a2a72d9d059b01c7e0ee20220a87f872a", "class_name": "RelatedNodeInfo"}}, "text": "Infection/CausativeSymptoms andDiagnosisTreatment and ProphylaxisComments\nConditionsorganismssigns\nAcute bacter ial- S. pneumoniaeFever, headache,Clinical assessmentPenicillin & ChloramphenicolRefer to a tertiary facility if\nMeningitisvomiting,ornecessary- H. influenzaeLaboratory:irritability, altered\n3rd generation cephalosporin- FBC- Salmonellasensorium,+ Gentamycin\nconvulsions- Blood culture- N. meningitidesSupportive treatment\nNuchal rigidity,- CSF analysis- Staph aureusbulging fontanelle\n(in children)\nScabies- SarcoptesIntense itchyClinical,25% Benzyl benzoate appliedTreat super -imposed bacterial\nscabeilesions mostwhole body, neck down nocteinfection with oral antibioticsLaboratory: Micros copyprominent in inter-for 3 days OR\non KOH prep. of skinTreat all household members evendigital web, spaces\nscrapingsPermethrin cream 5% appliedif asymptomaticof the fin gers,\nwhole body, neck down andIvermectin is not recommended forwrist, buttocks andwashed off after 8 \u201314 hours.children below 15kg and pregnantaxillary area;\nRepeat after 1 \u20132 weeks.or lactating womenPapular rashes orIf poor response to topical\ngeneralisedtreatment then oral(Norwegian)\nIvermectin tablet 200mcg/kg\nPresentation couldstat, repeat after 7 -14 days +/ -\nbe more25% benzy l benzoate or\ngeneralized in theCrotamiton.\ncontext ofWas h and sun -dry/ironHIV/AIDS\nclothings, beddings and\nfomites.\n\n                                          NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                  144", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1539, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "344bbeae-a796-4a75-98f8-6a9160b836c1": {"__data__": {"id_": "344bbeae-a796-4a75-98f8-6a9160b836c1", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b90a9650-38ea-4361-9564-678e8fb05c06", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "67df830bb2895fd083a51086a17b03baf404540a04aae5c0696c800e417f2460", "class_name": "RelatedNodeInfo"}}, "text": "Infection/CausativeSymptoms andDiagnosisTreatment and Prophylaxis Comments\nConditionsorganismssigns\nMycobacteriumM. Avium spp.Disseminated formClinicalAdult:Nausea and vomitingAvium Complex\u2013 recurrent fever,\nLaboratory: Multiple- Clarithromycin 500 mg b.d.chronic diarrhoea,blood cultures;+ ethambutol 15 mg/kg daily\nlymphadenopathy,Optic neuritis may occur withwith or without rifabutinLymph node biopsyforethambutolweight loss/failure(300 mg daily).\nto thrive,intracellular inclusions- Azithromycin (500-600 mgabdominal pain,\ndaily) can be substituted forRespiratoryclarithromycin.\nsymptoms mayoccurPaediatrics:\n- Clarithromycin7.5mg/kg/dose b.d or\nazithromycin 5-20mg/kg/dose once daily\nplus Ethambutol15mg/kg/day for 6 months.\nProphylaxis: guided by CD4+count\nLymphoidUnknown, butMay initially beClinicalSteroids (prednisoloneComplications of therapy with\ninterstitialassociated withasymptomatic.2mg/kg/day x 6 weeks, taperprednisolone includeDiagnosis of exclusion.pneumonitisco-infectionoff)\nRecurrent Cough,Hypertension, gastritis, adrenalChest X-Ray: reticulo-(LIP)with Epsteinrespiratory distress,Oxygeninsufficiency, seizures, pseudo-\nBarr Virusnodular infiltrates,parotidtumour cerebri, hypokalaemia,bilateral hilar/mediastinalBronchodilators (salbutamol)enlargement,fluid retention, glucose intolerance\nlymphadenopathy;Chest physiotherapygeneralized\nlymphadenopathy,Referral to a specialisthepatosplenomegal\n(paediatricpulmonologist)y, digital clubbing,\nand poor responseto TB therapy.\n\n                                     NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                 145", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1650, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "7a94fab1-3804-4e2c-93c5-4089d799f498": {"__data__": {"id_": "7a94fab1-3804-4e2c-93c5-4089d799f498", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "310e9874-aee8-4198-8285-2a0b438ec02e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "e3967c55f28cb9deaf51a805cb25858c65d270e92ddd74733886a50e1d297951", "class_name": "RelatedNodeInfo"}}, "text": "8.4 HIV-Related Co-Morbidities\nTable 8.13 Common HIV-Related Co-Morbidities\n\n  Comorbidities           Example                                             Comment\n  Cardiovascular          1. Hypertension                                     Asses all PLHIV for risk of CVD and\n                          2. Heart failure                                    implement risk reduction strategies.\n                          3. Cardiomyopathy                                   Treat uncomplicated hypertension\n                          4. Arrhythmias                                      and heart failure refer others for\n                          5. Artheroclerosis/Ischaemic heart                  specialist care\n                               diseases/Cerebrovascular diseases\n\n  Others                  Type 2 diabetes,                                    Clients should be assessed and\n                          Asthma                                              managed for these diseases including\n                          Chronic obstructive pulmonary                       referral for specialist care where\n                          disease(COPD)                                       necessary.\n                          Breast and Cervical cancers                         All women with HIV should be\n                                                                              screened for cervical cancer\n                                                                              regardless of age.\n\n8.5 Mental Health and HIV\nMental health problems can increase the risk of HIV acquisition both directly and indirectly. In\nsub-Saharan Africa (SSA) HIV constitutes a major burden on mental health-related challenges\n[28]. The prevalence of depressive illness amongst PLHIV on ART in SSA is estimated to range\nfrom 29 to 63.1% [28]. HIV neuro-inflammation occurs nearly in every person that is HIV\ninfected but may present with symptoms in only about 60% of patients [29] who are said to have\nHIV-associated neurocognitive disorder (HAND). Although the severity of HAND is said to\nreduce in the era of combination antiretroviral therapy the neuro-inflammation is a long-lasting\ninflammation that still manifests as symptoms even in some individuals on effective ARV giving\nrise to the notion that neurocognitive decline may be resistant to treatment in some patients [29].\nHIV-associated neurocognitive disorder (HAND) is not only a long-lasting disorder, it is\nassociated with a profound decrease in the quality of life. It complicates autonomy, may\nadversely modify ARV treatment adherence and can produce high-level vulnerability to wrong\njudgment and accidents. Therefore, this guideline recommends that every PLHIV should have a\nmental health assessment.\n\n8.5.1 Recommendations\n     1.    Conduct an assessment for HAND\n     2.    Manage HAND appropriately\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                       146", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 2994, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "34675f61-db43-4574-b11a-cc32d8f1346a": {"__data__": {"id_": "34675f61-db43-4574-b11a-cc32d8f1346a", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "048b611a-f1c6-47ba-8f70-6a8ed8d4a361", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "a89b4097f3395c0dc43594594f5978f53053352d44fe4f9f4a31d0e21e4c6d8d", "class_name": "RelatedNodeInfo"}}, "text": "Table 8.14: Assessment for HAND as Proposed by the National Institute of Neurological Diseases and Stroke\n\n           Hand Type\n\n\nHIV-associated asymptomatic\nneurocognitive impairment\n(ANI)\n\n\n\n\n\n\nHIV-associated mild\nneurocognitive disorder\n(MND)\n\n\n\n\n\n\n\nHIV-associated dementia\n(HAD)\nDiagnostic Criteria\n\u00b7    Slight cognitive deficits in two or more neuropsychological\n     domains\n\u00b7    Cognitive function impairment does not affect daily\n     functioning\n\u00b7    Neurocognitive disorders fail to meet the criteria for delirium\n     or dementia\n\u00b7    There is no evidence of pre -existing cause of ANI\n\u00b7    Mild or moderate cognitive function impairment in two or\n     more neuropsychological domains\n\u00b7    Cognitive disorders affect, at least to a mild extent, daily\n     functioning\n\u00b7    Cognitive disorders fail to meet the c riteria for delirium or\n     dementia\n\n\u00b7    They are not conditioned by other concomitant diseases\n\u00b7    A patient may display mild concentration, attention or memory\n     disturbances (e.g. complaints about difficulty in reading)\n\u00b7    Moderate or severe cognitive function impairment in two or\n     more neuropsychologica l domains\n\u00b7    Considerable difficulty in performing daily functions\n     associated with intensification of cognitive disorders\n\u00b7    Cognitive disorders fail to meet the criteria for delirium\n\n\n                                                                \u00b7    Cognitive disorders are not conditioned by comorbid diseases\n                                                                \u00b7    The patient may develop speech problems, emotional\n                                                                     shallowness, lack of spontaneity and social withdrawal\n\n                    8.5.2 Management Considerations\n                    The key principle to management of HAND is to:\n                          1    Exclude cerebral OIs which may mimic features of HAND or depression\n                          2.   Implementation of treatment for depression among people with HIV may require task-\n                               shifting, building health worker capacity, national adaptation of screening tools and\n                               simplification of tools for use by nonspecialized primary Health care providers.\n                          3. The patient is placed on effective ART with good central nervous system (CNS)\n                               penetration capacity.\n                          4. The patient is appropriately referred for expert Neuropsychiatric assessment\n\n                    Another Mental health screening tool for PLHIV according to the New York state department\n                    of Health AIDS Institute is described in appendix 2.\n\n                                   NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                  147", "mimetype": "text/plain", "start_char_idx": 20, "end_char_idx": 2881, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c339b8c4-bb46-4dc9-86e3-872dac43c971": {"__data__": {"id_": "c339b8c4-bb46-4dc9-86e3-872dac43c971", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "8d95142c-5263-4dc4-82e4-15213dfe785d", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "c27a885e1901753556971da875c2e1040c315f6cd156336320a7c4ee62484cb0", "class_name": "RelatedNodeInfo"}}, "text": "List of Contributors\nDr. Umo Mildred Ene-Obong\nDr Akudo Ikpeazu\nMr Araoye Segilola\nPharm Oloyede Yekini\nDr Akpan Nsebong\nOmbudadu Obadiah A\nDr Deborah Odoh\nMrs Semlek Rachael N\nDr Nwaokenneya Peter\nDr Chioma Ukanwa\n\nMs Rahila Agwom\nDr Chinwendu Ndukwe\nProf. Sulaimon Akanmu\nDr Damien Anweh\nDr Rita O. Oladele\nDr Charles Olomofe\nDr Oluwafunke Ilesanmi\nDr Dennis Onotu\nDr Obinna Ogbanufe\nDr Igboeline Onyeka Donald\nDr Abiye Kalio\nFolu Lufadeju\nPharm Willams Eigege\nDr Saswata Dutt\nDr Olufemi Oke\nDr Olawale Fadare\nDr Olayiwola Lanre\n                                                          Chapter 8\nHead/Director, Public Health Department FMoH\nNational Coordinator NASCP\nFormer, National Coordinator\nFormer, Director, Logistics Unit NASCP\nDeputy Director NASCP\nDeputy Director NASCP\nDeputy Director, NTTP & Performance Management NASCP\nChief Accountant NASCP\nAssistant Director, Adult ART/TB/HIV - NASCP\nSenior Medical Officer 1, NTTP & Performance Management\nNASCP\nChief Scientific Officer NASCP\nDeputy Director, Health Sector Response Support NACA\nChairman NTTA / Haematologist LUTH Lagos\nMember NTTA / Physician FMC, Markurdi\nMember NTTA / Microbiologist LUTH Lagos\nPublic Health Physician FETH Ido Ekiti\nTechnical Officer, HIV and Viral Hepatitis WHO\nBranch Chief, Continuum of care & treatment CDC\nSenior Program Specialist, HIV care and treatment CDC\nProgramme Manager, Treatment USAID\nProgramme Manager USAID\nDeputy Country Director CHAI\nAssociate CHAI\nSenior Technical Advisor, HIV/TB/DR -TB IHVN\nTechnical Advisor CRS\nTechnical Director TMEC/RISE Program\nSenior Technical Advisor CCFN\n\n                             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  148", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 1692, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c8194cb5-cd50-4f76-b819-5b2629b9c60a": {"__data__": {"id_": "c8194cb5-cd50-4f76-b819-5b2629b9c60a", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "577a22c1-14fa-4617-bda4-1e11d3cab9c3", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "9d25682a5a21225621165693a644d068f602638fe2ba9dabaa8242cacb638b04", "class_name": "RelatedNodeInfo"}}, "text": "9. SERVICE DELIVERY\n\nWhat\u2019s Inside:\n9.1 Introduction\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.....150\n 1.1 Objectives of the Guidelines\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\n9.2 Differentiated Service Delivery\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026.150\n 1.2 Epidemiology of HIV in Nigeria\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\n9.2 Standards for Quality HIV Service Delivery\u2026\u2026\u2026\u2026\u2026.......163\n 1.3 Natural History of HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\n9.3 Nutrition\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.167\n9.4 Service Delivery for Adolescents Living with HIV\u2026\u2026\u2026.....169", "mimetype": "text/plain", "start_char_idx": 11, "end_char_idx": 443, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "cccf2b2e-f493-49cb-96f2-869cf6febcb5": {"__data__": {"id_": "cccf2b2e-f493-49cb-96f2-869cf6febcb5", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "0bda1baa-41d3-4158-a38a-1c365d445adb", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "874a694f6f32e8c1fa8d378a01a03eff670966b105c58341fc53a97ad33babd7", "class_name": "RelatedNodeInfo"}}, "text": "9.1 Introduction\nHealthcare service delivery in the context of HIV management provides the continuum of care to\nPLHIV that ensures access to HIV prevention, treatment and care aimed at promoting sustained\nvirological suppression and improved quality of life.\n\nResponsive HIV service delivery that meets the needs of various sub-populations is required to\nensure equitable, accessible, acceptable, appropriate and effective health services for PLHIV. In\nNigeria barriers to treatment access still exist. These include service-related, structural, policy\nand stage of life barriers. With the introduction of 'Test and Treat', as recommended by the 2016\nNational Guidelines for HIV Prevention Treatment and Care in Nigeria, the burden of HIV\nservice delivery on health facilities has increased.\n\nTo achieve the goal of virological suppression and ensure client-centred care, Nigeria must adopt\ninnovative strategies at both the health facility and community level. These strategies reduce the\nchallenges and barriers associated with accessing HIV services and enable healthcare workers to\nstrategically focus HIV investments and resources on clients with AHD and those who are not\nstable on treatment. As a nation, they are critical to enabling us to achieve the UNAIDS 95:95:95\ngoals. They must be targeted at and appropriate for the various sub populations of PLHIV to\nensure that no group is left behind.\n\n9.2 Differentiated Service Delivery\nDifferentiated service delivery (DSD), which is synonymous with differentiated care, is \u201can\napproach that simplifies and adapts HIV services to better serve the needs of PLHIV whilst\nreducing unnecessary burdens on the health system\u201d [30]. The concept of DSD is client-centred,\nfocusing on the needs and expectations of PLHIV, those vulnerable to acquiring HIV and how to\nmeet these needs. It seeks to improve access, quality and efficiency of health systems by re-\nexamining traditional service delivery approaches and building upon existing structures in both\nthe health facilities and the communities. Differentiated service delivery integrates task shifting,\ndecentralization, integration and simplification of care across the HIV care continuum. This\nservice delivery approach provides strategies tailored to specific patient populations. It is also\ntermed patient-centred or focused care and aims to efficiently deliver quality services that are\ndeemed satisfactory by the client, whilst also empowering the clients and their communities.\n\nThere are various types of DSD models which prioritize access and linkage to HTS, rapid ART\ninitiation, re-engagement in care, adherence and retention, all with the goal of achieving\nsustained virological suppression.\n                       __________________________________________________________________________Differentiated Service Delivery\n                       I                                                                                I\n\n                           95%                            95%                             95%\n                       Diagnosed                            On                           Virally\n                                                       Treatment                     Suppressed\n                                                         I__________________________________________IDifferentiated ART Delivery\n  Figure 9.1: Differentiated Care \u2013 Application across the HIV Care continuum\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                         150", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3557, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "2cdcb6fe-3898-4865-b9a3-2e65c81e116b": {"__data__": {"id_": "2cdcb6fe-3898-4865-b9a3-2e65c81e116b", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "86d637d5-4d98-4820-a95d-2f579b09ffc8", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "88a1d7841bc4251784afd9788426a4bae67a17d839fa26c7d3126f89cd59094d", "class_name": "RelatedNodeInfo"}}, "text": "9.2.1 Differentiated HIV Testing Service Delivery\n                    HIV Testing Services (HTS) are the full range of services that should be provided together with\n                    HIV testing and the following components: counselling; linkage to appropriate HIV prevention,\n                    treatment and care services; other support services and coordination with laboratory services to\n                    support quality assurance and the delivery of correct results.\n                    This chapter will focus on Differentiated ART Service Delivery (Guidelines for Differentiated\n                    HIV Testing Services are addressed in Chapter Two).\n\n                    9.2.2 Differentiated ART Service Delivery\n                    Differentiated ART service delivery describes a series of management approaches that align with\n                    the clinical status (clinically stable or unstable) of PLHIV and their needs and preferences [30].\n                    Models are broadly classified as facility-based or community-based.\n                         \u00a7     Facility-based models are HIV treatment and care models where services are offered\n                               within the existing health facilities\n                         \u00a7     Community-based models are HIV treatment and care models where services are offered\n                               outside the existing health facilities.\n                    These models implement either one or a combination of the following approaches:\n                         \u00a7     Differentiated patient flow: dedicated client pathways at sites for specific patient\n                               populations based on patient needs e.g. new patients and those with AHD.\n                         \u00a7     Differentiated schedules: adapting clinic flow or dedicating hours, days or appointments\n                               for specific populations such as adolescents.\n                         \u00a7     Differentiated locations: providing services to certain groups of clients such as stable\n                               adults and adolescents within the community; and One Stop Shops for Key Populations.\n                    Table 9.1: Models of differentiated ART Service Delivery in the Country\n\nFACILITY - BASED\nFast track (Individual or Group): stable\nclients pick their drugs from the facility\npharmacy without going through the normal\nclinic flow, including a doct or\u2019s review\nCOMMUNITY - BASED\nCommunity drug distribution points : These\nare designated points within the community\nwhere ARVs and other medications are\ndispensed to stable PLHIV\n\nMulti-month dispensing: Medication\ndispensing interval of 3 months and above.\nHealth Facility Based ART Group\nThese are health facility -based groups formed\nvoluntarily by support groups of persons living\nwith HIV who are already meeting regularly at\nthe health facility for ARVs and other\nmedication refills. This can either be client-led\nor Healthcare provider-led:\n\n\nCommunity Pharmacy Refills\n\nCommunity ART Group (CAG\nThese are community -based groups formed\nvoluntarily by persons living with HIV within a\ncommunity for ARVs and other medication\nrefills. This can either be PLHIV led or\nhealthcare provider led.\nThese healthcare providers may include\ncommunity health workers, case managers and\nother trained volunteers.\n\n                                   NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                        151", "mimetype": "text/plain", "start_char_idx": 20, "end_char_idx": 3492, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "cb2ed1f4-c8f6-4058-87d3-1370e6ef57bf": {"__data__": {"id_": "cb2ed1f4-c8f6-4058-87d3-1370e6ef57bf", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b10b1a25-48f2-45b2-9691-702f7935423e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "cf4f33b7509b0f75c5046c54c1324148395a641a6850c89a8c66a0da141331c9", "class_name": "RelatedNodeInfo"}}, "text": "Decentralization : refers to the devolution of stable clients from la rger, centralized secondary and\n  tertiary facilities (hubs), to smaller more peripheral primary facilities (spokes). This can be either:\n  -    semi-autonomous model which restricts ART service delivery at PHCs to ARV and medication\n       refills only\n  -    autonomous model which allows for ART initiation at the PHC level and also ARV and\n       medication refills.\n  Adolescent clubs: Groups of adolescents and young people living with HIV for whom age-appropriate,\n  affordable, friendly health services are provided in an accessible and acceptable environment\n\n  Post Natal Clubs : Groups of women living with HIV who are supported in the postnatal period by\n  healthcare workers and other volunteers like mentor mothers to ensure improved maternal/child\n  health outcomes.\n\n  One-Stop Shops and Mobile Clinics are community-based service delivery sites where multiple\n  services are offered and clients can access all their needs under one roof targeted specifically at\n  providing services for Key Populations\n\nThe choice of service delivery model for each client is individualized and should be made\nfollowing consultation and consent obtained from the client. All community-based models of\nservice delivery must be linked to approved facility-based sites.\n\nDifferentiating service delivery should be based on local assessment which is targeted to\nimprove patient satisfaction, quality of care offered and outcomes. Clients are offered packages\nof care based on four building blocks (delivery components) and three elements [30] .These\ncharacteristics can be applied across the entire HIV care continuum, for both stable and unstable\nPLHIV who are new to treatment or on long-term follow-up. The building blocks are:\n     \u00a7      WHERE services are provided (service location)\n     \u00a7      WHAT service packages are offered (service intensity)\n     \u00a7      WHO is the service provider (health worker cadre)\n     \u00a7      WHEN the recommended frequency of visits (service frequency)\nThe 3 elements to be considered in each assessment for differentiating service delivery are:\n     \u00a7      Clinical Characteristics \u2013 Patient stability and associated co-morbidities\n     \u00a7      Specific Populations \u2013 Children, Adolescents, Women (Pregnant and breastfeeding),\n            Men and Key Populations\n     \u00a7      Context \u2013 Urban or rural location, unstable context (e.g. conflict, high migration) and\n            epidemic/pandemic scenarios\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                              152", "mimetype": "text/plain", "start_char_idx": 2, "end_char_idx": 2621, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "9067ba92-9016-441c-ad85-e15b0baa3dc9": {"__data__": {"id_": "9067ba92-9016-441c-ad85-e15b0baa3dc9", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "8a4e38c4-56ca-44b7-9164-239e4bc2f11c", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "803772e12c7755a24757932de2d483d0dec5d2182cf44f36a6307c9f08de387e", "class_name": "RelatedNodeInfo"}}, "text": "Monthly\n                                    ART Aatatlon\n                                    ciinieal mondtoring\n                                    adhetencesuppott\n                                    01 uroatment suppot(\n                                                        Labotatory Iciti\n                                                             Servlce                 Sorvico\n                                                            Intensity               froquoncy\n                                                                           Patlent\n                                                                                                                     Physician\n                                                                                                                     Clinical ollcer\n                                                                                         Hoalth workorcadre          comnmaunity\n                                    HIV   Iinlcrhotpital       Servlce\n                                                               location\n                                    Communite\n                                    Hnin \"\n                     Figure 9.2: Key factors in differentiated approaches to HIV care\n\n                     9.2.3 Differentiated Service Delivery Based on Clinical Characteristics\n                     Non- pregnant adult PLHIV can be categorized into four broad groups, each with distinct care\n                     needs namely;\n                           \u00a7     Newly diagnosed or re-engaging clients who are well\n                           \u00a7     Clients who present with AHD\n                           \u00a7     Clients who are on ART and stable\n                           \u00a7     Clients on ART and unstable\n                     It is recommended that each of these groups is offered care packages which address their\n                     peculiar needs.\n                     Table 9.2: Care Package Elements for Distinct Groups of PLHIV\n                       People living with HIV                         Care package elements and focus of care\n\nNewly diagnosed, generally\nwell at presentation, in WHO\nstage 1 and 2 with\nhigh CD4+ cell counts\n(>200 cells/mm3)\n\n\n\nAdvanced HIV disease\n(CD4+ cell count <200\ncells/mm and /or WHO disease3\nstages 3 and 4)\n\n\n\n\nPreparation for ART requires readiness and willingness to\ninitiate treatment. Adherence and retention in care are essential\nin committing to lifelong ART.