{"docstore/metadata": {"570e4a23-736a-4937-afc6-0790d7ab44a1": {"doc_hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d"}, "1be39814-a249-4beb-9742-aedeeac8f9cf": {"doc_hash": "00b6e1b9149d3264142795cdc39f3a78e45528106a8df64ec3566f3e21dc7b58", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "c917afa3-7e9c-4051-893e-cde6a22e2eae": {"doc_hash": "22b5b5015f200e0362255227d2323bc609c382f0e5d6bacf5cb3579bc5e71cb7", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "182c0ea7-396b-4837-8599-6d6dbacb7005": {"doc_hash": "10efa4b60050b335e29e8fa50907e99b2d3b475efb5c9c6b5193d483c43a5d83", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "7f05d90e-6603-4c55-9d6d-ff1c1cb022aa": {"doc_hash": "a840b2e0299f41e097ebb27e27f8feeb446891e5fcc9c00e73d781ed18040429", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "71cda16c-eddb-417f-b65b-76e85b24a519": {"doc_hash": "9a09944e3a75424028453a57acdde26cf83eb51640ec9a7867c16fa6e04375ea", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "dedf3b6c-5868-40ea-82a7-4fdadfcab74a": {"doc_hash": "8faa85d1cf6679c19a040b8a962c76a4111e2e7a6ca00cdc710ce7aeccfd716e", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "3b1708a5-0d86-4d65-bb50-0ca163399c44": {"doc_hash": "38f53fce41cc21f02aa46c959c0dc030f5dd52de7c395c72dece7b5c144b6c67", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "aa183659-830b-4122-8951-3129dedfea68": {"doc_hash": "8c4cecd97db2dc294f22abb1edba9e8d1ab9211c6d41c3d5874f0012d83c49c5", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "6f3454a0-948f-4cde-ad10-1b6aed794ed9": {"doc_hash": "cc33aa3196d4731d7aa8c73af9c29b6a325e5e6531c2455fbbe0e3375fcb3367", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "6169792c-ef1d-450c-9d2f-f02eb3edd3ed": {"doc_hash": "684d89bf8c64cb95e62c931b704f1579f75274ea059035dcf835bc3a7f37f63c", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "0cf5611b-e367-4e1d-94fb-a204337f5b59": {"doc_hash": "a20ad0a0a10c4ec2a92b6cbc0a1c3fdaca36b4a253e970a8a5071295ef851ec9", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "0d807e4e-524c-4de5-a445-65f2645055ff": {"doc_hash": "417978c1c5b4fb664200bc000a9f41d93f5c8fc33f28a31ea128339811468f81", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "773bb3cd-87f0-4aea-a0eb-9bf3ca65f2eb": {"doc_hash": "e124379cc83ef65d105231b4b5756de68f210012e6a17891649d702f549cf162", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "de65c2a1-97ff-4bfa-b7d0-52e200af1b61": {"doc_hash": "54d52a73421a01addc83fa2d69283f863de3b65baf59a3c1f081d077d2b35a14", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "ebc6c790-a421-45e6-beef-4782eeb79856": {"doc_hash": "a0ba7a8179be4b1cd0b18732e1d646d9170ad55cb252aa6e8360f5c1d00e4686", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "856b62f2-43df-4a71-9419-06d1bbd3e7de": {"doc_hash": "ac95551c4d25321deda327a9c095547b2113bab8d2b17232f3cc0c7afe5b4e29", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "c60d14ec-6b32-4dd3-a838-59461c2b8ced": {"doc_hash": "381e0454259e8476b24c19d6d20403db6745651bbf9a6532a5df8a2c6e0b6059", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "b132e3cd-9e1c-4143-be38-aabfe6f039a4": {"doc_hash": "e8920b597df851bc4a6954d8343132522ba1007928d63c9d013624cf659395aa", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "e9fe0eaa-658a-4901-9617-57d195b286d8": {"doc_hash": "87a500a2d3f2674d80bfdd3a34a04877fb2d9b66884a983c03d949764f4e2bee", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "08444e6b-7299-445d-a579-45b38638d531": {"doc_hash": "1dcc5f6979a3d2b5aeb03640b60b29f404b2c2741fa2f75570e7706fc3ff41cc", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "adc25c12-2748-4636-b682-3bcc9ef0ae8e": {"doc_hash": "f85c098a6438861d62493228ad3d7da1bb0a28536c87971851f855b94f2e5d50", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "c268ce2d-dad5-4184-b4cb-bc43a8b97797": {"doc_hash": "1960471789cbb4360fc43dd3a11eac6fad1d5b3f23a96e4e5f0a54c8c961432b", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "bb428944-f860-48cc-a583-35e574e586c7": {"doc_hash": "303e9cbf107b6158cb0606e9111543386498ab12afc7debe50651187c19a7caa", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "acdae45e-cd3e-4340-988f-6cf0b86bfecf": {"doc_hash": "88a9c47dc8f524d88f63b808ed1b45faf7ff98d40c98942d12bf2f8e4bec3086", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "6b58603d-7cc7-4197-a17c-e3384af73d0c": {"doc_hash": "9e21ef85c51dac08f643df1d33495241b92582ffa7a55c744617a9386fc3f8de", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "fc58a0be-8fc8-46cc-9913-79372ec5b371": {"doc_hash": "6c2d3e81ca6f052bb451088308e879ebcbade54de1bdd64faf5a5c1cb9cfde58", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "0a6de4b6-cc5d-49b2-9567-661e61fabf4b": {"doc_hash": "6d1100ffc383287c895c7767a3fd3b7a4356390e0c56120f64579101d71acd92", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "b1238e3b-068e-4192-b862-93fe607a37a2": {"doc_hash": "d97a555641ed6b5e8ad513a9dd1b5a29eb472a890f8ac248630da298d3408074", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "8487c36f-b154-409c-a194-cb38a34c6bd9": {"doc_hash": "e00ac56a4e9402a9e986cdacde3c927c8cbde980db815c1f33ced4ee7b13f5fb", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "e8ee475d-e9bf-4041-9054-d827b164f4ea": {"doc_hash": "184554d01da109b3e351e676911fb95a47ebe97311ecd0407a3cabfdb42966a2", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "66be3a16-0a4d-4efb-9177-b28c373a4da0": {"doc_hash": "bfc87d560c298a178033041cab8a4b4d93919c15c7462666d582944b4f93bdaa", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "3d134476-b69b-4975-9bde-35e3df8da770": {"doc_hash": "1f937841c07a558310641c3b43a3a751012877d00aa6b4e45df7e48e39cf6932", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "2cf1d939-3565-4dd1-92c4-576e43cf56ab": {"doc_hash": "c342051178218fd12f0c822104ed9af95a36fad4a6cedf180c1207dfc6ed6d80", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "225bc172-e222-4e71-9928-e96ee21d9b62": {"doc_hash": "44f058fdc7394301e7d6b1b9cb81c0d92e02842990a911d8d2737a81a5c24161", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "a2c58816-600c-4345-a8da-1b43314b1eeb": {"doc_hash": "4830552c8217edbc4a0c61291fb0481b1fac46654008bf467cb16a31a8e56973", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "da01d3e5-5774-4c96-9db6-de87248ba4aa": {"doc_hash": "6f392376ac8daa0da5c5e4c2aa03c55e46c6c67d610387eed42a47230dc7711c", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "8391fb3d-0f9f-40b3-b7ab-28325bcb41f7": {"doc_hash": "aed9158655a8af41743f611ab78e92e9ab1252cf994ad78a6b6c6e9d6e645d0c", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "768ad6e1-bb2e-4e0f-aae0-9326cb0d503a": {"doc_hash": "3eb972d3c939092a8122ded7f8d3605cce6080e25898b5f5616599cbc5a1ed63", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "2992863a-e3a3-4e28-8567-ccb60ad5988f": {"doc_hash": "4caac7851fe84968cf18f6c0ebb56f78b01d345f707e46e1631a83126ce8506c", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "934e5e60-8fbc-43eb-9667-95508dbc9dd4": {"doc_hash": "e3710c8cee5f44d41a933a36e328bbcfc9567392babf94bdd3b5d62d379e3b05", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "4faedd18-3ed4-44f5-92de-f8a37a477e3e": {"doc_hash": "c57a531add371a98df97e6d983de9b15cba0d888fb3276f8bcc51751ee19093a", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "48f6c872-48e2-4d22-b01d-6346cd593416": {"doc_hash": "6072d66e01e7a737a95a27dd225d4e3647106e1702fccbff6418a98b0cd502e3", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "8f48c9af-cc4a-45d3-9812-9e18b74cdf4e": {"doc_hash": "b3c263200b8db49029b53368926d67833227edc2a41a0cc4d0552889195a4023", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "9c44f389-1d28-4f71-980c-1578e1550fb0": {"doc_hash": "c1d6b35772d2484f736875a590b63af719411a68438003aa9d6f8a6f6a984bfe", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "768fa145-742c-4763-bd70-f252de065582": {"doc_hash": "2b7467090a622665773e96e7cb680be472f549427d36560077d48cf8dd2f2c48", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "fdd30f91-0a54-4d84-94e5-412656dae5c5": {"doc_hash": "59cc4b327234db629fea84531dfb4f7646de26a519b0171e6704c88178511200", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "a315f0f8-af27-4fe6-9ef2-9a99355e67b8": {"doc_hash": "85fd9fc7132275756c936f6f974c99cd0aceb96a97dbe7653b414426288f9060", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "d0ffd61a-1fc6-4dab-8563-dc6e70406c15": {"doc_hash": "9c5449821309385447668b4cf9edc405f0707a4f2081ab40dd67ab60f69d672d", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "9981c837-beee-49a4-8d2c-6736cfc6d7a1": {"doc_hash": "6992fa11c8e6a59f02a9dc25d7744ac9ff19c5e4a81b05517c1669978dca8e02", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "4e1f0313-44ae-46b8-bf73-f311cc8c925c": {"doc_hash": "3c077e419a183b6cf2f6593d672187b89e16ac003c007f4282e5e9e6869ad57a", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "aacb9127-6773-42f8-b854-3a8e54a53d3d": {"doc_hash": "bd145c27cdda907d04eb1af9f963fa4b0ef9753a14b6f09d98f7881550fcd6c0", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "72952e09-0f8b-4b41-b5d4-6f5e3200be74": {"doc_hash": "61cb1ecaa72f8b0cf2048579d1589099d942da69b3c4f95ba9311e0b14257cda", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "ee5d725b-c1de-48fc-9442-38f9a8c36c3d": {"doc_hash": "78318af07aea2c40e4e942c63c42f26c594ab2f07ce87f8e37bff7458ae61da6", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "1ebd72d6-6e31-4687-b953-e3498e8d9d8f": {"doc_hash": "e9c6c95c59cb368b77b976f686dbc8290073701d0b1f557411242633e09085cf", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "864e3900-17ba-4043-a25f-a69360de0f97": {"doc_hash": "6991ff046bd5c5396eaf248c759f3505078e9b8a2d3a61bff61f997f3893c347", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "24871fd0-80bb-4a0c-9dbd-2a8090bb673e": {"doc_hash": "a6fdf32e24a054753f2f79a464cdac696a163ca4bbfba9e56b6d11f9b4569951", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "3371b69f-ec01-4528-8ee5-1826662a7257": {"doc_hash": "1bfeeb45e0fa09bdd1db5ebce350c8db4b37a87970d46d24fa1b1d01befdd130", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "5b885312-bf3e-4bc2-a08b-1c30acc44439": {"doc_hash": "3dc2d4555e06fba45713276e22437567c951bf924a79f2d647ca07842b7c8236", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "536c8729-832f-4e37-9270-19eb6521c97b": {"doc_hash": "9fc5f939476e30924aa3c08207c4320dd97b381591816b184408836ae8b94e01", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "52e81834-d79f-4d6d-a8dd-c04bc659c89a": {"doc_hash": "08d86d9e05687529c3e1c134a26aa758aaf6245081ea8d4f9e186d9c21fdd088", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "8b178d80-74e9-4171-8b00-8ca7e99f88b5": {"doc_hash": "03e06857b8e69fd3e07df72a06af1982defd204d3285ce43335b05b6ef0587ff", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "51a3eb4e-c195-495a-a7f8-c1b5a59175d6": {"doc_hash": "1a4dc1dd5674a4270bb76d1542e593e968c81019c917ffc6b2ba913c6aa74c05", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "2876bcad-2f09-462d-a10c-aa1150e1bdd8": {"doc_hash": "e774ad921f431d44a4cb743bec9576600e3f29d132079835ea502d799c8b3167", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "3a0597d5-512e-4e79-a2da-fe54414a9754": {"doc_hash": "e31bda5e882fcbde29c813e7cba7c960c46bfaf34df14a3d7360fa7184294c4e", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "c96ea4c9-bf74-473e-827c-4a29733b79e3": {"doc_hash": "7f047a5f55381720b4ba034fa4bb9abdb2b2e95ef68c3298dad1391227a8adc8", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "fb741f10-a41a-410a-9761-620d24c25529": {"doc_hash": "b0a1e9b78d8eb285679f45d62240b9c3fbab524b6ef7c7685505eccf54bdf2d1", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "5b859628-c49c-4c48-b6a0-3541bd556f53": {"doc_hash": "0d39729879a9ee8a08a6ead3f92143e3ec3831356fa6e8826d321897bc2213cb", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "d0b319aa-5b24-4d0d-bb9b-3356f697502f": {"doc_hash": "917f59c548cc3705520a43d09570ee3f6c5572b5e838371e1b685e516f093849", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "6e46d6e4-6b98-4c16-af94-d1ce52418406": {"doc_hash": "abea2c9e5a2aa5dd03cd9eb308e0d74a297e2c52fa663caf2ed907fb462391a9", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "2e499b5c-095f-419a-820c-e70d05e34ad7": {"doc_hash": "5d1a4facde504e487d47306547bd06b52b186e10d0ba917ef7d9076773656e17", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "30cf4aa4-357a-40fc-a302-e0e8142f0c01": {"doc_hash": "21f87e06d4664dbea1663f7b796d42d034ebd96908eba12894bbf49efabd2af6", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "384b5810-f3a7-4f0e-808f-1abbfa534112": {"doc_hash": "9dad64b5f57c89fc946436eeeaf7712fbc33d0dc369715a6f0c0d6a47f919bf1", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "92acaea4-c99a-492e-8889-875fc6ce9912": {"doc_hash": "22246745045f1ee220569235f0bc4705e69fe7a329d9b352c67309ee11a4a6c6", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "762ac6ee-aa2e-4595-ad5b-1b5f0316bda4": {"doc_hash": "d8e934cf41de782f21dae7b159056bd5cb68ba7b4d8b6d43a864ea4d44ce5d73", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "b58857f8-fbee-4ff9-8e32-023953efe7d7": {"doc_hash": "7b84560cc22ef8bcf38dec1612b4a4dc412be11c8ae37f804bb31d1ecb9c1e06", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "724d4268-deac-488c-99f6-2e31a05009f4": {"doc_hash": "0c0a37b7dc71dacd2335a81bd58e3315e49b1a745af359417519e30ee14bca3c", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "05cbce19-bc3f-4963-83d6-1e77bd17790d": {"doc_hash": "4e1cbe5b5e17518c47c2a91133e4482147221336a852a9c00accbf2397b0d46b", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "72e340aa-8865-485a-8d95-ce8cb86298c9": {"doc_hash": "f5126ccdcd5c8ef9202f6b235224ec9a19d771107674d5818cc90e313d72028b", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "7aa2b209-d355-4edf-a025-663585c6d543": {"doc_hash": "0f7296fc5a6b3b5b5a1f313380bd0525a8e31480e6c336c3d667b2ac2e137c0e", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "1c8e8c27-a0a7-4d07-aca4-0a372248627a": {"doc_hash": "0f5a0191e887ef54b4461323c4b3cebc43b6109dfa8e03ee47bec0610aa8a562", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "7d76622d-c052-4fc8-bea4-39b920d597ea": {"doc_hash": "7f6efc47fb717b8d2c1ec39c26bc1ef74ae57fefea7825d8624271db2fa4a6d4", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "74aa6c80-4fa6-4e5a-ab61-5459f39e9521": {"doc_hash": "35d4e6eb8f2a49e3b6dab8cb415960ee3a362af9d9b53661b7e99e35f4a2cf6e", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "9a62be8c-002e-423c-ad65-b85bad865c4f": {"doc_hash": "f6f0fab8d73afa547bec01453d9ad1022b0ff2af1fb0fd9611ca6feb5b90f1bc", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "4a14b673-b704-4c53-bf82-86a2a9d82b04": {"doc_hash": "7e5f14d71fd8a4aaa8c9252d892a9376874889d3dc2c406bf08aed399ae4def9", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "bc9e66bf-23a6-47c7-9920-d18d7903002f": {"doc_hash": "deafc158dfa6cc58a3f4ec848f5f21fa0a14e92395bd4078e03279f4ed9f8378", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "78c000b2-808a-46fc-8390-486722342cf7": {"doc_hash": "74821bff6822ed1aa1bc7101e1c85293976f9cfddc763d93ce542f24c41fa1a7", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "abef2aa6-0090-461e-982c-e8880353d9f8": {"doc_hash": "552f44bb44dd710930a1609d29174c19fe3bc834b7fc361482809fa539c45403", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "a0ea8a83-92f2-421f-b583-e5d04834c259": {"doc_hash": "b05e72bfb93cb1bfa49e391fd763591596275ce91ab17bb15cfb3d16faf56aad", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "eeb1cdda-7b65-47d1-b142-5d532ac85cab": {"doc_hash": "7c5c66ed9f9c53114d772f4fc55bdd52b93e6b6f3168ab4c9bf82746348c2e13", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "c5ef7c56-7463-4737-9006-a4125c33a909": {"doc_hash": "71dd5dad03e9c7d222a862da39da7687f8ce3107306d95ba7b2df2322d27d459", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "1922b9cb-3833-488e-a0c4-c6ff0f6b1b99": {"doc_hash": "208f6bf05a246ded635082b4479f465b83fc8fcbf164f8b11c0bc27b447aab88", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "b4386fec-b92e-4f31-99f0-c1000563c82a": {"doc_hash": "b36e59f6f4c94860461e17f84bb3b5e16ab5703801883b12b2a1e31ae9944949", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "049328b1-bbcb-4bae-a28c-c5eaf96cf908": {"doc_hash": "59915ce5dad0075fc0bd37bbe403817bd9aa1048b939ab5aabfd9127129cb31b", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "4e1172eb-ec42-4e8d-84f2-9500acb0c007": {"doc_hash": "4310f5fd627e6420c18137035e84574f3a304cd1569cdfd2264b5181f1f6fcb0", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "89805267-89b6-4d46-93ec-c90570ad8da3": {"doc_hash": "c7375bcd72999e03041b478723ae3d3080a4e964170418d43d42c36a6b19750f", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "e6e74683-1f88-4425-9346-ccf52b68098a": {"doc_hash": "2cefb5ba0e169b1d103afbd25b87cde1bebfac8617d8776bc37b6f5930489fcf", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "fd13c817-0bd5-48ed-9c7e-889bea17e88b": {"doc_hash": "745be4ae590c45a46b0a2f8caef8336ee7c7eda3a5c76de27fcfd36b00366e53", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "ca780269-c4fe-4975-9c0e-6ea659664995": {"doc_hash": "62b0a9dec3c9e57a43895d0537a10b65449e2d52f2e0b7eefc3e2e546ca65c70", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "fc4c2773-3865-4163-a103-276e0408ca85": {"doc_hash": "ad929fbf4e96b3d87425b64fdfed2c389b520c3843f1a2eadb5438ebadd71a4f", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "34c80094-8287-4c44-bc16-088a133f62f0": {"doc_hash": "643f0e8181599d421c3236138d8011fdede03f31da02d19aceab0c9f898e4ed8", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "e3fc83c3-658e-4bc1-8184-4af3df01af48": {"doc_hash": "8ddeeddffbe8bd869803c61e0653136a48d646b1adcdc133caa0fce18771a1a4", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "9bb1b86d-d3ae-41b4-bd0f-1c54ec21a3c4": {"doc_hash": "b5d10459caa64c97d7c17af41646b3a5ac77abba2440d68a1aabee836e7694e1", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "ee1887b0-dfd0-4074-ab4b-290b1cfe94c6": {"doc_hash": "4e741edcc394aa238bcf09a3c8b94bcfb1d7ba04398b4e9d2a6e30dc6263e921", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "adbe517d-f0bc-4ad4-a660-6b852988e564": {"doc_hash": "a59fb33cf7f0d359204e24d915435ceb9c52326b58a23683ba3000c06432652a", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "719b0511-e145-4652-b14e-bc6a1aeeaa19": {"doc_hash": "36eaf09967f18ab4d188dc733689f1e31cb34164cba251da3f2a201fdf899f6b", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "7bd8ebd7-cbab-48e0-afaf-7691de62ea33": {"doc_hash": "fc71ddcb80625c522a179163652a13b4eaf8e921e121c3a733009877f5878234", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "290348b0-0903-42f6-9dee-89f395619ab9": {"doc_hash": "3915de3b0a5322fa0bfe5d8801930a7f136ac81d534172fa6403590d9ba67a8d", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "a53ff8fa-43d7-4c48-b5a4-f1fc4a15e5e6": {"doc_hash": "2afec7acad3487b8c6ec20f30086b48fc2347e7e9271a0738e9869fb97f46de3", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "00592b08-271a-4179-85b5-664a5fb0b4c8": {"doc_hash": "5378bc95e5eac365cff651bf528a7be2d0106857770acb7143aaadd2fd61a654", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "8748db76-7138-4631-b69f-c177c46c7ccd": {"doc_hash": "c801d4f48fa38b564831c447983a90029f83c515cc3e39a7965e4228e727d6b2", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "c558b0e8-3b18-42f1-afef-6f0734840d33": {"doc_hash": "ae7d6b30c9e9944d673e81ea943478e87460d39f1b837b55bbc80b6d79d0fa11", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "14a09a50-0bed-4733-b746-5389a1f64ed8": {"doc_hash": "47a2701a871eb17facf824d265293a7959537585311c47848a89bdae87e8ea34", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "bdd91bc2-8834-4bd7-9c6c-8d017eb043d2": {"doc_hash": "20d8972f1974ff358db8f75dfc5b672000aacf7352f4ade13edd5d21659f90c6", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "74ce8aca-8c4a-44ed-856d-b4a5f75531f1": {"doc_hash": "f91b76710b53ea1d0155c049212db5ee0f0472c6cebc137403bb0e427e19b423", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "de21296b-ca4d-4077-8ca6-1672b328f78c": {"doc_hash": "67be684ba13c90f8fb7a000a36359d0d1811cfa15184f7fcb40f2cdbdb1415af", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "6f34babe-4cfe-4d28-803f-81fa7142e2d0": {"doc_hash": "71dec4a24bf80bf43bc98accf50332494f21ebc1ca51f920bb14bcb154cd7cc6", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "f9f831ac-f9b9-4b1c-aa3c-0f3b9a7974eb": {"doc_hash": "c0e2adcfa06aa3c4ca0b4ed343c02f1ffddec968d1f01a23e778763602dab341", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "03e4ac44-fa49-4d5f-b06d-48aba85dcde9": {"doc_hash": "1511cbbd50ae46dc79f26d8580bb8cb18b9d99e8454099a93e9a4ea3b4623bb3", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "0fb8f16f-107c-4059-8128-46291c15f157": {"doc_hash": "1a1d55bddfdfe0bb6dff51c392ca7fd6dd7f1fd34533461077a742b47fd2e9f4", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "28e02e9b-68c8-4dea-983e-00c380d56686": {"doc_hash": "9ae96c0f6af2bc3bfa106b251379bf999ef7e677f540ac581179574a5059e0a5", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "57680c96-f3a7-4cfd-af10-727c4b4a47eb": {"doc_hash": "b873a6539fdb3c93913d20213ca152cc15bcb5a49a4b46210024ea9a3ec2d532", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "d167b9fc-757d-4e7e-8a12-cc0f87dc9a89": {"doc_hash": "2aeb3c47c10fffc315e8303c0a75649822e303c21a748b203f69a0d815cdcd01", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "152adb26-e7d9-4d13-a9dc-9a8bc02f47b0": {"doc_hash": "3d542fa5edd66a701cd26b7e35d5a5df71fdb186e4c17a68d6f1430435e7e51b", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "7538fc80-39bd-4699-add9-4e3b386ae671": {"doc_hash": "23671bd5b47117d8e9d48976c7f3e1f4a606e949fb40d4a15487125d6a677abe", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "7583dec9-c673-4686-b2a8-c38682e9d3bf": {"doc_hash": "939febb2c686e9cec9530a53b0aef2937f234a488b1bd4c195cb72d90fafdeee", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "d7d83cd6-cb9d-4ffa-aa21-158a96ad25cd": {"doc_hash": "4077a0dde6800cc6c6d26a4fd73028a488e32f5f4e80f97c0dd019b0e1c6adec", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "879c98e2-123e-4997-90a7-7aee15f0dbf3": {"doc_hash": "71d8853dfe6236cff164e13f1f095576a9190cbe9362f4b67978e9abddbbfdfc", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "5c6b3a8c-8bae-439f-be40-f2680b092249": {"doc_hash": "6b71a87ecada8330b03b77bf9943bd01c8f0840b77d5a62bfae5d9c0a2d6f215", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "b90a87b5-5e8d-464b-9cae-c3a7030cc97d": {"doc_hash": "8f4516ddf6f93b51f1aaaccfb10b237b9534425efd4843808875bbd5296d7b1d", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "bce74d45-e99d-4a9f-ab2e-7d93c88d1d68": {"doc_hash": "511fa01c8c2899f1373848d4f0bd6c17d8d021874d7cb8d17977e23d74aaaa69", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "8b42d6ab-1729-4f6f-ace2-6b4e2b7cc9b3": {"doc_hash": "5df59cf69bf85ddc723bfb03432276570d55eb922a699bacdcb08cbd9b0604d2", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "85f8bfe6-b093-4cb8-9a2a-d8d05265e257": {"doc_hash": "31221faf2ed2ce78b0a2b25611dcd12e74e89ae5ed7d956018ddfcfed4252444", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "c9bed0f4-7f44-4755-8517-eed6d7e265ff": {"doc_hash": "e2ed72ab5efc56cec9d15d6512cfd7db4a530501b96daddf790554ab7255e260", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "c5155a8f-80ac-48fd-af2a-8608883da8d9": {"doc_hash": "73de05b3ff3d30e08ee76d4c1f30efb6215299db5a2ce3e23bd8bc635e180820", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "9d0b650f-f03a-4211-af68-5e0780e74f58": {"doc_hash": "3d46bb0898f75a26f23a81da1530a81d67c634b4e032f410d0dc21d110605f0f", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "e44a04e9-7750-4cde-a5ab-ec31dadcd9f4": {"doc_hash": "c34fb822d05e5f0c2e6ea3f53930fde09a7ab62bc3231187a6a8d07cc60c9f00", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "6232c831-6164-4503-bd1d-56cd5088a779": {"doc_hash": "c84a54d7e89b13a7626a7cd7b382aa30c7eb23f1bd725319614ded102c67b569", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "8b349233-f4a6-417f-a745-551c92561564": {"doc_hash": "e99ec1618263858feedd9b3082b24a81ff741f16bd5e481577659603d3d57748", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "76bb6dfa-1357-482d-876c-e5e182e4d76c": {"doc_hash": "57b8ffe89eda9164fb025afb71edffce3ac4ffea7af438b8611b974b4e2836ab", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "9ae909bd-db93-45cf-816d-a40112115c04": {"doc_hash": "6aebee18943109f8bc78334ded0e598901fede8fa7f89b4263fbfd393b1bb70a", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "803f17f4-2e43-4d79-8393-ff8901454137": {"doc_hash": "16a2961769ecbf504c498c79959d904ca5f9a7d55da05b3c753293f1980b34eb", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "07c9d249-39c2-400e-889f-3f0e1879b3f1": {"doc_hash": "21e85fcafe66e245e6ba3d05b06b9cf98d8d31d9283c5d13441724690f480deb", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "6384850b-88e2-45f1-9857-984e8d1026df": {"doc_hash": "6e5e96e0dd5e01d045de488942dd63a856c18b8462d57b307a141c417c6ab637", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}, "886d0981-c66f-428d-8126-fb0c816909b4": {"doc_hash": "85caa5fd2baaed23bce91a0dd68cc18dba72ed1e91a077473adc65282799a45f", "ref_doc_id": "570e4a23-736a-4937-afc6-0790d7ab44a1"}}, "docstore/data": {"1be39814-a249-4beb-9742-aedeeac8f9cf": {"__data__": {"id_": "1be39814-a249-4beb-9742-aedeeac8f9cf", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "c917afa3-7e9c-4051-893e-cde6a22e2eae", "node_type": "1", "metadata": {}, "hash": "22b5b5015f200e0362255227d2323bc609c382f0e5d6bacf5cb3579bc5e71cb7", "class_name": "RelatedNodeInfo"}}, "text": "# NATIONAL GUIDELINES FOR HIV PREVENTION, TREATMENT AND CARE\n\nNATIONAL AIDS AND STIs CONTROL PROGRAMME\nFEDERAL MINISTRY OF HEALTH NIGERIA\n2020\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION, TREATMENT AND CARE\n\nNATIONAL AIDS AND STIs CONTROL PROGRAMME\nFEDERAL MINISTRY OF HEALTH NIGERIA\n\n2020\n\nCopyright 2020.\nFederal Ministry of Health, Abuja Nigeria\n\nISBN: 978-978-980-273-9\n\n# Foreword\n\nOver the years, the Federal Ministry of Health has put in place several response mechanisms aimed at reducing the impact of HIV and AIDS and ensuring people living with HIV (PLHIV) in Nigeria receive quality services by formulating national policies, protocols and standard operating procedures to guide implementation.\n\nThese new 2020 National Guidelines for HIV Prevention Treatment and Care further underscores the government's commitment to the welfare of all Nigerian children, adolescents, young persons, pregnant women and adults living with HIV. It was developed through extensive consultations involving government, bilateral and multilateral organizations, civil society organizations, the academia, and the patient community. The wellbeing of the recipients of care remained the principal consideration.\n\nThese new Guidelines support evidence-based interventions that can improve efficiency and effectiveness despite the limited resources in the country's HIV programme. Its implementation will require increased investment and shared responsibility from all arms of government, donors and implementing agencies. Implementing the guidelines fully will have an unprecedented impact on preventing new infections and reducing the number of people dying from HIV-related causes over the coming years.\n\nThe key recommendations of these guidelines include the use of novel testing strategies for improved case finding, initiating antiretroviral therapy (ART) in all HIV positive people including children, adolescents, adults, pregnant and breastfeeding women, regardless of clinical and immunological stages of the disease. Other recommendations include re-testing of patients prior to initiating ART, adoption of pre-exposure prophylaxis (PrEP) for individuals at high risk of acquiring the infection, TB/HIV co-infection management, provision of a specialized package of care for patients with Advanced HIV Disease (AHD), and one-off administration of tuberculosis preventive treatment (TPT), differentiated service delivery models (DSD), as well as the establishment of adolescent-friendly services.\n\nThese Guidelines provide all the guidance that health workers require to deliver comprehensive package of high-quality HIV prevention, treatment and care interventions that addresses the needs of PLHIV, 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 will help in effective management of HIV infections, bolster the HIV response, and ensure an irreversible decline of the epidemic.\n\nI therefore endorse and recommend this 2020 National Guidelines for HIV prevention, Treatment and Care for use across all the health facilities and service delivery points in the country and also for individuals 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\n\n# Acknowledgements\n\nThis document is the result of collaborative efforts led by the Federal Ministry of Health through its National HIV/AIDS, STIs & Hepatitis Control Programme (NASCP) with support from implementing partners, bilaterals, multilaterals, civil society organizations, and donor agencies.\n\nThe Federal Ministry of Health acknowledges with utmost gratitude, the inputs of all individuals who devoted their time, amidst the COVID-19 pandemic, to review and contribute to this very important document. We also extend our appreciation to representatives of the following organizations who carefully reviewed the various chapters and sections of the document and provided their invaluable contributions: UNICEF, UNAIDS, CDC, USAID & DOD and their implementing partners and AHF.\n\nOur special thanks go to WHO, Clinton Health Access Initiative (CHAI), the academia under the umbrella of the National Task Team on Antiretroviral Therapy, and the core editorial team for providing all the needed technical and/or financial support to convene the meetings that culminated in the development of the 2020 National Guidelines for HIV Prevention, Treatment and Care.\n\nWe also appreciate the patient community for providing insight into some of the strategies and programmatic considerations that were harnessed for inclusion into this document. We are grateful to the representatives of the departments of family health and hospital services, the National Tuberculosis and Leprosy Control Programme of the Federal Ministry of Health, the NPHCDA, NAFDAC, NACA, NEPWHAN, ASWHAN, CISHAN, and APYIN.\n\nFinally, I thank the Honourable Minister of Health and the entire Ministry leadership for the creation of an enabling environment for the staff to work. I also commend the staff in the Office of the Director Public Health for the immense support to the various programmes/divisions in the department.", "mimetype": "text/plain", "start_char_idx": 0, "end_char_idx": 5310, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c917afa3-7e9c-4051-893e-cde6a22e2eae": {"__data__": {"id_": "c917afa3-7e9c-4051-893e-cde6a22e2eae", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "1be39814-a249-4beb-9742-aedeeac8f9cf", "node_type": "1", "metadata": {}, "hash": "00b6e1b9149d3264142795cdc39f3a78e45528106a8df64ec3566f3e21dc7b58", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "182c0ea7-396b-4837-8599-6d6dbacb7005", "node_type": "1", "metadata": {}, "hash": "10efa4b60050b335e29e8fa50907e99b2d3b475efb5c9c6b5193d483c43a5d83", "class_name": "RelatedNodeInfo"}}, "text": "We also appreciate the patient community for providing insight into some of the strategies and programmatic considerations that were harnessed for inclusion into this document. We are grateful to the representatives of the departments of family health and hospital services, the National Tuberculosis and Leprosy Control Programme of the Federal Ministry of Health, the NPHCDA, NAFDAC, NACA, NEPWHAN, ASWHAN, CISHAN, and APYIN.\n\nFinally, I thank the Honourable Minister of Health and the entire Ministry leadership for the creation of an enabling environment for the staff to work. I also commend the staff in the Office of the Director Public Health for the immense support to the various programmes/divisions in the department. I appreciate the efforts of NASCP staff under the leadership of the National Coordinator, and especially the staff of the Treatment, Care and Support component of NASCP that coordinated all the activities and meetings that ultimately led to the completion of this document 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\n\n# Executive Summary\n\nThe 2020 National Prevention, Treatment and Care Guidelines is a ten-chapter consolidated document that provides general and specific guidance on the diagnosis of HIV infection, the use of antiretroviral (ARV) drugs for preventing and treating HIV infection, and the care of people living with HIV using a broad range of current technological innovations, interventions and evidence-based practices. This guideline is structured along the continuum of HIV testing, prevention, treatment and care.\n\nThe first chapter introduces the guidelines in general, its guiding principles, the process of reviewing and evaluating its implementation across service delivery points, the epidemiology of HIV 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 HIV self-testing, recency testing, use of HIV risk stratification checklists, and Nucleic acid testing 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 characteristics and mechanisms of action of ARVs, criteria for initiating ART in different age groups, the approved regimens for ART and management of treatment failure. It also provides guidance on the use of Tenofovir, Lamivudine and Dolutegravir (TLD) as the preferred first-line regimen for all adults and adolescents, the use of Dolutegravir in second-line ART for adults and adolescents, and the use of Dolutegravir based regimen as preferred first-line for children weighing 3kg and above.\n\nChapter four recognizes the need to track and manage adverse drug reactions 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 suppression, and guidance on monitoring and improving adherence. Chapter six is dedicated to the prevention of mother to child transmission (PMTCT) of HIV using ART and non-ART interventions including prophylaxis for the HIV exposed infant.\n\nIn chapter seven, preventive management of HIV is presented. This chapter provides detailed guidance for offering pre and post-exposure prophylaxis (PrEP and PEP). Chapter eight focuses on Advanced HIV Disease (AHD), Opportunistic infections (OIs) and the comorbidities. It provides guidance on the implementation of the AHD package of care, cotrimoxazole preventive therapy, tuberculosis preventive therapy, as well as the management of common opportunistic infections.\n\nChapter Nine focuses on improving the efficiency of service delivery by using Differentiated Service Delivery (DSD) models, and decentralized services. Special attention is given to differentiated service delivery based on clinical characteristics and sub-groups including key populations.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\nFinally, the tenth and the last chapter deals with the monitoring and evaluation of all the various strategies and interventions involved in the health sector response. It also provides basic information on the strategies for monitoring the implementation of HIV services under these guidelines, and relevant indicators used for measuring the impact as well as the effectiveness of all the HIV Interventions.\n\nDr Akudo. E. Ikpeazu\nNational Coordinator\nNASCP\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\niv\n\n# Editorial Team\n\n|Dr Bilkisu Jibrin|Head Treatment, Care & Support NASCP - Coordinating Editor|\n|---|---|\n|Dr Nwaokenneya Peter|Assistant Director, Adult ART/TB/HIV- NASCP|\n|Dr.", "mimetype": "text/plain", "start_char_idx": 4581, "end_char_idx": 9410, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "182c0ea7-396b-4837-8599-6d6dbacb7005": {"__data__": {"id_": "182c0ea7-396b-4837-8599-6d6dbacb7005", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "c917afa3-7e9c-4051-893e-cde6a22e2eae", "node_type": "1", "metadata": {}, "hash": "22b5b5015f200e0362255227d2323bc609c382f0e5d6bacf5cb3579bc5e71cb7", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "7f05d90e-6603-4c55-9d6d-ff1c1cb022aa", "node_type": "1", "metadata": {}, "hash": "a840b2e0299f41e097ebb27e27f8feeb446891e5fcc9c00e73d781ed18040429", "class_name": "RelatedNodeInfo"}}, "text": "# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\nFinally, the tenth and the last chapter deals with the monitoring and evaluation of all the various strategies and interventions involved in the health sector response. It also provides basic information on the strategies for monitoring the implementation of HIV services under these guidelines, and relevant indicators used for measuring the impact as well as the effectiveness of all the HIV Interventions.\n\nDr Akudo. E. Ikpeazu\nNational Coordinator\nNASCP\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\niv\n\n# Editorial Team\n\n|Dr Bilkisu Jibrin|Head Treatment, Care & Support NASCP - Coordinating Editor|\n|---|---|\n|Dr Nwaokenneya Peter|Assistant Director, Adult ART/TB/HIV- NASCP|\n|Dr. Urhioke Ochuko|Assistant Director, Childhood TB - NTBLCP|\n|Mrs Atu Uzoma|Assistant Director, Logistics Unit - NASCP|\n|Prof. Sulaimon Akanmu|Chairman NTTA / Haematologist LUTH Lagos|\n|Prof. Oche Agbaji|Member NTTA / Physician JUTH Jos|\n|Prof. Oliver Ezechi|Director of Research NIMR Lagos|\n|Dr Eugenia Ofondu|Member NTTA / Physician FMC Owerri|\n|Dr Damien Anweh|Member NTTA / Physician FMC Markurdi|\n|Dr Ali Onoja|Member HTS Task team / CEO African Health Project|\n|Dr Tolulope Oladele|Assistant Director, Health Sector Response Support NACA|\n|Dr Olufemi Oke|Technical Advisor, Paediatric HIV treatment and OVC Services,", "mimetype": "text/plain", "start_char_idx": 8637, "end_char_idx": 10030, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "7f05d90e-6603-4c55-9d6d-ff1c1cb022aa": {"__data__": {"id_": "7f05d90e-6603-4c55-9d6d-ff1c1cb022aa", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "182c0ea7-396b-4837-8599-6d6dbacb7005", "node_type": "1", "metadata": {}, "hash": "10efa4b60050b335e29e8fa50907e99b2d3b475efb5c9c6b5193d483c43a5d83", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "71cda16c-eddb-417f-b65b-76e85b24a519", "node_type": "1", "metadata": {}, "hash": "9a09944e3a75424028453a57acdde26cf83eb51640ec9a7867c16fa6e04375ea", "class_name": "RelatedNodeInfo"}}, "text": "Urhioke Ochuko|Assistant Director, Childhood TB - NTBLCP|\n|Mrs Atu Uzoma|Assistant Director, Logistics Unit - NASCP|\n|Prof. Sulaimon Akanmu|Chairman NTTA / Haematologist LUTH Lagos|\n|Prof. Oche Agbaji|Member NTTA / Physician JUTH Jos|\n|Prof. Oliver Ezechi|Director of Research NIMR Lagos|\n|Dr Eugenia Ofondu|Member NTTA / Physician FMC Owerri|\n|Dr Damien Anweh|Member NTTA / Physician FMC Markurdi|\n|Dr Ali Onoja|Member HTS Task team / CEO African Health Project|\n|Dr Tolulope Oladele|Assistant Director, Health Sector Response Support NACA|\n|Dr Olufemi Oke|Technical Advisor, Paediatric HIV treatment and OVC Services, CRS|\n|Emmanuel Clifford|National Secretary NEPWHAN|\n|Nere Otubu|Program Manager CHAI|\n|Pharm Williams Eigege|Associate CHAI|\n|Oluwakemi Sowale|Senior Analyst CHAI|\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Abbreviations and Acronyms\n\n|3TC|Lamivudine|\n|---|---|\n|ABC|Abacavir|\n|ABUTH|Ahmadu Bello University Teaching Hospital|\n|ACT|Artemisin-based Combination Therapy|\n|ADR|Adverse Drug Reaction|\n|AHD|Advanced HIV disease|\n|AIDS|Acquired Immunodeficiency Syndrome|\n|AKTH|Aminu Kano University Teaching Hospital|\n|ALP|Alkaline Phosphatase|\n|ALT|Alanine Transaminase|\n|ANC|Antenatal Care|\n|APIN|AIDS Prevention Initiative in Nigeria|\n|ARM|Artificial Rupture of Membrane|\n|ART|Antiretroviral Therapy|\n|ARV|Antiretroviral drugs|\n|AST|Aspartase Transaminase|\n|ASWHAN|Association of Women Living with HIV/AIDS in Nigeria|\n|ATV/r|ritonavir boosted Atazanavir|\n|AUC|Area under the curve|\n|UATH|University of Abuja Teaching Hospital|\n|AZT|Zidovudine|\n|c-ART|Combination ART|\n|CD4+|Cluster of Differentiation Antigen 4|\n|CDC|Centres for Disease Control|\n|CFCC|Client and Family Centred Care|\n|CHAI|Clinton Health Access Initiative|\n|CHEW|Community Health Extension Worker|\n|CIHP|Centres for Integrated Health Programs|\n|CiSHAN|Civil Society for HIV/AIDS in Nigeria|\n|CKD|Chronic Kidney Disease|\n|Cmax|Maximum Concentration|\n|CMS|Central Medical Stores Oshodi|\n|CMV|Cytomegalovirus|\n|CNS|Central Nervous System|\n|COBI|Cobicistat|\n|COPD|Chronic Obstructive Pulmonary Disease|\n|CPK|Creatinine Phospokinase|\n|CPT|Cotrimoxazole preventive Therapy|\n|CrAg|Cryptococcal Antigen|\n|CrCl|Creatinine Clearance|\n|CRRF|Combined Report and Requisition Form|\n|CS|Cesarean Section|\n|CSF|Cerebrospinal Fluid|\n|CSO|Civil Society Organization|\n|CT|Computed Tomography|\n|CTX|Cotrimoxazole|\n|CXR|Chest X-Ray|\n|D4T|Stavudine|\n|DAA|Directly Acting Antiviral|\n|DBS|Dried Blood Spot|\n|Ddl|Didanosine|\n|DHOS|Department of Hospital Services|\n|DLV|Delavirine|\n|DNA|Deoxyribonucleic Acid|\n|DOTS|Direct Observed Treatment Short Course|\n|DRESS|Drug Reaction, Eosinophilia,", "mimetype": "text/plain", "start_char_idx": 9411, "end_char_idx": 12088, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "71cda16c-eddb-417f-b65b-76e85b24a519": {"__data__": {"id_": "71cda16c-eddb-417f-b65b-76e85b24a519", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "7f05d90e-6603-4c55-9d6d-ff1c1cb022aa", "node_type": "1", "metadata": {}, "hash": "a840b2e0299f41e097ebb27e27f8feeb446891e5fcc9c00e73d781ed18040429", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "dedf3b6c-5868-40ea-82a7-4fdadfcab74a", "node_type": "1", "metadata": {}, "hash": "8faa85d1cf6679c19a040b8a962c76a4111e2e7a6ca00cdc710ce7aeccfd716e", "class_name": "RelatedNodeInfo"}}, "text": "Eosinophilia, Systemic Symptoms|\n|DRV/r|Ritonavir boosted Darunavir|\n|DRTB|Drug Resistant Tuberculosis|\n|DTG|Dolutegravir|\n|ED|Erectile Dysfunction|\n|EFV|Efavirenz|\n|EID|Early Infant Diagnosis|\n|ELISA|Enzyme Linked Immunosorbent Assay|\n|Emtct|Elimination of Mother to child transmission of HIV|\n|ENT|Ear Nose Throat|\n|EPTB|Extra Pulmonary Tuberculosis|\n|EQA|External Quality Assurance|\n|ESRD|End Stage Renal Disease|\n|ETR|Etravirine|\n|ECV|External Cephalic Version|\n|EVG|Elvitegravir|\n|FBO|Faith based Organization|\n|FBS|Fasting Blood Sugar|\n|FCT|Federal Capital Territory|\n|FCTA|Federal Capital Territory Administration|\n|FDC|Fixed Dose Combination|\n\n# Acronyms and Abbreviations\n\n|Acronym|Full Form|\n|---|---|\n|FETH|Federal Teaching Hospital|\n|FMC|Federal Medical Centre|\n|FMOH|Federal Ministry of Health|\n|FP|Family Planning|\n|FPV|Fosamprenavir|\n|FTC|Emtricitabine|\n|GFR|Glomerular Filtration Rate|\n|HAART|Highly Active Antiretroviral Therapy|\n|Hb|Haemoglobin|\n|HbsAg|Hepatitis B surface Antigen|\n|HBV|Hepatitis B Virus|\n|HCT|HIV Counselling and Testing|\n|HCV|Hepatitis C Virus|\n|HCW|Health Care Worker|\n|HIV|Human Immunodeficiency Virus|\n|HLA|Human Leucocyte Antigen|\n|HPV|Human Papilloma Virus|\n|HSR|Hypersensitivity Reaction|\n|HSV|Herpes Simplex Virus|\n|HTS|HIV Testing Services|\n|HU-PACE|Howard University Pharmacy and Continuing Education|\n|IBBSS|Integrated Biological Behavioural Sentinel Survey|\n|IDV|Indinavir|\n|IHVN|Institute of Human Virology Nigeria|\n|INH|Isoniazid|\n|INSTI|Integrase Strand Transfer inhibitor|\n|IPT|Isoniazid Preventive Therapy|\n|IPV|Intramuscular Polio Vaccine|\n|IRIS|Immune Reconstitution inflammatory Syndrome|\n|JUTH|Jos University Teaching Hospital|\n|LF-LAM|Lateral Flow Lipoarabinomannan|\n|LGBTI|Lesbian, Gay Bisexual Transgender and Intersex|\n|LIP|Lymphoid Interstitial Pneumonia|\n|LMCU|Logistic Management Coordinating Units|\n|LMIS|Logistic Management Information System|\n|LP|Lumbar Puncture|\n|LPV/r|Lopinavir/ritonavir|\n|LUTH|Lagos University Teaching Hospital|\n|M&E|Monitoring and Evaluation|\n|MAC|Mycobacterium Avium Complex|\n|MARPs|Most at Risk Populations|\n|MCH|Maternal and Child Health|\n|MLSCN|Medical Laboratory Science Council of Nigeria|\n|MNCH|Maternal, Newborn and Child Health|\n|MOH|Ministry of Health|\n|MP|Malaria Parasites|\n|MTB|Multidrug Resistance TB|\n|MTCT|Mother to Child Transmission|\n|MUAC|Mid Upper Arm Circumference|\n|NACA|National Agency for the Control of AIDS|\n|NACS|Nutrition Assessment Counselling and Support|\n|NARH|National AIDS and Reproductive Health Survey|\n|NASCP|National AIDS and STIs Control Programmed|\n|NAUTH|Nnamdi Azikiwe University Teaching Hospital|\n|NBBFSW|Non-Brothel Based Female Sex Worker|\n|NEPWHAN|Network of People Living with HIV in Nigeria|\n|NFV|Nelfinavir|\n|NIMR|Nigeria Institute of Medical Research|\n|NNRTI|Non-Nucleoside Transcriptase Inhibitors|\n|NPHCDA|National Primary Health Care Development Agency|\n|NRTI|Nucleoside Reverse Transcriptase Inhibitors|\n|NSAIDS|Non-Steroidal Anti-Inflammatory Drugs|\n|NTTA|National Task Team on ART|\n|NVP|Nevirapine|\n|OIs|Opportunistic infections|\n|Pap|Papanicolaou Test for cervical cancer screening|\n|PCR|Polymerase Chain Reaction|\n|PCV|Packed Cell Volume|\n|PDSA cycle|Plan, Do, Study,", "mimetype": "text/plain", "start_char_idx": 12075, "end_char_idx": 15290, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "dedf3b6c-5868-40ea-82a7-4fdadfcab74a": {"__data__": {"id_": "dedf3b6c-5868-40ea-82a7-4fdadfcab74a", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "71cda16c-eddb-417f-b65b-76e85b24a519", "node_type": "1", "metadata": {}, "hash": "9a09944e3a75424028453a57acdde26cf83eb51640ec9a7867c16fa6e04375ea", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "3b1708a5-0d86-4d65-bb50-0ca163399c44", "node_type": "1", "metadata": {}, "hash": "38f53fce41cc21f02aa46c959c0dc030f5dd52de7c395c72dece7b5c144b6c67", "class_name": "RelatedNodeInfo"}}, "text": "Do, Study, Act|\n|PEP|Post Exposure Prophylaxis|\n|PEPFAR|US President Emergency Plan For AIDS Relief|\n|PHC|Primary Health Care|\n\n# Acronyms\n\n|PHDP|Positive Health Dignity and Prevention|\n|---|---|\n|PI|Protease Inhibitor|\n|PI/r|Ritonavir boosted Protease Inhibitor|\n|PITC|Provider Initiated HIV Testing and Counselling|\n|PJP|Pneumocystis Jiroveci Pneumonia|\n|PLHIV|People Living with HIV|\n|PME|Programme Monitoring and Evaluation|\n|PMM|Patient Management and Monitoring|\n|PMTCT|Prevention of Mother to Child Transmission|\n|PrEP|Pre-Exposure Prophylaxis|\n|QA|Quality Assurance|\n|QI|Quality Improvement|\n|RAL|Raltegravir|\n|RNA|Ribonucleic Acid|\n|RTI|Reproductive Tract Infection|\n|RVP|Rilpivirine|\n|SACA|State Agency for the Control of AIDS|\n|SQV|Saquinavir|\n|STI|Sexually Transmitted Infection|\n|tARVp|Triple Antiretroviral Drug Prophylaxis|\n|TB|Tuberculosis|\n|TDF|Tenoforvir|\n|TPT|Tuberculosis Preventive Therapy|\n|TPV|Tipranavir|\n|TT|Tetanus Toxoid|\n|UBTH|University of Benin Teaching Hospital|\n|UCH|University College Hospital Ibadan|\n|UCTH|University of Calabar Teaching Hospital|\n|UNAIDS|Joint United Nations Programme on HIV/AIDS|\n|UNICEF|United Nations Children Emergency Fund|\n|UNN|University of Nigeria|\n|UNTH|University of Nigeria Teaching Hospital|\n|USAID|United States Agency for International Development|\n|VIA|Visual Inspection Acetic Acid for cervical cancer screening|\n|VL|Viral Load|\n|WBC|White Blood Cell|\n|WHO|World Health Organization|\n\n# Definition of Terms\n\nHIV-Retesting: This is a second HIV test conducted after a positive first test result. Re-testing is recommended before initiation of ART.\n\nHIV sero-discordant couples: Sexual relationship in which one partner is HIV positive and the other HIV negative.\n\nKey populations: These are groups of individuals who bear a high burden of HIV and are exposed 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 better viral suppression. Highly active anti-retroviral therapy (HAART) or combination Anti-Retroviral Therapy (cART) is used interchangeably.\n\nViral load: It is the number of HIV RNA copies in a milliliter of plasma.\n\nSustained viral suppression: This is an optimal response to ART such that the viral load remains 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 adverse drug reactions that require regular monitoring, no current illnesses, have a good understanding of lifelong adherence with evidence of treatment success (i.e. two consecutive viral load measurements below 1000 copies/mL).\n\nClinical failure in adults and adolescents: It is the presence of new or recurrent clinical event indicating severe immunodeficiency (WHO clinical stage 4 condition) following 6 months of effective treatment.\n\nClinical failure in Children: It is the presence of new or recurrent clinical event indicating advanced or severe immunodeficiency (WHO clinical stage 3 and 4 clinical condition with the exception of TB) after 6 months of effective treatment.\n\nImmunological failure in adults and adolescents: This is when the CD4+ cell count fall to or below pre-treatment baseline value or persistent CD4 levels below 100 cells/mm or 50% decline from on-therapy CD4+ cell count peak level.\n\nImmunological failure in Children younger than 5 years: It is persistent CD4 levels below 200 cells/mm or &lt;10%.\n\nImmunological failure in Children older than 5 years: It is persistent CD4 levels below 100 cells/mm3.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Virologic failure\n\nIt is a persistently detectable viral load exceeding 1000 copies/ml (that is, 2 consecutive viral load measurements within a 3-month interval, with adherence support between measurements) after at least six months of using ARV drugs.\n\n# Pharmacovigilance in HIV\n\nThis is also known as drug safety.", "mimetype": "text/plain", "start_char_idx": 15280, "end_char_idx": 19293, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "3b1708a5-0d86-4d65-bb50-0ca163399c44": {"__data__": {"id_": "3b1708a5-0d86-4d65-bb50-0ca163399c44", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "dedf3b6c-5868-40ea-82a7-4fdadfcab74a", "node_type": "1", "metadata": {}, "hash": "8faa85d1cf6679c19a040b8a962c76a4111e2e7a6ca00cdc710ce7aeccfd716e", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "aa183659-830b-4122-8951-3129dedfea68", "node_type": "1", "metadata": {}, "hash": "8c4cecd97db2dc294f22abb1edba9e8d1ab9211c6d41c3d5874f0012d83c49c5", "class_name": "RelatedNodeInfo"}}, "text": "Immunological failure in adults and adolescents: This is when the CD4+ cell count fall to or below pre-treatment baseline value or persistent CD4 levels below 100 cells/mm or 50% decline from on-therapy CD4+ cell count peak level.\n\nImmunological failure in Children younger than 5 years: It is persistent CD4 levels below 200 cells/mm or &lt;10%.\n\nImmunological failure in Children older than 5 years: It is persistent CD4 levels below 100 cells/mm3.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Virologic failure\n\nIt is a persistently detectable viral load exceeding 1000 copies/ml (that is, 2 consecutive viral load measurements within a 3-month interval, with adherence support between measurements) after at least six months of using ARV drugs.\n\n# Pharmacovigilance in HIV\n\nThis is also known as drug safety. It is the collection, detection, assessment, monitoring, and prevention of adverse effects in patients on antiretroviral drugs and other medicines associated with the management of HIV/AIDS.\n\n# Adherence to ART\n\nIt is the extent to which a PLHIV behaviour coincides with the ART regimen as agreed through mutual decision-making between the PLHIV and the adherence counsellor.\n\n# MTCT of HIV\n\nThis is mother to child transmission of HIV, which can occur in pregnancy, labour and delivery, or through breastfeeding.\n\n# PMTCT\n\nPrevention of mother to child transmission of HIV is the strategy for ensuring that HIV infection is not transmitted to an infant during pregnancy and lactation period.\n\n# HIV-exposed infants\n\nThese are infants delivered to HIV positive women.\n\n# High-risk infants\n\nThese are infants delivered to HIV positive women with an increased risk of viral transmission. These women may not have had ARVs or have had less than 4 weeks of ARV or have a viral load of greater than 1000 copies/ml in the last month prior to delivery.\n\n# Infant ARV prophylaxis\n\nThese are ARVs administered to all HIV exposed infants to prevent them from acquiring HIV infection.\n\n# EID\n\nEarly infant diagnosis of HIV is the testing of all HIV exposed babies to determine their HIV infection status by detecting the presence of HIV DNA using PCR.\n\n# DBS\n\nDried blood spot testing (DBS) is a form of biosampling where blood samples are blotted and dried on filter paper. The dried samples can easily be shipped to an analytical laboratory and analysed using various methods such as DNA amplification.\n\n# PCR DNA\n\nPolymerase chain reaction is the use of an enzyme to multiply both HIV DNA and RNA in blood sample.\n\n# PrEP\n\nIt is the use of oral ARVs to prevent HIV infection in individuals exposed to high risk of acquiring HIV.\n\n# PEP\n\nIt is the use of oral ARVs by individuals exposed to HIV in order to block the acquisition of HIV.\n\n# TB Preventive Therapy\n\nTB Preventive Therapy (TPT), previously referred to as Isoniazid preventive therapy (IPT) is the treatment offered to individuals who are considered to be at risk of developing 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\n\n# Latent TB Infection (LTBI)\n\nCPT: Cotrimoxazole preventive therapy is the routine administration of cotrimoxazole in all HIV 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 individual.\n\nCo-morbidity: Co-morbidity is the occurrence of one or more illnesses in an individual with a primary disease.\n\nOpportunistic infection: Opportunistic infections (OIs) are infections that occur more frequently and can become severe in individuals with HIV when their immune system becomes weakened.\n\nDifferentiated care: Differentiated care is the delivery of a minimum package of HIV/AIDS treatment care and support services according to the diversity of the care needs for people living with HIV.\n\nDecentralization in the context of HIV: Decentralization is the devolution of part responsibility for the offer of HIV treatment and care from the tertiary and secondary level ART centres 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 facility 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 who 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, allowing a wider range of cadres to offer certain services, safely and effectively as a means of rapidly expanding access and improving health care.", "mimetype": "text/plain", "start_char_idx": 18457, "end_char_idx": 23207, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "aa183659-830b-4122-8951-3129dedfea68": {"__data__": {"id_": "aa183659-830b-4122-8951-3129dedfea68", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "3b1708a5-0d86-4d65-bb50-0ca163399c44", "node_type": "1", "metadata": {}, "hash": "38f53fce41cc21f02aa46c959c0dc030f5dd52de7c395c72dece7b5c144b6c67", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "6f3454a0-948f-4cde-ad10-1b6aed794ed9", "node_type": "1", "metadata": {}, "hash": "cc33aa3196d4731d7aa8c73af9c29b6a325e5e6531c2455fbbe0e3375fcb3367", "class_name": "RelatedNodeInfo"}}, "text": "Differentiated care: Differentiated care is the delivery of a minimum package of HIV/AIDS treatment care and support services according to the diversity of the care needs for people living with HIV.\n\nDecentralization in the context of HIV: Decentralization is the devolution of part responsibility for the offer of HIV treatment and care from the tertiary and secondary level ART centres 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 facility 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 who 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, allowing a wider range of cadres to offer certain services, safely and effectively as a means of rapidly expanding access and improving health care.\n\nContinuum of care: it is an integrated system of care that guides and tracks clients over time, through a comprehensive range of health services starting from screening for HIV, through to initiation of ART, retention in care and psychosocial support.\n\nMonitoring in HIV: Monitoring in HIV is the regular observation, recording and process of routinely gathering information of activities taking place in HIV programme.\n\nEvaluation: Evaluation in HIV is a systematic assessment which focuses on expected and achieved accomplishments in HIV programmes.\n\nHIV Data flow: Data flow is the transmission of HIV data from source (health facilities) through local governments and states data platforms to the Federal Ministry of health as the final data repository.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\nHIV Data validation: Data validation is defined as the checking of all collected HIV data for completeness, thoroughness and reasonableness, and the elimination of errors.\n\nData Quality Assurance: Data Quality Assurance is a routine measure to ensure quality of data through a process of validation, reliability, precision, integrity and timeliness.", "mimetype": "text/plain", "start_char_idx": 22188, "end_char_idx": 24383, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6f3454a0-948f-4cde-ad10-1b6aed794ed9": {"__data__": {"id_": "6f3454a0-948f-4cde-ad10-1b6aed794ed9", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "aa183659-830b-4122-8951-3129dedfea68", "node_type": "1", "metadata": {}, "hash": "8c4cecd97db2dc294f22abb1edba9e8d1ab9211c6d41c3d5874f0012d83c49c5", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "6169792c-ef1d-450c-9d2f-f02eb3edd3ed", "node_type": "1", "metadata": {}, "hash": "684d89bf8c64cb95e62c931b704f1579f75274ea059035dcf835bc3a7f37f63c", "class_name": "RelatedNodeInfo"}}, "text": "Monitoring in HIV: Monitoring in HIV is the regular observation, recording and process of routinely gathering information of activities taking place in HIV programme.\n\nEvaluation: Evaluation in HIV is a systematic assessment which focuses on expected and achieved accomplishments in HIV programmes.\n\nHIV Data flow: Data flow is the transmission of HIV data from source (health facilities) through local governments and states data platforms to the Federal Ministry of health as the final data repository.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\nHIV Data validation: Data validation is defined as the checking of all collected HIV data for completeness, thoroughness and reasonableness, and the elimination of errors.\n\nData Quality Assurance: Data Quality Assurance is a routine measure to ensure quality of data through a process of validation, reliability, precision, integrity and timeliness.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Table of Contents\n\nForeword - i\n\nAcknowledgements - ii\n\nExecutive Summary - iii\n\nEditorial Team - v\n\nAbbreviations & Acronyms - vi\n\nDefinition of terms - ix\n\nTable of Contents - xiii\n\n# CHAPTER 1 \u2013 INTRODUCTION\n\n1.1 Objectives of the Guidelines - 3\n\n1.2 Epidemiology of HIV in Nigeria - 6\n\n- 1.2.1 HIV Transmission - 6\n\n1.3 Natural History of HIV - 7\n\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\n\n# CHAPTER 2 - DIAGNOSIS OF HIV INFECTION\n\n2.1 Introduction - 11\n\n2.2 HIV Testing Services - 11\n\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\n\n2.3 HTS in Pregnancy - 14\n\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\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - xiii\n\n# 2.4 Re-testing\n\n15\n\n# 2.5 Repeat HIV Testing\n\n15\n\n# 2.6 Disclosure Scenarios\n\n16\n\n# 2.7 Linkage of HTS to care and ART\n\n16\n\n# 2.8 Laboratory Diagnosis of HIV Infection\n\n17\n\n|2.8.1 Antibody Assays|17|\n|---|---|\n|2.8.2 Enzyme-Linked Immunosorbent Assay (ELISA) or Enzyme 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|\n\n# 2.9 Laboratory Diagnosis of HIV Infection in Children by Age Group\n\n20\n\n|2.9.1 Children aged \u226418 months|20|\n|---|---|\n|2.9.2 Children aged \u226518 months|22|\n\n# 2.10 Clinical Diagnosis and Staging of HIV Infection\n\n22\n\n# CHAPTER 3 - ANTIRETROVIRAL THERAPY\n\n# 3.1 Introduction\n\n27\n\n# 3.2 Classes of Antiretroviral Drugs\n\n27\n\n# 3.3.", "mimetype": "text/plain", "start_char_idx": 23462, "end_char_idx": 26411, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6169792c-ef1d-450c-9d2f-f02eb3edd3ed": {"__data__": {"id_": "6169792c-ef1d-450c-9d2f-f02eb3edd3ed", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "6f3454a0-948f-4cde-ad10-1b6aed794ed9", "node_type": "1", "metadata": {}, "hash": "cc33aa3196d4731d7aa8c73af9c29b6a325e5e6531c2455fbbe0e3375fcb3367", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "0cf5611b-e367-4e1d-94fb-a204337f5b59", "node_type": "1", "metadata": {}, "hash": "a20ad0a0a10c4ec2a92b6cbc0a1c3fdaca36b4a253e970a8a5071295ef851ec9", "class_name": "RelatedNodeInfo"}}, "text": "Preparation of Adults, Adolescents and Children for ART\n\n29\n\n|3.3.1 Baseline Assessment for ART|29|\n|---|---|\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|\n\n# 3.4 Recommended ART Regimen for Adults, Adolescents and Children\n\n33\n\n|3.4.1 First -line ART regimens for adults and adolescents|33|\n|---|---|\n|3.4.2 First -line ART for children|33|\n|3.4.3 Programming Transitioning to DTG -based regimen|34|\n\n# 3.5 Monitoring Patients on ART\n\n34\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\nxiv\n\n# 3.5.1 Monitoring and Follow-up in Adults\n\n34\n\n# 3.5.2 Monitoring Children and Adolescents on ART\n\n35\n\n# 3.6 Management of HIV Treatment Failure\n\n# 3.6.1 Definition of HIV Treatment Failure\n\n37\n\n# 3.6.2 Causes of HIV Treatment Failure\n\n39\n\n# 3.6.3 Substitution and switch of ARV drugs\n\n40\n\n# 3.6.4 Second-line ART Regimens\n\n40\n\n# 3.7 Third-line ART\n\n# 3.7.1 Criteria for Switch to Third-Line ART\n\n42\n\n# 3.7.2 Operational Guidance for Third-Line ART\n\n42\n\n# 3.8 Low-Level Viremia (LLV)\n\n# 3.8.1 Management of Low -level viremia (LLV)\n\n43\n\n# 3.9 ART in Special Circumstances\n\n# 3.9.1 Kidney impairment\n\n44\n\n# 3.9.2 Cardiomyopathy\n\n44\n\n# 3.9.3 Osteoporosis\n\n44\n\n# CHAPTER 4- PHARMACOVIGILANCE IN ANTIRETROVIRAL THERAPY\n\n# 4.1 Introduction\n\n48\n\n# 4.1.1 Active Pharmacovigilance\n\n48\n\n# 4.2 Pregnancy Monitoring for Patients on ARVs\n\n48\n\n# 4.3 HIV Drug Resistance (HIVDR)\n\n49\n\n# 4.4 Adverse drug reactions (ADRs)\n\n# 4.4.1 Classification of Adverse Drug Reactions (ADRs)\n\n49\n\n# 4.5 Drug toxicity\n\n# 4.5.1 Laboratory monitoring of toxicity:\n\n50\n\n# 4.6 Steps to Recognize ADRs\n\n54\n\n# 4.7 Who is to Report ADRs?\n\n54\n\n# 4.8 What ADRs Should be Reported?", "mimetype": "text/plain", "start_char_idx": 26412, "end_char_idx": 28432, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "0cf5611b-e367-4e1d-94fb-a204337f5b59": {"__data__": {"id_": "0cf5611b-e367-4e1d-94fb-a204337f5b59", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "6169792c-ef1d-450c-9d2f-f02eb3edd3ed", "node_type": "1", "metadata": {}, "hash": "684d89bf8c64cb95e62c931b704f1579f75274ea059035dcf835bc3a7f37f63c", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "0d807e4e-524c-4de5-a445-65f2645055ff", "node_type": "1", "metadata": {}, "hash": "417978c1c5b4fb664200bc000a9f41d93f5c8fc33f28a31ea128339811468f81", "class_name": "RelatedNodeInfo"}}, "text": "54\n\n# 4.8 What ADRs Should be Reported?\n\n54\n\n# 4.9 Pharmacovigilance Data Collection and Reporting Process\n\n55\n\n# 4.10 Principles of Management of Adverse Drug Reactions\n\n55\n\n# 4.10.1 Management of Specific ARV Adverse Drug Reactions\n\n57\n\n# 4.11 Prevention of Adverse Drug Reactions\n\n61\n\n# 4.12 ARV Drug Interactions\n\n62\n\n# CHAPTER 4.12.1 Interactions Between Contraceptives and Antiretroviral Drugs\n\nPage 62\n\n# CHAPTER 5 - ADHERENCE TO ANTIRETROVIRAL THERAPY\n\nPage 65\n\n# 5.1 Introduction\n\nPage 66\n\n# 5.2 Adherence Preparation for ART\n\nPage 66\n\n# 5.3 On-going adherence for clients on ART\n\nPage 67\n\n# 5.4 Monitoring of Adherence\n\nPage 67\n\n# 5.4.1 Factors known to improve adherence\n\nPage 68\n\n# 5.4.2 Factors associated with poor adherence\n\nPage 68\n\n# 5.4.3 Adherence in Specific Populations\n\nPage 69\n\n# 5.4.4 Recommendations for improving adherence\n\nPage 70\n\n# CHAPTER 6 - PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV INFECTION\n\nPage 72\n\n# 6.1 Introduction\n\nPage 73\n\n# 6.2 Mother-to-Child Transmission of HIV\n\nPage 73\n\n# 6.2.1 Prevention of MTCT\n\nPage 74\n\n# 6.2.2 Benefit of PMTCT\n\nPage 77\n\n# 6.3 Pre-ART Care for HIV-positive pregnant women\n\nPage 78\n\n# 6.3.1 Initial evaluation of HIV pregnant women\n\nPage 78\n\n# 6.3.2 Initial Clinical Examination of HIV Positive Pregnant Women\n\nPage 78\n\n# 6.3.3 Laboratory Investigation of HIV Positive Pregnant Women\n\nPage 79\n\n# 6.3.4 Syphilis testing for pregnant women\n\nPage 80\n\n# 6.4 Use of Antiretroviral Therapy for PMTCT\n\nPage 80\n\n# 6.4.1 Recommended first-line regimen for pregnant and breastfeeding women.\n\nPage 80\n\n# 6.4.2 ARV prophylaxis for the HIV exposed infant\n\nPage 80\n\n# 6.4.3 Cotrimoxazole Prophylaxis for HIV exposed infants\n\nPage 81\n\n# 6.4.4 Antenatal Care for HIV positive pregnant women\n\nPage 82\n\n# 6.5 Management of HIV positive women in labour, delivery and within 72 hours of delivery\n\nPage 82\n\n# 6.5.1 Induction of Labour\n\nPage 83\n\n# 6.5.2 Conduct of Delivery\n\nPage 83\n\n# 6.5.3 Vaginal Delivery\n\nPage 83\n\n# 6.5.4 Caesarean Section (CS)\n\nPage 83\n\n# 6.5.5 Specific Modification of Obstetric Care for HIV Positive Women\n\nPage 84\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\nPage xvi\n\n# 6.6 PMTCT/TB integration services\n\n|6.6.1 Pregnant women with TB and HIV co-infection|84|\n|---|---|\n|6.6.2 Infection Control|86|\n|6.6.3 Management of Newborn of a Mother/ Household contacts with LTBI|86|\n\n# 6.7 Care and Support of the HIV-Exposed Infant\n\n|6.7.1 Immediate and on-going care of the new-born of HIV positive women|86|\n|---|---|\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|\n\n# 6.8 Special Considerations for Adolescent and Young Women in PMTCT\n\n6.9 Linkage of PMTCT with comprehensive HIV Treatment, Care and Support Services for Mothers and Infants\n\n6.9.1 Engagement of Non-Formal Health Actors (NFHA) in the (referral and Linkage) of PMTCT services\n91\n\n# CHAPTER 7- PREVENTIVE MANAGEMENT IN HIV\n\n# 7.1 Introduction\n\n7.1.1 Combination prevention / Minimum Prevention Package Intervention (MPPI)\n\n# 7.2 Pre-Exposure Prophylaxis\n\n|7.2.1 Criteria for PrEP initiation|95|\n|---|---|\n|7.2.", "mimetype": "text/plain", "start_char_idx": 28393, "end_char_idx": 31559, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "0d807e4e-524c-4de5-a445-65f2645055ff": {"__data__": {"id_": "0d807e4e-524c-4de5-a445-65f2645055ff", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "0cf5611b-e367-4e1d-94fb-a204337f5b59", "node_type": "1", "metadata": {}, "hash": "a20ad0a0a10c4ec2a92b6cbc0a1c3fdaca36b4a253e970a8a5071295ef851ec9", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "773bb3cd-87f0-4aea-a0eb-9bf3ca65f2eb", "node_type": "1", "metadata": {}, "hash": "e124379cc83ef65d105231b4b5756de68f210012e6a17891649d702f549cf162", "class_name": "RelatedNodeInfo"}}, "text": "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|\n\n# 6.8 Special Considerations for Adolescent and Young Women in PMTCT\n\n6.9 Linkage of PMTCT with comprehensive HIV Treatment, Care and Support Services for Mothers and Infants\n\n6.9.1 Engagement of Non-Formal Health Actors (NFHA) in the (referral and Linkage) of PMTCT services\n91\n\n# CHAPTER 7- PREVENTIVE MANAGEMENT IN HIV\n\n# 7.1 Introduction\n\n7.1.1 Combination prevention / Minimum Prevention Package Intervention (MPPI)\n\n# 7.2 Pre-Exposure Prophylaxis\n\n|7.2.1 Criteria for PrEP initiation|95|\n|---|---|\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|\n\n# 7.3 Post -Exposure Prophylaxis\n\n|7.3.1 Post-Exposure Prophylaxis for Occupational HIV exposure|99|\n|---|---|\n|7.3.2 Evaluation for Post-Exposure Prophylaxis|100|\n|7.3.4 Determination of Risk and ARV drugs for PEP|100|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 7.3.5 Recommendations for PEP\n\n100\n\n# 7.3.6 Recommended Drug Combinations for PEP\n\n101\n\n# 7.4 Post-Sexual Assault Exposure Prophylaxis\n\n102\n\n# 7.4.1 Recommendations\n\n103\n\n# 7.4.2 Clinical considerations\n\n103\n\n# 7.5 Interventions for Key Populations\n\n104\n\n# 7.5.1 Recommended comprehensive prevention package of Interventions for key populations\n\n104\n\n# 7.6 Condom availability and promotion for HIV programme\n\n105\n\n# 7.6.1 Elements of Condom Programing\n\n105\n\n# 7.6.2 Key Steps in Condom Programing\n\n106\n\n# 7.7 Gender-Based Violence\n\n106\n\n# 7.7.1 GBV Prevention\n\n107\n\n# 7.7.2 GBV Case Identification and First-line Support Recommendations\n\n107\n\n# 7.7.3 GBV Clinical Response Recommendations\n\n107\n\n# 7.8 Management of Sexually Transmitted Infections (STIs)\n\n108\n\n# 7.8.1 Objectives of STIs/RTIs management\n\n108\n\n# 7.8.2 Components of syndromic management\n\n108\n\n# 7.8.3 Prevention of STIs/RTIs\n\n108\n\n# 7.9 Prevention for Adolescent and Young Persons (AYPs)\n\n109\n\n# 7.9.1 Harm Reduction program\n\n109\n\n# 7.9.2 Cervical Cancer Prevention\n\n110\n\n# CHAPTER 8-ADVANCED HIV DISEASE, OPPORTUNISTIC INFECTIONS, AND CO-MORBIDITIES\n\n# 8.1 Advanced HIV Disease\n\n113\n\n# 8.1.1 Introduction\n\n113\n\n# 8.1.2 Definition of advanced HIV disease\n\n114\n\n# 8.1.3 Components of AHD package of care\n\n115\n\n# 8.1.4 Diagnostics for AHD and associated OIs\n\n115\n\n# 8.1.5 Management of opportunistic infections in AHD\n\n117\n\n# 8.1.6 ART Initiation and Intensive Adherence Support for Patients with AHD\n\n121\n\n# 8.1.7 Vaccination for People with AHD\n\n122\n\n# 8.1.8 Immune Reconstitution Inflammatory syndrome (IRIS)\n\n123\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\nxviii\n\n# 8.1.9 Management of AHD among Children less than ten years\n\n124\n\n# 8.2 Other Opportunistic Infections (OIs)\n\n126\n\n# 8.3 Preventing Opportunistic Infections (OIs)\n\n# 8.3.", "mimetype": "text/plain", "start_char_idx": 30907, "end_char_idx": 34038, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "773bb3cd-87f0-4aea-a0eb-9bf3ca65f2eb": {"__data__": {"id_": "773bb3cd-87f0-4aea-a0eb-9bf3ca65f2eb", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "0d807e4e-524c-4de5-a445-65f2645055ff", "node_type": "1", "metadata": {}, "hash": "417978c1c5b4fb664200bc000a9f41d93f5c8fc33f28a31ea128339811468f81", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "de65c2a1-97ff-4bfa-b7d0-52e200af1b61", "node_type": "1", "metadata": {}, "hash": "54d52a73421a01addc83fa2d69283f863de3b65baf59a3c1f081d077d2b35a14", "class_name": "RelatedNodeInfo"}}, "text": "1.3 Components of AHD package of care\n\n115\n\n# 8.1.4 Diagnostics for AHD and associated OIs\n\n115\n\n# 8.1.5 Management of opportunistic infections in AHD\n\n117\n\n# 8.1.6 ART Initiation and Intensive Adherence Support for Patients with AHD\n\n121\n\n# 8.1.7 Vaccination for People with AHD\n\n122\n\n# 8.1.8 Immune Reconstitution Inflammatory syndrome (IRIS)\n\n123\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\nxviii\n\n# 8.1.9 Management of AHD among Children less than ten years\n\n124\n\n# 8.2 Other Opportunistic Infections (OIs)\n\n126\n\n# 8.3 Preventing Opportunistic Infections (OIs)\n\n# 8.3.1 Cotrimoxazole Preventive Therapy (CPT)\n\n127\n\n# 8.3.2 Tuberculosis Preventive Treatment (TPT)\n\n128\n\n# 8.4 HIV-RELATED CO-MORBIDITIES\n\n146\n\n# 8.5 Mental Health and HIV\n\n# 8.5.1 Recommendations\n\n146\n\n# 8.5.2 Management Considerations\n\n147\n\n# CHAPTER 9 -SERVICE DELIVERY\n\n# 9.1 Introduction\n\n150\n\n# 9.2 Differentiated Service Delivery\n\n# 9.2.1 Differentiated HIV Testing Service Delivery\n\n151\n\n# 9.2.2 Differentiated ART Service Delivery\n\n151\n\n# 9.2.3 Differentiated Service Delivery Based on Clinical Characteristics\n\n153\n\n# 9.2.4 Differentiated Service Delivery based on Sub-Populations\n\n155\n\n# 9.2.5 Differentiated Service Delivery Based on Context\n\n161\n\n# 9.2.6 Integration of Service Delivery\n\n161\n\n# 9.2.7 Family-Centred Differentiated Service Delivery\n\n162\n\n# 9.3 Standards for Quality HIV Service Delivery\n\n# 9.3.1 Standards of Care\n\n163\n\n# 9.3.2 Standard Precautions\n\n166\n\n# 9.4 Nutrition\n\n# 9.4.1 Nutrition in HIV Positive Pregnant and Lactating Woman\n\n167\n\n# 9.4.2 Nutrition in Children Living with HIV\n\n167\n\n# 9.4.3 Nutrition and Antiretroviral Therapy\n\n169\n\n# 9.5 Service Delivery for Adolescents Living with HIV\n\n# 9.5.1 Adolescent Friendly Health Service\n\n169\n\n# 9.5.2 Package of services for adolescents living with HIV\n\n170\n\n# 9.5.4 Psychosocial support for adolescents living with HIV\n\n172\n\n# 9.5.5 Transitioning to adult care\n\n172\n\n# 9.5.6 Peer-driven adolescent service delivery models\n\n174\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 xix\n\n# CHAPTER 10- MONITORING & EVALUATION\n\n10.1 Introduction\n\n10.2 Selection of Indicators\n\n10.3 Data Management\n\n- 10.3.1 Data Collection\n\n10.4 HIV Data Dissemination and Use\n\n10.5 Human Resource for M&E\n\n10.6 HIV M&E Logistics\n\n10.7 Additional strategies in M&E\n\n10.8 HIV Research\n\n10.9 Periodic monitoring of the implementation of the guidelines and content update\n\nReferences - 187\n\nAppendix - 189\n\nAppendix 1: Commonly used Adult and Paediatric ARV Formulations and Dosage - 190Appendix 2: Mental Health Screening - 198Appendix 3: Energy and Nutritional Recommendations for PLHIV - 199Appendix 4: Recommended activities for adolescent HIV service delivery - 200Appendix 5: Guide on Age-Appropriate Disclosure for Children and Adolescents - 203Appendix 6: Self-management timeline for transitioning ALHIV - 204Appendix 7: Algorithm for Screening and Diagnosing TB in PLHIV - 206Appendix 8: Global Standards for Quality Health-Care Services for Adolescents - 210Appendix 9: Pharmacovigilance or Drug and Therapeutic Committees (PVC) - Terms of Reference - 211Appendix 10: NAFDAC ADR Form - 212\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - xx\n\n# INTRODUCTION\n\n|What\u2019s Inside:| |\n|---|---|\n|1.1 Objectives of the Guidelines|3|\n|1.2 Epidemiology of HIV in Nigeria|6|\n|1.", "mimetype": "text/plain", "start_char_idx": 33445, "end_char_idx": 36802, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "de65c2a1-97ff-4bfa-b7d0-52e200af1b61": {"__data__": {"id_": "de65c2a1-97ff-4bfa-b7d0-52e200af1b61", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "773bb3cd-87f0-4aea-a0eb-9bf3ca65f2eb", "node_type": "1", "metadata": {}, "hash": "e124379cc83ef65d105231b4b5756de68f210012e6a17891649d702f549cf162", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "ebc6c790-a421-45e6-beef-4782eeb79856", "node_type": "1", "metadata": {}, "hash": "a0ba7a8179be4b1cd0b18732e1d646d9170ad55cb252aa6e8360f5c1d00e4686", "class_name": "RelatedNodeInfo"}}, "text": "1 Objectives of the Guidelines|3|\n|1.2 Epidemiology of HIV in Nigeria|6|\n|1.3 Natural History of HIV|7|\n\n# The 2020 Nigeria HIV Guidelines\n\nThe 2020 Nigeria HIV Guidelines are informed by the basic principles of equality, equity, and social justice and they align strongly with the universal declarations of human rights. They promote universal access to comprehensive HIV prevention, treatment, and care for all persons in Nigeria. The recommendations of these guidelines are the product of careful balancing of science and public health. The core principles of these guidelines include:\n\n# 1. Public Health Approach\n\nThese guidelines reinforce the objectives of the national strategy for decentralization of HIV services in Nigeria. They seek to make HIV prevention, treatment, and care services universally available to all Nigerians irrespective of socioeconomic class and creed. This approach uses simplified drug formularies, fixed-dose combinations, task shifting and sharing, and simplified systems for clinical mentoring.\n\n# 2. Promotion of human rights and equity\n\nAccess to quality health care services including HIV prevention, treatment, care, and support is a basic human right which is the entitlement of all people regardless of nationality, sex, sexual orientation, ethnicity, race, religion, or other status. These rights should be recognized as fundamental to realizing the universal right to health. These guidelines will support the equitable provision of quality HIV services including ART and related interventions to all the people who need them; especially pregnant women, children, and high-risk populations. These services should be provided in an environment that minimizes stigma and discrimination. Basic rights and freedom of all clients will be respected in the implementation of the guidelines. For example, informed consent (for HIV testing and initiation of ART) and adequate health information safeguards should be put in place to ensure consent and confidentiality. Priority should be given to people who are most ill and those who are already on treatment.\n\n# 3. Implementation guided by in-country peculiarities\n\nImplementation of the recommendations of these guidelines will be informed by local context including; HIV epidemiology, availability of resources, the organization and capacity of the health systems at all levels of care. Indigenous best practices will be promoted alongside global standard practices.\n\n# 4. Strengthening health systems through innovation and learning\n\nService delivery approaches recommended in these guidelines will be implemented in a manner that strengthens health systems and enhances the local capacity to keep pace with the rapidly evolving science of HIV medicine.\n\n# 5. Increasing the effectiveness and efficiency of programmes\n\nAs the country scales-up access to ART in the face of competing national priorities, efforts will be made to optimize the effectiveness and efficiency of National HIV programmes through provision of ART to people living with HIV and implementing strategies and recommendations that are sustainable and less dependent on foreign aid.\n\n# 6. Differentiation and Integration of Services\n\nWith the UNAIDS 95-95-95 targets, scale-up of HIV care, treatment, and support services, and differentiating ART treatment\n\n# Objectives of the Guidelines\n\n- To provide updated and evidence-based clinical recommendations for the provision of HIV prevention, treatment, care and support services\n- To provide guidance on key service delivery and operational issues needed to increase the effectiveness and efficiency of HIV service delivery and strengthen the continuum of HIV care through linkage and integration\n- To provide programmatic guidance for the effective delivery of HIV prevention, treatment, care and support services at all levels of the health care system\n\nThese Guidelines will support:\n\n- Early HIV diagnosis and timely initiation of lifelong combination ART\n- Package of care for the management of PLHIV presenting with advanced HIV disease\n- Use of viral load testing for monitoring ART treatment success and diagnosis of treatment failure\n- Monitoring drug toxicity in every individual on ART\n- ARV prophylaxis to HIV exposed infants, timely DNA PCR testing and early linkage of HIV positive infants to treatment and care\n\n# The HIV Continuum of Care\n\nThese guidelines are predicated on HIV continuum of care. The diagnosis of HIV should be followed with timely initiation of ART and retention in care, sustained virological suppression resulting in improved quality of life. As many more PLHIV live longer, stable and healthier, HIV has become a chronic health condition. This requires that health systems and community interventions should be modified to optimize the chronic care model.\n\n# Contribution to National and Global Health Goals\n\nThese guidelines have taken into consideration the letter of the 2016 United Nations General Assembly Special Session (UNGASS) Political Declaration on HIV which affirms the 2030 agenda for sustainable development including the resolve of member states to end the AIDS epidemic by 2030. The 2016 guideline was designed to ensure that the UNAIDS 2014 declaration of 90-90-90 was achievable; however, huge gaps still exist.", "mimetype": "text/plain", "start_char_idx": 36726, "end_char_idx": 42002, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ebc6c790-a421-45e6-beef-4782eeb79856": {"__data__": {"id_": "ebc6c790-a421-45e6-beef-4782eeb79856", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "de65c2a1-97ff-4bfa-b7d0-52e200af1b61", "node_type": "1", "metadata": {}, "hash": "54d52a73421a01addc83fa2d69283f863de3b65baf59a3c1f081d077d2b35a14", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "856b62f2-43df-4a71-9419-06d1bbd3e7de", "node_type": "1", "metadata": {}, "hash": "ac95551c4d25321deda327a9c095547b2113bab8d2b17232f3cc0c7afe5b4e29", "class_name": "RelatedNodeInfo"}}, "text": "The diagnosis of HIV should be followed with timely initiation of ART and retention in care, sustained virological suppression resulting in improved quality of life. As many more PLHIV live longer, stable and healthier, HIV has become a chronic health condition. This requires that health systems and community interventions should be modified to optimize the chronic care model.\n\n# Contribution to National and Global Health Goals\n\nThese guidelines have taken into consideration the letter of the 2016 United Nations General Assembly Special Session (UNGASS) Political Declaration on HIV which affirms the 2030 agenda for sustainable development including the resolve of member states to end the AIDS epidemic by 2030. The 2016 guideline was designed to ensure that the UNAIDS 2014 declaration of 90-90-90 was achievable; however, huge gaps still exist. In particular, the 2018 National AIDS Indicator and Impact Survey (NAIIS) showed that an estimated 800,000 individuals are yet to be identified. As at the end of 2019, approximately 1.14 million people were on treatment out of the estimated 1.9 million people living with HIV. Thus, the country is at 60% ART coverage. Although there are facility reports of giant strides being made concerning the third 90 at tertiary institutions in Nigeria, nationwide report showed widely variable suppression rates as low as 50% in some facilities to 80% in others. Specifically, the current guidelines seek to contribute towards the achievement of UNAIDS 95-95-95 targets. In addition, this document will contribute to achieving the goals and targets articulated in the National HIV/AIDS strategic framework (NSF 2021-2025).\n\n# Prevention of new HIV infections among adults, adolescents, pregnant and breastfeeding women and children\n\n# Strengthened adherence to ART and retention in care\n\n# Improved quality ART service delivery all over the country\n\nWhat is new in the 2020 National Guidelines for HIV Prevention, Treatment and Care?\n\nART should be initiated in all adults, adolescents, pregnant and breastfeeding women, and children with a diagnosis of HIV regardless of WHO clinical stage and CD4+ cell count. This recommendation (as in the 2016 Guidelines) maintains that people who test HIV positive will be initiated on ART once they are willing and ready to start ART for life.", "mimetype": "text/plain", "start_char_idx": 41148, "end_char_idx": 43477, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "856b62f2-43df-4a71-9419-06d1bbd3e7de": {"__data__": {"id_": "856b62f2-43df-4a71-9419-06d1bbd3e7de", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "ebc6c790-a421-45e6-beef-4782eeb79856", "node_type": "1", "metadata": {}, "hash": "a0ba7a8179be4b1cd0b18732e1d646d9170ad55cb252aa6e8360f5c1d00e4686", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "c60d14ec-6b32-4dd3-a838-59461c2b8ced", "node_type": "1", "metadata": {}, "hash": "381e0454259e8476b24c19d6d20403db6745651bbf9a6532a5df8a2c6e0b6059", "class_name": "RelatedNodeInfo"}}, "text": "Specifically, the current guidelines seek to contribute towards the achievement of UNAIDS 95-95-95 targets. In addition, this document will contribute to achieving the goals and targets articulated in the National HIV/AIDS strategic framework (NSF 2021-2025).\n\n# Prevention of new HIV infections among adults, adolescents, pregnant and breastfeeding women and children\n\n# Strengthened adherence to ART and retention in care\n\n# Improved quality ART service delivery all over the country\n\nWhat is new in the 2020 National Guidelines for HIV Prevention, Treatment and Care?\n\nART should be initiated in all adults, adolescents, pregnant and breastfeeding women, and children with a diagnosis of HIV regardless of WHO clinical stage and CD4+ cell count. This recommendation (as in the 2016 Guidelines) maintains that people who test HIV positive will be initiated 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\n- All adults and adolescents with severe or advanced HIV clinical disease (WHO stage 3 or 4)\n- All adults and adolescents with HIV and CD4+ cell count of less than 350 cells/mm\u00b3\n- All HIV positive pregnant and breastfeeding women\n- All HIV positive children older than 5 years of age with severe or advanced disease (WHO stage 3 or 4)\n- All HIV positive children older than 5 years of age with CD4+ cell count less than 350 cells/mm\u00b3\n- All HIV positive children less than 2 years of age\n- All HIV positive children less than 5 years of age with CD4+ cell count of less than 750 cells/mm\u00b3; or CD4+ percentage less than 25%\n\n**List of new recommendations**\n|Service Area|New update|\n|---|---|\n|HIV diagnosis|Current innovative testing strategies for improved case finding and efficient 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|HIV Treatment|Tenofovir+Lamivudine+Dolutegravir as preferred first-line ART for all 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# Service Delivery\n\nExpansion on models for Differentiated service delivery for specific populationsAdolescent friendly services and modelsIntegration of family planning service in ART\n\n# Laboratory testing\n\nUse of point of care devices for rapid assessment of:Viral load in pregnant women presenting close to labourEarly infant diagnosis in hard to reach areasSame day CD4+ cell countDiagnostics for opportunistic infectionsUrine Lateral Flow Lipoarabinomannan (LF-LAM) assayStool for Xpert MTB/RIF assay in childrenCrAg testHistoplasma antigen testIgG/IgM Toxoplasma Antibody Test\n\n# HIV exposed infants\n\nNucleic acid testing at birth (NAT)\n\n# Prevention\n\nEvent-driven Pre-Exposure Prophylaxis\n\n# Process of guidelines review\n\nThe review and development of the 2020 National Guidelines on HIV prevention, treatment, and care, commenced in June 2019 when the Federal Ministry of Health established working groups of the National Task Team on ART. These working groups included:\n\n1. PMTCT working group\n2. Adult/Pediatric ART working group\n3. Service Delivery working group\n4. AHD working group\n5. Lab/HTS working group\n\nThe working groups were mandated to review the respective sections of the 2016 National guidelines for HIV Prevention, treatment and Care in line with emerging HIV management modalities. The committees worked remotely and also met in person to review the guidelines and develop recommendations for inclusion in the 2020 guidelines. Following the completion of the tasks by the groups, the FMOH convened series of stakeholders' meetings to review the output from the working groups and integrate into a final document. Resources used for the review included the WHO Policy brief on Antiretroviral Regimens (July 2019), NAIIS 2018 Technical Report and the Nigerian National data repository amongst others.\n\nRecommendations contained in this document are the product of stakeholder consensus, and the principal consideration is the wellbeing of the patients. The recommendations are essentially guidance on HIV diagnosis, general HIV care and support, rational use of ARV drugs for treating and preventing HIV infection and effective delivery of services.", "mimetype": "text/plain", "start_char_idx": 42557, "end_char_idx": 47018, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c60d14ec-6b32-4dd3-a838-59461c2b8ced": {"__data__": {"id_": "c60d14ec-6b32-4dd3-a838-59461c2b8ced", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "856b62f2-43df-4a71-9419-06d1bbd3e7de", "node_type": "1", "metadata": {}, "hash": "ac95551c4d25321deda327a9c095547b2113bab8d2b17232f3cc0c7afe5b4e29", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "b132e3cd-9e1c-4143-be38-aabfe6f039a4", "node_type": "1", "metadata": {}, "hash": "e8920b597df851bc4a6954d8343132522ba1007928d63c9d013624cf659395aa", "class_name": "RelatedNodeInfo"}}, "text": "The committees worked remotely and also met in person to review the guidelines and develop recommendations for inclusion in the 2020 guidelines. Following the completion of the tasks by the groups, the FMOH convened series of stakeholders' meetings to review the output from the working groups and integrate into a final document. Resources used for the review included the WHO Policy brief on Antiretroviral Regimens (July 2019), NAIIS 2018 Technical Report and the Nigerian National data repository amongst others.\n\nRecommendations contained in this document are the product of stakeholder consensus, and the principal consideration is the wellbeing of the patients. The recommendations are essentially guidance on HIV diagnosis, general HIV care and support, rational use of ARV drugs for treating and preventing HIV infection and effective delivery of services.\n\nStakeholders involved in the review and development of the 2020 national guidelines included\n\n# representatives of the FMOH, SMOH, NPHCDA, NACA, NAFDAC, NTBLCP, CHAI, UNAIDS, WHO, UNICEF, PEPFAR, CDC, USAID, HIV Implementing Partners, NEPWHAN, CSOs, National Task Teams for ART, PMTCT and HTS, facility-level HIV service providers.\n\nThe process was coordinated by the NASCP.\n\n# Target audience\n\nThe 2020 National Guidelines for HIV Prevention, Treatment and Care is intended primarily for use by HIV programme managers and service providers at all levels of HIV service delivery. The critical audiences for the guidelines include:\n\n- Health facility level service providers\n- National and State level HIV Programme Managers\n- National HIV treatment and prevention technical working groups\n- National TB programme managers\n- Managers of maternal, newborn and child health and reproductive health programmes\n- Clinicians and other health service providers in private practice\n- Managers of national laboratory services\n- Community-based organizations including People living with HIV\n- International and bilateral agencies and organizations\n\n# 1.2 Epidemiology of HIV in Nigeria\n\nNigeria reported the first case of AIDS in 1986. Since then, the National HIV prevalence increased exponentially from 1.8% in 1991 peaking at 5.8% in 2001 and progressively declining through 4.4% in 2005, 3% in 2014. Based on the report from NAIIS, the current prevalence of individuals aged 15 - 64 is 1.4%. As at 2019, Nigeria had an estimated HIV burden of 1.9 million people, the fourth largest in the world. The incidence of HIV in 2018 was estimated at 8 per 10,000 persons (NAIIS). The prevalence varied across Regions and States with the highest prevalence being in the South-South (3.1%) while the North-West had the lowest prevalence (0.6%). Akwa Ibom state had the highest prevalence (5.5%) while Katsina had the lowest prevalence (0.3%).\n\n# 1.2.1 HIV Transmission\n\nHeterosexual sex still accounts for the majority of transmissions in Nigeria. Over 90% of transmissions are via unprotected sexual intercourse between heterosexual individuals. However, current data suggest that homosexuality is contributing disproportionately to the overall National epidemic. It is estimated that MSM constitutes only about 1% of the Nigerian population, yet this group now contributes 20% of new infections in Nigeria. This is not unexpected given the fact that 2018 NAIIS documented National population HIV prevalence of 1.4% whereas the prevalence of the infection among MSM has been rising consistently from 14% 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. Most children less than 15 years living with HIV acquire the infection through mother-to-child transmission (MTCT). This can occur during pregnancy, labour and delivery or during breast-feeding.\n\n# Other Modes of HIV Transmission\n\nOther modes of transmission of HIV whose incidence rate is not well documented include transmission from transfusion with infected blood and blood products, contact with sharp skin-piercing objects used for scarifications, tattoos, and surgical procedures.\n\n# Natural History of HIV\n\n# Adults and Children older than 5 years\n\nA typical HIV infection can be divided into three stages: primary infection, asymptomatic infection, and symptomatic infection including AIDS. Following primary HIV infection, the CD4+ cell count decreases and the HIV RNA rises significantly. With sufficient exposure to viral antigens, cytotoxic T-lymphocyte responses are generated, and the HIV viral load typically declines to an equilibrium known as a virologic \u201cset-point\u201d within 6 to 12 weeks of infection.", "mimetype": "text/plain", "start_char_idx": 46153, "end_char_idx": 50762, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "b132e3cd-9e1c-4143-be38-aabfe6f039a4": {"__data__": {"id_": "b132e3cd-9e1c-4143-be38-aabfe6f039a4", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "c60d14ec-6b32-4dd3-a838-59461c2b8ced", "node_type": "1", "metadata": {}, "hash": "381e0454259e8476b24c19d6d20403db6745651bbf9a6532a5df8a2c6e0b6059", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "e9fe0eaa-658a-4901-9617-57d195b286d8", "node_type": "1", "metadata": {}, "hash": "87a500a2d3f2674d80bfdd3a34a04877fb2d9b66884a983c03d949764f4e2bee", "class_name": "RelatedNodeInfo"}}, "text": "This can occur during pregnancy, labour and delivery or during breast-feeding.\n\n# Other Modes of HIV Transmission\n\nOther modes of transmission of HIV whose incidence rate is not well documented include transmission from transfusion with infected blood and blood products, contact with sharp skin-piercing objects used for scarifications, tattoos, and surgical procedures.\n\n# Natural History of HIV\n\n# Adults and Children older than 5 years\n\nA typical HIV infection can be divided into three stages: primary infection, asymptomatic infection, and symptomatic infection including AIDS. Following primary HIV infection, the CD4+ cell count decreases and the HIV RNA rises significantly. With sufficient exposure to viral antigens, cytotoxic T-lymphocyte responses are generated, and the HIV viral load typically declines to an equilibrium known as a virologic \u201cset-point\u201d within 6 to 12 weeks of infection. Once this viral set-point is reached, the CD4+ cell count may rebound again marginally, although it does not often return to baseline values. Concurrent with these events are clinical manifestations 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 asymptomatic. Once infected, adults experience an asymptomatic clinical latency that lasts 2 to 10 years, during which HIV is produced and removed by the immune system and CD4+ T cells are killed and replaced. This latency period is considerably shorter in children. During this asymptomatic period, the number of infected circulating CD4+ cells and free virions are relatively low. Moreover, the hematopoietic system can replace most T cells that are destroyed, thus keeping the CD4+ cell counts in the normal range for adults and children >6 years (636-9773 cells/mm).\n\nA number of opportunistic infections (OIs), including recurrent oral candidiasis and tuberculosis are common during the early symptomatic phase of AIDS. As the CD4+ cell count declines to an even lower level, additional life-threatening OIs such as herpes zoster, amoebiasis, microsporidiosis, strongyloidiasis, toxoplasmosis, dermatophytosis etc. may occur with increasing frequency and severity. In the later stages of symptomatic HIV infection, the viral load levels rise again. Quantitative PCR methods (viral load assays) demonstrate:\n\n- Continuous replication of HIV in nearly all infected individuals, although the rates of virus production vary by as much as 70-fold in different individuals\n- The average half-life of an HIV infected cell in vivo is 2.1 days. Recent reports have suggested an even faster turnover of plasma virus of 28 to 110 per minute\n- Up to 10 \u20131010 HIV particles are produced each day, and averages of 2 x 10 CD4+ cells are produced each day.\n\n# HIV in Pregnancy\n\nIn pregnancy, immune function is suppressed in both HIV-infected and uninfected women. There is a decrease in immunoglobulin and complement levels in early pregnancy and a more significant decrease in cell-mediated immunity. Studies have shown that pregnancy may however not affect the progression of HIV or the rate of death. On the other hand, HIV infected pregnant women are more likely to develop early pregnancy complications such as bacterial pneumonia, urinary tract infections, spontaneous abortion, higher rates of ectopic pregnancy and increased stillbirth rates, especially from areas where the epidemic has been present for a long time. The risk appears to be lower in asymptomatic HIV positive pregnant women.\n\n# National Guidelines for HIV Prevention Treatment and Care 2020\n\n7\n\n# 1.3.3 HIV infection in children under 5 years\n\nThere are critical differences between HIV progression in children and adults. Stemming largely from the lower efficiency of a child's immature immune system, these differences usually result in 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 values well above 100,000 copies/ml. Thereafter the viral load remains high until the age of 2 or 3 years after which it declines gradually to reach the viral load set point. These viral dynamics are significantly different from the rapid increase and decrease of the viral load seen in horizontally infected older children and adults.\n\nIn children, the higher viral load is associated with the level of somatic growth of the lymphatic system and the inability of their immature immune system to mount an HIV-specific response. When assessing the immune system in infants and children, it is very important to compare the child's CD4+ cell count with the age-appropriate values. Lymphocyte counts are very high in infancy and decline to adult levels around 6 years of age.\n\nHigher mortality in HIV-infected children may result from intercurrent infections, malnutrition, and lack of access to primary HIV care including delayed definitive diagnosis.", "mimetype": "text/plain", "start_char_idx": 49859, "end_char_idx": 54833, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "e9fe0eaa-658a-4901-9617-57d195b286d8": {"__data__": {"id_": "e9fe0eaa-658a-4901-9617-57d195b286d8", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "b132e3cd-9e1c-4143-be38-aabfe6f039a4", "node_type": "1", "metadata": {}, "hash": "e8920b597df851bc4a6954d8343132522ba1007928d63c9d013624cf659395aa", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "08444e6b-7299-445d-a579-45b38638d531", "node_type": "1", "metadata": {}, "hash": "1dcc5f6979a3d2b5aeb03640b60b29f404b2c2741fa2f75570e7706fc3ff41cc", "class_name": "RelatedNodeInfo"}}, "text": "Thereafter the viral load remains high until the age of 2 or 3 years after which it declines gradually to reach the viral load set point. These viral dynamics are significantly different from the rapid increase and decrease of the viral load seen in horizontally infected older children and adults.\n\nIn children, the higher viral load is associated with the level of somatic growth of the lymphatic system and the inability of their immature immune system to mount an HIV-specific response. When assessing the immune system in infants and children, it is very important to compare the child's CD4+ cell count with the age-appropriate values. Lymphocyte counts are very high in infancy and decline to adult levels around 6 years of age.\n\nHigher mortality in HIV-infected children may result from intercurrent infections, malnutrition, and lack of access to primary HIV care including delayed definitive diagnosis. With no interventions, the majority of children who acquired HIV perinatally develop HIV-related symptoms by 6 months of age.\n\nPerinatally infected children fit into one of three categories:\n\nCategory 1: Rapid progressors develop signs and symptoms of HIV and AIDS and die by age 1 year. These children are likely to have acquired the infection in-utero or during the early perinatal period (about 25 \u2013 30%)Category 2: Children develop symptoms early in life, followed by rapid deterioration and death by age 3 to 5 years (about 50 \u2013 60%)Category 3: Long-term survivors live beyond age 8 years (5 - 25%)\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# List of Contributors\n\n|Dr. Umo Mildred Ene-Obong|Head/Director, Public Health Department FMoH|\n|---|---|\n|Dr Akudo Ikpeazu|National Coordinator NASCP|\n|Mr Araoye Segilola|Former, National Coordinator|\n|Pharm Oloyede Yekini|Former, Director, Logistics Unit NASCP|\n|Dr Akpan Nsebong|Deputy Director NASCP|\n|Ombudadu Obadiah A|Deputy Director NASCP|\n|Dr Deborah Odoh|Deputy Director, NTTP & Performance Management NASCP|\n|Mrs Semlek Rachael N|Chief Accountant NASCP|\n|Dr Nwaokenneya Peter|Assistant Director, Adult ART/TB/HIV - NASCP|\n|Dr Chioma Ukanwa|Senior Medical Officer 1, NTTP & Performance Management NASCP|\n|Ms Rahila Agwom|Chief Scientific Officer NASCP|\n|Dr Chinwendu Daniel Ndukwe|Deputy Director, Health Sector Response Support NACA|\n|Prof.", "mimetype": "text/plain", "start_char_idx": 53921, "end_char_idx": 56254, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "08444e6b-7299-445d-a579-45b38638d531": {"__data__": {"id_": "08444e6b-7299-445d-a579-45b38638d531", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "e9fe0eaa-658a-4901-9617-57d195b286d8", "node_type": "1", "metadata": {}, "hash": "87a500a2d3f2674d80bfdd3a34a04877fb2d9b66884a983c03d949764f4e2bee", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "adc25c12-2748-4636-b682-3bcc9ef0ae8e", "node_type": "1", "metadata": {}, "hash": "f85c098a6438861d62493228ad3d7da1bb0a28536c87971851f855b94f2e5d50", "class_name": "RelatedNodeInfo"}}, "text": "Sulaimon Akanmu|Chairman NTTA / Haematologist LUTH Lagos|\n|Dr Damien Anweh|Member NTTA / Physician FMC, Markurdi|\n|Dr Rita O. Oladele|Member NTTA / Microbiologist LUTH Lagos|\n|Dr Charles Olomofe|Public Health Physician FETH Ido Ekiti|\n|Dr Oluwafunke Ilesanmi|Technical Officer, HIV and Viral Hepatitis WHO|\n|Dr Dennis Onotu|Branch Chief, Continuum of care & treatment CDC|\n|Dr Obinna Ogbanufe|Senior Program Specialist, HIV care and treatment CDC|\n|Dr Igboeline Onyeka Donald|Programme Manager, Treatment USAID|\n|Dr Abiye Kalio|Programme Manager USAID|\n|Folu Lufadeju|Deputy Country Director CHAI|\n|Pharm Willams Eigege|Associate CHAI|\n|Dr Saswata Dutt|Senior Technical Advisor, HIV/TB/DR -TB IHVN|\n|Dr Olufemi Oke|Technical Advisor CRS|\n|Dr Olawale Fadare|Technical Director TMEC/RISE Program|\n|Dr Olayiwola Lanre|Senior Technical Advisor CCFN|\n\n# DIAGNOSIS OF HIV INFECTION\n\nWhat\u2019s Inside:\n\n|2.1 Introduction|11|\n|---|---|\n|2.2 HIV Testing Services|11|\n|2.3 HTS in Pregnancy|14|\n|2.4 Re-testing|15|\n|2.5 Repeat HIV Testing|15|\n|2.6 Disclosure Scenarios|16|\n|2.7 Linkage of HTS to care and ART|16|\n|2.8 Laboratory Diagnosis of HIV Infection|17|\n|2.9 Laboratory Diagnosis of HIV Infection in Children by Age Group|20|\n|2.10 Clinical Diagnosis and Staging of HIV Infection|22|\n\n# 2.1 Introduction\n\nDiagnosis of HIV infection is simply a proof of the presence of HIV in an individual, and this can be achieved by demonstrating either the presence of HIV antibodies in plasma or serum (indirect test) or the virus in blood (direct test). Available tests for diagnosis of HIV include antibody, antigen and nucleic acid tests. The antibody detection tests are suitable for the diagnosis of HIV infection in adults and children 18 months and above, while the nucleic acid test is used mainly for the diagnosis of HIV infection in children under 18 months. The diagnosis of HIV infection should not be made without first obtaining a positive result from any of the test methods highlighted above. It is recommended that before commencing ART all persons who have tested HIV positive should be re-tested.\n\n# 2.2 HIV Testing Services\n\nHIV Testing Services (HTS) provides a gateway to HIV prevention, treatment and care services. HTS consists of a range of services that include diagnosis of HIV using HIV testing methods, counselling (pre-test information and post-test counselling), linkage to HIV prevention, treatment and care and other clinical services, and coordination with laboratory services for quality 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, confidentiality, counselling, correct test results and connections to care, treatment and prevention services. The WHO five C's are principles that apply to all models of HTS and in all circumstances. For further information, refer to the National HTS Guidelines 2017.\n\n# 2.2.1 Risk Stratification\n\nRisk stratification is a strategy that identifies those who are likely to be infected with HIV based on their risk exposure. The HIV risk stratification tool enables service providers to determine if a client presenting at the health facility or community is eligible for an HIV test or not, following an assessment using a set of predetermined criteria. The Risk stratification Tool (RST) has been useful in aiding the programme to be more efficient in the testing of clients.\n\n# 2.2.2 Pre-test services\n\nPre-test information may be provided through individual or group information sessions and media such as posters, brochures, and short video clips shown in waiting rooms. When children and adolescents are receiving HTS, information should be presented to them in an age-appropriate manner and in a way their guardians can understand. Pre-test information sessions for people receiving HIV testing should emphasize the benefits of HIV testing, the meaning of an HIV-positive and an HIV-negative test, and an assessment of clients' readiness for HIV testing. For further information, refer to the National HTS Guidelines 2017.", "mimetype": "text/plain", "start_char_idx": 56255, "end_char_idx": 60319, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "adc25c12-2748-4636-b682-3bcc9ef0ae8e": {"__data__": {"id_": "adc25c12-2748-4636-b682-3bcc9ef0ae8e", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "08444e6b-7299-445d-a579-45b38638d531", "node_type": "1", "metadata": {}, "hash": "1dcc5f6979a3d2b5aeb03640b60b29f404b2c2741fa2f75570e7706fc3ff41cc", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "c268ce2d-dad5-4184-b4cb-bc43a8b97797", "node_type": "1", "metadata": {}, "hash": "1960471789cbb4360fc43dd3a11eac6fad1d5b3f23a96e4e5f0a54c8c961432b", "class_name": "RelatedNodeInfo"}}, "text": "The HIV risk stratification tool enables service providers to determine if a client presenting at the health facility or community is eligible for an HIV test or not, following an assessment using a set of predetermined criteria. The Risk stratification Tool (RST) has been useful in aiding the programme to be more efficient in the testing of clients.\n\n# 2.2.2 Pre-test services\n\nPre-test information may be provided through individual or group information sessions and media such as posters, brochures, and short video clips shown in waiting rooms. When children and adolescents are receiving HTS, information should be presented to them in an age-appropriate manner and in a way their guardians can understand. Pre-test information sessions for people receiving HIV testing should emphasize the benefits of HIV testing, the meaning of an HIV-positive and an HIV-negative test, and an assessment of clients' readiness for HIV testing. For further information, refer to the National HTS Guidelines 2017.\n\n# 2.2.3 Post-test services\n\nPost-test information and counselling for people who test HIV negative should emphasize an explanation of the test result, referral and linkage to other relevant HIV prevention services, and advise to return in 4 weeks for repeat testing in the event of recent risky behaviour. For those people who test HIV positive, post-test information should emphasize an explanation of the test result and helping the client to cope with emotions arising from the diagnosis, clear information\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 2.2.4 Index Testing Services\n\nIndex testing services (ITS) is a focused HTS approach in which the household, family members (including children) and partners of people diagnosed with HIV are offered HTS. ITS should be offered by a trained provider in an appropriate, safe and ethical manner. The provider should ask people diagnosed with HIV (index clients) to list their sexual partners, drug-injecting partners (where applicable), children, and other family members. If the index client agrees, offer these partners and the children HIV testing services (HTS). The process is completely voluntary. Such services 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 voluntary safe and ethical ITS:\n\n- All providers conducting index testing must be trained and supervised on index testing procedures including 5Cs, intimate partner violence (IPV) screening, adverse event monitoring, and ethics (respect for the rights of clients, informed consent and 'do no harm').\n- Strict Adherence to 5C's should be observed/assessed at least quarterly, as well as provision of additional voluntary and ethical practices as detailed below:\n- Providers must offer clients a choice of all four partner notification strategies (client, contract, provider, dual referral) and indicate that there are both ways to notify contacts that do not involve disclosure and ways to ensure anonymity.\n- Providers will work with clients experiencing IPV to choose a partner notification method that ensures their safety (which may be declining of index testing service).\n- All HIV testing clients, including index clients, should be provided with all available HIV prevention, care and treatment services, regardless of whether or not they provide details about their contacts. Clients must NEVER be pressured into sharing the names of their contacts for fear of being denied services. Services must NEVER be withheld under any circumstances.\n- Clients should be informed of their right to decline participation in index testing services throughout the process, not just during the elicitation interview.\n- IPV risk assessment should be conducted for each contact elicited, with referral options to necessary services using SOPs (available at www.humanitarianresponse.info/files/document/nigeria_sops_gbv_prevention_response_2019.pdf).\n- Onsite provision of first-line services (Listen, Inquire, Validate, Ensure safety, Support) for anyone reporting IPV, and additional services offered either onsite or as referral.\n- A secure environment (e.g. lockable cabinets) to store patient information.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n12\n\n# See the figure below for detailed information:\n\n| |1. Monitor|Compliance|with minimum|standards| |\n|---|---|---|---|---|---|\n| | |2. Obtain Informed|consent| | |\n| | |3. Intimate Partner|Violence Risk|Assessment and|Service Provision|\n|4. Quality|assurance and|accountability| | | |\n|5.", "mimetype": "text/plain", "start_char_idx": 59315, "end_char_idx": 63936, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c268ce2d-dad5-4184-b4cb-bc43a8b97797": {"__data__": {"id_": "c268ce2d-dad5-4184-b4cb-bc43a8b97797", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "adc25c12-2748-4636-b682-3bcc9ef0ae8e", "node_type": "1", "metadata": {}, "hash": "f85c098a6438861d62493228ad3d7da1bb0a28536c87971851f855b94f2e5d50", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "bb428944-f860-48cc-a583-35e574e586c7", "node_type": "1", "metadata": {}, "hash": "303e9cbf107b6158cb0606e9111543386498ab12afc7debe50651187c19a7caa", "class_name": "RelatedNodeInfo"}}, "text": "- Onsite provision of first-line services (Listen, Inquire, Validate, Ensure safety, Support) for anyone reporting IPV, and additional services offered either onsite or as referral.\n- A secure environment (e.g. lockable cabinets) to store patient information.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n12\n\n# See the figure below for detailed information:\n\n| |1. Monitor|Compliance|with minimum|standards| |\n|---|---|---|---|---|---|\n| | |2. Obtain Informed|consent| | |\n| | |3. Intimate Partner|Violence Risk|Assessment and|Service Provision|\n|4. Quality|assurance and|accountability| | | |\n|5. Adverse Event|Monitoring| | | | |\n\nFigure 2.1: Safe and Ethical Index Testing Services\n\n2.2.5 Social Network Testing\n\nSocial Network Testing (SNT) is when HIV-positive and/or high-risk HIV-negative persons, particularly from key populations (KP) are enlisted as recruiters to identify individuals from their social, sexual, and drug-using networks (network associates) for HTS. Social and risk network strategies complement traditional peer outreach by engaging previously unidentified KP and other high-risk populations for HIV prevention and testing. The goal is to reach hidden, high-risk networks, expand HIV case detection potential, and, as an integrated part of a differentiated model, link HIV-positive individuals to rapid treatment, and connect HIV-negative individuals to services that will help them remain HIV-negative.\n\n2.2.6 Blended Index and Social Network Strategies\n\nIt is valuable to synergistically build upon a core foundation of index testing to introduce social network strategies (SNS) to expand case-finding options for high-risk groups. The two strategies can be used in concert to ensure that all high-risk, direct exposure contacts and social network members are tested and that HTS extends into harder-to-reach networks of undiagnosed PLHIV.\n\n2.2.7 HIV Self-testing\n\nHIV self-testing (HIVST) refers to a process in which a person collects his or her specimen (oral fluid or blood) and then performs an HIV test and interprets the result, often in a private setting, either alone or with someone he or she trusts. As with all approaches to HTS, HIVST should always be voluntary, not coercive or mandatory. Although reported misuse and social harm are rare, efforts to prevent, monitor, and further mitigate related risks are essential. A reactive (HIV-positive) HIVST result always requires further testing and confirmation from a trained provider, starting from the beginning of the validated national testing algorithm. Importantly, HIVST is a screening test and should not be used to provide a definitive HIV diagnosis. Clear messages are essential to ensure that HIVST users understand how to perform the test, the meaning of the test results, and where and how to access follow-up services following a test, including retesting, care, and treatment. Linkage to HIV testing services through a facility or HTS provider is critical following a reactive HIVST. A negative HIVST is reliable evidence of no infection and does not\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# require additional testing unless PrEP is planned\n\nin which case the negative result should be confirmed using the national testing algorithm before PrEP initiation. Interpretation of a non-reactive (HIV-negative) self-test result will also depend on the ongoing risk of HIV exposure. Individuals at high ongoing risk, or who test within six weeks of possible HIV exposure, should be encouraged to retest. HIVST is not recommended for users with a known HIV status who are taking antiretroviral drugs, as this may lead to an incorrect self-test result (false non-reactive). HIVST for children 2-11 years must be caregiver assisted or health care worker assisted with caregiver consent. Provisions should also be made for persons with disabilities to access appropriate information and educational materials about HIVST and to receive support to conduct the HIVST as needed. For further information, refer to the National HIVST Operational Guidelines 2019.\n\n# Recency Testing\n\nRecency testing refers to an anti-body-based test to distinguish recent from long-term HIV infection using antibody avidity (binding strength). The recency test kit is used to indicate whether a person's HIV infection was recently acquired (i.e. in the last 4-6 months). This promises to be a useful tool for disease monitoring and surveillance. All kits for this procedure should be evaluated in line with National standards before deployment or public health use after post-market validation. This test should be done immediately after the client tests positive using the National testing algorithm.", "mimetype": "text/plain", "start_char_idx": 63317, "end_char_idx": 68038, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "bb428944-f860-48cc-a583-35e574e586c7": {"__data__": {"id_": "bb428944-f860-48cc-a583-35e574e586c7", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "c268ce2d-dad5-4184-b4cb-bc43a8b97797", "node_type": "1", "metadata": {}, "hash": "1960471789cbb4360fc43dd3a11eac6fad1d5b3f23a96e4e5f0a54c8c961432b", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "acdae45e-cd3e-4340-988f-6cf0b86bfecf", "node_type": "1", "metadata": {}, "hash": "88a9c47dc8f524d88f63b808ed1b45faf7ff98d40c98942d12bf2f8e4bec3086", "class_name": "RelatedNodeInfo"}}, "text": "HIVST for children 2-11 years must be caregiver assisted or health care worker assisted with caregiver consent. Provisions should also be made for persons with disabilities to access appropriate information and educational materials about HIVST and to receive support to conduct the HIVST as needed. For further information, refer to the National HIVST Operational Guidelines 2019.\n\n# Recency Testing\n\nRecency testing refers to an anti-body-based test to distinguish recent from long-term HIV infection using antibody avidity (binding strength). The recency test kit is used to indicate whether a person's HIV infection was recently acquired (i.e. in the last 4-6 months). This promises to be a useful tool for disease monitoring and surveillance. All kits for this procedure should be evaluated in line with National standards before deployment or public health use after post-market validation. This test should be done immediately after the client tests positive using the National testing algorithm.\n\n# HTS in Pregnancy\n\nThe entry-point for PMTCT services is through HIV testing of pregnant women at the earliest opportunity; during antenatal care, labour and delivery including post-partum. In all settings, HTS should be offered to all pregnant women seeking antenatal care. Retesting for HIV in late pregnancy and early in labour is recommended for pregnant women who tested negative in early pregnancy.\n\n# Approach to HTS in Pregnant Women\n\nHIV testing of pregnant women should be accompanied by culturally acceptable counselling that highlights the benefits of knowing one's HIV status and its implications for the woman's health, pregnancy and the unborn child. The elements of effective counselling are confidentiality, timeliness, acceptance, accessibility, consistency and accuracy.\n\nThe recommended approach to testing and counselling is the routine approach (also referred to as the PITC \u201copt-out\u201d approach) where HIV testing is offered as part of routine tests in antenatal clinics. The pregnant woman reserves the right to refuse the test.\n\n# Essential Components of HTS for PMTCT\n\nPre-test informationHIV testing with same-day resultPost-test counsellingFollow-up counselling\n\n# Women should be encouraged to start antenatal care early (within first trimester from 14 weeks of pregnancy) and HTS should be provided during the first ANC visit.\n\n# 2.3.3 HTS for women in labour\n\nHIV testing in labour should be provided for all women of unknown HIV status and those who tested negative during pregnancy. This is because some women might not have registered in the antenatal clinic and are presenting for the first time in labour. Such women should be offered the opt-out approach and given appropriate post-test counselling in the post-partum period or pre-test counselling if she had declined the test. The following steps should be taken:\n\n- Determine HIV test history\n- Discuss the benefits of HIV testing and ART\n- Explain the HIV testing process\n- Offer the test\n\nIf the above is not feasible at the time the woman presents, steps should be taken to offer the test as soon as possible after delivery.\n\n# 2.3.4 HTS for post-partum women\n\nTo reduce the number of new paediatric infections, additional efforts are required to reduce mother to child transmission post-partum (especially during breastfeeding). Breastfeeding mothers of unknown HIV status and those who tested negative during pregnancy should be counselled and assessed to determine exposure and offered testing if indicated at the 6-week infant immunization visit. If negative, breastfeeding mothers should be retested at 6-month intervals until the cessation of breastfeeding. Counselling on the HIV retesting schedule both in pregnancy and the postpartum period should be integrated into routine ANC and postnatal education.\n\n# 2.4 Re-testing\n\nWith the advent of the \u201cTest and Treat\u201d policy in Nigeria, all HIV-positive persons are now eligible to receive ART, regardless of CD4+ cell count. To ensure that individuals are not needlessly placed on life-long ART (with potential side-effects, waste of resources, psychological impact of misdiagnosis), all individuals should be retested to verify their HIV status before or at the time of starting ART. Misdiagnosing HIV infection, irrespective of its scale is of critical importance. Any incorrect diagnosis, whether false-positive or false-negative has severe 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 new specimen. Retesting should be conducted at a different site, ideally, the site where the decision about ART initiation will be made. Retesting according to this procedure aims to rule out possible technical or clerical errors, including specimen mix-up through mislabelling and transcription errors, as well as random error either by the provider or of the test device.\n\n# 2.5 Repeat HIV Testing\n\nIf an antibody only test is negative, repeat HIV testing should occur at 6 weeks, 3 months and 6 months following the exposure.", "mimetype": "text/plain", "start_char_idx": 67035, "end_char_idx": 72119, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "acdae45e-cd3e-4340-988f-6cf0b86bfecf": {"__data__": {"id_": "acdae45e-cd3e-4340-988f-6cf0b86bfecf", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "bb428944-f860-48cc-a583-35e574e586c7", "node_type": "1", "metadata": {}, "hash": "303e9cbf107b6158cb0606e9111543386498ab12afc7debe50651187c19a7caa", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "6b58603d-7cc7-4197-a17c-e3384af73d0c", "node_type": "1", "metadata": {}, "hash": "9e21ef85c51dac08f643df1d33495241b92582ffa7a55c744617a9386fc3f8de", "class_name": "RelatedNodeInfo"}}, "text": "Misdiagnosing HIV infection, irrespective of its scale is of critical importance. Any incorrect diagnosis, whether false-positive or false-negative has severe 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 new specimen. Retesting should be conducted at a different site, ideally, the site where the decision about ART initiation will be made. Retesting according to this procedure aims to rule out possible technical or clerical errors, including specimen mix-up through mislabelling and transcription errors, as well as random error either by the provider or of the test device.\n\n# 2.5 Repeat HIV Testing\n\nIf an antibody only test is negative, repeat HIV testing should occur at 6 weeks, 3 months and 6 months following the exposure. The following scenarios are applicable for repeat HIV testing:\n\n- Window period: Post-test counselling messages should include a recommendation that\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 2.6 Disclosure Scenarios\n\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\n- Disclosure to partners who may be at risk of HIV and who need to be tested is also important for the partner's health and well-being and should be supported through couple HIV counselling and testing or partner notification services as described in the National HTS Guidelines 2017.\n- In the event where efforts to encourage the client to disclose their HIV status fail, and if the client is placing a sexual partner(s) or other persons at risk, a service provider may disclose that person's HIV status to their sex partner(s) or other people at risk. However, persons must be given a reasonable opportunity to disclose their HIV status to the sexual partner(s) on their own before the service provider intervenes.\n- In some situations, a provider may disclose a client's HIV-positive results to another medical provider involved in the client's care, to ensure the client receives appropriate medical care. Such disclosure should respect the client's right to privacy and confidentiality.\n\n# 2.7 Linkage of HTS to care and ART\n\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\n- Enhanced linkage with case management\n- Support for HIV disclosure\n- Patient tracking for those who failed to enroll in care\n- Training staff to provide multiple services\n- Streamlined services to accelerate time to initiation\n\n# Peer Support and Navigation Approaches for Linkage and Quality Improvement Approaches Using Data to Improve Linkage\n\n# Laboratory Diagnosis of HIV Infection\n\nLaboratory diagnosis of HIV infection is based on the demonstration of antibodies in plasma or serum (indirect testing) or of the viral nucleic acid in the blood (direct testing). With the technology that is available at present, HIV antibodies are usually detectable within four to six weeks of infection, and within 24 weeks in virtually all infected individuals. The virus can be demonstrated in the blood with nucleic acid-based tests (PCR for proviral HIV DNA and RT-PCR for plasma viral RNA) and viral culture.\n\n# Antibody Assays\n\nAntibody testing is performed with serial or parallel testing algorithms using rapid test kits (RTK). Screening tests include Enzyme-linked Immunosorbent Assay (ELISA), which is mainly used in blood banks.\n\n# HIV Rapid Testing Algorithm\n\nSerial and parallel testing algorithms are the two HIV testing algorithms. The algorithm recommended for routine HIV testing is the serial HIV testing algorithm. Rapid test kits (RTKs) recommended for use under this algorithm include Determine, Unigold, Stat-Pak, Double-check Gold, Sure-Check, and HIV Quick Check among others. HIV serological assays adopted for use should have a minimum sensitivity of 99% and specificity of 98%. All test kits meeting these conditions should be approved by the Honorable Minister of Health following formal evaluation by appropriate government agencies. All groups and organizations wishing to procure test kits for use in the country should adhere to the approved RTKs. Similarly, all newly procured batches of RTKs should undergo Post-Market Validation (PMV) duly endorsed by the national and State HIV Program.\n\nSerial testing: This is the use of 2 different screening tests employed sequentially to test for HIV antibody.", "mimetype": "text/plain", "start_char_idx": 71272, "end_char_idx": 76386, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6b58603d-7cc7-4197-a17c-e3384af73d0c": {"__data__": {"id_": "6b58603d-7cc7-4197-a17c-e3384af73d0c", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "acdae45e-cd3e-4340-988f-6cf0b86bfecf", "node_type": "1", "metadata": {}, "hash": "88a9c47dc8f524d88f63b808ed1b45faf7ff98d40c98942d12bf2f8e4bec3086", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "fc58a0be-8fc8-46cc-9913-79372ec5b371", "node_type": "1", "metadata": {}, "hash": "6c2d3e81ca6f052bb451088308e879ebcbade54de1bdd64faf5a5c1cb9cfde58", "class_name": "RelatedNodeInfo"}}, "text": "The algorithm recommended for routine HIV testing is the serial HIV testing algorithm. Rapid test kits (RTKs) recommended for use under this algorithm include Determine, Unigold, Stat-Pak, Double-check Gold, Sure-Check, and HIV Quick Check among others. HIV serological assays adopted for use should have a minimum sensitivity of 99% and specificity of 98%. All test kits meeting these conditions should be approved by the Honorable Minister of Health following formal evaluation by appropriate government agencies. All groups and organizations wishing to procure test kits for use in the country should adhere to the approved RTKs. Similarly, all newly procured batches of RTKs should undergo Post-Market Validation (PMV) duly endorsed by the national and State HIV Program.