\n-    Adherence counselling\n-    ART Initiation\n-    TPT\n-    Retention support\n-    TB screening\nAccelerated clinical response to prevent death and reduce illness\nwith the following:\n-    Appropriately timed initiation of ART (taking the risk of IRIS\n     into consideration)\n-     Screening and management of OIs and other care and support\n     services\n-    TB screening, diagnosis and treatment\n-    CPT and TPT\n\n                                     NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                   153", "mimetype": "text/plain", "start_char_idx": 110, "end_char_idx": 3160, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "7d41889d-1ba8-4a72-b74e-6e3262a5eba3": {"__data__": {"id_": "7d41889d-1ba8-4a72-b74e-6e3262a5eba3", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "9a246569-681a-47f2-9ce8-0e59582eca9a", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "64e790194379d7a71a1537408c80b2cf5276fa89e95ff269ed1b6571b281d2c7", "class_name": "RelatedNodeInfo"}}, "text": "People living with HIV                         Care package elements and focus of care\n                                                 -    Close monitoring for identification and management of\n                                                      opportunistic infections\n                                                 -    Adherence monitoring\n  Patients who are on ART and                    -    Treatment literacy and retention support\n  are unstable                                   -    Viral load testing\n                                                 -    Switch to second- or third-line ART if indicated\n                                                 -    TB screening, diagnosis and treatment\n                                                 -    CPT and TPT\n                                                 -    Monitoring for HIV drug resistance (HIVDR)\n                                                 -    Other care and support services\n  Patients who are on ART and                    -    Reduced frequency of clinic visits\n  are stable                                     -    Community ART delivery models\nThese groupings are fluid with clients moving from one group to another whilst in care but\nenabling health systems to differentiate and target individuals requiring intense facility-based\nservices from those who require less frequent clinical consultations and could collect their ART\nfrom the community- based models of care.\n\nStability is defined based on duration on ART, age, clinical status, level of adherence and\ntreatment success. Children, men and non-pregnant/breastfeeding women living with HIV are\nstated to be stable or unstable based on the following criteria:\n\nTable 9.3: Stability Criteria for Children, Adult Men and Non-Pregnant Women\n  Criteria            STABLE                                                      UNSTABLE/COMPLEX\n  Age                 Adults, Adolescents and Children > 5yrs                     Children < 5yrs\n  Duration of         On ART for at least one year                                -    ART na\u00efve patients\n  ART                                                                             -    On ART less than one year\n                                                                                  -    AHD (WHO clinical stages 3-4)\n  Clinical            Clinically stable with no opportunistic                     -    Co-morbidities e.g. diabetes\n  status *            infections or current illnesses                                  mellitus, heart, chronic liver, and\n                                                                                       chronic kidney diseases\n                      -    Adherent with an optimal\n  Adherence                understanding of lifelong treatment                    -    Poor adherence\n                      -    Age-appropriate disclosure desirable                   -    Orphans and vulnerable children\n                           for children and adolescents\n                      -    Evidence of treatment success - two                    -    Unsuppressed viral load\n                           consecutive viral load measurements                    -    On 2nd or 3 line regimenrd\n  Treatment                < 1,000 copies/ul                                      -    On recently changed regimen <\n                      -    Has initiated/completed TPT                                 6months\n                      -    Has no adverse drug reactions that                     -    Experiencing treatment failure\n                           require regular monitoring\n  Monitoring          -    Does not require close monitoring at                   -    Close monitoring necessary at the\n                           the facility level                                          facility level\n                      -    Regular CD4+ cell count monitoring                     -    CD4+ cell count monitoring may be\n                           is unnecessary                                              required\n*All mentally impaired or retarded PLHIV, including those with psychiatric manifestations should be classified as unstable, irrespective of the\nage, CD4+cell count or viral load ;Unstable clients require closer monitoring and should receive facility-based care. They should not be\ndevolved into any community model of differentiated ART delivery; Clients devolved to community- based models who become unstable should\nbe referred back to the mainstream facility for closer monitoring.\n\n                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                 154", "mimetype": "text/plain", "start_char_idx": 2, "end_char_idx": 4666, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "641985c7-0e0d-4ac3-b625-f0a3d100752c": {"__data__": {"id_": "641985c7-0e0d-4ac3-b625-f0a3d100752c", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b049fba1-172f-4229-94a6-65e276e6babf", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "f9942a657f28e45138dc9ed29a66813f7345bb725cf63d5b24a991a4c417b427", "class_name": "RelatedNodeInfo"}}, "text": "Stable clients can be offered packages of care at the community level that do not include\n     CD4+ cell count monitoring and also a reduction in the frequency of:\n          \u00b7    Clinical consultations to every 3-6 months\n          \u00b7    ARV drug refills and medication pickup to every 3 months\n\n 9.2.4 Differentiated Service Delivery based on Sub-Populations\n The various sub-populations of PLHIV considered for differentiated ART service delivery\n include :\n     \u00a7     Pregnant and breastfeeding women\n     \u00a7     Children\n     \u00a7     Adolescents and young people\n     \u00a7     Adult men and non-pregnant women\n     \u00a7     Key Populations (KPs)\n\n 9.2.4.1 Differentiated Service Delivery for Pregnant and Breastfeeding Women\n The facility-based DSD model of care is recommended for Pregnant and Breastfeeding women\n as it makes provision for safe delivery practices, promotes mother/baby pair, in addition to\n prevention of mother-to-child transmission and antiretroviral therapy.\n\n Stability Criteria for Pregnant and Breastfeeding Women: The stability criteria for pregnant and\n breastfeeding women differs from the criteria for non-pregnant adults and children and is based\n on the viral load in the index pregnancy and previous PMTCT outcomes.\n A pregnant or breast-feeding woman is stated to be stable or unstable based on the criteria\n outlined in Table 9.4.\nTable 9.4: Stability Criteria for Pregnant and Breastfeeding Women\n\n  STABLE                                                 UNSTABLE\n  Viral load < 1000copies/ml in index pregnancy Viral load >1000copies/ml or unknown VL\n  Has had a previous PMTCT experience and                -    Is a newly diagnosed PLHIV\n  had a child with a HIV negative test result at         -    Is less than 20 years of age\n  18 months                                              -    Has an obstetric or medical condition\n                                                         -    First PMTCT experience irrespective of ART status\n                                                         -    Previous PMTCT experience with a negative outcome\n\n It is recommended that pregnant and breastfeeding women be categorized into the following\n groups. This categorization will assist in deciding the most appropriate DSD model especially if\n a facility-based DSD model is not available in the environment.\n     \u00a7     It is recommended that stable pregnant and breastfeeding women should continue on\n           DSD as appropriate to their peculiar situation. Their ART and antenatal clinic visits\n           should be synchronized for those previously receiving care in a facility model of DSD.\n           However, if she had been devolved into a community model of DSD, she should be\n           linked to a health facility for antenatal services and to a health care provider-led group or\n           mentor mother-led group for her drug pick up.\n     \u00a7     The facility-based DSD model of care is recommended for all unstable pregnant and\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                    155", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 3095, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "01e98b3a-c0be-4504-84fb-883246d359df": {"__data__": {"id_": "01e98b3a-c0be-4504-84fb-883246d359df", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "7396f99a-ce3c-4089-959d-27a74c2b116e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "cc725c0d89c606374b9fc7ac722f98d8a25b34ae6e4179a43e67922d94107b59", "class_name": "RelatedNodeInfo"}}, "text": "breastfeeding women and children up to five years, at the secondary or tertiary facility\n          level, to ensure PMTCT and Safe delivery. Women on facility-based DSD models prior\n          to delivery may choose to maintain such but clinical consultation should be aligned with\n          Mother-Infant Pair (MIP) visits. It is recommended that ARV/medication refills should\n          not exceed 3 months.\n\n        \u00a7   It is recommended that all unstable pregnant women should be managed at\n            a facility model of DSD\n        \u00a7   Stable pregnant and breastfeeding women who were devolved to a community\n            model of DSD prior to pregnancy can continue to receive ARV/medication\n            refills at the community level but should be linked to a facility for ANC.\n        \u00a7   Alignment of clinical visits and ARV/medication refills for the mother-infant\n            pair is recommended\n        \u00a7   ARV/medication refills should NOT exceed 3 months\n\n9.2.4.2 Differentiated Service Delivery for Children\nChildren are peculiar and are often not adequately catered for in most health care programs.\nBased on this, it is recommended that the DSD model a child is devolved to should, as much as\npossible align with that of the mother or the caregiver (if also on ART).\n\nChildren should be considered for enrollment into DSD from 5 years and above when they meet\nthe enrollment criteria. It is imperative that the time frame for children to be seen at the primary\ntreatment facilities should not be longer than 3 months in any case scenario. If, however, at any\npoint after enrollment the criteria for eligibility for DSD are not met, the child should be\npromptly referred back to the facility of primary treatment for review and continued\nmanagement.\n\nSpecial Scenarios: Incarcerated children, those in boarding schools and children whose parents\nare classified as KPs, should also be categorized as stable or unstable based on the criteria listed\nin table 9.3 above. Provision should also be made for their caregivers, lay providers, and school\nmatrons to pick up their ART drug refills. It is recommended that clinical consultations for those\nin boarding schools should be aligned as much as possible with school holidays.\n\n   It is recommended that all unstable children should be managed at a facility model of DSD.\n   Children (from 5 years), who are stable can be devolved into a community model of DSD,\n   however, ARV/medication refills should NOT be dispensed for more than 3 months and\n   clinical consultation visits should take place at the mainstream health facility every 3\n   months\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          156", "mimetype": "text/plain", "start_char_idx": 10, "end_char_idx": 2728, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "49f9bb08-505c-40e0-8598-c8962155c594": {"__data__": {"id_": "49f9bb08-505c-40e0-8598-c8962155c594", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "7551ed4b-25d7-43ea-b838-2000207acfea", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "7f0d5fccaa99c24a0d4eadeb729ee3baede65cc420c05f687723742b6b8db7fb", "class_name": "RelatedNodeInfo"}}, "text": "9.2.4.3 Differentiated Service Delivery for Adolescents and Young People (AYP)\n Differentiated service delivery for AYP focuses on the preferences and expectations of this sub-\n population. It aims at offering fewer intensive services to those who are stable on ART.\n Adolescents and young people with AHD at initiation should be provided with a package of care\n targeted to ensure stability within the first year of care. Stable clients on DSD who become\n unstable should be referred back to the mainstream facility for the continuum of care.\n It is recommended that a family approach be adopted for stable AYP, whereby families receive\n same-day appointments, same-length ART refills or allowing one family member (rotated) to\n collect ART refills for other stable family members.\n The principles of DSD models for AYP living with HIV should include the following:\n      \u00a7     AYP- centred (friendly, accessible, acceptable, affordable and stigma/discrimination-\n            free)\n      \u00a7     Leverage on the existing adolescent support groups/clubs either at the facility or\n            community\n      \u00a7     Preferably peer-led, especially amongst the older AYP\n      \u00a7     Adaptable (after school hours, weekends and holidays)\n      \u00a7     Pregnant adolescents should not be differentiated to community- based models\n DSD Modelling Approaches for AYP: These models outlined in Figures 9.3 and 9.4 below\n should be implemented primarily for stable adolescents whose ART refill should be every three\n to six months with clinical reviews completed at each visit. ART refills can also take place at the\n adolescents' club or support group meetings or within community ART groups. Where feasible,\n community volunteers should conduct monthly home visits to stable adolescents in community\n models. Unstable adolescents should have ART refills and clinical consultations conducted\n more frequently (one to two-monthly basis) at the facility.\n Figure 9.3: Building Blocks for DSD in AYP 10 \u2013 19 years\n                                       Receiving services                          Delivering services\n                                       \u00a7 Young Adolescents                         \u00a7 ART Clinician\n                                       \u00a7 Caregivers and family                     \u00a7 ART Nurse\n               WHO                                                                 \u00a7 Adherence officer\n                                                                                   \u00a7 Laboratory officer\n                                                                                   \u00a7 Pharmacist\n\n                                      Facility-based                                Community -based\n                                      \u00a7 Out-of school clinic hours managed          \u00a7 Community Pharmacies\n                                         by HCWs                                    \u00a7 Adolescent community ART\n            WHERE                     \u00a7 Weekend adolescent focused clinic\n                                      \u00a7 Using adolescent support groups             \u00a7 School based clinicsdistribution groups\n                                      \u00a7 Adolescent clubs (peer-led)\n\n                                       \u00a7 ART initiation/fill                        \u00a7 Linkage of caregivers to\n                                       \u00a7 Laboratory tests                              household economic\n              WHEN                     \u00a7 Clinical monitoring                           empowerment and\n                                       \u00a7 Psychosocial support                          livelihood opportunities\n                                       \u00a7 Treatment of OI\u2019s\n                                       \u00a7 Adherence support\n\n*For already mapped-out schools with established clinics\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                         157", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 3918, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "1bc8347c-b586-4d83-9b84-cdbd07e6fb69": {"__data__": {"id_": "1bc8347c-b586-4d83-9b84-cdbd07e6fb69", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "69e1e644-ab5b-464b-b59b-fb86dc30dbb5", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "892e51710e1b2ab7853f448082ad335c3abc6c710a074212086e27e52fcc8091", "class_name": "RelatedNodeInfo"}}, "text": "Figure 9.4: Building Blocks for DSD in AYP 20 \u2013 24 years\n\n                                                            Receiving services                     Delivering services\n                                                            \u00a7 Young persons                        \u00a7 ART Clinician\n                                                            \u00a7 Peers                                \u00a7 ART Nurse\n                                   WHO                                                             \u00a7 Adherence officer\n                                                                                                   \u00a7 Laboratory officer\n                                                                                                   \u00a7 Pharmacist\n\n                                                            Facility-based                        Community -based\n                                                            \u00a7 Support group                        \u00a7 Community pharmacies\n                                                            \u00a7 Youth clubs                          \u00a7 Adolescent community ART\n                                WHERE                                                                 distribution groups\n                                                                                                   \u00a7 Higher institution-based clinics\n\n                                                            \u00a7 ART initiation/fill             \u00a7 Linkage of caregivers to household\n                                                            \u00a7 Laboratory tests                   economic empowerment and livelihood\n                                 WHEN                       \u00a7 Clinical monitoring                opportunities\n                                                            \u00a7 Psychosocial support            \u00a7 Peer support\n                                                            \u00a7 Treatment of OI\u2019s               \u00a7 SMS adherence support\n                                                            \u00a7 Adherence support               \u00a7 Youth Whatsapp platforms\n\n                    *For already mapped-out institutions with established clinics\n\n                     9.2.4.4 Differentiated Service Delivery for Men and Non- Pregnant Women\n                     It is recommended that adult men and non-pregnant women who are stable on ART be\n                     differentiated to models of care that offer less frequent clinical consultations (3-6 months) and\n                     drug refills (3-6 months).\n\n                     Recommendations made below for service delivery in adults will be divided into those\n                     recommended at baseline, for those presenting well or with AHD and also for those who are\n                     stable or unstable after at least 1 year on ART.\n                    Table 9.5: Packages of Care for Newly Diagnosed, Re-engaging or AHD Clients\n\nBaseline Package of Care                Client Presenting Well\nWho qualifies for the package           Client with WHO clinical stage 1 3\n\nof care                                 or 2 or CD4+ count > 200 cell/mm\n                                        Healthcare workers trained to\n                                        provide ART services (Clinician,\nWho is the Service Provider             Nurse, adherence counsellor,\n                                        laboratory and pharmacy\n                                        personnel) *\nService Location                        Approved health facilities\nService Intensity (Packages Offered) and Service Frequency\n\n                                        **Monthly for the first 2 months,\nClinical consultations                  thereafter 2-monthly for the first\n                                        year.\n\n Advanced HIV Disease\n Client with WHO clinical stage 3\n or 4 orCD4+ count <200 cell/mm3\n\n Healthcare workers trained to\n provide ART services ( Clinician,\n Nurse, adherence counsellor,\n laboratory and pharmacy\n personnel)\n Approved health facilities\n\n** Weekly/Bi-weekly in the first 1\n    month\n Monthly for the first 2 months,\n thereafter 2-monthly for the first\n year\n\n                                   NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                      158", "mimetype": "text/plain", "start_char_idx": 21, "end_char_idx": 4325, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "132c295f-d124-44b3-b853-688be410adf2": {"__data__": {"id_": "132c295f-d124-44b3-b853-688be410adf2", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "45c4afaf-81fa-4fc7-84c3-fe22d8207be7", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "adae503dcfdbf30aa807347e4020868d924d21b386a0298092e90601c4fb8477", "class_name": "RelatedNodeInfo"}}, "text": "Baseline Package of Care                     Client Presenting Well                              Advanced HIV Disease\n                                                                       **Monthly for the first 2 months,                   **Monthly for the first 2 months,\n                          ART Refill Visits                            thereafter 2 -monthly for the first                 thereafter 2 -monthly for the first\n                                                                       year.                                               year\n                                                                                                                           Laboratory monitoring tests may\n                                                                       Laboratory monitoring tests may                     differ according to the level of the\n                                                                       differ according to the level of the                health care facility and should be\n                                                                       health care facility and should be                  done according to the schedule\n                                                                       done according to the schedule                      approved in the National\n                          Monitoring                                   approved in the National                            Guidelines. Additional tests may\n                                                                       Guidelines                                          be indicated based on\n                                                                                                                           diagnosed OIs\n                          Ancillary services: psycho-                                                                      Every week for the first 1 month\n                          social services, intensified                 At every clinic contact                             At every clinic contact\n                          adherence support                                                                                subsequen tly\n                          chronic care/PHDP Services\n\n                       *Adherence counselling/support and clinical screening for TB should be done at every clinic contact.\n                       **The client should be informed to return to the health facility IMMEDIATELY if s/he develops adverse drug reaction(s) or has any complaints\n\n                       Table 9.6: Packages of Care for Clients who have been on ART for at least 1 year\n\nPackage of Care                               Stable Client\nService Location                              Community models of DSD\n                                              and Approved health facilities\nService Intensity (Packages Offered) and Service Frequency\nClinical consultations                        Less frequent \u2013 3 to 6\n                                              monthly\nART Refill Visits                             Less frequent \u2013 3 to 6\n                                              monthly\n                                              VL monitoring annually\n                                              Cessation of CD4+ count\nMonitoring                                    monitoring if viral load\n                                              testing is available\nAncillary services: psycho-\nsocial services intensified                   Aligned with clinic visit and\nadherence support                             ART refill\nchronic care/PHDP Services\nUnstable Client\nApproved health facilities\nNo devolvement till stable\n\nFrequent - Monthly for 3 months or as\nindicated; subsequently as indicated.\nFrequent - monthly for 3 months;\nsubsequently 2 monthly or as indicated\nVL monitoring at the end of 3 months\nafter EAC for unsuppressed patients;\nsubsequently according to National\nguidelines\n\nMonthly for 3 months or as indicated;\nsubsequently aligned with clinic visits\n\n\n                                        NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                           159", "mimetype": "text/plain", "start_char_idx": 26, "end_char_idx": 4250, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "07e39027-7e4f-4329-965a-5f63c08153c6": {"__data__": {"id_": "07e39027-7e4f-4329-965a-5f63c08153c6", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "fafa00af-92ab-4cef-aafd-b4f9f4059279", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "805f022e8f865914a9a9adbefb9c4573a1dcfb1e7e7f4c5022a1139af91f1ccb", "class_name": "RelatedNodeInfo"}}, "text": "9.2.4.5 Differentiated Service Delivery for Key Populations\nKey populations (KPs) are defined as \u201cgroups who due to specific higher-risk behaviours, are at\nincreased risk of HIV irrespective of the epidemic type or local context\u201d [1].\nInternally Displaced Persons (IDPs), people in closed settings, fishing communities, truckers,\nmarginalized or minority groups such as undocumented migrants, ethnic and sexual minorities\netc. are also categorized as vulnerable and hard-to-reach populations.\n\nThe stability criteria used in streamlining service delivery for PLHIV are not as suitable for KPs\ndue to the following reasons:\n     \u00a7     The health-seeking behaviour of KPs is geared towards alternative structures that are\n           community- based and not facility-based and this also means that identification of new\n           cases will be at these alternative community structures.\n     \u00a7     Key Populations are also highly mobile in nature.\n     \u00a7     There are ancillary services uniquely demanded by KPs which include legal aid\n           support, interventions for gender-based violence, Mental Health and Psychosocial\n           Services (MHPSS). These are not provided under one roof or in most health facilities\n           and this mitigates against KPs accessing and being retained in care at these health\n           facilities.\n     \u00a7     The fear of stigmatization, discrimination and a criminalizing legal environment is also\n           a huge challenge at the health facilities. An enabling environment (safe space) that\n           provides the full complement of services required by this group is pertinent.