\n\nSerial testing: This is the use of 2 different screening tests employed sequentially to test for HIV antibody. If the initial screening is negative, no further testing is required. If the initial test is positive, it is followed by a second test. The first test should be the most sensitive test and the second test should be very specific and based on an antigen source different from that of the first test. Samples that produce discordant results in the two tests are subjected to a third test called a tiebreaker. The main advantage of the serial over parallel testing is the cost-savings in testing.\n\n# National Guidelines for HIV Prevention Treatment and Care 2020\n\nFigure 2.2 Serial Testing Algorithm\n\nKey:\n\nTest 1: Screening\n\nTest 2: Confirmatory\n\nTest 3: Tie Breaker\n\n2.8.2 Enzyme-Linked Immunosorbent Assay (ELISA) or Enzyme Immunoassay (EIA) for Blood Screening\n\nThis test detects HIV antibodies, which the body starts producing between 2-12 weeks after becoming infected with HIV. Current HIV antibody test can detect antibodies as early as 3 weeks after exposure. ELISA test system is grouped into 1st to 4th generation. While all can detect HIV antibody as early as 3 weeks, the 4th generation can detect both IgG and IgM antibodies, HIV-\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n18\n\n# 2.8 Laboratory Diagnosis of HIV Infection\n\n2.8.3 Nucleic Acid-based Testing\n\nThis consists of DNA Polymerase Chain Reaction (DNA-PCR) and Reverse Transcriptase Polymerase Chain Reaction (RT-PCR). These tests are not routinely used for laboratory diagnosis of HIV infection in adults and adolescents. Nucleic acid tests are virologic assays that detect, confirm and measure the number of viral particles in the blood. It is recommended that virologic assays used for clinical diagnostic testing (usually at birth, 6-8 weeks of age and below 18 months of age) should have a sensitivity of >95% and a specificity of >98% under quality-assured, standardized and validated laboratory conditions.\n\n2.8.4 HIV DNA Polymerase Chain Reaction (PCR)\n\nThe HIV DNA-PCR test involves the amplification of specific DNA sequences in the proviral DNA that has been integrated into the host cell. This test is the preferred option for diagnosing or confirming HIV infection in infants less than 18 months of age. However, false-positive results may occur as a result of contamination or improper specimen handling. There is a need therefore to always ensure quality assurance and validation procedures in the laboratory.\n\n2.8.5 Viral Load Assay- Reverse Transcriptase Polymerase Chain Reaction (RT-PCR)\n\nViral load RT-PCR test is used to detect and quantify the amount of HIV RNA in plasma, Dried Blood Spot (DBS) and plasma separation cards. The assay requires the conversion of viral RNA to DNA and amplification of specific sequences in the DNA produced by a process known as reverse transcriptase polymerase chain reaction (RT-PCR). Results are reported in copies/ml of plasma.\n\nSample Referral System:\n\nVL and EID samples are moved from areas without PCR laboratories to testing laboratories in the optimized networks and results returned by the National Integrated Sample Referral Network (NISRN). Clinical sample types have been expanded from the traditional whole blood EDTA-plasma and DBS for VL to include Plasma Separation Card (PSC) and Plasma Preparation Tubes (PPT) to facilitate improved viral load quantification testing, equitable viral load access for both clinic and community service-points across Nigeria through ease of handling, storage and transportation. All the standard of care PCR laboratories should be linked to the National Laboratory Information Management Systems (LIMS) which is in turn linked to Nigeria Medical Records System (NMRS) and National Data Repository (NDR) for real-time reporting of patients results into the health facility records and health repository.", "mimetype": "text/plain", "start_char_idx": 75499, "end_char_idx": 80183, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "fc58a0be-8fc8-46cc-9913-79372ec5b371": {"__data__": {"id_": "fc58a0be-8fc8-46cc-9913-79372ec5b371", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "6b58603d-7cc7-4197-a17c-e3384af73d0c", "node_type": "1", "metadata": {}, "hash": "9e21ef85c51dac08f643df1d33495241b92582ffa7a55c744617a9386fc3f8de", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "0a6de4b6-cc5d-49b2-9567-661e61fabf4b", "node_type": "1", "metadata": {}, "hash": "6d1100ffc383287c895c7767a3fd3b7a4356390e0c56120f64579101d71acd92", "class_name": "RelatedNodeInfo"}}, "text": "Results are reported in copies/ml of plasma.\n\nSample Referral System:\n\nVL and EID samples are moved from areas without PCR laboratories to testing laboratories in the optimized networks and results returned by the National Integrated Sample Referral Network (NISRN). Clinical sample types have been expanded from the traditional whole blood EDTA-plasma and DBS for VL to include Plasma Separation Card (PSC) and Plasma Preparation Tubes (PPT) to facilitate improved viral load quantification testing, equitable viral load access for both clinic and community service-points across Nigeria through ease of handling, storage and transportation. All the standard of care PCR laboratories should be linked to the National Laboratory Information Management Systems (LIMS) which is in turn linked to Nigeria Medical Records System (NMRS) and National Data Repository (NDR) for real-time reporting of patients results into the health facility records and health repository. Point of Care Testing (POCT) devices are being introduced into the HIV program to further ensure equitable viral load access to key populations: paediatrics, pregnant/breastfeeding mothers, MSM, FSW, PWID; hard-to-reach communities, security challenged and other settings to bring testing closer to the clients, enhance effective viral load coverage and quick Turnaround Time (TAT) of results for clinical management of patients. Capacity development and Quality Assurance (QA) oversight will be provided quarterly by experts supporting the standard of care laboratories. All the POCT devices for viral load will participate in National EQA supported by the National Reference Laboratory/National External Quality Assurance Lab. This is to ensure quality assured results are produced from these devices and are useful for the management of patients.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n19\n\n# Laboratory Diagnosis of HIV Infection in Children by Age Group\n\n# Children aged \u226418 months\n\nNucleic Acid Amplification Testing (NAAT) or Nucleic Amplification Testing (NAT) to detect DNA - can be used to detect HIV infection in neonates at birth, 6-8 weeks and 9 months. Testing at birth will plug the gap of loss to follow up between birth and 6 months. Exposed infants are brought into care as early as possible to reduce morbidity and mortality. NAAT has a specificity of 99.6% and sensitivity of 100% for infants infected during pregnancy or at least 4 weeks prior to sample collection for testing. However, there is a need for follow-up testing at 6 weeks, 9 months and 6 weeks after cessation of breastfeeding at a standard of care laboratory because of the possibility of a false positive or negative result.\n\nPolymerase Chain Reaction (PCR) should be used for the detection of HIV DNA in children between the ages of 6 weeks to 18 months. Standard PCR laboratories available as referral network in the six geopolitical zones of Nigeria will support EID testing and return of results back to facilities through the linkage of Laboratory Information Management Systems (LIMS) to EMR platform.\n\n- All HIV\u2013 exposed infants should have initial DNA PCR testing at 0-3 days of age, then at 6-8 weeks of age (or earliest opportunity thereafter) and 6 weeks after complete cessation of breastfeeding. DNA PCR test results should be provided to the clinic and caregiver as soon as possible; latest within four weeks of specimen collection.\n- HIV- exposed children 9 -18 months of age may have circulating maternal antibodies which could be from the child and/or the mother. In this case, DNA or RNA PCR is the test of choice for a definitive diagnosis.\n- If a screening antibody test is negative, HIV-infection is excluded if the test has been conducted at least 6 weeks after complete cessation of breastfeeding.\n- For sick children <18 months in whom HIV infection is being considered, in the absence of virological tests (DNA-PCR), HIV serological testing (RTKs) and use of the algorithm (WHO clinical staging) for presumptive clinical diagnosis are recommended.\n- In a child <18 months with an initial positive virological test result, it is recommended that ART should be started immediately, while a second specimen is collected to confirm the result. It is not advised to defer ART until the confirmation result is received.\n- HIV-exposed infants who are well should undergo HIV serological testing at 9 months of age (or at the time of last immunization visit).\n- Infants who have reactive serological assays at 9 months should have an immediate virological test to confirm HIV infection and the need for ART.\n- It is strongly recommended that children <18 months of age, with signs and symptoms suggestive of HIV infection should undergo HIV serological testing in a setting where DNA-PCR is not immediately available and if positive (reactive), do a DNA PCR test or NAAT.\n- NAT technologies that are developed and validated for use at or near to the point of care can be used for early infant HIV testing.", "mimetype": "text/plain", "start_char_idx": 79217, "end_char_idx": 84220, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "0a6de4b6-cc5d-49b2-9567-661e61fabf4b": {"__data__": {"id_": "0a6de4b6-cc5d-49b2-9567-661e61fabf4b", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "fc58a0be-8fc8-46cc-9913-79372ec5b371", "node_type": "1", "metadata": {}, "hash": "6c2d3e81ca6f052bb451088308e879ebcbade54de1bdd64faf5a5c1cb9cfde58", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "b1238e3b-068e-4192-b862-93fe607a37a2", "node_type": "1", "metadata": {}, "hash": "d97a555641ed6b5e8ad513a9dd1b5a29eb472a890f8ac248630da298d3408074", "class_name": "RelatedNodeInfo"}}, "text": "- In a child <18 months with an initial positive virological test result, it is recommended that ART should be started immediately, while a second specimen is collected to confirm the result. It is not advised to defer ART until the confirmation result is received.\n- HIV-exposed infants who are well should undergo HIV serological testing at 9 months of age (or at the time of last immunization visit).\n- Infants who have reactive serological assays at 9 months should have an immediate virological test to confirm HIV infection and the need for ART.\n- It is strongly recommended that children <18 months of age, with signs and symptoms suggestive of HIV infection should undergo HIV serological testing in a setting where DNA-PCR is not immediately available and if positive (reactive), do a DNA PCR test or NAAT.\n- NAT technologies that are developed and validated for use at or near to the point of care can be used for early infant HIV testing.\n\n20\n\n|POSITIVE| | |\n|---|---|---|\n|POSITIVE|NEGATIVE| |\n| |NEGATIVE| |\n| |POSITIVE| |\n| |POSITIVE|NEGATIVE|\n\nFigure 2.3: Nigeria diagnostic testing protocol: HIV-exposed infants (&lt; 18 months of age)\n\n|NEGATIVE| |\n|---|---|\n|POSITIVE|NEGATIVE|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  21\n\n# Children aged \u226518 months\n\nAntibody detection is reliable and recommended for children \u226518 months. The exception is during the window period (6-8 weeks post-exposure) where antibodies may not be present at a detectable level. For children testing negative, a repeat antibody testing 3 months later is recommended if the window period is suspected.\n\nFrom 18 months of life, an antibody test should be performed irrespective of whether a child received breast milk or replacement feeds.\n\nIf the child is receiving breast milk after 18 months of age, repeat the test 12 weeks after complete cessation of breastfeeding.\n\nMethods such as DNA/RNA PCR could be used to resolve suspected false-negative result.\n\n# Clinical Diagnosis and Staging of HIV Infection\n\nThe WHO clinical staging of HIV for adults and adolescents that are HIV positive is as shown in Tables 2.1 and 2.2. Staging is based on the patient's clinical presentation at the time of initial assessment with the healthcare provider. The most advanced symptoms at the time of evaluation represent the initial clinical stage of HIV infection.", "mimetype": "text/plain", "start_char_idx": 83271, "end_char_idx": 85635, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "b1238e3b-068e-4192-b862-93fe607a37a2": {"__data__": {"id_": "b1238e3b-068e-4192-b862-93fe607a37a2", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "0a6de4b6-cc5d-49b2-9567-661e61fabf4b", "node_type": "1", "metadata": {}, "hash": "6d1100ffc383287c895c7767a3fd3b7a4356390e0c56120f64579101d71acd92", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "8487c36f-b154-409c-a194-cb38a34c6bd9", "node_type": "1", "metadata": {}, "hash": "e00ac56a4e9402a9e986cdacde3c927c8cbde980db815c1f33ced4ee7b13f5fb", "class_name": "RelatedNodeInfo"}}, "text": "The exception is during the window period (6-8 weeks post-exposure) where antibodies may not be present at a detectable level. For children testing negative, a repeat antibody testing 3 months later is recommended if the window period is suspected.\n\nFrom 18 months of life, an antibody test should be performed irrespective of whether a child received breast milk or replacement feeds.\n\nIf the child is receiving breast milk after 18 months of age, repeat the test 12 weeks after complete cessation of breastfeeding.\n\nMethods such as DNA/RNA PCR could be used to resolve suspected false-negative result.\n\n# Clinical Diagnosis and Staging of HIV Infection\n\nThe WHO clinical staging of HIV for adults and adolescents that are HIV positive is as shown in Tables 2.1 and 2.2. Staging is based on the patient's clinical presentation at the time of initial assessment with the healthcare provider. The most advanced symptoms at the time of evaluation represent the initial clinical stage of HIV infection.\n\n**Table 2.1 WHO Clinical Classification of Established HIV Infection**\n|HIV - Associated Symptomatology|WHO Clinical Stage|\n|---|---|\n|Asymptomatic|1|\n|Mild Symptoms|2|\n|Advanced Symptoms|3|\n|Severe Symptoms|4|\n\nThe staging systems include:\n\n- Presumptive clinical diagnoses that can be made in the absence of laboratory tests\n- Definitive clinical criteria that require confirmatory laboratory tests\n\n|Adults and adolescents|Children|\n|---|---|\n|Clinical stage 1| |\n|- Asymptomatic|- Asymptomatic|\n|- Persistent generalized lymphadenopathy|- Persistent generalized lymphadenopathy|\n|Clinical stage 2| |\n|- Moderate unexplained weight loss (<10% of presumed or measured body weight)|- Unexplained persistent hepatosplenomegaly|\n|- Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis)|- Recurrent or chronic upper respiratory tract infections (otitis media, otorrhoea, sinusitis, tonsillitis)|\n|- Herpes zoster|- Lineal gingival erythema Recurrent oral ulceration Papular pruritic eruption Fungal nail infections Extensive wart virus infection|\n|- Recurrent oral ulceration Papular pruritic eruption Fungal nail infections Seborrhoeic dermatitis|- Extensive molluscum contagiosum|\n| |- Unexplained persistent parotid enlargement|\n|Clinical stage 3| |\n|- Unexplained severe weight loss (>10% of presumed or measured body weight)|- Unexplained moderate malnutrition not adequately responding to standard therapy|\n|- Unexplained chronic diarrhoea for longer than 1 month|- Unexplained persistent diarrhoea (14 days or more)|\n|- Unexplained persistent fever (intermittent or constant for longer than 1 month)|- Unexplained persistent fever (above 37.5\u00b0C, intermittent or constant, for longer than one 1 month)|\n|- Persistent oral candidiasis Oral hairy leukoplakia Pulmonary tuberculosis|- Lymph node tuberculosis; pulmonary tuberculosis Severe recurrent bacterial pneumonia|\n|- Severe bacterial infections (such as pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteraemia)|- Acute necrotizing ulcerative gingivitis or periodontitis|\n|- Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis|- Unexplained anaemia (<8 g/dl), neutropaenia (<0.5 \u00d7 109/L) or chronic thrombocytopaenia (<50 \u00d7 109/L)|\n|- Unexplained anaemia (<8 g/dl), neutropaenia (<0.5 \u00d7 109/L) and/or chronic thrombocytopaenia (<50 \u00d7 109/L)|- Symptomatic lymphoid interstitial pneumonitis Chronic HIV-associated lung disease, including bronchiectasis|\n|Clinical stage 4| |\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n|HIV wasting syndrome|Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy|\n|---|---|\n|Pneumocystis (jirovecii) pneumonia|Recurrent severe bacterial pneumonia|\n|Chronic herpes simplex infection|Recurrent severe bacterial infections (such as empyema, pyomyositis, bone or joint infection, meningitis, but excluding pneumonia)|\n|Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)| |\n|Extrapulmonary tuberculosis Kaposi sarcoma| |\n|Cytomegalovirus infection (retinitis or infection of other organs)| |\n|Central nervous system toxoplasmosis| |\n|Extrapulmonary cryptococcosis, including meningitis| |\n|Disseminated nontuberculous mycobacterial infection| |\n|Progressive multifocal leukoencephalopathy| |\n|Chronic cryptosporidiosis|Chronic isosporiasis|\n|Disseminated mycosis (extrapulmonary histoplasmosis, coccidioidomycosis)| |\n|Lymphoma (cerebral or B-cell non-Hodgkin)| |\n|Symptomatic HIV-associated nephropathy or cardiomyopathy| |\n|Recurrent septicaemia (including nontyphoidal Salmonella)| |\n|Invasive cervical carcinoma|Atypical disseminated leishmaniasis|\n\nIn the development of this table, adolescents were defined as 15 years or older.", "mimetype": "text/plain", "start_char_idx": 84636, "end_char_idx": 89416, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8487c36f-b154-409c-a194-cb38a34c6bd9": {"__data__": {"id_": "8487c36f-b154-409c-a194-cb38a34c6bd9", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "b1238e3b-068e-4192-b862-93fe607a37a2", "node_type": "1", "metadata": {}, "hash": "d97a555641ed6b5e8ad513a9dd1b5a29eb472a890f8ac248630da298d3408074", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "e8ee475d-e9bf-4041-9054-d827b164f4ea", "node_type": "1", "metadata": {}, "hash": "184554d01da109b3e351e676911fb95a47ebe97311ecd0407a3cabfdb42966a2", "class_name": "RelatedNodeInfo"}}, "text": "For those younger than 15 years, the clinical staging for children should be used.\n\nFor children younger than 5 years, moderate malnutrition is defined as weight-for-height < \u20132 z-score or mid-upper arm circumference 115 mm to <125 mm.\n\nSome additional specific conditions can be included in regional classifications, such as penicilliosis in Asia, HIV-associated rectovaginal fistula in southern Africa and reactivation of trypanosomiasis in Latin America.\n\nFor children younger than five years of age, severe wasting is defined as weight-for-height < \u20133 z-score; stunting is defined as length-for-age/height-for-age < \u20132 z-score; and severe acute malnutrition is either weight for height < \u20133 z-score or mid-upper arm circumference <115 mm or the presence of oedema.\n\nSource: Adapted from: WHO case definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-related disease in adults and children. Geneva, World Health Organization, 2007 (www.who.int/hiv/pub/guidelines/HIVstaging150307.pdf).\n\n# List of Contributors\n\nMrs Grace Mfon BasseyMrs Ima-Dada JohnMrs Katherine IgbosofuluMr Envuladu OvyeMrs Etubi EruonaOkorie UcheSamson OmoigheJames YohannaAgba Janet CDr Rex MpazanjeAdegoke Olufemi DicksonOkoye McPaulDr Jerry GwamnaChidozie MeribeDr Aminu SuleimanDr Yusuf AhmedAngela AgweyeKingston Omo-EmmanuelMrs Pamela Nenpanmwa GadoJibrin KamaAisha EjigboObed Ikechukwu NnamdiChinelo EkweremaduChris OgarAbutu Abraham.E.Mr Mark AkhigbeFortune KailoDr Ali OnojaMr Manason Rubainu\n\n# Chapter 2\n\nAssistant Director, Head LAB NASCPAssistant Director, Head HTS NASCPAssistant Director, ACSM NASCPChief Science Lab. Technologist NASCPACMLS, Treatment, Care and Support NASCPSenior Medical Laboratory Scientist NASCPScientific officer 1 NASCPScientific Officer/PDA NASCPAD MLS NTBS/FMOHHIV Adviser WHOLaboratory Systems Specialist CDCLaboratory Branch Chief/Project Officer CDCPrevention Branch Chief CDCSenior Program Specialist HTS CDCLab Lead US DoDPrevention Team Lead US DoDProject Management Specialist Testing and Linkages USAIDClinical Laboratory Manager USAIDHIV Testing Services Programme Manager USAIDSenior Program Manager CHAISenior Analyst CHAILaboratory Quality Assurance/LMIS Specialist SFHSenior Technical Specialist CRSMSHMonitoring & Evaluation Officer NEPWHANLaboratory Advisor Heartland AllianceNational Coordinator APYINCEO African Health ProjectCEO Peak Medical Laboratories\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 25\n\n# 3. ANTIRETROVIRAL THERAPY\n\nWhat\u2019s Inside:\n\n- 3.1 Introduction - 27\n- 3.2 Classes of Antiretroviral Drugs - 27\n- 3.3 Preparation of Adults, Adolescents and Children for ART - 29\n- 3.4 Recommended ART Regimen for Adults, Adolescents and Children - 33\n- 3.5 Monitoring Patients on ART - 34\n- 3.6 Management of HIV Treatment Failure - 37\n- 3.7 Third-line ART - 42\n- 3.8 Low-Level Viremia (LLV) - 43\n- 3.9 ART in Special Circumstances - 44\n\n# Introduction\n\nAntiretroviral therapy (ART) is the treatment of HIV infection using a combination of antiretroviral drugs (ARVs). All HIV infected persons irrespective of clinical stage and CD4+ cell count without contraindications should be initiated the same day or within 7 days of HIV diagnosis if possible. Pregnant and breastfeeding women, infants and children under 5 years, and patients with advanced HIV disease (AHD) should be prioritized for rapid initiation of ART. Antiretroviral therapy (ART) should be offered in a comprehensive manner that includes access to on-going adherence counselling, baseline and periodic clinical and laboratory monitoring, prevention and management of opportunistic infection (OIs), treatment monitoring and follow-up.\n\nThe goal of ART includes achievement of sustained virologic, immunologic, clinical, and epidemiologic control of HIV. Sustained viral suppression is necessary to prevent the development of ARV drug resistance, reduce morbidity from OIs and improve the quality of life of HIV infected individuals. In children, ART will promote and restore normal growth and development.", "mimetype": "text/plain", "start_char_idx": 89417, "end_char_idx": 93496, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "e8ee475d-e9bf-4041-9054-d827b164f4ea": {"__data__": {"id_": "e8ee475d-e9bf-4041-9054-d827b164f4ea", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "8487c36f-b154-409c-a194-cb38a34c6bd9", "node_type": "1", "metadata": {}, "hash": "e00ac56a4e9402a9e986cdacde3c927c8cbde980db815c1f33ced4ee7b13f5fb", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "66be3a16-0a4d-4efb-9177-b28c373a4da0", "node_type": "1", "metadata": {}, "hash": "bfc87d560c298a178033041cab8a4b4d93919c15c7462666d582944b4f93bdaa", "class_name": "RelatedNodeInfo"}}, "text": "All HIV infected persons irrespective of clinical stage and CD4+ cell count without contraindications should be initiated the same day or within 7 days of HIV diagnosis if possible. Pregnant and breastfeeding women, infants and children under 5 years, and patients with advanced HIV disease (AHD) should be prioritized for rapid initiation of ART. Antiretroviral therapy (ART) should be offered in a comprehensive manner that includes access to on-going adherence counselling, baseline and periodic clinical and laboratory monitoring, prevention and management of opportunistic infection (OIs), treatment monitoring and follow-up.\n\nThe goal of ART includes achievement of sustained virologic, immunologic, clinical, and epidemiologic control of HIV. Sustained viral suppression is necessary to prevent the development of ARV drug resistance, reduce morbidity from OIs and improve the quality of life of HIV infected individuals. In children, ART will promote and restore normal growth and development.\n\n# Classes of Antiretroviral Drugs\n\nAntiretroviral drugs (ARVs) are classified according to their modes of action. Each class targets a different step in the viral life cycle. The classes of antiretroviral drugs are:\n\n- Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs): These compete with host nucleotides to serve as the substrate for reverse transcriptase chain elongation. Absence of 3'OH group on sugar moiety prevents the addition of another nucleotide, resulting in chain termination, abortion of viral DNA chain elongation and cessation of viral replication.\n- Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): Inhibit HIV reverse transcriptase by binding a hydrophobic pocket close to the active site thereby locking the site in an inactive conformation.\n- Protease Inhibitors (PI): Inhibit HIV protease by binding to its active site, preventing the cleavage of gag and gag-pol precursor. Virions are produced but they are incomplete and non-infectious.\n- Entry Inhibitors: Block the mechanisms by which HIV gains access into the cytoplasm of CD4+ cell molecule bearing cell. There are 3 classes:\n- (a) Attachment inhibitors: These agents complex with glycoprotein 120 and prevent it from interacting with the CD4+ molecule thus, the attachment of the virus to the cell is blocked.\n- (b) Fusion inhibitors: These are agents designed to complex with the viral GP41. GP41 is the viral protein that is capable of fusing with cellular membrane molecules called chemokine receptors. The interaction of fusion inhibitors with GP41 blocks the fusion of viral membrane with cellular membrane.\n- (c) Chemokine Receptor Antagonists: These are agents that complex with cell membrane receptors that serve as fusion proteins i.e. CXCR4, CCR5.\n\n# HIV Integrase Inhibitors\n\nAlso known as Integrase Strand Transfer Inhibitors (INSTI). These inhibit DNA strand transfer into the host-cell genome and thus prevent viral integration. Integrase Inhibitors do not confer resistance to other ART classes.\n\n# Pharmacokinetic enhancers/ PI boosters\n\nThese are drugs used in HIV treatment to increase the effectiveness of certain classes of ARV drugs. The PIs are metabolized by cytochrome P450 (CYP) 3A enzymes; and intentional inhibition of these enzymes' lead to higher drug exposure, lower pill burden and simplified dosing schedules (pharmacokinetic enhancement). In HIV therapy, two pharmacokinetic enhancers or boosting agents are used: ritonavir and cobicistat. These agents inhibit CYP3A4, with cobicistat being a more specific CYP inhibitor than ritonavir. Unlike ritonavir, cobicistat does not have antiretroviral activity.", "mimetype": "text/plain", "start_char_idx": 92495, "end_char_idx": 96136, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "66be3a16-0a4d-4efb-9177-b28c373a4da0": {"__data__": {"id_": "66be3a16-0a4d-4efb-9177-b28c373a4da0", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "e8ee475d-e9bf-4041-9054-d827b164f4ea", "node_type": "1", "metadata": {}, "hash": "184554d01da109b3e351e676911fb95a47ebe97311ecd0407a3cabfdb42966a2", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "3d134476-b69b-4975-9bde-35e3df8da770", "node_type": "1", "metadata": {}, "hash": "1f937841c07a558310641c3b43a3a751012877d00aa6b4e45df7e48e39cf6932", "class_name": "RelatedNodeInfo"}}, "text": "These inhibit DNA strand transfer into the host-cell genome and thus prevent viral integration. Integrase Inhibitors do not confer resistance to other ART classes.\n\n# Pharmacokinetic enhancers/ PI boosters\n\nThese are drugs used in HIV treatment to increase the effectiveness of certain classes of ARV drugs. The PIs are metabolized by cytochrome P450 (CYP) 3A enzymes; and intentional inhibition of these enzymes' lead to higher drug exposure, lower pill burden and simplified dosing schedules (pharmacokinetic enhancement). In HIV therapy, two pharmacokinetic enhancers or boosting agents are used: ritonavir and cobicistat. These agents inhibit CYP3A4, with cobicistat being a more specific CYP inhibitor than ritonavir. Unlike ritonavir, cobicistat does not have antiretroviral activity.\n\n**Table 3.1 Classes of Antiretroviral Drugs**\n|Class|Drugs|\n|---|---|\n|Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs)|Abacavir (ABC); Emtricitabine (FTC); Lamivudine (3TC); Tenofovir Disoproxil fumarate (TDF); Tenofovir Alafenamide (TAF); Zidovudine (AZT, ZDV); Didanosine (ddI); Stavudine (d4T)*|\n|Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)|Efavirenz (EFV); Etravirine (ETR); Nevirapine (NVP); Rilpivirine (RPV)|\n|Protease Inhibitors (PIs)|Atazanavir (ATV); Darunavir (DRV); Lopinavir (LPV); Fosamprenavir (FPV); Indinavir (IDV); Nelfinavir (NFV); Saquinavir (SQV); Tipranavir (TPV)|\n|Protease Inhibitors (PIs) boosters|Ritonavir (RTV); Cobicistat (COBI)|\n|Integrase Strand Transfer Inhibitors (INSTIs)|Dolutegravir (DTG); Elvitegravir (EVG); Raltegravir (RAL); Cabotegravir (CAB)|\n|Attachment Inhibitors|Fostemsavir; Ibalizumab; Anti CD4 adnectin|\n|Fusion Inhibitors|Enfuvirtide; Anti-GP41 Adnectin; Combinectin|\n|Chemokine receptor antagonists|Maraviroc; Vicroviroc; Cenicriviroc|\n\n# Antiretroviral Drug Combination for HIV Treatment\n\nIt is recommended that combinations of a minimum of three drugs from at least two different classes of ARVs be used for ART. These ARVs are expected to act at different points of the HIV life cycle. Typically, a backbone of 2 NRTIs combined with an Integrase inhibitor, an NNRTI or a PI is used. Monotherapy or dual ARV therapy for HIV infection is not recommended for treatment because of the increased risk of development of drug resistance.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 3.3. Preparation of Adults, Adolescents and Children for ART\n\n# 3.3.1 Baseline Assessment for ART\n\nBaseline assessment and preparation of patients for ART should include: - Re-testing for HIV to verify HIV positive status - A comprehensive history and clinical examination - Assessment of patient's readiness for initiation of ART (regimen, dosage, scheduling, benefits, adverse effects, follow up, monitoring visits and age-appropriate disclosure) - Development of patient-centred adherence strategy - Baseline laboratory assessment\n\nIt is noteworthy that the first few months of therapy are important especially as certain occurrences during the period can influence the outcome of treatment. These include Adverse drug reactions, immune reconstitution inflammatory syndrome (IRIS) and opportunistic infections following commencement of treatment. These may confuse healthcare workers and patients leading to poor adherence and treatment failure. Patients should be warned to expect these complications but reassured that they are usually transient and would abate in the course of treatment. The importance of adherence for positive treatment outcomes must be emphasized and health care workers are encouraged to develop individualized treatment adherence plans for each patient. Patients should be advised that poor adherence to treatment at any time following initiation of ART is associated with treatment failure, rapid development of drug resistance, ill health and possibly death. HIV positive adolescents and adults who are not willing and ready to start ART should receive on-going counselling and education to promote retention in care.", "mimetype": "text/plain", "start_char_idx": 95346, "end_char_idx": 99365, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "3d134476-b69b-4975-9bde-35e3df8da770": {"__data__": {"id_": "3d134476-b69b-4975-9bde-35e3df8da770", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "66be3a16-0a4d-4efb-9177-b28c373a4da0", "node_type": "1", "metadata": {}, "hash": "bfc87d560c298a178033041cab8a4b4d93919c15c7462666d582944b4f93bdaa", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "2cf1d939-3565-4dd1-92c4-576e43cf56ab", "node_type": "1", "metadata": {}, "hash": "c342051178218fd12f0c822104ed9af95a36fad4a6cedf180c1207dfc6ed6d80", "class_name": "RelatedNodeInfo"}}, "text": "These include Adverse drug reactions, immune reconstitution inflammatory syndrome (IRIS) and opportunistic infections following commencement of treatment. These may confuse healthcare workers and patients leading to poor adherence and treatment failure. Patients should be warned to expect these complications but reassured that they are usually transient and would abate in the course of treatment. The importance of adherence for positive treatment outcomes must be emphasized and health care workers are encouraged to develop individualized treatment adherence plans for each patient. Patients should be advised that poor adherence to treatment at any time following initiation of ART is associated with treatment failure, rapid development of drug resistance, ill health and possibly death. HIV positive adolescents and adults who are not willing and ready to start ART should receive on-going counselling and education to promote retention in care.\n\n# 3.3.2 Further Baseline Assessment\n\n1. Complete history and physical examination: Anthropometric assessment (weight, height/length, OFC, chest & mid-upper arm circumference). History of comorbidities (renal, cardiovascular disease), pregnancy, anaemia, STI, prior ART use - including single-dose Nevirapine, prescribed medications, drug misuse (heroin, alcohol), should be documented. Social and sexual history should also be determined especially for adolescents.\n2. Screening for TB and Hepatitis (B and C) should be done. Xpert MTB/RIF assay should be used for cases of presumptive TB. Where GeneXpert equipment is not accessible or specimen not available for Xpert MTB/RIF assay, PLHIV with CD4+ cell count <200 cells/mm3 or severely ill irrespective of CD4+ cell count should receive a urine LF - LAM assay for TB diagnosis.\n3. Determination of nutritional, psychosocial, growth and immunization status of patient (including determination of BMI for adults)\n4. Rectal and vaginal examination (including cervical cancer screening)\n5. Screen for mental health issues and substance abuse\n6. Screen for Non-Communicable diseases\n7. Determination of WHO clinical stage for HIV/AIDS\n8. Pregnancy assessment, family planning and counselling services, where required\n9. Conducting baseline laboratory assessments\n\nThis assessment should not delay the commencement of ART.\n\n# 3.3.3 Initiating ART in Adults\n\nART should be initiated in all adults living with HIV without contraindications, regardless of WHO clinical stage and CD4+ cell count. Initiating ART early in PLHIV is associated with reduced mortality and ill health. Untreated HIV infection may be associated with the development of serious co-morbidities such as cardiovascular, kidney and liver diseases, cancers and mental illness. Early initiation of ART serves the useful purpose of preventing the occurrence of these diseases. An additional advantage of early initiation of ART is that it substantially reduces the risk of sexual transmission to HIV-negative partners.\n\n# 3.3.4 Initiating ART in Adolescents (10-19 years of age)\n\nImplementation considerations\n\nTo ensure that adolescents (10-19 years) achieve the goals of ART, it will require developing adolescent-friendly health services, appropriate provider training and implementing programmes that emphasize support for age-appropriate disclosure, adherence and retention in care, including peer to peer support.\n\nHealthcare providers are advised to leverage the influence that parents and caregivers exercise on their adolescents to improve adherence to ART. Hence, parents and caregivers should be involved in developing a treatment adherence plan for their wards.\n\nRecommendations for ART initiation in adolescents (10-19 years)\n\nIt is recommended that the implementation of early ART in adolescents should be prioritized to ensure that effective and age-appropriate counselling approaches are a prominent component of the ART package for this age group.ART should be initiated in all adolescents living with HIV, regardless of WHO clinical stage and at any CD4+ cell count.Use of DTG with NRTI backbone as the preferred 1st line regimen for adolescents including women of childbearing age (TDF + 3TC (or FTC) + DTG). Women should however be given all necessary information to enable them make informed choices.Adolescents with severe or advanced HIV clinical disease (WHO clinical stage 3 or 4) and a CD4+ cell count of <200 cells/mm3 should be given priority for ART initiation.\n\n# 3.3.5 Initiation of ART in infants and children younger than 10 years of age\n\nART should be initiated in all children with HIV, regardless of WHO clinical stage, or at any CD4+ cell count. Infants and young children living with HIV are more likely to die within the first two years of life from the disease in the absence of any intervention. As they grow older the risk of disease progression and mortality, in the absence of treatment, falls to rates similar to those of young adults.", "mimetype": "text/plain", "start_char_idx": 98412, "end_char_idx": 103359, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "2cf1d939-3565-4dd1-92c4-576e43cf56ab": {"__data__": {"id_": "2cf1d939-3565-4dd1-92c4-576e43cf56ab", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "3d134476-b69b-4975-9bde-35e3df8da770", "node_type": "1", "metadata": {}, "hash": "1f937841c07a558310641c3b43a3a751012877d00aa6b4e45df7e48e39cf6932", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "225bc172-e222-4e71-9928-e96ee21d9b62", "node_type": "1", "metadata": {}, "hash": "44f058fdc7394301e7d6b1b9cb81c0d92e02842990a911d8d2737a81a5c24161", "class_name": "RelatedNodeInfo"}}, "text": "Women should however be given all necessary information to enable them make informed choices.Adolescents with severe or advanced HIV clinical disease (WHO clinical stage 3 or 4) and a CD4+ cell count of <200 cells/mm3 should be given priority for ART initiation.\n\n# 3.3.5 Initiation of ART in infants and children younger than 10 years of age\n\nART should be initiated in all children with HIV, regardless of WHO clinical stage, or at any CD4+ cell count. Infants and young children living with HIV are more likely to die within the first two years of life from the disease in the absence of any intervention. As they grow older the risk of disease progression and mortality, in the absence of treatment, falls to rates similar to those of young adults.\n\nAside from preventing illness and death in very young children, earlier initiation of ART can mitigate the negative effects of HIV infection on growth, pubertal and nervous system development.\n\n# 3.3.6 Recommendations for Use of ART in TB/HIV Co-infection\n\nThere is strong evidence that initiation of ART within two weeks of TB treatment is associated with a marked reduction in overall TB-related morbidity and mortality. ART should be started in\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - 30\n\n# all TB patients (adults, adolescents and children) living with HIV, regardless of CD4+ cell count.\n\nTB treatment should be initiated first, followed by ART as soon as possible within the first 2 weeks of treatment. This strategy will:\n\n- Simplify patient management\n- Improve adherence\n- Avoid ARV and TB drug interactions\n- Avoid overlapping toxicities\n- Minimize the risk of immune reconstitution inflammatory syndrome (IRIS)\n- Reduces the confusion over which drug (ARV or Anti-TB) to take first\n\n# Key considerations when treating PLHIV with TB:\n\n1. Patients on ART who develop TB should have the ARVs reviewed to accommodate the use of Rifampicin in the anti-TB regimen.\n2. For patients on a PI-based initial or subsequent ART regimen, rifabutin should be substituted for rifampicin.\n3. Rifampicin significantly lowers the plasma concentration of DTG therefore a double dose of DTG should be used (Give DTG 50 mg twice daily if rifampicin is being used as the anti-TB regimen).\n4. Efavirenz cannot be used with Bedaquiline (BDQ) among PLHIV with drug-resistant TB (DR-TB), as it decreases the concentration of BDQ. Nevirapine or DTG is considered the best option for treatment of DR-TB with BDQ - based regimen.\n5. In the treatment of DR-TB, Delamanid is generally considered safe to be administered with all ARVs.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Table 3.2: Scenarios for the management of TB/HIV co-infected patients\n\n|Scenario|Action|\n|---|---|\n|Newly registered TB patients diagnosed with HIV|- Start TB treatment regimen immediately\n- Commence ART within 2 weeks of anti TB (irrespective of the CD4+ cell count)\n- Initiate CPT\n|\n|PLHIV on ART who develop TB|- Continue ART (Substitute N VP with E FV, if on DTG then administer twice daily)\n- Start TB treatment immediately\n- Continue/initiate CPT\n- Reassess for HIV treatment failure\n|\n|PLHIV on second-line ART who develop active TB|- Reassess for HIV treatment failure\n- Continue ART\n- Start TB treatment immediately, change anti-TB to single drugs with rifabutin-containing regimen if on protease inhibitors\n|\n|Pregnant PLHIV on ART who develop TB|- Continue ART\n- EFV not contraindicated\n- Double-dose DTG\n- Start TB treatment immediately\n- Continue/Initiate CPT (avoid CPT in 1st trimester)\n- Reassess for HIV treatment failure\n|\n\n# 3.3.8 Recommendations for use of ART in HIV/Hepatitis Co-infection\n\nAntiretroviral therapy (ART) should be initiated in all HIV/Hepatitis co-infected individuals regardless of CD4+ cell count and stage of liver disease.\n\n- HIV/HBV Coinfection: The recommended ART for HIV/HBV coinfected PLHIV is TDF + 3TC (or FTC) + DTG. This is because TDF and 3TC are active against HBV.\n- HIV/HCV Coinfection: Antiretroviral therapy should be initiated first in HIV/HCV co-infected patients before commencing Direct Acting Antivirals (DAAs) for HCV treatment.", "mimetype": "text/plain", "start_char_idx": 102607, "end_char_idx": 106759, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "225bc172-e222-4e71-9928-e96ee21d9b62": {"__data__": {"id_": "225bc172-e222-4e71-9928-e96ee21d9b62", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "2cf1d939-3565-4dd1-92c4-576e43cf56ab", "node_type": "1", "metadata": {}, "hash": "c342051178218fd12f0c822104ed9af95a36fad4a6cedf180c1207dfc6ed6d80", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "a2c58816-600c-4345-a8da-1b43314b1eeb", "node_type": "1", "metadata": {}, "hash": "4830552c8217edbc4a0c61291fb0481b1fac46654008bf467cb16a31a8e56973", "class_name": "RelatedNodeInfo"}}, "text": "- HIV/HBV Coinfection: The recommended ART for HIV/HBV coinfected PLHIV is TDF + 3TC (or FTC) + DTG. This is because TDF and 3TC are active against HBV.\n- HIV/HCV Coinfection: Antiretroviral therapy should be initiated first in HIV/HCV co-infected patients before commencing Direct Acting Antivirals (DAAs) for HCV treatment. Drug-drug interactions (DDIs) should be carefully considered and the appropriate ARV or hepatitis drug substitutions/dose adjustments made before commencing treatment.\n\n# Healthcare workers need to note that there is a risk of IRIS associated with early initiation of ART in HIV/hepatitis coinfection, referred to as 'hepatitis flare' which usually occurs within the first 6 to 12 weeks after ART initiation. (see section 8.1.8).\n\n# Recommended ART Regimen for Adults, Adolescents and Children\n\n# First-line ART regimens for adults and adolescents\n\n|First-line ART|Preferred first-line regimen|Alternative first-line regimens|Special Circumstances|\n|---|---|---|---|\n|Adults and Adolescents|TDF + 3TC (or FTC) + DTG|TDF + 3TC (or FTC) + EFV 400|TAF + 3TC (or FTC) + DTG|\n| | |ABC + 3TC + DTG| |\n| | |AZT + 3TC + EFV 400| |\n\n# First-line ART for children\n\n|Weight (Kg)|Age (years)|Preferred First Line Regimen|Alternative First Line Regimen|Special Circumstances|\n|---|---|---|---|---|\n|Neonates|&lt; 3kg|AZT + 3TC + DTG* or RAL|AZT + 3TC + LPV/r**|AZT+3TC+NVP|\n|Infants & Children|&lt; 20kg|ABC +3TC + DTG|ABC+3TC +LPV/r|ABC + 3TC + EFV*+(or NVP)|\n| | |AZT + 3TC +LPV/r| |AZT + 3TC + EFV (or NVP)|\n|20 \u2013 30kg|6-10years|ABC+3TC+DTG Or TDF***(TAF)**** + 3TC +DTG|ABC+3TC +LPV/r|AZT + 3TC + LPV/r (or RAL)|\n\nNote:\n\n*DTG 5mg and 10mg (scored/dispersible) formulations are available for use in children from 4 weeks of age and weighing at least 3kg to children &lt;20kg\n\n**LPV/r pellets or granules can be used if starting after two weeks of age\n\n***TDF is used for children aged 6-10 years weighing &gt;30kg\n\n****TAF is used for children with weight &gt;25kg\n\n*+EFV is used for children above 3 years (&gt;15kg)\n\n**+The use of this INSTI could be considered where available in instances of poor tolerability or administration challenges with LPV/r, particularly in settings where the rapid expansion of maternal treatment could lead to infants and children at very high risk of carrying an NNRTI resistance virus.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 3.4.3 Programming Transitioning to DTG - based regimen\n\nThe transitioning of non-DTG based first-line regimens to DTG-based regimens should be done in virally suppressed and stable patients. Patients failing on a non-DTG based first-line regimen should be switched to the preferred second-line regimen.", "mimetype": "text/plain", "start_char_idx": 106434, "end_char_idx": 109139, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "a2c58816-600c-4345-a8da-1b43314b1eeb": {"__data__": {"id_": "a2c58816-600c-4345-a8da-1b43314b1eeb", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "225bc172-e222-4e71-9928-e96ee21d9b62", "node_type": "1", "metadata": {}, "hash": "44f058fdc7394301e7d6b1b9cb81c0d92e02842990a911d8d2737a81a5c24161", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "da01d3e5-5774-4c96-9db6-de87248ba4aa", "node_type": "1", "metadata": {}, "hash": "6f392376ac8daa0da5c5e4c2aa03c55e46c6c67d610387eed42a47230dc7711c", "class_name": "RelatedNodeInfo"}}, "text": "NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 3.4.3 Programming Transitioning to DTG - based regimen\n\nThe transitioning of non-DTG based first-line regimens to DTG-based regimens should be done in virally suppressed and stable patients. Patients failing on a non-DTG based first-line regimen 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\nOnce a patient is initiated on ART, assessment should look out for:\n\n- Any persisting or new signs/symptoms of HIV related conditions\n- Potential drug toxicities\n- Optimal Adherence\n- Response to therapy (Clinical, Immunological and Virological)\n- Weight changes, growth and development including height in children\n- Abnormal Laboratory parameters\n\n| |Pre-Treatment (Baseline)|Month three|Every six months|Every Scheduled Clinical Consultation|\n|---|---|---|---|---|\n|Physical exam|X|X|X|X|\n|* Adherence counselling|X|X|X|X|\n|* Clinical Screening for TB|X|X|X|X|\n|Clinical screening for chronic care & PHDP Services|X|X|X|X|\n\n*Adherence counselling and clinical screening for TB should be done at every clinical or drug pick up visit\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - Page 34\n\n# Table 3.6 Recommended Schedule for Monitoring Adults on ART: Laboratory Tests\n\n| |Pre-Treatment (Baseline)|Month on ART|Every 6 Months|Every 12 Months (Annual)|\n|---|---|---|---|---|\n|HIV-1 RNA (VL)| | |X\u2021|X|\n|CD4+*|X| | | |\n|*Cryptococcal antigen test (CrAg) and 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 indicated| | | |\n|Cervical cancer screening (VIA/Pap Smear/HPV screen)| |X| |Every 3 years if a screening test is negative|\n|AST, ALP, FBS, Amylase, Pregnancy test, Lipid profile, U/E, Xpert MTB/RIF test, Chest X-Rays| | |As clinically indicated| |\n\nX Essential\n\n1For patients on AZT; 2 Patients on NVP; 3 patients on TDF.\n\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 months later, then repeat at least every 12 months if remains <1000 copies/ml. If the VL is \u22651000copies/ml, the patient should receive enhanced adherence counselling (EAC) and have a repeat VL only after three months of GOOD adherence. A repeat VL test result of \u22651000 cp/ml following EAC is indicative of virologic failure. Clients with persistent virologic failure despite EAC interventions may need to have their drug regimen switched to second-line ART if they have been on a DTG-based regimen (e.g., TLD) for at least 1 year.\n\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 recommended every 6 months until two consecutive values over 200 cells/mm ).\n\nLaboratory monitoring tests may differ according to the level of the health care facility and should be done according to the above schedule.\n\n# 3.5.2 Monitoring Children and Adolescents on ART\n\nClinical and laboratory monitoring are essential parts of HIV and AIDS care in children and adolescents. However, laboratory results do not have to be available on the same day following HIV diagnosis to initiate ART, provided there is no evidence of TB, meningitis or renal disease.", "mimetype": "text/plain", "start_char_idx": 108771, "end_char_idx": 112275, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "da01d3e5-5774-4c96-9db6-de87248ba4aa": {"__data__": {"id_": "da01d3e5-5774-4c96-9db6-de87248ba4aa", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "a2c58816-600c-4345-a8da-1b43314b1eeb", "node_type": "1", "metadata": {}, "hash": "4830552c8217edbc4a0c61291fb0481b1fac46654008bf467cb16a31a8e56973", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "8391fb3d-0f9f-40b3-b7ab-28325bcb41f7", "node_type": "1", "metadata": {}, "hash": "aed9158655a8af41743f611ab78e92e9ab1252cf994ad78a6b6c6e9d6e645d0c", "class_name": "RelatedNodeInfo"}}, "text": "Clients with persistent virologic failure despite EAC interventions may need to have their drug regimen switched to second-line ART if they have been on a DTG-based regimen (e.g., TLD) for at least 1 year.\n\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 recommended every 6 months until two consecutive values over 200 cells/mm ).\n\nLaboratory monitoring tests may differ according to the level of the health care facility and should be done according to the above schedule.\n\n# 3.5.2 Monitoring Children and Adolescents on ART\n\nClinical and laboratory monitoring are essential parts of HIV and AIDS care in children and adolescents. However, laboratory results do not have to be available on the same day following HIV diagnosis to initiate ART, provided there is no evidence of TB, meningitis or renal disease.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n35\n\n# Table 3.7 Recommended Schedule for Monitoring Children and Adolescents on ART: Clinical Assessments\n\n|History and Physical Exam|Pre-treatment (Baseline)|Week on ART|Every 2nd|Every 4th|Every 8th|Every 12th|Every 3 months+|\n|---|---|---|---|---|---|---|---|\n|Anthropometric Measurements (Wt, Ht, Length, OFC, MUAC*, Chest circumference, BMI**)|X|X|X|X|X|X|X|\n|Nutrition (Feeding, diet)|X|X|X|X|X|X|X|\n|Immunization status***|X| | | | | | |\n|HPV Vaccination Assessment****|X| | | | | | |\n|Adherence monitoring|X|X|X|X|X|X|X|\n|Psychosocial assessment*****|X|X|X|X|X|X|X|\n|Clinical Screening for TB, Meningitis, and other OIs (assessment INH and CTX Prophylaxis) and other infectious diseases|X| | | |As indicated| | |\n\n# Table 3.8 Recommended Schedule for Monitoring Children and Adolescents on ART: Laboratory Tests\n\n|Investigations|Pre-Treatment (Baseline)|Month on ART|Every 1st|Every 3rd|Every 6th|Every 12th|Every 6 Months|Every 12 Months (Annual)|\n|---|---|---|---|---|---|---|---|---|\n|HIV-1 RNA (viral load estimation)| | | |X|X|X| | |\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|Cervical Cancer Screening**| |X| | | | | | |\n|CrAg Test| |X| | | | | | |\n|AST, ALP, FBS, Amylase, Pregnancy test*, LF- LAM test for TB infection| |As clinically indicated| | | | | | |\n\n*Most appropriate for adolescents especially where pregnancy is suspected;\n\n**Older or sexually active adolescents;\n\n\u2021 Desirable: Baseline viral load can be performed especially for those with prior exposure to ARVs but is not routinely recommended. We recommend that all children and Adolescents initiating ART should have viral load determined 6 months following initiation of therapy and every 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 months of GOOD adherence. A viral load test result of >1000copies/ml following reinforced adherence counselling and support is indicative of virologic failure. Clients with persistent virologic failure despite adherence interventions should have their drug regimen switched to second-line ART regimen.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n36\n\n# Management of HIV Treatment Failure\n\n# Definition of HIV Treatment Failure\n\nHIV treatment failure may be defined as sub-optimal treatment outcomes following the initiation\nof ART.", "mimetype": "text/plain", "start_char_idx": 111380, "end_char_idx": 115112, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8391fb3d-0f9f-40b3-b7ab-28325bcb41f7": {"__data__": {"id_": "8391fb3d-0f9f-40b3-b7ab-28325bcb41f7", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "da01d3e5-5774-4c96-9db6-de87248ba4aa", "node_type": "1", "metadata": {}, "hash": "6f392376ac8daa0da5c5e4c2aa03c55e46c6c67d610387eed42a47230dc7711c", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "768ad6e1-bb2e-4e0f-aae0-9326cb0d503a", "node_type": "1", "metadata": {}, "hash": "3eb972d3c939092a8122ded7f8d3605cce6080e25898b5f5616599cbc5a1ed63", "class_name": "RelatedNodeInfo"}}, "text": "We recommend that all children and Adolescents initiating ART should have viral load determined 6 months following initiation of therapy and every 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 months of GOOD adherence. A viral load test result of >1000copies/ml following reinforced adherence counselling and support is indicative of virologic failure. Clients with persistent virologic failure despite adherence interventions should have their drug regimen switched to second-line ART regimen.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n36\n\n# Management of HIV Treatment Failure\n\n# Definition of HIV Treatment Failure\n\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\n|Virologic failure|Immunologic failure|Clinical failure|\n|---|---|---|\n|Defined as a VL above 1000 copies/ml based on two consecutive VL measurements 3 months apart, and after an adherence intervention Non-suppressed VL (VL \u2265 1000copies/ml) and its management. Critical to the goal of viral suppression is the return of results to the clinical staff and patient, and actions for non-suppressed VL. A VL \u2265 1000copies/ml should be considered a critical lab value and communicated to the clinical staff and the patient in an expedited fashion. All patients with non-suppressed VL results should undergo Enhanced Adherence Counseling (EAC) sessions.| | |\n\nEnhanced Adherence Counseling (EAC) sessions involve:\n\n1. Step 1: A structured assessment of ART adherence\n2. Step 2: Exploration of specific barriers contributing to poor adherence (as well as the possibility of drug interactions, intercurrent infections, incorrect dosage in children)\n3. Step 3: Identification of potential solutions to address barriers\n4. Step 4: Joint development of an individualized adherence intervention plan and the follow 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 VL is still unsuppressed. In particular, it is important to ensure that effective laboratory information management systems are in place for the prompt identification and notification of the sites, HCWs and unsuppressed patients for timely management. All VL results must be returned to the patient in addition to their charts.\n\n# Table 3.9 Classification of HIV Treatment Failure\n\n|Failure|Definition|Comments|\n|---|---|---|\n|Clinical Failure|Adults and adolescents|The condition must be differentiated from IRIS occurring after initiating ART|\n|Children|New or recurrent clinical event indicating advanced or severe immunodeficiency (WHO clinical stage 3 and 4 clinical condition with exception of TB) after 6 months of effective treatment| |\n|Immunological failure|Adults and adolescents|CD4+ cell count falls to the baseline (or below) Or Persistent CD4+ cell count below 100 cells/mm3 Or 50% decline from on-therapy CD4+ cell count peak level|\n|Children Younger than 5 years|Persistent CD4+ cell count below 200 cells/mm3 or <10%| |\n|Children Older than 5 years|Persistent CD4+ cell count below 100 cells/mm3| |\n|Virological Failure|Plasma viral load \u2265 1000 copies/ml 6 months after starting ART on consecutive VL measurements|An individual must be taking ART for at least 12 months before it can be determined that a regimen has failed|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n38\n\n# Figure 3.1: Algorithm for Treatment Failure Evaluation in Adults, Adolescents and Children\n\n3.6.2 Causes of HIV Treatment Failure\n\nViral factorsAcquired drug resistance: Patients may develop drug-resistant mutations while on ART if maximal adherence (\u226595%) is not maintained.Transmitted drug resistance: Patients may be infected with drug-resistant virus during their initial exposure or be re-infected with drug-resistant virus while on ART.Non-viral FactorsHIV Treatment failure may result when ARV plasma drug levels do not reach therapeutic concentration.", "mimetype": "text/plain", "start_char_idx": 114261, "end_char_idx": 118514, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "768ad6e1-bb2e-4e0f-aae0-9326cb0d503a": {"__data__": {"id_": "768ad6e1-bb2e-4e0f-aae0-9326cb0d503a", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "8391fb3d-0f9f-40b3-b7ab-28325bcb41f7", "node_type": "1", "metadata": {}, "hash": "aed9158655a8af41743f611ab78e92e9ab1252cf994ad78a6b6c6e9d6e645d0c", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "2992863a-e3a3-4e28-8567-ccb60ad5988f", "node_type": "1", "metadata": {}, "hash": "4caac7851fe84968cf18f6c0ebb56f78b01d345f707e46e1631a83126ce8506c", "class_name": "RelatedNodeInfo"}}, "text": "This may be due to:Host factors: poor adherence to ART, malnutrition and malabsorption of drugsChoice of initial ART regimen, poor potency or improper dosingDrug-drug interactions\n\n3.6.3 Substitution and switch of ARV drugs\n\nSubstitution is the replacement of one or two ARV drugs in a regimen with another drug of the same class usually because of the following;\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Toxicity/ adverse drug reactions\n\nSwitching is the replacement of two or more ARV drugs in a regimen with other drugs, including drugs of a class due to treatment failure. Switching can also be referred to as changing a patient from a first-line regimen to a second-line regimen or from a second-line regimen to third-line or salvage regimen.\n\n# When to Switch to Second Line:\n\nThe longer an individual is maintained on a failing regimen, the longer there is ongoing viral replication. This will lead to a worse clinical outcome, greater opportunity for drug resistance and increased risk of transmission.\n\nIn some patients with repeat VL >1,000 copies/ml it may be useful to consider the extent of viral load reduction by log scale. A reduction of >1 log per month with good adherence may suggest viral load suppression is achievable on the current regimen with additional time. Such patients should continue the current regimen and repeat viral load in another few months to see if it has gone below 1,000 copies/ml.\n\nBefore switching to a second-line regimen, improved ART adherence should be reported and detected, and treatment failure should be confirmed (repeat VL>1,000 copies/ml). Health facilities should constitute a multidisciplinary Switch committee to review, track, and make decisions about switching to second-line.\n\nIdeally, the committee should consist of a healthcare worker (medical doctor) and a nurse who knows the client and is conversant with his/her ART treatment history, and the adherence counsellor who has provided EAC to the client and is aware of his/her barriers to adherence.\n\n# Second-line ART Regimens\n\nProtease inhibitor-based regimen is recommended as the preferred ARV drug for second-line ART among adults, adolescents and children. However, DTG may be used as an alternative second-line regimen if an individual is intolerant of LPV/r or has a contraindication to ATV/r or if the first-line regimen does not contain DTG.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n40\n\n# Table 3.10 Preferred and Alternative Second-line ART regimens for Adult and Adolescents including Pregnant and Breastfeeding Women\n\n|Target Population|Failing First-line Regimen|Preferred Second-line Regimen|Alternative Second-line Regimens|\n|---|---|---|---|\n|Adults and Adolescents|TDF+3TC (or FTC) +DTG|AZT+3TC (or FTC) +ATV/r or LPV/r|AZT+3TC (or FTC) +DRV/r|\n| |TDF+3TC (or FTC) +EFV|AZT+3TC (or FTC) +ATV/r or LPV/r|AZT+3TC (or FTC) +DTG|\n| |AZT+3TC (or FTC) +EFV|TDF+3TC (or FTC) +ATV/r or LPV/r|TDF+3TC (or FTC) +DTG|\n|TB/HIV Co-infection|Same regimens as recommended above for adults and adolescents; however, DTG should be administered at 50 mg twice daily with first-line anti-TB medicines and rifabutin substituted for rifampicin in patients receiving protease inhibitors.", "mimetype": "text/plain", "start_char_idx": 118515, "end_char_idx": 121761, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "2992863a-e3a3-4e28-8567-ccb60ad5988f": {"__data__": {"id_": "2992863a-e3a3-4e28-8567-ccb60ad5988f", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "768ad6e1-bb2e-4e0f-aae0-9326cb0d503a", "node_type": "1", "metadata": {}, "hash": "3eb972d3c939092a8122ded7f8d3605cce6080e25898b5f5616599cbc5a1ed63", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "934e5e60-8fbc-43eb-9667-95508dbc9dd4", "node_type": "1", "metadata": {}, "hash": "e3710c8cee5f44d41a933a36e328bbcfc9567392babf94bdd3b5d62d379e3b05", "class_name": "RelatedNodeInfo"}}, "text": "Alternatively, double-dose LPV/r (that is, LPV/r 800 mg/200 mg twice daily) is recommended for TB/HIV co-infected patients on first-line anti-TB medicines.| | |\n|TB/HBV Co-infection|TDF + 3TC (OR FTC) + ATV/r or LPV/r| | |\n\n# Table 3.11: Recommended Second-line ART Regimen for Neonates, Infants, and Children\n\n|Weight (Kg)|Age (years)|Failing First Line Regimen|Preferred 2nd Line Regimen|\n|---|---|---|---|\n|Neonates|&lt; 3 kg|AZT + 3TC + DTG or RAL|AZT + 3TC + LPV/r|\n|Infants & Children|&lt; 20kg|ABC +3TC + DTG|AZT+ 3TC + LPV/r or ATV/r|\n| | |ABC+3TC+LPV/r| |\n| | |ABC (or AZT) +3TC+ RAL| |\n|20 - &lt;30kg|6 \u2013 10years|ABC+3TC+DTG|AZT + 3TC + LPV/r or ATV/r or DRV/r+|\n| | |OR| |\n| | |TDF* (TAF**) + 3TC (or FTC) + *DTG|ABC +3TC + LPV/r or ATV/r DRV/r+|\n|TB/HIV Co-infection|Same recommendations as for adults and adolescents. However, RAL dose should be doubled and administered twice daily with first-line anti-TB medicines| | |\n\n*TDF is used for children aged 6-10 years weighing &gt;30kg\n\n**TAF is used for children weighing &gt; 25kg\n\n***ATV/r can be used as an alternative to LPV/r for children older than 3 months, but limited availability of suitable formulations for children younger than 6 years\n\n+ Should not be used for children &lt; 3 years and combine with appropriate dosing of ritonavir\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 3.7 Third-line ART\n\nThird-line therapy refers to the ART offered to PLHIV in response to the failure of second-line treatment. Efforts should be made to assess and optimize adherence and rule out any significant drug interactions. It is recommended that switch to third-line therapy be left in the hands of HIV specialists with requisite experience and expertise in the management of treatment-experienced HIV patients. The choice of third-line therapy is more difficult in the absence of HIV drug resistance.\n\nThird-line regimens should include new drugs with minimal risk of cross-resistance to previously used regimens, such as INSTIs and second or third-generation NNRTIs and PIs. The WHO has recommended that National ART programmes in resource-limited settings develop policies for access to third-line ART, containing ritonavir-boosted darunavir, integrase inhibitors, and etravirine. These agents have been shown to be effective in highly treatment-experienced patients in trial settings.\n\nThe FMOH has set up a third-line ART Committee to oversee the implementation of third-line ART in Nigeria; and designated some sites spread across the six geo-political zones of the country as third-line ART sites. Also, it has developed and disseminated the criteria for the switch and operational guidance for third-line ART.\n\n# 3.7.1 Criteria for Switch to Third-Line ART\n\nIn the event of suspected treatment failure on second-line ART, the following criteria should be met 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|---|---|\n|2.|The patient should have a viral load result suggestive of treatment failure (>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 EAC; the EAC must assess and optimize adherence and rule out any significant drug 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 ARVs that are still active.|\n\n# 3.7.2 Operational Guidance for Third-Line ART\n\nPatients that meet the criteria stated above for switch to third-line ART should be referred to the third-line site closest to the referring facility with a filled third-Line ART eligibility form, a recent HIV viral load result (done within the last 6 months) and a result of HIV drug resistance testing.", "mimetype": "text/plain", "start_char_idx": 121762, "end_char_idx": 125713, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "934e5e60-8fbc-43eb-9667-95508dbc9dd4": {"__data__": {"id_": "934e5e60-8fbc-43eb-9667-95508dbc9dd4", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "2992863a-e3a3-4e28-8567-ccb60ad5988f", "node_type": "1", "metadata": {}, "hash": "4caac7851fe84968cf18f6c0ebb56f78b01d345f707e46e1631a83126ce8506c", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "4faedd18-3ed4-44f5-92de-f8a37a477e3e", "node_type": "1", "metadata": {}, "hash": "c57a531add371a98df97e6d983de9b15cba0d888fb3276f8bcc51751ee19093a", "class_name": "RelatedNodeInfo"}}, "text": "The third-line ART site will review the third-line ART eligibility form and forward the completed forms to the National third-line Committee through the email: nationalthirdline@gmail.com\n\nUpon approval by the National third-line Committee, the patient will commence treatment at the third-line site.\n\nPatients commenced on third-line ART should have a viral load test done 3 months after the commencement of therapy.\n\n# Table 3.12 Sequence of Switching ART from first-Line to third-Line regimens\n\n|Target Population|First-line Regimens|Second-line Regimens|Third-line Regimens|\n|---|---|---|---|\n|Adults and Adolescents|TDF + 3TC (or FTC) + DTG|AZT + 3TC (or FTC) + ATV/r or LPV/r or DRV/r|TDF + 3TC (or FTC) + DRV/r + DTG +/ - ETV|\n| |TDF + 3TC (or FTC) + EFV 400mg|AZT + 3TC (or FTC) + ATV/r or LPV/r or DTG or DRV/r|AZT+3TC (or FTC) + DRV/r \u00b1 ETV +/ - DTG|\n|Children and infants|ABC + 3TC + DTG|AZT + 3TC + LPV/r (or ATV/r)|RAL or DTG + DRV/r (children >3years) + ABC or AZT + 3TC|\n| |ABC (or AZT) + 3TC + LPV/r|AZT + 3TC + DRV/r (children > 3years)| |\n| |ABC (or AZT) + 3TC + EFV|AZT (or ABC) + 3TC + DTG| |\n| |ABC (or AZT) + 3TC + EFV|AZT (or ABC) + 3TC + LPV/r (or ATV/r)| |\n\n# 3.8 Low-Level Viremia (LLV)\n\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\n# 3.8.1 Management of Low-level viremia (LLV)\n\n- All clients with low-level viremia (VL 200 - 999 copies/ml) should undergo a thorough\nassessment of the cause of the elevated VL and specifically consider the possibility of\n(ABCDE):\n- Adherence problems\n- Bugs (Intercurrent infections)\n- In-Correct ART dosage\n- Drug Interactions\n- Resistance\n- Implement interventions to re-suppress the VL, including EAC (1-3)\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 3.9 ART in Special Circumstances\n\nA number of non-communicable diseases (NCDs) adversely affect the outcome of ART in PLHIV. These NCDs must be taken into consideration as dose adjustment helps significantly to limit the complications of ART in these settings. The most common NCD in HIV infection is kidney impairment. Many patients also have drug-induced or disease-related cardio-myopathy. Osteoporosis is also becoming a common complication being reported among older women on TDF-containing ART.\n\n# 3.9.1 Kidney impairment\n\nExperience from Nigeria has shown that 23.8% [2] of newly diagnosed HIV infected patients present with evidence of kidney impairment. Long term follow-up of about 5,000 patients on TDF containing regimen in another study from Jos, Nigeria [3] showed that 10% of patients without baseline evidence of kidney impairment develop laboratory features of kidney impairment by week 24 of follow up. This proportion increased to 45% by week 144. The authors concluded that ART regimens in Nigeria need to be reviewed concerning the use of TDF. They suggested an alternative regimen such as ABC or TAF. There is also the need to dose adjust 3TC as this drug is 80 - 90% eliminated by the kidney.", "mimetype": "text/plain", "start_char_idx": 125715, "end_char_idx": 129407, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "4faedd18-3ed4-44f5-92de-f8a37a477e3e": {"__data__": {"id_": "4faedd18-3ed4-44f5-92de-f8a37a477e3e", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "934e5e60-8fbc-43eb-9667-95508dbc9dd4", "node_type": "1", "metadata": {}, "hash": "e3710c8cee5f44d41a933a36e328bbcfc9567392babf94bdd3b5d62d379e3b05", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "48f6c872-48e2-4d22-b01d-6346cd593416", "node_type": "1", "metadata": {}, "hash": "6072d66e01e7a737a95a27dd225d4e3647106e1702fccbff6418a98b0cd502e3", "class_name": "RelatedNodeInfo"}}, "text": "Osteoporosis is also becoming a common complication being reported among older women on TDF-containing ART.\n\n# 3.9.1 Kidney impairment\n\nExperience from Nigeria has shown that 23.8% [2] of newly diagnosed HIV infected patients present with evidence of kidney impairment. Long term follow-up of about 5,000 patients on TDF containing regimen in another study from Jos, Nigeria [3] showed that 10% of patients without baseline evidence of kidney impairment develop laboratory features of kidney impairment by week 24 of follow up. This proportion increased to 45% by week 144. The authors concluded that ART regimens in Nigeria need to be reviewed concerning the use of TDF. They suggested an alternative regimen such as ABC or TAF. There is also the need to dose adjust 3TC as this drug is 80 - 90% eliminated by the kidney.\n\n# 3.9.2 Cardiomyopathy\n\nThere is no current published national data regarding HIV and ARV related cardiomyopathy. However, anecdotal reports from high volume sites in Nigeria suggest that a significant number of HIV infected Nigerians are now developing hypertension and electrocardiographic and echocardiographic features of cardiomyopathy. Research is ongoing in Nigeria to study and report this phenomenon. While awaiting this report, present knowledge suggests that cardiomyopathy is more associated with the use of ABC. Other studies have established a relationship between ABC and increased hyperactivity of platelets. The platelet endothelial cell interaction is suggested to be a major factor predisposing to cardiovascular diseases in HIV infected population.\n\n# 3.9.3 Osteoporosis\n\nDecreased bone mineral density has been reported as a long-term complication of TDF. This is the reason why paediatricians do not recommend the use of TDF in children in order not to limit growth potential. In adults, however, particularly post-menopausal females, decreased bone mineral density associated with post-menopausal age may become complicated with long term use of TDF. Presently, we do not have in-country data to support the magnitude of this problem.\n\n# 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 600mg* OR replace with TAF 25mg|\n| |3TC toxicity|Dose adjustment based on eGFR eGFR>50, no adjustment, 300mg daily eGFR 30-49ml/min, 150mg daily eGFR 15-29ml/min, 75mg daily eGFR <15ml/min or dialysis dependent, 75mg alternate days|\n|Cardiomyopathy|ABC toxicity|Refer the patient for cardiology review and HIV specialist opinion|\n|Osteoporosis|TDF toxicity|Replace with TAF|\n\n*eGFR >50ml/min, recommended regimen is ABC+3TC+DTG, 600/300/50mg daily\n\neGFR 30-49ml/min, recommended regimen is ABC/3TC/DTG, 600/150/50mg daily\n\neGFR 15-29ml/min, recommended regimen is ABC/3TC/DTG, 600/75/50mg daily\n\neGFR <15ml/min or on renal dialysis, recommended regimen is ABC/3TC/DTG, 600 daily, 75mg alternate days (or 37.5mg daily), 50mg daily\n\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\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# List of Contributors\n\nDr Bilikisu JibrinDr Etiobhio EhimenDr. Urhioke OchukoChika-Onyiah OgechukwuProf. Oche AgbajiProf. Augustine OmoigberaleProf.", "mimetype": "text/plain", "start_char_idx": 128585, "end_char_idx": 131989, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "48f6c872-48e2-4d22-b01d-6346cd593416": {"__data__": {"id_": "48f6c872-48e2-4d22-b01d-6346cd593416", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "4faedd18-3ed4-44f5-92de-f8a37a477e3e", "node_type": "1", "metadata": {}, "hash": "c57a531add371a98df97e6d983de9b15cba0d888fb3276f8bcc51751ee19093a", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "8f48c9af-cc4a-45d3-9812-9e18b74cdf4e", "node_type": "1", "metadata": {}, "hash": "b3c263200b8db49029b53368926d67833227edc2a41a0cc4d0552889195a4023", "class_name": "RelatedNodeInfo"}}, "text": "Urhioke OchukoChika-Onyiah OgechukwuProf. Oche AgbajiProf. Augustine OmoigberaleProf. Stephen OgucheDr Sunny OchigboDr Abiola DaviesDr Omoniyi Amos FadareDr Andrew AbutuDr Fagbamigbe Omodele JohnsonAdemola OladapoDr Adegbenga OlarinoyeDr Ismail LawalDr Chux AnagoDr Nere OtubuDr Iboro NtaDr Emerenini Franklin ChimeDr Olanrewaju OlaiyaMrs Aisha Nantim DadiDr Rosemary AduDr Plang JwanleDr Echey IjezieIkechukwu EzekpeazuDr Austin Azihaiwe-JustineDr Pius NwaokoroDr Felicia MairigaPrince GamboEmmanuel CliffordDr Ugwuike, Joseph EzeChike AnyachorDr Valentine Uche\n\n# Chapter 3\n\nAssistant Director, Head Treatment, Care and Support NASCPSenior Medical Officer, Treatment, Care and Support NASCPAssistant Director, Childhood TB - NTBLCPSenior Scientific Officer I NASCPMember NTTA / Physician JUTH JosMember NTTA / Paediatrician UBTH BeninMember NTTA / Paediatrician JUTH JosMember NTTA / Paediatrician UCTH CalabarHealth Manager UNICEFNational Professional Officer TB/HIV WHOART Program Manager CDCSenior Program Specialist, HIV Care and Treatment CDCSenior Progam specialist SI CDCSenior Program Specialist - Pediatric Treatment US DoDLead for HIV Care and Treatment US DoDProgram Manager CHAIProgram Manager CHAIAssociate CHAIPaediatrics PMTCT Lead ICAPProject Director, Pro-Health InternationalProject Manager SFHHead of Programmes (GF HIV) SFHAssociate Director APINCountry Program Director AHF APINSenior Technical Advisor FHI360Deputy Director Technical FHI360 FHI360Deputy Coordinator NEPWHAN NEPWHANTreatment Advisor Heartland AllianceAccess Manager, Johnson & Johnson Global Public HealthMedical Affairs Manager, Johnson & Johnson Global Public Health\n\n# PHARMACOVIGILANCE IN ANTIRETROVIRAL THERAPY\n\nWhat\u2019s Inside:\n\n|4.1 Introduction|48|\n|---|---|\n|4.2 Pregnancy Monitoring for Patients on ARVs|48|\n|4.3 HIV Drug Resistance (HIVDR)|49|\n|4.4 Adverse drug reactions (ADRs)|49|\n|4.5 Drug toxicity|46|\n|4.6 Steps to Recognize ADRs|54|\n|4.7 Who is to Report ADRs?|54|\n|4.8 What ADRs Should be Reported|54|\n|4.9 Pharmacovigilance Data Collection and Reporting Process|55|\n|4.10 Principles of Management of Adverse Drug Reactions|55|\n|4.11 Prevention of Adverse Drug Reactions|61|\n|4.12 ARV Drug Interactions|62|\n\n# 4.1 Introduction\n\nPharmacovigilance (PV) is defined as the science and activities relating to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problem including medication errors, drug misuse, and abuse. Pharmacovigilance is an arm of patient care that aims at making the best use of medicines for the treatment or prevention of disease. Good pharmacovigilance practice will identify the risks and the risk factors in the shortest possible time so that harm can be avoided or minimized.\n\nThere are two methods of pharmacovigilance:\n\n- Active pharmacovigilance\n- Passive pharmacovigilance\n\nMonitoring and reporting of drug therapy problems including adverse drug reactions (ADRs) and medication errors should be an integral part of clinical practice for ensuring patient safety and optimal treatment outcomes. All healthcare providers (doctors, pharmacists, nurses, and counselors, etc.) at various service delivery points should, therefore, assess patients for ADRs at every encounter and report all suspected adverse events using the NAFDAC ADR form (Yellow form). All facilities should establish a functional hospital-based pharmacovigilance committee in all ART/PMTCT centers to coordinate ARV clinical pharmacovigilance. This committee is very vital to the success of pharmacovigilance and management of ADRs in a clinical setting.\n\n# 4.1.1 Active Pharmacovigilance\n\nActive (or proactive) safety surveillance means that active measures are taken to detect adverse events. This is managed by active follow-up after treatment and the events may be detected by asking patients directly or screening patient records.", "mimetype": "text/plain", "start_char_idx": 131904, "end_char_idx": 135789, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8f48c9af-cc4a-45d3-9812-9e18b74cdf4e": {"__data__": {"id_": "8f48c9af-cc4a-45d3-9812-9e18b74cdf4e", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "48f6c872-48e2-4d22-b01d-6346cd593416", "node_type": "1", "metadata": {}, "hash": "6072d66e01e7a737a95a27dd225d4e3647106e1702fccbff6418a98b0cd502e3", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "9c44f389-1d28-4f71-980c-1578e1550fb0", "node_type": "1", "metadata": {}, "hash": "c1d6b35772d2484f736875a590b63af719411a68438003aa9d6f8a6f6a984bfe", "class_name": "RelatedNodeInfo"}}, "text": "All healthcare providers (doctors, pharmacists, nurses, and counselors, etc.) at various service delivery points should, therefore, assess patients for ADRs at every encounter and report all suspected adverse events using the NAFDAC ADR form (Yellow form). All facilities should establish a functional hospital-based pharmacovigilance committee in all ART/PMTCT centers to coordinate ARV clinical pharmacovigilance. This committee is very vital to the success of pharmacovigilance and management of ADRs in a clinical setting.\n\n# 4.1.1 Active Pharmacovigilance\n\nActive (or proactive) safety surveillance means that active measures are taken to detect adverse events. This is managed by active follow-up after treatment and the events may be detected by asking patients directly or screening patient records. It is based on structured procedures to obtain detailed information about patient populations, thereby allowing consideration of modifying factors such as polypharmacy, comorbidity, and socio-demographic characteristics. In addition, it enables targeted monitoring of specific drugs and adverse reactions to optimize the quality and quantity of reports as well as quantifying the frequency and severity of both expected and unanticipated adverse drug reactions. This surveillance is best done prospectively. Active pharmacovigilance is sometimes descriptively referred to as hot 'pursuit'. The most comprehensive method of active pharmacovigilance is Cohort Event Monitoring (CEM). It is an adaptable and powerful method of getting good comprehensive data. Other methods of active monitoring include the use of registers, record linkage and screening of laboratory results in medical laboratories.\n\nActive pharmacovigilance is compulsory for all new drugs imported or manufactured for use within the country. It may be initiated, managed or financed by the Market Authorization Holder/PHP voluntarily or pursuant to an obligation imposed by the National Agency for Foods and Drugs Administration and Control (NAFDAC). In any case, the process must be done in collaboration with NAFDAC.\n\n# 4.2 Pregnancy Monitoring for Patients on ARVs\n\nIt is strongly recommended that all women who are known to be pregnant on ART should be followed up to find out the outcome of the pregnancy and the health status of the infant. Health care providers should collect data on all ARV drug exposure during pregnancy using an appropriate data collection tool. Data collected should include:\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n48\n\n# Baseline information on the pregnancy\n\nWhat ARV is the woman on?, Did the woman get pregnant while on ART?, or Was ART initiated during pregnancy?\n\n# Details on any pregnancy-related problems\n\nin the woman, foetal death and or abnormalities observed when the infant is examined at birth or postnatally\n\n# 4.3 HIV Drug Resistance (HIVDR)\n\nThe global risk of further increases in HIVDR is heightened by the implementation of WHO guidelines recommending \"Treat All\" and pre-exposure prophylaxis, and many more people initiating HIV treatment. While concerns about resistance should not stop the provision of antiretroviral therapy (ART) to all in need, the long-term implications of earlier initiation on adherence 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 significant proportion of patients. These patients would have to be switched to more expensive second-line or even third-line regimens. With higher levels of HIVDR, more resources would be needed to treat the same number of patients, or more likely, fewer patients could be treated with the same resources.\n\nTherefore, surveillance of HIVDR and implementation of effective responses are key to preserving the effectiveness of first-line ART which is the goal of any ART programme.\n\n# 4.4 Adverse drug reactions (ADRs)\n\nAn adverse drug reaction (ADR) is defined by WHO as \u201ca response to a drug which is noxious and unintended, and which occurs at doses normally used in man for the prophylaxis, diagnosis, or therapy of disease, or the modification of physiological function.\u201d Side Effect refers to the unintended effect of a health product occurring at doses normally used in man which is related to the pharmacological properties of the drug.\n\nThe therapeutic benefits of ARV use far outweigh the risk, thus despite the ADRs and toxicities encountered with ARV use, they are still essential inpatient management. ARVs resulting in ADRs that pose a serious threat to the health and well-being should be discontinued without delay and necessary consultations made regarding the next line of actions.\n\n# 4.4.1 Classification of Adverse Drug Reactions (ADRs)\n\nThe WHO classifies ADRs into four categories based on severity. Severity is a subjective assessment made by the healthcare provider and/or patients. Despite being subjective, it is useful in identifying adverse reactions that may affect adherence or further harm that needs prompt intervention.", "mimetype": "text/plain", "start_char_idx": 134982, "end_char_idx": 140063, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "9c44f389-1d28-4f71-980c-1578e1550fb0": {"__data__": {"id_": "9c44f389-1d28-4f71-980c-1578e1550fb0", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "8f48c9af-cc4a-45d3-9812-9e18b74cdf4e", "node_type": "1", "metadata": {}, "hash": "b3c263200b8db49029b53368926d67833227edc2a41a0cc4d0552889195a4023", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "768fa145-742c-4763-bd70-f252de065582", "node_type": "1", "metadata": {}, "hash": "2b7467090a622665773e96e7cb680be472f549427d36560077d48cf8dd2f2c48", "class_name": "RelatedNodeInfo"}}, "text": "The therapeutic benefits of ARV use far outweigh the risk, thus despite the ADRs and toxicities encountered with ARV use, they are still essential inpatient management. ARVs resulting in ADRs that pose a serious threat to the health and well-being should be discontinued without delay and necessary consultations made regarding the next line of actions.\n\n# 4.4.1 Classification of Adverse Drug Reactions (ADRs)\n\nThe WHO classifies ADRs into four categories based on severity. Severity is a subjective assessment made by the healthcare provider and/or patients. Despite being subjective, it is useful in identifying adverse reactions that may affect adherence or further harm that needs prompt intervention.\n\n|Severity Category|Description|\n|---|---|\n|Mild|Minimal or no treatment required|\n|Moderate|Requires treatment and may interfere with daily activities|\n|Severe|Significant, requires urgent intervention|\n|Life-threatening|Extreme, requires immediate life-saving intervention|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Table 4.1: WHO Severity Grading of ADR\n\n|Severity Grade|Characteristics|\n|---|---|\n|1 \u2013 Mild ADR|- Transient or mild discomfort (&lt;48 hours)\n- No limitation of activity\n- No medical intervention or therapy required\n|\n|2 \u2013 Moderate ADR|- Mild to moderate limitation of activity\n- Some assistance may be needed\n- No or minimal medical intervention required\n|\n|3 \u2013 Severe ADR|- Marked limitation of activity\n- Some assistance usually required\n- Medical intervention or therapy required\n- Hospitalization possible\n|\n|4 \u2013 Life-Threatening ADR|- Extreme limitation of activity\n- Significant assistance required\n- Significant medical intervention or therapy required\n- Hospitalization or hospice care probable\n|\n\nIn the event of severe/life-threatening ADRs, the offending drug(s) must be discontinued and changed to another drug from within its class.\n\n# 4.5 Drug toxicity\n\nThis is the unwanted effect of drugs resulting from administration in excess of the required therapeutic dose, or accumulation of drugs in the body due to inefficient absorption, distribution, metabolism, or excretion. Some clinical conditions e.g. renal impairment and chronic liver disease may also predispose patients to drug toxicity. Drug toxicity can be detected clinically (history and clinical examination) and/or through laboratory testing (table 4.2).\n\nIn the event of drug toxicity, dose adjustment is recommended where feasible; otherwise, the offending drug should be discontinued and changed to another drug from within its class.\n\n# 4.5.1 Laboratory monitoring of toxicity:\n\nLaboratory monitoring of patients receiving ARVs for either HIV treatment or prophylaxis is very important for early detection and prevention of some ADRs. Abnormal laboratory values may be early warning signals preceding the clinical manifestations of some ADRs in patients receiving antiretroviral drugs. Symptom-related monitoring is useful and there are also several laboratory tests (but not routinely required) for assessing the safety and toxicity of ART, especially in high-risk clients.\n\nThe table below shows the ARV drug class, clinical abnormality, and the laboratory test that could be used for its monitoring.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n50\n\n# 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|---|---|---|---|---|\n|NRTI|Abacavir (ABC)|Hypersensitivity|Presence of HLA-B*5701 gene|CPK, Liver enzymes|\n|Emtricitabine (FTC)|Hepatotoxicity| |Liver enzymes| |\n|Lamivudine (3TC)|Cough, diarrhoea, fatigue, malaria, headache, lethargy, Nausea, vomiting and pancreatitis (in children)|Non-specific| | |\n|Tenofovir Disoproxil Fumarate (TDF)|Renal Toxicity|Underlying renal disease; Age >50 years old; BMI <18.5 or low body weight (<50 kg), diabetes, hypertension Concomitant use of nephrotoxic drugs or a boosted PI|Creatinine, Urinalysis| |\n|Zidovudine (AZT)|Anaemia, leukopenia, neutropenia, Lactic acidosis, severe hepatomegaly with Myopathy|Baseline anaemia or neutropenia CD4+ cell 3 count of \u2264200 cells/mm BMI >25 (or bodyweight >75 kg) Prolonged exposure to NRTIs|Full blood count, E/U/Cr, CPK| |\n|NNRTI|Efavirenz (EFV)|CNS manifestations|Depression or other mental disorder (previous or at baseline),", "mimetype": "text/plain", "start_char_idx": 139357, "end_char_idx": 143711, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "768fa145-742c-4763-bd70-f252de065582": {"__data__": {"id_": "768fa145-742c-4763-bd70-f252de065582", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "9c44f389-1d28-4f71-980c-1578e1550fb0", "node_type": "1", "metadata": {}, "hash": "c1d6b35772d2484f736875a590b63af719411a68438003aa9d6f8a6f6a984bfe", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "fdd30f91-0a54-4d84-94e5-412656dae5c5", "node_type": "1", "metadata": {}, "hash": "59cc4b327234db629fea84531dfb4f7646de26a519b0171e6704c88178511200", "class_name": "RelatedNodeInfo"}}, "text": "Age >50 years old; BMI <18.5 or low body weight (<50 kg), diabetes, hypertension Concomitant use of nephrotoxic drugs or a boosted PI|Creatinine, Urinalysis| |\n|Zidovudine (AZT)|Anaemia, leukopenia, neutropenia, Lactic acidosis, severe hepatomegaly with Myopathy|Baseline anaemia or neutropenia CD4+ cell 3 count of \u2264200 cells/mm BMI >25 (or bodyweight >75 kg) Prolonged exposure to NRTIs|Full blood count, E/U/Cr, CPK| |\n|NNRTI|Efavirenz (EFV)|CNS manifestations|Depression or other mental disorder (previous or at baseline), Daytime dosing Serum cholesterol|Liver enzymes|\n| |Hepatotoxicity|Underlying HBV and HCV co-infection, Concomitant use of hepatotoxic drugs| | |\n| |Hypercholesterolemia|Risk factor(s) unknown| | |\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n51\n\n# Drug class Drug\n\n|Drug|Common ADRs|Risk factors|Laboratory Tests|\n|---|---|---|---|\n|Nevirapine (NVP)|Gynaecomastia|Risk factor(s) unknown| |\n| |Hepatotoxicity|Underlying hepatic disease|HBV and HCV co-infection Liver enzymes|\n| |Severe skin rash and hypersensitivity reaction, including Stevens-Johnson syndrome|High baseline CD4+ cell count| |\n|Atazanavir/ritonavir (ATV/r)|Electrocardiographic abnormalities (PR and QRS interval prolongation)|Pre-existing conduction system disease Concomitant use of drugs which may prolong the PR or QRS intervals Congenital long QT syndrome|ECG|\n| |Indirect hyperbilirubinemia (clinical jaundice)|Presence of UDP Glucuronyl transferase 1A1*28 (UGT1A1*28) gene| |\n| |Nephrolithiasis|Previous history| |\n|Darunavir/ritonavir (DRV/r)|Hepatotoxicity|Underlying hepatic disease, Concomitant use of hepatotoxic drugs|Liver enzymes|\n| |Severe skin and hypersensitivity reactions| | |\n|Lopinavir/ritonavir (LPV/r)|Hepatotoxicity|Underlying hepatic disease HBV and HCV co-infection Concomitant use of hepatotoxic drugs|Liver enzymes Serum amylase ECG Lipid profile|\n| |Pancreatitis|Advanced HIV disease, alcohol| |\n| |Arrhythmias|People with pre-existing conduction system disease| |\n| |Dyslipidaemia|Cardiovascular risk factors as obesity and diabetes| |\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Drug class Drug\n\nDrugRitonavir (RTV)Integrase inhibitorsDolutegravir (DTG)Raltegravir (RAL)\n\n# Common ADRs\n\n|Common ADRs|Risk factors|Laboratory Tests|\n|---|---|---|\n|Diarrhoea|Risk factor(s) unknown|Liver enzymes|\n|Hepatotoxicity|Underlying hepatic disease|Liver enzymes|\n|Hyperglycaemia|HBV and HCV co-infection|Urinalysis, BSL- blood sugar level|\n|Hyperlipidemia| |Serum lipids, CPK, Uric acid|\n|Hepatotoxicity|Underlying hepatic disease, Concomitant use of hepatotoxic drugs|Liver enzymes|\n|Hypersensitivity reactions|Risk factor(s) unknown| |\n|Insomnia|Risk factor(s) unknown| |\n|IRIS, Neural Tube Defects (NTDs)|PLHIV with AHD| |\n|Rhabdomyolysis, myopathy, myalgia.|Concomitant use of other drugs that increase the risk of myopathy and rhabdomyolysis, including statin|CPK, Liver enzymes|\n|Hepatotoxicity, Severe skin rash and hypersensitivity reaction|Risk factor(s) unknown| |\n\n# Table 4.3: Common ADRs associated with drugs used in the management of Ois\n\n|Drug|Common ADRs|Laboratory Tests|\n|---|---|---|\n|Cotrimoxazole|Hypersensitivity, Steven Johnson\u2019s Syndrome, Anaemia and Liver problems|CBC and Liver function test|\n|Isoniazid|Liver problems,", "mimetype": "text/plain", "start_char_idx": 143185, "end_char_idx": 146491, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "fdd30f91-0a54-4d84-94e5-412656dae5c5": {"__data__": {"id_": "fdd30f91-0a54-4d84-94e5-412656dae5c5", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "768fa145-742c-4763-bd70-f252de065582", "node_type": "1", "metadata": {}, "hash": "2b7467090a622665773e96e7cb680be472f549427d36560077d48cf8dd2f2c48", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "a315f0f8-af27-4fe6-9ef2-9a99355e67b8", "node_type": "1", "metadata": {}, "hash": "85fd9fc7132275756c936f6f974c99cd0aceb96a97dbe7653b414426288f9060", "class_name": "RelatedNodeInfo"}}, "text": "Neural Tube Defects (NTDs)|PLHIV with AHD| |\n|Rhabdomyolysis, myopathy, myalgia.|Concomitant use of other drugs that increase the risk of myopathy and rhabdomyolysis, including statin|CPK, Liver enzymes|\n|Hepatotoxicity, Severe skin rash and hypersensitivity reaction|Risk factor(s) unknown| |\n\n# Table 4.3: Common ADRs associated with drugs used in the management of Ois\n\n|Drug|Common ADRs|Laboratory Tests|\n|---|---|---|\n|Cotrimoxazole|Hypersensitivity, Steven Johnson\u2019s Syndrome, Anaemia and Liver problems|CBC and Liver function test|\n|Isoniazid|Liver problems, Musculoskeletal symptoms and GI symptoms|LFT|\n|Fluconazole|CNS and GI symptoms| |\n|Amphotericin B|Injection site reactions, hypersensitivity reactions, GI symptoms, musculoskeletal symptoms, respiratory symptoms, CNS symptoms, vision changes, low potassium, and dysuria|E/U/Cr|\n|Flucytosine|Hypersensitivity, Hepatic disorders, Haematological, Respiratory, Renal, GI and CNS disorders|LFT, E/U/Cr, CBC & RBS|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Steps to Recognize ADRs\n\n1. Take adequate history and do a thorough physical examination of the patient2. Establish time relationships, between start of therapy to the time of onset of the suspected reaction.3. Carry out appropriate laboratory investigations, where indicated4. Check the pharmacological properties of the suspected drugs if required\n\n# Who is to Report ADRs?\n\nAdverse drug reactions (ADRs) should be reported by Physicians, Pharmacists, Nurses, Medical laboratory scientists, other health and community health care workers, caregivers, and patients. The original copy should be sent to NAFDAC by the facility pharmacovigilance focal staff, while the duplicate copy should remain in the patient's folder. The third copy should remain in the booklet at the Service Delivery Point. All completed booklets should be sent to the pharmacovigilance focal staff for safekeeping.\n\n# Reporting Timelines\n\n|Type of ADR Report|Time frame for Reporting|\n|---|---|\n|Serious (expected and unexpected)|15 days|\n|Non-serious(unexpected)|15 days|\n|Non-serious (expected)|Within 90 days|\n|Foreign report (Spontaneous/published/study)|Within 90 days|\n|Notification of change in nature, severity or frequency or risk factor|15 days|\n|New information impacting on benefits \u2013 risk profile of product including international regulatory decisions|3 days|\n\n# What ADRs Should be Reported\n\n1. All serious reactions (expected or unexpected) that one suspects for established or well-known drugs\n2. All suspected reactions, including minor ones for new drugs\n3. If an increased frequency of a given reaction is observed\n4. All suspected adverse reactions associated with drug-drug, drug-food, or drug-food supplement interactions and drug-disease interactions.\n5. ADRs during pregnancy and lactation\n6. ADRs occurring from an overdose or medication error\n7. Lack of efficacy of a medication, or when suspected pharmaceutical defects are observed\n8. Reactions suspected of causing death, danger to life, admission to hospital, prolongation of hospitalization, or birth defects.\n9. When in doubt whether the suspected adverse event/reaction is an ADR or not, you must report to the National Pharmacovigilance Centre.\n\n# 4.9 Pharmacovigilance Data Collection and Reporting Process\n\nAll ADRs should be reported to the National Pharmacovigilance Centre using the NAFDAC ADR form (yellow form). The following steps should be taken:\n\nRefer to the NAFDAC website for all reported ADRs (https://www.nafdac.gov.ng/)\n\n# 4.10 Principles of Management of Adverse Drug Reactions\n\nEnsure strict adherence to the standard procedures outlined below for detecting, evaluating and reporting ADRs in ART/PMTCT Clinical Settings\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n55\n\n|Figure 4.2: Management of Adverse Drug Reactions|Figure 4.2: Management of Adverse Drug Reactions|\n|---|\n|NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020|56|\n\n# Management of Specific ARV Adverse Drug Reactions\n\nAdverse reactions associated with ARV drugs usually have a class similarity; however certain drugs in each of the classes present more severe forms of adverse reactions than others.", "mimetype": "text/plain", "start_char_idx": 145926, "end_char_idx": 150141, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "a315f0f8-af27-4fe6-9ef2-9a99355e67b8": {"__data__": {"id_": "a315f0f8-af27-4fe6-9ef2-9a99355e67b8", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "fdd30f91-0a54-4d84-94e5-412656dae5c5", "node_type": "1", "metadata": {}, "hash": "59cc4b327234db629fea84531dfb4f7646de26a519b0171e6704c88178511200", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "d0ffd61a-1fc6-4dab-8563-dc6e70406c15", "node_type": "1", "metadata": {}, "hash": "9c5449821309385447668b4cf9edc405f0707a4f2081ab40dd67ab60f69d672d", "class_name": "RelatedNodeInfo"}}, "text": "The following steps should be taken:\n\nRefer to the NAFDAC website for all reported ADRs (https://www.nafdac.gov.ng/)\n\n# 4.10 Principles of Management of Adverse Drug Reactions\n\nEnsure strict adherence to the standard procedures outlined below for detecting, evaluating and reporting ADRs in ART/PMTCT Clinical Settings\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n55\n\n|Figure 4.2: Management of Adverse Drug Reactions|Figure 4.2: Management of Adverse Drug Reactions|\n|---|\n|NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020|56|\n\n# Management of Specific ARV Adverse Drug Reactions\n\nAdverse reactions associated with ARV drugs usually have a class similarity; however certain drugs in each of the classes present more severe forms of adverse reactions than others. In the management of adverse events, special attention should, therefore, be paid to drug-specific adverse reactions. For example, Zidovudine is implicated in ARV-induced anaemia more than any other ARV in the same class, just as Efavirenz is more likely to cause CNS toxicity than the other ARV drugs in the same class.\n\n# Nucleoside Reverse Transcriptase Inhibitors (NRTIs)\n\nAll NRTIs are capable of inhibiting mitochondria DNA (mtDNA) gamma polymerase enzyme resulting in mitochondrial toxicity. As NRTIs inhibit DNA polymerase, all tissues that have DNA can be affected. The manifestation of NRTI adverse drug reaction is dependent on the organ involved; there can be myopathy presenting with muscle weakness, bone marrow disorders causing depression of haemopoiesis and leading to anaemia, leucopenia and thrombocytopenia; lipolysis resulting in fat atrophy (lipoatrophy). It can cause myelotoxicity and neuropathy when it affects peripheral neurons, thus precipitating peripheral neuropathy. Though rare, prolonged usage of NRTIs may also affect myocardial cells resulting in cardiomyopathy. Others include hepatitis, pancreatitis, and lactic acidosis.\n\n# Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)\n\nThey increase the incidence of severe hepatotoxicity in women with CD4+ cell count > 250cells/mm and men with CD4+ cell count > 400cells/mm. Other common reactions include skin rash and CNS disorders.\n\n# Protease Inhibitors (Pis)\n\nPIs are potent CYP3A4 inhibitors hence many drug-drug interactions can occur on co-administration with other drugs. ADRs due to PIs can be severe. These include acute effects of diarrhoea, vomiting and hepatotoxicity; and long-term toxicity which includes peripheral loss of subcutaneous fat (lipoatrophy), fat accumulation within the abdominal cavity (protease paunch or crix-belly), fat accumulation in the upper back (dorsocervical pad or buffalo hump), gynecomastia in males, fat accumulation in the breast in females and fat accumulation in subcutaneous tissue (peripheral lipomatosis). Management of acute ADRs includes reassurance and symptomatic treatment as it clears within 4-6 weeks of therapy.\n\n# Integrase Inhibitors\n\nNeuropsychiatric (NP) symptoms have been reported with all INSTIs, and their onset is usually described during the first few weeks after introduction. Symptoms include headaches, reduced concentration, anxiety, irritability, dizziness, insomnia, altered dreams, depression, unexplained pain, and more recently, mood changes.\n\nAll INSTIs have been associated with mild increases in creatinine levels, usually without clinical significance, but caution is needed in patients with low eGFR (<30mls/min), when using other nephrotoxic drugs, such as TDF. There is also a potential risk of weight gain associated with DTG. Some of the following approaches may be helpful for patients on DTG:\n\n- Clinicians should avoid DTG for patients with a history of severe Neuro-Psychiatric symptoms.\n- DTG should also not be given at the same time as supplements containing Magnesium (Mg), or Zinc (Zn). These may be in multivitamins, certain laxatives, or antacids, it is therefore important to know what other tablets your patients are taking.\n\n# If your patients are taking any of these, advise them to take their ARVs at least 2 hours before or at least 6 hours afterwards\n\nDTG may be given with calcium (Ca) or Iron (Fe) supplements if taken with food\n\nClinicians should monitor the body weight and BMI of patients.", "mimetype": "text/plain", "start_char_idx": 149345, "end_char_idx": 153627, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d0ffd61a-1fc6-4dab-8563-dc6e70406c15": {"__data__": {"id_": "d0ffd61a-1fc6-4dab-8563-dc6e70406c15", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "a315f0f8-af27-4fe6-9ef2-9a99355e67b8", "node_type": "1", "metadata": {}, "hash": "85fd9fc7132275756c936f6f974c99cd0aceb96a97dbe7653b414426288f9060", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "9981c837-beee-49a4-8d2c-6736cfc6d7a1", "node_type": "1", "metadata": {}, "hash": "6992fa11c8e6a59f02a9dc25d7744ac9ff19c5e4a81b05517c1669978dca8e02", "class_name": "RelatedNodeInfo"}}, "text": "There is also a potential risk of weight gain associated with DTG. Some of the following approaches may be helpful for patients on DTG:\n\n- Clinicians should avoid DTG for patients with a history of severe Neuro-Psychiatric symptoms.\n- DTG should also not be given at the same time as supplements containing Magnesium (Mg), or Zinc (Zn). These may be in multivitamins, certain laxatives, or antacids, it is therefore important to know what other tablets your patients are taking.\n\n# If your patients are taking any of these, advise them to take their ARVs at least 2 hours before or at least 6 hours afterwards\n\nDTG may be given with calcium (Ca) or Iron (Fe) supplements if taken with food\n\nClinicians should monitor the body weight and BMI of patients.\n\n|Antiretroviral Drug|Primary toxicities|Minor toxicities|Monitoring/Management|\n|---|---|---|---|\n|Zidovudine (AZT)|Anaemia, neutropenia, myopathy, lipoatrophy or lipodystrophy [Risk factors include -Baseline anaemia or neutropenia; CD4+ cell count \u2264200 cells/mm3]|Blue to black discolouration of nails, nausea, and headache|For anaemia: - Change to TDF and/or transfuse\n- Do not use AZT if Hb < 8.0 g/dl(PCV <24%)\nFor myopathy, discontinue if CPK rises. If AZT is being used in first-line ART, substitute with TDF or ABC. If AZT is being used in second-line ART, substitute with ABC|\n|Lamivudine (3TC)|Pancreatitis, Liver toxicity|Skin rash, headache|Discontinue if serum amylase elevated. Restart when resolved or change to ABC|\n|Emtricitabine (FTC)|Similar to lamivudine|Occasional hyperpigmentation of skin (palms/ soles)| |\n|Tenofovir Disoproxil Fumarate (TDF)|Tubular renal dysfunction, Fanconi syndrome [Risk factors: Underlying renal disease; Older age; BMI <18.5 (or bodyweight <50 kg); Untreated diabetes mellitus; Untreated hypertension; Concomitant use of nephrotoxic drugs or a boosted PI]|Occasional GI intolerance|If creatinine clearance declines, substitute with non-nephrotoxic drugs such as ABC or adjust the dosage. (See section on co-morbidities) If TDF is being used in first-line ART, substitute with AZT or ABC. If TDF is being used in second-line ART (after AZT use in first-line ART), substitute with ABC.|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Lactic acidosis or severe hepatomegaly with steatosis\n\nRisk factors: Prolonged exposure to nucleoside analogues; Obesity\n\n# Exacerbation of hepatitis B (hepatic flares)\n\nRisk factors: Discontinuation of TDF due to toxicity\n\nUse an alternative drug for hepatitis B treatment.\n\n|Abacavir (ABC)|Life-threatening hypersensitivity|\n|---|---|\n|Discontinue therapy if hypersensitivity develops. Abacavir should never be used in that individual again.| |\n|Risk factors: the presence of HLA-B*5701 Gene| |\n|Lactic acidosis may also occur with/without hepatic steatosis| |\n|If ABC is being used in first-line ART, substitute with TDF or AZT.| |\n|If ABC is being used in second-line ART, substitute with TDF| |\n\n|Nevirapine (NVP)|Life-threatening skin rash and hypersensitivity reaction (Stevens-Johnson syndrome) which occurs in less than 5% of patients and usually within 8 weeks of treatment|\n|---|---|\n|DRESS syndrome (drug rash, eosinophilia, and systemic symptoms) manifesting as fever, arthralgia, etc.| |\n|Low dose over first 2 weeks minimizes rash occurrence. If mild or moderate (Grade 1/2) continue cautiously or substitute with EFV.| |\n|If severe discontinue NVP and permanently if hepatitis confirmed.| |\n|Change to EFV.", "mimetype": "text/plain", "start_char_idx": 152874, "end_char_idx": 156350, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "9981c837-beee-49a4-8d2c-6736cfc6d7a1": {"__data__": {"id_": "9981c837-beee-49a4-8d2c-6736cfc6d7a1", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "d0ffd61a-1fc6-4dab-8563-dc6e70406c15", "node_type": "1", "metadata": {}, "hash": "9c5449821309385447668b4cf9edc405f0707a4f2081ab40dd67ab60f69d672d", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "4e1f0313-44ae-46b8-bf73-f311cc8c925c", "node_type": "1", "metadata": {}, "hash": "3c077e419a183b6cf2f6593d672187b89e16ac003c007f4282e5e9e6869ad57a", "class_name": "RelatedNodeInfo"}}, "text": "If mild or moderate (Grade 1/2) continue cautiously or substitute with EFV.| |\n|If severe discontinue NVP and permanently if hepatitis confirmed.| |\n|Change to EFV. If the person cannot tolerate either NNRTI, use boosted PIs| |\n\n|Efavirenz (EFV)|Persistent central nervous system toxicity (such as abnormal dreams, hallucination, insomnia, amnesia, depression or mental confusion)|\n|---|---|\n|Dizziness Rash in 10% but rarely severe in <1%; CNS symptoms often resolve 2-4 weeks.| |\n|EFV is contraindicated in patients who already have psychiatric manifestations.| |\n|Change to NVP. If the person cannot tolerate either NNRTI, use boosted PIs| |\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Convulsions\n\nRisk factor: History of seizure\n\nHypersensitivity reaction, Stevens-Johnson syndrome. Mobiliform rash may appear but usually not life-threatening.\n\nPotential risk of neural tube birth defects (very low risk in humans).\n\nMale gynecomastia.\n\n# Etravirine (ETR)\n\nSevere skin rash; hypersensitivity reactions (Stevens-Johnson syndrome), Erythema multiforme, hepatotoxicity, lipid abnormality and psychiatric disordersGI Intolerance, rashMonitor liver enzymes and lipids.Rarely discontinue (<2%) due to adverse reaction.Limited options are available\n\n# Atazanavir/ritonavir (ATV/r)\n\nElectrocardiographic abnormalities (PR interval prolongation) [Risk factors: Pre-existing conduction disease; Concomitant use of other drugs that may prolong the PR interval]\nNausea and diarrhoea, skin rash\n\nClinical jaundice is cosmetic and not related to hepatitis or liver damage. Substitute only if adherence is compromised.\n\nMonitor liver enzymes\n\nIndirect hyperbilirubinaemia (clinical jaundice) [Risk factors: Underlying hepatic disease HBV and HCV co-infection; Concomitant use of hepatotoxic drugs]\n\nChange to LPV/r or DRV/r. If boosted PIs are contraindicated and NNRTIs have failed in first-line ART, consider integrase inhibitors.\n\nNephrolithiasis and risk of prematurity [Risk factor unknown]\n\n# Lopinavir/ritonavir (LPV/r)\n\nElectrocardiographic abnormalities (PR and QT interval prolongation, torsades de pointes) [Risk factors: People with pre-existing conduction system disease; Concomitant use of other drugs that may prolong the PR interval]\nHeadache, weakness, nausea, vomiting, diarrhoea and skin rash\n\nDiarrhoea is rarely severe should be managed with antispasmodics- usually resolves after weeks to months of therapy.\n\nIf LPV/r is used in first-line ART for children, use an age-appropriate NNRTI (NVP for children younger than 3 years and EFV for children 3 years and older). ATV can be used for children older than 6 years.\n\nIf LPV/r is used in second-line ART for adults, use ATV/r or DRV/r. If boosted PIs are contraindicated and the person has failed on treatment with NNRTI in first-line ART, consider integrase inhibitors.\n\nPancreatitis [Risk factors: Advanced HIV disease]\n\n# Risk of prematurity, lipoatrophy or metabolic syndrome, dyslipidaemia or severe diarrhoea [Risk factors unknown]\n\n|Darunavir/ritonavir (DRV/r)|Hepatotoxicity [Risk factors: Underlying hepatic disease HBV and HCV co-infection, Concomitant use of hepatotoxic drugs]|\n|---|---|\n|Darunavir/ritonavir (DRV/r)|Hepatotoxicity [Risk factors: Underlying hepatic disease HBV and HCV co-infection, Concomitant use of hepatotoxic drugs] Severe skin and hypersensitivity reactions [Risk factors: Sulfonamide allergy]|\n\nIf DRV/r is being used in second-line ART, substituting with ATV/r or LPV/r can be considered. When it is used in third-line ART, limited options are available.", "mimetype": "text/plain", "start_char_idx": 156186, "end_char_idx": 159761, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "4e1f0313-44ae-46b8-bf73-f311cc8c925c": {"__data__": {"id_": "4e1f0313-44ae-46b8-bf73-f311cc8c925c", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "9981c837-beee-49a4-8d2c-6736cfc6d7a1", "node_type": "1", "metadata": {}, "hash": "6992fa11c8e6a59f02a9dc25d7744ac9ff19c5e4a81b05517c1669978dca8e02", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "aacb9127-6773-42f8-b854-3a8e54a53d3d", "node_type": "1", "metadata": {}, "hash": "bd145c27cdda907d04eb1af9f963fa4b0ef9753a14b6f09d98f7881550fcd6c0", "class_name": "RelatedNodeInfo"}}, "text": "Pancreatitis [Risk factors: Advanced HIV disease]\n\n# Risk of prematurity, lipoatrophy or metabolic syndrome, dyslipidaemia or severe diarrhoea [Risk factors unknown]\n\n|Darunavir/ritonavir (DRV/r)|Hepatotoxicity [Risk factors: Underlying hepatic disease HBV and HCV co-infection, Concomitant use of hepatotoxic drugs]|\n|---|---|\n|Darunavir/ritonavir (DRV/r)|Hepatotoxicity [Risk factors: Underlying hepatic disease HBV and HCV co-infection, Concomitant use of hepatotoxic drugs] Severe skin and hypersensitivity reactions [Risk factors: Sulfonamide allergy]|\n\nIf DRV/r is being used in second-line ART, substituting with ATV/r or LPV/r can be considered. When it is used in third-line ART, limited options are available.\n\nRaltegravir (RAL)\nRare, hypersensitivity, acute renal failure\n\nMyopathy, myalgia, mild to moderate nausea, headache and diarrhoea\n\nDolutegravir (DTG)\nHepatotoxicity Severe allergic reactions (hypersensitivity) Insomnia, headache Monitor liver function and toxicity may worsen with existing hepatitis B or C Patient should be advised to take drugs in the morning\n\n# Prevention of Adverse Drug Reactions\n\nApplying the principles of rational use of medicines can prevent most ADRs, some of the principles include the following:\n\n- Use of few drugs, whenever possible\n- Use drugs that you are familiar with\n- Do not change therapy from known drugs to unfamiliar ones without good reason\n- All patients commencing ARV should be properly counselled on the ADRs related to the medications, preventive measures, where applicable, and what to do when it occurs or is suspected. The healthcare provider should be very knowledgeable about this\n- Be vigilant and look out for these adverse effects when initiating therapy and during follow-up\n- Encourage patients to be actively involved in ADR reporting. ADR monitoring tools can be made available for patients to document ADRs they are experiencing while on ART; and this can be validated by the HCW during clinic visits.\n\n# 4.12 ARV Drug Interactions\n\nDrug interaction refers to the modification of the action of one drug by another, and can be useful, of no consequence, or harmful. Multiple drug use (polypharmacy) is extremely common in ART/PMTCT settings, so the potential for drug interaction is enormous. Adverse interactions may be catastrophic but are often avoidable. Patients receiving care for HIV infection have the likelihood of experiencing various drug interactions because of the drugs in ART combinations, co-administered drugs for OIs, and co-administered drugs for other concurrent ailments. There are two major groups of ARV drug interactions:\n\n- Non-ARV vs. ARV Drug Interactions\n- ARV vs. ARV Drug Interactions\n\nAs a rule of thumb, most ARV drugs are metabolized by the Cytochrome P450 3A4 isoenzyme in the liver. Many other drugs are also metabolized by this enzyme and ARV drugs will either raise or lower these other drug levels and either be increased or decreased themselves by these interactions. All PIs, as well as all current clinically used NNRTIs, are metabolized by CYP 450 enzyme cascade (particularly CYP 3A4) which can be induced and/or inhibited by several drugs thus the possibilities of many drug/drug interactions.\n\n|Drug|Interaction|Action|\n|---|---|---|\n|EFV; NVP|Decreased level of Atazanavir and LPV/r significantly occur when used concomitantly with EFV or NVP|Avoid the combination or consider increase LPV/r dose to 533mg/133mg twice daily in PI-experienced patients.|\n|TDF|Concomitant use with ATV: TDF level is increased by 24%-37% and Atazanavir level is decreased by 25%|Dose: ATV/r (300/100 mg) daily co-administered with TDF 300 mg daily. Avoid concomitant use without RTV. If using TDF and H2 receptor antagonist in ART-experienced patients, use ATV/r (400 mg/100 mg) daily. Monitor for TDF-associated toxicity.|\n\nAbacavir (ABC) is not currently associated with any clinically significant pharmacokinetic drug interactions. However, a large dose of ethanol (>0.7g/kg body weight) increases ABC plasma AUC by 41% as well as prolongs ABC elimination half-life by 26%. Patients must therefore be cautioned on alcohol use during ABC therapy.", "mimetype": "text/plain", "start_char_idx": 159042, "end_char_idx": 163196, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "aacb9127-6773-42f8-b854-3a8e54a53d3d": {"__data__": {"id_": "aacb9127-6773-42f8-b854-3a8e54a53d3d", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "4e1f0313-44ae-46b8-bf73-f311cc8c925c", "node_type": "1", "metadata": {}, "hash": "3c077e419a183b6cf2f6593d672187b89e16ac003c007f4282e5e9e6869ad57a", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "72952e09-0f8b-4b41-b5d4-6f5e3200be74", "node_type": "1", "metadata": {}, "hash": "61cb1ecaa72f8b0cf2048579d1589099d942da69b3c4f95ba9311e0b14257cda", "class_name": "RelatedNodeInfo"}}, "text": "Avoid concomitant use without RTV. If using TDF and H2 receptor antagonist in ART-experienced patients, use ATV/r (400 mg/100 mg) daily. Monitor for TDF-associated toxicity.|\n\nAbacavir (ABC) is not currently associated with any clinically significant pharmacokinetic drug interactions. However, a large dose of ethanol (>0.7g/kg body weight) increases ABC plasma AUC by 41% as well as prolongs ABC elimination half-life by 26%. Patients must therefore be cautioned on alcohol use during ABC therapy.\n\n# 4.12.1 Interactions Between Contraceptives and Antiretroviral Drugs\n\nIn line with standard recommendations, ALHIV can use all available contraceptive methods, including hormonal contraceptives, implantable devices, intrauterine devices, the transdermal patch, and vaginal ring.\n\nMany PIs and NNRTIs alter the metabolism of oral contraceptives and may reduce the efficacy of oral contraceptive agents or increase the risk of estrogen \u2013 or progestin \u2013 related adverse effects. Integrase strand transfer inhibitors (specifically raltegravir) appear to have no interaction with estrogen-based contraceptives. Dolutegravir (DTG) has been found safe and\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 62\n\neffective to use with hormonal contraceptives among women living with HIV. Unless there is clinical evidence or concern of bone fragility, providers may use depot medroxyprogesterone acetate (DMPA) with or without ART (specifically TDF), as an effective long-term contraceptive.\n\nAdditional resources for other possible drug interactions can be found in the following sites:\n\n- www.hiv-druginteractions.org\n- www.hiv-interactionslite.org\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n63\n\n# List of Contributors\n\nPharm. Ologun Taiye JosephPharm. Atu UzomaPharm. Chidi OKorieTuraki AbdulMr Ogbeke Geoffrey IghowhoDr Fatimah JajereProf. Ebun AdejuyigbeDr Hadiza KhamofuOluwakemi SowaleDr Opeyemi AbudiorePharm Anthonia IbemeNkiru AnonyuoMr Batholomew IgweTimothy YakubuPharm. Adebanjo Adeyemi OlowuDr Kenneth Anene AguOmeh Idoko OnuchePharm. (Dr) Peter AgadaPharm. Agboola OguntonadePharm Usman IsmailNkem Chukwuemeka\n\n# Chapter 4\n\nDirector, Logistics Unit NASCPAssistant Director, Logistics Unit NASCPPrincipal Pharmacist NASCPPrincipal Pharmacist Technician NASCPSenior Scientific Officer NASCPACRO NAFDACMember NTTA / Paediatrician OAUTH, Ile IfeChief of Party FHI360Senior Analyst CHAISenior Analyst CHAIForecasting & Supply Planning Manager GHSC-PSMPlan and Source Director GHSC-PSMHealth System Strengthening and Logistics Specialist FHI360Senior Laboratory Advisor ICAPSupply Chain Lead JHPIEGOAssociate Director, Howard University Pace CenterAssociate Director, Howard University Pace CenterState Program Manager, Howard University Pace CenterPharmacy Advisor Heartland AllianceIntern NAFDACSouth-South Deputy ASWHAN\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 64\n\n# 5. ADHERENCE TO ANTIRETROVIRAL THERAPY\n\nWhat\u2019s Inside:\n\n|5.1 Introduction|66|\n|---|---|\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\n# 5.1 Introduction\n\nAdherence is the patients' behaviour of taking drugs correctly based on mutual agreement between the patient and health care provider. It is the act of taking the right drugs, at the right dose, at the right frequency, and at the right time.\n\nAdherence to ART is necessary for achieving sustained suppression, delaying the onset of drug resistance, enhancing immune recovery, and improving the overall health and quality of life of the individual. Poor or non-adherence to ART results in suboptimal viral suppression which may lead 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. Face-to-face and virtual adherence support may be provided by health workers, family, friends, treatment partners, and support groups. Adherence support IEC materials in the form of posters and patient information leaflets are also essential.", "mimetype": "text/plain", "start_char_idx": 162697, "end_char_idx": 166802, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "72952e09-0f8b-4b41-b5d4-6f5e3200be74": {"__data__": {"id_": "72952e09-0f8b-4b41-b5d4-6f5e3200be74", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "aacb9127-6773-42f8-b854-3a8e54a53d3d", "node_type": "1", "metadata": {}, "hash": "bd145c27cdda907d04eb1af9f963fa4b0ef9753a14b6f09d98f7881550fcd6c0", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "ee5d725b-c1de-48fc-9442-38f9a8c36c3d", "node_type": "1", "metadata": {}, "hash": "78318af07aea2c40e4e942c63c42f26c594ab2f07ce87f8e37bff7458ae61da6", "class_name": "RelatedNodeInfo"}}, "text": "It is the act of taking the right drugs, at the right dose, at the right frequency, and at the right time.\n\nAdherence to ART is necessary for achieving sustained suppression, delaying the onset of drug resistance, enhancing immune recovery, and improving the overall health and quality of life of the individual. Poor or non-adherence to ART results in suboptimal viral suppression which may lead 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. Face-to-face and virtual adherence support may be provided by health workers, family, friends, treatment partners, and support groups. Adherence support IEC materials in the form of posters and patient information leaflets are also essential.\n\n# 5.2 Adherence Preparation for ART\n\nAdherence counselling and support has become even more important with the advent of the test and treat policy. This is because we have asymptomatic persons initiated on ART. It is recommended that patients should undergo adherence preparation before they commence ART. It is also recommended that adherence preparation should be implemented as an ongoing multidisciplinary task that involves as many relevant health workers as possible that are involved in the care of the patient including the doctor, pharmacists, laboratory scientists, nurses, and the officer officially designated as adherence counsellor.\n\nHealth workers should note that the success of any adherence strategy adopted depends on:\n\n- Information and education provided to clients before the initiation of ART\n- Assessing their understanding of the information provided\n- Willingness and readiness for the client to commence treatment\n- Assessing and addressing barriers to initiating ART\n\nAdherence counselling is central to any adherence strategy and should:\n\n- Provide basic information on HIV and its manifestations.\n- Provide information on ARV medication which should include dosing, frequency, duration, and adverse effects of ARV medications including how the medications should be taken and what to do in case of missed dose.\n- Provide information on ART and the benefits of early initiation.\n- Highlight the importance of 100% adherence, which implies not missing any dose. Emphasize that non-adherence is the single most important factor that can lead to the development of drug resistance.\n- Provide information to the patient in whom ART initiation will be delayed due to AHD (e.g. information on the increased risk of mortality when patients with AHD are commenced on certain ARVs such as DTG etc.).\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 5.3 On-going adherence for clients on ART\n\nContinuous adherence counselling is essential in ART and should be accessible to every patient on ART. This should include adherence assessments and documentation at every clinic visit; emphasis should be on the importance of continued adherence, good nutrition, and involvement of support systems (relatives, friends, peers and/or community support personnel). Ongoing adherence support should be face-to-face or virtual. When provided by health workers, the checklist must be used to document the interaction, and this should be filed in the client's folder. Barriers to adherence should also be assessed and addressed.\n\n# 5.4 Monitoring of Adherence\n\nSustained viral suppression is dependent on adherence to ARVs. Adherence monitoring provides an opportunity to reinforce the positive behaviour of the adherent patient, and to flag patients that require support to improve adherence. Adherence in many studies is measured by expressing the number of doses taken as a percentage of the number of doses prescribed. For example, if 20 doses are prescribed and 19 doses are taken, adherence is 95%. This translates to missing one dose in ten days on a twice-daily regimen.\n\nEffective monitoring of adherence involves a combination of approaches based on resource capacity (human/financial), acceptability by client and providers, and comprehension of the local context. These include:\n\n|a. Viral load monitoring:|This is considered the gold standard for monitoring adherence and treatment success. Where the viral load is not effectively suppressed an adherence intervention should precede a repeat viral load test. Viral load monitoring has a high likelihood to motivate adherence by engaging clients in the process of monitoring their own results and understanding the meaning of their results.|\n|---|---|\n|b. Pharmacy refill records:|These records document the dates a client collected their ARVs. Irregular collection may indicate adherence challenges. As with other adherence assessment methods, pharmacy refill records may over-estimate adherence, as collecting ARVs does not guarantee that they are being taken or taken correctly. This is however an acceptable proxy.|\n|c. Self-reporting:|This is a quick and inexpensive approach to adherence monitoring. It is easily carried out in clinical settings and frequently used in routine care; however, it is subject to recall bias.|\n|d. Pill counts:|This involves a physical count of the remaining pills at each pharmacy refill visit.", "mimetype": "text/plain", "start_char_idx": 165992, "end_char_idx": 171219, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ee5d725b-c1de-48fc-9442-38f9a8c36c3d": {"__data__": {"id_": "ee5d725b-c1de-48fc-9442-38f9a8c36c3d", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "72952e09-0f8b-4b41-b5d4-6f5e3200be74", "node_type": "1", "metadata": {}, "hash": "61cb1ecaa72f8b0cf2048579d1589099d942da69b3c4f95ba9311e0b14257cda", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "1ebd72d6-6e31-4687-b953-e3498e8d9d8f", "node_type": "1", "metadata": {}, "hash": "e9c6c95c59cb368b77b976f686dbc8290073701d0b1f557411242633e09085cf", "class_name": "RelatedNodeInfo"}}, "text": "Viral load monitoring has a high likelihood to motivate adherence by engaging clients in the process of monitoring their own results and understanding the meaning of their results.|\n|---|---|\n|b. Pharmacy refill records:|These records document the dates a client collected their ARVs. Irregular collection may indicate adherence challenges. As with other adherence assessment methods, pharmacy refill records may over-estimate adherence, as collecting ARVs does not guarantee that they are being taken or taken correctly. This is however an acceptable proxy.|\n|c. Self-reporting:|This is a quick and inexpensive approach to adherence monitoring. It is easily carried out in clinical settings and frequently used in routine care; however, it is subject to recall bias.|\n|d. Pill counts:|This involves a physical count of the remaining pills at each pharmacy refill visit. It is used to compare the actual to the expected consumption of ARVs for a given period. The effectiveness of pill counting is limited by the fact that some clients may discard tablets not taken before their routine clinic visits leading to over-estimated adherence. Additionally, the time required by health providers to conduct pill counts may not be available, especially in resource-limited settings. Other approaches may include electronic methods e.g. Medication Event Monitoring System (MEMSCap). This involves the use of an electronic device that monitors the dates and time the pill bottle is opened. The bottle opening represents medicine intake. Another method that can be used is the quantification of drug levels in body fluids (plasma, urine, saliva) of clients.