\n          Based on the above peculiarities the following models are advocated for service\n          delivery to key populations\n     \u00a7     One-Stop-Shop (OSS) strategy: This refers to the delivery of a comprehensive service\n           package, under one roof, which is non-discriminatory, non-stigmatizing, safe, friendly\n           and in a conducive environment.\n     \u00a7     Mobile ART teams (MART): These are trained healthcare service providers that often\n           compose of at least 3 members namely; a clinician, a pharmacist and a laboratory\n           scientist. These teams leverage on outreaches and designated hot spots to provide\n           services to KPs.\n     \u00a7     Community Pharmacy (CP): These are pharmacies within the community used for ARV\n           refills to maintain good adherence to ARVs and retention on ART.\n     \u00a7     Focal Service Providers (FSP): These are trained personnel who reside within the\n           community and can easily be called upon to provide tailored services to KPs within their\n           environment.\n     \u00a7     Peer-led support group meetings: This is a confidential platform where meetings are\n           routinely held during which ART refills, adherence education/reinforcement and\n           general social support are provided basically to strengthen retention in care. Guidance is\n           also provided by experts during such meetings.\n     \u00a7     Key Population Friendly Health Facility: These facilities provide comprehensive\n           services for KPs in a friendly and conducive environment. They ensure that all\n           community-level DSD models for KPs are provided with a strong linkage to the Health\n           facilities.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           160", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3433, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "e2d73742-e980-4375-905c-ce237c3967e6": {"__data__": {"id_": "e2d73742-e980-4375-905c-ce237c3967e6", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "757a097a-07da-43f8-aeee-e07b8b15caf1", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "0e0702ab143053b377f2f6d2833a89c889608cfff1fe46364dee70182e31120d", "class_name": "RelatedNodeInfo"}}, "text": "Table 9.7: Service Package and Level of Provision\n\nWhere service is delivered\n\nService Delivery Model\n\n\nHTS\nART enrolment/Initiation\nARV refills (3,6 MMD)\nSTI screening /diagnosis\nTPT/CPT\nGBV intervention\nLegal support services\nHarm reduction (NSP, Overdose\n&wound management)\nHarm Reduction (OST)\nHepatitis screening\nTB screening (five questions using\nscreening tool)\nCervical cancer screening\nPMTCT (ANC/ART)\nHIV exposed infant prophylaxis/\nEID\nCommunity Level                                                Facility\n                                                               Level\nOSS           MART        FSP        CP          Peer          HCP\n                                                 Support\n                                                 Group\n     \u00fc             \u00fc          \u00fc           \u00fc                         \u00fc\n     \u00fc             \u00fc          \u00fc                                     \u00fc\n     \u00fc             \u00fc          \u00fc           \u00fc           \u00fc             \u00fc\n     \u00fc             \u00fc          \u00fc           \u00fc           \u00fc             \u00fc\n     \u00fc             \u00fc          \u00fc           \u00fc           \u00fc             \u00fc\n     \u00fc             \u00fc                                                \u00fc\n     \u00fc                                                \u00fc\n     \u00fc             \u00fc          \u00fc           \u00fc           \u00fc             \u00fc\n\n                                                                    \u00fc\n     \u00fc                                                              \u00fc\n     \u00fc             \u00fc          \u00fc           \u00fc           \u00fc             \u00fc\n\n     \u00fc                                                              \u00fc\n                                                                    \u00fc\n     \u00fc                                                              \u00fc\n\n\n                   9.2.5 Differentiated Service Delivery Based on Context\n                   The context in which HIV services are offered takes into consideration the prevalence rates of\n                   HIV in these areas (high or low), whether the epidemic is concentrated, generalized or mixed and\n                   also the location (urban or rural), where services are offered. Unstable, challenging settings such\n                   as conflict regions, high migration areas and border towns also require specifically tailored\n                   interventions to ensure that affected populations can access quality HIV services within these\n                   challenging scenarios. Linkages to and sustained care may be hindered by distance, terrain,\n                   safety concerns, transportation costs and few, over-burdened health facilities with long waiting\n                   times. It is recommended that differentiated service delivery models take into consideration the\n                   context in which services are required in such communities and be tailored to the specific needs\n                   of these individuals.\n\n                   Pandemics associated with other infectious diseases lead to scenarios where there may be\n                   competing needs for human, infrastructural and financial resources. When these scenarios also\n                   involve nationwide or regional lockdowns, physical and social distancing, the challenges to\n                   healthcare service delivery are increased. These scenarios such as with the COVID-19 pandemic\n                   require innovative approaches to service delivery to ensure continuity of services, retention in\n                   care of clients and sustained viral load suppression. Refer to the guidelines on providing ART\n                   services in the presence of a complex emergency.\n\n                   9.2.6 Integration of Service Delivery\n                   It is recommended that facility and community- based sites leverage on differentiated service\n                   delivery models for ART and integrate other services. This is cost-effective in terms of human\n\n                                 NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         161", "mimetype": "text/plain", "start_char_idx": 20, "end_char_idx": 4060, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "5e28954f-75d5-4fa9-adf3-16f60a58b177": {"__data__": {"id_": "5e28954f-75d5-4fa9-adf3-16f60a58b177", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "4c9b934e-4fa2-40dc-a552-dc59dd7ad3de", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "4a455c55083ac656c3a1034677e06af7c5b0350268c0fd4375e422cb35541fc4", "class_name": "RelatedNodeInfo"}}, "text": "and financial resources and will also improve the scale-up of these services. The following can\nbe integrated into differentiated care models for ART service delivery:\n     \u00a7    Tuberculosis Preventive Therapy (TPT)\n     \u00a7    Sexual and Reproductive Health Services (SRHS)\n     \u00a7    Viral hepatitis\n     \u00a7    Sexually transmitted Infections\n     \u00a7    Mental health services\n     \u00a7    Men's health\n     \u00a7    Substance use/abuse services\n     \u00a7    Non-communicable disease services\n     \u00a7    Food and nutrition support\nSelf- care is defined as \u201cthe ability of individuals, families and communities to promote health,\nmaintain health, prevent disease and to cope with illness and disability, with or without the\nsupport of a healthcare provider\u201d[30]. It empowers individuals, families and communities for\ninformed health decision-making, improved access, ensure health equity and improved\nefficiency of health systems. Community-based DSD with its pre-established linkages to health\nfacilities provides an enabling environment for the implementation of self-care interventions\nwhilst ensuring the availability of hospital/specialist care, where necessary. Self-care\ninterventions share common elements across health programs for SRHS, communicable and\nnon-communicable diseases. The recommended interventions for self-care in PLHIV include\nthe following:\n     \u00a7    Self-testing/monitoring: HIV self\u2013testing, hepatitis B and C testing, blood pressure and\n          blood sugar monitoring\n     \u00a7    HPV self-sampling\n     \u00a7    Prevention transmission interventions - to combat STIs and promote sexual health\n          o     PrEP and PEP\n          o     safer sexual and injection drug use practices (including over the counter condoms,\n                oral contraceptive pills and provision of safe injection packs)\n          o     eliminating unsafe abortion\n     \u00a7    Healthy lifestyle routines \u2013 nutrition, physical exercise, sleep patterns, water/sanitation\n          hygiene and stress management\n\n9.2.7 Family-Centred Differentiated Service Delivery\nFamily-centred DSD in the context of HIV services provides integrated services for family\nmembers at the same time (when), by the same healthcare provider (who) at the same venue\n(where). Family-centred care, though not new have had limited applicability. These\ninterventions seek to align visits at facility or community level for family members, including\nchildren and adolescents to further improve efficiency, adherence, retention in care and\nvirological suppression of patients. It also reduces the multiplicity of healthcare workers\noffering one family services, thereby reducing the frequency and intensity of contact with\nhealthcare providers. It is recommended that implementation of DSD models provide an avenue\nto implement and scale-up family-centred interventions which have benefits for not only the\npatients and affected caregivers, but also the healthcare system itself.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           162", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3045, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "aa510b42-bd88-4b4d-87b0-dd1e79c6bf13": {"__data__": {"id_": "aa510b42-bd88-4b4d-87b0-dd1e79c6bf13", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f7245caf-4a7f-4bdd-a2e7-b8a25bb42e5d", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "457dc5a3c722dc83738755c010a66798b7458f078e870c311632534da06660d5", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7 Differentiated ART service delivery models are broadly classified as facility-based\n       or community-based and all community-based models of service delivery should\n       be linked to an approved facility.\n   \u00a7 It is recommended that all unstable PLHIV be managed at a facility model of DSD\n   \u00a7 Stable clients can be offered and devolved to packages of care at the community\n       level with a reduction in the frequency of clinical consultations and ARV/medication\n       drug refills\n   \u00a7 Alignment of consultation and refill visits for family members and integration of\n       other services into differentiated ART service delivery models is recommended\n\n9.3 Standards for Quality HIV Service Delivery\nQuality is defined as the totality of features and characteristics of an entity that bears on its ability\nto satisfy a stated or implied need. The perception of the healthcare needs of a client or\ncommunity will vary based on the views and perspectives of the client, service provider, society\nand the social, political and economic environment. Standards are seen as expectations of\nperformance and help organizations understand how they can meet the diverse treatment needs\nof a variety of populations and thus are patient-centred.\n\nThe standards for quality HIV service delivery in Nigeria spans the entire care continuum from\nprevention, testing, care and treatment across both public and private health facilities as well as\nat the community level. The need for streamlined standards for HIV service delivery across all\nstrata of health care cannot be over-emphasized, bearing in mind the differences in unmet need\nacross the various sub-populations of PLHIV.\n\nThe best quality system may not function if there is no commitment on the part of the people\ninvolved to implement it. On the other hand, the simplest of systems can work very effectively if\nthere is motivation and commitment on the part of those involved to improve the quality of care.\nContinuous quality improvement can therefore be achieved by encouraging a quality culture that\nis based on a common vision, purpose, understanding, values and principles.\n\n9.3.1 Standards of Care\nThe standard care continuum for HIV extends from testing and counselling to care, treatment,\nand monitoring. The care continuum is not a \u201cone size fits all\u201d rather there are peculiarities for\nthe various sub-populations, such as children, adolescents, key populations and\npregnant/breastfeeding women. With more than 1.14 million (at 2019) PLHIV enrolled in care,\nit is important to employ strategies that strengthen linkages to care, retention in care and\nadherence to therapy to ensure that at least 95% of each of the various sub-populations of PLHIV\nachieve and sustain virological suppression.\nCertain strategies have been shown to strengthen/optimize the indices necessary to cater to the\nunmet need in HIV service delivery, key among them are:\nImproving Quality of Health Service Delivery\nQuality of care emphasizes that services should be effective in achieving desired health\noutcomes and that health care practices should be people-centred and safe. Efficient and\neffective HIV service delivery in Nigeria requires the following:\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                               163", "mimetype": "text/plain", "start_char_idx": 3, "end_char_idx": 3318, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "1696e7c5-9185-4c7e-a1b7-55033c0e50ab": {"__data__": {"id_": "1696e7c5-9185-4c7e-a1b7-55033c0e50ab", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "9da68751-96d5-4b90-82ea-d133dc20ff8c", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "024aa3a468ad460805e2f54233e4cb31b62b46f27c300fea674902857735b910", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7     Health system strengthening and well-coordinated systemic linkages across primary,\n           secondary and tertiary health facilities as well as with community-based facilities, social\n           support services and support groups.\n     \u00a7     National quality evaluation and accreditation processes for health facilities and health\n           providers at both the facility and the community level aimed at:\n           o    creating new service delivery sites at both facility and community levels\n           o    reviewing existing facilities for potential designation as service delivery site\n           o    assessing community capacity and identifying interventions to train and coordinate\n                public education\n           o    allocating new resources or reallocating existing scarce resources to HIV care\n           o    overseeing national treatment programmes\n     \u00a7     Capacity building for healthcare providers at both the facility and community level and\n           also of PLHIV for effective service delivery and communication. Tasks must be clearly\n           delineated and performance expectations well defined.\n     \u00a7     Providing information and supporting clients to make informed decisions about their\n           health, their engagement with health care and management of their health\n     \u00a7     Strengthening existing patient appointment systems with acceptable frequency of clinic\n           and medication refill visits and an efficient system for identification and tracking of\n           PLHIV who default on their appointments\n     \u00a7     Adoption of differentiated service delivery models and quality improvement strategies\n           to reduce waiting and turnaround times in clinics, laboratories and drug refill centres\n     \u00a7     Integrating the delivery of other services into HIV service delivery platforms as\n           appropriate and relevant e.g. TB, hepatitis, STIs, mental health, substance abuse, NCDs,\n           nutrition and SRHS\n     \u00a7     Quality control for test kits, medications (including ARVs and OI drugs ) and diagnostic\n           equipment.\n     \u00a7     Data Management\nThe need to continually monitor and improve on perceived gaps in service delivery cannot be\nover-emphasized therefore continuous quality improvement should be integrated into routine\nservice delivery. The framework in use in Nigeria for quality improvement programs is the\nNigeriaQual.\n                         FMOH and\n                               IPs\n                                              State MP\n                                           teams and IP\n                                              QI teams\n                                                                   Site and\n                                                                 Network QI\n                                                                     teams\n Figure 9.5: NigeriaQual Implementation Structure\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           164", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 3054, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "93e28e44-1949-48cd-900d-d7c519fbb7e7": {"__data__": {"id_": "93e28e44-1949-48cd-900d-d7c519fbb7e7", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f8f9d631-1175-4171-8975-f014f290e4ae", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "c9493dab415c8113d147087f67c793bcee52e7be2d6eabe225b845075adc4c40", "class_name": "RelatedNodeInfo"}}, "text": "NigeriaQual builds upon the HealthQual framework and has the following components:\n         \u00a7         Performance measurement\n                   o        Indicator development, data collection, analysis and reporting\n         \u00a7         Quality management structure\n                   o        Quality improvement teams at sites\n                   o        Multidisciplinary management teams at facility, local government, state and federal\n                            government level.\n         \u00a7         Quality improvement\n                   o        Problem identification, prioritization, implementation of tests of change\n                   o        Plan, Do, Study, Act (PDSA) cycle guides sustainable ongoing change\n                  Review the findings of your quality\n                  management system\n\n                  Re-evaluate both the processesproduct\n                  andthe\n                                                                                                                     PLAN\n                  Begin the quality monagcmentJgain                              ACT\n                  pTOCLS S\n\n        Control; mcusur und monitor your outpulsthey meet expected criteria CHECK                                          DO\n\n\n\n        Identify areas vhere there       opportunity\n        tor improvement\n\n\nFigure 9.6: The Four Main Components of Quality Control Management\n\n\n\n\n\n\n\n\n\n\n Identily your gouks and baseline\n\n Assemble Interal resources\n\n\n Determine quality standards and the\n re quiremengs      meetihose standatds\n Determine hat procedures villbe used\n    COSUFC Critong      being met\ntraining materia policies; procedures;\n documenkation\n              Orgunize supporting documentation (ISO\n                       work Instructions; CtC |\n      documenc manngement system\n\n Train employees on new processies)\n Deploy the quallty management system\n\n\n                                   Human Resource for Health\n                                   The inadequacy of the right number and mix of health workers to deliver quality ART services is\n                                   a major obstacle to the achievement of universal access to quality HIV prevention, treatment and\n                                   care. Evidence-based interventions should be implemented to boost human resource for HIV\n                                   service delivery. There is also the need to minimize staff attrition/incessant transfer of trained\n                                   ART service providers. There is also a need for government and responsible agencies to\n                                   consistently employ competent healthcare providers for the provision of ART services.\n\n                                   Training of Health Workers\n                                   It is recommended that:\n                                           \u00a7         All health workers and lay providers involved in the provision of HIV treatment and care\n                                                     should receive training prior to offering services and periodic re-training thereafter\n                                           \u00a7         Training of health workers and lay providers should conform with globally accepted\n                                                     standards for high-quality training\n                                           \u00a7         Training of health workers and lay providers should be conducted using nationally\n                                                     approved training curricula and manuals\n                                           \u00a7         Training curricula for the different cadres of healthcare providers, lay providers, peer\n                                                     educators, mentor mothers etc should be age and context appropriate\n\n                                                           NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                      165", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3986, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c878259b-8280-4d94-bbd1-b93171807f28": {"__data__": {"id_": "c878259b-8280-4d94-bbd1-b93171807f28", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "0a6e6dee-0a4a-45c0-a007-425d3375466e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "8b862ef60b159c3471ffc7ccb950231577520af85eb8507b913f714eb0aaebcd", "class_name": "RelatedNodeInfo"}}, "text": "Task shifting and Task sharing\nTask shifting and task sharing involve the redistribution of tasks within health workforce teams\nthat allows specialized health workers more time to focus on advanced clinical conditions while\nnon-physician providers attend to more stable patients. It also makes it possible for lay providers\nto offer certain non-specialized services especially in community models of HIV service\ndelivery. Task shifting and task sharing has enhanced linkage to care, addressed the high patient-\nto-doctor ratio, helped reduce the high default rates among patients already on ART, improved\ntreatment adherence, patient satisfaction and also strengthened community systems. Task\nshifting and sharing must be implemented with clear cut clarification of roles and assignments. It\nalso requires mentorship and supportive supervision to ensure continuous quality improvement.\nThe National Policy on Task Shifting provides guidelines and recommendations on task shifting\nand service provision and should be referred to for support in ensuring consistent quality of\nservice delivery.\n\n9.3.2 Standard Precautions\nThese are general guidelines to safeguard the various individuals involved in HIV service\ndelivery, including healthcare workers, lay providers, clients and the community at large. In the\nday to day delivery of HIV services, there are safety measures that must be considered if optimal\nservices are to be sustained; these include:\n\nInfection Prevention and Control (IPC) Measures\nThese are measures/protocols put in place to ensure protection from infectious agents either as a\nresult of nosocomial exposure or wide-spread infection at the community level. It is necessary to\nput in place protocols which will provide guidance in cases of infections of public health\nconcern. In the case of HIV, it is necessary to prevent accidental infections, occupational\ninfections and any widespread infection within a vulnerable sub population due to harmful\npractices or low level of awareness. There should be an established IPC policy in all health\nfacilities in the private and public sectors to ensure the prevention of accidental/occupational\nexposure to blood, body fluids and airborne pathogens that may result in infection with HIV or\nany other infectious disease.\n\nStandard Precautions\nThese are minimum infection prevention practices that should be observed by ALL health\nworkers/lay providers in the provision of HIV services, regardless of suspected or confirmed\ninfection status and include:\n     \u00a7     Hand Hygiene - Routine hand washing with soap and water before and after contact with\n           each patient, regardless of the HIV status\n     \u00a7     Respiratory hygiene/cough etiquette\n     \u00a7     Use of barrier precautions including Personal Protective Equipment (PPE) such as\n           gloves, gowns and masks etc.\n     \u00a7     Sharps Safety/Safe Injection Practices - Safe handling and disposal of sharp instruments\n           and equipment, including needles and syringes\n     \u00a7     Clean and disinfected work surfaces\nFor more details, refer to the National Guideline for Continuity of HIV service delivery in the\ncontext of complex emergencies It is recommended that ALL health facilities should provide the\nfollowing for their workers:\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         166", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3375, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "42598a82-bb2e-4f90-8e44-fc27a70a6938": {"__data__": {"id_": "42598a82-bb2e-4f90-8e44-fc27a70a6938", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "96a379f9-60d5-416a-ac2f-0e15c345c6e9", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "5abcacbe8497c68166060aa12c6c1f3e231770388ebb0706d4ad46e1728cfc24", "class_name": "RelatedNodeInfo"}}, "text": "\u00a7     Vaccinations against vaccine-preventable diseases such as Hepatitis B and tuberculosis\n     \u00a7     Post-Exposure Prophylaxis\n     \u00a7     Screening for HIV, TB, HBV, HCV, SARS\u2013Cov-2 and other infections\n     \u00a7     A safe working environment. This includes the adaptation and dissemination of policies\n           and SOPs on universal safety precautions, IPC and workplace safety to ensure the safety\n           and health of the employees within the workplace\n\n9.4 Nutrition\nNutritional interventions, both food-based approaches and micronutrient supplementation, are\nan essential component of comprehensive HIV care. Infection with HIV affects the nutritional\nstatus of PLHIV by causing increased energy requirements, metabolic alterations, reduced\ndietary intake and nutrient malabsorption. These eventually lead to weight loss, malnutrition and\nwasting in PLHIV.           Malnutrition also affects the immune system in similar ways as HIV\ninfection itself with abnormal B-cell responses, suppression of delayed hypersensitivity and\ndecrease in CD4+ T-cells.\n\nGood nutrition contributes to an optimal nutritional status that enhances the wellbeing of the\nPLHIV at all stages of the disease and contributes to the prolongation of life. It requires the\nconsumption of adequate both macronutrients (proteins, carbohydrates and fats) and\nmicronutrients (vitamins and minerals).\n\nFigure 9.7: Relationship between nutrition and HIV\n\n9.4.1 Nutrition in HIV Positive Pregnant and Lactating Woman\nThe nutritional status of an HIV positive woman before, during and after pregnancy affects not\njust her health but also the outcome of the pregnancy and survival of the newborn. Anaemia may\nbe more severe in HIV positive pregnant women, and severe anaemia (Hb < 7g/dL) is associated\nwith poor pregnancy outcomes and increased maternal and perinatal mortality. Extra nutrients\nare required during pregnancy to support the growth and development of the baby in utero.