|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Factors known to improve adherence\n\n- Increased access to ART.\n- Individual patients, family, peers, and friends, community members, or treatment-supporter engagement in adherence education and support.\n- Family-centred care when more than one family member is infected with HIV\n- Continuous and effective adherence counselling, which includes knowledge and understanding of HIV infection, course of treatment, and expected adverse reactions and what to do in the event of an adverse reaction occurring.\n- Drug regimen simplicity e.g. Fixed Drug Combination (low pill burden)\n- The use of drugs with fewer adverse effects.\n\n# Factors associated with poor adherence\n\n|Patient factors|Treatment Factors|Patient-Provider Relationship|\n|---|---|---|\n|Self-efficacy (belief in one\u2019s ability to succeed) regarding adherence.|Drug toxicity|Poor patient-caregiver relationship|\n|Substance abuse e.g. Active drug or alcohol use|High pill burden|Lack of trust|\n|Lack of social support|Long duration of treatment|Poor conception of maintenance of client\u2019s confidentiality|\n|Incarceration|Complexity of the treatment|Lack of empathy/warmth|\n|Pregnancy-related conditions|Medication side effects|Poor communication skills|\n|Inability of patients to identify their medications|Clinical Environment|Stigma and discrimination|\n|Lack of patient education.|Distance to facility|Lack of client\u2019s openness/cooperation|\n|Forgetfulness|Poor quality of adherence counselling| |\n|Stressful life events|Clinic staff attitude| |\n|Self-stigmatization|Cost of treatment| |\n|Health status e.g. severe illness, dementia, mental health| | |\n\nFigure 5.1: Factors associated with poor Adherence\n\n# Adherence in Specific Populations\n\nWhile stigma, discrimination and health facility challenges are cross-cutting issues affecting adherence, some factors are peculiar to specific populations:\n\n|Population|Factors affecting adherence|\n|---|---|\n|Infants and young children|- Poor taste and large volumes of liquid formulations\n- Large pill size, pill burden, and difficulty in swallowing pills.\n- Changing dosage requirement in relation to weight gain\n- Inadequate nutrition\n- Identification of responsible caregivers and a family-centred approach would improve adherence\n|\n|Adolescents|- Psychosocial factors such as peer pressure\n- Limited adolescent-friendly health services including skilled health workforce\n- The transition from paediatric to adolescent care\n- Limited adolescent-tailored treatment literacy and adherence training tools\n- Disclosure issues\n|\n|Pregnant and postpartum women|- Nausea and vomiting\n- Post-partum depression\n- Non-disclosure to significant persons\n- Inadequate awareness and knowledge of HIV and PMTCT\n|\n|People with substance use and mental health conditions|- Use of alcohol and substances abuse can lead to forgetfulness\n- Poor comprehension of treatment plans\n- Drug interaction and ADRs\n|\n|Key populations including prisoners|- Stigma and discrimination\n- Poor access to health services\n- Absence of health care which targets their specific needs\n- Risk of drug-drug interaction\n|\n|Persons with disability|- Poor access to health facilities\n- Lack of appropriate patient education channels (e.g.", "mimetype": "text/plain", "start_char_idx": 170349, "end_char_idx": 175264, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "1ebd72d6-6e31-4687-b953-e3498e8d9d8f": {"__data__": {"id_": "1ebd72d6-6e31-4687-b953-e3498e8d9d8f", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "ee5d725b-c1de-48fc-9442-38f9a8c36c3d", "node_type": "1", "metadata": {}, "hash": "78318af07aea2c40e4e942c63c42f26c594ab2f07ce87f8e37bff7458ae61da6", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "864e3900-17ba-4043-a25f-a69360de0f97", "node_type": "1", "metadata": {}, "hash": "6991ff046bd5c5396eaf248c759f3505078e9b8a2d3a61bff61f997f3893c347", "class_name": "RelatedNodeInfo"}}, "text": "for visually and hearing impaired)\n|\n\nHealth workers are required to take note of the adherence challenges peculiar to each of the groups and design for each patient an individualized adherence plan that adjusts for their lifestyle, work, and social environment.\n\n# Recommendations for improving adherence\n\n- Treatment education for patients and treatment supporters\n- Treatment-supporter involvement\n- Peer health education/peer counsellors\n- Routine assessment and reinforcement of adherence during follow up\n- The use of Fixed-Dose Combination (FDC) and drugs with lower dosing frequency\n- Reminders and patient engagement tools (e.g. a cell phone, SMS text messages, alarm clock, calendars, social media platforms etc.)\n- Convenient ARV packs\n- Follow up visits before ARV supplies are exhausted\n- Positive feedback on health improvements\n- Nutritional assessment, care, and support\n- Prevent and/or adequately manage ADR\n- Address lifestyle factors e.g. alcohol abuse\n- Adapting therapy to the client's lifestyle\n- Minimizing out-of-pocket payments at the point of care as much as possible\n- Encourage participation in support groups\n- Improved social support\n- Directly Observed Therapy \u2013where possible\n- Cognitive-behavioral therapy and behavioral skill training\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - Page 70\n\n# List of Contributors\n\nPharm. Ologun Taiye JosephPharm. Atu UzomaPharm. Chidi OKorieTuraki AbdulMr Ogbeke Geoffrey IghowhoDr Fatimah JajereProf. Ebun AdejuyigbeDr Hadiza KhamofuOluwakemi SowaleDr Opeyemi AbudiorePharm Anthonia IbemeNkiru AnonyuoMr Batholomew IgweTimothy YakubuPharm. Adebanjo Adeyemi OlowuDr Kenneth Anene AguOmeh Idoko OnuchePharm. (Dr) Peter AgadaPharm. Agboola OguntonadePharm Usman IsmailNkem Chukwuemeka\n\n# Chapter 5\n\nDirector, Logistics Unit NASCPAssistant Director, Logistics Unit NASCPPrincipal Pharmacist NASCPPrincipal Pharmacist Technician NASCPSenior Scientific Officer NASCPACRO NAFDACMember NTTA / Paediatrician OAUTH, Ile IfeChief of Party FHI360Senior Analyst CHAISenior Analyst CHAIForecasting & Supply Planning Manager GHSC-PSMPlan and Source Director GHSC-PSMHealth System Strengthening and Logistics Specialist FHI360Senior Laboratory Advisor ICAPSupply Chain Lead JHPIEGOAssociate Director, Howard University Pace CenterAssociate Director, Howard University Pace CenterState Program Manager, Howard University Pace CenterPharmacy Advisor Heartland AllianceIntern NAFDACSouth-South Deputy ASWHAN\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 71\n\n# 6. PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV INFECTION\n\nWhat\u2019s Inside:\n\n|6.1 Introduction|73|\n|---|---|\n|6.2 Mother-to-Child Transmission of HIV|73|\n|6.3 Pre-ART Care for HIV-positive pregnant women|78|\n|6.4 Use of Antiretroviral Therapy for PMTCT|80|\n|6.5 Management of HIV positive women in labour, delivery and within 72 hours of delivery|82|\n|6.6 PMTCT/TB integration services|84|\n|6.7 Care and Support of the HIV-Exposed Infant|86|\n|6.8 Special Considerations for Adolescent and Young Women in PMTCT|90|\n|6.9 Linkage of PMTCT with comprehensive HIV Treatment, Care and Support Services for Mothers and Infants|91|\n\n# 6.1 Introduction\n\nHIV can be transmitted from an infected mother to her child during pregnancy and delivery, and subsequently through breastfeeding. This mother-to-child transmission of HIV (MTCT) is also referred to as vertical transmission while measures to prevent its occurrence are the Prevention of Mother-to-Child Transmission (PMTCT). Given the successes recorded in the PMTCT, the global community is moving towards the elimination of Mother to Child Transmission of HIV (eMTCT).\n\n# 6.2 Mother-to-Child Transmission of HIV\n\nIn the absence of any preventive measures, the rate of occurrence of MTCT is about 25-40% (Figure 6.1). This mode of HIV transmission is responsible for most HIV infections in children. The following factors have been associated with increased risk of MTCT in any population, high prevalence of HIV among women of reproductive age and their partners, low contraceptive use resulting in unintended pregnancies among HIV positive women.", "mimetype": "text/plain", "start_char_idx": 175265, "end_char_idx": 179413, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "864e3900-17ba-4043-a25f-a69360de0f97": {"__data__": {"id_": "864e3900-17ba-4043-a25f-a69360de0f97", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "1ebd72d6-6e31-4687-b953-e3498e8d9d8f", "node_type": "1", "metadata": {}, "hash": "e9c6c95c59cb368b77b976f686dbc8290073701d0b1f557411242633e09085cf", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "24871fd0-80bb-4a0c-9dbd-2a8090bb673e", "node_type": "1", "metadata": {}, "hash": "a6fdf32e24a054753f2f79a464cdac696a163ca4bbfba9e56b6d11f9b4569951", "class_name": "RelatedNodeInfo"}}, "text": "This mother-to-child transmission of HIV (MTCT) is also referred to as vertical transmission while measures to prevent its occurrence are the Prevention of Mother-to-Child Transmission (PMTCT). Given the successes recorded in the PMTCT, the global community is moving towards the elimination of Mother to Child Transmission of HIV (eMTCT).\n\n# 6.2 Mother-to-Child Transmission of HIV\n\nIn the absence of any preventive measures, the rate of occurrence of MTCT is about 25-40% (Figure 6.1). This mode of HIV transmission is responsible for most HIV infections in children. The following factors have been associated with increased risk of MTCT in any population, high prevalence of HIV among women of reproductive age and their partners, low contraceptive use resulting in unintended pregnancies among HIV positive women. Increased risk of MTCT in a HIV positive woman during pregnancy, labour, delivery and breastfeeding has been associated with high maternal viral load (from new or re-infection, advanced disease or treatment failure); wide range of infections, including STIs and those of the genital tract and maternal malnutrition. Obstetric factors such as antepartum haemorrhage, external cephalic version, early rupture of membrane exceeding four hours before delivery, chorioamnionitis, prolonged labour, invasive delivery procedures including use of forceps and episiotomy have also been observed to increase MTCT of HIV. Other risk factors include; preterm birth, first infant in multiple births, breastfeeding and extended duration of breastfeeding, early mixed feeding, breast abscesses, nipple fissure, mastitis, and oral disease in the infant.\n\n|100 infants born to HIV infected women who breastfeed without any interventions|60 to 75 infants will not be HIV-infected| |\n|---|---|---|\n|5-10 infants infected during pregnancy|About 15 infants infected during labour and delivery|5-15 infants infected during breastfeeding|\n\n25-40 infants will be HIV-infected\n\nFigure 6.1: The Pattern of Mother-to-Child Transmission of HIV (MTCT) during Pregnancy, Delivery and Breastfeeding in Untreated Women Living with HIV.\n\nAlthough the current HIV prevalence of 1.4% in Nigerian adults and 0.2% among children (NAIIS 2018) suggest a low MTCT, two findings in the report have an ominous outcome;\n\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 Nigerian women bear children.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Figure 6.2: Trends in Estimated Pattern of MTCT in Nigeria\n\n| |2010|2011|2012|2013|2014|2015|2016|2017|2018|2019|\n|---|---|---|---|---|---|---|---|---|---|---|\n|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\n# 6.2.1 Prevention of MTCT\n\nTo stop the vertical transmission of HIV, WHO introduced a set of interrelated public health interventions designed to prevent transmission of the virus from an HIV positive mother to her child during the period of pregnancy, delivery and breastfeeding. Prevention of MTCT is the package of care given to pregnant women, their families and communities, aimed at preventing transmission of HIV from infected mothers to their babies (vertical transmission).", "mimetype": "text/plain", "start_char_idx": 178595, "end_char_idx": 182157, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "24871fd0-80bb-4a0c-9dbd-2a8090bb673e": {"__data__": {"id_": "24871fd0-80bb-4a0c-9dbd-2a8090bb673e", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "864e3900-17ba-4043-a25f-a69360de0f97", "node_type": "1", "metadata": {}, "hash": "6991ff046bd5c5396eaf248c759f3505078e9b8a2d3a61bff61f997f3893c347", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "3371b69f-ec01-4528-8ee5-1826662a7257", "node_type": "1", "metadata": {}, "hash": "1bfeeb45e0fa09bdd1db5ebce350c8db4b37a87970d46d24fa1b1d01befdd130", "class_name": "RelatedNodeInfo"}}, "text": "Prevention of MTCT is the package of care given to pregnant women, their families and communities, aimed at preventing transmission of HIV from infected mothers to their babies (vertical transmission). It operates on 4 pillars:\n\n- Pillar 1 - Primary prevention of HIV infection in women of reproductive age (WRA) & their partners\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- Pillar 4 - Provision of appropriate treatment, care and support to HIV Positive mothers, their infants & families\n\n# Pillar 1:\n\nPrimary prevention of HIV infection in women of reproductive age and their partners include the following:\n\n- Use of the \u201cABC\u201d approach to enhance safer and responsible sexual behaviour and practices. This involves:\n- A = Abstinence from having sexual intercourse\n- B = Be faithful to a faithful partner\n- C = Condom use correctly and consistently\n- Safe and responsible sexual practices include:\n- Delaying the onset of sexual activity until marriage\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Pillar 1:\n\nReducing the number of sexual partners\n\nConsistent and correct use of condoms.\n\nProvision of early diagnosis and treatment of STIs: The early diagnosis and treatment of STIs can reduce the incidence of HIV in the general population by about 40%. Comprehensive STI treatment services present an opportunity to provide information on HIV infection, MTCT and referral to HIV testing services (HTS). Making HIV testing services widely available especially to women attending antenatal clinic ensures that they know their HIV status. All HIV pregnant women should be linked to PMTCT services on-site or by referral.\n\nProvision of appropriate counselling for women who are HIV negative: Counselling provides an opportunity for a woman who is HIV negative to better understand how to protect herself and her infant from HIV infection. It also serves as motivation to adopt safer sex, family planning practices and encourages partner testing.\n\n# Pillar 2:\n\nPrevention of unintended pregnancy among HIV positive women improves the lives of these women and their children and is essential for eliminating mother-to-child transmission of HIV. Nigeria has an unmet need for family planning of 19% (NDHS 2018). The unintended pregnancy rate among women living with HIV reaches an estimated 51-90% in some settings, accounting for 27% of maternal death, which can be prevented by meeting the unmet need for family planning.\n\nIt is the responsibility of health services to provide HIV positive women and their partners with comprehensive information and education about the risks associated with childbearing as part of routine public information about HIV and AIDS. This is to ensure that HIV positive women and their partners have informed choices of action and to respect and support the decisions they reach as this is their sexual and reproductive rights. This implies:\n\n- Providing good quality, user-friendly, and easily accessible family planning services to HIV positive women that can prevent unwanted pregnancy.\n- Providing and promoting consistent condom (male/female) use combined with a more effective method of contraception (dual method) for dual protection from HIV and other STIs and from unplanned pregnancies.\n- Integrating dual protection messages into family planning counselling services\n- Offering contraception including emergency contraception to all HIV positive mothers in the immediate postpartum period to prevent unintended pregnancy. Lactational amenorrhoea does not guarantee adequate contraception even in women who exclusively breastfeed. (Refer to medical eligibility criteria for contraceptive use in HIV positive women).\n\n# Pillar 3:\n\nPrevention of HIV transmission from HIV Positive mothers to their infants includes;\n\n- HIV testing services\n- HIV and Infant feeding counselling\n- Modification of obstetric practices\n- Administration of ART to all HIV positive pregnant women irrespective of their WHO clinical stage and CD4+ cell count\n- Administration of single or dual ARV prophylaxis to all infants delivered to HIV positive women.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Pillar 4: Provision of appropriate treatment, care and support to HIV Positive mothers, their infants and family\n\n# Package of services for mothers\n\nART for all HIV positive womenCotrimoxazole prophylaxisTB screening, prophylaxis and treatmentContinued infant feeding counselling and supportNutritional counselling and supportSexual and reproductive health services including family planningCervical cancer screeningPsychosocial supportPartner counselling and testingPre-Exposure Prophylaxis (PrEP) for serodiscordant couples\n\n# Package of services for HIV exposed children\n\nARV prophylaxisRoutine immunization and growth monitoring and supportCotrimoxazole prophylaxis starting at 6 weeksHIV diagnostic testing using DBS for DNA-PCR or NAT at birth (when available), 6 to 8 weeks of age and 6 weeks after breastfeeding has ended.", "mimetype": "text/plain", "start_char_idx": 181956, "end_char_idx": 187064, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "3371b69f-ec01-4528-8ee5-1826662a7257": {"__data__": {"id_": "3371b69f-ec01-4528-8ee5-1826662a7257", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "24871fd0-80bb-4a0c-9dbd-2a8090bb673e", "node_type": "1", "metadata": {}, "hash": "a6fdf32e24a054753f2f79a464cdac696a163ca4bbfba9e56b6d11f9b4569951", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "5b885312-bf3e-4bc2-a08b-1c30acc44439", "node_type": "1", "metadata": {}, "hash": "3dc2d4555e06fba45713276e22437567c951bf924a79f2d647ca07842b7c8236", "class_name": "RelatedNodeInfo"}}, "text": "NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Pillar 4: Provision of appropriate treatment, care and support to HIV Positive mothers, their infants and family\n\n# Package of services for mothers\n\nART for all HIV positive womenCotrimoxazole prophylaxisTB screening, prophylaxis and treatmentContinued infant feeding counselling and supportNutritional counselling and supportSexual and reproductive health services including family planningCervical cancer screeningPsychosocial supportPartner counselling and testingPre-Exposure Prophylaxis (PrEP) for serodiscordant couples\n\n# Package of services for HIV exposed children\n\nARV prophylaxisRoutine immunization and growth monitoring and supportCotrimoxazole prophylaxis starting at 6 weeksHIV diagnostic testing using DBS for DNA-PCR or NAT at birth (when available), 6 to 8 weeks of age and 6 weeks after breastfeeding has ended. HIV antibody test can be used for HIV screening for children older than 9 months where virologic test is not available. HIV antibody test is the recommended diagnostic testing for children older than 18 months.HIV antibody tests should primarily be used for screening of infants and children less than 18 months of age, so as to establish exposure status where the mother has not herself been tested for HIV or is not willing to be testedOngoing infant feeding counselling and supportScreening and management of tuberculosisPrevention and treatment of malariaNutritional care and supportPsychosocial care and supportAntiretroviral therapy for all HIV infected children (see Chapter 3)Symptom management and palliative care if needed\n\nTo achieve effective PMTCT across Nigeria, the following challenges should be addressed (Table 6.1)\n\n# Table 6.2 Challenges and Strategies to achieve effective PMTCT in Nigeria\n\nChallengesOnly 46% WRA (45% of Males) have comprehensive knowledge of HIV Transmission & Prevention*Only 57% WRA (52% Males) know MTCT*1% WRA (13% Males) have 2= sexual partners*Only 12% of married women use modern contraceptive*High PMTCT Cascade gaps & MTCT of 5% at 2 months (NASCP)Dwindling funding for supporting PMTCT programmesHigh out-of-pocket expenses for PLHIV*NDHS 2018\n\n# Strategies to Achieve Effective PMTCT\n\n- Primary prevention of HIV in WRA & Partners\n- Prevention of unintended pregnancy in PLHIV\n- Prevention of MTCT in pregnant PLHIV\n- Treatment, care & support to HIV Positive mothers, children & families\n\n# 6.2.2 Benefit of PMTCT\n\nThe benefits of PMTCT is not limited to the baby alone, a successful PMTCT intervention benefits the mother, the family, community and health system as outlined in table 6.2\n\nBenefits of PMTCTIdentification of HIV positive mothers for targeted interventions to reduce risk of transmission of infection to their infants and to access treatment, care and support servicesPromotion of positive behaviour change and reduction in risk of HIV transmissionIncrease the use of dual protection methods of family planning and STI preventionPromotion of optimal infant feeding practices and supportPromotion of access to early preventive and medical carePrevention of HIV transmission to infantsPromotion of early diagnosis and intervention for the HIV exposed infants including linkage to care for HIV positive infantsImprovement of child health and survivalPromotion of communication between couples and testing of both partnersReduction in the risk of sexual transmission to sero-discordant partnersProvision of opportunity for testing other family membersAccess to reproductive health servicesContribution to reduction of stigma and discriminationProvision of infant feeding support\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Promotion of the understanding of the HIV and AIDS epidemic among those living with HIV and AIDS within the community thereby strengthening community support structures\n\n- Promotion of uptake of risk reduction practices\n- Promotion of acceptance and uptake of HIV testing services\n- Contribution to reduction of stigma and discrimination\n- Provision of infant feeding support\n\n# Health System\n\n- Provision of opportunity to strengthen the health system\n\n# Pre-ART Care for HIV-positive pregnant women\n\n# Initial evaluation of HIV pregnant women\n\nAll HIV- positive pregnant women should have a full physical examination. In addition to routine antenatal services, special focus should be placed on HIV-related illnesses including symptoms and signs of opportunistic infections (OIs) especially tuberculosis.", "mimetype": "text/plain", "start_char_idx": 186168, "end_char_idx": 190681, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "5b885312-bf3e-4bc2-a08b-1c30acc44439": {"__data__": {"id_": "5b885312-bf3e-4bc2-a08b-1c30acc44439", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "3371b69f-ec01-4528-8ee5-1826662a7257", "node_type": "1", "metadata": {}, "hash": "1bfeeb45e0fa09bdd1db5ebce350c8db4b37a87970d46d24fa1b1d01befdd130", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "536c8729-832f-4e37-9270-19eb6521c97b", "node_type": "1", "metadata": {}, "hash": "9fc5f939476e30924aa3c08207c4320dd97b381591816b184408836ae8b94e01", "class_name": "RelatedNodeInfo"}}, "text": "In addition to routine antenatal services, special focus should be placed on HIV-related illnesses including symptoms and signs of opportunistic infections (OIs) especially tuberculosis. Special attention should also be paid to the following:\n\n- Anaemia\n- Persistent diarrhoea\n- Respiratory infections: TB and other bacterial respiratory infections are common OIs in HIV positive women\n- Oral and vaginal candidiasis\n- Lymphadenopathy\n- Herpes zoster (chronic/recurrent) is a common presenting sign of HIV infection, occurring early in the disease, often before there is much immune suppression\n- Other skin conditions such as candidiasis, vaginal wart, and others\n- Other sexually transmitted infections\n- Weight gain or loss\n\nFurthermore, pregnant women found to have Advanced HIV Disease (AHD) should be managed accordingly (see chapter 8).\n\n# Initial Clinical Examination of HIV Positive Pregnant Women\n\nThe initial examination of the HIV positive pregnant woman is done to identify possible problems and complications that might be present. This examination should be done in a way that respects clients' privacy and rights. All pregnant women should be counselled and told why it is important to conduct clinical examinations. A complete physical examination should be performed and care taken to maintain all safety precautions. The examination should be holistic. However, special attention should be paid to HIV related signs of OIs:\n\n- Palor: anaemia is common in pregnancy and can also occur as a result of ARV related side effect (AZT) and OIs.\n- Dehydration: this could occur as a result of persistent diarrhoea.\n- Abnormal chest finding: respiratory infections, especially TB, are common OIs among HIV positive women.\n- Oral, oesophagal and vaginal candidiasis: candidiasis is common and may be recurrent\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Other skin conditions:\n\nsuch as pityriasis versicolor, vaginal warts, Kaposi sarcoma, herpes zoster etc may also be found. It is therefore important to look out for these skin conditions.\n\n# Signs of other STIs:\n\nHIV positive women may have other STIs. It is therefore important to look out for these signs (see the section on STIs).\n\n# Laboratory Investigation of HIV Positive Pregnant Women\n\nHIV positive pregnant women should have all routine laboratory investigations conducted for pregnant women. They should have additional tests performed to monitor the progression of their clinical condition. They should have haemoglobin or hematocrit estimation at least four times during the pregnancy and urinalysis done at every clinic visit. The following investigations are recommended. (See table 6.3 for appropriate laboratory investigation).\n\n|Laboratory Investigations|At Booking/Presentation|2nd visit (26-28 weeks)|3rd visit (30-32 weeks)|4th visit (34-36 weeks)|\n|---|---|---|---|---|\n|Routine for all pregnant women|PCV or FBC where available|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 pregnancy| |\n| |HBsAg and HCV|X| | |\n| |Syphilis test|X| | |\n| |Urinalysis|X|X|X|\n| |MP|As clinically indicated| | |\n|Specific for HIV positive|CD4+|X| |X|\n| |Viral load|At 3 months 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 be used.\n\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\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Syphilis testing for pregnant women\n\nSyphilis has devastating effects on the unborn baby and mother. Untreated syphilis increases the risk of spontaneous miscarriage and congenital infection which has lifelong impact. Syphilis is an opportunistic infection whose presence if not treated increases the risk of MTCT of HIV during pregnancy. The spirochete has been documented to bore through the placental barrier thereby promoting MTCT of HIV. All pregnant women should be screened for syphilis using available Treponema pallidum-based test.", "mimetype": "text/plain", "start_char_idx": 190495, "end_char_idx": 194809, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "536c8729-832f-4e37-9270-19eb6521c97b": {"__data__": {"id_": "536c8729-832f-4e37-9270-19eb6521c97b", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "5b885312-bf3e-4bc2-a08b-1c30acc44439", "node_type": "1", "metadata": {}, "hash": "3dc2d4555e06fba45713276e22437567c951bf924a79f2d647ca07842b7c8236", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "52e81834-d79f-4d6d-a8dd-c04bc659c89a", "node_type": "1", "metadata": {}, "hash": "08d86d9e05687529c3e1c134a26aa758aaf6245081ea8d4f9e186d9c21fdd088", "class_name": "RelatedNodeInfo"}}, "text": "When positive, ART regimen containing TDF+ 3TC or FTC should be used.\n\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\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Syphilis testing for pregnant women\n\nSyphilis has devastating effects on the unborn baby and mother. Untreated syphilis increases the risk of spontaneous miscarriage and congenital infection which has lifelong impact. Syphilis is an opportunistic infection whose presence if not treated increases the risk of MTCT of HIV during pregnancy. The spirochete has been documented to bore through the placental barrier thereby promoting MTCT of HIV. All pregnant women should be screened for syphilis using available Treponema pallidum-based test.\n\n# Use of Antiretroviral Therapy for PMTCT\n\nPregnancy in HIV positive women is an absolute indication for ART. ART should be initiated in all HIV pregnant and breast-feeding women regardless of gestational age, WHO clinical stage and 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 identified late in pregnancy or postpartum. This is the most effective way to prevent MTCT of HIV through the reduction of maternal viral load. Same day initiation of ART is preferred except in patients with AHD (see chapter 8).\n\n# Recommended first-line regimen for pregnant and breastfeeding women\n\nIn line with National recommendations, DTG-based regimen is the preferred first-line ART for HIV positive pregnant women.\n\n|Target Population|Preferred first-line regimens|Alternative first-line regimens|\n|---|---|---|\n|Pregnant or breastfeeding women|TDF + 3TC + DTG|TDF + 3TC (or FTC) + EFV400|\n| | |AZT + 3TC + EFV400|\n| | |TDF + 3TC (or FTC) + EFV400|\n| | |AZT + 3TC + NVP|\n| | |TDF + 3TC (or FTC) + NVP|\n| | |ABC + 3TC + DTG|\n\nIn order to serve this preferred 1 line regimen, all women of reproductive age who can potentially be on DTG-based regimen during the 1 trimester of pregnancy should receive intensive counselling on the benefits and potential risks. This includes those already on the DTG-based regimen and those newly diagnosed.\n\n# ARV prophylaxis for the HIV exposed infant\n\nAll HIV exposed infants should receive ARV prophylaxis. Infants at low risk of acquiring HIV from their mothers should receive NVP only once daily for 6 weeks. While infants born to mothers with HIV who are at high risk of acquiring HIV should receive dual prophylaxis with AZT (twice daily) and NVP (once daily) for the first 12 weeks of life, whether they are breastfed or formula-fed. Antiretroviral prophylaxis should commence within 72 hours of birth.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 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 &lt;2.5kg|10 mg (1 ml) once daily|\n|Birth weight =2.5kg|15 mg (1.5 ml) once daily|\n\n# ARV prophylaxis for high-risk Infants\n\nHigh-risk infants are defined as those:\n\n- Born to women with established HIV infection who have received less than four weeks of ART at the time of delivery\n- Born to women with established HIV infection with viral load &gt;1000 copies/mL in the four weeks before delivery;\n- Born to women with incident HIV infection during pregnancy (this includes women diagnosed in labour) or breastfeeding;\n- Identified for the first time during the postpartum period, with or without a negative HIV test prenatally.", "mimetype": "text/plain", "start_char_idx": 193993, "end_char_idx": 197559, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "52e81834-d79f-4d6d-a8dd-c04bc659c89a": {"__data__": {"id_": "52e81834-d79f-4d6d-a8dd-c04bc659c89a", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "536c8729-832f-4e37-9270-19eb6521c97b", "node_type": "1", "metadata": {}, "hash": "9fc5f939476e30924aa3c08207c4320dd97b381591816b184408836ae8b94e01", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "8b178d80-74e9-4171-8b00-8ca7e99f88b5", "node_type": "1", "metadata": {}, "hash": "03e06857b8e69fd3e07df72a06af1982defd204d3285ce43335b05b6ef0587ff", "class_name": "RelatedNodeInfo"}}, "text": "# Table 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 &lt;2.5kg|10mg (1ml) once daily|10mg (1ml) twice daily|\n|Birth weight &gt;2.5kg|15mg (1.5ml) once daily|15mg (1.5ml) twice daily|\n|6 weeks to 12 weeks|20mg (2ml) once daily|60 mg (6ml) twice daily|\n\n# 6.4.3 Cotrimoxazole Prophylaxis for HIV exposed infants\n\nCotrimoxazole prophylaxis is recommended for HIV-exposed infants from 6 weeks of age and should be continued until HIV infection has been excluded by an age-appropriate HIV test 8-12 weeks after complete cessation of breastfeeding.\n\n# Table 6.7 Dosing for Cotrimoxazole Prophylaxis in HIV-Exposed Infants and HIV-Infected Children\n\n|SN|Infant Age / Weight|Dosage|\n|---|---|---|\n|1|For infants below 6 months or &lt; 5 kg|120mg daily|\n|2|For children 6 months - 5 years or 5 -15 kg|240 mg daily|\n\n# 6.4.4 Antenatal Care for HIV positive pregnant women\n\nWhen a woman is known to be HIV positive or is diagnosed as HIV positive during pregnancy, her obstetric and medical care will need to be strengthened and modified. Post-test counselling for HIV positive pregnant women should include information on the following:\n\n- Disclosure, partner notification and testing\n- Benefits of PMTCT intervention\n- ART\n- Nutrition\n- Delivery\n- Infant feeding and infant testing\n- Importance of testing other children and benefits of paediatric ART\n- The need for follow-up and adherence\n- Continuous screening for active TB infections and TB Preventive Therapy (TPT) for 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 delivery. In a situation where the life of the woman is being threatened by the continuation of the pregnancy, consideration of termination of pregnancy should be in accordance with the provisions of the law (see National Guidelines on the termination of pregnancy for legal indications 2018).\n\n# 6.5 Management of HIV positive women in labour, delivery and within 72 hours of delivery\n\nThe current use of very efficacious ARVs, such as DTG assures that most women should be virologically suppressed by the time their delivery is due. Nonetheless, viral load estimation is recommended between 32-36 weeks of gestation to confirm this and enhance the preference of vaginal delivery. The management of Labour should therefore follow standard obstetric practice (see National obstetric protocol). Analgesia should be given in labour if required and epidural analgesia 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. Supportive measures, empathy and caring attitudes by the health care provider are important for all women, particularly for HIV positive women who are concerned about their condition and risks of HIV transmission to their children. HIV positive pregnant women should not be stigmatized nor discriminated against by medical staff including those who may not have disclosed their status to their partner or family members.\n\nWhenever possible, during labour, HIV positive women should have the option to have a companion of their choice who can provide supportive companionship. Where this is not possible, labour ward staff must be sensitive to the fears and concerns of the HIV positive mother.", "mimetype": "text/plain", "start_char_idx": 197561, "end_char_idx": 201056, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8b178d80-74e9-4171-8b00-8ca7e99f88b5": {"__data__": {"id_": "8b178d80-74e9-4171-8b00-8ca7e99f88b5", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "52e81834-d79f-4d6d-a8dd-c04bc659c89a", "node_type": "1", "metadata": {}, "hash": "08d86d9e05687529c3e1c134a26aa758aaf6245081ea8d4f9e186d9c21fdd088", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "51a3eb4e-c195-495a-a7f8-c1b5a59175d6", "node_type": "1", "metadata": {}, "hash": "1a4dc1dd5674a4270bb76d1542e593e968c81019c917ffc6b2ba913c6aa74c05", "class_name": "RelatedNodeInfo"}}, "text": "The management of Labour should therefore follow standard obstetric practice (see National obstetric protocol). Analgesia should be given in labour if required and epidural analgesia 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. Supportive measures, empathy and caring attitudes by the health care provider are important for all women, particularly for HIV positive women who are concerned about their condition and risks of HIV transmission to their children. HIV positive pregnant women should not be stigmatized nor discriminated against by medical staff including those who may not have disclosed their status to their partner or family members.\n\nWhenever possible, during labour, HIV positive women should have the option to have a companion of their choice who can provide supportive companionship. Where this is not possible, labour ward staff must be sensitive to the fears and concerns of the HIV positive mother.\n\nNote\n\n- Avoid invasive procedures such as chorionic villous sampling, amniocentesis or cordocentesis\n- External cephalic version (ECV) may carry a risk of HIV transmission to the foetus and should therefore be avoided\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - 82\n\n# 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|Perform vaginal cleansing with warm (0.25%) chlorhexidine solution to prevent genital infections|\u00a7 Wipe baby\u2019s mouth and nostrils with gauze at the delivery of the head.|\n|Avoid the following: - Frequent vaginal examinations\n- Episiotomies (unless absolutely necessary)\n- Instrumental delivery (unless when necessary)\n- Milking the cord before clamping\n- Clamp cord immediately after the baby is delivered and cut, under cover of wrapped gauze swab to avoid blood spurting.\n|Handle all babies with gloves regardless of the mother\u2019s HIV status until blood and secretions are washed off|\n| |Keep all babies warm soon after delivery|\n| |Where suctioning is indicated, a mechanical suction unit (at a pressure below 100mmHg) or bulb suction should be used; mouth operated suction should be avoided|\n| |Place the baby on the mother\u2019s body for skin-to-skin contact soon after delivery|\n\n# 6.5.1 Induction of Labour\n\nAs prolonged rupture of membranes is associated with increased risk of MTCT, careful assessment of the desirability of Caesarean Section (CS) rather than induction of labour is necessary. The use of prostaglandins or its analogues (misoprostol) can be considered.\n\n# 6.5.2 Conduct of Delivery\n\nDelivery should be conducted using standard practices and aseptic techniques while avoiding unnecessary trauma or prolongation of the second stage.\n\n# 6.5.3 Vaginal Delivery\n\nHIV positive women who are on ART should be allowed to deliver vaginally where there is no obstetric contraindication. Vaginal delivery remains the primary delivery mode of choice.\n\n# 6.5.4 Caesarean Section (CS)\n\nHIV infection on its own is not an indication for CS. Available evidence shows that elective CS for women on ART who have achieved viral suppression has no added advantage over vaginal delivery. Every pregnant woman including adolescents should be monitored closely.\n\nElective CS can be considered for HIV positive women before the onset of labour or rupture of membranes in cases where the woman is not on ART and/or where the maternal viral load is known to be high (> 1000copies/ml). Available evidence shows that when elective CS is performed before the onset of labour or rupture of membranes, it reduces the risk of MTCT by greater than 50% as compared to vaginal delivery among women not on ART or with high viral load. These guidelines, however, do not recommend routine offer of elective CS for any group of HIV positive pregnant women.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n83\n\n# Specific Modification of Obstetric Care for HIV Positive Women\n\n- Care should be individualized in special circumstances such as premature rupture of membranes (preterm and term) and ante-partum haemorrhage\n- Use of the partograph: proper and consistent use of the partograph in monitoring the progress of labour will improve the management and reduce the risk of prolonged labour in all women\n- Artificial rupture of membranes (ARM) is practised routinely in many settings although it should be reserved for women with abnormal progress of labour. Rupture of membranes of more than four (4) hours duration is associated with an increased risk of HIV transmission. Therefore, early ARM should be reserved for those with foetal distress or abnormal progress.", "mimetype": "text/plain", "start_char_idx": 200006, "end_char_idx": 204770, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "51a3eb4e-c195-495a-a7f8-c1b5a59175d6": {"__data__": {"id_": "51a3eb4e-c195-495a-a7f8-c1b5a59175d6", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "8b178d80-74e9-4171-8b00-8ca7e99f88b5", "node_type": "1", "metadata": {}, "hash": "03e06857b8e69fd3e07df72a06af1982defd204d3285ce43335b05b6ef0587ff", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "2876bcad-2f09-462d-a10c-aa1150e1bdd8", "node_type": "1", "metadata": {}, "hash": "e774ad921f431d44a4cb743bec9576600e3f29d132079835ea502d799c8b3167", "class_name": "RelatedNodeInfo"}}, "text": "These guidelines, however, do not recommend routine offer of elective CS for any group of HIV positive pregnant women.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n83\n\n# Specific Modification of Obstetric Care for HIV Positive Women\n\n- Care should be individualized in special circumstances such as premature rupture of membranes (preterm and term) and ante-partum haemorrhage\n- Use of the partograph: proper and consistent use of the partograph in monitoring the progress of labour will improve the management and reduce the risk of prolonged labour in all women\n- Artificial rupture of membranes (ARM) is practised routinely in many settings although it should be reserved for women with abnormal progress of labour. Rupture of membranes of more than four (4) hours duration is associated with an increased risk of HIV transmission. Therefore, early ARM should be reserved for those with foetal distress or abnormal progress. ARM can be done if cervical dilatation is 7 cm or more.\n- Instrumental delivery: forceps and vacuum delivery should be avoided as they have been shown to be associated with increased risk of MTCT. If it has to be done, vacuum with silastic cup is preferred\n- Vaginal cleansing with chlorhexidine (0.25% solution) reduces the risk of puerperal and neonatal sepsis. It may also have some effect on HIV transmission where membranes are ruptured for more than 4 hours. The number of vaginal examinations should be kept to a minimum.\n- Routine episiotomy has been shown to have no obstetric benefit; it should be used only for specific obstetric indications\n\n# PMTCT/TB integration services\n\n# Pregnant women with TB and HIV co-infection\n\nNigeria has the highest TB burden in Africa and the sixth highest in the world. TB causes one in three deaths among PLHIV, and co-morbidity of TB and HIV in pregnancy causes up to 40% mortality. These are the reasons why continuous screening of HIV positive pregnant women should be conducted throughout pregnancy to identify women who have active TB disease. Those with the disease should be given immediate access to TB treatment according to the NTBLCP Guidelines. Those without the disease should be placed on TB Preventive Therapy (TPT) irrespective of the duration of pregnancy.\n\nEvery ANC provider should be prepared and equipped to screen every pregnant woman for TB disease at each clinic visit, whether they are HIV positive or not. The screening of those who are HIV positive is even more important because not detecting the co-infection of HIV and TB in pregnancy 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 major symptoms of TB; cough, fever, weight loss or night sweats (especially drenching type). Refer to Appendix 7 for Algorithm for Screening Adults and Adolescents Living with HIV for TPT.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Management of Pregnant or Breastfeeding HIV Positive Women\n\nAt each visit, the pregnant or breastfeeding HIV positive woman should be identified to belong to any of the following three categories:\n\n|1)|Has no cough but has other symptoms of TB|The patient should be referred to the medical officer to exclude TB (according to NTBLCP Guidelines)|\n|---|---|---|\n|2)|Has cough with other symptoms of TB|The patient is likely to have TB disease that requires confirmation with Xpert MTB/RIF assay, and subsequent management according to NTBLCP Guidelines|\n|3)|Has none of the four symptoms|The patient should be counselled and started on Tuberculosis Preventive Therapy (TPT) irrespective of the gestational age of the pregnancy|\n\n# Tuberculosis Preventive Therapy (TPT)\n\nTPT involves the administration of medicines (e.g. Isoniazid 300mg daily) for a minimum period of six months to a pregnant/breastfeeding PLHIV who does not have active TB disease. It is purposed to protect her from developing active TB disease.\n\nThe triple pill combination of Isoniazid + Cotrimoxazole + Pyridoxine is available and a good option for TPT among pregnant and postpartum women with HIV.\n\n# Management of Newborn of a Mother/Household contacts with active TB\n\nInfants born to mothers with active TB disease may become infected with TB. When infected, the infant may be asymptomatic or present with acute symptoms that are often non-specific. Management depends on the peculiar situation, but evaluation should be at a referral centre.", "mimetype": "text/plain", "start_char_idx": 203823, "end_char_idx": 208283, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "2876bcad-2f09-462d-a10c-aa1150e1bdd8": {"__data__": {"id_": "2876bcad-2f09-462d-a10c-aa1150e1bdd8", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "51a3eb4e-c195-495a-a7f8-c1b5a59175d6", "node_type": "1", "metadata": {}, "hash": "1a4dc1dd5674a4270bb76d1542e593e968c81019c917ffc6b2ba913c6aa74c05", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "3a0597d5-512e-4e79-a2da-fe54414a9754", "node_type": "1", "metadata": {}, "hash": "e31bda5e882fcbde29c813e7cba7c960c46bfaf34df14a3d7360fa7184294c4e", "class_name": "RelatedNodeInfo"}}, "text": "Isoniazid 300mg daily) for a minimum period of six months to a pregnant/breastfeeding PLHIV who does not have active TB disease. It is purposed to protect her from developing active TB disease.\n\nThe triple pill combination of Isoniazid + Cotrimoxazole + Pyridoxine is available and a good option for TPT among pregnant and postpartum women with HIV.\n\n# Management of Newborn of a Mother/Household contacts with active TB\n\nInfants born to mothers with active TB disease may become infected with TB. When infected, the infant may be asymptomatic or present with acute symptoms that are often non-specific. Management depends on the peculiar situation, but evaluation should be at a referral centre.\n\nSome possible scenarios regarding infants born to mothers with TB include:\n\n- If a mother is diagnosed with TB before the third trimester of pregnancy and taking TB medications with good adherence and is improving:\n- Examine the newborn\n- - If symptoms and signs of TB are not present, administer BCG\n- If symptoms and signs of TB are present, evaluate further for TB disease\n- If symptoms and signs suggest other diseases, manage/refer as appropriate\n\nPerform maternal HIV screening (if not done in ANC)\n- Refer all other household contacts for TB evaluation\n- If a mother is diagnosed with TB in the third trimester or shortly after delivery:\n- Evaluate for maternal PTB or EPTB disease including uterine TB\n- Perform maternal HIV screening (if not done in ANC)\n- Defer BCG vaccine administration for the newborn\n- Evaluate infant for congenital TB if the newborn is symptomatic or where the mother is AFB positive or has untreated disseminated or partially treated TB/poor adherence\n- Evaluate infant if the mother is diagnosed with endometrial TB regardless of treatment status with:\n- - CXR\n- Gastric aspirates for Xpert MTB/Rif and culture of 3 consecutive samples\n- Abdominal ultrasound\n- Lumbar puncture for CSF Xpert MTB/Rif, LPA, and cultures\n\nIf TB disease is confirmed in the newborn, initiate TB therapy promptly in consultation with a pediatrician where available\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 6.6 Management of Tuberculosis (TB) in Newborns\n\n- If congenital TB is excluded, administer TPT for LTBI until age of 6 months. Perform Mantoux or IGRA test and if positive, reassess for active TB.\n- If active disease is ruled out, give TPT for LTBI.\n- If the Mantoux/IGRA is negative and TB disease is ruled out and mother/household contact becomes smear-negative, stop INH and administer BCG vaccine two weeks after stopping TPT.\n- Follow-up infant monthly.\n- Refer all other household contacts for TB evaluation.\n\n# 6.6.2 Infection Control\n\n- Separate the newborn from any active TB case in the household including the mother during the evaluation period.\n- Newborn should receive expressed breastmilk during period of isolation.\n- Mother/adult contact should wear a facemask while handling the baby.\n- Follow isolation precautions.\n- Once the baby is on INH and the mother or adult source is on continuation phase of treatment, no need to separate the baby, and the mother can again breastfeed the baby.\n\n# 6.6.3 Management of Newborn of a Mother/ Household contacts with LTBI\n\nIn a newborn whose mother or other household contact has LTBI:\n\n- Treat the mother or household contact for LTBI (if mother or household contact are contacts of an infectious TB index case).\n- Perform maternal HIV screening (if not done in ANC).\n- Since a positive Mantoux/IGRA result is a marker for an unrecognised case of active TB in the household, evaluate all other household members for TB disease/LTBI.\n- The newborn needs no special evaluation.\n- Administer BCG vaccine if no active case of TB is detected in the household.\n\n# 6.7 Care and Support of the HIV-Exposed Infant\n\n# 6.7.1 Immediate and on-going care of the new-born of HIV positive women\n\nThe immediate care of the new-born follows standard practice regardless of the mothers' HIV status. At delivery all newborns should:\n\n- Be handled with latex gloves until maternal blood and secretions are washed off.\n- Have their mouths and nostrils wiped with sterile gauze after delivery of the head.\n- Have the cord clamped immediately after the baby is delivered and avoid milking the cord.\n- Have the cord cut under cover of a lightly wrapped gauze swab to avoid blood spurting.\n- Be kept warm.\n- Be suctioned if indicated using a mechanical/electrical suction unit at a pressure below 100mmHg or bulb suction. Mouth operated suction is contraindicated.", "mimetype": "text/plain", "start_char_idx": 207587, "end_char_idx": 212129, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "3a0597d5-512e-4e79-a2da-fe54414a9754": {"__data__": {"id_": "3a0597d5-512e-4e79-a2da-fe54414a9754", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "2876bcad-2f09-462d-a10c-aa1150e1bdd8", "node_type": "1", "metadata": {}, "hash": "e774ad921f431d44a4cb743bec9576600e3f29d132079835ea502d799c8b3167", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "c96ea4c9-bf74-473e-827c-4a29733b79e3", "node_type": "1", "metadata": {}, "hash": "7f047a5f55381720b4ba034fa4bb9abdb2b2e95ef68c3298dad1391227a8adc8", "class_name": "RelatedNodeInfo"}}, "text": "- Administer BCG vaccine if no active case of TB is detected in the household.\n\n# 6.7 Care and Support of the HIV-Exposed Infant\n\n# 6.7.1 Immediate and on-going care of the new-born of HIV positive women\n\nThe immediate care of the new-born follows standard practice regardless of the mothers' HIV status. At delivery all newborns should:\n\n- Be handled with latex gloves until maternal blood and secretions are washed off.\n- Have their mouths and nostrils wiped with sterile gauze after delivery of the head.\n- Have the cord clamped immediately after the baby is delivered and avoid milking the cord.\n- Have the cord cut under cover of a lightly wrapped gauze swab to avoid blood spurting.\n- Be kept warm.\n- Be suctioned if indicated using a mechanical/electrical suction unit at a pressure below 100mmHg or bulb suction. Mouth operated suction is contraindicated.\n- Be cleaned with warm chlorhexidine solution or wiped dry with a towel or surgical cloth to remove maternal body fluids.\n- Place the baby on the mother's chest for skin to skin contact soon after delivery. In this position, the baby will latch on to one of the mother's breasts to initiate feeding unless the mother opted for an alternative feeding method.\n- Have vitamin K administered, ensuring injection safety.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 6.7.2 Infant feeding in the context of HIV\n\nAppropriate infant feeding is critical to child survival because the natural food for infants is breast milk. In the context of maternal HIV infection, infant feeding can become complex. HIV infection may be transmitted through breast milk from mother to child and this risk approaches 5%-15% in the absence of any intervention. Breast milk substitute has the benefit of zero HIV transmission but carries with it the risk of increased morbidity and mortality from malnutrition, diarrhea, and pneumonia.\n\n- It is recommended that mothers of HIV exposed infants breastfeed their babies exclusively for the first six (6) months of life.\n- Adequate complementary feeds should be introduced at 6 months in addition to breast milk.\n- Breastfeeding complemented by adequate complementary and household foods should be continued till 12 months of age.\n\nMothers who breastfeed should be aware that:\n\n- Mixed feeding (breast milk plus substitutes or foods) increases the risk of MTCT of HIV.\n- ARV provided during labor and to the mother/infant pair throughout breastfeeding protects the infant from MTCT of HIV.\n- The risk of transmitting HIV to her infant during breastfeeding is higher in certain conditions such as:\n- When the woman is severely ill (by clinical or laboratory measures)\n- When she has mastitis, breast abscess, or other similar conditions\n- When the child has ulcers in the mouth\n- When breastfeeding is prolonged beyond 12 months of age\n\nBreast milk substitute: Breast milk substitute means feeding infants who are receiving no breast milk with correctly prepared commercial infant formula that provides most of the nutrients infants need until the age at which they can be fully fed on family foods. Unlike breastfeeding, it does not protect against infections. During the first 6 months of life, breast milk substitutes should be with a suitable commercial infant formula prepared hygienically. After 6 months the suitable commercial formula should be complemented with other foods.\n\n# 6.7.3 Early Infant Diagnosis (EID)\n\nAll HIV-exposed infants should have DNA PCR testing or NAT at birth, 6 \u2013 8 weeks of age, 9 months and 8-12 weeks after complete cessation of breastfeeding. If the baby is not being breastfed, DNA PCR testing should be done at birth and 6 weeks [Refer to figure 2.3].\n\n# 6.7.4 Childhood Immunizations in the Context of HIV\n\nHIV-exposed infants, children and adolescents with HIV should receive all vaccines under routine vaccination according to recommended national immunization schedule (NPI) as shown on Table 6.9. The WHO recommends that the certain situations require special considerations for HIV exposed and infected neonates, infants and children as outlined below.\n\n# 6.7.4.1 Considerations for BCG vaccine\n\n- Neonates born to women of unknown HIV status should be vaccinated as the benefits of BCG vaccination outweigh the risks\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Neonatal Vaccination Guidelines for HIV-Infected Individuals\n\nNeonates of unknown HIV status born to HIV infected women should be vaccinated if they have no clinical evidence suggestive of HIV disease, regardless of whether the mother is receiving ART.\n\nNeonates with HIV infection confirmed by early virological testing, BCG vaccination should be delayed until ART has been started and the infant confirmed to be immunologically stable (CD4>25%).", "mimetype": "text/plain", "start_char_idx": 211266, "end_char_idx": 216045, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c96ea4c9-bf74-473e-827c-4a29733b79e3": {"__data__": {"id_": "c96ea4c9-bf74-473e-827c-4a29733b79e3", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "3a0597d5-512e-4e79-a2da-fe54414a9754", "node_type": "1", "metadata": {}, "hash": "e31bda5e882fcbde29c813e7cba7c960c46bfaf34df14a3d7360fa7184294c4e", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "fb741f10-a41a-410a-9761-620d24c25529", "node_type": "1", "metadata": {}, "hash": "b0a1e9b78d8eb285679f45d62240b9c3fbab524b6ef7c7685505eccf54bdf2d1", "class_name": "RelatedNodeInfo"}}, "text": "The WHO recommends that the certain situations require special considerations for HIV exposed and infected neonates, infants and children as outlined below.\n\n# 6.7.4.1 Considerations for BCG vaccine\n\n- Neonates born to women of unknown HIV status should be vaccinated as the benefits of BCG vaccination outweigh the risks\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Neonatal Vaccination Guidelines for HIV-Infected Individuals\n\nNeonates of unknown HIV status born to HIV infected women should be vaccinated if they have no clinical evidence suggestive of HIV disease, regardless of whether the mother is receiving ART.\n\nNeonates with HIV infection confirmed by early virological testing, BCG vaccination should be delayed until ART has been started and the infant confirmed to be immunologically stable (CD4>25%).\n\nHIV-infected children on ART, those clinically and immunologically stable (CD4% >25% for <5 years or CD4 count \u2265200 for >5 years) should be vaccinated with BCG.\n\n# Considerations for Pneumococcal vaccines\n\nHIV-positive infants and pre-term neonates who have received their 3 primary vaccine doses before 12 months of age may benefit from a booster dose in the second year of life.\n\nUnvaccinated children aged 1\u20135 years at high risk for pneumococcal infection due to underlying conditions, such as HIV infection or sickle-cell disease, should receive at least 2 doses separated by at least 8 weeks.\n\n# Considerations for Measles vaccines\n\nIn the following situations, a supplementary dose of MCV should be given to infants from 6 months of age:\n\n- Measles vaccine should be routinely administered to potentially susceptible, asymptomatic HIV infected children and adults, given the severe course of measles in patients with advanced HIV disease (AHD).\n- Vaccination may be considered for those with symptomatic HIV infection if they are not severely immunosuppressed.\n- Where there is a high incidence of both HIV infection and measles, an initial dose of Measles vaccine may be offered as early as age 6 months (recorded as MCV0).\n- The 2 routine doses of Measles vaccines (MCV1 and MCV2) should then be administered to these children according to NPI schedule.\n- An additional dose of Measles vaccine should be administered to HIV-infected children receiving HAART following immune reconstitution.\n- If CD4+ counts are monitored, an additional dose of MCV should be administered when immune reconstitution has been achieved, e.g. when the CD4+ count reaches 20\u201325%.\n- Where CD4+ monitoring is not available, children should receive an additional dose at 6\u201312 months after initiation of HAART.\n- A supplementary dose (recorded as MCV0) should be considered for infants known to be exposed (i.e. born to an HIV-infected woman) or soon after diagnosis of HIV infection in children older than 6 months who are not receiving HAART and for whom the risk of measles is high, with the aim of providing partial protection until they are revaccinated after immune reconstitution with HAART.\n\n# Considerations for Human Papillomavirus vaccine\n\nA 3-dose schedule (0, 1-2, 6 months) should be used for all vaccinations initiated \u226515 years of age, including in girls <15 years known to be immunocompromised and/or HIV infected (regardless of whether they on HAART or not).\n\nIt is not necessary to screen for HPV infection or HIV infection prior to HPV vaccination.", "mimetype": "text/plain", "start_char_idx": 215209, "end_char_idx": 218598, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "fb741f10-a41a-410a-9761-620d24c25529": {"__data__": {"id_": "fb741f10-a41a-410a-9761-620d24c25529", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "c96ea4c9-bf74-473e-827c-4a29733b79e3", "node_type": "1", "metadata": {}, "hash": "7f047a5f55381720b4ba034fa4bb9abdb2b2e95ef68c3298dad1391227a8adc8", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "5b859628-c49c-4c48-b6a0-3541bd556f53", "node_type": "1", "metadata": {}, "hash": "0d39729879a9ee8a08a6ead3f92143e3ec3831356fa6e8826d321897bc2213cb", "class_name": "RelatedNodeInfo"}}, "text": "- A supplementary dose (recorded as MCV0) should be considered for infants known to be exposed (i.e. born to an HIV-infected woman) or soon after diagnosis of HIV infection in children older than 6 months who are not receiving HAART and for whom the risk of measles is high, with the aim of providing partial protection until they are revaccinated after immune reconstitution with HAART.\n\n# Considerations for Human Papillomavirus vaccine\n\nA 3-dose schedule (0, 1-2, 6 months) should be used for all vaccinations initiated \u226515 years of age, including in girls <15 years known to be immunocompromised and/or HIV infected (regardless of whether they on HAART or not).\n\nIt is not necessary to screen for HPV infection or HIV infection prior to HPV vaccination.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - Page 88\n\n# Table 6.9 National Routine Immunization Schedule\n\n|Minimum Target age|Vaccine|Dosage|Route of delivery|Site of administration|\n|---|---|---|---|---|\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 aspect)|\n|6 Weeks|Pentavalent (DPT, Hep B, Hib) 1|0.5ml|Intramuscular|Left thigh (antero-lateral aspect)|\n| |Pneumococcal Conjugate Vaccine (PCV) 1|0.5ml|Intramuscular|Left thigh (antero-lateral aspect)|\n| |OPV1|2 drops|Oral|Mouth|\n| |Rota 1|1ml|Oral|Mouth|\n|10 Weeks|Pentavalent (DPT, Hep B, Hib) 2|0.5ml|Intramuscular|Left thigh (antero-lateral aspect)|\n| |Pneumococcal Conjugate Vaccine (PCV) 2|0.5ml|Intramuscular|Right thigh (antero-lateral aspect)|\n| |OPV2|2 drops|Oral|Mouth|\n| |Rota 2|1ml|Oral|Mouth|\n|14 Weeks|Pentavalent (DPT, Hep B, Hib) 3|0.5ml|Intramuscular|Left thigh (antero-lateral aspect)|\n| |Pneumococcal Conjugate Vaccine (PCV) 3|0.5ml|Intramuscular|Right thigh (antero-lateral aspect)|\n| |OPV3|2 drops|Oral|Mouth|\n| |IPV|0.5ml|Intramuscular|Right thigh (antero-lateral aspect, 25cm away from PCV3 site)|\n|6 Months|Vitamin A|100,000 IU|Oral|Mouth|\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 IU|Oral|Mouth|\n| |Measles (MCV1)|0.5ml|Subcutaneous|Left upper arm|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Special Considerations for Adolescent and Young Women in PMTCT\n\nIn Nigeria, an estimated 23% of women aged 15-19 years begun childbearing, of which 17% have had their first child and 5% are pregnant for their first child.