\n\n9.4.2 Nutrition in Children Living with HIV\nSuccessfully treating a child requires the commitment and involvement of a responsible\ncaregiver. Parents and other family members of children living with HIV may themselves be\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                        167", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 2291, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8a05beb9-2d17-4fcb-9515-e1c783cd51d7": {"__data__": {"id_": "8a05beb9-2d17-4fcb-9515-e1c783cd51d7", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "c7fa90d6-7145-47eb-a9f7-22221bfe6c8f", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "5fb66516e7dae0e029df5404af8b517daaee3f3b22a79636011217ec9287915c", "class_name": "RelatedNodeInfo"}}, "text": "infected with HIV, and sub-optimal HIV care and treatment for family members could result in\n                   sub-optimal care for the child. Another challenge to optimal treatment is lack of nutritional\n                   support.\n\n                   The nutritional needs of infants, young children, adolescents and adults alike should be\n                   adequately addressed during the initial evaluation, and it should be balanced with the need for\n                   their medication. It is important to ensure that nutritional counselling starts as soon as the\n                   diagnosis of HIV is made and is re-emphasized at each subsequent contact with healthcare\n                   providers at both the facility and the community level. All CLHIV should benefit from\n                   nutritional assessment, counselling and support (NACS).\n\n                   Improving the nutritional status of CLHIV should be based on scientific evidence, available\n                   local resources and expert opinion from clinical and programmatic experiences.\n                   Nutritional counselling, care and support requires the following steps:\n                       \u00a7     Assessment of the specific circumstances of each CLHIV\n                             o    Present nutritional status and diet\n                             o    Identification of factors mitigating against and facilitating adequate dietary intake\n                       \u00a7     Nutritional counselling to address specific areas identified during assessment and\n                             mutual agreements on the dietary plan based on available local resources\n                       \u00a7     Monitoring and documentation of nutritional status\n                   Table 9.8: Strategies and Guides for Improving and Monitoring the Nutritional Status of PLHIV\n\n                    Diet and Lifestyle                                                          Monitoring\n\n\u00a7  Eat a variety of foods that include proteins,\n   carbohydrates, and a little good fat (nuts, avocado,\n   fish, soybean)\n\u00a7  Eat a diet high in fresh fruits and vegetables\n\u00a7  Daily intake of lean, low-fat protein \u2013skinless\n   chicken, fish, extra-lean meat, beans, groundnuts,\n   soya beans, eggs and low-fat dairy products\n   -    Use salt sparingly\n\u00a7  Ensure adequate water intake\n\u00a7  Avoid alcohol and cigarette smoking\n\u00a7  Limit simple sugars in sweets, soft drinks, cakes\n   and foods with added sugar\n\u00a7  Hygienically prepared food, drinking water and\n   bev erages\n\u00a7  Nutrition educ ation and counselling\n\u00a7  Prompt treatment of OIs that interfere with\n   nutrition (mouth disorders, diarrhoea etc)\n\u00a7  Nutritional Support-macro/micronutrients\n\n\u00a7  Regular exercise and physical activity\n\u00a7  Economic empowerment\n\u00a7  Clinical assessment\n   -     History taking (intake, weight\n         changes and growth, GI symptoms,\n         and functional capacity)\n\u00a7  Physical examination\n   -     Anthropometric measurements for\n         growth monitoring in children\n   -     Height, Weight, BMI for age and\n         Sex MUAC,\n\u00a7  Bodyweight changes in adults (BMI in\n   kg/m 2)\n   - underweight \u2264 18.5\n   - normal = 18.5 \u2013 24.9\n   - overweight = 25 \u2013 29.9\n   - obese \u2265 29.9\n\u00a7  Waist -Hip Ratio\n\u00a7  Biochemical measurements of\n   metabolic parameters, serum proteins,\n   and micronutrients\n\n\n\n                                 NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          168", "mimetype": "text/plain", "start_char_idx": 19, "end_char_idx": 3475, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "adcab31e-b518-48a6-9750-decf616b4d60": {"__data__": {"id_": "adcab31e-b518-48a6-9750-decf616b4d60", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f200ecbd-46b2-4d0b-ace2-61acaf709c1c", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "bf9ce49017417b2b23e446cedf9555c3aecacb46d2cc38fefb5b14a47fc14dea", "class_name": "RelatedNodeInfo"}}, "text": "9.4.3 Nutrition and Antiretroviral Therapy\nMetabolic complications associated with the use of some ART such as lactic acidosis, alterations\nin bone metabolism, derangement in blood glucose and lipid metabolism must be taken into\nconsideration whilst planning an adequate diet for all PLHIV. Co-morbidities such as diabetes\nmellitus, cardiovascular and renal diseases may also require additional dietary modifications.\nAn optimal nutritional status may enhance adherence to ART, its acceptability, effectiveness and\nultimately virological suppression.\n\n    Nutritional support is an essential component of comprehensive HIV care. It is\n    recommended that nutritional interventions, both food-based approaches and\n    micronutrient supplementation (where applicable), are included as part of the routine care\n    of infants, young children, adolescents and adults living with HIV and their family\n    members\n\n9.5 Service Delivery for Adolescents Living with HIV\nThere are about 120,000 adolescents (10-19 years) living with HIV (ALHIV) in Nigeria, with\n70,000 (nearly 60%) being female [6]. Adolescents are a heterogenous group undergoing rapid\ndevelopmental, emotional and social changes. Unique changes that occur during adolescence\ninclude: emerging autonomy but limited access to resources; dramatic increase in number and\nvariety of social relations that could increase vulnerability; developing self and sexual identity,\nincluding capacity for self-direction; enhanced but evolving cognitive ability and greater\nimpulsivity; and a gap between biological maturity and assumption of adult roles. Adolescents,\ntherefore, have peculiar needs and challenges which have implications for their health and well-\nbeing.\n\nAddressing the distinct and diverse needs of adolescents living with HIV (ALHIV) to improve\ntheir HIV-related outcomes requires a comprehensive and integrated approach. Adolescent HIV\nservices in Nigeria (where available) often have limited integration with other adolescent health\nservices. Surveys and HIV program results have shown that over the years, adolescents living\nwith HIV in Nigeria have been underserved and have significantly worse access to HIV testing,\nlower ART coverage, and lower viral load suppression rates compared to adults. They are at\nhigher risk of loss to follow-up both before and after antiretroviral therapy initiation, with\npregnant adolescents living with HIV and adolescent key populations particularly vulnerable.\nIn 2014, the FMOH developed consensus guidelines to reconcile key ethical, legal and socio-\ncultural issues that pose serious challenges to the conduct of SRH research and access to HIV\nservices. Globally, specific interventions, service delivery models and approaches tailored to the\nspecific needs of adolescents have shown significant improvements in health outcomes for\nadolescents underscoring the need for the tailoring service delivery for adolescents living with\nHIV to their specific needs through what is now widely termed adolescent-friendly health\nservices (AFHS).\n\n9.5.1 Adolescent Friendly Health Services\nAdolescent-friendly health services (AFHS) encompasses interventions, service delivery\nmodels and approaches tailored to the specific needs of adolescents. AFHS has the twin goals of\npromoting healthy development in adolescents, and the prevention and response to health\nproblems if and when they arise.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         169", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3496, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "80816433-6e94-4cd4-9ea5-baa5f7eda25a": {"__data__": {"id_": "80816433-6e94-4cd4-9ea5-baa5f7eda25a", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "283f304f-8dab-42d8-8c50-7105fae05270", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "3ca11a1370212fedcd7ad5bcddcda4f00d8810c1e4952d11d1ffa0b034399def", "class_name": "RelatedNodeInfo"}}, "text": "To make HIV services adolescent-friendly, the principles below should be followed\n        \u00a7  Equitable: all adolescents, not just certain groups, are able to obtain the health\n           services they need\n        \u00a7  Accessible: adolescents are able to obtain the services that are provided\n        \u00a7  Acceptable: health services are provided in ways that meet the expectations of\n           adolescent clients\n        \u00a7  Appropriate: the right health services that adolescents need is provided\n        \u00a7  Effective: the right health services are provided in the right way and make a\n           positive contribution to the health of adolescents\n\n9.5.2 Package of services for adolescents living with HIV\nAdolescents living with HIV (ALHIV) need additional specific HIV-related services in addition\nto routine health services. Providing an appropriate package of services is one of the global\nstandards for high-quality health services for adolescents. The package of services for ALHIV\nshould be standardized and aligned with the principles of adolescent-friendly health services and\nthe global standards for quality health-care services for adolescents (Fig 9.8). To ensure high-\nquality HIV services for adolescents in Nigeria, a package of HIV services for ALHIV is here\ndefined and is recommended for implementation at health facilities and through referral links to\nother service delivery channels using a standardized approach.\n                    Principle of                                                     Global standards for\n                    adolescent-friendly                                              quality health care\n                    health services                                                  services for adolescent\n                                                       High quality\n                                                      HIV services for\n                                                        adolescents\n                                                      Standardized\n                                                      package of services\n                                                      for ALHIV\nFigure 9.8: Key elements for high-quality adolescent HIV service delivery\n\n9.5.3 Age-appropriate disclosure support\nDisclosure of HIV status is the process of informing a child or adolescent of his/her HIV status. It\nalso refers to the adolescent sharing his/her HIV status with a family member, friend or\nsignificant other. Disclosure is not a one-time event, but rather a process that involves ongoing\ndiscussions about the disease as the child or adolescent matures cognitively, socially,\nemotionally, and sexually.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                  170", "mimetype": "text/plain", "start_char_idx": 6, "end_char_idx": 2806, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d11fc540-78f4-4393-8d35-0f3870ba6fc4": {"__data__": {"id_": "d11fc540-78f4-4393-8d35-0f3870ba6fc4", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "1e0261b9-7d54-4f79-a781-e29b516e44e5", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "bcd1d9efc3325a256a29f7bb7a3fd2a6d3fad061408869142cf91ea35d2efd58", "class_name": "RelatedNodeInfo"}}, "text": "Phases of disclosure and age recommendations\n     No disclosure: There is no mention of any illness or HIV and no information is\n     provided about HIV diagnosis. This is recommended for children aged 0-4years..\n     Partial Disclosure: Children are given some but not all information about their\n     illness. Information may be given on immunity and the need to take medicines in\n     order to keep illness at bay. There is no mention of HIV or AIDS.This is\n     recommended for children aged 5 -8 years.\n     Full Disclosure: Children are told the name of the illness (HIV and/or AIDS),\n     disease specific information (e.g., how the virus works, how it is transmitted),\n     and how they acquired the disease.\n     This is recommended for children/ adolescents aged 9 -12 years with the goal\n     of completing full disclosure by age 10-12 years.\n     Post-disclosure:Period following disclosure, commonly described as early\n     post-disclosure (first three to six months) and late post-disclosure (over six months)\n     periods. The objective of post-disclosure evaluation and follow-up is to identify\n     the feelings, perception, and degree of coping with the diagnosis and to prevent\n     any complications after disclosure.\n\nAccidental disclosure occurs when someone talks about the HIV status of a child or adolescent\nwithout knowing that he/she is not aware of it. The service provider should carry out at least a\npartial disclosure of an HIV status to the child or adolescent when this occurs, and a readiness\nassessment and discussions with the parents or caregiver should be undertaken as soon as\nfeasibly possible.\n\nDisclosure helps the child/adolescent to know the HIV diagnosis, infection, understand the\ndisease process and health changes that could occur; develop strategies to lead a healthy life; and\nunderstand his/her responsibilities thereby promoting adherence to care and treatment, which is\nvital to achieving viral suppression. It has a positive long-term psychological impact and may\nimprove social functioning and school performance. Both the health care team and caregivers\nshould be involved throughout the disclosure process. Disclosure service provision should\ninvolve facility-based health care providers\u2014such as doctors, psychologists, nurses\u2014as well as\nsocial workers and community health workers.\n\nKey considerations for successful disclosure:\n     \u00a7    Service providers and healthcare workers should build up trust and establish rapport\n          with children and adolescents and their caregivers from the start of service delivery\n     \u00a7    The disclosure process should be aligned with recommended age guidance and should\n          take child's cognitive development into account, while remaining flexible and sensitive\n           to the family's feelings and needs as they evolve through the phases of disclosure\n     \u00a7    An individual plan for disclosure should be developed for each child/ adolescent and\n          documented using a disclosure checklist/ tracker as part of his/her medical records\n     \u00a7    The clinical team/care providers should provide intensive support and services to\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         171", "mimetype": "text/plain", "start_char_idx": 5, "end_char_idx": 3253, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "a73671ce-d0d6-4ce6-bdfa-9ef62b0b0fec": {"__data__": {"id_": "a73671ce-d0d6-4ce6-bdfa-9ef62b0b0fec", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "a2a87e20-e2bb-471f-a0a6-fc86dd657a7b", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "97f1360f3dfec81fe14bb2200762a3e562aecfef00539c326aa27c3b8f8a1b20", "class_name": "RelatedNodeInfo"}}, "text": "caregivers who object to disclosing an adolescent's HIV diagnosis to address their\n          concerns\n    \u00a7     Beyond disclosure support by the healthcare team for informing an adolescent of his/her\n          HIV status, support for onward disclosure to others such as family members, friend and\n          significant other should be provided\n\n9.5.4 Psychosocial support for adolescents living with HIV\nHIV affects adolescents in various ways in addition to the peculiarities of adolescence. One of\nthe gaps in the delivery of paediatric and adolescent HIV care and treatment services is the\nprovision of psychosocial counselling to HIV infected/affected adolescents and their caregivers.\nPsychosocial support entails attendance to the emotional, psychological, social, spiritual, and\npractical needs of the adolescent within his/her current situation, family, environment and\nrelationships. It is important for health care workers to receive adequate knowledge and skills\nneeded to comfortably provide psychosocial counselling to HIV positive children/adolescents\nand their caregivers. There is also a need to provide on-going supportive counselling, to address\ncare and treatment adherence issues.\nRecommendations for addressing gaps in the provision of psychosocial support for ALHIV:\n    \u00a7     Training of healthcare workers on the provision of psychosocial support to children and\n          adolescents and their caregivers using a standard curriculum.\n    \u00a7     Provision of child/adolescent centred counselling using appropriate SOPs and job aids.\n          Service providers should bear in mind that each adolescent is unique and so should not\n          generalize when providing support.\n    \u00a7     Provision of strength-based counselling for adolescents.\n    \u00a7     Psychosocial support should be available and accessible as part of the package of care at\n          ART refill visits\n    \u00a7     Counselling should be provided based on the needs of the adolescents.\n    \u00a7     There should be multidisciplinary team involvement when providing psychosocial\n          support to handle other issues like disclosure, nutritional support, mental health, caring\n          for a sick caregiver etc.\n    \u00a7     Availability of peer support through individual engagement, peer support groups, virtual\n          platforms etc. is important for adolescents.\n    \u00a7     Provision of access to basic education and literacy programs.\n    \u00a7     Provision of life skill coaching and empowerment which helps build their confidence\n          and self-sufficiency.\nFor adherence support and SRH in adolescents, refer to the chapters on adherence and PMTCT\nrespectively.\n\n9.5.5 Transitioning to adult care\nTransitioning is a purposeful, planned process to facilitate and support the movement of\nadolescents and young people from child/adolescent care- to adult-centred healthcare. A\nnationwide study reported that most secondary and tertiary health facilities in Nigeria\ntransitioned adolescents to adult care at 15 or 18 years of age [31]. Less than 30% of facilities\nhad an adolescent-specific clinic or transition policy, and most care was provided in a family-\ncentred fashion.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                          172", "mimetype": "text/plain", "start_char_idx": 10, "end_char_idx": 3283, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "21c87890-86cc-42e4-aaf4-1a272950ca5a": {"__data__": {"id_": "21c87890-86cc-42e4-aaf4-1a272950ca5a", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "d1711439-8a98-4753-b051-4be6576ae2a7", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "cb601af6c46c66397b82a043bc28d9cb65e699e720584e079480148b7df4e46f", "class_name": "RelatedNodeInfo"}}, "text": "9.5.5.1 Organizing a Transition Plan\nTransition should involve a multidisciplinary team of paediatricians, adult physicians, nurses,\nsocial workers, adolescent peer mentors and mental health professionals where available. All\nhealthcare facilities and providers should have a written standard plan in place to transition\nadolescents to adult care. This plan should include a schedule for the transition process initiated\nfrom early adolescence and engaging both the adolescent and the parents/caregivers. The plan\nshould not be a \u201cone-size-fits-all,\u201d but should be flexible and tailored to clients' individual\ncapacities, readiness, and developmental age. Caregivers should be active stakeholders in the\ntransition process. Disclosure is important for successful transitioning and recommendations for\ndisclosure provided in this document should be implemented.\n\nDiscussions on the transition to adult care should be initiated latest by age 14 years and barriers\nto adherence, retention and viral suppression addressed. During the transition process,\nadolescents should be empowered to take full responsibility for their health and commit to\nachieving good treatment outcomes. Some services may not be available at all levels of care and\nmay require a referral.\n\n9.5.5.2 Key Considerations for the Transition Process\nTransitioning should be a continuous and seamless process rather than a \u201cone-off\u201d event that\noccurs with one meeting. Flexibility will ensure those involved in the process can recognize and\nrespond to the unique needs of ALHIV. Informed decision-making is the key to mature self-care\nand is the overall goal of successful transitioning. The following are key principles to guide the\ntransition process:\n     \u00a7    Individualize the approach for each child and adolescent based on their developmental\n          readiness\n     \u00a7    Identify HCWs to engage in the transition\n     \u00a7    Begin the process early, ensuring communication among the adolescent, caregivers, and\n          the HCWs in the adult health care setting, before, during, and after\n     \u00a7    Develop and follow an individualized transition plan for each adolescent; in addition to\n          developing an orientation plan in the adult health care setting;\n          o     Plans should be flexible to meet the adolescent's needs, and also should include\n                provisions for any regressions that an adolescent may have\n          o     A checklist may be useful to develop such a plan\n     \u00a7    Use a multidisciplinary transition team including peers who are in the process of\n          transitioning or who have transitioned successfully\n     \u00a7    Address comprehensive care needs of each adolescent, as part of the transition,\n          including medical, psychosocial, and financial aspects of transitioning\n     \u00a7    Allow adolescents to express their opinions\n     \u00a7    Educate HIV care teams and staff about transitioning\n     \u00a7    Follow up transitioned adolescents in the adult clinic for 6 - 12 months to ensure\n          adherence and retention in care\n\nThere may be various barriers to seamless transitioning at the provider, adolescent and family\nlevels and these should be identified and addressed to minimize interruptions in care and\ntreatment. Poor communication among all stakeholders forms one of the largest barriers and\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         173", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3433, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "abd8822f-6b3f-4661-a585-f1134dd05ca2": {"__data__": {"id_": "abd8822f-6b3f-4661-a585-f1134dd05ca2", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b030bb5f-ae1f-437d-989d-2fb1159cc7f7", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "c3b0283523099db58f207cbbce6055dc8a5cfaa9ca2040cee46c007e0732b048", "class_name": "RelatedNodeInfo"}}, "text": "should be addressed. The transition should only occur when all parties have agreed that the child\nor adolescent has met the required criteria and is also mentally prepared.\n\n9.5.6 Peer-driven adolescent service delivery models\nMeaningful adolescent engagement is one of the standards for high-quality health services for\nadolescents. It entails intentionally involving adolescents in the planning, monitoring and\nevaluation of health services; inappropriate aspects of service provision; and in decisions\nregarding their care. It is essential that the meaningful participation and engagement of\nadolescent peers are encouraged and supported, and adolescents empowered and trained as\neffective peer educators, counsellors, trainers and advocates.\n\nWHO recently selected and profiled some adolescent peer-based models that are currently being\nimplemented in multiple countries across sub-Saharan Africa which have shown evidence of\nimprovement in linkage to care, adherence to antiretroviral therapy, retention in care, and viral\nsuppression. Some of these models are being tested in Nigeria but are yet to be harmonized and\nevaluated. They include:\n     \u00a7     Ariel Adherence Clubs\n     \u00a7     Baylor College of Medicine International Pediatric Aids Initiative Teen Club\n           Programme\n     \u00a7     Operation Triple Zero (OTZ) Model\n     \u00a7     REACH (Re-engage Adolescents and Children with HIV) Programme\n     \u00a7     Zvandiri Model\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                       174", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1537, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "633233de-0ba0-4bb4-be45-6533cfd434f9": {"__data__": {"id_": "633233de-0ba0-4bb4-be45-6533cfd434f9", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "fc7204e6-0737-42a6-9788-3a47e137e621", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "2963ef226b1e1e0f691fabc5dcc933c0306701598c54274ab9490fe1cd8e963a", "class_name": "RelatedNodeInfo"}}, "text": "List of Contributors\nMs Bridget Onyebuchi\nMr Usman Mohammed\nMr Sani Khalil A.\nMrs Sanni Kudirat\nProf. Lawal Umar\nDr Eugenia Ofondu\nDr Egejuru Ukabiala\nDr Olufunke Bolaji\nDr Richard Amenyah\nDr Olumuyiwa Ojo\nDr Helen Sagay\nOdelola Babatunji\nDr Uzoma Ene\nMs. Dolapo T. Ogundehin\nDr Adamu Yakubu\nDr Ikechukwu Amamilo\nChiedozie Nwafor\nDr Philip Imohi\nDr Majekodunmi Omololuoye\nDr Eluke Francis Blessing\nDr Onyekwelu Innocent\nDr Otoyo Eskor Toyo\nDr Chidubem Oraelosi\nDr Temi Omole\nDr Honey D. Okpe\nDr Chinyerem Frances Immanuel\nDr Emmanuel Nwabueze\nDr Torbunde Nguavese\nDr Nadia Sam-Agudu\nDr Oladokun Oluwatosin\nDr Kemi Akagwu\nDr Winifred Ezeobi\nDr Chioma Helga Law-Maduka\nDr Dominic Umoru\n                                                           Chapter 9\nAssistant Chief Scientific Officer, NASCP\nSenior Scientific Officer NASCP\nSenior Medical Laboratory Scientist NASCP\nCNO NASCP\nMember NTTA / Paediatrician ABUTH, Zaria\nMember NTTA / Dermatologist FMC Owerri\nMember NTTA / Paediatrician, Military Hospital, Lagos\nMember NTTA / Paediatrician, FTH Ido Ekiti\nFast Track Advisor UNAIDS\nNational Professional Officer (NPO) WHO\nTechnical Assistance- NTTP WHO\nLead, Integrated Service Delivery Team/HIV/AIDS-TB USAID\nSenior Program Specialist HIV Care and Treatment CDC\nCare and Treatment Lead (Acting) USAID\nDeputy Director, Public Health Programs US DoD\nSenior Technical Advisor CHAI\nAnalyst CHAI\nAssociate Director - Prevention, Care and Treatment FHI360\nSenior Technical Officer FHI360\nSenior Technical Officer FHI360\nTechnical Officer FHI360\nAssociate Director FHI360\nSenior Technical Advisor, Prevention Care and Treatment FHI360\nSenior Technical Advisor APIN\nSenior Technical Officer APIN\nCare and Treatment Lead ICAP\nMedical Director AHF\nSenior Program Officer, Pediatric/Adolescent HIV IHVN\nSenior Technical Advisor, Pediatric and Adolescent HIV IHVN\nClinical Service Manager Paediatrics and Adolescent CIHP\nCSO PMTCT CIHP\nTechnical Advisor CCFN\nProgram Advisor Heartland Alliance\nMember NTTA/Paediatrician\n\n                                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  175", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 2110, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d92ade4d-aaea-40cd-8e5a-b2b22860f227": {"__data__": {"id_": "d92ade4d-aaea-40cd-8e5a-b2b22860f227", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "a456936d-946f-44e3-af3f-f9040cedf8af", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "ad39b75e0728219c60cee4b681326e8401f245f534d99d2b86f5871e828734a1", "class_name": "RelatedNodeInfo"}}, "text": "10. MONITORING AND EVALUATION\n\n  What\u2019s Inside:\n 10.1 Introduction \u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..177\n  1.1 Objectives of the Guidelines\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\n 10.2 Selection of Indicators\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026\u2026...177\n  1.2 Epidemiology of HIV in Nigeria\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\n 10.3 Data Management\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026\u2026\u2026.....182\n  1.3 Natural History of HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\n 10.4 HIV Data Dissemination and Use\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..184\n 10.5 Human Resource for M&E\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026.......184\n 10.6 HIV M&E Logistics\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026\u2026\u2026..185\n 10.7 Additional Strategies in M&E\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026........185\n 10.8 HIV Research\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026\u2026\u2026\u2026\u2026\u2026....185\n 10.9 Periodic monitoring of the implementation of\n     the guidelines and content update\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026...185", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 679, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "20db49a4-797f-4a02-ac68-f2a9efca5b8d": {"__data__": {"id_": "20db49a4-797f-4a02-ac68-f2a9efca5b8d", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "70fdc4e2-7722-4cdb-880c-bc7acaa4b04f", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "71714dc796c81c5859b901b204a8cd1e7602f168d5fd2a1e766571db86ebd737", "class_name": "RelatedNodeInfo"}}, "text": "10.1 Introduction\nMonitoring and evaluation of the HIV programme enables the country to measure the level of\neffectiveness of interventions and linkages between services. This will enable the country track\nprogress toward achieving its programme goals and set targets. It also provides data for informed\ndecision-making on the programme and allocation of resources.\n\nThe M&E objectives include:\n     1.   Monitoring programme performance across the domain of HIV prevention, treatment,\n          care and support.\n     2. Improving data quality to inform decision making and programme planning.\n     3. Strengthening capacity in data management across all levels of implementation.\n     4. Improving data reporting from private, public and community level.\n     5. Strengthening and utilizing HIV surveillance and research.\nNew strategies in the management of HIV and co-infections, along with changes in the\nimplementation environment call for a broadening of the M&E system in order to adequately\nmeasure and assess the impact of the interventions. In addition, routine monitoring shall be\ncomplemented by periodic systematic evaluations and programme reviews to assess the\nperformance and impact of HIV programmes. Data triangulation, modelling and other analytic\ntools will be utilized to improve the accuracy and usability of HIV data.\n\n10.2 Selection of Indicators\nIn 2017, the country adopted WHO global indicators for M&E reporting of the HIV programme.\nThe categories of national indicators relate to the following:\n     1. HIV testing services\n     2. Treatment and care for pregnant and breastfeeding women (prevention of mother-to-\n          child transmission (PMTCT)\n     3. Paediatric, adolescent and adult HIV treatment and care\n     4. Advanced HIV disease\n     5. TB/HIV co-infection\n     6. Other comorbidities and co-infections\n     7. Post-exposure prophylaxis (PEP) and Pre-exposure prophylaxis (PrEP)\n     8. Services for key populations\n     9. Linkage, enrolment and retention in care\n     10. Toxicity monitoring\n     11. HIV drug resistance (HIV-DR)\n     12. Viral suppression and\n     13. Impact evaluation (mortality, prevalence and incidence)\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                       177", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2276, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "b4b466a6-5b5d-428a-9839-81f1bbc40c88": {"__data__": {"id_": "b4b466a6-5b5d-428a-9839-81f1bbc40c88", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "0b4f543a-2652-45e4-9cab-8787d5c42656", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "78e991ad9e2ddee9a10b67c0f8b55cee0342de1f290ff4a29225ac3c59c81e66", "class_name": "RelatedNodeInfo"}}, "text": "Table 10.1: MONITORING AND EVALUATION FRAMEWORK\nDATAFREQUENCY INDICATORSDEFINITIONDisaggregationRESPONSIBLEHow oftenSOURCE\nHow is it calculated/measured?will itHow will itWho will\nbe measured?be measured?measure it?\nIMPACT INDICATORS\n% of annual AIDS death amongN: Number of annual AIDS deaths amongAge (<1, 1\u20134, 5\u20139,ProgrammeAnnuallySTATE/FMOH\nPLHIV during the reportingPLHIV.10-14, 15\u201319, 20\u2013Data.24, 2549, 50+\u2013period.D: Estimated number of PLHIV.Spectrum.\nyears); sex\nNumber of new infectionsN&D:NAAge (<1, 1\u20134, 5\u20139,Spectrum.AnnuallySTATE/FMOH\n10-14, 15\u201319, 20\u2013averted\u201324, 2549, 50+\nyears); sex\nOUTCOME INDICATORS\nN: Number of PLHIV who are virally% PLHIV on ART who areAge (<1, 1\u20134, 5\u20139,ProgrammeBi-annuallySTATE/FMOHsuppressed at 6 months of initiation\n10-14, 15\u201319, 20\u2013Data (PMMvirally suppressed at 6 monthson ART.49, 50+\u201324, 25& PM Eduring the reporting period.\nD:Number of PLHIV on ART thatyears); sexTools)..received a VL test result at 6 months of\ninitiation on ART\nN:Number of PLHIV who are virally% of PLHIV on ART who areAge (<1, 1\u20134, 5\u20139,ProgrammeAnnuallySTATE/FMOHsuppressed at 12 months of initiation\nvirally suppressed at 12 months10-14, 15\u201319, 20\u2013Data (PMMon ART.during the reporting period.24, 25& PME49, 50+\u2013\nD: Number of PLHIV on ART that receivedyears); sexTools).a VL test result at 12 months of initiation\non ART.\nN:Number of PLHIV alive and on ART at 6% of PLHIV on ART who areAge (<1, 1\u20134, 5\u20139,ProgrammeBi-annuallySMOH/ FMOHmonths of ART initiation.\nretained on ART at 6 months10-14, 15\u201319, 20 \u2013Data (PMM24, 25& PME49, 50+\u2013after initiation during theD: Number of PLHIV initiating ART up\nyears); sexTools).Cohort Analysisreporting period.to 6 months before the beginning of the\nreporting year. (This includes those who\nhave died since starting therapy, those who\nhave stopped therapy and those lost to\nfollow-up as of month 6.)\n\n                                  NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                         178", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1995, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "4ce2c15a-8792-46c3-9b42-efbf3df07416": {"__data__": {"id_": "4ce2c15a-8792-46c3-9b42-efbf3df07416", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "927a2413-ad18-46f8-8ca6-59f5e79b3e19", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "186613a3f7029e834e9a49ac42cc485064753ee06750e241cb13d66bb7e37d74", "class_name": "RelatedNodeInfo"}}, "text": "% of PLHIV on ART who areN: Number of PLHIV alive and on ART at 12Age (<1, 1 \u20134, 5 \u20139,ProgrammeAnnuallySMOH/ FMOH\nretained on ART at 12 months ofmonths of ART initiation.10-14, 15 \u201319, 20 \u2013Data (PMM\ninitiation during the reporting24, 25& PME49, 50+\u2013D: Number of PLHIV initiating ART up to 12period.years); sexTools).Cohort Analysis\nmonths before the beginning of the reporting\nyear. (This includes those who have died since\nstarting therapy, those who have stopped\ntherapy and those lost to follow-up as of month\n12)\nOUTPUT INDICATORS\nNumber counselled, tested for HIVAge (<1, 1 \u20134, 5 \u20139,ProgrammeN&D: NABi-annuallySMOH/ FMOH\nand received results during the10-14, 15 \u201319, 20 \u2013Data (PMM\nreporting period.24, 25& PME49, 50+\u2013\nyears); sexTools).\n% of infants born to HIV -positiveN: Number of HIV- exposed infants whoProgrammeBi-annuallySMOH/ FMOH\nwomen receiving a DNA -PCR testreceived EID/DNA-PCR test for HIV withinData (PMM\nfor HIV within 2 months ofbirthtwo months of birth during the reporting period.& PME\nduring the reporting period.Tools).D: Population-based denominator:\nEstimated number of HIV-positive pregnantwomen during the r eporting period.Spectrum\nFacility-based denominator: Number of HIV-\npositive pregnant women.\n% o f HIV Exposed babies whoN: No. of HIV Exposed babies who tested forProgrammeBi-annuallySMOH/ FMOH\ntested for HIV within 18 months ofHIV within 18 months of birth by Rapid Test.Data (PMM\nbirth by Rapid Test during the& PMED: Estimated number of HIV -positive pregnantreporting period.Tools).\nwomen during the reporting period.\nFacility-based denominator: Number of HIVSpectrumpositive pregnant women\n\n                                       NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                 179", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1772, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "831b646d-fe08-4bf6-9e33-3e5114ea59a6": {"__data__": {"id_": "831b646d-fe08-4bf6-9e33-3e5114ea59a6", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "63eb10c2-e4fe-4634-b509-aaa82b8a85f5", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "e5c9478052b0647fa99bdcb22b1f03dbe4bf88881d8757b19530b5bc70c09401", "class_name": "RelatedNodeInfo"}}, "text": "% of persons who testN: Number of persons who testProgrammeAnnuallySMOH/ FMOHHIV-positiveDataHIV-positive.\nduring the reporting period.(numerator)D: Number of persons counselled tested.Spectrum\nand received\nProportion of newly diagnosedN:Number of newly diagnosed PLHIVProgrammeBi-annuallySMOH/ FMOHData (PMMHIV-positive PLHIV newlynewly enrolled in clinical care during\n& PMEenrolled in clinical care duringthe reporting period.Tools).the reporting periodD: Number of newly diagnosed PLHIV\nN:Number of positive PLHIV who% of positive PLHIV whoAge (<1, 1\u20134, 5\u20139,ProgrammeSMOH/ FMOHBi-annuallyreceived at least one of the following\nreceived clinical assessment10-14, 15\u201319, 20\u2013Data (PMMduring the reporting period: clinical24, 25& PME49, 50+\u2013(WHO staging) OR CD4+count\nassessment (WHO staging) OR CD4+years); sexTools).OR viral load OR current oncount OR viral load OR current\ntreatment during the reportingon treatment.period.\nD: Estimated number of PLHIV.Facility-based denominator:\nNumber of PLHIV newlyN & D:N/AAge (<1, 1\u20134, 5\u20139,ProgrammeBi-annuallySMOH/ FMOHstarted on ART during the10-14, 15\u201319, 20\u2013Data (PMM\nreporting period.24, 25& PME49, 50+\u2013\nyears); sexTools).\nART coverage among PLHIVN:Number of PLHIV currentlyAge (<1, 1\u20134, 5\u20139,ProgrammeBi-annuallySMOH/ FMOHduring the reporting period.10-14, 15\u201319, 20\u2013Data (PMMreceiving ART.\n24, 25& PME49, 50+\u2013D: Estimated number of PLHIVyears); sexTools).\n% of PLHIV in care (includingN:Number of PLHIV enrolled in HIV careAge (<1, 1\u20134, 5\u20139,ProgrammeBi-annuallySMOH/ FMOHwhose TB status was assessed and recordedPMTCT) who were clinically10-14, 15\u201319, 20\u2013Data (PMM\nat their last visit during the reporting period.screened for TB in HIV care and24, 25& PME49, 50+\u2013D: Total number of PLHIV currentlytreatment settin gs during theyears); sexTools).\nreceiving HIV care during the reportingreporting period.period.\n\n                                  NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                         180", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1999, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "fa7e6db6-e252-45da-b925-bd538fc29d7a": {"__data__": {"id_": "fa7e6db6-e252-45da-b925-bd538fc29d7a", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "00cecad4-7f6c-45a4-87df-e60bb217db01", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "14ec9ae3d9c9fd9e9509efd7875fa4c6827c3faf4b498d1a40e241c5e41299ed", "class_name": "RelatedNodeInfo"}}, "text": "% of PLHIV Enrolled in HIV CareN: Total number of PLHIV enrolled in careAge (<1, 1 \u20134, 5\u20139,ProgrammeBi-annuallySMOH/ FMOH\nwho have Active TB Disease.who have active TB disease during the10-14, 15 \u201319, 20 \u2013Data (PMMreporting period.24, 25& PME\nyears); sexTools).D: Total number of PLHIV currently in HIV\ncare who were screened for TB during the\nreporting period\nART coverage amongN:Total number of HIV-positive new andAge (<1, 1 \u20134, 5\u20139,ProgrammeBi-annuallySMOH/ FMOH\nHIV-Positive New and Relapsedrelapsed TB PLHIV started on TB treatment10-14, 15 \u201319, 20 \u2013Data (PMM49, 50+\u2013TB PLHIVduring TB Treatment.during the reporting period who are already on24, 25& PME\nART or started on ART during TB treatment.years); sexTools).\nD: Total number of H-positive new and\nrelapsed TB PLHIV registered during the\nreporting period\n\n                                     NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                  181", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 968, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "41b3e944-1c8c-4be8-a4a4-25aca1df993e": {"__data__": {"id_": "41b3e944-1c8c-4be8-a4a4-25aca1df993e", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "99ec8667-938d-47da-8d32-1804bfa5eb0e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "98009a3dfdb1c183b9bb2e4b8ba54e353576992be43b689610f8aa702c567461", "class_name": "RelatedNodeInfo"}}, "text": "10.3 Data Management\nHIV data management is a process that includes the collection, collation, analysis, dissemination\nand use of HIV data for planning and implementing HIV services. The data is disaggregated by\nage, sex, location (LGA, state and national), breastfeeding and pregnancy status to improve\ndecision making.\n\n10.3.1 Data Collection\nRoutine HIV data is collected through both paper-based and electronic platforms. Efforts are to\nbe geared towards strengthening the platforms to improve the quality of data.\nPatients' information is collected using 2 types of tools;\n     1. Patient Management and Monitoring (PMM) tools\n     2. Programme Monitoring and Evaluation (PME) tools.\nPMM tools are used to collect data on individual patients and help in improving the management\nof PLHIV. The tools are available at every point of HIV service delivery. This information is\nmonitored over time and enables healthcare providers to assess a patient's response to treatment.\nPME tools are used to track the progress of services provided to PLHIV. The data can be used to\nroutinely monitor and evaluate the effectiveness, efficiency and acceptability of HIV service\nprovision at all levels of healthcare.\n\nHCWs at service delivery points should ensure proper documentation of all HIV services\nprovided. Facility M&E staff are responsible for the collection of data from all service delivery\npoints for monthly reporting.\n\nIn general, the emphasis will be on using the PMM/PME tools to continuously inform HIV\nprogramming. Process and outcome evaluations will be periodically conducted to assess\nprogramme performance for informed decisions.\n\nThe following are current tools used for M&E in the national HIV programme:\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                       182", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1821, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "52101444-081f-432a-85b4-cc74b90f695e": {"__data__": {"id_": "52101444-081f-432a-85b4-cc74b90f695e", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "9e575d79-5c49-4c94-bb0a-1ef813e8298e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "6831ce3866acf4600475e82691ae2dafb023565bd0c5459681febe1e16387d76", "class_name": "RelatedNodeInfo"}}, "text": "Table 10.2: Tools used for M&E in the national HIV programme\n  HTS                                   PMTCT\n  PMM                                   PME\n  -Client Intake form                    - PMTCT Monthly Summary\n  -Request & Result form                  form\n  -Client Referral form                  - General ANC Register\n                                         - PMTCT HTS Register\n                                         -Maternal Cohort Register\n  PME\n  - HTS Register                         -Child Follow-up Register\n  - Daily HIV & Syphilis Test            -Partner Register\n    Worksheet                            -PMTCT Delivery Register\n\n  - Referral Register\n  - HTS Monthly Summary\n    form\n\n\n\n\n\n\n\n\n\n\nART\nPMM\n - Care card\n - Adult Initial Clinical Evaluation\n  form\n - Paediatric Initial Clinical\n  Evaluation form\n - Lab Order & Results form\n - Pharmacy Order form\n - HIV Care & Treatment transfer\n   form\n - Client Tracking & Termination\n   form\nPME\n -Care card\n -Enrolment Register\n -ART Register\n -ART monthly summary form\n -Pharmacy Daily Worksheet\n -HIV Care & Treatment Client\n Tracking Register\n -Post Exposure Prophylaxis\n  Register\n -Cohort analysis report\n\n                   10.3.2 Data Security, Collation & Reporting Flow\n                   Handling of PMM/PME tools requires confidentiality and efficiency to give the clients a sense of\n                   security. A filing system for HIV programme records should be developed and followed within\n                   each facility. All records should be kept confidential and stored in a secure room with lockable\n                   cabinets. Backup records should be secured from damage or loss.\n\n                   At the end of each month, routine HIV programme data should be validated for quality and\n                   collated into monthly summary forms. Completed monthly summary forms should be forwarded\n                   to the Local Government Area (LGA), where data from all the HIV sites in the LGA are collated\n                   and transmitted to the State Ministry of Health and District Health Information System (DHIS).\n                   At State M&E review meetings HIV data should be validated, collated and analysed by all\n                   relevant HIV programme stakeholders. States should in turn forward to the NASCP of the\n                   FMOH.\n\n                   The respective health authorities at the various levels will have responsibility for reporting to the\n                   HIV and AIDS coordinating authorities at the various levels (i.e. health facility to LGA to State\n                   MOH to FMOH).\n\n                   Facilities can now upload information on the monthly summary forms directly on the DHIS.\n                   Validation is conducted by the L.G.A. and the State. The information can be viewed at the local,\n                   state and national level. With the electronic medical record (EMR) system, facilities upload\n                   patient-level data into the National Data Repository (NDR) which can be reviewed for quality at\n                   all levels and analysed by stakeholders. Electronic data record should be stored and secured in a\n\n                                 NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           183", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3330, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "961f114a-5d67-40e9-bfcb-6c822849803a": {"__data__": {"id_": "961f114a-5d67-40e9-bfcb-6c822849803a", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "5e162e99-8488-4256-bd77-719b2e1b2453", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "d9cc4099e8b7ac1ff34c129e506dadfc0a33c99953f90d9ca26064493a429468", "class_name": "RelatedNodeInfo"}}, "text": "passworded device for authorised users and uploaded to secured networks and servers. It is\n recommended that health facilities should migrate to the EMR system.\n                                      HIV Program Datd Flow Chart\n                                                       Naticnal DhIS\n          Tational level                                    Senet\n             State Ievel\n                                                            DHIS 2\n                                                           Catacase\n            LGee\n         Pape Basea Tools                            Patient    evel Data\n                                                    Health Facilities\nFigure 10.1 \u2013 Data Flow Chart for HIV reporting\n\n\n\n   Naticnal Dara\n    Recosttory\n\n\n\n\nElectonic MedicalRecords (FMR)\n\n\n\n                   10.4 HIV Data Dissemination and Use\n                   The significance of data cannot be fully realized until it is disseminated to all relevant\n                   stakeholders for effective planning and decision making. The dissemination of HIV data and\n                   information products will be via regular fact sheets, bulletins, report and official social media\n                   platforms. Also validated data are shared with the states biannually as a way of feedback. Data\n                   use should be encouraged at all levels especially at the health facilities where these data are\n                   generated, to improve patient management and monitoring.\n\n                   10.5 Human Resource for M&E\n                   The relevant human resource for monitoring and evaluation should be employed at all levels to\n                   support data management. The FMOH in collaboration with relevant stakeholders will ensure\n                   training and retraining of healthcare workers, local government and state officers on data\n                   management and use.\n\n                                 NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                       184", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 2044, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "67391fcb-0681-4d2a-8453-919342ff4be9": {"__data__": {"id_": "67391fcb-0681-4d2a-8453-919342ff4be9", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "e46e5154-f662-4841-902b-5bb8b0cc803e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "77c8250e48407cc857fd4bac97ecb799292adefdae7cbb0d4c4f75598c9fc1c4", "class_name": "RelatedNodeInfo"}}, "text": "10.6 HIV M&E Logistics\nNational M&E tools and infrastructure should be made available to all sites delivering HIV\nservices to facilitate service documentation and reporting of routine data. Indicator Reference\nSheets and User Guides should be made available to end-users to aid understanding of\nprogramme indicators and also help in the completion of M&E tools.\n\n10.7 Additional Strategies in M&E\nAs the country makes progress towards epidemic control, the need to put in place innovative\nstrategies in monitoring and evaluating national HIV health sector response has become highly\nimperative. This enables evidence-based planning, resource allocation and decision making in\nline with innovations within the response. Some of the innovative strategies include the\nintroduction of case-based surveillance, mortality surveillance and recency surveillance.\n     \u00a7    The case-based surveillance allows a shift from aggregate reporting to focus on\n          individual follow up from the time of identification of a new case to retention in care and\n          even death. This longitudinal form of data collection is used to track clinical outcomes\n          and monitor the quality of linkage to care.\n     \u00a7    Recency surveillance provides insight into the timeline of an individual's HIV infection.\n          This information is important to public health because of the ability to use such data for\n          targeted interventions, programmatic shifts and to achieve epidemic control.\n     \u00a7    The mortality surveillance also determines the distribution, trends and patterns of\n          leading causes of death attributable to HIV among people receiving ART in the program.\nAdditional M&E tools are being developed to capture data on Recency testing, Self-testing,\nPrEP, AHD and DSD.\n\n10.8 HIV Research\nThe National HIV research policy and agenda seeks to inform HIV implementation and\nformative research that provide evidence-based data to improve the effectiveness and efficiency\nof HIV programme management in Nigeria.\nResearch programmes will be prioritized to identify cost-effective mechanisms for HIV\ntreatment, care, and support. It should also prioritize research that promotes the reduction of\nHIV risk behaviours among key, vulnerable and general populations, enhance prevention\nprogrammes, strengthen basic and implementation research, clinical trials, social science\nresearch and systematic reviews.\n\n10.9 Periodic monitoring of the implementation of the guidelines and content update\nHIV medicine is a dynamic speciality with continuously emerging evidence and innovations that\noptimizes prevention, treatment and care of PLHIV. Consequently, this necessitates periodic\nupdates to these guidelines. In addition, there is also a need to monitor and evaluate the level of\nimplementation of these guidelines at service delivery points with the aim of re-strategizing for\neffective programme implementation. It is recommended that FMOH should take the lead with\nthe support of all stakeholders to ensure regular reviews and update of these guidelines.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           185", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3174, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "f0bdb314-0c25-4cee-a82f-878e7af2b070": {"__data__": {"id_": "f0bdb314-0c25-4cee-a82f-878e7af2b070", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "86df646d-5a16-4909-84f8-fa2221464ae1", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "fe745961b034fbfe8927a67afbf6cc960004bddb2bc6e0ffc78be8110f686d89", "class_name": "RelatedNodeInfo"}}, "text": "List of Contributors                                                                                Chapter 10\nDr Uba Sabo                              Assistant Director, PREP/STI NASCP\nDr Onifade Bodunde                       Senior Medical Officer II, HIV Data Manager NASCP\nMr Adebayo Adesina                       Senior Scientific Officer, M&E NASCP\nDr Yewande Olaifa                        Assistant Director NACA\nDr Tolulope Oladele                      Assistant Director, Health Sector Response Support NACA\nProf. Musa Babashani                     Member NTTA / Physician AKTH Kano\nDr Elon W. Isaac                         Senior Lecturer Paediatrics / College of Medical Sciences,\n                                         GSU Gombe\nChika Obiora-Okafo                       Director Monitoring & Evaluation FHI360\nDr Augustine Idemudia                    Associate Director; Monitoring & Evaluation FHI360\nDr Levy-Braide Boma                      Senior Analyst CHAI\nOmaye Victoria Negedu                    Senior Analyst CHAI\nDr Akanmu                                Analyst CHAI\nMuhammad-Mujtaba\nOlusegun Adewole                         Technical Officer APIN\nDr Abiodun Hassan                        Technical Director FHI360\nDr Chizoba Mbanefo                       Technical Director CRS\nOyedokun Aliu Ope                        Medical Officer II, NASCP\nNkechi Okoro                             M&E Officer NEPWHAN\nIjeoma Amazue                            US DoD\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                               186", "mimetype": "text/plain", "start_char_idx": 1, "end_char_idx": 1592, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "de68bc12-f3a3-4ba9-a052-423a16f2a484": {"__data__": {"id_": "de68bc12-f3a3-4ba9-a052-423a16f2a484", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "22461f09-8be9-4899-bed1-8d44d5b2f745", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "fe52a06321f46e38d355d859777f93c573552a1157461bb60ed72c3e5ad7aeed", "class_name": "RelatedNodeInfo"}}, "text": "REFERENCES\n[1]   World Health Organisation, \u201cConsolidated guidelines on the use of antiretroviral drugs\n      for treating and preventing HIV infection,\u201d WHO, 2016.\n[2]   O. Agbaji , P. Agaba , K. Falang , A. Onu, M. Muazu and J. Idoko, \u201cPredictors of impaired\n      renal function among HIV infected patients commencing highly active antiretroviral\n      therapy in Jos, Nigeria.,\u201d Nigerian Medical Journal. 2011, 2011.\n[3]   O. Agbaji , P. Agaba, A. Ebonyi, Z. Gimba, E. Abene and S. Gomerep, \u201cLong term\n      exposure to tenofovir disoproxil fumarate-containing antiretroviral therapy is associated\n      with renal impairment in an African cohort of HIV-infected adults,\u201d vol. 18, pp. 1-9,\n      2019.\n[4]   World Health Organisation, \u201cGLOBAL TB REPORT,\u201d WHO, 2018.\n[5]   National Population Commission Nigeria, \u201cNigeria Demographic Health Survey,\u201d NPC,\n      2018.\n[6]   National Agency for the Control of AIDS, \u201cNational HIV strategy for adolescents and\n      young people 2016-2020,\u201d NACA, 2016.\n[7]   UNAIDS, \u201c90-90-90 An ambitious treatment target to help end the AIDS epidemic,\u201d\n      UNAIDS, 2014.