\n\nTo achieve eMTCT in Nigeria, it is therefore very important to pay special attention to any adolescent girl presenting with pregnancy in a health facility. Efforts should be made to seek out the many pregnant adolescents in the community that do not present to health facilities for ANC and delivery. The needs of Adolescent Girls and Young Women (AGYW) in eMTCT are like those of an adult woman, the major difference is the fact that their vulnerabilities are heightened physiologically, emotionally and socially.", "mimetype": "text/plain", "start_char_idx": 217841, "end_char_idx": 220909, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "5b859628-c49c-4c48-b6a0-3541bd556f53": {"__data__": {"id_": "5b859628-c49c-4c48-b6a0-3541bd556f53", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "fb741f10-a41a-410a-9761-620d24c25529", "node_type": "1", "metadata": {}, "hash": "b0a1e9b78d8eb285679f45d62240b9c3fbab524b6ef7c7685505eccf54bdf2d1", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "d0b319aa-5b24-4d0d-bb9b-3356f697502f", "node_type": "1", "metadata": {}, "hash": "917f59c548cc3705520a43d09570ee3f6c5572b5e838371e1b685e516f093849", "class_name": "RelatedNodeInfo"}}, "text": "To achieve eMTCT in Nigeria, it is therefore very important to pay special attention to any adolescent girl presenting with pregnancy in a health facility. Efforts should be made to seek out the many pregnant adolescents in the community that do not present to health facilities for ANC and delivery. The needs of Adolescent Girls and Young Women (AGYW) in eMTCT are like those of an adult woman, the major difference is the fact that their vulnerabilities are heightened physiologically, emotionally and socially. Service delivery thus needs to be responsive to their needs across the 4 pillars of PMTCT as below:\n\n# Pillar 1:\n\nKey concerns for AGYW include:\n\n- Low knowledge of HIV transmission\n- Low-risk perception\n- Lack of awareness of prevention options/methods to reduce risks and/or skills to use them\n- Late start of ANC\n\nPMTCT programmes should make provision for integration of HIV prevention messages/information targeting AGYW at the community level and through women groups, mobile services, social media platforms, peer-groups, youth centres etc. Provider-facilitated screening, lay or peer counsellor, self-assessment (considering sexual risk, risky relationships, lifestyle risk and situational risk) are additional considerations required.\n\n# Pillar 2:\n\nConsidering the high rates of unintended pregnancies in AGYW, unsafe abortion among adolescents contributes to maternal mortality for this age group. The specific challenges faced by pregnant AGYW living with HIV include lack of knowledge of contraceptive options, life skills and self-efficacy, inaccessible and non-friendly services, lack of support for dual protection and limited access to contraceptives beyond condoms.\n\nSpecific considerations required include:\n\n- FP/SRH information and life skills tailored for Adolescents living with HIV (ALHIV)\n- Contraception and dual protection tailored to their needs integrated within HIV care, safe conception and pregnancy planning\n- Support group-based approaches\n- Community-based distribution and activities to optimize contraceptive options available to ALHIV\n\n# Pillar 3:\n\nThe major risk factors associated with vertical transmission in pregnant AGYW living with HIV are late start of ANC, delayed HIV testing and treatment initiation leading to suboptimal treatment outcomes.\n\nSpecial considerations to be offered to AGYW include:\n\n- Tailored approaches to case finding, earlier pregnancy testing, and early initiation on treatment for young mothers\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Pillar 4\n\nThe major concern for AGYW living with HIV postpartum (post EID) is treatment continuity. Other concerns include SRH needs, age of young mother and spacing of children. The PMTCT program should ensure young mothers living with HIV receive:\n\n- Longer-term care and support focused on retaining young mothers and children in care\n- Integrated delivery of ARV, SRHR, FP\n- Care involving men\n- Family-based care\n- Mental health screening and intervention approaches in the context of HIV care\n- Integrated case management systems\n\n# Linkage of PMTCT with comprehensive HIV Treatment, Care and Support Services for Mothers and Infants\n\nThe follow-up treatment, care and support for HIV-positive mothers after delivery, the care of their HIV exposed infant and other children is important as part of the continuum of care package. A family-focused care should be the standard, this is designed to identify, engage and care for all HIV-positive family members, prevent new infections among family members at risk, raise family support and awareness within the HIV department at a health facility depending on the PMTCT service model.\n\nPMTCT services can be offered in both public and private health facilities. Mother-infant pairs from health facilities with no capacity for comprehensive HIV care should be referred to comprehensive health services that provide HIV treatment, care and support by 6 weeks after delivery or at the earliest possible time thereafter. This is because it is important that treatment and care extend beyond the prevention of MTCT for women, infants, and family members at risk for or infected with HIV.\n\n# Engagement of Non-Formal Health Actors (NFHA) in the (referral and Linkage) of PMTCT services\n\nThere are human resource gaps in the health sector in Nigeria, while the implementation of the task shifting policy is ongoing, there is a need for a medium-term intervention in the form of engagement 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 role in PMTCT will include the following:\n\n1. Community sensitization and awareness creation\n2. Community mobilization\n3. HIV case identification\n4. Peer influence for PMTCT service uptake\n5. Referral and linkage including EID and immunization services\n6. Tracking and contact tracing\n7.", "mimetype": "text/plain", "start_char_idx": 220395, "end_char_idx": 225337, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d0b319aa-5b24-4d0d-bb9b-3356f697502f": {"__data__": {"id_": "d0b319aa-5b24-4d0d-bb9b-3356f697502f", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "5b859628-c49c-4c48-b6a0-3541bd556f53", "node_type": "1", "metadata": {}, "hash": "0d39729879a9ee8a08a6ead3f92143e3ec3831356fa6e8826d321897bc2213cb", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "6e46d6e4-6b98-4c16-af94-d1ce52418406", "node_type": "1", "metadata": {}, "hash": "abea2c9e5a2aa5dd03cd9eb308e0d74a297e2c52fa663caf2ed907fb462391a9", "class_name": "RelatedNodeInfo"}}, "text": "# Engagement of Non-Formal Health Actors (NFHA) in the (referral and Linkage) of PMTCT services\n\nThere are human resource gaps in the health sector in Nigeria, while the implementation of the task shifting policy is ongoing, there is a need for a medium-term intervention in the form of engagement 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 role in PMTCT will include the following:\n\n1. Community sensitization and awareness creation\n2. Community mobilization\n3. HIV case identification\n4. Peer influence for PMTCT service uptake\n5. Referral and linkage including EID and immunization services\n6. Tracking and contact tracing\n7. Non-clinical care and support\n\n# List of Contributors\n\nDr Adesigbin Clement\n\nDr Ijaodola Olugbenga\n\nTaiwo Olakunle\n\nZainab E. Abdullahi\n\nDr Adeyinka Adewemimo\n\nDr Benson Udu\n\nMrs. Hidayat Bukola Yahaya\n\nDr Gideon Sorochi Okorie\n\nProf. Oladapo Shittu\n\nProf. Solomon Sagay\n\nProf Anteinette Ofili\n\nProf. Oliver Ezechi\n\nDr Idowu Adebara\n\nDr Stephen B. Bature\n\nDr Chinyere Ukamaka Onubogu\n\nDr Benjamin Aiwondagbon\n\nDr Ochola-Odonga Dorothy\n\nDr Victoria Isiramen\n\nDr Idayat Uthman\n\nDr. Efuntoye Adeola Tim\n\nBennett Okechukwu Urama\n\nDr Chris Obanubi\n\nLilian Anomnachi\n\nDr Andrew Etsetsowaghan\n\nDr Omoregie Godpower\n\nDr Amalachukwu Ukaere\n\nHalima Ibrahim\n\nMrs Ehi Adejo-Ogiri\n\nOgochukwu Ginigeme\n\nDr Helen Omuh\n\nRuth Dauda Akolo\n\nChinwe Aganekwu\n\nAbang Roger\n\nMwoltu Nanribet Gabriel\n\nAkanji Michael O\n\n# Chapter 6\n\nDeputy Director, Head of Prevention NASCPAssistant Director, National Officer PMTCT NASCPChief Scientific Officer NASCPPopulation Programme Officer I NASCPSenior Medical Officer I NASCPSASPC, FCTProgramme Officer Health Sector Response Support NACAAssistant Chief program officer/ PMTCT/HTS Focal Officer NACAChairman, PMTCT Task Team / OBY/GYNAE ABUTH ZariaMember PMTCT Task team / OBY/GYNAE JUTH JosPublic Health Physician, UBTH BeninDirector of Research, NIMR LagosConsultant OBY/GYN, FTH Ido EkitiMember PMTCT Task Team / OBY/GYN, BDTH/KASU KadunaPaediatrician, NAUTH, NnewiWHOHealth & HIV Section UNICEFHealth Manager UNICEFNational Program Officer UNAIDSSenior Specialist PMTCT, CDCForecasting and Supply Planning Advisor GHSC-PSMProgramme Manager USAIDDeputy Program Director CHAITechnical Director FHI360Head/Practice Lead, HIV and TB SFHProgram Director SFHProgram Manager SFHGender Officer/POC JHPIEGOICAPDeputy Director IHVNWelfare - Deputy ASWHANCoordinator, FGI CISHANDirector of Programs Heartland AllianceMental Health Technical Advisor Heartland AllianceKey Populations Advisor Heartland Alliance\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 92\n\n# 7. PREVENTIVE MANAGEMENT IN HIV\n\nWhat\u2019s Inside:\n\n|7.1 Introduction|94|\n|---|---|\n|7.2 Pre-Exposure Prophylaxis|95|\n|7.3 Post-Exposure Prophylaxis|99|\n|7.4 Post-Sexual Assault Exposure Prophylaxis|102|\n|7.5 Interventions for Key Populations|104|\n|7.6 Condom availability and promotion for HIV programme|105|\n|7.7 Gender-Based Violence|106|\n|7.8 Management of Sexually Transmitted Infections (STIs)|108|\n|7.9 Prevention for Adolescent and Young Persons (AYPs)|109|\n\n# 7.1 Introduction\n\nPreventive management of HIV is a broad term for different interventions that protect individuals from contracting/transmitting HIV infection. It also includes interventions that protect the HIV positive individual from common opportunistic infections (OIs) including tuberculosis. It is recommended that all persons who come in contact with health services should be allowed access to any combination of HIV prevention interventions most suitable to their needs.", "mimetype": "text/plain", "start_char_idx": 224577, "end_char_idx": 228276, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6e46d6e4-6b98-4c16-af94-d1ce52418406": {"__data__": {"id_": "6e46d6e4-6b98-4c16-af94-d1ce52418406", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "d0b319aa-5b24-4d0d-bb9b-3356f697502f", "node_type": "1", "metadata": {}, "hash": "917f59c548cc3705520a43d09570ee3f6c5572b5e838371e1b685e516f093849", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "2e499b5c-095f-419a-820c-e70d05e34ad7", "node_type": "1", "metadata": {}, "hash": "5d1a4facde504e487d47306547bd06b52b186e10d0ba917ef7d9076773656e17", "class_name": "RelatedNodeInfo"}}, "text": "It also includes interventions that protect the HIV positive individual from common opportunistic infections (OIs) including tuberculosis. It is recommended that all persons who come in contact with health services should be allowed access to any combination of HIV prevention interventions most suitable to their needs. The necessity for the simultaneous employment of different approaches and intervention types for the prevention of HIV infection has led to the concept of combination prevention.\n\n# 7.1.1 Combination prevention / Minimum Prevention Package Intervention (MPPI)\n\nThe National Prevention Plan (NPP) 2010-2012 introduced the combination prevention approach, locally called the \u201cMinimum Prevention Package Intervention\u201d (MPPI), which are defined prevention intervention packages that address the drivers of the epidemic. The package emphasized dosage and intensity and promoted ownership and sustainability. The MPPI is defined as, \u201cthe strategic, simultaneous use of different classes of prevention activities (biomedical, behavioural, structural) that operate on multiple levels (individual, community and structural), to respond to the specific needs of particular audiences and modes of HIV transmission, and to make efficient use of resources through prioritization, partnership, and engagement of affected communities\u201d (UNAIDS Prevention Reference Group Definition).\n\nBehavioural interventions include a range of behaviour change communication activities designed to promote HIV risk-reducing and protective behaviours. These activities span, and often combine, mass media, community mobilization, advocacy and interpersonal communication (IPC) such as one-to-one or one-to-group educational activities. Social media and mobile technology are important tools that should be integrated into HIV prevention programmes and is particularly critical in informing about and providing prevention services to key populations.\n\nBiomedical interventions include several medical interventions that can prevent HIV infection, reduce transmission, and/or reduce the risk of infection. These are interventions that directly influence the biological systems through which the virus infects a new host, such as preventing infection (e.g., male and female condoms), reducing transmission (e.g., ART as prevention), or reducing acquisition/infection risk. These interventions include correct and consistent use of male and female condoms and lubricants, HIV testing and counselling, PMTCT, STI diagnosis and treatment, ARV for PrEP and PEP, microbicides, and vaccines.\n\nStructural interventions are strategies recommended for change in social, legal, political and economic factors that increase vulnerability to HIV. These interventions address stigma and discrimination, legal and human rights violations, gender-based violence and inequality. They are also designed to support income-generating activities, promote the integration referral, adherence and retention in health services.\n\nEffective implementation of combination prevention in the country will require political commitment and leadership, programme coordination and management, partnerships and collaboration, adequate HR, advocacy, community and social mobilization, functional commodity supply management systems, M&E and research.\n\n94\n\n# 7.2 Pre-Exposure Prophylaxis\n\nPre-exposure prophylaxis (PrEP) is the pre-emptive use of ARVs to reduce the probability of HIV negative individuals acquiring HIV infection, especially in persons who are deemed at substantial risk.\n\nRationale: A systematic review and meta-analysis of oral PrEP trials using TDF-based ARV drug combinations demonstrated that daily oral PrEP is effective in reducing the risk of acquiring HIV infection. The level of protection did not differ by age, sex, mode of acquiring HIV (rectal, penile or vaginal exposure).\n\n# 7.2.1 Criteria for PrEP initiation\n\nThe criteria for PrEP initiation are as follow:\n\n- HIV seronegative\n- No suspicion of acute HIV infection\n- A substantial risk of HIV infection\n- Urinalysis to rule out proteinuria\n- Willingness to use PrEP as prescribed\n\n# 7.2.2 PrEP minimum package\n\nThe PrEP minimum package of services includes:\n\n1. HIV testing and counselling, including index testing, self-testing and couple testing2. eGFR* and monitoring of kidney function3. Hepatitis screening4. Comprehensive HIV prevention including risk-reduction counselling and condom/lubricant distribution5. Assessment of need for contraceptives and/or pregnancy testing6. Sexually Transmitted Infection screening, diagnosis and treatment7. Screening for NCDs, such as diabetes mellitus and hypertension8. Referral for services for gender-based violence, legal aid services, or mental health issues identified during counselling9. Adherence assessment and counselling, help identify possible barriers to good adherence\n\n# 7.2.3 PrEP effectiveness\n\nWhen used as directed, PrEP can reduce the risk of HIV among at-risk individuals by more than 90%. PrEP can be more effective if it is combined with other HIV prevention mechanisms such as condom use, drug abuse treatment and harm reduction services for people living with HIV.", "mimetype": "text/plain", "start_char_idx": 227956, "end_char_idx": 233126, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "2e499b5c-095f-419a-820c-e70d05e34ad7": {"__data__": {"id_": "2e499b5c-095f-419a-820c-e70d05e34ad7", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "6e46d6e4-6b98-4c16-af94-d1ce52418406", "node_type": "1", "metadata": {}, "hash": "abea2c9e5a2aa5dd03cd9eb308e0d74a297e2c52fa663caf2ed907fb462391a9", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "30cf4aa4-357a-40fc-a302-e0e8142f0c01", "node_type": "1", "metadata": {}, "hash": "21f87e06d4664dbea1663f7b796d42d034ebd96908eba12894bbf49efabd2af6", "class_name": "RelatedNodeInfo"}}, "text": "eGFR* and monitoring of kidney function3. Hepatitis screening4. Comprehensive HIV prevention including risk-reduction counselling and condom/lubricant distribution5. Assessment of need for contraceptives and/or pregnancy testing6. Sexually Transmitted Infection screening, diagnosis and treatment7. Screening for NCDs, such as diabetes mellitus and hypertension8. Referral for services for gender-based violence, legal aid services, or mental health issues identified during counselling9. Adherence assessment and counselling, help identify possible barriers to good adherence\n\n# 7.2.3 PrEP effectiveness\n\nWhen used as directed, PrEP can reduce the risk of HIV among at-risk individuals by more than 90%. PrEP can be more effective if it is combined with other HIV prevention mechanisms such as condom use, drug abuse treatment and harm reduction services for people living with HIV.\n\n# 7.2.4 Approved drugs for PrEP\n\nThe preferred drug regimen for PrEP is the combination of daily TDF + FTC / TDF + 3TC. The alternate 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. Waiting for eGFR result should not delay initiation of PrEP. However, if urinalysis is not normal, PrEP initiation should be delayed until creatinine results come back. eGFR should be performed at 6 months, followed by annual screening.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 7.2.5 PrEP administration guidance\n\nPrEP must be prescribed by a healthcare professional who has completed training on the National Guidelines for the use of ARVs for PrEP. Daily PrEP should be used during periods of substantial risk of HIV acquisition and can be stopped during periods of low or no risk. The category of individuals prioritized for PrEP are listed below:\n\n|1.|Sero-discordant couples/partners|\n|---|---|\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\n# 7.2.6 Daily PrEP and Event-Driven PrEP\n\nThere are two options for the dosing frequency of PrEP: daily dosing and event-driven dosing. Daily dosing is recommended for men, women, and transgender people. Event-driven PrEP is ONLY recommended for MSM.\n\nDaily dosing is the provision of PrEP given as 1 tablet daily. People must take their PrEP for 7 consecutive days before drug levels are high enough to prevent HIV infection. Daily dosing with a single pill should be sustained throughout the period of HIV risk for as long as substantial risk is ongoing. Those wanting to stop PrEP should continue taking the single pill daily dose for 28 days after the last HIV exposure.\n\nEvent-driven PrEP (ED-PrEP) is only recommended for men who have sex with men. The first dose of 2 pills (TDF/FTC or TDF/3TC), called the loading dose, should be taken between 2 and 24 hours prior to exposure. The second dose (after sex) is a single pill taken 24 hours after the first dose. The third dose is a single pill taken 24 hours after the second dose. ED-PrEP has been described as \u201c2+1+1\u201d dosing. This 2+1+1 dosing is the only ED-PrEP regimen that has been demonstrated to be effective. The 2+1+1 dosing describes ED-PrEP when an isolated act of sex is involved. If more sex acts take place over the following days, a single PrEP pill can be continued daily for as long as sex continues, with a single daily pill taken for the next two days after the last sex act.\n\n# 7.2.7 PrEP for Serodiscordant Couples\n\nHIV transmission occurs among sero-discordant couples. Where additional HIV prevention choices are needed for sero-discordant couples, daily oral PrEP may be considered as a possible additional intervention for the uninfected partner. PrEP can be discontinued by the uninfected partner when the infected partner has achieved viral load suppression and is adhering to their ARVs.", "mimetype": "text/plain", "start_char_idx": 232243, "end_char_idx": 236223, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "30cf4aa4-357a-40fc-a302-e0e8142f0c01": {"__data__": {"id_": "30cf4aa4-357a-40fc-a302-e0e8142f0c01", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "2e499b5c-095f-419a-820c-e70d05e34ad7", "node_type": "1", "metadata": {}, "hash": "5d1a4facde504e487d47306547bd06b52b186e10d0ba917ef7d9076773656e17", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "384b5810-f3a7-4f0e-808f-1abbfa534112", "node_type": "1", "metadata": {}, "hash": "9dad64b5f57c89fc946436eeeaf7712fbc33d0dc369715a6f0c0d6a47f919bf1", "class_name": "RelatedNodeInfo"}}, "text": "This 2+1+1 dosing is the only ED-PrEP regimen that has been demonstrated to be effective. The 2+1+1 dosing describes ED-PrEP when an isolated act of sex is involved. If more sex acts take place over the following days, a single PrEP pill can be continued daily for as long as sex continues, with a single daily pill taken for the next two days after the last sex act.\n\n# 7.2.7 PrEP for Serodiscordant Couples\n\nHIV transmission occurs among sero-discordant couples. Where additional HIV prevention choices are needed for sero-discordant couples, daily oral PrEP may be considered as a possible additional intervention for the uninfected partner. PrEP can be discontinued by the uninfected partner when the infected partner has achieved viral load suppression and is adhering to their ARVs.\n\n# 7.2.8 Settings Where PrEP can be Accessed\n\nPrEP implementation can be integrated into any setting that meets the conditions for initial evaluation and initiation including:\n\n- One-Stop-Shop (OSS) for KPs (including community and facility settings)\n- HIV clinics\n- ANC/MNCH/RH and STI clinics\n- Community settings meeting the criteria for initial client assessment and evaluation e.g. integrated prevention centres\n- Adolescent and youth-friendly outlets\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - 96\n\n# Table 7.1: Services provided by cadre\n\n|Human resource cadre|Services Provided|\n|---|---|\n|Doctors|Risk screening, clinical eligibility assessment, counselling, initiation, prescriptions and follow up reviews|\n|Nurses|Counselling and refills|\n|Pharmacists|Dispensing PrEP drugs, counselling on adherence and side effects|\n|Laboratory Scientists/Technicians|Conducting laboratory tests and providing results|\n|HTS Counsellors|Counselling and risk screening, laboratory samples (if trained as a phlebotomist)|\n|Community and facility support cadres (i.e. expert clients, Outreach Workers, peer educators)|Demand creation, health education, counselling and risk screening, appointment reminders and follow up|\n\n# 7.2.9 Contraindications for PrEP\n\nPrEP should NOT be provided to people with:\n\n- HIV positive test on the day of PrEP initiation using the Nigeria national HIV testing algorithm\n- Known exposure to HIV in the past 72 hours (requires PEP)\n- Signs of Acute HIV Infection (AHI) (Box 7.1) (Defer PrEP and consider PEP counselling for clients with a history of high-risk unprotected sex in the past three days, even in the absence of symptoms of AHI).\n- A client unable to commit to PrEP adherence, and to attend scheduled PrEP visits\n- Drug allergy to TDF or FTC\n- eGFR &lt; 60 ml/min\n- Concurrent nephrotoxic medication\n\n# Box 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# 7.2.10 Client follow-up\n\nOnce on PrEP, clients should return after one month to assess and confirm HIV-negative test status, assess for early side effects, discuss any difficulties with medication adherence, and any other client concerns. Follow-up should be every 3 months from the initiation visit. Table 7.2 outlines the procedures for each of the follow-up visits.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Table 7.2. Follow-up visits procedures\n\n|Visit|Procedure|\n|---|---|\n|Visit 2 (Month 1)|- Safety monitoring clinical assessment\n- HIV testing and counselling\n- Adherence and risk reduction counselling\n- Offer HBV vaccination if available and HBsAg negative (follow HBV vaccination schedule complete series)\n|\n|Visits for Months 3, 9, 15|- HIV testing and counselling\n- HIV risk assessment for PrEP continuation\n- Adherence and risk reduction counselling\n- Assess for adverse drug reactions\n|\n|Visits for Months 6, 12, 18, 24, 36|- HIV testing and counselling\n- Creatinine and eGFR *\n- HIV risk review and assessment for PrEP continuation\n- Adherence and risk reduction counselling\n- Assess for adverse drug reactions\n|\n|Unscheduled visits: as per need.|- Determine if the reason for the visit is PrEP related or not e.g.", "mimetype": "text/plain", "start_char_idx": 235435, "end_char_idx": 239545, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "384b5810-f3a7-4f0e-808f-1abbfa534112": {"__data__": {"id_": "384b5810-f3a7-4f0e-808f-1abbfa534112", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "30cf4aa4-357a-40fc-a302-e0e8142f0c01", "node_type": "1", "metadata": {}, "hash": "21f87e06d4664dbea1663f7b796d42d034ebd96908eba12894bbf49efabd2af6", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "92acaea4-c99a-492e-8889-875fc6ce9912", "node_type": "1", "metadata": {}, "hash": "22246745045f1ee220569235f0bc4705e69fe7a329d9b352c67309ee11a4a6c6", "class_name": "RelatedNodeInfo"}}, "text": "Follow-up visits procedures\n\n|Visit|Procedure|\n|---|---|\n|Visit 2 (Month 1)|- Safety monitoring clinical assessment\n- HIV testing and counselling\n- Adherence and risk reduction counselling\n- Offer HBV vaccination if available and HBsAg negative (follow HBV vaccination schedule complete series)\n|\n|Visits for Months 3, 9, 15|- HIV testing and counselling\n- HIV risk assessment for PrEP continuation\n- Adherence and risk reduction counselling\n- Assess for adverse drug reactions\n|\n|Visits for Months 6, 12, 18, 24, 36|- HIV testing and counselling\n- Creatinine and eGFR *\n- HIV risk review and assessment for PrEP continuation\n- Adherence and risk reduction counselling\n- Assess for adverse drug reactions\n|\n|Unscheduled visits: as per need.|- Determine if the reason for the visit is PrEP related or not e.g. adverse events\n- Assess and manage the reason for the unscheduled visit according to national guidelines e.g. acute or chronic illnesses, worsening existing conditions\n- Provide HIV risk reduction and PrEP adherence counselling\n- Agree on follow up schedule\n|\n\nDuring every visit, remind PrEP users on the dosage of PrEP needed to achieve adequate levels of the ARVs in tissues to be effective and importance of adherence. During these window periods, safer sex practices should be encouraged (including abstinence and condoms).\n\nManagement of clients with inconclusive HIV test result during follow-up visits:\n\n- For non-pregnant or lactating clients:\n\n*creatinine clearance should be performed at 6 months, followed by annual screening.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - Page 98\n\n# 7.2.11 PrEP discontinuation\n\nIdeally, clients should inform their service provider when they want to discontinue PrEP. Health care workers should discuss the options of when to discontinue PrEP with their clients. PrEP can be stopped for the following reasons:\n\n- Client request\n- Positive HIV test (clients who seroconvert while on PrEP should be linked to care and initiated on ART in line with national guidelines)\n- Safety concerns, such as eGFR &lt;60mls/min\n- No longer at substantial risk\n- Persistent side effects\n\nDocumentation for persons on PrEP should be as rigorous as for persons who are on ART. Upon discontinuation of PrEP, the following information should be documented:\n\n- HIV status at the time of discontinuation\n- Reasons for discontinuation\n\n# 7.3 Post-Exposure Prophylaxis\n\nPost-Exposure Prophylaxis (PEP) is the short-term use of ARVs to prevent HIV infection in persons accidentally exposed to a potential risk of acquiring HIV infection. This applies usually to accidental exposure to HIV either in the course of legitimate work as could occur among health workers who are vulnerable to needle stick injuries or contact with infectious body fluids. It also applies to sexual assault victims especially in cases where the HIV status of the perpetrator cannot be readily determined.\n\nIt is recommended that PEP for HIV infection should be offered and initiated as early as possible in all individuals with an exposure that has the potential for HIV transmission, as soon as possible within 72 hours.\n\n# 7.3.1 Post-Exposure Prophylaxis for Occupational HIV exposure\n\nNeedlestick injuries are major risks for HIV transmission in the workplace. The risk of transmission is greatly increased if associated with deep injury, visible blood on the sharp instrument, procedures involving a needle placed in the source patient's blood vessel, virally unsuppressed patients and terminal illness in the source patient.", "mimetype": "text/plain", "start_char_idx": 238737, "end_char_idx": 242293, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "92acaea4-c99a-492e-8889-875fc6ce9912": {"__data__": {"id_": "92acaea4-c99a-492e-8889-875fc6ce9912", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "384b5810-f3a7-4f0e-808f-1abbfa534112", "node_type": "1", "metadata": {}, "hash": "9dad64b5f57c89fc946436eeeaf7712fbc33d0dc369715a6f0c0d6a47f919bf1", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "762ac6ee-aa2e-4595-ad5b-1b5f0316bda4", "node_type": "1", "metadata": {}, "hash": "d8e934cf41de782f21dae7b159056bd5cb68ba7b4d8b6d43a864ea4d44ce5d73", "class_name": "RelatedNodeInfo"}}, "text": "This applies usually to accidental exposure to HIV either in the course of legitimate work as could occur among health workers who are vulnerable to needle stick injuries or contact with infectious body fluids. It also applies to sexual assault victims especially in cases where the HIV status of the perpetrator cannot be readily determined.\n\nIt is recommended that PEP for HIV infection should be offered and initiated as early as possible in all individuals with an exposure that has the potential for HIV transmission, as soon as possible within 72 hours.\n\n# 7.3.1 Post-Exposure Prophylaxis for Occupational HIV exposure\n\nNeedlestick injuries are major risks for HIV transmission in the workplace. The risk of transmission is greatly increased if associated with deep injury, visible blood on the sharp instrument, procedures involving a needle placed in the source patient's blood vessel, virally unsuppressed patients and terminal illness in the source patient.\n\nThe following types of exposures may pose the risk of HIV transmission for health workers and should be considered for PEP:\n\n- Needlestick injury or injury with a sharp object that has been used on an HIV positive patient\n- Mucosal exposure of the mouth, eye, or nose by splashing infectious body fluids\n- Broken skin exposed to blood, blood stained body fluids, or other infectious body fluids (breast milk, genital secretions, cerebrospinal, amniotic, peritoneal, synovial, pericardial and pleural fluids)\n\nSteps to take following a needle-stick injury or mucosal exposure:\n\nIn the event of an injury with a sharp object such as a needle or scalpel that has been used on a patient or in the event of a mucous surface being in contact with blood or secretions from a patient, the following steps should be followed:\n\n- Do not squeeze, suck or rub the injury site\n\n# 7.3.2 Evaluation for Post-Exposure Prophylaxis\n\nEvaluating exposed person's eligibility for HIV PEP involves assessing the following:\n\n- Timing of the potential exposure\n- HIV status of exposed person\n- The nature and risk of the exposure\n- HIV status of the source of the potential exposure\n\n# 7.3.4 Determination of Risk and ARV drugs for PEP\n\nThe exposure should be classified as \u201clow risk\u201d or \u201chigh risk\u201d for HIV infection as below:\n\n|Low Risk:|Solid needle or superficial exposure on intact skin|\n|---|---|\n| |Small volume (drops of blood) on mucous membrane or non-intact skin exposures|\n| |Source is asymptomatic or viral load &lt;1000 copies/ml|\n|High Risk:|Large bore needle, deep injury, visible blood on device, needle in patient artery/vein|\n| |Large volume (major blood splash on mucous membrane or non-intact skin exposures)|\n| |Source patient is symptomatic, in acute seroconversion and has high viral load (&gt;1000 copies/ml)|\n\n# 7.3.5 Recommendations for PEP\n\n- Immediately after exposure to HIV, all exposed individuals should take a 3drug ARV combination for PEP.\n- The chosen regimen should be continued for 28 days or until the result of the HIV test for the source patient is known to be negative.\n- Enhanced adherence counselling and support (psychosocial, mental, etc.) should be provided for PEP users\n- If the preferred regimen is not available, it is better to administer an alternative regimen than to wait.\n\n# Table 7.3 Recommended actions following HIV testing in PEP\n\n|If the source person is HIV negative|No PEP is necessary for the exposed health worker unless there is suspicion that the source is newly infected and in the window period.|\n|---|---|\n|If the exposed health worker is HIV positive|No PEP is necessary|\n| |The health worker should be referred for further counselling and initiation of ART/ long-term management|\n|If the health worker is HIV negative and the source patient is HIV positive|Give ARV drugs for four weeks; Repeat health worker\u2019s HIV test at 3 and 6 months after the initial test. Should the health worker seroconvert during this period, provide appropriate care and counselling; refer for expert opinion and long-term management.|\n|If it is not possible to determine the HIV status of the source patient|Assume that the source patient is positive and proceed according to the guidelines above|\n\n# 7.3.6 Recommended Drug Combinations for PEP\n\nIt is recommended that a three-drug ARV regimen should be used for PEP. TDF + 3TC (or FTC) is recommended as the preferred backbone regimen for HIV PEP for adults and adolescents. DTG or EFV are recommended as the preferred third drug for HIV PEP for adults and adolescents. However, where available, LPV/r, RAL, or DRV/r, can be considered as alternative options.", "mimetype": "text/plain", "start_char_idx": 241326, "end_char_idx": 245931, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "762ac6ee-aa2e-4595-ad5b-1b5f0316bda4": {"__data__": {"id_": "762ac6ee-aa2e-4595-ad5b-1b5f0316bda4", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "92acaea4-c99a-492e-8889-875fc6ce9912", "node_type": "1", "metadata": {}, "hash": "22246745045f1ee220569235f0bc4705e69fe7a329d9b352c67309ee11a4a6c6", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "b58857f8-fbee-4ff9-8e32-023953efe7d7", "node_type": "1", "metadata": {}, "hash": "7b84560cc22ef8bcf38dec1612b4a4dc412be11c8ae37f804bb31d1ecb9c1e06", "class_name": "RelatedNodeInfo"}}, "text": "Should the health worker seroconvert during this period, provide appropriate care and counselling; refer for expert opinion and long-term management.|\n|If it is not possible to determine the HIV status of the source patient|Assume that the source patient is positive and proceed according to the guidelines above|\n\n# 7.3.6 Recommended Drug Combinations for PEP\n\nIt is recommended that a three-drug ARV regimen should be used for PEP. TDF + 3TC (or FTC) is recommended as the preferred backbone regimen for HIV PEP for adults and adolescents. DTG or EFV are recommended as the preferred third drug for HIV PEP for adults and adolescents. However, where available, LPV/r, RAL, or DRV/r, can be considered as alternative options. If the source person is known to be on a second-line regimen or has failed first-line regimen, the preferred prophylaxis regimen should be \u201ca second-line regimen\u201d. If the source person on the second-line regimen has a detectable viral load, the prophylaxis should be a third-line regimen Children above 30kg should receive TDF/3TC/DTG or EFV. In children <10 years or less than 30kg, AZT + 3TC is recommended as the preferred backbone regimen for HIV PEP. Alternative backbone regimen for this age category will include ABC + 3TC or TDF + 3TC (or FTC). DTG is recommended as the preferred third drug for HIV PEP for children < 10 years. An age-appropriate alternative regimen can be identified from LPV/r, ATV/r, RAL, DRV/r.\n\n# Table 7.4 Recommended Drug Combinations for Post-Exposure Prophylaxis\n\nRecommended 3-Drug ARV Combinations1. TDF/3TC/DTG (Preferred)2. TDF/3TC/EFV or AZT/3TC + EFV\nNevirapine should never be used for PEP as the risk of fatal hepatotoxicity outweighs the risk of HIV infection. Where DTG and EFV is contraindicated, either of the 2drug combinations may be combined with LPV/r, RAL, or DRV/r\n\nNote:\n\n- NVP should not be used in children above the age of 2 years.\n- A 28-day prescription of antiretroviral drugs should be provided for HIV PEP following initial risk assessment.\n- Enhanced adherence counselling is suggested for individuals initiating HIV PEP\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n101\n\n# In areas of high HIV incidence\n\nA significant number of HIV positive individuals may be in the 'window period' of acute infection and test antibody negative. A high level of suspicion for acute HIV infection should therefore be maintained and PEP continued if there is suspicion that the source patient has recently been infected with HIV.\n\n# Guidance on Risk Reduction\n\nGuidance should be given on risk reduction measures until the exposed person is known to be HIV negative. It is important to consider the risk of exposure to viral hepatitis when evaluating persons for post-exposure management.\n\n# Recommended schedules of investigations following HIV exposure\n\n|Period|Recommended Investigations|\n|---|---|\n|Baseline|HIV, HBV, HCV screening, FBC, LFT, Renal function test|\n|Two weeks|FBC, Liver function test, Renal function test|\n|Six weeks|HIV screening|\n|3 months|HIV screening|\n|6 months|HIV screening|\n\n# Post-Sexual Assault Exposure Prophylaxis\n\nThe possibility of HIV exposure from sexual assault should be assessed at the time of the post-assault examination. The benefit of PEP in the prevention of HIV infection should be discussed with the assault survivors if the risk of HIV exposure exists.", "mimetype": "text/plain", "start_char_idx": 245205, "end_char_idx": 248597, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "b58857f8-fbee-4ff9-8e32-023953efe7d7": {"__data__": {"id_": "b58857f8-fbee-4ff9-8e32-023953efe7d7", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "762ac6ee-aa2e-4595-ad5b-1b5f0316bda4", "node_type": "1", "metadata": {}, "hash": "d8e934cf41de782f21dae7b159056bd5cb68ba7b4d8b6d43a864ea4d44ce5d73", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "724d4268-deac-488c-99f6-2e31a05009f4", "node_type": "1", "metadata": {}, "hash": "0c0a37b7dc71dacd2335a81bd58e3315e49b1a745af359417519e30ee14bca3c", "class_name": "RelatedNodeInfo"}}, "text": "# Guidance on Risk Reduction\n\nGuidance should be given on risk reduction measures until the exposed person is known to be HIV negative. It is important to consider the risk of exposure to viral hepatitis when evaluating persons for post-exposure management.\n\n# Recommended schedules of investigations following HIV exposure\n\n|Period|Recommended Investigations|\n|---|---|\n|Baseline|HIV, HBV, HCV screening, FBC, LFT, Renal function test|\n|Two weeks|FBC, Liver function test, Renal function test|\n|Six weeks|HIV screening|\n|3 months|HIV screening|\n|6 months|HIV screening|\n\n# Post-Sexual Assault Exposure Prophylaxis\n\nThe possibility of HIV exposure from sexual assault should be assessed at the time of the post-assault examination. The benefit of PEP in the prevention of HIV infection should be discussed with the assault survivors if the risk of HIV exposure exists. Factors impacting the medical recommendation for PEP and the assault survivor's acceptance of the recommendation include:\n\n- Occurrence of vaginal or anal penetration\n- Occurrence of ejaculation on mucous membranes\n- Involvement of multiple assailants\n- Presence of mucosal lesions on the assailant or survivor\n- Other characteristics of the assault, survivor, or assailant that might increase the risk for HIV transmission\n\nIf PEP is offered, the following should be discussed with the patient:\n\nBenefits and known toxicities of ARV\nFollow-up that will be necessary\nBenefit of adherence to recommended ARV dosing\nEarly initiation of PEP to optimize potential benefits (as soon as possible after and preferably within 72 hours after the assault)\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 7.4.1 Recommendations\n\n- A three-drug ARV regimen should be used for post-sexual exposure PEP (see ART Section)\n- As with all cases of sexual assault, it is important to arrange for continuous counselling and support (psychosocial, mental and legal, etc.) for the survivor\n- Emergency contraception should also be provided if indicated\n\n# 7.4.2 Clinical considerations\n\n- Assessment of HBV infection status should not be a precondition for offering TDF-, 3TC- or FTC- based PEP, but people with established chronic HBV infection should be monitored for hepatic flare after PEP discontinuation. Among people with unknown HBV status and where HBV testing is readily available, people started on TDF-, 3TC- or FTC-based PEP should be tested for HBV to detect active HBV infection and the need for ongoing HBV therapy after discontinuing PEP\n- NVP should not be used for PEP among adults, adolescents and older children because of the risk of life-threatening adverse events associated with HIV-negative adults using this drug\n- DTG or EFV is widely available as a third agent, as this drug is used as part of the preferred first-line ART regimen. EFV is well tolerated for treatment but has limited acceptability for use as PEP, as there are concerns about giving a drug associated with early neuropsychiatric adverse events to HIV-negative people who may have anxiety related to HIV exposure\n- NVP has been widely used to prevent the transmission of HIV from mothers to HIV uninfected infants and should be used for preterm babies or infants younger than two weeks of age where LPV/r oral liquid cannot be used. However, because the NV toxicity profile beyond infancy remains unclear, its use should be avoided in children older than 2 years of age\n- Flow chart for the provision of care for a sexually assaulted child is shown in figure 7.1\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - Page 103\n\n# Figure 7.1. Algorithm for screening of sexual assault in children\n\n# 7.5 Interventions for Key Populations\n\nKey Populations (KPs) are defined groups who, due to specific high-risk behaviours, are at increased risk of HIV irrespective of the epidemic type or local context. Also, they often have legal and psycho-social issues related to their behaviours that increase their vulnerability to HIV. The KPs are important to the dynamics of HIV transmission. In Nigeria, the various KPs makeup only 3.4% of the population, yet account for around 32% of new HIV infections. Without addressing the needs of key populations, a sustainable response to HIV will not be achieved.\n\n# 7.5.1 Recommended comprehensive prevention package of Interventions for key populations\n\nA combination of interventions is required to respond effectively to HIV among KPs. The following comprehensive package of interventions is recommended to assist programming for HIV prevention among KPs.\n\n|1.", "mimetype": "text/plain", "start_char_idx": 247729, "end_char_idx": 252299, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "724d4268-deac-488c-99f6-2e31a05009f4": {"__data__": {"id_": "724d4268-deac-488c-99f6-2e31a05009f4", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "b58857f8-fbee-4ff9-8e32-023953efe7d7", "node_type": "1", "metadata": {}, "hash": "7b84560cc22ef8bcf38dec1612b4a4dc412be11c8ae37f804bb31d1ecb9c1e06", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "05cbce19-bc3f-4963-83d6-1e77bd17790d", "node_type": "1", "metadata": {}, "hash": "4e1cbe5b5e17518c47c2a91133e4482147221336a852a9c00accbf2397b0d46b", "class_name": "RelatedNodeInfo"}}, "text": "Algorithm for screening of sexual assault in children\n\n# 7.5 Interventions for Key Populations\n\nKey Populations (KPs) are defined groups who, due to specific high-risk behaviours, are at increased risk of HIV irrespective of the epidemic type or local context. Also, they often have legal and psycho-social issues related to their behaviours that increase their vulnerability to HIV. The KPs are important to the dynamics of HIV transmission. In Nigeria, the various KPs makeup only 3.4% of the population, yet account for around 32% of new HIV infections. Without addressing the needs of key populations, a sustainable response to HIV will not be achieved.\n\n# 7.5.1 Recommended comprehensive prevention package of Interventions for key populations\n\nA combination of interventions is required to respond effectively to HIV among KPs. The following comprehensive package of interventions is recommended to assist programming for HIV prevention among KPs.\n\n|1. HIV prevention|\u00a7 Provision of condom for correct and consistent use with compatible lubricants.|\n|---|---|\n| |\u00a7 PrEP should be offered as an additional prevention choice (see PrEP section for guidance).|\n| |\u00a7 PEP should be available to all eligible people (see PEP section for guidance).|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - 104\n\n# HIV Testing Services\n\nHTS including HIVST and index testing should be routinely offered to all KPs.\n\n# Treatment as Prevention\n\n- Key populations living with HIV should have the same access to antiretroviral therapy (ART) as achieving viral suppression is also key to HIV prevention.\n- All pregnant women from KPs should have access to PMTCT services (see PMTCT section for guidance)\n\n# Prevention, diagnoses and treatment of TB, viral hepatitis, cervical cancer screening, STIs etc. (see the relevant sections for guidance)\n\n# Routine screening and management of mental health disorders should be provided to KPs\n\n# Harm reduction for PWID:\n\n- Improving access to sterile injecting equipment through needle and syringe programme\n- Ensuring that KPs dependent on opioids should be offered and have access to Opioid Substitution Therapy (OST)\n- Community distribution of Naloxone for overdose management\n- Ensuring that KPs using harmful alcohol or other substance should have access to evidence-based interventions\n\n# Condom availability and promotion for HIV programme\n\nUniversally, condoms are pivotal in stemming the tide of the spread of HIV and STIs among any population. This is because they are the only known device that protects against STIs including HIV. Condom programming for key and general populations with latex condoms, compatible with lubricants, substantially reduces the risk of HIV infection by 94% provided the condoms are used correctly and consistently. Condoms have in addition, contraceptive benefits hence their popularity as a product for dual protection (against unintended pregnancies and STIs including HIV).\n\nHowever, challenges with affordability, accessibility, availability, acceptability, perception including breakage and consistent and correct usage, have created a gap between the number of condoms distributed and the amount needed for populations to protect themselves from HIV and STIs. Improved condom programming can help close the gap in condom supply and use to reduce the spread of HIV and other STIs.\n\n# Elements of Condom Programing\n\nCondom programming is a strategic approach to ensure that sexually active persons at risk of HIV and STIs are motivated to use condoms, have access to quality condoms, and can use them consistently and correctly. Thus, condom programming must address both the supply of and demand (see figure 7.2) for good quality condoms as well as the environment, which is the critical operating framework through which access to and use of condoms is ensured.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n105\n\n# DEMAND\n\nTarget specific client groups\n\nIdentify barriers to access and use.\n\nUse counselling and educational materials to promote condoms at distribution points\n\nBuild community, social, and political support for condom use.\n\nFigure 7.2. Elements of condom programming\n\n# SUPPLY\n\nSelect products that appeal to clients and meet their needs.\n\nForecast condom needs\n\nProcure high-quality condoms\n\nManage inventory and use accepted standards to store and transport condoms.\n\nDistribute condoms through multiple channels and outlets\n\n# 7.6.2 Key Steps in Condom Programming\n\nThe goal of condom programming is to ensure that the sexually active persons at risk of STIs are motivated to use condoms, have easy access to quality condoms and can use them consistently and correctly. It addresses the supply of and demand for condoms as well as the political, socio-cultural, and economic environment.", "mimetype": "text/plain", "start_char_idx": 251341, "end_char_idx": 256159, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "05cbce19-bc3f-4963-83d6-1e77bd17790d": {"__data__": {"id_": "05cbce19-bc3f-4963-83d6-1e77bd17790d", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "724d4268-deac-488c-99f6-2e31a05009f4", "node_type": "1", "metadata": {}, "hash": "0c0a37b7dc71dacd2335a81bd58e3315e49b1a745af359417519e30ee14bca3c", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "72e340aa-8865-485a-8d95-ce8cb86298c9", "node_type": "1", "metadata": {}, "hash": "f5126ccdcd5c8ef9202f6b235224ec9a19d771107674d5818cc90e313d72028b", "class_name": "RelatedNodeInfo"}}, "text": "# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n105\n\n# DEMAND\n\nTarget specific client groups\n\nIdentify barriers to access and use.\n\nUse counselling and educational materials to promote condoms at distribution points\n\nBuild community, social, and political support for condom use.\n\nFigure 7.2. Elements of condom programming\n\n# SUPPLY\n\nSelect products that appeal to clients and meet their needs.\n\nForecast condom needs\n\nProcure high-quality condoms\n\nManage inventory and use accepted standards to store and transport condoms.\n\nDistribute condoms through multiple channels and outlets\n\n# 7.6.2 Key Steps in Condom Programming\n\nThe goal of condom programming is to ensure that the sexually active persons at risk of STIs are motivated to use condoms, have easy access to quality condoms and can use them consistently and correctly. It addresses the supply of and demand for condoms as well as the political, socio-cultural, and economic environment. (see figure 7.3 below for the key steps)\n\n- Understand condom clients and the environment\n- Assess programme and plan, create action\n- Monitor programme progress and evaluate outcomes\n- Promote condoms at the community, district, and national levels\n- Procure high-quality condoms and manage the pipeline\n- Expand distribution systems\n\nFigure 7.3. Seven steps for condom programming for HIV prevention\n\n# 7.7 Gender-Based Violence\n\nGender-Based Violence (GBV), is a problem throughout the world, occurring in every society, country, and region. When individuals or groups do not \u201cfit\u201d established gender expectations/norms they often face stigma, discriminatory practices or social exclusion \u2013 all of which adversely affect health and increase vulnerability to HIV.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 106\n\n# Ignoring gender-related barriers and its integration into HIV programs can negatively affect prevention efforts, service utilization, adherence and health outcomes for everyone. In line with this, all health care service providers should ensure the following is implemented in health care settings:\n\n# 7.7.1 GBV Prevention\n\nPrevent risk before it begins by using evidence-based and age-appropriate approaches to prevent sexual violence and any form of coercive/forced/non-consensual sex, prevent early sexual debut, and support for healthy choices.Implement activities to prevent Intimate Partner Violence (IPV), sexual violence, and provide training of HCWs to deliver evidence-based violence prevention and how to respond should participants in GBV prevention activities disclose an experience of violence.\n\n# 7.7.2 GBV Case Identification and First-line Support Recommendations\n\nConduct routine clinical inquiry to actively identify cases of GBV in the following settings:\n\n- Care & Treatment\n- ANC/PMTCT\n- Adolescent friendly services\n- PrEP and PEP services\n- HTS\n\n# 7.7.3 GBV Clinical Response Recommendations\n\nProvide comprehensive and age-appropriate clinical post-GBV care that meets the expressed need of survivors. Clinical care should include the following:\n\n- Providers identify survivors via routine and/or clinical enquiry during ART initiation and routine clinical care.\n- Survivors offered support and provided with or referred to GBV clinical care interventions that help improve the mental health and psychosocial functioning of survivors.\n- Ensure that all sites delivering post-violence clinical care services provide the full minimum package of post-violence care, including:\n- Treatment of injuries\n- Rapid HIV testing and counselling with linkage to treatment as needed\n- STI testing/screening and treatment\n- Post-exposure prophylaxis (PEP)\n- Emergency contraception\n- Counselling (first-line support)\n- Referral to non-clinical GBV response services, such as longer-term psychosocial support, child protection, police, legal aid, shelter, economic empowerment, etc.\n- Improve the quality of post-violence clinical care services in care and treatment sites by strengthening HIV/GBV health systems and service delivery\n\nGBV considerations: Providers only ask about violence in a private setting, ensuring confidentiality, which requires space, thus an audio-visual private room/space should be considered and provided accordingly.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n107\n\n# 7.8 Management of Sexually Transmitted Infections (STIs)\n\nGlobally, STIs / Reproductive Tract Infections (RTIs) remain a very important public health challenge, and with the emergence of the HIV pandemic, it has become imperative for a more coordinated approach to reduce its burden.\n\nA syndromic approach to the management of STIs/RTIs makes treatment accessible and affordable to a majority of the population because trained workers at all levels can use it as this approach does not require the use of sophisticated equipment, but a flow chart of symptoms presented by the patient and signs elicited by the health care provider is used for treatment.", "mimetype": "text/plain", "start_char_idx": 255194, "end_char_idx": 260179, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "72e340aa-8865-485a-8d95-ce8cb86298c9": {"__data__": {"id_": "72e340aa-8865-485a-8d95-ce8cb86298c9", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "05cbce19-bc3f-4963-83d6-1e77bd17790d", "node_type": "1", "metadata": {}, "hash": "4e1cbe5b5e17518c47c2a91133e4482147221336a852a9c00accbf2397b0d46b", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "7aa2b209-d355-4edf-a025-663585c6d543", "node_type": "1", "metadata": {}, "hash": "0f7296fc5a6b3b5b5a1f313380bd0525a8e31480e6c336c3d667b2ac2e137c0e", "class_name": "RelatedNodeInfo"}}, "text": "# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n107\n\n# 7.8 Management of Sexually Transmitted Infections (STIs)\n\nGlobally, STIs / Reproductive Tract Infections (RTIs) remain a very important public health challenge, and with the emergence of the HIV pandemic, it has become imperative for a more coordinated approach to reduce its burden.\n\nA syndromic approach to the management of STIs/RTIs makes treatment accessible and affordable to a majority of the population because trained workers at all levels can use it as this approach does not require the use of sophisticated equipment, but a flow chart of symptoms presented 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 chain of transmission, avoid complications, patient education, partner treatment, provision of condoms, diagnosis and prescription.\n\n# 7.8.1 Objectives of STIs/RTIs management\n\n- To make a correct diagnosis based on appropriate clinical assessment\n- To provide proper antimicrobial therapy, obtain cure, decrease infectivity and avoid complications.\n- To reduce and prevent future high-risk behaviour\n- To treat sexual partners in order to break the transmission chain.\n\n# 7.8.2 Components of syndromic management\n\n- Building the capacity of the health care provider\n- Provision of counselling for STIs/RTIs\n- Identifying /treating all STIs/RTIs syndromes\n- Conducting risk assessment\n- Specific antimicrobial therapy\n- Partner notification\n- Prevention of ophthalmia neonatorum\n- Prevention of mother-to-child transmission of HIV\n- Referral to secondary/tertiary Healthcare levels for further management.\n- Data collection/management\n\n# 7.8.3 Prevention of STIs/RTIs\n\nSexually transmitted infections (STIs) and RTIs can be prevented by the following measures:\n\n- Primary preventive measures: abstinence, faithful sexual relationships, correct and consistent use of condoms and vaccination\n- Secondary preventive measures: encouraging STI care-seeking behaviour, rapid and effective treatment and case finding\n- Tertiary preventive measures: limitation of disability and rehabilitation including psychosocial support\n\nThere is the risk assessment for all patients presenting with symptoms of STIs and anyone who falls into two or more of the categories listed in the assessment is considered to be \u201crisk assessment positive\u201d and is assessed based on the flow charts that fits his/her symptoms. Below are flow charts that describe the steps to be taken in managing a patient with STI using the syndromic approach.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Prevention for Adolescent and Young Persons (AYPs)\n\nAdolescents and young people are persons between 10 and 24 years of age. This age is characterized by rapid physical growth and development as well as sexual maturation. It is a period that can be marked by the need to try out new things such as sex, experiment with injectable drugs as well as other drug types. As a result of engaging in these high-risk behaviours, there has been an upsurge in the prevalence of HIV and other STIs in AYPs. The low social and economic status of most AYPs complicates the situation.\n\nAYPs make up 31% of the entire population of Nigeria. Data from the Nigeria AIDS Control Agency (NACA) put the prevalence of HIV at 4.2% for young people aged 15 to 24. Forty percent of all reported new cases of HIV occur in young persons aged 15 to 24 which is the highest when compared to other age groups.\n\nIn Nigeria, there are social and contextual factors that make AYP vulnerable to HIV infection. Identification of the prevailing sociocultural factors in a particular community and designing interventions to address them is key to success. The drivers of the epidemic pertinent to Nigerian AYP include multiple and concurrent sexual partnerships, intergenerational sex, sexual coercion, low-risk perception, and transactional sex. Married adolescents and young women may also be exposed to increased risk of HIV infections from their husbands. Exacerbating high-risk behaviours are socioeconomic conditions like pervasive gender inequalities and gender-based violence, poverty, unemployment or underemployment, and widespread HIV-related stigma and discrimination. There are also a number of traditional, religious, and cultural factors that increase the risk of HIV infection and other sexual and reproductive health (SRH) morbidities among young women and girls such as child and forced marriage, female genital mutilation, and widow inheritance. In addition, ineffective STI programming, poor integration of HIV and SRH services are other factors.", "mimetype": "text/plain", "start_char_idx": 259453, "end_char_idx": 264188, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "7aa2b209-d355-4edf-a025-663585c6d543": {"__data__": {"id_": "7aa2b209-d355-4edf-a025-663585c6d543", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "72e340aa-8865-485a-8d95-ce8cb86298c9", "node_type": "1", "metadata": {}, "hash": "f5126ccdcd5c8ef9202f6b235224ec9a19d771107674d5818cc90e313d72028b", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "1c8e8c27-a0a7-4d07-aca4-0a372248627a", "node_type": "1", "metadata": {}, "hash": "0f5a0191e887ef54b4461323c4b3cebc43b6109dfa8e03ee47bec0610aa8a562", "class_name": "RelatedNodeInfo"}}, "text": "Identification of the prevailing sociocultural factors in a particular community and designing interventions to address them is key to success. The drivers of the epidemic pertinent to Nigerian AYP include multiple and concurrent sexual partnerships, intergenerational sex, sexual coercion, low-risk perception, and transactional sex. Married adolescents and young women may also be exposed to increased risk of HIV infections from their husbands. Exacerbating high-risk behaviours are socioeconomic conditions like pervasive gender inequalities and gender-based violence, poverty, unemployment or underemployment, and widespread HIV-related stigma and discrimination. There are also a number of traditional, religious, and cultural factors that increase the risk of HIV infection and other sexual and reproductive health (SRH) morbidities among young women and girls such as child and forced marriage, female genital mutilation, and widow inheritance. In addition, ineffective STI programming, poor integration of HIV and SRH services are other factors.\n\nHIV program for AYPs in Nigeria has a goal to reduce new HIV infections and should be delivered as a package of interventions for AYP in line with Minimum Prevention Package Intervention (MPPI).\n\n# Harm Reduction program\n\nHarm Reduction (HR) is a range of public health policies and practices that are designed to lessen the negative psychosocial and/or physical consequences associated with various human behaviours, both legal and illegal. As relates to HIV, drug-related harms include overdose, drug-related deaths, blood-borne infections such as HIV, HCV, HBV and bacteremia/sepsis. HR programming in Nigeria include services such as:\n\n- Needle and syringe programmes (NSPs).\n- Opioid substitution therapy (OST) and other evidence-based drug dependence prevention services\n- Use of own snorting straws and crack pipes\n- Peer interventions to reduce the incidence of viral hepatitis and HIV\n- Use of motivational techniques to increase behavioural change\n- Distribution of condoms and lubricants\n- IEC materials for PWID\n- Testing and management of STI, HIV, HCV, HBV\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Vaccination, diagnosis and treatment of viral hepatitis\n\nPrevention, diagnosis and treatment of other opportunistic infections (including HIV and tuberculosis). If scaled-up, these evidence-based harm reduction-oriented practices are known to reduce transmission of blood-borne illnesses and injection related infections among PLHIV, as well as prevent fatal drug-related overdose and other harm associated with risky behaviours.\n\n# Cervical Cancer Prevention\n\nCervical cancer is preventable and curable if diagnosed and treated early. The most effective strategy available for primary prevention of cervical cancer is the vaccination against the HPV aetiologic agent of cervical cancer. HPV vaccines are indicated for pre-pubertal girls and offer most hope to effectively stop cervical cancer epidemic in Nigeria. HIV positive children can also receive HPV vaccination because available evidence has shown that they develop sufficient immune response.\n\nWomen living with HIV (WLHIV) have a higher risk of pre-cancer and invasive cervical cancer. The risk and persistence of HPV infection increases with low CD4+ cell count and high HIV viral load. Cervical cancer screening leads to early detection of precancerous and cancerous cervical lesions that will prevent serious morbidity and mortality. WLHIV should be screened every three years for evidence of precancerous changes in the cervix, regardless of whether they are taking ART or their CD4+ cell count or viral load. All WLHIV should be screened for cervical cancer regardless of age. Immediate management for precancerous and cancerous lesions should be provided. For further detail, refer to the National Cervical Cancer Prevention and Control Policy.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - Page 110\n\n# List of Contributors\n\nDr Adesigbin Clement\n\nDr Ijaodola Olugbenga\n\nTaiwo Olakunle\n\nZainab E. Abdullahi\n\nDr Adeyinka Adewemimo\n\nDr Benson Udu\n\nMrs. Hidayat Bukola Yahaya\n\nDr Gideon Sorochi Okorie\n\nProf. Oladapo Shittu\n\nProf. Solomon Sagay\n\nProf Anteinette Ofili\n\nProf. Oliver Ezechi\n\nDr Idowu Adebara\n\nDr Stephen B. Bature\n\nDr Chinyere Ukamaka Onubogu\n\nDr Benjamin Aiwondagbon\n\nDr Ochola-Odonga Dorothy\n\nDr Victoria Isiramen\n\nDr Idayat Uthman\n\nDr.", "mimetype": "text/plain", "start_char_idx": 263134, "end_char_idx": 267564, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "1c8e8c27-a0a7-4d07-aca4-0a372248627a": {"__data__": {"id_": "1c8e8c27-a0a7-4d07-aca4-0a372248627a", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "7aa2b209-d355-4edf-a025-663585c6d543", "node_type": "1", "metadata": {}, "hash": "0f7296fc5a6b3b5b5a1f313380bd0525a8e31480e6c336c3d667b2ac2e137c0e", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "7d76622d-c052-4fc8-bea4-39b920d597ea", "node_type": "1", "metadata": {}, "hash": "7f6efc47fb717b8d2c1ec39c26bc1ef74ae57fefea7825d8624271db2fa4a6d4", "class_name": "RelatedNodeInfo"}}, "text": "NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - Page 110\n\n# List of Contributors\n\nDr Adesigbin Clement\n\nDr Ijaodola Olugbenga\n\nTaiwo Olakunle\n\nZainab E. Abdullahi\n\nDr Adeyinka Adewemimo\n\nDr Benson Udu\n\nMrs. Hidayat Bukola Yahaya\n\nDr Gideon Sorochi Okorie\n\nProf. Oladapo Shittu\n\nProf. Solomon Sagay\n\nProf Anteinette Ofili\n\nProf. Oliver Ezechi\n\nDr Idowu Adebara\n\nDr Stephen B. Bature\n\nDr Chinyere Ukamaka Onubogu\n\nDr Benjamin Aiwondagbon\n\nDr Ochola-Odonga Dorothy\n\nDr Victoria Isiramen\n\nDr Idayat Uthman\n\nDr. Efuntoye Adeola Tim\n\nBennett Okechukwu Urama\n\nDr Chris Obanubi\n\nLilian Anomnachi\n\nDr Andrew Etsetsowaghan\n\nDr Omoregie Godpower\n\nDr Amalachukwu Ukaere\n\nHalima Ibrahim\n\nMrs Ehi Adejo-Ogiri\n\nOgochukwu Ginigeme\n\nDr Helen Omuh\n\nRuth Dauda Akolo\n\nChinwe Aganekwu\n\nAbang Roger\n\nMwoltu Nanribet Gabriel\n\nAkanji Michael O\n\n# Chapter 7\n\nDeputy Director, Head of Prevention NASCPAssistant Director, National Officer PMTCT NASCPChief Scientific Officer NASCPPopulation Programme Officer I NASCPSenior Medical Officer I NASCPSASPC, FCTProgramme Officer Health Sector Response Support NACAAssistant Chief program officer/ PMTCT/HTS Focal Officer NACAChairman, PMTCT Task Team / OBY/GYNAE ABUTH ZariaMember PMTCT Task team / OBY/GYNAE JUTH JosPublic Health Physician, UBTH BeninDirector of Research, NIMR LagosConsultant OBY/GYN, FTH Ido EkitiMember PMTCT Task Team / OBY/GYN, BDTH/KASU KadunaPaediatrician, NAUTH, NnewiWHOHealth & HIV Section UNICEFHealth Manager UNICEFNational Program Officer UNAIDSSenior Specialist PMTCT, CDCForecasting and Supply Planning Advisor GHSC-PSMProgramme Manager USAIDDeputy Program Director CHAITechnical Director FHI360Head/Practice Lead, HIV and TB SFHProgram Director SFHProgram Manager SFHGender Officer/POC JHPIEGOICAPDeputy Director IHVNWelfare - Deputy ASWHANCoordinator, FGI CISHANDirector of Programs Heartland AllianceMental Health Technical Advisor Heartland AllianceKey Populations Advisor Heartland Alliance\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020  111\n\n# 8. ADVANCED HIV DISEASE, OPPORTUNISTIC INFECTIONS, AND CO-MORBIDITIES\n\n|What\u2019s Inside:| |\n|---|---|\n|8.1 Advanced HIV Disease|113|\n|8.2 Other Opportunistic Infections (OIs)|126|\n|8.3 Preventing Opportunistic Infections (OIs)|126|\n|8.4 HIV-Related Co-Morbidities|146|\n|8.5 Mental Health and HIV|146|\n\n# 8.1 Advanced HIV Disease\n\n# 8.1.1 Introduction\n\nThe morbidity and mortality associated with HIV infection have decreased over the past decade as access to ART has increased. Worldwide, AIDS-related deaths rose to 1.7 million in 2004 but have been on a steady decline to 770,000 as at 2018 [6]. In Nigeria, there were 94,000 AIDS death in 2003, but declined to 53,000 in 2018 [6]. Notwithstanding this progress, the decline in AIDS-related deaths appears to have plateaued in recent years. This is largely due to the persistent challenge of Advanced HIV Disease (AHD) [8]. Globally, the proportion of people presenting with AHD has remained largely unchanged during the past five years although the number of people receiving ART in low- and middle-income countries (LMIC) has more than doubled over this period. Recent estimates suggest that about 30\u201340% of people living with HIV starting ART in LMIC have a CD4+ cell count of < 200 cells/mm and 20% have a CD4+ cell count <1003 cells/mm [9]. In some settings, up to 50% of people present to care with advanced HIV disease [9].", "mimetype": "text/plain", "start_char_idx": 267041, "end_char_idx": 270460, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "7d76622d-c052-4fc8-bea4-39b920d597ea": {"__data__": {"id_": "7d76622d-c052-4fc8-bea4-39b920d597ea", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "1c8e8c27-a0a7-4d07-aca4-0a372248627a", "node_type": "1", "metadata": {}, "hash": "0f5a0191e887ef54b4461323c4b3cebc43b6109dfa8e03ee47bec0610aa8a562", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "74aa6c80-4fa6-4e5a-ab61-5459f39e9521", "node_type": "1", "metadata": {}, "hash": "35d4e6eb8f2a49e3b6dab8cb415960ee3a362af9d9b53661b7e99e35f4a2cf6e", "class_name": "RelatedNodeInfo"}}, "text": "In Nigeria, there were 94,000 AIDS death in 2003, but declined to 53,000 in 2018 [6]. Notwithstanding this progress, the decline in AIDS-related deaths appears to have plateaued in recent years. This is largely due to the persistent challenge of Advanced HIV Disease (AHD) [8]. Globally, the proportion of people presenting with AHD has remained largely unchanged during the past five years although the number of people receiving ART in low- and middle-income countries (LMIC) has more than doubled over this period. Recent estimates suggest that about 30\u201340% of people living with HIV starting ART in LMIC have a CD4+ cell count of < 200 cells/mm and 20% have a CD4+ cell count <1003 cells/mm [9]. In some settings, up to 50% of people present to care with advanced HIV disease [9]. In Nigeria, 32% of patients that commenced ART in 2018 presented with advanced HIV disease [9]. Similarly, data from six high volume ART sites in the country suggests that the burden of AHD ranges from 16% - 50% [11].\n\nHIV infects the CD4+ cells leading to their destruction. The resultant immunosuppression predisposes the individual to severe opportunistic infections. These opportunistic infections include Tuberculosis, Cryptococcal meningitis, Oro-esophageal candidiasis, Toxoplasmosis, Pneumocystis jiroveci pneumonia, histoplasmosis and septicemia [9]. Nigeria has the first and sixth highest TB burden in Africa and globally respectively [4]. Cryptococcus and Histoplasmosis, initially thought not to be prevalent, are now becoming increasingly endemic in Nigeria with more than 25,000 cases of Cryptococcus reported annually [9] and about 124 cases of Histoplasmosis also reported in Nigeria. These infections account for significant morbidity and mortality in the AHD population. Thus, the Nigerian government is committed to focusing efforts to ensure that those infected with HIV achieve virological suppression, minimize the risk of HIV transmission, prevent and treat co-morbidities, improve survival rate and ultimately move Nigeria closer to ending the HIV epidemic.\n\nDifferentiated service delivery (DSD) is an approach that simplifies and adapts HIV services to better serve the needs of PLHIV and reduce unnecessary burdens on the health system. Under a DSD approach, people who are stable on treatment would have a reduced frequency of clinical consultations and drug refills three monthly and in exceptional circumstances six monthly. This allows health service resources to focus on care for patients who are ill and need intensive clinical follow-up. Management of AHD is one of the DSD models which the country has now adopted to control the HIV epidemic.\n\nThe 2017 WHO guidelines on the management of AHD recommend a package of care for screening, prophylaxis, rapid ART initiation and intensified adherence interventions. These are offered to everyone living with HIV presenting with advanced disease. The guidelines include an algorithm to support decision making for providing care for people with AHD. Even though the 2016 Nigeria treatment guidelines also highlighted the need to provide a differentiated package of care for OIs, the entity AHD was not clearly defined.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020113\n\n# Definition of advanced HIV disease\n\nWHO defines AHD in adults, adolescents and children older than five years as CD4+ cell count <200cells/mm or WHO stage 3 or 4 event. All children younger than five years of age with HIV are considered as having AHD. The appearance of OIs is directly related to the extent of immune deficiency; the lower the CD4+ cell count, the higher the likelihood of the appearance of OIs [12]. The common OIs associated with AHD include the following:\n\n|Tuberculosis|Tuberculosis is the leading cause of morbidity and mortality among PLHIV, accounting for one-third of the estimated 1.1 million people dying from AIDS-related causes globally in 2015 [9]. Most of these TB-associated deaths (200,000 cases) occurred among men [9]. TB also remains a leading cause of HIV-associated hospitalization among adults and children living with HIV worldwide. In 2017, the number of AIDS-related deaths reported in Nigeria was 51,000, and 35,000 (68%) were associated with TB [6]. Furthermore, 11% (12,521) out of the diagnosed 120,266 TB cases in Nigeria in 2019 were co-infected with HIV [13].", "mimetype": "text/plain", "start_char_idx": 269676, "end_char_idx": 274039, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "74aa6c80-4fa6-4e5a-ab61-5459f39e9521": {"__data__": {"id_": "74aa6c80-4fa6-4e5a-ab61-5459f39e9521", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "7d76622d-c052-4fc8-bea4-39b920d597ea", "node_type": "1", "metadata": {}, "hash": "7f6efc47fb717b8d2c1ec39c26bc1ef74ae57fefea7825d8624271db2fa4a6d4", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "9a62be8c-002e-423c-ad65-b85bad865c4f", "node_type": "1", "metadata": {}, "hash": "f6f0fab8d73afa547bec01453d9ad1022b0ff2af1fb0fd9611ca6feb5b90f1bc", "class_name": "RelatedNodeInfo"}}, "text": "The common OIs associated with AHD include the following:\n\n|Tuberculosis|Tuberculosis is the leading cause of morbidity and mortality among PLHIV, accounting for one-third of the estimated 1.1 million people dying from AIDS-related causes globally in 2015 [9]. Most of these TB-associated deaths (200,000 cases) occurred among men [9]. TB also remains a leading cause of HIV-associated hospitalization among adults and children living with HIV worldwide. In 2017, the number of AIDS-related deaths reported in Nigeria was 51,000, and 35,000 (68%) were associated with TB [6]. Furthermore, 11% (12,521) out of the diagnosed 120,266 TB cases in Nigeria in 2019 were co-infected with HIV [13]. Factors responsible for the persistent high burden of TB among PLHIV include low ART coverage, low uptake of Tuberculosis Preventive Therapy (TPT) and sub-optimal diagnosis of active TB.|\n|---|---|\n|Cryptococcal meningitis|The incidence of cryptococcal meningitis remains substantial despite the scale-up of ART [9]. A recent review estimated that there were 223,100 incident cryptococcal meningitis cases globally in 2014, with 73% of the cases occurring in sub-Saharan Africa; the annual global deaths from cryptococcal meningitis were estimated to be 181,100. Cryptococcal meningitis is a leading cause of mortality among hospitalized adults living with HIV, accounting for 15\u201320% of adult deaths but is less common among children living with HIV [14]. An average global cryptococcal antigenemia of 6% is reported among people with CD4+ cell count of < 100 cells/mm [14]. In Nigeria, there is an estimated 25,000 cases of Cryptococcosis annually [9]. Several studies from Nigeria have revealed rates of 2% 12.9% of Cryptococcus with geographical variations [15]. An earlier study on cryptococcal meningitis revealed a 36% hospital-based frequency amongst patients presenting with neurological symptoms at Jos University Teaching Hospital [16]. The 2018 WHO guidelines on the diagnosis, prevention and treatment of cryptococcal disease among adults, adolescents and children summarizes the recommendations for the prevention, diagnosis and treatment of cryptococcal meningitis. Pre-emptive therapy for cryptococcal antigen-positive asymptomatic people is a key strategy to prevent cryptococcal meningitis.|\n|Toxoplasmosis|Cerebral toxoplasmosis is the most frequent cause of meningo-encephalitis among adults living with HIV not receiving co-trimoxazole. Toxoplasmosis is a common protozoan infection among people with HIV. The prevalence of co-infection is especially high in sub-Saharan Africa (45%), Latin America, the Caribbean (49%), North Africa and the Middle East (61%) [9]. People with latent toxoplasmosis infection are at risk of developing cerebral toxoplasmosis when their CD4+ cell count <200 cells/mm . About 15% of hospitalized adults living with HIV died from AIDS-related illnesses were associated with cerebral toxoplasmosis [9]. The diagnosis of cerebral toxoplasmosis requires imaging techniques, such as computed tomography scans. In 2005, a study from JUTH revealed 32% prevalence of Toxoplasmosis among|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - 114\n\n# Components of AHD package of care\n\n1. Diagnostics for AHD and associated OIs2. Prophylaxis against associated OIs with AHD3. Pre-emptive treatment for OIs associated with AHD4. Treatment of confirmed OIs associated with AHD5. ART initiation in the setting of AHD6. Intensive adherence counselling and monitoring7. Vaccination\n\n# Diagnostics for AHD and associated OIs\n\nThese include CD4+ cell count test required to diagnose AHD and specific tests to diagnose the country defined AHD associated OIs.\n\n# Role of CD4+ cell count testing in the diagnosis of AHD\n\nThe 2016 National treatment guidelines recommended starting ART regardless of CD4+ cell count and that it should be done at baseline and every six months in addition to routine VL\n\n# monitoring\n\nRelying on clinical staging alone risks missing substantial numbers of PLHIV with severe immunosuppression [24]. In a study from Zimbabwe, Uganda, Kenya and Malawi, close to half the people with CD4+ cell count <100 cells/mm were classified as having WHO clinical stage 1 or 2 disease [24].", "mimetype": "text/plain", "start_char_idx": 273349, "end_char_idx": 277588, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "9a62be8c-002e-423c-ad65-b85bad865c4f": {"__data__": {"id_": "9a62be8c-002e-423c-ad65-b85bad865c4f", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "74aa6c80-4fa6-4e5a-ab61-5459f39e9521", "node_type": "1", "metadata": {}, "hash": "35d4e6eb8f2a49e3b6dab8cb415960ee3a362af9d9b53661b7e99e35f4a2cf6e", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "4a14b673-b704-4c53-bf82-86a2a9d82b04", "node_type": "1", "metadata": {}, "hash": "7e5f14d71fd8a4aaa8c9252d892a9376874889d3dc2c406bf08aed399ae4def9", "class_name": "RelatedNodeInfo"}}, "text": "Treatment of confirmed OIs associated with AHD5. ART initiation in the setting of AHD6. Intensive adherence counselling and monitoring7. Vaccination\n\n# Diagnostics for AHD and associated OIs\n\nThese include CD4+ cell count test required to diagnose AHD and specific tests to diagnose the country defined AHD associated OIs.\n\n# Role of CD4+ cell count testing in the diagnosis of AHD\n\nThe 2016 National treatment guidelines recommended starting ART regardless of CD4+ cell count and that it should be done at baseline and every six months in addition to routine VL\n\n# monitoring\n\nRelying on clinical staging alone risks missing substantial numbers of PLHIV with severe immunosuppression [24]. In a study from Zimbabwe, Uganda, Kenya and Malawi, close to half the people with CD4+ cell count <100 cells/mm were classified as having WHO clinical stage 1 or 2 disease [24]. A five year (2005-2010) retrospective cohort study involving over 14,000 patients revealed that 63% of PLHIV presented with AHD in Nigeria [25]. Despite the implementation of the 'test and treat' strategy, data from the national treatment program revealed that 32% of PLHIV presented with AHD in 2018. Consequently, it is imperative that all newly diagnosed PLHIV and those returning to care should have a baseline CD4+ cell count and same-day results obtained.\n\n**Table 8.1: Diagnostics for associated opportunistic infections in AHD**\n|Associated OIs|Screening & diagnosis|Required Sample|CD4+ Cell Count|\n|---|---|---|---|\n|Tuberculosis|Xpert MTB/RIF assay as the first test for TB diagnosis in symptomatic patients|Sputum|Any|\n| |AFB, Xpert MTB/RIF assay|Sputum/non-sputum (stool, CSF and Cold Abscess)| |\n|Adults & Adolescents|Yes|Yes| |\n| |LF-LAM|Urine|Urine LF-LAM assay for patients with CD4+ cell count <200 cells/mm3|\n|Cryptococcosis|Cryptococcal antigen (CrAg) screening|Serum, plasma or whole blood|<200 cells/mm3|\n|Histoplasmosis|Histoplasma urinary antigen screening|Urine|<200 cells/mm3|\n|Pneumocystis jiroveci pneumonia (PJP)|Giemsa stain, Grocott Methenamine Silver stain|Bronchial aspirate|<200 cells/mm3|\n\nAdapted from WHO advanced HIV disease package of care 2018\n\n* Limited data available for children\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n116\n\n# Table 8.2: Prophylaxis for AHD associated OIs\n\n|Disease|Prophylactic Intervention|Pre-emptive Treatment|Criteria for Prophylaxis & Pre-emptive Treatment|Target Population|\n|---|---|---|---|---|\n|Tuberculosis|Yes (TPT)|No|Any CD4+ cell count value.|Adult and children|\n|Pneumocystis jiroveci pneumonia (PJP)|Yes (CPT)|No|CD4+ cell count \u2264500 cells/mm or WHO3 clinical stage 3 or 4 event. Any CD4+ cell count value in settings with high prevalence of malaria and/or severe bacterial infections|Adult and children|\n|Cryptococcal Meningitis|No|Yes (Fluconazole pre-emptive therapy for CrAg positive patients without evidence of meningitis)|AHD|Adult and adolescent|\n\n# 8.1.5 Management of opportunistic infections in AHD\n\n# 8.1.5.1 Tuberculosis\n\nDiagnosis\n\n- Xpert MTB/RIF assay and TB-LF LAM are the recommended diagnostic tests for PLHIV presenting with AHD\n- Where the above tests are not available, AFB microscopy can be used, or representative samples referred to sites where Xpert MTB/RIF assay or TB-LF LAM is available\n\nWHO strongly recommends the use of LF-LAM to assist in diagnosing active TB among children and Adolescent living with HIV,\n\n- with signs and symptoms of TB (pulmonary and/or extrapulmonary)\n- with advanced HIV disease or who are seriously ill, regardless of signs and symptoms of TB and with a CD4+ count <200 cells/ mm\n\nProphylaxis & Treatment\n\n- Manage as in the national TB guidelines.", "mimetype": "text/plain", "start_char_idx": 276720, "end_char_idx": 280398, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "4a14b673-b704-4c53-bf82-86a2a9d82b04": {"__data__": {"id_": "4a14b673-b704-4c53-bf82-86a2a9d82b04", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "9a62be8c-002e-423c-ad65-b85bad865c4f", "node_type": "1", "metadata": {}, "hash": "f6f0fab8d73afa547bec01453d9ad1022b0ff2af1fb0fd9611ca6feb5b90f1bc", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "bc9e66bf-23a6-47c7-9920-d18d7903002f", "node_type": "1", "metadata": {}, "hash": "deafc158dfa6cc58a3f4ec848f5f21fa0a14e92395bd4078e03279f4ed9f8378", "class_name": "RelatedNodeInfo"}}, "text": "ART Initiation\n\n- Immediate ART initiation is not recommended for adults, adolescents and children living with HIV who have TB, because of the risk of increased mortality and should be deferred by 2 weeks (if CD4+ cell count is < 50), or 4 weeks (if CD4+ cell count is > 503 cells/mm ) after the initiation of anti-TB drugs.\n\n# 8.1.5.2 Cryptococcal Meningitis\n\nDiagnosis\n\nFor adults, adolescents and children living with HIV suspected of having a first episode of cryptococcal meningitis, prompt lumbar puncture with measurement of cerebrospinal fluid (CSF) opening pressure and rapid cryptococcal antigen assay is recommended as the preferred diagnostic approach.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 117\n\n# The following diagnostic approaches are recommended, according to the context:\n\n|a.|In settings with ready access to and no contraindication for lumbar puncture:|\n|---|---|\n|i.|If both access to a cryptococcal antigen assay (either lateral flow assay or latex agglutination assay) and rapid results (<24 hours) are available, proceed with Lumbar puncture (LP) for a rapid CSF cryptococcal antigen assay as the preferred diagnostic approach|\n|ii.|If access to a cryptococcal antigen assay is not available and/or rapid results are not available, proceed with LP with CSF India ink test as the preferred diagnostic approach|\n| |In settings without immediate access to LP or when LP is clinically contraindicated:|\n|b.| |\n|i.|If both access to a cryptococcal antigen assay and rapid results are available within < 24 hours, proceed with rapid serum, plasma or whole-blood cryptococcal antigen assays as the preferred diagnostic approaches|\n|ii.|If a cryptococcal antigen assay is not available and/or rapid access to results is not ensured, prompt referral for further investigation and treatment is required|\n\n# Prophylaxis\n\nScreening for cryptococcal antigen followed by pre-emptive antifungal therapy among cryptococcal antigen-positive people to prevent the development of invasive cryptococcal disease is recommended before initiating or reinitiating ART for adults and adolescents living with HIV who have a CD4+ cell count < 200 cells/mm\u00b3.\n\nFluconazole 800 mg/day for two weeks, then 400 mg/day for eight weeks and continued maintenance with fluconazole 200 mg/day is recommended for pre-emptive antifungal therapy. When cryptococcal antigen screening is not available, fluconazole primary prophylaxis should be given to adults and adolescents living with HIV who have a CD4+ cell count < 200 cells/mm\u00b3. Fluconazole 100mg daily for 8 weeks is recommended. Screening and primary prophylaxis are not recommended for children, given the low incidence of cryptococcal meningitis in this age group.\n\n# Induction\n\nThe following is recommended as the preferred induction regimen: For adults, adolescents and children, a short-course (one-week) induction regimen with liposomal amphotericin B (3.0 mg/kg/day) and flucytosine (100 mg/kg/day, divided into four doses per day), followed by 1 week of fluconazole (1200mg/day for adults, 12 mg/kg/day for children and adolescents, up to a maximum dose of 800mg daily)\n\nThe following induction regimens are recommended as alternative options depending on drug availability:\n\nContraindications include significant coagulopathy or suspected space-occupying lesion based on focal nervous system signs (excluding cranial nerve VI palsy) or recurrent seizures and, where possible, confirmed by computed tomography. Raised intracranial pressure does not contraindicate LP in (suspected) cryptococcal meningitis. Other contraindications include major spinal deformity and patient refusal despite adequate counselling.\n\nGood practice principle: All PLHIV with a positive cryptococcal antigen result on screening should be carefully evaluated for signs and symptoms of meningitis and undergo an LP if feasible with CSF examination and cryptococcal antigen assay (or India ink if cryptococcal antigen assay is not available) to exclude active cryptococcal disease.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\nTwo weeks of fluconazole (1200 mg daily for adults, 12 mg/kg/day for children and adolescents) + flucytosine (100 mg/kg/day, divided into four doses per day)\n\nTwo weeks of amphotericin B deoxycholate (1.0 mg/kg/day) + fluconazole (1200 mg daily for adults, 12 mg/kg/day for children and adolescents up to a maximum of 800 mg daily).", "mimetype": "text/plain", "start_char_idx": 280400, "end_char_idx": 284828, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "bc9e66bf-23a6-47c7-9920-d18d7903002f": {"__data__": {"id_": "bc9e66bf-23a6-47c7-9920-d18d7903002f", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "4a14b673-b704-4c53-bf82-86a2a9d82b04", "node_type": "1", "metadata": {}, "hash": "7e5f14d71fd8a4aaa8c9252d892a9376874889d3dc2c406bf08aed399ae4def9", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "78c000b2-808a-46fc-8390-486722342cf7", "node_type": "1", "metadata": {}, "hash": "74821bff6822ed1aa1bc7101e1c85293976f9cfddc763d93ce542f24c41fa1a7", "class_name": "RelatedNodeInfo"}}, "text": "Other contraindications include major spinal deformity and patient refusal despite adequate counselling.\n\nGood practice principle: All PLHIV with a positive cryptococcal antigen result on screening should be carefully evaluated for signs and symptoms of meningitis and undergo an LP if feasible with CSF examination and cryptococcal antigen assay (or India ink if cryptococcal antigen assay is not available) to exclude active cryptococcal disease.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\nTwo weeks of fluconazole (1200 mg daily for adults, 12 mg/kg/day for children and adolescents) + flucytosine (100 mg/kg/day, divided into four doses per day)\n\nTwo weeks of amphotericin B deoxycholate (1.0 mg/kg/day) + fluconazole (1200 mg daily for adults, 12 mg/kg/day for children and adolescents up to a maximum of 800 mg daily).\n\n# Consolidation\n\nFluconazole (800 mg daily for adults, 6\u201312 mg/kg/day for children and adolescents up to a maximum of 800 mg daily) is recommended for the consolidation phase (for eight weeks following the induction phase)\n\n# Maintenance\n\nFluconazole (200 mg daily for adults, 6mg/kg/day for adolescents and children) is recommended for the maintenance phase\n\nDiscontinuation of maintenance therapy should be done when the patient is stable on and adherent to ART and has had antifungal maintenance treatment for at least one year and has a CD4+ cell count \u2265200 cells/mm and a fully suppressed VL\n\n# Therapeutic Lumbar Puncture\n\nUsing drugs (mannitol, acetazolamide, furosemide or steroids) for managing raised intracranial pressure is not being recommended because there is no evidence that these drugs improve outcomes in managing cryptococcal meningitis\u2013associated raised intracranial pressure; and available evidence suggests their utilization may be harmful\n\nInitial measurement of intracranial pressure and management of raised intracranial pressure is an essential part of cryptococcal meningitis management to prevent death and serious nervous system complications\n\nReduction of raised CSF pressure is associated with clinical improvement and survival benefit, regardless of initial opening pressure. Conversely, failure to reduce CSF pressure is associated with poor nervous system outcome and increased mortality\n\nPressure should be relieved by draining a volume sufficient to reduce the CSF pressure to < 20cm H20 or halving the baseline pressure if extremely high\n\nFor people with initial intracranial pressure of 20cmH 0 or more or subsequent development or recurrence of symptoms or signs of raised intracranial pressure, repeat therapeutic LP should be carried out\n\n# ART Initiation\n\nImmediate ART initiation is not recommended for PLHIV who have cryptococcal meningitis because of the risk of increased mortality and should be deferred by 4\u20136 weeks from the initiation of antifungal treatment.\n\nNote: A minimum package of pre-emptive hydration, electrolyte replacement, toxicity monitoring and management should be provided to minimize toxicity related to amphotericin B and flucytosine.\n\nEnsure manometers are available\n\n# 8.1.5.3 Oro-oesophagal candidiasis\n\nDiagnosis\n\n- Clinically diagnosed by retrosternal chest pain (heartburn), pain or discomfort on swallowing and features of candidiasis (pseudo membranous, erythematous lesions and angular cheilitis) in the mouth or throat\n- Laboratory: Wet mount microscopy using KOH preparation\n- Endoscopy should be conducted for the patient if no response to antifungal therapy and collect a representative sample for testing.\n\nTreatment\n\nAdult:\n\n- Fluconazole \u2013 oral 200mg on day 1, then 100 mg daily; doses up to 400 mg/day may be used based on patient's response. Treat for a minimum of 3 weeks and at least 2 weeks after resolution of symptoms\n- or\n- Itraconazole \u2013 oral 200mg daily for at least 2 weeks after resolution of symptoms\n- or\n- Oral Nystatin 400,000 \u2013 600,000 IU qds for at least 2 weeks after resolution of symptoms\n\nPaediatric:\n\n- Fluconazole \u2013 oral, 6mg/kg stat on day 1, then 3mg/kg/day for 14-21 days.", "mimetype": "text/plain", "start_char_idx": 283982, "end_char_idx": 288014, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "78c000b2-808a-46fc-8390-486722342cf7": {"__data__": {"id_": "78c000b2-808a-46fc-8390-486722342cf7", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "bc9e66bf-23a6-47c7-9920-d18d7903002f", "node_type": "1", "metadata": {}, "hash": "deafc158dfa6cc58a3f4ec848f5f21fa0a14e92395bd4078e03279f4ed9f8378", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "abef2aa6-0090-461e-982c-e8880353d9f8", "node_type": "1", "metadata": {}, "hash": "552f44bb44dd710930a1609d29174c19fe3bc834b7fc361482809fa539c45403", "class_name": "RelatedNodeInfo"}}, "text": "Treatment\n\nAdult:\n\n- Fluconazole \u2013 oral 200mg on day 1, then 100 mg daily; doses up to 400 mg/day may be used based on patient's response. Treat for a minimum of 3 weeks and at least 2 weeks after resolution of symptoms\n- or\n- Itraconazole \u2013 oral 200mg daily for at least 2 weeks after resolution of symptoms\n- or\n- Oral Nystatin 400,000 \u2013 600,000 IU qds for at least 2 weeks after resolution of symptoms\n\nPaediatric:\n\n- Fluconazole \u2013 oral, 6mg/kg stat on day 1, then 3mg/kg/day for 14-21 days.\n- or\n- Oral Nystatin 100,000 \u2013 200,000 IU qds for at least 2 weeks after resolution of symptoms\n\n# 8.1.5.4 Toxoplasmosis\n\nDiagnosis\n\n- Symptoms include fever, reduced alertness, headache, focal neurological deficits, seizures, chorio-retinitis\n- The following diagnostic tool can be used on CSF sample: Dye test, indirect fluorescent antibody test (IFA), enzyme immunoassays (ELISA, immunoblots), agglutination test, avidity test\n\nProphylaxis\n\n- Cotrimoxazole until CD4+ cell levels increase to more than 200 cell/mm for more than 3 months\n- Alternatively, dapsone \u2013 pyrimethamine plus leucovorin\n\nTreatment\n\n- Pyrimethamine 100mg stat and 50mg daily with folinic acid 10-25mg daily plus clindamycin 300mg given qds for 6 weeks followed by life-long suppressive therapy until full immunological recovery.\n- or\n- Cotrimoxazole (Trimethoprim 10mg/kg/day + Sulphamethoxazole 50mg/kg/day) for 4 weeks if there is clinical and radiological improvement. Longer therapy may be necessary if a response is incomplete at 6 weeks\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 8.1.5.5 Pneumocystis jiroveci pneumonia (PJP)\n\nDiagnosis\n\n- Acute/sub-acute nonproductive cough with difficulty in breathing. Oxygen saturation of &lt;92% at rest on room air\n- Sample types: bronchoalveolar lavage (BAL), induced and expectorated sputum, nasopharyngeal aspirates and oral washing\n- Giemsa stain or GMS stain can be used for identification\n\nProphylaxis\n\n- Cotrimoxazole in adult and children (Children 6-8mg/kg/day PO, Adults 960mg daily)\n- Alternatively, Dapsone (100mg daily) or Dapsone plus pyrimethamine (50mg) plus folinic acid 10mg weekly can be used.\n\nTreatment\n\n- For Moderate to severe PJP: IV Cotrimoxazole (TMP 15\u2013 20 mg and SMX 75\u2013 100 mg) / kg/ day given qds or tds (switch to PO after clinical improvement for 21 days).", "mimetype": "text/plain", "start_char_idx": 287520, "end_char_idx": 289849, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "abef2aa6-0090-461e-982c-e8880353d9f8": {"__data__": {"id_": "abef2aa6-0090-461e-982c-e8880353d9f8", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "78c000b2-808a-46fc-8390-486722342cf7", "node_type": "1", "metadata": {}, "hash": "74821bff6822ed1aa1bc7101e1c85293976f9cfddc763d93ce542f24c41fa1a7", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "a0ea8a83-92f2-421f-b583-e5d04834c259", "node_type": "1", "metadata": {}, "hash": "b05e72bfb93cb1bfa49e391fd763591596275ce91ab17bb15cfb3d16faf56aad", "class_name": "RelatedNodeInfo"}}, "text": "Oxygen saturation of &lt;92% at rest on room air\n- Sample types: bronchoalveolar lavage (BAL), induced and expectorated sputum, nasopharyngeal aspirates and oral washing\n- Giemsa stain or GMS stain can be used for identification\n\nProphylaxis\n\n- Cotrimoxazole in adult and children (Children 6-8mg/kg/day PO, Adults 960mg daily)\n- Alternatively, Dapsone (100mg daily) or Dapsone plus pyrimethamine (50mg) plus folinic acid 10mg weekly can be used.\n\nTreatment\n\n- For Moderate to severe PJP: IV Cotrimoxazole (TMP 15\u2013 20 mg and SMX 75\u2013 100 mg) / kg/ day given qds or tds (switch to PO after clinical improvement for 21 days).\n- For Mild PJP: Cotrimoxazole: (TMP 15\u2013 20 mg/ kg/ day and SMX 75\u2013 100 mg/ kg/ day), given PO in 3 divided doses for 21 days\n\nAlternative\n\n- Moderate to Severe PJP: Primaquine 30 mg (base) PO once daily + clindamycin [IV 600 qds or 900 mg tds] or [PO 300 mg q6h or 450 mg q8h], Or Pentamidine 4 mg/ kg IV once daily infused over at least 60 minutes, may reduce the dose to 3mg/kg IV once daily because of toxicities\n- For Mild PJP: Dapsone 100 mg PO daily + TMP 15 mg/kg/day PO (3 divided doses), OR Primaquine 30 mg (base) PO daily + clindamycin PO (300 mg q6h or 450 mg q8h)\n\n# 8.1.5.6 Histoplasmosis\n\nDiagnosis\n\n- Symptoms are non-specific mimicking TB (pulmonary or extrapulmonary)\n- Histoplasma urinary antigen screening\n- Tissue diagnosis will require histology of representative sample\n\nTreatment\n\n- Liposomal amphotericin B (3.0 \u2013 5.0 mg/kg daily intravenously for 1 -2 weeks) followed by itraconazole (200mg 3 times daily for 3 days and then 200mg twice daily, for a total of 12 weeks) is the preferred therapy for disseminated Histoplasmosis\n- For mild to moderate disease, itraconazole (200mg 3 times daily for 3 days and then twice daily for at least 12 months is recommended).\n\n# 8.1.6 ART Initiation and Intensive Adherence Support for Patients with AHD\n\nThese Guidelines recommend that;\n\n- People who have no clinical signs and symptoms of TB or other OIs and whose CrAg test is negative should initiate ART the same day in combination with their package of prophylaxis outlined above.\n- In settings where CrAg testing is not available; ART should be initiated, and fluconazole prophylaxis may be considered for people with AHD and be monitored with CD4+ cell count test until immunological recovery is achieved.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n121\n\n# 8.1.6.1 Intensive Follow-Up for Patients with AHD\n\nPeople with AHD require closer follow-up during the initial period of receiving ART to monitor the response to ART and to identify signs and symptoms of possible IRIS. The guidelines recommend that:\n\n- Weekly telephone calls or home visits be provided during the first month on ART.\n- Intensive follow-up may be required after discharge for AHD.\n- People missing appointments should also be actively tracked by phone or through home visits.\n- Where face-to-face contact is not feasible; distance contact through telephone consultation, mHealth, text messaging or other mobile interventions, or visits through a community health worker or home-based caregiver should be considered, with the consent of the client.\n\n# 8.1.6.2 Initiating ART in Patients with AHD\n\nPeople presenting for the first time or those returning to care should undergo history and clinical examination to evaluate for significant OIs (such as signs and symptoms of TB and signs and symptoms suggesting meningitis) before rapid ART initiation is offered. Baseline CD4+ cell count testing should be performed to determine whether the patient has AHD before initiating on ART.\n\nPeople who have no clinical signs and symptoms of TB or other OIs and whose cryptococcal antigen test is negative may initiate ART the same day in combination with their package of prophylaxis outlined in Chapter 3.", "mimetype": "text/plain", "start_char_idx": 289227, "end_char_idx": 293062, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "a0ea8a83-92f2-421f-b583-e5d04834c259": {"__data__": {"id_": "a0ea8a83-92f2-421f-b583-e5d04834c259", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "abef2aa6-0090-461e-982c-e8880353d9f8", "node_type": "1", "metadata": {}, "hash": "552f44bb44dd710930a1609d29174c19fe3bc834b7fc361482809fa539c45403", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "eeb1cdda-7b65-47d1-b142-5d532ac85cab", "node_type": "1", "metadata": {}, "hash": "7c5c66ed9f9c53114d772f4fc55bdd52b93e6b6f3168ab4c9bf82746348c2e13", "class_name": "RelatedNodeInfo"}}, "text": "- People missing appointments should also be actively tracked by phone or through home visits.\n- Where face-to-face contact is not feasible; distance contact through telephone consultation, mHealth, text messaging or other mobile interventions, or visits through a community health worker or home-based caregiver should be considered, with the consent of the client.\n\n# 8.1.6.2 Initiating ART in Patients with AHD\n\nPeople presenting for the first time or those returning to care should undergo history and clinical examination to evaluate for significant OIs (such as signs and symptoms of TB and signs and symptoms suggesting meningitis) before rapid ART initiation is offered. Baseline CD4+ cell count testing should be performed to determine whether the patient has AHD before initiating on ART.\n\nPeople who have no clinical signs and symptoms of TB or other OIs and whose cryptococcal antigen test is negative may initiate ART the same day in combination with their package of prophylaxis outlined in Chapter 3. For people with CD4+ cell count <100 cells/mm in settings where cryptococcal antigen testing result is not available on the same day, consideration could be given to starting fluconazole prophylaxis and discontinuing if a cryptococcal antigen screening result is negative.\n\n|Package|Intervention|CD4+ cell count|Adults and adolescents|Children|\n|---|---|---|---|---|\n|ART initiation|Rapid ART initiation|Any|Yes|Yes|\n| |Defer ART initiation if clinical signs and symptoms are suggestive of TB or cryptococcal meningitis|Any|Yes|Yes|\n|Intensive adherence support|Tailored counselling to ensure optimal adherence to advance disease care package, including home visits if feasible.|&lt; 200 cells/mm3|Yes|Yes|\n\n# 8.1.7 Vaccination for People with AHD\n\nProviding vaccinations to PLHIV does not appear to accelerate HIV disease progression and is recommended as an important part of the HIV care package. However, people with severe immunosuppression may be at higher risk of complications from some live attenuated vaccines, and the response to other inactivated vaccines may be less effective because of the degree of immunosuppression. Additional doses or revaccination after immune reconstitution on ART may therefore be required.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 122\n\n# Human papillomavirus:\n\nDue to increased risk of cervical cancer, vaccine schedule for HPV as recommended by National Cervical Cancer Prevention and Control Policy\n\n- A three-dose schedule (0, 1\u20132 and 6 months) should be used if HPV vaccination is initiated between the ages of 9 to 13 years and up to 26 years if not sexually exposed\n\n# Measles:\n\n- Children and adults with HIV infection are at increased risk of measles. However, live vaccine should not be used for those with severe immunosuppression (CD4+3 cell count &lt;50 cells/mm )\n- Vaccination should be routinely administered to potentially susceptible, asymptomatic children and adults living with HIV and should be considered for those with symptomatic HIV infection if they are not severely immunosuppressed\n\n# Meningococcal vaccination:\n\n- Meningococcal vaccination should be offered to everyone with immunodeficiency, including those patients with AHD\n\n# Polio vaccine:\n\nPolio vaccine is live attenuated and its use in patients with AHD should be in line with WHO recommendation as indicated below.\n\n- Inactivated polio vaccine or bivalent OPV may be administered safely to asymptomatic infants living with HIV. HIV testing is not a prerequisite for vaccination.\n- Bivalent OPV is contraindicated among severely immunocompromised people with known underlying conditions such as primary immunodeficiencies, thymus disorders, symptomatic HIV infection or low CD4+ cell count; these populations can safely receive inactivated polio vaccine Vaccines not currently recommended for people with AHD include BCG, Rotavirus, Yellow Fever. This is because the safety and immunogenicity of these vaccines in individuals with CD4+ cell count3 less than 200 cell/mm ; is not certain.\n\n# Immune Reconstitution Inflammatory syndrome (IRIS)\n\nAHD package of care is designed to ensure that early initiation of ART in severely immunocompromised individuals does not precipitate immune reconstitution inflammatory syndrome (IRIS) particularly in the setting of the use of highly potent DTG based first-line regimens. The package of care recommends that individuals with AHD initiate ART immediately if the AHD defining OIs have been excluded. Despite this recommendation, other OIs that are associated with IRIS but whose management are not included in the package of care for AHD may still occur when severely immunocompromised individuals initiate ART. Consequently, clinicians should be familiar with the risk factors associated with the development of IRIS, its diagnosis and management.", "mimetype": "text/plain", "start_char_idx": 292047, "end_char_idx": 296901, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "eeb1cdda-7b65-47d1-b142-5d532ac85cab": {"__data__": {"id_": "eeb1cdda-7b65-47d1-b142-5d532ac85cab", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "a0ea8a83-92f2-421f-b583-e5d04834c259", "node_type": "1", "metadata": {}, "hash": "b05e72bfb93cb1bfa49e391fd763591596275ce91ab17bb15cfb3d16faf56aad", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "c5ef7c56-7463-4737-9006-a4125c33a909", "node_type": "1", "metadata": {}, "hash": "71dd5dad03e9c7d222a862da39da7687f8ce3107306d95ba7b2df2322d27d459", "class_name": "RelatedNodeInfo"}}, "text": "This is because the safety and immunogenicity of these vaccines in individuals with CD4+ cell count3 less than 200 cell/mm ; is not certain.\n\n# Immune Reconstitution Inflammatory syndrome (IRIS)\n\nAHD package of care is designed to ensure that early initiation of ART in severely immunocompromised individuals does not precipitate immune reconstitution inflammatory syndrome (IRIS) particularly in the setting of the use of highly potent DTG based first-line regimens. The package of care recommends that individuals with AHD initiate ART immediately if the AHD defining OIs have been excluded. Despite this recommendation, other OIs that are associated with IRIS but whose management are not included in the package of care for AHD may still occur when severely immunocompromised individuals initiate ART. Consequently, clinicians should be familiar with the risk factors associated with the development of IRIS, its diagnosis and management.\n\nThe risk factors for IRIS include:\n\n- High baseline viral load (>100,000 copies/ml)3\n- Low CD4+ cell count (\u2264200 cells/mm ) at ART initiation\n- Disseminated OIs or malignancies\n- Shorter duration of therapy for OIs before ART initiation\n- A potent ART regimen e.g TDF/3TC/DTG\n\nThe management of IRIS involves prompt and effective treatment of any co-infections, reassurance of the patient to prevent discontinuation or poor adherence and supportive management. The prevention of IRIS includes:\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020123\n\n# Appropriate screening and treatment of Opportunistic Infections (OIs) before initiation of Antiretroviral Therapy (ART)\n\nWith the exception of TB and cryptococcal meningitis, outcomes are improved with early ART in patients with OIs.\n\n- TB: Start ART 2 weeks after initiating TB treatment. However, if the patient has TB Meningitis, ART initiation should be started after 4 weeks of starting TB treatment.\n- Cryptococcal meningitis (CCM): Start ART 4 - 6 weeks after initiating CCM treatment.\n\nIt is important for healthcare workers to exercise a high index of suspicion for Immune Reconstitution Inflammatory Syndrome (IRIS) in People Living with HIV (PLHIV) commencing ART.\n\n# Management of Advanced HIV Disease (AHD) among Children less than ten years\n\nAll children less than 5 years are considered to have AHD. This is based on the rationale that most children younger than five years usually present for care with advanced immunosuppression, younger children have an increased risk of disease progression and mortality regardless of clinical and immune condition. Thus, varying age dependent CD4+ cell count definitions for advanced immunosuppression among children younger than five years make definitions based on CD4+ cell count difficult to implement. Children under 5 years diagnosed with HIV should immediately be offered the requisite screening tests, and where applicable, provided with prophylaxis, treatment and vaccination for the major OIs based on the outcome of the screening. For children between 5 and 9 years of age, a positive HIV test should be followed with a CD4+ test and clinical evaluation. If diagnosed with AHD, the child should receive the applicable package of care that involves screening, prevention and treatment of OIs and comorbid conditions, and optimized care.\n\n# Screen\n\nIn addition to clinical screening using signs and symptoms of common OIs, HIV positive children with AHD less than 10 years should be screened for TB using available laboratory tools such as urine LF-LAM assay, Xpert MTB/RIF, and AFB Microscopy.\n\n# Treat\n\nThe major OIs and co-morbidity associated with AHD in children <10 years are TB, severe pneumonia, severe bacterial infections, and malnutrition. Refer to table 8.4 and the section on management of OIs for the recommended treatment options for these conditions.\n\n# Prevent\n\nThe care package for children on AHD should include TPT and CPT. Screening and primary prophylaxis of cryptococcal meningitis are not recommended for children younger than 10 years, given the low incidence of cryptococcal meningitis in this age group. Live vaccines should be avoided in children with advanced HIV disease, however, vaccination is recommended for some of the OIs as the benefits outweigh the risk. Some of the vaccines include BCG, measles, catch up pneumococcal vaccine, and HPV (mainly for adolescent females). Neonates with confirmed HIV infection should delay BCG vaccination until ART has started and they are confirmed to be immunologically stable (CD4% >25%). See table 8.4 for details on the screening, diagnosis, prevention, and treatment components of the AHD package of care for children under 10 years. Recommendations for adolescents are similar to what obtains for adults.", "mimetype": "text/plain", "start_char_idx": 295959, "end_char_idx": 300711, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c5ef7c56-7463-4737-9006-a4125c33a909": {"__data__": {"id_": "c5ef7c56-7463-4737-9006-a4125c33a909", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "eeb1cdda-7b65-47d1-b142-5d532ac85cab", "node_type": "1", "metadata": {}, "hash": "7c5c66ed9f9c53114d772f4fc55bdd52b93e6b6f3168ab4c9bf82746348c2e13", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "1922b9cb-3833-488e-a0c4-c6ff0f6b1b99", "node_type": "1", "metadata": {}, "hash": "208f6bf05a246ded635082b4479f465b83fc8fcbf164f8b11c0bc27b447aab88", "class_name": "RelatedNodeInfo"}}, "text": "# Prevent\n\nThe care package for children on AHD should include TPT and CPT. Screening and primary prophylaxis of cryptococcal meningitis are not recommended for children younger than 10 years, given the low incidence of cryptococcal meningitis in this age group. Live vaccines should be avoided in children with advanced HIV disease, however, vaccination is recommended for some of the OIs as the benefits outweigh the risk. Some of the vaccines include BCG, measles, catch up pneumococcal vaccine, and HPV (mainly for adolescent females). Neonates with confirmed HIV infection should delay BCG vaccination until ART has started and they are confirmed to be immunologically stable (CD4% >25%). See table 8.4 for details on the screening, diagnosis, prevention, and treatment components of the AHD package of care for children under 10 years. Recommendations for adolescents are similar to what obtains for adults.\n\n# Optimize\n\nAlthough rapid ART initiation within seven days of diagnosis is a priority, children with AHD who present with severe acute malnutrition or TB or other illnesses that require hospitalization need to be stabilized first. However, initiating ART is encouraged as part of the child's hospital admission to minimize loss to follow-up.\n\n# Components of the Package of Care for Children with AHD\n\n|Intervention Component|< 5 years|5 \u2013 9 years|\n|---|---|---|\n|Screening and diagnosis|Screen for TB using clinical algorithm followed by X-ray when indicated and if available Xpert\u00ae MTB/RIF or Xpert\u00ae Ultra assay as the first test (Induced or expectorated) sputum, gastric aspirate, stool or nasopharyngeal aspirate or other extrapulmonary specimens LF-LAM assay|Yes Yes Yes|\n| |Cryptococcal antigen screening using serum, plasma, or whole blood specimen Pneumococcal conjugate vaccine (catch-up) Human Papilloma Vaccine (HPV) Measles BCG Co-trimoxazole|Yes No No Yes No Yes|\n|Prevention, prophylaxis and preemptive treatment|TB preventive treatment - INH for 6 months - Daily rifampicin and isoniazid for three months (3HR) - Weekly rifapentine and isoniazid for three months (3HP) could be used from two years of age Fluconazole pre-emptive therapy for cryptococcal antigen positive without evidence of meningitis Tuberculosis - based on current TB guidelines Severe Pneumonia (if diagnosed) - for children less than one, empirical treatment with Cotrimoxazole|Yes Yes Yes Not Applicable Yes Yes Yes|\n|Treatment|Severe bacterial infection - treat according to the confirmed organism Malnutrition treatment|Yes Yes Yes|\n\nScreening and primary prophylaxis of cryptococcal meningitis are not recommended for children younger than 10 years given the low incidence of cryptococcal meningitis in this age group; although this guideline does not recommend routine screening of children with AHD for cryptococcal infection because of the rarity of this condition in children, studies are appearing in literature reporting cases among children. As such, clinicians are encouraged to use their clinical judgement and screen their pediatric patients for cryptococcal infections and cryptococcal meningitis when clinical features are suggestive.\n\nEvidence indicates that adolescent females living with perinatally-acquired HIV have a higher prevalence of high-risk HPV and abnormal cervical cytology than uninfected adolescents. WHO recommends a three-dose series (0, 1\u20132 and 6 months) for females older than nine years living with HIV rather than the standard two-dose series;\n\nonly if the child missed birth and early childhood dose;\n\nTo be discontinued when CD4+ cell count >350 and viral load suppressed for at least 6 months;\n\nTB preventive treatment is currently not recommended for infants living with HIV younger than 12 months of age unless they have a household contact of a TB case;\n\n# 8.2 Other Opportunistic Infections (OIs)\n\nPersons living with HIV (PLHIV) are more prone to developing infections than persons not infected with the virus largely because of the immune system damage associated with HIV infection. Most of the infections that occur in PLHIVs are called OIs because they depend on a compromised immune system. The appearance of OIs in PLHIV is directly related to the extent of immune deficiency that is the degree of depletion of CD4+cells. The lower the CD4+ cell count, the higher the likelihood of the appearance of OIs. Most OIs in PLHIV begin to appear at CD4+ cell counts of &lt;350cells/mm; and many of the OIs are useful for staging the severity of HIV disease.", "mimetype": "text/plain", "start_char_idx": 299798, "end_char_idx": 304303, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "1922b9cb-3833-488e-a0c4-c6ff0f6b1b99": {"__data__": {"id_": "1922b9cb-3833-488e-a0c4-c6ff0f6b1b99", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "c5ef7c56-7463-4737-9006-a4125c33a909", "node_type": "1", "metadata": {}, "hash": "71dd5dad03e9c7d222a862da39da7687f8ce3107306d95ba7b2df2322d27d459", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "b4386fec-b92e-4f31-99f0-c1000563c82a", "node_type": "1", "metadata": {}, "hash": "b36e59f6f4c94860461e17f84bb3b5e16ab5703801883b12b2a1e31ae9944949", "class_name": "RelatedNodeInfo"}}, "text": "Most of the infections that occur in PLHIVs are called OIs because they depend on a compromised immune system. The appearance of OIs in PLHIV is directly related to the extent of immune deficiency that is the degree of depletion of CD4+cells. The lower the CD4+ cell count, the higher the likelihood of the appearance of OIs. Most OIs in PLHIV begin to appear at CD4+ cell counts of &lt;350cells/mm; and many of the OIs are useful for staging the severity of HIV disease.\n\nOpportunistic infections (OIs) associated with HIV fall into four broad categories namely, bacterial, viral, fungal and protozoal infections. The infections affect all major systems of the body including the; nervous, gastrointestinal, respiratory, skin, musculoskeletal, eyes, ear, nose and throat. When OIs occur among PLHIV they should be treated immediately since they can cause considerable damage to the immune system and lead to a rapid increase in viral replication and disease progression and death.\n\nXpert MTB/RIF has enhanced the diagnosis of TB in HIV positive patients and its widespread use in the country should improve health outcomes for HIV/TB co-infected patients. Chronic non-communicable diseases (NCDs), including cardiovascular disease (CVD), hypertension, diabetes, chronic obstructive pulmonary disease (COPD), kidney disease and mental health illnesses present important considerations in adults and adolescents living with HIV and requires early assessment and management. Pre-disposing factors such as lack of physical activities, smoking, and unhealthy dietary habits should be addressed. Early initiation of ART, appropriate treatment of identified OIs and comorbidities, lead to a reversal of immune system damage with reconstitution and prevention of AIDS-related death.\n\n# 8.3 Preventing Opportunistic Infections (OIs)\n\nThe relationship between HIV and OIs is bi-directional; HIV depresses the immunity of an individual thereby increasing predisposition to OIs, while OIs and other similar infections may lead to an acceleration of HIV disease progression.\n\nIt is therefore important that health workers have a good understanding of the role of chemotherapy in the prevention and treatment of OIs because while chemoprophylaxis directly prevent pathogen-specific morbidity and mortality, they also contribute to a reduced rate of progression of HIV disease.\n\nFor instance, there is evidence that chemoprophylaxis with trimethoprim-sulfamethoxazole can both decrease OI-related morbidity and improve survival. The reduced progression of HIV infection would reduce the risk of subsequent OIs.\n\nThere are currently two main strategies for the prevention of OIs; CPT, which provides protection to a wide range of bacterial infections and TPT, which is useful for treating latent tuberculosis.\n\n|NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020| | |\n|---|---|---|\n|126| | |\n\n# 8.3.1 Cotrimoxazole Preventive Therapy (CPT)\n\nCotrimoxazole Preventive Therapy (CPT) is a fixed-dose combination of two antimicrobial agents (sulfamethoxazole and trimethoprim) used for the prevention of some AIDS-associated OIs (Pneumocystis jirovecii pneumonia [PCP] and toxoplasmosis) and the reduction of HIV-associated mortality in people with low CD4+ cell counts. CPT is also used to treat a variety of bacterial, fungal and protozoan infections.\n\n# 8.3.1.1 Cotrimoxazole prophylaxis for adults\n\nCotrimoxazole (CTX) prophylaxis is recommended for adults (including pregnant women) with severe or advanced HIV clinical disease (WHO stage 3 or 4) and/or with a CD4+ cell count \u22645003 cells/mm3:\n\n- Due to the high prevalence of malaria and severe bacterial infections in Nigeria, Cotrimoxazole prophylaxis should be initiated regardless of CD4+ cell count or WHO stage. Priority should be given to adults (including pregnant women) with severe or advanced HIV clinical disease (WHO stage 3 or 4) and/or with a CD4+ cell count &lt;500 cells/mm3.\n- Routine cotrimoxazole prophylaxis should be given to all HIV-infected patients with active TB disease regardless of CD4+ cell count.\n- Cotrimoxazole prophylaxis may be discontinued in adults (including pregnant women) with HIV who are clinically stable on ART, with evidence of immune recovery and virological suppression.\n\n# 8.3.1.2 Cotrimoxazole prophylaxis for HIV-infected infants, children and Adolescents\n\nCotrimoxazole prophylaxis is recommended:\n\n- For infants, children and adolescents with HIV, irrespective of clinical and immune conditions.", "mimetype": "text/plain", "start_char_idx": 303832, "end_char_idx": 308327, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "b4386fec-b92e-4f31-99f0-c1000563c82a": {"__data__": {"id_": "b4386fec-b92e-4f31-99f0-c1000563c82a", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "1922b9cb-3833-488e-a0c4-c6ff0f6b1b99", "node_type": "1", "metadata": {}, "hash": "208f6bf05a246ded635082b4479f465b83fc8fcbf164f8b11c0bc27b447aab88", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "049328b1-bbcb-4bae-a28c-c5eaf96cf908", "node_type": "1", "metadata": {}, "hash": "59915ce5dad0075fc0bd37bbe403817bd9aa1048b939ab5aabfd9127129cb31b", "class_name": "RelatedNodeInfo"}}, "text": "Priority should be given to adults (including pregnant women) with severe or advanced HIV clinical disease (WHO stage 3 or 4) and/or with a CD4+ cell count &lt;500 cells/mm3.\n- Routine cotrimoxazole prophylaxis should be given to all HIV-infected patients with active TB disease regardless of CD4+ cell count.\n- Cotrimoxazole prophylaxis may be discontinued in adults (including pregnant women) with HIV who are clinically stable on ART, with evidence of immune recovery and virological suppression.\n\n# 8.3.1.2 Cotrimoxazole prophylaxis for HIV-infected infants, children and Adolescents\n\nCotrimoxazole prophylaxis is recommended:\n\n- For infants, children and adolescents with HIV, irrespective of clinical and immune conditions. Priority should be given to all children younger than 5 years old regardless of CD4+ cell count or clinical stage, and children with severe or advanced HIV clinical disease (WHO clinical stage 3 or 4) and/or those with a CD4+ cell count \u2264500 cells/mm3.\n- Should be continued until adulthood, irrespective of whether ART is provided.\n- For HIV-exposed infants 6 weeks of age and should be continued until HIV infection has been excluded by an age-appropriate HIV test to establish a final diagnosis after complete cessation of breastfeeding.\n- In all persons with active TB regardless of CD4+ cell count and continued until criteria for discontinuation in adults and children is met.\n\nIn HIV positive individuals who have ADR to cotrimoxazole, options for prophylaxis of PJP include dapsone, dapsone plus pyrimethamine plus folinic acid and atovaquone. For those who will be started on dapsone, do a G6PD deficiency test. Dapsone should be avoided in individuals with G6PD deficiency.\n\n# 8.3.1.3 Starting Patients on CPT\n\nBefore commencing a client on CPT the health worker should undertake the following actions:\n\n- Verify HIV status\n- Take medical history\n- Conduct physical examination\n- Counsel on OIs in HIV infection\n- Treat pre-existing OIs\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Screen for contraindications to CPT:\n\ne.g. known allergy to Sulphur-containing drugs, first trimester pregnancy, kidney or liver disease\n\nIn addition, the patient should be counselled for drug adherence and given detailed information of the likely side effects of cotrimoxazole and action to take in the event of the occurrence of any. Common side effects associated with CPT include skin eruptions, which may be severe (Stevens Johnson syndrome), nephritis, hepatitis, anaemia and hyperkalaemia.\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# Tuberculosis Preventive Treatment (TPT)\n\nTuberculosis Preventive Treatment (TPT), previously referred to as Isoniazid preventive therapy (IPT) is the treatment offered to individuals who are considered to be at risk of developing TB disease, in order to reduce that risk. It is also referred to as the treatment of TB infection or LTBI treatment. TB is a disease that is driven by HIIV and so it is frequently associated with HIV and a common cause of illness and death among PLHIV.\n\nTPT is effective in preventing the development of active TB in HIV positive individuals. However, it is not a treatment for active TB, therefore this should be excluded before commencing a patient on TPT.