\n[8]   Federal Ministry of Health Nigeria, \u201cNigeria HIV/AIDS Indicator and Impact Survey,\u201d\n      FMOH, 2018.\n[9]   National Agency for the Control of AIDS, \u201cNATIONAL AGENCY FOR THE Cnational\n      HIV and AIDS Strategic Framework 2017-2021,\u201d NACA, 2017.\n[10]  Eluwa G, Adebajo S, Eluwa T, Ogbanufe O, Ilesanmi O and Nzelu C, \u201cEluwa GIE,\n      Rising HIV prevalence among men who have sex with men in Nigeria: A trend\n      analysis.,\u201d BMC Public Health, vol. 1, no. 19, pp. 1-10, 2019.\n[11]  National Agency for the Control of AIDS, \u201cNational HTS Guidelines,\u201d NACA, 2017.\n[12]  World Health Organisation, \u201cGuidelines for managing advanced HIV disease and rapid\n      initiation of antiretroviral therapy,\u201d WHO, 2017.\n[13]  Federal Ministry of Health, \u201cNational Tuberculosis and Leprosy Control Programme\n      report,\u201d NTBLCP, 2019.\n[14]  World Health Organisation, \u201cGuidelines for the diagnosis, prevention and management\n      of cryptococcal disease in HIV-infected adults, adolescents and children: supplement to\n      the 2016 consolidated guidelines on the use of antiretroviral drugs for treating and\n      preventing HIV infection.,\u201d WHO, 2018.\n[15]  Gomerep S, Idoko J and Ladep N, \u201cFrequency of cryptococcal meningitis in HIV-1\n      infected patients in north central Nigeria.,\u201d Nigerian Journal of Medicine. 2010; 19(4): ,\n      vol. 19, no. 4, p. 395\u2013399, 2010.\n[16]  Oladele R, Jordan A, Akande P, Akanmu S, Akase I and Aliyu S, \u201cTackling cryptococcal\n      meningitis in Nigeria, one-step at a time; the impact of training.,\u201d PLoS One, vol. 15, no.\n      7, 2020.\n[17]  Uneke C, Duhlinska D and Njoku M, \u201cSeroprevalence of acquired toxoplasmosis in\n      HIV- infected and apparently healthy individuals in Jos, Nigeria.,\u201d Parassitologia.\n      2005;47(2):233\u20136., vol. 47, no. 2, pp. 233-6, 2005.\n[18]  Morris A, Lundgren J, Masur H, Walzer P, Hanson D, Frederick T, Huang L, Beard C and\n      Kaplan J,\u201cCurrent epidemiology of Pneumocystis pneumonia,\u201d Emerg Infect Dis., vol.\n      10, no. 10, pp. 1713-20, 2004.\n\n          NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           187", "mimetype": "text/plain", "start_char_idx": 41, "end_char_idx": 3281, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "427a0e62-9e55-4340-a2b0-78399a34799a": {"__data__": {"id_": "427a0e62-9e55-4340-a2b0-78399a34799a", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "a2c686c7-b9b6-4c52-864b-9a0c7e046567", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "1b7034f7bdb06d2680c29bf9f88144407034b9b1f8a6c1973f18524bdc17bc37", "class_name": "RelatedNodeInfo"}}, "text": "[19]  Ogba, Ofonime, Abia-Bassey, Lydia, Epoke and James, \u201cThe relationship between\n      opportunistic pulmonary fungal infections and CD4 count levels among HIV\n      seropositive patients in Calabar, Nigeria,\u201d Royal Society of Tropical Medicine, 2013.\n[20]  Oladele R, Anyanlowo O, Richardson M and Denning D, \u201cHistoplasmosis in Africa: An\n      emerging or a neglected disease? . 2018 Jan 18;12(1):e0006046. doi:,\u201d PLoS Negl Trop\n      Dis, vol. 12, no. 1, 2018.\n[21]  Oladele R, Toriello C, Ogunsola F, Ayanlowo O, Foden P and Fayemiwo A, \u201cPrior\n      subclinical histoplasmosis revealed in Nigeria using histoplasmin skin testing,\u201d PLoS\n      ONE, vol. 13, no. 5, pp. 1-11, 2018.\n[22]  Adeyemi A, Sulaiman A, Solomon B, Chinedu O and Victor I, \u201cBacterial bloodstream\n      infections in HIV-infected adults attending a Lagos teaching hospital,\u201d J Health Popul\n      Nutr, vol. 28, no. 4, pp. 318-26, 2010.\n[23]  Ogunsola F, Arewa D, Akinsete I, Oduyebo O, Akanmu A and Odugbemi T, \u201cAetiology\n      of bacteraemia among adult AIDS patients attending Lagos University Teaching\n      Hospital (LUTH), Lagos, Nigeria.,\u201d Niger Postgrad Med J, vol. 16, no. 3, pp. 186-92,\n      2009.\n[24]  Ford N et al, \u201cManaging Advanced HIV Disease in a Public Health Approach.,\u201d Clinical\n      Infectious Diseases, 2018.\n[25]  Agaba P, Meloni S, Sule H, Agbaji O, Ekeh P, Job G, Nyango N, Ugoagwu P, Imade G,\n      Idoko J and Kanki P, Patients who present late to HIV care and associated risk factors in\n      Nigeria. HIV medicine, vol. 15, no. 7, pp. 396-405, 2014 .\n[26]  World Health Organisation, \u201cLatent TB Infection: Updated and consolidated guidelines\n      for programmatic management.,\u201d WHO, 2018.\n[27]  World Health Organisation, \u201cOperational handbook on tuberculosis: module 1:\n      prevention: tuberculosis preventive treatment,\u201d WHO, 2020.\n[28]  Nakimuli-Mpungu E, Wamala K, Okello J, Ndyanabangi S, Kanters S and Mojtabai R,\n      \u201cProcess Evaluation of a Randomized Controlled Trial of Group Support Psychotherapy\n      for Depression Treatment Among People with HIV/AIDS in Northern Uganda,\u201d\n      Community Ment Health J, vol. 58, no. 3, p.991\u20131004., 2017.\n[29]  Elbrit D, Mahlab-Guri K, Bezalel-Rosenberg S, Gill H, Attali M and Asher I, \u201cHIV-\n      associated neurocognitive disorders (HAND),\u201d Isr Med Assoc J., vol. 17, no. 1, pp. 54-9,\n      2015.\n[30]  World Health Organisation, \u201cConsultation on HIV differentiated service delivery models\n      for specific populations and settings: Pregnant and breastfeeding women, children,\n      adolescents and key populations,\u201d WHO, 2016.\n[31]  Badejo O, Menson W, Sam-Agudu N, Pharr J, Erekaha S and Bruno T, \u201cPediatric to adult\n      healthcare transitioning for adolescents living with HIV in Nigeria: A national survey,\u201d\n      PLoS ONE, vol. 13, no. 6, pp. 1-13, 2018.\n\n          NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                         188", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2927, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "5ddb25d3-af1c-4bd4-bdfd-f6958b74319d": {"__data__": {"id_": "5ddb25d3-af1c-4bd4-bdfd-f6958b74319d", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "31fae95c-ea2d-4a91-b4be-de8419512066", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "5273e6e7ef5415b43eafb44c4fe7b1424d775fb4c84644539be7e62fd5768f71", "class_name": "RelatedNodeInfo"}}, "text": "APPENDIX\n\n1.1 Objectives of the Guidelines\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026..\n1.2 Epidemiology of HIV in Nigeria\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\n1.3 Natural History of HIV\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.\u2026\u2026", "mimetype": "text/plain", "start_char_idx": 19, "end_char_idx": 159, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "0b7b37bf-3793-4e87-9a1d-1a6e13b6104b": {"__data__": {"id_": "0b7b37bf-3793-4e87-9a1d-1a6e13b6104b", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f1540df5-37c1-4232-8633-802ef4e942d0", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "2913f728ea32d1a802a58920537140636d6fabe81ca2937232e27749ad78e6d5", "class_name": "RelatedNodeInfo"}}, "text": "Appendix 1: Commonly used Adult and Paediatric ARV Formulations and Dosage\n\nTable 1.1 Dosages of ARV drugs for adults and adolescents\n  Generic name                                                  Dose\n  Nucleoside reverse-transcriptase inhibitors (NRTIs)\n  Abacavir (ABC)                                                300 mg twice daily or 600 mg once daily\n  Emtricitabine (FTC)                                           200 mg once daily\n  Lamivudine (3TC)                                              150 mg twice daily or 300 mg once daily\n  Zidovudine (AZT)                                              300 mg twice daily\n  Nucleotide reverse-transcriptase inhibitors (NtRTIs)\n  Tenofovir disoproxil fumarate (TDF)                           300 mg once daily\n  Tenofovir alfenamide (TAF)                                    10-25 mg once dailya\n  Non-nucleoside reverse-transcriptase inhibitors (NNRTIs)\n  Efavirenz (EFV)                                               400\u2013600 mg once daily\n  Etravirine (ETV)                                              200 mg twice daily\n  Nevirapine (NVP)                                              200 mg once daily for 14 days followed by 200 mg twice\n                                                                daily\n  Proteases inhibitors (PIs)\n  Atazanavir/ritonavir (ATV/r)                                  300 mg/100 mg once daily\n  Darunavir + ritonavir (DRV/r)                                 800 mg + 100 mg once daily or 600 mg + 100 mg twice\n                                                                daily\n  Lopinavir/ritonavir (LPV/r)                                   400 mg/100 mg twice daily\n                                                                Considerations for individuals receiving TB therapy\n                                                                In the presence of rifampicin, adjusted dose of LPV/r\n                                                                (\u201cDouble dose\u201d LPV 800 mg/ + ritonavir 200 mg twice\n                                                                daily or \u201csuper boosted\u201d with LPV 400 mg/ + ritonavir\n                                                                100 mg twice daily plus additional doses of RTV 300 mg\n                                                                twice daily), with close monitoring. In the presence of\n                                                                rifabutin, no dose adjustment required. Rifapentine\n                                                                should not be used.\n  Integrase strand transfer inhibitors (integrase inhibitors)\n  Dolutegravir (DTG)                                            50 mg once dailyb\n  Raltegravir (RAL)                                             400 mg twice daily\n                                                                Considerations for individuals receiving TB therapy\n                                                                In the presence of rifampicin, adjusted dose of DTG (50 mg\n                                                                twice daily) and RAL (800 mg twice daily), with close\n                                                                monitoring. In the presence of rifabutin or rifapentine, no dose\n                                                                adjustmentis required.\na TAF 25 mg and TAF/FTC/DTG (TAF 25 mg, Emtricitabine 200 mg, Dolutegravir 50 mg fixed dose combination) can be used once daily in\nadolescents living with HIV weighing at least 25 kg.\nb DTG 50 mg and TLD (Tenofovir 300 mg, Lamivudine 300 mg, Dolutegravir 50 mg fixed dose combination) can be used once daily in\nadolescents living with HIV weighing at least 30 kg.\n\n                 NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                   190", "mimetype": "text/plain", "start_char_idx": 6, "end_char_idx": 3874, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "5b859e22-53fb-41b7-b3f3-081336fcc73e": {"__data__": {"id_": "5b859e22-53fb-41b7-b3f3-081336fcc73e", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "2bb659eb-85b9-4d0a-bcaa-6144fec1425b", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "4a89948c59a29124d0dfb9ffad1806c4dbc8e58e8d952a4c747c77fe2c75a3b9", "class_name": "RelatedNodeInfo"}}, "text": "Table 1.2: Dosing of optimal pediatric ARVs\n                     3\u20135.9         6\u20139.9        10\u201314.9       15\u201319.9        20\u201324.9     25\u201329.9        \u226530 kg\n Formulation           kg           kg            kg              kg            kg          kg\n                     A      P     A      P      A      P      A       P      A       P  AM      PM   AM       PM\n                     M     M      M     M      M       M      M       M      M      M\n ABC/3TC                                                                                  1 adult       1 adult\n 120/60mg                                                                                   tab           tab\n scored                 1           1.5             2            2.5             3      (600/300      (600/300\n dispersible                                                                                mg)           mg)\n tablet\n LPV/r 40/10\n mg pellets          2      2     3      3      4      4       5      5       6      6        -             -\n (capsules)\n LPV/r 40/10\n mg granules         2      2     3      3      4      4       5      5       6      6        -             -\n (sachets)\n LPV/r\n 100/25 mg                                      2      1       2      2       2      2   3       3     3       3\n tablets\n 4-in-1\n ABC/3TC/L\n PV/r                2      2     3      3      4      4       5      5       6      6        -             -\n 30/60/40/10\n mg\n (capsules)\n DTG 5 mg\n dispersible            2            3          4      5       -       -      -      -    -       -     -       -\n tablets\n DTG 10 mg\n scored                0.5          1.5             2            2.5          -      -    -       -     -       -\n dispersible\n tablet\n DTG 50 mg               -            -             -              -             1           1             1\n tablet\n TDF/3TC\n (or\n FTC)/DTG                -            -             -              -             -            -            1\n 300/300 (or\n 200)/50 mg\n tablet\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                               191", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2118, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "7ba35358-c6c2-43fc-8966-4104a610c663": {"__data__": {"id_": "7ba35358-c6c2-43fc-8966-4104a610c663", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "6715f99d-56fe-44ab-932e-b6f39f683928", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "80ef03863ac9751319ab2558b3466e793a630d8b08b92f811f97a515e17a7d95", "class_name": "RelatedNodeInfo"}}, "text": "aTable 1.3 Simplified dosing of child-friendly fixed-dose solid formulations for twice-daily dosing in infants and children 4 weeks of age and older\nDrugStrength ofNumber of tablets by weight band morning and eveningStrength ofNumber of\npaediatric tabletsadult tablettablets by\nweight band\n3\u20135.9 kg6\u20139.9 kg10 \u201313.9 kg14 \u201319.9 kg20 \u201324.9 kg25 \u201334.9 kg\n\nAMPMAMPMAMPMAMPMAMPMAMPM\n\nTablet300 mg/150AZT/3T C(dispersible) 60111.51.5222.52.53311mg\nmg/30 mg\nTablet (dispersible)300 mg/150\n60 mg/30 mg/50111.51.5222.52.533mg/11AZT/3TC/ NVP b\nmg200 mg\nTablet600 mg/300(dispersible) 60111.51.5222.52.5330.50.5mg\ncmg/30 mg ABC/3TC\nTablet (dispersible)600 mg/3000.50.50.511111.51.51.50.50.5120/60 mgmg\na For infants younger than 4 weeks of age refer to table 4 for more accurate dosing which is reduced due to the decreased ability to excrete and\nmetabolize medications. For infants who are at least 4 weeks of age but less than 3 kg, immaturity of renal and hepatic pathways of elimination\nare less of a concern but uncertainty still exists on the appropriate dosing of ARVs in preterm and low birth weight infants.b Please note that this regimen and formulation is no longer recommended and should only be used in special circumstances where other age\nappropriate formulations are not available.c This formulation will be phased out of use over time and programs should transition to use of the 120 mg/ 60 mg dispersible scored tablets.\n\n                                      NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                     192", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1583, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "29a769f1-2b7a-4023-a285-947d22463812": {"__data__": {"id_": "29a769f1-2b7a-4023-a285-947d22463812", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "6f0bc367-3c0b-46ac-a591-da8ba6a36785", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "ca543b4e9370be829aed4f158069b9c6bcb186c49b4487ac9546a47063dbd9a1", "class_name": "RelatedNodeInfo"}}, "text": "aTable 1.4 Simplified dosing of child-friendly solid formulations for once-daily dosing in infants and children 4 weeks of age and older\nDrugStrength ofNumber of tablets or capsules by weight band once dailyStrength ofNumber of t ablets\npaediatric tabletadult tabletor capsules by\nweight band once\ndaily\n3\u20135.9 kg6\u20139.9 kg10\u201313.9 kg14\u201319.9 kg20\u201324.9 kg25\u201334.9 kg\nTablet (scored) 200b\u2013\u201311.51.5\u20132EFV mg\nTablet (dispersible)ABC /3TC2345660/30 mg600 mg/300\n1mgTablet (dispersible)\nABC/3TC11.522.53120/60 mg\ncTablet 25 mg\u2013\u2013\u2013\u2013\u201325 mg1TAF\nCapsules 100 mg\u2013\u2013222d300 mg1eATV\nCapsules 200 mg\u2013\u2013111\nTablet 600 mg\u2013\u2013\u201311f600 mg1DRV\nTablet 150 mg\u2013\u2013\u201344\nTablet 25 mg\u2013\u2013\u201344g100 mg1RTV\nTablet 50 mg\u2013\u2013\u201322\nFilm -coated Tableth\u2013\u2013\u2013\u2013150 mg1DTG 50 mg\na See table 1.6 for dosing recommendations for infants younger than 4 weeks old. Doses for this age group are reduced to account for the decreased ability to excrete and metabolize medications. For infants\nwho are at least 4 weeks of age but less than 3 kg, immaturity of renal and hepatic pathways of elimination are less of a concern but uncertainty still exists on the appropriate dosing of ARVs in preterm and\nlow birth weight infants.\nb EFV is not recommended for children younger than 3 years and weighing less than 10 kg.\nc At the time of this update, TAF film coated tablets were approved for children above 6 years by FDA for use in un-boosted regimens such as with DTG. A fixed dose combination containing TAF/FTC/ DTG\n(TAF 25 mg, Emtricitabine 200 mg, Dolutegravir 50 mg fixed dose combination) received tentative approval by US FDA and can be used once daily in children and adolescents living with HIV weighing at\nleast 25 kg.\nd ATV is only approved for use in children 3 months and older. ATV single strength capsules should be administered with RTV 100 mg for all weight bands 10 kg and above. ATV powder formulation has\n\n                                             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                                        193", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2039, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d41c7db8-7093-4ede-9c09-b7a848bda2b6": {"__data__": {"id_": "d41c7db8-7093-4ede-9c09-b7a848bda2b6", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b791b31f-669d-4ee4-8d3b-e3c86b9df924", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "805d2b32ccd1cbcf328ae8d2796cebe8ed78d83dfcae9e2ccc18c22516e1de1d", "class_name": "RelatedNodeInfo"}}, "text": "limited availability in LMIC, but enables administration of ATV to infants and children as young as 3 months. Infants and children 5-15 kg should be administered 200 mg of ATV powder (4 packets, 50 mg/\npacket) with 80 mg of RTV oral solution (1 ml).\nhttps://www.accessdata.fda.gov/drugsatfda_docs/label/2018/021567s042,206352s007lbl.pdf\ne A 300 mg dose for 25-29.9 kg is recommended on the basis of findings from the PRINCE-2 study8\nf DRV in combination with RTV should be used, in children older than 3 years, once daily when this is used without previous exposure to PI. While approved dosing for 30-35kg is 675 mg, preliminary data\nfrom adult studies suggest that even lower DRV doses may be effective, therefore use of 600 mg dose was extended to the entire 25-35 kg weight band.\ng RTV should only be use as a boosting agent in combination with ATV or DRV or to \u201csuper boost\u201d LPV/r when given with concomitant rifampicin for TB (see table 5).\nh At the time of this update, 10 mg and 25 mg DTG film coated tables were approved for children above 6 years by the FDA (35mg FCT for weight 30 to < 40kg, 50mg FCT for weight \u0000 40 kg)8 and by the EMA\n(20mg FTC 15 to < 20, 25mg FCT for 20 to < 30, and 35 FCT for 30 to < 40, 50mg FCT for weight \u0000 40 kg)7 based on data from the IMPAACT 1093 trial.9 Simplified weight band dosing which deviates from\ncurrent US FDA and EMA dosing recommendations is being investigated in the Odyssey trial5 which supports the use of DTG 50 mg FCT dose for all children \u0000 20 kg. In January 2019 the PAWG reviewed\nand discussed unpublished data from the Odyssey trial investigating the use of 50 mg FCT in children weighting 20-25 kg10. The PAWG members acknowledged the short follow up and limited clinical\nexperience, but had no major concerns and agreed with recommending the use of 50 mg FCT from 20 kg, as proposed here. Routine standard toxicity monitoring remains of critical importance in light of the\ncurrent limited experience with this dosing. All children over 20kg receiving 50mg FCT will continue to be followed up in ODYSSEY and toxicity data collected. For adolescents living with HIV weighting\nmore than 30 Kg a fixed dose formulation of TDF 300mg/3TC 300mg/DTG 50mg (TLD) can be used and is preferred\n\n                                                 NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                                                        194", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2449, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "77dd84ef-e107-43fc-9b50-710f7cc03846": {"__data__": {"id_": "77dd84ef-e107-43fc-9b50-710f7cc03846", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "43c4e0ab-39c1-47b7-82d2-b0452209bf06", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "7472911db22d189346b2545367fd0df9e232f8df248714513804856614341d92", "class_name": "RelatedNodeInfo"}}, "text": "aTable 1.5: Simplified dosing of child-friendly solid and oral liquid formulations for twice-daily dosing in infants and children 4 weeks of age and older\nDrugStrength of paedaitricNumber of tablets or MLS by weight -band morning (AM) and eveningStrength ofNumber of\ntablets or oral liquid(PM)adulttablets by\ntabletweight\nband\n3\u20135.9 kg6\u20139.9 kg10\u201313.9 kg14\u201319.9 kg20\u201324.9 kg25\u201334.9 kg\nAMPMAMPMAMPMAMPMAMPMAMPM\nSolid formulations\nTablet (dispersible) 60AZT111.51.5222.52.533300 mg11mg\nTablet (dispersible) 60ABC111.51.5222.52.533300 mg11mg\nTablet (dispersible) 50111.51.5222.52.533200 mg11NVPbmg\nTablet 100 mg/25 mg\u2013\u2013\u2013\u2013212222\u201333\nPellets 40 mg/10 mg2233445566\u2013\u2013\u2013LPV/rc\nGranules 40 mg/10 mg2233445566\u2013\u2013\u2013sachet\nTablet 75 mg\u2013\u2013\u2013\u2013\u2013\u20135555400 mg11DRVd\nTablet 25 mg\u2013\u2013\u2013\u2013\u2013\u20132222RTVe\n100 mg11Tablet 50 mg\u2013\u2013\u2013\u2013\u2013\u20131111\nChewable tablets 25 mg1122334466RALf\n400 mg11Chewable tablets 100 mg\u2013\u2013\u2013\u2013\u2013\u2013111.51.5\n\n                                   NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                            195", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1027, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ea3365ca-cc8b-4001-8241-3e409f072774": {"__data__": {"id_": "ea3365ca-cc8b-4001-8241-3e409f072774", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "476b9c77-09ba-4bef-8b2e-8bff9d32dffb", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "a891a0d18a88731d33f552b7ea8e23fd398a65a49e302455585afe02f8caff5a", "class_name": "RelatedNodeInfo"}}, "text": "Liquid formulations\nAZT10 mg/ml6 ml6 ml9 ml9 ml12 ml12 ml\u2013\u2013\u2013\u2013\u2013\u2013\u2013\nABC20 mg/ml3 ml3 ml4 ml4 ml6 ml6 ml\u2013\u2013\u2013\u2013\u2013\u2013\u2013\n3TC10 mg/ml3 ml3 ml4 ml4 ml6 ml6 ml\u2013\u2013\u2013\u2013\u2013\u2013\u2013\n10 mg/ml5 ml5 ml8 ml8 ml10 ml 10 ml\u2013\u2013\u2013\u2013\u2013\u2013\u2013NVPb\n80/20 mg/ml1 ml1 ml1.5 ml 1.5 ml2 ml2 ml2.5 ml 2.5 ml 3 ml3 ml\u2013\u2013\u2013LPV/rc\n100 mg/ml\u2013\u2013\u2013\u20132.5 ml 2.5 ml 3.5 ml 3.5 ml\u2013\u2013\u2013\u2013\u2013DRVd\nRTV80 mg/ml\u2013\u2013\u2013\u20130.5 ml 0.5 ml 0.6 ml 0.6 ml\u2013\u2013\u2013\u2013\u2013\n10 mg/mL (Oral granules1010for suspension: 1003 mL3 mL5 mL5 mL8 mL8 mL\u2013\u2013\u2013\u2013\u2013RALfmLmL\nmg/sachet)\na See table 1.6 for dosing recommendations for infants younger than 4 weeks old. Doses for this age group are reduced to account for the decreased ability to excrete and metabolize medications. For\ninfants who are at least 4 weeks of age but less than 3 kg, immaturity of renal and hepatic pathways of elimination are less of a concern but uncertainty still exists on the dosing of ARVs in preterm\nand low birth weight infants.\nb NVP dose escalation with half dose for 2 weeks when initiating ART is still recommended to avoid toxicity from high initial NVP levels. However, secondary analysis from the (CHAPAS)-1 trial\nsuggested that younger children have a lower risk of toxicity, and consideration can be given to starting with a full dose11. Please note that this regimen is no longer recommended and should only\nbe used in special circumstances where other age appropriate formulations are not available.\nc LPV/r liquid requires a cold chain during transport and storage. The LPV/r heat-stable tablet formulation must be swallowed whole and should not be split, chewed, dissolved or crushed. Adult\n200/50 tablet could be used for patients 14-24.9kg (1 tab am and 1 tab pm) and for patients 25-34.9kg (2 tab am and 1 tab pm). LPVr pellets formulation should not be used in infants younger than 3\nmonths. More details on the administration of LPVr pellets can be found at https://www.who.int/hiv/pub/toolkits/iatt-factsheet-lopinavir-ritonavir/en/ . This dosing schedule applies to equivalent solid\ndosage forms such as LPVr granules which can be use from 2 weeks of age. Since supply is currently constrained both pellets and granules should be discouraged for children above 14 kg who\nshould receive LPVr 100/25mg tablets instead. Info on LPVr formulations for children available at: https://www.arvprocurementworkinggroup.org/lpv-r-supply\nd DRV, DRV, to be used in children older than 3 years, must be administered with 0.5 ml of RTV 80 mg/mL oral suspension if less than 15 kg and with RTV 50mg (using 25mg or 50 mg solid\nformulation) in children 15 to 30 kg. RTV 100 mg tablets can be used as booster if lower-strength RTV tablets are not available. This is based on limited experience suggesting good acceptability and\ntolerability. But no efficacy data.\ne RTV should only be used at this dose as a boosting agent in combination with ATV or DRV.\nf RAL granules are approved from birth. Feasibility and acceptability of such formulations has not been widely investigated and concerns have been raised regarding administration in resource\nlimited settings. Due to the administration challenges presented by the granule formulation the use of the 25 mg chewable tablets as dispersible has been endorsed by the PAWG for infants and\nchildren older than 4 weeks and weighting at least 3 kg. This was largely based on in vitro data on solubility and bioequivalence between tablets and granules6 as well as considering the limited\navailability of adequate alternatives for this age group. However, findings from a feasibility and acceptability assessment conducted in South Africa demonstrate that administration of RAL granules\nin rural settings is feasible as long as supported with adequate training and counselling.\n\n                                               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                                               196", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3876, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "f3c18737-a320-409e-85a3-131ac33dd781": {"__data__": {"id_": "f3c18737-a320-409e-85a3-131ac33dd781", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "97c626ec-d21a-4d01-bfce-3dec6c6dbee2", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "3e8a270a3fc1a2a2c3e331d7198fd18f3024f3b9b13fb76290373e010f4a746a", "class_name": "RelatedNodeInfo"}}, "text": "aTable 1.6 Drug dosing of liquid formulations in infants less than 4 weeks of age\nDrugStrength of oral liquid2-3 kg3-4 kg4-5 kg\nAMPMAMPMAMPM\nAZT10 mg/mL1 mL1 mL1.5 mL1.5 mL2 mL2 mL\nNVP10 mg/mL1.5 mL1.5 mL2 mL2 mL3 mL3 mL\n3TC10 mg/mL0.5 mL0.5 m L0.8 mL0.8 mL1 mL1 mL\n80/20 mg/mL0.6 mL0.6 mL0.8 mL0.8 mL1 mL1 mL\nLPV/r bGranules 40 mg/10 mg sachet\u2013\u20132222\n10 mg/mLCCC<1 week0.4 mL (once daily)0.5 mL (once daily)0.7 mL (once daily)\n(Oral granules forRALsuspension: 100>1 week0.8 mL0.8 mL1 mL1 mL1.5 mL1.5 mL\nmg/sachet) C\na PK data in preterm infants are available only for AZT; there is limited data and considerable uncertainty of appropriate dosing for NVP, RAL and 3TC in preterm and low birth weight infants. In\naddition, LPV/r solution should not be given to preterm infants until they have reached 42 weeks gestational age, because of the risk of adverse effects that may occur in this population. This guidance\nwill be updated when more evidence is available from ongoing trials.\nb Do not use LPV/r solution in infants aged <2 weeks of age. LPVr pellets should not be used in infants younger than 3 months. More details on the administration of LPVr pellets can be found at\nhttps://www.who.int/hiv/pub/toolkits/iatt-factsheet-lopinavir-ritonavir/en/. Due to lack of clinical data to fully inform the use of LPVr granules in neonates, these dosing recommendations were\ndeveloped on the basis of the current US FDA approval (supporting use of LPVr granules from 2 weeks) and considering the substantial uncertainty which exist particularly for neonates weighting 2-3\nkg. Where no other formulation exist, 1 sachet twice a day could be considered for neonates above 2 weeks who are 2-3 kg in order to minimize the risk of potential toxicity with overdosing.\nc RAL granules for oral suspension should use in neonates of at least 2 kg and be administered in once a day during the first week of life (http://www.merck.com/product/usa/pi_circulars/i/\nisentress/isentress_pi.pdf) and twice a day afterwards.\n\n                                            NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                                        197", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 2184, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "b2d0b90e-a974-41c7-bf69-e1c89c237224": {"__data__": {"id_": "b2d0b90e-a974-41c7-bf69-e1c89c237224", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "5003f484-a420-47b7-bf0b-af833c8c6312", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "336d9fdc72dd5054c745b20f5f7945f867aaae216715697c1bba4731f0d9463a", "class_name": "RelatedNodeInfo"}}, "text": "Appendix 2: Mental Health Screening\n\n   Mental Health Screening for HIV Infected Patients According to the New York state\n                                     Department of Health AIDS Institute\nAll HIV-infected patients should receive baseline and ongoing assessment of the following:\n    \u00b7     Mental health disorders:\n          o     Depression (every visit)\n          o     Anxiety (at least annually)\n          o     Post-traumatic stress disorder (at least annually)\n    \u00b7     Cognitive function (at least annually)\n    \u00b7     Sleep habits and appetite (every visit)\n    \u00b7     Psychosocial status (at least annually)\n    \u00b7     Suicidal/violent ideation (every visit)\n    \u00b7     Alcohol and substance use (at least annually)\n    \u00b7     Screening Questions to Identify Depression in HIV infected patients\n          o     In the past year, were you ever on medication or antidepressants for depression or\n                nerve problems?\n          o     In the past year, was there ever a time when you felt sad, blue, ordepressed for more\n                than 2 weeks in a row?\n          o     In the past year, was there ever a time lasting more than 2 weeks when you lost interest\n                in most things like hobbies, work, or activities that usually give you pleasure n?\n    \u00b7     Screening Questions to Identify Anxiety in HIV infected patients\n          o     In the past year, did you ever have a period lasting more than 1 month when most of\n                the time you felt worried and anxious?\n          o     In the past year, did you have a spell or an attack when all of a sudden you felt\n                frightened, anxious, or very uneasy when most people would not be afraid or\n                anxious?\n          o     In the past year, did you ever have a spell or an attack when for no reason your heart\n                suddenly started to race, you felt faint, or you couldn't catch your breath?\n    \u00b7     Screening Questions to Identify Post Traumatic Stress Disorder in HIV infected patients\n          o     During your lifetime, as a child, or adult, have you experienced or witnessed\n                traumatic event(s) that involved harm to yourself or others?\n          o     If \u201cyes\u201d:\n    \u00a7     In the past year, have you been troubled by flashbacks, nightmares, or thoughts of the\n          trauma?\n          o     In the past 3 months, have you experienced any event(s) or received information that\n                was so upsetting it affected how you cope with everyday life?\n    \u00b7     Screening Questions to Identify Mania in HIV infected patients\n    \u00b7     In the past year, when not high or intoxicated, did you ever feel extremely energetic or\n          irritable and more talkative than usual?\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                              198", "mimetype": "text/plain", "start_char_idx": 39, "end_char_idx": 2884, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "2e3e7253-94de-41bc-a782-aea43a47f743": {"__data__": {"id_": "2e3e7253-94de-41bc-a782-aea43a47f743", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "63289e26-a5b4-4db2-af96-98ec8e10012f", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "3d4638abcc25dcf20f10b6f9dc5aa4c0b024e23b9194e7a50937e2678f3cf78f", "class_name": "RelatedNodeInfo"}}, "text": "Appendix 3: Energy and Nutritional Recommendations for PLHIV\n                         Energy and Nutritional Recommendations for PLHIV\n\nMACRONUTRIENT INTAKE\nNormal Energy Requirements for Health:\nCarbohydrates - 45% to 65% of total energy intake\nProtein             - 10% - 30% of total energy intake\nFat                 - 20% to 35% of total energy intake\nChildren                                   Adults                                       Pregnant and Lactating Women\nA 10% increase in energy                   A 10% increase in energy intake              The recommended energy intake\nintake is recommended to                   is recommended to maintain                   for HIV-infected adolescents and\nmaintain growth in                         body weight and physical                     pregnant and lactating women\nasymptomatic children.                     activity in asymptomatic HIV-                should be the same as their HIV\n                                           infected adults                              negative counterparts\nA 50% - 100% increase in                   A 20% - 30% increase in energy               Additional energy requirement\nenergy intake over established             intake is recommended during                 during pregnancy and lactation:\n                                                                                        1st Trimester = 90kcal/day\nrequirements for healthy                   symptomatic disease or                        nd Trimester = 300kcal/day\nuninfected children is                     opportunistic infections to                  2rd Trimester = 450kcal/day\nrecommended in children who                maintain body weight                         3\nhave weight loss                                                                        Lactation = 500kcal/day\nMICRONUTRIENT INTAKE\nPeople LHIV require extra vitamins and minerals to help repair and heal damaged cells. Consumption of a\nhealthy diet may be insufficient to correct nutritional deficiencies in PLHIV and supplementation may be\nrequired. The following vitamins can be found in the foods listed:\n  \u00b7    Vitamin A and beta-carotene: dark green, yellow, orange, or red vegetables and fruit; liver; whole\n       eggs; milk\n  \u00b7    Vitamins B: meat, fish, chicken, grains, nuts, white beans, avocados,broccoli, and green leafy\n       vegetables\n  \u00b7    Vitamin C: citrus fruits\n  \u00b7    Vitamin E: green leafy vegetables, peanuts, and vegetable oils\n  \u00b7    Selenium: whole grains, nuts, poultry, fish, eggs, and peanut butter\n  \u00b7    Zinc: meat, poultry, fish, beans, peanuts, milk and other dairy products\nChildren                                     Pregnant and Lactating Women\nVitamin A Supplementation                    Vitamin A Supplementation\nIn keeping with WHO                          Daily vitamin A intake by HIV-infected women during pregnancy\nrecommendations,                             and lactation should not exceed the RDA.\n6 month to 60 month-old                      In areas of endemic vitamin A deficiency, a\nexposed/infected children born to            single high-dose of vitamin A (200 000 IU) is recommended to be\nHIV-infected mothers living in               given to women as soon as possible after delivery, but no later than\nresource-limited settings should             six weeks after delivery.\nreceive periodic (every 4\u20136                  Iron Folate Supplementation\nmonths)                                      To prevent anaemia, WHO recommends daily iron-folate\nvitamin A supplements (100,000               supplementation (400 \u0000g of folate and 60 mg of iron) during six\nIU for infants 6 to 12 months and            months of pregnancy, and twice-daily supplements to treat severe\n200,000 IU for children >12                  anaemia. Available data do not support a change in this\nmonths)                                      recommendation for women living with HIV\n\n             NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                               199", "mimetype": "text/plain", "start_char_idx": 15, "end_char_idx": 4085, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "fdafd5d5-6dbe-4e41-8185-7386c7a7b618": {"__data__": {"id_": "fdafd5d5-6dbe-4e41-8185-7386c7a7b618", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "ddccfc66-d4f1-4b6e-beb4-daa93da5e2b2", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "a4ae050283c395c16c54a72f4fd76de648fb3ca842e9c9d1eafc66ca659a6fb2", "class_name": "RelatedNodeInfo"}}, "text": "Appendix 4: Recommended activities for adolescent HIV service delivery\n\n   Recommended activities for adolescent HIV service delivery aligned with the global\n                        standards for quality of health-care services for adolescents\n\nGlobal standard                 Description                                  Recommended activities\n\n 1. Adolescents\u2019                 The health facility implements                    Training of peer supporters and adolescents living with\n     health literacy             systems to ensure that                            HIV(ALHIV)in HIV prevention, sexual and\n                                 adolescents are knowledgeable                     reproductive health, mental health and life skills\n                                 about their own health and they                   Developing job aides on HIV testing, care and\n                                 know where and when to obtain                     treatment, viral load monitoring, adherence counselling\n                                 health services                                   and contraceptive information and provision specific to\n                                                                                   adolescents\n                                                                                   Peer supporters and treatment literacy staff address\n                                                                                   HIV knowledge and adherence concerns of adolescents\n 2. Community                    The health facility implements                    Facilities create strong linkages with bi-directional\n     support                     systems to ensure that parents,                   referral to community-based services such as orphans\n                                 guardians and other                               and vulnerable children (OVC), gender-based violence\n                                 community members and                             prevention and support, social and legal protection,\n                                 community organizations                           vocational training etc. through partnerships\n                                 recognize the value of providing                  Facilities and relevant community-based organizations\n                                 health services to adolescents                    (CBOs) establish formalized relationships (e.g. through\n                                 and support such provision and                    memoranda of understanding) for shared implementation,\n                                 the utilization of services by                    monitoring and reporting whenever feasible\n                                 adolescents\n                                                                                   Facilities participate and support the training of\n                                                                                   community service providers as appropriate\n                                                                                   Provision of community -based support for both ALHIV\n                                                                                   and their caregivers\n                                                                                   Conducting sensitization sessions within schools to\n                                                                                   eliminate stigma and promote testing, adherence and\n                                                                                   retention by school attending ALHIV\n\n 3. Appropriate                  The health facility provides a                    Standard operating procedures and job aids developed\n     package of                  package of information,                           and implemented to provide standard and simplified\n     services                    counselling, diagnostic,                          information on the package of services for adolescents\n                                 treatment and care services                       Constitute a multidisciplinary mentorship team on\n                                 that fulfils the needs of all                     capacity-building for the needs of the adolescents\n                                 adolescents. Services are\n                                 provided in the facility and\n                                 through referral links and\n                                 outreach\n\n                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                              200", "mimetype": "text/plain", "start_char_idx": 12, "end_char_idx": 4718, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "36785430-75b6-40a2-96f4-9faaa41c6d12": {"__data__": {"id_": "36785430-75b6-40a2-96f4-9faaa41c6d12", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "705ee283-1407-4a5d-918c-3095ad7f5e0d", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "8c14a42ba9b45ed14b7946f6a0d83f26fabc45b8a7bb34d29860ca9cfd671092", "class_name": "RelatedNodeInfo"}}, "text": "4. Providers\u2019                    Health-care providers                          Development of training curriculum for facility and\n    competencies                 demonstrate the technical                      community health care workers, training curriculum for\n                                 competence required to provide                 peer educators, and adolescent club guide\n                                 effective health services to                   Trainingofhealth-care workers at service delivery points\n                                 adolescents. Health-care                       on providing adolescent-friendly health services within\n                                 providers and support staff                    an integrated service package\n                                 respect protect and fulfil\n                                 adolescents\u2019 rights to                         Regular meetings, on-site support and mentorship, and\n                                 information, privacy,                          refresher workshops\n                                 confidentiality, non-\n                                 discrimination, non-judgmental\n                                 attitude and respect\n5. Facility                      The health facility has                        Age band clinic appointment and flexible opening hours\n    characteristics              convenient operating hours, a                  outside regular clinic hours, such as evenings or\n                                 welcoming and clean                            weekends or school holidays to facilitate convenience\n                                 environment and maintains                      A safe space for adolescent HIV care and psychosocial\n                                 privacy and confidentiality. It has            support discussions, and peer interactions\n                                 the equipment, medicines,\n                                 supplies and technology needed                 This could be designated spaces or multi-use spaces\n                                 to ensure effective service                    with time allotments\n                                 provision to adolescents                       Scheduling of multidisciplinary teams to provide\n                                                                                various services including counselling, antiretroviral\n                                                                                medicine refill, viral load testing\n                                                                                Development and adherence to infection prevention\n                                                                                and control policies\n\n6. Equity and                    The health facility provides                   Services provided free of charge with no out-of-pocket\n    nondiscriminatio             high-quality services to all                   expenses\n    n                            adolescents regardless of their                Client satisfactory survey done periodically to\n                                 ability to pay, age, sex, marital              get feedback for improvement\n                                 status, education level, ethnic\n                                 origin, sexual orientation or                  Involvement and collaboration by multi-layered\n                                 other characteristics                          and multisectoral agencies, including social\n                                                                                protection services and government health\n                                                                                ministries/agencies at all levels\n7. Data and quality              The health facility collects,                  Develop and implement standard data collection tools\n    improvement                  analyses and uses data on                      at the facility level and a reporting template that\n                                 service utilization and quality                capture age, sex and outcomes\n                                 of care, disaggregated by age                  Establish quality improvement teams at health\n                                 and sex, to support quality                    facilities and build their capacity to use data\n                                 improvement. Health facility\n                                 personnel are supported in                     Quality improvement teams to routinely review\n                                 participating in continual                     disaggregated data, identify, test and implement\n                                 quality improvement                            appropriate solutions\n\n                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                            201", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 5003, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "9c932005-cfed-492b-9d4e-a703f695ccb3": {"__data__": {"id_": "9c932005-cfed-492b-9d4e-a703f695ccb3", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "d46930cc-683c-4bc4-9ef9-91c4bb0de7dd", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "0edc6a90a0b8f458011bffa9e9b542b50b9ac879def9e47c9a40fbeaeba007e8", "class_name": "RelatedNodeInfo"}}, "text": "8. Adolescents\u2019                  Adolescents are involved in                    Involvement of peer supporters/educators in relevant\n     participation               planning, monitoring and                       facility health team activities and meetings such as\n                                 evaluating health services and                 case reviews and advocacy for adolescent-friendly\n                                 in decisions regarding their                   health services\n                                 care and in certain appropriate                Training of peers to be self-health managers, to\n                                 aspects of service provision                   motivate self and others and to be a source of positive\n                                                                                peer pressure to others\n                                                                                Developing viable and effective mechanisms for\n                                                                                harnessing input and feedback from adolescents on the\n                                                                                planning, implementation, monitoring and evaluation\n                                                                                of services provided\n\n                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                           202", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 1496, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "33db7fc4-8365-4269-9fb4-860dc093aa64": {"__data__": {"id_": "33db7fc4-8365-4269-9fb4-860dc093aa64", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "21f752b9-47bb-458e-a8ef-86bff0d7b7a5", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "e161512a23956be3037eecbd8552bff21525255b6f34fbf13c82f0d2c95852cf", "class_name": "RelatedNodeInfo"}}, "text": "Appendix 5: Guide on Age Appropriate Disclosure for Children and Adolescents\n\n                      Guide on Age-Appropriate Disclosure for Children and Adolescents\n\nAge characteristics                Stage of            Provider Action\n                                   Disclosure\n\n0 - 4 years                        No                  At this stage, no disclosure is done since the child is too young to understand\n                                   disclosure          about HIV\n\n5 - 8 years                        Partial             At this age , the child can understand a lot. Define the virus as a germ and\n                                   disclosure          the CD4+ as the soldier in the body that keep fighting and one has to take\n                                                       the drugs to strengthen the soldiers in the body\n\n                                                       Full disclosure is important since most children at this stage a                   re able to\n                                                       understand more about HIV and would have heard about HIV as part of\n                                                       formal education at school\n                                                       Follow the following stages in the disclosure process\n                                                       Stage 1\n                                                       Assessing the child social support system to ensure                     the availability of\n                                                       sufficient support once disclosure is completed\n                                                       Stage2\n                                   Full                Assess the child's prior knowledge about HIV/ AIDS including information\n                                   disclosure          given at school, any myths and misconceptions. Offer or reinforce accurate\n                                                       information\n                                                       Stage 3\n                                                       Use an imaginary exercise or story to assess a child's reaction to disclosure\n9 to 12 years                                          of HIV status\n                                                       Stage4\n                                                       Tell the child about their HIV status. Support parents to disclose to the child\n                                                       and clarify the mode of infection.\n                                                       Address immediate reaction and concerns a child might have\n\n                                   Post-               Find out from the parent/guardian if they have observed anything after\n                                   disclosure          disclosure, e.g. behaviour change:\n                                   (3-6 months              \u2022 Introduce the child to tell their story and emerge as a hero (a comic\n                                   after full                book may be a useful aid)\n                                   disclosure)              \u2022 Link the child to a support group or with an older child who has been\n                                                             disclosed to\n                                                       NB: Find out how the child is doing at every visit after full disclosure\n\n                NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                               203", "mimetype": "text/plain", "start_char_idx": 6, "end_char_idx": 3602, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "39230fd2-7c76-4039-8c20-2d736ce71ed0": {"__data__": {"id_": "39230fd2-7c76-4039-8c20-2d736ce71ed0", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "c637d363-62f9-44f6-b880-252ab09fc04e", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "8dd9078b19ffa6d2dcdc7e86d03e4f13981d251a52618aa3e33c8b04f3438471", "class_name": "RelatedNodeInfo"}}, "text": "Appendix 6: Self-management timeline for transitioning ALHIV\n\n                             Self-management timeline for transitioning ALHIV\n\nAge                        From 10-12 years                    From 13-16 years            From 17-19 years             (Capacity to\n                           (Envisioning a future)              (Working towards            transition)\n                                                               responsibility)\nIndividual growth and environmental support: Encouraging healthy decisions\n\nPsycho-social                  \u00b7    Link to relevant           \u00b7    Link to relevant       \u00b7    Link to relevant support groups\nsupport                             support groups and              support groups and          and programs\n                                    programs                        programs               \u00b7    Support mentorship of younger\n                                                                                                positive adolescents\n\nSexual and                     \u00b7    Answer any                 \u00b7    Link to an             \u00b7    Continue sexuality\nreproductive health,                questions that                  adolescent-friendly         conversations, encourage\npositive health and                 emerge honestly                 reproductive health         questions about HIV, pregnancy,\nprevention                          and truthfully                  provider and clinics,       and sexuality\n                                                                    review sexuality       \u00b7    Refer for regular sexual health\n                                                                    issues and safe sex         check-ups\n                                                                    practices\n                                                               \u00b7    Refer for regular      \u00b7    Discuss HIV prevention methods\n                                                                    sexual health check-\n                                                                    ups\n                                                               \u00b7    Discuss HIV\n                                                                    prevention methods\n\nSubstance use                  \u00b7    Discuss substance          \u00b7    Discuss the links      \u00b7    Discuss the links between\n                                    use and how it can              between sexually            sexually risky behaviours and\n                                    impact health                   risky behaviours,           substance abuse, and poor health\n                                                                    substance abuse, and        outcomes; assess if using\n                                                                    poor health                 substances and what triggers use\n                                                                    outcomes; assess if\n                                                                    using substances and\n                                                                    what triggers use\n\nFuture planning                \u00b7    Initiate                   \u00b7    Promote peer           \u00b7    Connect ALHIV to job training,\n                                    conversation about              education                   vocational training, and\n                                    future goals (work,             opportunities               continued education\n                                    school, etc.)              \u00b7    Connect ALHIV               opportunities\n                                                                    with relevant NGOs\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                 204", "mimetype": "text/plain", "start_char_idx": 18, "end_char_idx": 3856, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "dffbb00b-d07a-44fe-aafe-e25c5445acb5": {"__data__": {"id_": "dffbb00b-d07a-44fe-aafe-e25c5445acb5", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "1f1cd899-6ca5-4838-897e-c748e5290c49", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "f17c1e26fcf17cdd04da1079b6676d3739e766efc0134346b1bf3935fe50b76f", "class_name": "RelatedNodeInfo"}}, "text": "Clinical support: Providing or facilitating referrals for needed services\n\nSelf-care                       \u00b7    Support caregivers           \u00b7     Build a                \u00b7  Reinforce responsibility in\n                                     to disclose to the                 schedule/calendar         taking medications and keeping\n                                     adolescent if not                  with the adolescent       appointments\n                                     already done                       to strengthen\n                                \u00b7    Talk to the child to               adherence to\n                                     start mapping out                  treatment and\n                                     the transition                     retention\n                                     timeline after               \u00b7     Discuss and address\n                                     disclosure                         transport barriers\n                                                                        and other issues that\n                                                                        hinder Clinic and\n                                                                        ART adherence\n\nClinical                        \u00b7    Talk about HIV               \u00b7     Talk to the            \u00b7  Help identify appropriate adult\nmanagement                           and prevention                     adolescent about          providers/clinics\n                                     measures                           diagnosis,             \u00b7  Solicit questions about care,\n                                \u00b7    Begin to explain                   medications,              treatment, and potential future\n                                     medications and                    appointment keeping       changes in treatment\n                                     reinforce adherence                and adherence\n                                     messages                     \u00b7     Talk to adolescent     \u00b7  Link to counselling (including\n                                                                        about how to seek         lay or peer) for any mental\n                                \u00b7    Talk about                         clinical care for         health issues\n                                     adherence issues                   symptoms or            \u00b7  . Ensure that viral load\n                                \u00b7    Link to counselling                emergencies               suppression (<1000 copies/ml) is\n                                     (including lay or            \u00b7     Link to counselling       achieved within the last one year\n                                     peer) for any                      (including lay or         prior to completion of\n                                     mental health                      peer) for any mental      transitioning to adult care\n                                     issues                             health issues          \u00b7  Follow up with transitioned\n                                                                  \u00b7     Orient adolescent in      adolescents6 months to ensure\n                                                                        adult clinic              adherence and retention in care\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                      205", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 3462, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "cde173cc-b66e-4174-92e6-9b44d63973b1": {"__data__": {"id_": "cde173cc-b66e-4174-92e6-9b44d63973b1", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "b35122a1-f71a-4c93-bf05-c0ee0c3ae107", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "aeedd44b868206d4a4d4532a1eb32e00af3ca822ce2ff08412e365568cb4b328", "class_name": "RelatedNodeInfo"}}, "text": "Appendix 7: Algorithm for Screening and Diagnosing TB in PLHIV\n\n                     Figure 7.1: Algorithm for Screening Children aged \u2265 1 year living with HIV\n                                                    for TB Preventive Therapy\n\n                                        Children aged         \u2265 12 months\n                                        living with HIV *\n\n                         Screen for TB with a           ny one of the following symptoms:\n                                           Weight loss or poor weight gain\n                                                               Fever\n                                                        Current cough\n                                     History of contact with a person with TB\n\n                      No                                                                                Yes\n\n   Assess for contraindications to TPT                                      Investigate for TB and other diseases\n\n         No                            Yes                       Other Diagnosis                     Not TB                    TB\n\n                                  Defer TPT                      Give                            Follow up                  Treat\n                                  until                          Appropriate                     and                        for TB\n   Administer                     problem                        Treatment                       consider\n         TPT                      resolved                       and consider                    TPT\n                                                                 TPT\n\n                                Screen regularly for TB at each encounter with the patient\n\n *All infants <1 year should only be given TPT if they have a history of household contact with a TB caseand do not have active TB after\nevaluation\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                    206", "mimetype": "text/plain", "start_char_idx": 19, "end_char_idx": 2039, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "1d6c64c9-99b0-420f-a83e-3eb49fb1a8df": {"__data__": {"id_": "1d6c64c9-99b0-420f-a83e-3eb49fb1a8df", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "39ef4b5d-f2de-49b2-ba03-06e311d1631a", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "edaf52960e69ae71a6f25e8809c9de5b4312671f1b512ea5a25f6f4600621466", "class_name": "RelatedNodeInfo"}}, "text": "Figure 7.2: Algorithm for screening Adult and Adolescent Living with\n                            HIV(including pregnant PLHIV) for TB Preventive therapy\n\n                                                   All Adults and\n                                        Adolescents living with HIV\n\n                          Screen for TB with any one of the following symptoms:\n                                                  Current cough\n                                                        Fever\n                  No                                Weight loss                                 Yes\n                                                   Night sweats\n\n                  No                                                                            Yes\n\n  Assess for contraindications to TPT                                    Investigate for TB and other\n                                                                          diseases\n\n      No                           Yes                            Other                       No t TB      TB\n                                                               Diagnosis\n\n                               Defer TPT                     Give                          Follow up\n                               until                         Appropriate                   and         Treat\nAdminister                     problem                       Treatment                     consider\n      TPT                      resolved                      and consider                  TPT         for TB\n                                                             TPT\n\n                     Screen regularly for TB at each encounter with the patient\n\n            NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                    207", "mimetype": "text/plain", "start_char_idx": 22, "end_char_idx": 1833, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "f853fd4c-f9e8-4061-9033-2f07bd56b8a9": {"__data__": {"id_": "f853fd4c-f9e8-4061-9033-2f07bd56b8a9", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "0bd12f60-4e63-4315-aa79-01a63a4413a5", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "32ed1339e00e667c06a0e99dd809461a40b83a8dec62ef334fda0ee70c9851a5", "class_name": "RelatedNodeInfo"}}, "text": "Figure 7.3: Algorithm for Diagnosing TB in Children and Adolescent\n\n    Presume TB in a child living with HIV if any of the following is present:\n    a. Current cough\n    b. Unexplained fever\n    c. Weight loss or failure to gain weight\n    d. History of contact with an adult TB\n    e. Features of Extra-pulmonary TB\n\n                                                                    If specimen is available:\n                                                                    \u2022 Collect appropriate specimen (e.g. sputum, stool,\n                                                                     lymph node/gastric aspirate, cerebrospinal fluid,\n                                                                     abscess/pus and other body fluids) for Xpert\n                                                                     MTB/RIF assay OR collect sputum only for\n                                                                     Truenat MTB/RIF test\n\n   If specimen is unavailable (e.g.                                                              MTB                       MTB\n   presumptive EPTB) or MTB not detected *:                                                      detected,                 detected,\n   1. History of contact with TB patient or                               MTB not                RIF                       RIF\n       positive Mantoux test                                              detected               resistance                resistance\n   2. Physical signs suggestive of TB                                                            not detected              detected\n   3. TB suggestive imaging features (e.g.\n       chest x -ray and computed tomography\n       scan)                                                                                   Treat as Drug             Inform State\n                                                                                               Susceptible               TB\n    If only one of three features                       If two or more                         TB (DS-TB)                Programme\n    present                                             features present **                    if child is not           and LGA\n                                                                                               a contact of              Supervisor\n                                                                                               DR-TB case                to initiate\n    If child is ill:                          If child is well:                                ***                       DR-TB\n    Refer to Medical Officer                  Review after 2 - 4 weeks                                                   Treatment\n\n  Presume DR-TB if in addition to symptoms of TB, the child has any of the under -listed risk factors:\n    Close contact with confirmed DR -TB patients\n    Close contact with patient that died from TB, failed or is not adherent to TB treatment\n    History of previous TB treatment (in the past 6 - 12months)\n    Not improving after 2 months of DS-TB treatment\n\n*Clinical diagnosis is recommended if all effort at bacteriological c confirmation using\n  Xpert MTB/RIF assay/Truenat test (or Urine LF- LAM assay in PLHIV with advanced disease) is not possible\n** In settings where there is no doctor (e.g. hard to reach areas), the trained health care\n   worker can make a diagnosis of TB and commence anti -TB treatment..\n***Treat as DR-TB if child is a contact of DR-TB case\n\n               NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                     208", "mimetype": "text/plain", "start_char_idx": 27, "end_char_idx": 3684, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "da148e4a-83d0-4fc4-a073-7d3aab17a533": {"__data__": {"id_": "da148e4a-83d0-4fc4-a073-7d3aab17a533", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "20635d72-9797-4998-90e5-b8f275cf77f7", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "d8d40bfebdb1bbc049228b920d211b741f1dc8de7e870c2374ed267f06e52182", "class_name": "RelatedNodeInfo"}}, "text": "Figure 7.4: Algorithm TB in Diagnosis in Adults\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020             209", "mimetype": "text/plain", "start_char_idx": 26, "end_char_idx": 153, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "935fccc8-eebf-4d27-bcef-dd4fa4e5a7bf": {"__data__": {"id_": "935fccc8-eebf-4d27-bcef-dd4fa4e5a7bf", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "c444cf44-e1d3-4ea6-896a-c69d53ba8953", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "29fe8227cb4b239f39a73f4a4d4b10ea1f325f70532115ded73af9ca9e6a8e86", "class_name": "RelatedNodeInfo"}}, "text": "Appendix 8: Global Standards for Quality Health-Care Services for Adolescents\n\nEight global standards define the required level of quality in the delivery of services as shown in\nthe table below. Each standard reflects an important facet of quality services, and to meet the\nneeds of adolescents all standards need to be met. This section presents each of these standards\nand its criteria, categorized as input, process and output criteria.\n\n   Adolescents\u2019                  Standard 1-The health facility implements systems to ensure that\n   health literacy               adolescents are knowledgeable about their own health, and know where and\n                                 when to obtain health services.\n   Community                     Standard 2-The health facility implements systems to ensure that parents,\n   support                       guardians and other community members and community organizations\n                                 recognize the value of providing health services to adolescents and support\n                                 such provision and the utilization of services by adolescents.\n   Appropriate                   Standard 3-The health facility provides a package of information,\n   package of                    counselling, diagnostic, treatment, and care services that fulfils the needs\n   services                      of all adolescents. Services are provided in the facility and through referral\n                                 linkages and outreach.1\n   Providers\u2019                    Standard 4-Health-care providers demonstrate the technical competence\n   competencies                  required to provide effective health services to adolescents. Both healthcare\n                                 providers and support staff respect, protect and fulfil adolescents\u2019 rights to\n                                 information, privacy, confidentiality, non-discrimination, non-judgmental attitude,\n                                 and respect.\n   Facility                      Standard 5-The health facility has convenient operating hours, a\n   characteristics               welcoming and clean environment and maintains privacy and\n                                 confidentiality. It has the equipment, medicines, supplies, and technology\n                                 needed to ensure effective service provision to adolescents.\n   Equity and non -              Standard 6-The health facility provides quality services to all adolescents\n   discrimination                irrespective of their ability to pay, age, sex, marital status, education level,\n                                 ethnic origin, sexual orientation, or other characteristics.\n   Data and quality              Standard 7- The health facility collects, analyses and uses data on service\n   improvement                   utilization and quality of care, disaggregated by age and sex, to support\n                                 quality improvement. Health facility staff is supported to participate in\n                                 continuous quality improvement.\n   Adolescents\u2019                  Standard 8-Adolescents are involved in the planning, monitoring, and\n   participation                 evaluation of health services and in decisions regarding their own care, as\n                                 well as in certain appropriate aspects of service provision.\n 1 Service provision in the facility should be linked, as relevant, with service provision in referral level health facilities, schools, and other\n community settings.\n\n                 NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                                                    210", "mimetype": "text/plain", "start_char_idx": 7, "end_char_idx": 3700, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c3f573c9-744b-4218-9d56-e7d22b77f41e": {"__data__": {"id_": "c3f573c9-744b-4218-9d56-e7d22b77f41e", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "18dd116c-a660-477c-b628-93aa921cdceb", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "017e45084eed214ce51bd56b070691eb885f0b417849baf0bb2b6a353eee29e1", "class_name": "RelatedNodeInfo"}}, "text": "Appendix 9: Pharmacovigilance or Drug and Therapeutic Committees (PVC)\n                                               - Terms of Reference\n\nThere should be the existence of a functional Pharmacovigilance or drug and therapeutic\ncommittee at the facility level, which meets regularly to provide oversight, review all the\ndocumented/reported cases of ADRs and advise on the management of such patients. The\ncommittee should be comprised minimally of a clinician, Pharmacist, Nurse, Adherence\ncounselor, and a Lab scientist; may also include data/record officer, Mentor mother and other\nsupport staff where available.\n\nTerms of Reference of the PVC or DTC\nThe Pharmacovigilance or Drug and Therapeutic committee will hold regular meetings in\npursuant of their roles and responsibilities as stated below. If necessary, the committee will need\nto enforce mandatory attendance to accomplish the functions of the committee. Minutes and\nMOVs need to be prepared for each meeting and distributed to the appropriate departments.\nFinally, all goals, terms of reference, policies, decisions, and other actions of the PVC or DTC\nshould be documented, and the records kept.\n\nRoles and Responsibilities\nThe responsibilities of the PVC or DTC include but are not limited to \u2013\n     1.    Medication advisory role to the facility\n          \u2013     On VL optimization and results review, pharmacovigilance & management\n                activities, regimen switch and substitutions decisions etc.\n     2.    Identifying drug use problems and promoting rational drug use.\n           \u2013    Through examinations of reports such as Medication error reports; Drug-drug\n                interactions; VL reports for treatment failure (unsuppressed clients to be considered\n                for EAC and decision to switch); ADR reports, etc.\n     3.    Promoting interventions that improve drug use such as education program (e.g., CME,\n           bulletin publication, in-service training) and managerial program (such as conduct Drug\n           Use evaluation).\n     4.    Promoting pharmacovigilance activities by encouraging, monitoring, assessing,\n           reporting, and prevention of ADRs and other medication related problems:\n           \u2013    To review the availability and adequacy of tools (ADR Screening form, NAFDAC\n                yellow/ADR reporting form), and the skills of HCWs to monitor and report ADR at\n                the facility.\n           \u2013    Liaise with supporting Implementing Partners, state LMCU, or other partners to\n                address identified gaps in Pharmacovigilance monitoring and reporting at the\n                facility level.\n           \u2013    Ensure the documentation, collation, and routine reporting of identified ADRs from\n                the facility to the National Pharmacovigilance Centre (NPC) managed by\n                NAFDAC.\n           \u2013    Provide guidance to community pharmacies and other out of facility DSD models, to\n                ensure that the capacity and tools are available to monitor and report ADRs among\n                the patients they serve.\n\n              NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020                           211", "mimetype": "text/plain", "start_char_idx": 8, "end_char_idx": 3205, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "1815b7d3-b8ac-47bc-8015-f7f194094ff5": {"__data__": {"id_": "1815b7d3-b8ac-47bc-8015-f7f194094ff5", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "excluded_embed_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "excluded_llm_metadata_keys": ["file_name", "file_type", "file_size", "creation_date", "last_modified_date", "last_accessed_date"], "relationships": {"1": {"node_id": "f8c7f3b1-d276-4512-b1af-1adc0b23139f", "node_type": "4", "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": "application/pdf", "file_size": 13919171, "creation_date": "2024-08-08", "last_modified_date": "2024-08-08"}, "hash": "56de0c6d52f7d7db9cde04ed2dab3b65dba1eee1fbf236763627c137e39ce185", "class_name": "RelatedNodeInfo"}}, "text": "Appendix 10: NAFDAC ADR Form\n   ANNEXURE                                                            PVPMS-003-01\nNational Agency for Food und Drug\nAdministration and Control (NAFDAC\nCorporate Headquaren\nPlot 2032 Olusegun Obasanjo\nWuse Zone     Abuja                                                                 NAFDAC\n                                                                        National Pharmacovig lance Centre\n          PATIENT INFORMATION\n     Pattent\" $ Full Name    Inltfab (In Confidencc)\n                                                                                 Weight (kg)\n                                                   Female\n                                                   Male\n   Or Date =  Birth (eg 03 May 1925)\n\n\n   Hospital Treatment Centre                                        Patient\n                                                                    Rercord No\n\n          ADVERSE EVENT\n     Describe Event\n\n\n     Seriousness of Adveret Event (Check all that apply)\n        Death Incude date (dd-mmm-YYYY)\n        Life threatening\n        HospitalizationInitial\n                Prolonged\n        Dicability  PermanentDamage\n        Congenital AnomalyfBirth Defects\n        Rtaulitd Interenton      Prerent Permanent [mpairment       Disability (Devices)\n        Othets (Specify)\n\n     Outcomes\n\n       Recovering fully\n        Reco hed\n        Unknowin\n        Others (Sptaty)\n                     Event (dd-mmm-Y)\n     Onset Date                                       Stop Date of Event (dd-mmm-YYY)\n\n           SUSPECTED DRUG (Including Biologicals Traditional/Herbal\n   Medicines        Cosmetics)\n     Prduct Debelk [Namaundother details uttechproduct abel_product sample if available)\n  Brnd Namgi                                                       Batch No' Ko\n  Gentnc Name-                                                     NAFDAC\n  Name and Address of Manulaciurer                                 Expiry Date:\n\n                       NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n                           SERIAL NO:             00024981\n                                                NAFDAC USE ONLY\n\n\n\n\n\n    Indkcatlons for Use (Dlagnosis)\n   Dotage                                Frequency                 Route     Administration\n    Date Medicatlon Started (dd-mmm-YYx)           Date Medication Stopped (dd-mmm-YYYY)\n\n\n\n  Reaction Stopped      Reduced                            Reaction Reappeared After Drug\n  After Drug Withdrawal                                    Reintroduction?\n\n                   Doesn t apply                               Doesn t apely\n        CONCOMITANT MEDICINES\n     medicines taken within the       months including herbalandscll-medication)\nBrnd      Ganaric     Dozage          Route          Date                        Reaton\nNante                                                Started       Stopped      for Ust\n E: RELEVANT TESTS             LABORATORY DATA WITH DATES\n\n\n\n F.OTHER RELEVANT HISTORY\n\n Including Preexisting Medical Conditions:\n                Pregnancy\n                                                                Akohol use\n                 Smoking                                        Liver Problems\n                 Kidney - Problems\n Allergles\n Others (Specify)\n\n\n        REPORTER\n\n    Name undAddress\n Last Name;                                    First Name:\n Addmess:\n City;                                        State:\n Countn'                                     Date:\n Phone No:                                   Emai:\n   Health Profexlonah?\n\n\n   Orcupatlon:\n                                                                                 212", "mimetype": "text/plain", "start_char_idx": 60, "end_char_idx": 3763, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "7b7ceae5-c68f-4e89-952a-4cf915d6ceb7": {"__data__": {"id_": "7b7ceae5-c68f-4e89-952a-4cf915d6ceb7", "embedding": null, "metadata": {"file_path": "Data\\Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_name": "Nigeria-Guidelines-for-HIV-Prevention-Treatment-and-Care.pdf", "file_type": 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