\n\nFor a patient to benefit from TPT, he/she must:\n\n1. Be HIV positive\n2. Not have active TB\n3. Be counselled and motivated to adhere to treatment\n\n# Recommendations for TPT\n\nAdults and adolescents living with HIV\n\n- Adults and adolescents living with HIV should be screened with a clinical algorithm; those who do not report any one of the symptoms of current cough, fever, weight loss or night sweats are unlikely to have active TB and should be offered TPT\n- Adults and adolescents living with HIV who are unlikely to have active TB or in whom active TB has been safely ruled out should receive TPT as part of a comprehensive package of HIV care. TPT should be given to such individuals regardless of the degree of immunosuppression, and also to those on ART, those who have previously been treated for TB and pregnant women\n\nChildren\n\n- Children living with HIV who do not have poor weight gain, fever or current cough are unlikely to have active TB.", "mimetype": "text/plain", "start_char_idx": 307598, "end_char_idx": 312002, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "049328b1-bbcb-4bae-a28c-c5eaf96cf908": {"__data__": {"id_": "049328b1-bbcb-4bae-a28c-c5eaf96cf908", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "b4386fec-b92e-4f31-99f0-c1000563c82a", "node_type": "1", "metadata": {}, "hash": "b36e59f6f4c94860461e17f84bb3b5e16ab5703801883b12b2a1e31ae9944949", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "4e1172eb-ec42-4e8d-84f2-9500acb0c007", "node_type": "1", "metadata": {}, "hash": "4310f5fd627e6420c18137035e84574f3a304cd1569cdfd2264b5181f1f6fcb0", "class_name": "RelatedNodeInfo"}}, "text": "Be HIV positive\n2. Not have active TB\n3. Be counselled and motivated to adhere to treatment\n\n# Recommendations for TPT\n\nAdults and adolescents living with HIV\n\n- Adults and adolescents living with HIV should be screened with a clinical algorithm; those who do not report any one of the symptoms of current cough, fever, weight loss or night sweats are unlikely to have active TB and should be offered TPT\n- Adults and adolescents living with HIV who are unlikely to have active TB or in whom active TB has been safely ruled out should receive TPT as part of a comprehensive package of HIV care. TPT should be given to such individuals regardless of the degree of immunosuppression, and also to those on ART, those who have previously been treated for TB and pregnant women\n\nChildren\n\n- Children living with HIV who do not have poor weight gain, fever or current cough are unlikely to have active TB. Children living with HIV who have poor weight gain, fever or current cough or contact history with a TB case may have TB and should be\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# evaluated for TB and other conditions. If the evaluation shows no TB, they should be offered TPT regardless of their age\n\nChildren living with HIV who are \u2265 12 months of age and who are unlikely to have active TB on symptom-based screening and have no contact with a TB case should receive six months of TPT (Isoniazid 10 mg/kg/day) but not more than 300mg/day as part of a comprehensive package of HIV prevention and care if they live in a setting with high TB transmission, regardless of contact with TB\n\nIn children living with HIV who are < 12 months of age, only those who have contact with a TB case and who are evaluated for TB (using standard lab investigations) should receive 6 months of TPT if the evaluation shows no TB disease\n\nAll children living with HIV, after successful completion of treatment for TB, should receive TPT for an additional 6 months\n\nChildren aged < 5 years who are household contacts of people with confirmed pulmonary TB and who are found not to have active TB on an appropriate clinical evaluation or according to national guidelines should be given TPT even if LTBI testing is unavailable\n\nChildren aged \u2265 5 years, adolescents and adults who are household contacts of people with confirmed pulmonary TB who are found not to have active TB by an appropriate clinical evaluation or according to national guidelines may be given TPT\n\n# Commencing TPT\n\nIt is recommended that health workers should undertake the following actions before initiating patients on TPT;\n\n1. Verify/Confirm HIV Status\n2. Counsel clients on TB/HIV interactions\n3. Exclude active TB by asking the client about:\n- Ask the patients about cough, weight loss, fever and night sweats\n- Check for lymph node enlargement\n- For patients who answer no to (a) and (b) above, assess for contraindications to TPT, counsel on adherence, and commence TPT\n- For those with symptoms/signs in (a) and (b) above:\n- Xpert MTB/RIF should be done\n- If positive refer/commence short-course chemotherapy for TB (DOTS, preferably)\n- Those with negative results should be referred to medical officers for confirmation of diagnosis.\n- If signs and symptoms are absent, do a chest x-ray\n- If no active TB is confirmed, assess for contraindications to TPT, counsel on adherence, and commence TPT.\n4. Counsel patient/caregiver on:\n- Importance of Treatment adherence\n- Side effects of INH: peripheral neuropathy, jaundice, rash and what is expected in such circumstances\n- Immediate recognition and reporting of signs and symptoms of active TB If a patient develops active TB during the course of TPT, discontinue TPT and refer/ commence anti-TB treatment (DOTS)\n\n# During the monthly visit, monitor the patients for:\n\n- a. Signs and symptoms of active TB\n- b. Side effects. The most common side effect is peripheral neuropathy (numbness/tingling sensation of extremities). In addition, allergic skin eruptions and jaundice can occur. Since INH is co-formulated with Pyridoxine, complications such as numbness/tingling/burning sensation are not expected. However, if jaundice develops, discontinue TPT and refer to the clinician for assessment.", "mimetype": "text/plain", "start_char_idx": 311103, "end_char_idx": 315328, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "4e1172eb-ec42-4e8d-84f2-9500acb0c007": {"__data__": {"id_": "4e1172eb-ec42-4e8d-84f2-9500acb0c007", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "049328b1-bbcb-4bae-a28c-c5eaf96cf908", "node_type": "1", "metadata": {}, "hash": "59915ce5dad0075fc0bd37bbe403817bd9aa1048b939ab5aabfd9127129cb31b", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "89805267-89b6-4d46-93ec-c90570ad8da3", "node_type": "1", "metadata": {}, "hash": "c7375bcd72999e03041b478723ae3d3080a4e964170418d43d42c36a6b19750f", "class_name": "RelatedNodeInfo"}}, "text": "4. Counsel patient/caregiver on:\n- Importance of Treatment adherence\n- Side effects of INH: peripheral neuropathy, jaundice, rash and what is expected in such circumstances\n- Immediate recognition and reporting of signs and symptoms of active TB If a patient develops active TB during the course of TPT, discontinue TPT and refer/ commence anti-TB treatment (DOTS)\n\n# During the monthly visit, monitor the patients for:\n\n- a. Signs and symptoms of active TB\n- b. Side effects. The most common side effect is peripheral neuropathy (numbness/tingling sensation of extremities). In addition, allergic skin eruptions and jaundice can occur. Since INH is co-formulated with Pyridoxine, complications such as numbness/tingling/burning sensation are not expected. However, if jaundice develops, discontinue TPT and refer to the clinician for assessment.\n\n# TPT options\n\nThe following options are recommended for the treatment of LTBI regardless of HIV status:\n\n- 6 or 9 months of daily isoniazid\n- 3-month regimen of weekly rifapentine plus isoniazid (3HP)\n- 3-month regimen of daily isoniazid plus rifampicin (3HR)\n- 1-month of daily Isoniazid and Rifapentine (1HP)\n\nHarmonize dispensing schedule with that of ARVs and emphasize the importance of adherence at each visit. Complete necessary INH prophylaxis register and INH appointment card.\n\n# Dosages of the Different TPT Regimens\n\nThe recommended dosages of medicines used for treatment of LTBI is as shown in Table 8.6 below.\n\n|TPT regimen|Dose per kg body weight in children|Maximum dose|\n|---|---|---|\n|Isoniazid alone daily for 6 months (6H)|10mg (range: 7-15mg)|300mg|\n|Weekly Rifapentine plus Isoniazid for 3 months- 12 doses (3HP)|Isoniazid: Individuals aged \u2265 12 years - 15mg Individuals aged 2 -11 years - 25mg Rifapentine: 10.0 - 14.0 kg = 300mg 14.1 - 25.0 kg = 450mg 25.1 - 32.0 kg = 600mg 32.1 -50.0 kg = 750mg > 50 kg = 900mg|Isoniazid - 900mg Rifapentine - 900mg|\n|Daily Isoniazid plus Rifampicin for 3 months (3HR)|Rifampicin: Age < 10 years = 15mg (range: 10\u201320mg) Age \u2265 10 years = 10mg Isoniazid: Age < 10 years = 10mg (range: 7\u201315mg) Age \u2265 10 years = 5mg|Rifampicin - 600mg Isoniazid - 300mg|\n|Daily Isoniazid and Rifapentine for 1 month|Age \u2265 13 years (regardless of weight band) Isoniazid \u2013 300mg Rifapentine - 600mg|Isoniazid \u2013 300mg Rifapentine - 600mg|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Dosage of INH for TPT\n\ni. Dosage of INH for TPT in children: INH is administered daily for TPT in children for a total duration of 6 months as stated in Table 8.7 below\n\nii. The dosage of INH for TPT in adults is 300mg daily for 6 months.\n\n**Table 8.7: Dosage of INH for TPT in Children**\n|Weight in kg|INH dosages in mg/day|INH in Tablet/day|\n|---|---|---|\n|&lt;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\n# Dosage of 3HP for TPT\n\ni. Dosages of 3HP in children: The Dosages of 3HP in children is as stated in Table 8.8 below.", "mimetype": "text/plain", "start_char_idx": 314482, "end_char_idx": 317487, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "89805267-89b6-4d46-93ec-c90570ad8da3": {"__data__": {"id_": "89805267-89b6-4d46-93ec-c90570ad8da3", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "4e1172eb-ec42-4e8d-84f2-9500acb0c007", "node_type": "1", "metadata": {}, "hash": "4310f5fd627e6420c18137035e84574f3a304cd1569cdfd2264b5181f1f6fcb0", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "e6e74683-1f88-4425-9346-ccf52b68098a", "node_type": "1", "metadata": {}, "hash": "2cefb5ba0e169b1d103afbd25b87cde1bebfac8617d8776bc37b6f5930489fcf", "class_name": "RelatedNodeInfo"}}, "text": "The dosage of INH for TPT in adults is 300mg daily for 6 months.\n\n**Table 8.7: Dosage of INH for TPT in Children**\n|Weight in kg|INH dosages in mg/day|INH in Tablet/day|\n|---|---|---|\n|&lt;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\n# Dosage of 3HP for TPT\n\ni. Dosages of 3HP in children: The Dosages of 3HP in children is as stated in Table 8.8 below.\n\n|Weight|Rifapentine** (150mg tablets)| |Isoniazid (100mg tablets)| |\n|---|---|---|---|---|\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|&gt; 31kg|750mg|5|700mg|7|\n\n*Patient aged 15 years and older should receive adult dosing\n\n**Rifapentine has a bitter taste. For young children who cannot swallow, crush the tablet and mix with a small amount of multivitamin syrup\n\nii. Dosages of 3HP in adults: The Dosages of 3HP in adults is as stated in Table 8.9 below\n\n|Medicine|Formulation|Weight bands for patients &gt;14 years| | | | |\n|---|---|---|---|---|---|---|\n|Isoniazid|300mg|3|3|3|3|3|\n|Rifapentine|150mg|6|6|6|6|6|\n\n# Dosage of 3HR for TPT\n\nThe dosage of fixed-dose combination of 3HR for TPT in both children and adults is as stated in Table 8.10\n\nNote: A triple pill combination containing isoniazid 300 mg + pyridoxine 25 mg + sulfamethoxazole 800 mg + trimethoprim 160 mg (scored) is available (1 pill daily for adults, half pill for children 5 years and older of age and quarter for children &lt; 5 years of age).\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 131\n\n# Table 8.10: Dosage of Fixed Dose Combination of 3HR for TPT\n\n|Children| | | |Adult| |\n|---|---|---|---|---|---|\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|25 - 37 kg| |2|\n|8 - 11kg| |2| | | |\n|12 - 15kg| |3| | | |\n|16 - 24kg|4| |38 - 54 kg|3| |\n|>= 25| |Use adult Regimen|>= 55| |4|\n\n# General Contraindications to TPT\n\n- Active hepatitis (acute or chronic)\n- Active TB\n- Regular and heavy alcohol consumption\n- Symptoms of peripheral neuropathy\n- Allergy to TPT medicines\n\n# Contraindications to the use of Rifapentine plus INH\n\n- Individuals taking medications that may have drug interactions that are difficult to manage with the regimen (e.g. PLHIV on Protease Inhibitors and NVP)\n- Persons presumed infected with MTB resistant to INH and RIF\n- Pregnant women or women planning to become pregnant during treatment\n- Individuals who have had prior adverse events or hypersensitivity to INH or Rifapentine\n- Known pre-existing liver damage\n- Children under two years (no dosing for children < 2 years)\n\n- In patients with severe malaria (impaired consciousness, low blood glucose, jaundice, kidney failure, anaemia and parasitaemia >10%), stop 3HP, treat malaria urgently. Restart 3HP once the episode of Malaria is resolved, to avoid drug - drug interactions\n- Supplement with Pyridoxine 25mg daily for six months if available when INH is given for 6 months.", "mimetype": "text/plain", "start_char_idx": 317047, "end_char_idx": 320105, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "e6e74683-1f88-4425-9346-ccf52b68098a": {"__data__": {"id_": "e6e74683-1f88-4425-9346-ccf52b68098a", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "89805267-89b6-4d46-93ec-c90570ad8da3", "node_type": "1", "metadata": {}, "hash": "c7375bcd72999e03041b478723ae3d3080a4e964170418d43d42c36a6b19750f", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "fd13c817-0bd5-48ed-9c7e-889bea17e88b", "node_type": "1", "metadata": {}, "hash": "745be4ae590c45a46b0a2f8caef8336ee7c7eda3a5c76de27fcfd36b00366e53", "class_name": "RelatedNodeInfo"}}, "text": "PLHIV on Protease Inhibitors and NVP)\n- Persons presumed infected with MTB resistant to INH and RIF\n- Pregnant women or women planning to become pregnant during treatment\n- Individuals who have had prior adverse events or hypersensitivity to INH or Rifapentine\n- Known pre-existing liver damage\n- Children under two years (no dosing for children < 2 years)\n\n- In patients with severe malaria (impaired consciousness, low blood glucose, jaundice, kidney failure, anaemia and parasitaemia >10%), stop 3HP, treat malaria urgently. Restart 3HP once the episode of Malaria is resolved, to avoid drug - drug interactions\n- Supplement with Pyridoxine 25mg daily for six months if available when INH is given for 6 months. However, lack of pyridoxine should not become a barrier to commencing TPT.\n- 3HP is recommended for PLHIV on ART that have acceptable drug-drug interactions with Rifapentine such as efavirenz as well as DTG and RAL in adults. 3HP is NOT recommended for PLHIVs on PI or NVP based ART. In cases where 3HP is contraindicated or cannot be administered, use Isoniazid for 6 months.\n- INH is the preferred regimen in HIV positive children on LPV/r, NVP, DTG or RAL\n- In view of test and treat policy as well as significant virological suppression from DTG containing regimens, repeat TPT after 2 years of completion is no longer recommended\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n132\n\n# 8.3.2.6 Monitoring of Patients on TPT\n\nDuring monthly drug refills, monitor patient for:\n\n- Development of active TB (clinical assessment of signs and symptoms of active TB).\n- Development of side-effects; e.g. peripheral neuropathy (numbness/tingling sensation of extremities). If present give Pyridoxine 50 - 75 mg daily.\n- Check for jaundice (yellowish eyes), abdominal pain, nausea, vomiting and yellowish urine. If present, stop TPT and refer to medical officer to rule out active liver disease.\n- Check for allergic skin eruptions. If present stop treatment and refer to the medical officer.\n- Evaluate adherence and counsel appropriately.\n- Any client who did not come a week after his/her TPT appointment day should be tracked and managed appropriately.\n\nIf patient develops symptoms suggestive of active TB during the course of TPT:\n\n- Discontinue TPT\n- Assess for active TB\n- Commence DOTS if confirmed or refer to medical officer\n- Assess for ART/re-assess for ART failure\n\n# 8.3.2.7 Management of children and adults whose TPT is interrupted\n\nInterrupted treatment or incomplete TB preventive treatment is defined as the loss of at least one-third of the intended LTBI treatment regimen (a lapse in treatment that lasted at least 1 or 2 months consecutively depending on the TPT regimen employed).\n\nFor any client who misses appointment:\n\nTrace the client/care giver\nFind out the reason for missed appointment and address as appropriate\nOffer adherence counseling\nEvaluate to rule out active TB disease\nProlong treatment to compensate for the missed doses\n\nRefer to Table 8.11 below on management of IPT interruption\n\n|TPT Regimen|Length of Interruption|Next Step|\n|---|---|---|\n|3HR, 6H|Less than 2 weeks|a. Resume preventive treatment immediately upon return b. Add the number of days of missed doses to the total treatment duration.|\n|3HR, 6H|More than 2 weeks|a. If treatment interruption occurred after more than 80% of doses expected in the regimen were taken - No action is required. - Continue and complete the remaining treatment as per original plan.|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# TPT Regimen Length of Interruption Next Step\n\n|Regimen|Length of Interruption|Next Step|\n|---|---|---|\n|3HR, 6H|More than 2 weeks|b. If less than 80% of doses expected in the regimen were taken, and the treatment course can still be completed within the expected time for completion, i.e. treatment duration + 33% additional time. - No action is required.\n- Continue and complete the remaining treatment as per original plan.\nc. If less than 80% of doses expected in the regimen were taken, and the treatment course cannot be completed within the expected time for completion - Restart the full TPT course.\n|\n|3HP|Weekly schedule of one dose missed|a.", "mimetype": "text/plain", "start_char_idx": 319391, "end_char_idx": 323605, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "fd13c817-0bd5-48ed-9c7e-889bea17e88b": {"__data__": {"id_": "fd13c817-0bd5-48ed-9c7e-889bea17e88b", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "e6e74683-1f88-4425-9346-ccf52b68098a", "node_type": "1", "metadata": {}, "hash": "2cefb5ba0e169b1d103afbd25b87cde1bebfac8617d8776bc37b6f5930489fcf", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "ca780269-c4fe-4975-9c0e-6ea659664995", "node_type": "1", "metadata": {}, "hash": "62b0a9dec3c9e57a43895d0537a10b65449e2d52f2e0b7eefc3e2e546ca65c70", "class_name": "RelatedNodeInfo"}}, "text": "- Continue and complete the remaining treatment as per original plan.|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# TPT Regimen Length of Interruption Next Step\n\n|Regimen|Length of Interruption|Next Step|\n|---|---|---|\n|3HR, 6H|More than 2 weeks|b. If less than 80% of doses expected in the regimen were taken, and the treatment course can still be completed within the expected time for completion, i.e. treatment duration + 33% additional time. - No action is required.\n- Continue and complete the remaining treatment as per original plan.\nc. If less than 80% of doses expected in the regimen were taken, and the treatment course cannot be completed within the expected time for completion - Restart the full TPT course.\n|\n|3HP|Weekly schedule of one dose missed|a. If the missed dose is remembered within the next 2 days - Take the dose immediately.\n- Continue the schedule as originally planned\nb. If the missed dose is remembered more than 2 days later. - Take the missed dose immediately and change the schedule for weekly intake to the day the missed dose was taken until treatment completion.\nMore than 1 weekly doses of 3HP missed - a. If between 1-3 weekly doses are missed.\n- Treatment is continued until all 12 doses are taken, thus prolonging the treatment duration to a maximum of 16 weeks\n- b. If 4 or more weekly doses are missed, restart the full TPT course.\n|\n|1HP|Less than 1 week|a. If more than 80% (23) of doses expected in the regimen were taken. - No action is required, complete the remaining doses\nb. If less than 80% (23) of doses expected in the regimen were taken. - Resume treatment immediately upon return\n- Add the missed doses to the total treatment duration to complete the course within a maximum of 6 weeks.\nMore than 1 week - a. If more than 7 consecutive doses were missed.\n- Consider restarting the complete course of 1HP regimen.\n- b. If more than 7 doses were missed intermittently.\n- Resume preventive treatment immediately upon return\n- Add the missed doses to the total treatment duration to complete the course within a maximum of 8 weeks\n- c. If adherence to 1HP is not possible\n- consider discontinuing it and offering an alternative daily regimen or 3HP\n|\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\n\n134\n\n# Outcomes of TPT\n\nHealth care workers (HCW) should ensure that all children started on TPT are evaluated after completing their treatment and assigned a treatment outcome which should be documented in the recording and reporting tools. The following are the possible treatment outcomes:\n\n|1.|Completed treatment|\n|---|---|\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 HIV for TB.\n\nFor further information on TPT, refer to the National TB Guidelines and the National Guidelines on Programmatic Management of Latent TB Infection in Nigeria.\n\n|Infection/Causative Organisms|Symptoms and Diagnosis|Treatment and Prophylaxis|Comments|\n|---|---|---|---|\n|Hepatitis B Virus|HBsAg quantification if positive, screen for the following; 1. HBsAg 2. Anti HBeAg 3. Anti HBcAg 4. Anti HCV 5. HBV-DNA Baseline alpha feto-proteinas (AFP) if possible|Screen for HBsAg. If positive, screen for the following; The regimen should include TDF and 3TC, and where TDF is contraindicated, substitute for TDF and add Entecavir Some may require Peg-Interferon treatment Abdominal ultrasound Baseline AFP if possible|There may be no signs and symptoms except in chronic liver disease. Refer for specialist care if complicated.|\n|Hepatitis C Virus|There may be no signs and symptoms except in chronic liver disease. Direct-acting antiviral (DAA); LFT Abdominal ultrasound.", "mimetype": "text/plain", "start_char_idx": 322816, "end_char_idx": 326687, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ca780269-c4fe-4975-9c0e-6ea659664995": {"__data__": {"id_": "ca780269-c4fe-4975-9c0e-6ea659664995", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "fd13c817-0bd5-48ed-9c7e-889bea17e88b", "node_type": "1", "metadata": {}, "hash": "745be4ae590c45a46b0a2f8caef8336ee7c7eda3a5c76de27fcfd36b00366e53", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "fc4c2773-3865-4163-a103-276e0408ca85", "node_type": "1", "metadata": {}, "hash": "ad929fbf4e96b3d87425b64fdfed2c389b520c3843f1a2eadb5438ebadd71a4f", "class_name": "RelatedNodeInfo"}}, "text": "HBsAg 2. Anti HBeAg 3. Anti HBcAg 4. Anti HCV 5. HBV-DNA Baseline alpha feto-proteinas (AFP) if possible|Screen for HBsAg. If positive, screen for the following; The regimen should include TDF and 3TC, and where TDF is contraindicated, substitute for TDF and add Entecavir Some may require Peg-Interferon treatment Abdominal ultrasound Baseline AFP if possible|There may be no signs and symptoms except in chronic liver disease. Refer for specialist care if complicated.|\n|Hepatitis C Virus|There may be no signs and symptoms except in chronic liver disease. Direct-acting antiviral (DAA); LFT Abdominal ultrasound. HCV RNA (Refer if positive)|The Guideline Recommends the pangenotypic regimen consisting of Sofosbuvir-Daclatasvir Refer for specialist care for complicated cases.| |\n|Acute watery Diarrhoea|Viruses: Rotavirus, Enteroviruses Bacteria: Enterobacteriae, E. Coli, C. jejuni Other viruses Frequent watery stools Laboratory: Stool m/c/s, Serology Zinc supplement 20mg daily for 10-14 days for paediatric patients|Clinical: Rehydrate Provide and maintain SSS, ORS or Resomal as required E,U,Cr is useful to monitor renal complications|SSS: Oral Rehydration Solution ORS: Oral Rehydration Salts|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n136\n\n# Infection/Causative Conditions, Symptoms and Diagnosis\n\n|Conditions|Organisms|Signs|\n|---|---|---|\n|Dysentery|- E. histolytica - G. Lamblia - C. jejuni - Isospora belli - Cyclospora - Microsporidia - Cryptosporidia - Salmonella spp. - S. Stercoralis|Frequent watery stools, abdominal cramps, bloody stools, fever, nausea, vomiting, dehydration|\n|Diagnosis|- Stool m/c/s - Serology, e.g. Widal test - E, U. Creatinine|-|\n|Treatment and Prophylaxis|- Oral rehydration - Provide and maintain adequate nutrition - Antibiotics if required: Ciprofloxacin, Metronidazole, Albendazole, Oral Zinc therapy|- For Strongyloidiasis: Albendazole - Clostridium difficile: Oral therapy with itraconazole/fluconazole|\n\n# Comments\n\n- If antibiotics are required, extra caution for possible interactions with ketoconazole\n- Monitor renal complications\n- Shigella and CTX for complications\n\n# Tinea corporis\n\n|Organism|Malassezia furfur|\n|---|---|\n|Symptoms|Itchy circular lesions with raised edges, fine scaly|\n|Diagnosis|Laboratory: skin scrapings stained with KOH|\n|Treatment|Topical application of Whitfield\u2019s ointment applied b.d. for 3-5 weeks|\n\n# Tinea capitis\n\n|Organism|Trichophyton rubrum|\n|---|---|\n|Symptoms|Area in the centre, loss of hair|\n|Diagnosis|Laboratory: skin scrapings stained with KOH|\n|Treatment|- 2% Miconazole cream b.d. to the skin for 3-5 weeks - Extra caution for possible interactions with ketoconazole|\n\n# Seborrhoeic dermatitis\n\n- Allergic reaction to yeast\n- Greasy scales over scalp and redness\n- Secondary bacterial infection may be common\n\nTreatment:\n\n- Selenium sulphide shampoo\n- Tar shampoo followed by sulphur salicylic acid cream or 1% hydrocortisone\n- Ketoconazole cream\n\n# Infection/Causative Conditions, Symptoms and Diagnosis\n\n|Conditions|Causative organisms|Signs|\n|---|---|---|\n|Herpes zoster (Shingles)|Varicella zoster virus|Painful vesicular lesions in a dermatomal distribution, on the face and trunk|\n|Herpes simplex Genitalis|Herpes simplex virus (HSV)|Blisters or painful sores on or around the genitals, rectum|\n\n# Treatment and Prophylaxis\n\nHerpes zoster (Shingles)\n\n- Acyclovir: 800mg 5 times/day for 7 days\n- Refer intractable cases for specialist care.\n- Refer cases of herpes zoster involving the eye and ear for specialist care.\n- Acyclovir: 10 mg/kg IV q8hr for 7 days\n- Analgesics\u2013 NSAIDS, carbamazepine, amitriptyline\n- Local application of calamine lotion;", "mimetype": "text/plain", "start_char_idx": 326072, "end_char_idx": 329751, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "fc4c2773-3865-4163-a103-276e0408ca85": {"__data__": {"id_": "fc4c2773-3865-4163-a103-276e0408ca85", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "ca780269-c4fe-4975-9c0e-6ea659664995", "node_type": "1", "metadata": {}, "hash": "62b0a9dec3c9e57a43895d0537a10b65449e2d52f2e0b7eefc3e2e546ca65c70", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "34c80094-8287-4c44-bc16-088a133f62f0", "node_type": "1", "metadata": {}, "hash": "643f0e8181599d421c3236138d8011fdede03f31da02d19aceab0c9f898e4ed8", "class_name": "RelatedNodeInfo"}}, "text": "- Refer cases of herpes zoster involving the eye and ear for specialist care.\n- Acyclovir: 10 mg/kg IV q8hr for 7 days\n- Analgesics\u2013 NSAIDS, carbamazepine, amitriptyline\n- Local application of calamine lotion;\n- Topical application of Acyclovir cream\n- For painful vesicular unilateral lesions on face or trunk - Add gentian violet topical application, tab pregabalin 75mg BD (adult) 7 to 10 days\n\nPaediatrics: Tab Acyclovir 30mg/kg/day tds x 7 days\n\nHerpes simplex Genitalis\n\n- Acyclovir Tab 400mg tds for 7 \u201314 days\n- OR 200mg 5 times daily for 7 -14 days\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Infection/Causative Conditions, Symptoms and Diagnosis\n\n|Organisms|Signs|\n|---|---|\n|Herpes virus Herpes simplex virus 1 and 2|Fever, altered consciousness, headache, malaise, rash, seizures, convulsions \u00b1 focal neurological signs|\n|Cytomegalovirus (CMV)|Enterocolitis: Fever, cramps, dysphagia, odynophagia, diarrhoea \u00b1 blood; Enteritis: Laboratory: Foscarnet IV 40-60mg/kg 8 hrly x 2-3 weeks; Biopsy: intracellular inclusions; Colitis; Retinitis \u2013 Ophthalmological examination; CNS involvement: Delirium, lethargy, headache, disorientation, neck stiffness, photophobia, cranial nerve palsy, blurred vision or \"floaters\"; CMV in CSF|\n|Measles Measles virus|Fever, cough, red eyes, keratoconjunctivitis, coryza, maculopapular rash; Highly contagious; Antipyretics; Supportive therapy; Refer Complications; Nutrition support; Complications: Pneumonia, diarrhoeal disease, malnutrition.|\n\n# Treatment and Prophylaxis\n\n|Diagnosis|Treatment|Comments|\n|---|---|---|\n|Herpes simplex virus|IV Acyclovir; Paediatrics: 20mg/kg tid x 21 days; Adult: 10-15 mg/kg IV q8hr for 14-21 days|Nausea, vomiting, diarrhoea, renal dysfunction|\n|Cytomegalovirus|Ganciclovir 5mg/kg IV bid x 2-3 weeks; same drug therapy as above| |\n|Measles virus|Supportive therapy; Vitamin A, antibiotics as indicated, adequate hydration| |\n\n# Infection/Causative Conditions, Symptoms and Diagnosis\n\n|Conditions|Organisms|Signs|\n|---|---|---|\n|Herpes virus encephalitis|Herpes simplex virus 1 and 2|Fever, altered consciousness, headache, malaise, rash, seizures, convulsions \u00b1 focal neurological signs|\n|Cytomegalovirus (CMV)|Cytomegalovirus|Enterocolitis: Fever, cramps, dysphagia, diarrhoea \u00b1 blood; Enteritis: odynophagia, Colitis: diarrhoea \u00b1 blood; CNS involvement: Delirium, lethargy, headache, malaise; CMV in CSF: disorientation, neck stiffness, photophobia, cranial nerve palsy, blurred vision or \"floaters\"|\n|Measles|Measles virus|Fever, cough, red eyes, keratoconjunctivitis, coryza, maculopapular rash; Complications: Pneumonia, diarrhoeal disease, malnutrition|\n\n# Treatment and Prophylaxis\n\n|Diagnosis|Treatment|Comments|\n|---|---|---|\n|Herpes virus encephalitis|IV Acyclovir|Paediatrics: 20mg/kg tid x 21 days; Adult: 10-15 mg/kg IV q8hr for 14-21 days|\n|Cytomegalovirus (CMV)|Ganciclovir 5mg/kg IV bid x 2-3 weeks; Foscarnet IV 40-60mg/kg 8 hrly x 2-3 weeks|Clinical Laboratory: Biopsy; Retinitis - Ophthalmological examination; same drug therapy as above|\n|Measles|Supportive therapy; Antipyretics; Refer Complications; Nutrition support|Highly contagious; Vitamin A, antibiotics as indicated, adequate hydration|\n\n# Infection/Causative Conditions,", "mimetype": "text/plain", "start_char_idx": 329542, "end_char_idx": 332795, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "34c80094-8287-4c44-bc16-088a133f62f0": {"__data__": {"id_": "34c80094-8287-4c44-bc16-088a133f62f0", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "fc4c2773-3865-4163-a103-276e0408ca85", "node_type": "1", "metadata": {}, "hash": "ad929fbf4e96b3d87425b64fdfed2c389b520c3843f1a2eadb5438ebadd71a4f", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "e3fc83c3-658e-4bc1-8184-4af3df01af48", "node_type": "1", "metadata": {}, "hash": "8ddeeddffbe8bd869803c61e0653136a48d646b1adcdc133caa0fce18771a1a4", "class_name": "RelatedNodeInfo"}}, "text": "diarrhoeal disease, malnutrition|\n\n# Treatment and Prophylaxis\n\n|Diagnosis|Treatment|Comments|\n|---|---|---|\n|Herpes virus encephalitis|IV Acyclovir|Paediatrics: 20mg/kg tid x 21 days; Adult: 10-15 mg/kg IV q8hr for 14-21 days|\n|Cytomegalovirus (CMV)|Ganciclovir 5mg/kg IV bid x 2-3 weeks; Foscarnet IV 40-60mg/kg 8 hrly x 2-3 weeks|Clinical Laboratory: Biopsy; Retinitis - Ophthalmological examination; same drug therapy as above|\n|Measles|Supportive therapy; Antipyretics; Refer Complications; Nutrition support|Highly contagious; Vitamin A, antibiotics as indicated, adequate hydration|\n\n# Infection/Causative Conditions, Symptoms and Diagnosis\n\n|Conditions|Organisms|Symptoms|Diagnosis|\n|---|---|---|---|\n|Pneumonia|Respiratory viruses and bacteria|Fever, chills, cough, pleuritic chest pain, difficulty/fast breathing|Clinical: Viral pneumonia is self-limiting \u2013 requires only supportive care. For severe pneumonia in children <12 months old treat PJPS presumptively with CTX. Laboratory: blood culture, sputum examination. Chest x-ray. Bacterial infections: If facilities to exclude PJPS pneumoniae infections are not available or if a child on CPT develops bacterial pneumonia do not treat with CTX but refer. Out-patient therapy with Amoxicillin or CTX. For in-patient therapy: H. influenza - Amoxicillin or Amoxicillin/clavulanic acid. M. catarhalis - Amoxicillin/clavulanic acid. Kl. pneumonia - Quinolones are a 2nd line anti TB drug hence rule out TB before using quinolones (levofloxacin). P. aeruginosa - 2nd and 3rd generation cephalosporin as 2nd line. Azithromycin or clarithromycin. Respiratory quinolones (levofloxacin) in adults.|\n|Acute Pharyngo-pneumonia|Viruses and bacteria|Fever, cough, vomiting, refusal of feeds, drooling of saliva, inflamed tonsils/pharynx|Clinical: Amoxicillin or Amoxicillin/clavulanic acid. Laboratory: Throat swab for m/c/s. 2nd generation cephalosporins, 3rd and 4th generation cephalosporin, and respiratory quinolones (levofloxacin). H. influenza, Moxerella Catarhalis, Klebs. pneumoniae|\n\n|Infection/Causative Conditions|Symptoms and signs|Diagnosis|Treatment and Prophylaxis|Comments|\n|---|---|---|---|---|\n|Acute otitis|Respiratory viruses|Fever, vomiting, cough, ear-tugging; Hyperaemic tympanic membrane, purulent ear discharge|Clinical: Amoxicillin or 2nd generation cephalosporin Laboratory: - Ear swab for m/c/s Bacteria: - Strep. pneumoniae - H. influenza - Staph. Aureus - Moraxella catarhalis - Klebs. pneumoniae|Amoxicillin/ clavulanic acid - Levofloxacin - Refer to ENT specialist|\n|Chronic suppurative otitis media|S. pneumoniae H. influenza S. Aureus M. Catarhalis Kl. pneumoniae P. aeruginosa|Ear discharge X-ray of mastoid|Clinical: Refer to ENT specialist Laboratory: - Ear swab for m/c/s|Hearing loss is a complication lasting &gt;14 days|\n|Impetigo|Streptococcus spp, Staph.", "mimetype": "text/plain", "start_char_idx": 332171, "end_char_idx": 335017, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "e3fc83c3-658e-4bc1-8184-4af3df01af48": {"__data__": {"id_": "e3fc83c3-658e-4bc1-8184-4af3df01af48", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "34c80094-8287-4c44-bc16-088a133f62f0", "node_type": "1", "metadata": {}, "hash": "643f0e8181599d421c3236138d8011fdede03f31da02d19aceab0c9f898e4ed8", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "9bb1b86d-d3ae-41b4-bd0f-1c54ec21a3c4", "node_type": "1", "metadata": {}, "hash": "b5d10459caa64c97d7c17af41646b3a5ac77abba2440d68a1aabee836e7694e1", "class_name": "RelatedNodeInfo"}}, "text": "pneumoniae - H. influenza - Staph. Aureus - Moraxella catarhalis - Klebs. pneumoniae|Amoxicillin/ clavulanic acid - Levofloxacin - Refer to ENT specialist|\n|Chronic suppurative otitis media|S. pneumoniae H. influenza S. Aureus M. Catarhalis Kl. pneumoniae P. aeruginosa|Ear discharge X-ray of mastoid|Clinical: Refer to ENT specialist Laboratory: - Ear swab for m/c/s|Hearing loss is a complication lasting &gt;14 days|\n|Impetigo|Streptococcus spp, Staph. Aureus|Skin pustules, crusts, Drain pus if fluctuant|Clinical: Clean sore with antiseptics - Ampicillin/cloxacillin - Cefuroxime, cefixime, amoxicillin-clavulanic acid and flucloxacillin - Topical agents such as Mupirocin or Retapamulin|Fever (rarely)|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n142\n\n# Infection/Causative Conditions, Symptoms, and Diagnosis\n\n|Conditions|Organisms|Signs|\n|---|---|---|\n|Uncomplicated Malaria|Mainly P. falciparum|Fever, chills, rigour, headache, nausea, vomiting|\n|Laboratory: malaria|Parasite in blood film|Refer to a higher-level facility if complicated|\n|Complicated Malaria|RDT|Injectable Artesunate|\n\n# Treatment and Prophylaxis\n\nAvoid ACT containing amodiaquine in patients taking zidovudine or EFV. There is an increased risk of neutropenia with AZT and increased risk of hepatotoxicity with EFV.\n\nAvoid ACT containing sulfadoxine-pyrimethamine combination if a patient is on CPT.\n\nAvoid Intermittent Preventive Treatment (IPT) for malaria in pregnancy if the patient is on CPT.\n\n# While awaiting m/c/s\n\nSepsis\n\n- S. pneumoniae\n- Fever\n- Clinical assessment\n\nRefer to a tertiary facility if necessary\n\nShock\n\n- H. influenzae\n- Laboratory: Penicillin + Gentamycin\n- If in shock, provide supportive therapy\n\nSalmonella\n\n- FBC\n- Amoxicillin/clavulanic acid + genticin\n\nN. meningitides\n\n- Blood culture\n- Metronidazole for anaerobes\n\nStaph aureus\n\n- Urine culture\n- Organ-specific signs/focus of infection determines the needed test(s)\n\nGram-negatives\n\n- 2nd or 3rd generation cephalosporin and amoxicillin-clavulanic acid with/out other antibiotics\n\nAnaerobes\n\n- Depending on the focus of infection\n\n|Infection/Causative Conditions|Symptoms and signs|Diagnosis|Treatment and Prophylaxis|Comments|\n|---|---|---|---|---|\n|Acute bacterial Meningitis|S. pneumoniae Fever, headache, vomiting, irritability, altered sensorium, convulsions, nuchal rigidity, bulging fontanelle (in children)|Clinical assessment 3rd generation cephalosporin FBC Blood culture CSF analysis|Penicillin & Chloramphenicol Supportive treatment + Gentamycin|Refer to a tertiary facility if necessary|\n|H. influenzae|Laboratory: Salmonella N. meningitides Staph aureus| | | |\n|Scabies|Sarcoptes scabiei Intense itchy lesions most prominent in interdigital web spaces|Clinical,25% Benzyl benzoate applied whole body, neck down nocte Laboratory: Microscopy on KOH prep. of skin Treat all household members even if asymptomatic|Treat super-imposed bacterial infection with oral antibiotics Permethrin cream 5% applied whole body, neck down and axillary area; washed off after 8 \u201314 hours. Repeat after 1 \u20132 weeks.", "mimetype": "text/plain", "start_char_idx": 334562, "end_char_idx": 337656, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "9bb1b86d-d3ae-41b4-bd0f-1c54ec21a3c4": {"__data__": {"id_": "9bb1b86d-d3ae-41b4-bd0f-1c54ec21a3c4", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "e3fc83c3-658e-4bc1-8184-4af3df01af48", "node_type": "1", "metadata": {}, "hash": "8ddeeddffbe8bd869803c61e0653136a48d646b1adcdc133caa0fce18771a1a4", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "ee1887b0-dfd0-4074-ab4b-290b1cfe94c6", "node_type": "1", "metadata": {}, "hash": "4e741edcc394aa238bcf09a3c8b94bcfb1d7ba04398b4e9d2a6e30dc6263e921", "class_name": "RelatedNodeInfo"}}, "text": "influenzae|Laboratory: Salmonella N. meningitides Staph aureus| | | |\n|Scabies|Sarcoptes scabiei Intense itchy lesions most prominent in interdigital web spaces|Clinical,25% Benzyl benzoate applied whole body, neck down nocte Laboratory: Microscopy on KOH prep. of skin Treat all household members even if asymptomatic|Treat super-imposed bacterial infection with oral antibiotics Permethrin cream 5% applied whole body, neck down and axillary area; washed off after 8 \u201314 hours. Repeat after 1 \u20132 weeks. Ivermectin is not recommended for children below 15kg and pregnant or lactating women If poor response to topical treatment then oral Ivermectin tablet 200mcg/kg stat, repeat after 7 -14 days +/ - 25% benzy l benzoate or Crotamiton.|Papular rashes or generalised (Norwegian) Presentation could be more generalized in the context of HIV/AIDS Wash and sun-dry/iron clothings, beddings and fomites.|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n144\n\n# Infection/Causative Conditions, Symptoms and Diagnosis\n\n|Organisms|Signs|\n|---|---|\n|Mycobacterium Avium spp.|Disseminated form: Clinical: Adult - Nausea and vomiting, recurrent fever, chronic diarrhea, weight loss/failure to thrive, abdominal pain, intracellular inclusions. Laboratory: Multiple lymphadenopathy. Optic neuritis may occur.|\n| |- Respiratory symptoms may occur.|\n| |- Lymph node biopsy for diagnosis.|\n|Treatment and Prophylaxis|- Clarithromycin 500 mg b.d. + ethambutol 15 mg/kg daily with or without rifabutin. - Azithromycin (500-600 mg daily) can be substituted for clarithromycin.|\n| |Paediatrics: - Clarithromycin 7.5 mg/kg/dose b.d. or azithromycin 5-20 mg/kg/dose once daily plus Ethambutol 15 mg/kg/day for 6 months.|\n|Prophylaxis|- Guided by CD4+ count.|\n|Lymphoid interstitial pneumonitis|Unknown, but may initially be asymptomatic. Associated with Epstein-Barr Virus co-infection.|\n|Clinical|- Recurrent cough, respiratory distress, oxygen insufficiency, seizures, pseudo-parotid tumor cerebri, hypokalemia, bilateral hilar/mediastinal lymphadenopathy.|\n|Diagnosis|- Diagnosis of exclusion.|\n\n# Treatment and Prophylaxis\n\nComplications of therapy with prednisolone include- Hypertension, gastritis, adrenal insufficiency, seizures, pseudo-parotid tumor cerebri, hypokalemia, fluid retention, glucose intolerance.- Chest X-Ray: reticulo-nodular infiltrates, generalized lymphadenopathy, hepatosplenomegaly.- Referral to a specialist (paediatric pulmonologist).- Bronchodilators (salbutamol).- Chest physiotherapy.\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n145\n\n# 8.4 HIV-Related Co-Morbidities\n\n|Comorbidities|Example|Comment|\n|---|---|---|\n|Cardiovascular|1. Hypertension|Asses all PLHIV for risk of CVD and implement risk reduction strategies.|\n| |2. Heart failure| |\n| |3. Cardiomyopathy|Treat uncomplicated hypertension and heart failure refer others for specialist care|\n| |4. Arrhythmias| |\n| |5. Artheroclerosis/Ischaemic heart diseases/Cerebrovascular diseases| |\n|Others|Type 2 diabetes,|Clients should be assessed and managed for these diseases including referral for specialist care where necessary.|\n| |Asthma| |\n| |Chronic obstructive pulmonary disease(COPD)| |\n| |Breast and Cervical cancers|All women with HIV should be screened for cervical cancer regardless of age.|\n\n# 8.5 Mental Health and HIV\n\nMental health problems can increase the risk of HIV acquisition both directly and indirectly. In sub-Saharan Africa (SSA) HIV constitutes a major burden on mental health-related challenges [28]. The prevalence of depressive illness amongst PLHIV on ART in SSA is estimated to range from 29 to 63.1% [28].", "mimetype": "text/plain", "start_char_idx": 337152, "end_char_idx": 340793, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "ee1887b0-dfd0-4074-ab4b-290b1cfe94c6": {"__data__": {"id_": "ee1887b0-dfd0-4074-ab4b-290b1cfe94c6", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "9bb1b86d-d3ae-41b4-bd0f-1c54ec21a3c4", "node_type": "1", "metadata": {}, "hash": "b5d10459caa64c97d7c17af41646b3a5ac77abba2440d68a1aabee836e7694e1", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "adbe517d-f0bc-4ad4-a660-6b852988e564", "node_type": "1", "metadata": {}, "hash": "a59fb33cf7f0d359204e24d915435ceb9c52326b58a23683ba3000c06432652a", "class_name": "RelatedNodeInfo"}}, "text": "Arrhythmias| |\n| |5. Artheroclerosis/Ischaemic heart diseases/Cerebrovascular diseases| |\n|Others|Type 2 diabetes,|Clients should be assessed and managed for these diseases including referral for specialist care where necessary.|\n| |Asthma| |\n| |Chronic obstructive pulmonary disease(COPD)| |\n| |Breast and Cervical cancers|All women with HIV should be screened for cervical cancer regardless of age.|\n\n# 8.5 Mental Health and HIV\n\nMental health problems can increase the risk of HIV acquisition both directly and indirectly. In sub-Saharan Africa (SSA) HIV constitutes a major burden on mental health-related challenges [28]. The prevalence of depressive illness amongst PLHIV on ART in SSA is estimated to range from 29 to 63.1% [28]. HIV neuro-inflammation occurs nearly in every person that is HIV infected but may present with symptoms in only about 60% of patients [29] who are said to have HIV-associated neurocognitive disorder (HAND). Although the severity of HAND is said to reduce in the era of combination antiretroviral therapy the neuro-inflammation is a long-lasting inflammation that still manifests as symptoms even in some individuals on effective ARV giving rise to the notion that neurocognitive decline may be resistant to treatment in some patients [29]. HIV-associated neurocognitive disorder (HAND) is not only a long-lasting disorder, it is associated with a profound decrease in the quality of life. It complicates autonomy, may adversely modify ARV treatment adherence and can produce high-level vulnerability to wrong judgment and accidents. Therefore, this guideline recommends that every PLHIV should have a mental health assessment.\n\n# 8.5.1 Recommendations\n\n1. Conduct an assessment for HAND\n2. Manage HAND appropriately\n\n# Table 8.14: Assessment for HAND as Proposed by the National Institute of Neurological Diseases and Stroke\n\nHand TypeHIV-associated asymptomatic neurocognitive impairment (ANI)HIV-associated mild neurocognitive disorder (MND)HIV-associated dementia (HAD)\n\n# Diagnostic Criteria\n\n- Slight cognitive deficits in two or more neuropsychological domains\n- Cognitive function impairment does not affect daily functioning\n- Neurocognitive disorders fail to meet the criteria for delirium or dementia\n- There is no evidence of pre-existing cause of ANI\n\n- Mild or moderate cognitive function impairment in two or more neuropsychological domains\n- Cognitive disorders affect, at least to a mild extent, daily functioning\n- Cognitive disorders fail to meet the criteria for delirium or dementia\n- They are not conditioned by other concomitant diseases\n- A patient may display mild concentration, attention or memory disturbances (e.g. complaints about difficulty in reading)\n\n- Moderate or severe cognitive function impairment in two or more neuropsychological domains\n- Considerable difficulty in performing daily functions associated with intensification of cognitive disorders\n- Cognitive disorders fail to meet the criteria for delirium\n- Cognitive disorders are not conditioned by comorbid diseases\n- The patient may develop speech problems, emotional shallowness, lack of spontaneity and social withdrawal\n\n# 8.5.2 Management Considerations\n\nThe key principle to management of HAND is to:\n\n1. Exclude cerebral OIs which may mimic features of HAND or depression\n2. Implementation of treatment for depression among people with HIV may require task-shifting, building health worker capacity, national adaptation of screening tools and simplification of tools for use by nonspecialized primary Health care providers.\n3. The patient is placed on effective ART with good central nervous system (CNS) penetration capacity.\n4. The patient is appropriately referred for expert Neuropsychiatric assessment\n\nAnother Mental health screening tool for PLHIV according to the New York state department of Health AIDS Institute is described in appendix 2.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# List of Contributors\n\n|Dr.", "mimetype": "text/plain", "start_char_idx": 340057, "end_char_idx": 344041, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "adbe517d-f0bc-4ad4-a660-6b852988e564": {"__data__": {"id_": "adbe517d-f0bc-4ad4-a660-6b852988e564", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "ee1887b0-dfd0-4074-ab4b-290b1cfe94c6", "node_type": "1", "metadata": {}, "hash": "4e741edcc394aa238bcf09a3c8b94bcfb1d7ba04398b4e9d2a6e30dc6263e921", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "719b0511-e145-4652-b14e-bc6a1aeeaa19", "node_type": "1", "metadata": {}, "hash": "36eaf09967f18ab4d188dc733689f1e31cb34164cba251da3f2a201fdf899f6b", "class_name": "RelatedNodeInfo"}}, "text": "Exclude cerebral OIs which may mimic features of HAND or depression\n2. Implementation of treatment for depression among people with HIV may require task-shifting, building health worker capacity, national adaptation of screening tools and simplification of tools for use by nonspecialized primary Health care providers.\n3. The patient is placed on effective ART with good central nervous system (CNS) penetration capacity.\n4. The patient is appropriately referred for expert Neuropsychiatric assessment\n\nAnother Mental health screening tool for PLHIV according to the New York state department of Health AIDS Institute is described in appendix 2.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# List of Contributors\n\n|Dr. Umo Mildred Ene-Obong|Head/Director, Public Health Department FMoH|\n|---|---|\n|Dr Akudo Ikpeazu|National Coordinator NASCP|\n|Mr Araoye Segilola|Former, National Coordinator|\n|Pharm Oloyede Yekini|Former, Director, Logistics Unit NASCP|\n|Dr Akpan Nsebong|Deputy Director NASCP|\n|Ombudadu Obadiah A|Deputy Director NASCP|\n|Dr Deborah Odoh|Deputy Director, NTTP & Performance Management NASCP|\n|Mrs Semlek Rachael N|Chief Accountant NASCP|\n|Dr Nwaokenneya Peter|Assistant Director, Adult ART/TB/HIV - NASCP|\n|Dr Chioma Ukanwa|Senior Medical Officer 1, NTTP & Performance Management NASCP|\n|Ms Rahila Agwom|Chief Scientific Officer NASCP|\n|Dr Chinwendu Ndukwe|Deputy Director, Health Sector Response Support NACA|\n|Prof. Sulaimon Akanmu|Chairman NTTA / Haematologist LUTH Lagos|\n|Dr Damien Anweh|Member NTTA / Physician FMC, Markurdi|\n|Dr Rita O. Oladele|Member NTTA / Microbiologist LUTH Lagos|\n|Dr Charles Olomofe|Public Health Physician FETH Ido Ekiti|\n|Dr Oluwafunke Ilesanmi|Technical Officer, HIV and Viral Hepatitis WHO|\n|Dr Dennis Onotu|Branch Chief, Continuum of care & treatment CDC|\n|Dr Obinna Ogbanufe|Senior Program Specialist, HIV care and treatment CDC|\n|Dr Igboeline Onyeka Donald|Programme Manager, Treatment USAID|\n|Dr Abiye Kalio|Programme Manager USAID|\n|Folu Lufadeju|Deputy Country Director CHAI|\n|Pharm Willams Eigege|Associate CHAI|\n|Dr Saswata Dutt|Senior Technical Advisor, HIV/TB/DR -TB IHVN|\n|Dr Olufemi Oke|Technical Advisor CRS|\n|Dr Olawale Fadare|Technical Director TMEC/RISE Program|\n|Dr Olayiwola Lanre|Senior Technical Advisor CCFN|\n\n# 9. SERVICE DELIVERY\n\n|What\u2019s Inside:|9.1 Introduction|150|\n|---|---|---|\n| |1.1 Objectives of the Guidelines| |\n|9.2 Differentiated Service Delivery| |150|\n| |1.2 Epidemiology of HIV in Nigeria| |\n|9.2 Standards for Quality HIV Service Delivery| |163|\n| |1.3 Natural History of HIV| |\n|9.3 Nutrition| |167|\n|9.4 Service Delivery for Adolescents Living with HIV| |169|\n\n# 9.1 Introduction\n\nHealthcare service delivery in the context of HIV management provides the continuum of care to PLHIV that ensures access to HIV prevention, treatment and care aimed at promoting sustained virological suppression and improved quality of life.\n\nResponsive HIV service delivery that meets the needs of various sub-populations is required to ensure equitable, accessible, acceptable, appropriate and effective health services for PLHIV. In Nigeria barriers to treatment access still exist. These include service-related, structural, policy and stage of life barriers. With the introduction of 'Test and Treat', as recommended by the 2016 National Guidelines for HIV Prevention Treatment and Care in Nigeria, the burden of HIV service delivery on health facilities has increased.\n\nTo achieve the goal of virological suppression and ensure client-centred care, Nigeria must adopt innovative strategies at both the health facility and community level. These strategies reduce the challenges and barriers associated with accessing HIV services and enable healthcare workers to strategically focus HIV investments and resources on clients with AHD and those who are not stable on treatment. As a nation, they are critical to enabling us to achieve the UNAIDS 95:95:95 goals. They must be targeted at and appropriate for the various sub populations of PLHIV to ensure that no group is left behind.", "mimetype": "text/plain", "start_char_idx": 343301, "end_char_idx": 347384, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "719b0511-e145-4652-b14e-bc6a1aeeaa19": {"__data__": {"id_": "719b0511-e145-4652-b14e-bc6a1aeeaa19", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "adbe517d-f0bc-4ad4-a660-6b852988e564", "node_type": "1", "metadata": {}, "hash": "a59fb33cf7f0d359204e24d915435ceb9c52326b58a23683ba3000c06432652a", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "7bd8ebd7-cbab-48e0-afaf-7691de62ea33", "node_type": "1", "metadata": {}, "hash": "fc71ddcb80625c522a179163652a13b4eaf8e921e121c3a733009877f5878234", "class_name": "RelatedNodeInfo"}}, "text": "In Nigeria barriers to treatment access still exist. These include service-related, structural, policy and stage of life barriers. With the introduction of 'Test and Treat', as recommended by the 2016 National Guidelines for HIV Prevention Treatment and Care in Nigeria, the burden of HIV service delivery on health facilities has increased.\n\nTo achieve the goal of virological suppression and ensure client-centred care, Nigeria must adopt innovative strategies at both the health facility and community level. These strategies reduce the challenges and barriers associated with accessing HIV services and enable healthcare workers to strategically focus HIV investments and resources on clients with AHD and those who are not stable on treatment. As a nation, they are critical to enabling us to achieve the UNAIDS 95:95:95 goals. They must be targeted at and appropriate for the various sub populations of PLHIV to ensure that no group is left behind.\n\n# 9.2 Differentiated Service Delivery\n\nDifferentiated service delivery (DSD), which is synonymous with differentiated care, is \u201can approach that simplifies and adapts HIV services to better serve the needs of PLHIV whilst reducing unnecessary burdens on the health system\u201d [30]. The concept of DSD is client-centred, focusing on the needs and expectations of PLHIV, those vulnerable to acquiring HIV and how to meet these needs. It seeks to improve access, quality and efficiency of health systems by re-examining traditional service delivery approaches and building upon existing structures in both the health facilities and the communities. Differentiated service delivery integrates task shifting, decentralization, integration and simplification of care across the HIV care continuum. This service delivery approach provides strategies tailored to specific patient populations. It is also termed patient-centred or focused care and aims to efficiently deliver quality services that are deemed 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 initiation, re-engagement in care, adherence and retention, all with the goal of achieving sustained virological suppression.\n\n|Differentiated Service Delivery|Differentiated Service Delivery|Differentiated Service Delivery|\n|---|\n|95% Diagnosed|95% On Treatment|95% Virally Suppressed|\n\nFigure 9.1: Differentiated Care \u2013 Application across the HIV Care continuum\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 150\n\n# 9.2.1 Differentiated HIV Testing Service Delivery\n\nHIV Testing Services (HTS) are the full range of services that should be provided together with HIV testing and the following components: counselling; linkage to appropriate HIV prevention, treatment and care services; other support services and coordination with laboratory services to support quality assurance and the delivery of correct results. This chapter will focus on Differentiated ART Service Delivery (Guidelines for Differentiated HIV Testing Services are addressed in Chapter Two).\n\n# 9.2.2 Differentiated ART Service Delivery\n\nDifferentiated ART service delivery describes a series of management approaches that align with the clinical status (clinically stable or unstable) of PLHIV and their needs and preferences [30]. Models are broadly classified as facility-based or community-based.\n\n- Facility-based models are HIV treatment and care models where services are offered within the existing health facilities\n- Community-based models are HIV treatment and care models where services are offered outside the existing health facilities.\n\nThese models implement either one or a combination of the following approaches:\n\n- Differentiated patient flow: dedicated client pathways at sites for specific patient populations based on patient needs e.g. new patients and those with AHD.\n- Differentiated schedules: adapting clinic flow or dedicating hours, days or appointments for specific populations such as adolescents.\n- Differentiated locations: providing services to certain groups of clients such as stable adults and adolescents within the community; and One Stop Shops for Key Populations.\n\n| |Models of differentiated ART Service Delivery in the Country| | | |\n|---|---|---|---|---|\n|FACILITY - BASED|Fast track (Individual or Group): stable clients pick their drugs from the facility pharmacy without going through the normal clinic flow, including a doctor\u2019s review| | | |\n|COMMUNITY - BASED|Community drug distribution points: These are designated points within the community where ARVs and other medications are dispensed to stable PLHIV| | | |\n|Multi-month dispensing|Medication dispensing interval of 3 months and above.| | | |\n|Health Facility Based ART Group|These are health facility-based groups formed voluntarily by support groups of persons living with HIV who are already meeting regularly at the health facility for ARVs and other medication refills.", "mimetype": "text/plain", "start_char_idx": 346430, "end_char_idx": 351434, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "7bd8ebd7-cbab-48e0-afaf-7691de62ea33": {"__data__": {"id_": "7bd8ebd7-cbab-48e0-afaf-7691de62ea33", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "719b0511-e145-4652-b14e-bc6a1aeeaa19", "node_type": "1", "metadata": {}, "hash": "36eaf09967f18ab4d188dc733689f1e31cb34164cba251da3f2a201fdf899f6b", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "290348b0-0903-42f6-9dee-89f395619ab9", "node_type": "1", "metadata": {}, "hash": "3915de3b0a5322fa0bfe5d8801930a7f136ac81d534172fa6403590d9ba67a8d", "class_name": "RelatedNodeInfo"}}, "text": "- Differentiated locations: providing services to certain groups of clients such as stable adults and adolescents within the community; and One Stop Shops for Key Populations.\n\n| |Models of differentiated ART Service Delivery in the Country| | | |\n|---|---|---|---|---|\n|FACILITY - BASED|Fast track (Individual or Group): stable clients pick their drugs from the facility pharmacy without going through the normal clinic flow, including a doctor\u2019s review| | | |\n|COMMUNITY - BASED|Community drug distribution points: These are designated points within the community where ARVs and other medications are dispensed to stable PLHIV| | | |\n|Multi-month dispensing|Medication dispensing interval of 3 months and above.| | | |\n|Health Facility Based ART Group|These are health facility-based groups formed voluntarily by support groups of persons living with HIV who are already meeting regularly at the health facility for ARVs and other medication refills. This can either be client-led or Healthcare provider-led:| | | |\n|Community Pharmacy Refills| | | | |\n|Community ART Group (CAG)|These are community-based groups formed voluntarily by persons living with HIV within a community for ARVs and other medication refills. This can either be PLHIV led or healthcare provider led. These healthcare providers may include community health workers, case managers and other trained volunteers.| | | |\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Decentralization\n\nRefers to the devolution of stable clients from larger, centralized secondary and tertiary facilities (hubs), to smaller more peripheral primary facilities (spokes). This can be either:\n\n- Semi-autonomous model which restricts ART service delivery at PHCs to ARV and medication refills only\n- Autonomous model which allows for ART initiation at the PHC level and also ARV and medication refills\n\n# Adolescent clubs\n\nGroups of adolescents and young people living with HIV for whom age-appropriate, affordable, friendly health services are provided in an accessible and acceptable environment\n\n# Post Natal Clubs\n\nGroups of women living with HIV who are supported in the postnatal period by healthcare workers and other volunteers like mentor mothers to ensure improved maternal/child health outcomes\n\n# One-Stop Shops and Mobile Clinics\n\nCommunity-based service delivery sites where multiple services are offered and clients can access all their needs under one roof targeted specifically at providing services for Key Populations\n\nThe choice of service delivery model for each client is individualized and should be made following consultation and consent obtained from the client. All community-based models of service delivery must be linked to approved facility-based sites.\n\nDifferentiating service delivery should be based on local assessment which is targeted to improve patient satisfaction, quality of care offered and outcomes. Clients are offered packages of care based on four building blocks (delivery components) and three elements. These characteristics can be applied across the entire HIV care continuum, for both stable and unstable PLHIV who are new to treatment or on long-term follow-up. The building blocks are:\n\n- WHERE services are provided (service location)\n- WHAT service packages are offered (service intensity)\n- WHO is the service provider (health worker cadre)\n- WHEN the recommended frequency of visits (service frequency)\n\nThe 3 elements to be considered in each assessment for differentiating service delivery are:\n\n- Clinical Characteristics \u2013 Patient stability and associated co-morbidities\n- Specific Populations \u2013 Children, Adolescents, Women (Pregnant and breastfeeding), Men and Key Populations\n- Context \u2013 Urban or rural location, unstable context (e.g. conflict, high migration) and epidemic/pandemic scenarios\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n152\n\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\nNon-pregnant adult PLHIV can be categorized into four broad groups, each with distinct care needs namely;\n\n- Newly diagnosed or re-engaging clients who are well\n- Clients who present with AHD\n- Clients who are on ART and stable\n- Clients on ART and unstable\n\nIt is recommended that each of these groups is offered care packages which address their peculiar needs.\n\n|People living with HIV|Care package elements and focus of care|\n|---|---|\n|Newly diagnosed, generally well at presentation, in WHO stage 1 and 2 with high CD4+ cell counts (>200 cells/mm3)|- Preparation for ART requires readiness and willingness to initiate treatment. Adherence and retention in care are essential in committing to lifelong ART.", "mimetype": "text/plain", "start_char_idx": 350482, "end_char_idx": 355237, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "290348b0-0903-42f6-9dee-89f395619ab9": {"__data__": {"id_": "290348b0-0903-42f6-9dee-89f395619ab9", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "7bd8ebd7-cbab-48e0-afaf-7691de62ea33", "node_type": "1", "metadata": {}, "hash": "fc71ddcb80625c522a179163652a13b4eaf8e921e121c3a733009877f5878234", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "a53ff8fa-43d7-4c48-b5a4-f1fc4a15e5e6", "node_type": "1", "metadata": {}, "hash": "2afec7acad3487b8c6ec20f30086b48fc2347e7e9271a0738e9869fb97f46de3", "class_name": "RelatedNodeInfo"}}, "text": "|People living with HIV|Care package elements and focus of care|\n|---|---|\n|Newly diagnosed, generally well at presentation, in WHO stage 1 and 2 with high CD4+ cell counts (>200 cells/mm3)|- Preparation for ART requires readiness and willingness to initiate treatment. Adherence and retention in care are essential in committing to lifelong ART.\n- Adherence counselling\n- ART Initiation\n- TPT\n- Retention support\n- TB screening\n|\n|Advanced HIV disease (CD4+ cell count <200 cells/mm and /or WHO disease stages 3 and 4)|- Accelerated clinical response to prevent death and reduce illness with the following:\n- Appropriately timed initiation of ART (taking the risk of IRIS into consideration)\n- Screening and management of OIs and other care and support services\n- TB screening, diagnosis and treatment\n- CPT and TPT\n|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n153\n\n# People living with HIV\n\nCare package elements and focus of care- Close monitoring for identification and management of opportunistic infections- Adherence monitoring\n\n# Patients who are on ART and are unstable\n\n- Treatment literacy and retention support- Viral load testing- Switch to second- or third-line ART if indicated- TB screening, diagnosis and treatment- CPT and TPT- Monitoring for HIV drug resistance (HIVDR)- Other care and support services\n\n# Patients who are on ART and are stable\n\n- Reduced frequency of clinic visits- Community ART delivery models\n\nThese groupings are fluid with clients moving from one group to another whilst in care but enabling health systems to differentiate and target individuals requiring intense facility-based services from those who require less frequent clinical consultations and could collect their ART from the community-based models of care.\n\nStability is defined based on duration on ART, age, clinical status, level of adherence and treatment success. Children, men and non-pregnant/breastfeeding women living with HIV are stated to be stable or unstable based on specific criteria.\n\n# Table 9.3: Stability Criteria for Children, Adult Men and Non-Pregnant Women\n\n|Criteria|STABLE|UNSTABLE/COMPLEX|\n|---|---|---|\n|Age|Adults, Adolescents and Children > 5yrs|Children < 5yrs|\n|Duration of ART|On ART for at least one year|- ART na\u00efve patients - On ART less than one year - AHD (WHO clinical stages 3-4)|\n|Clinical status *|Clinically stable with no opportunistic infections or current illnesses - Adherent with an optimal understanding of lifelong treatment - Age-appropriate disclosure desirable for children and adolescents - Evidence of treatment success - two consecutive viral load measurements < 1,000 copies/ul - Has initiated/completed TPT - Has no adverse drug reactions that require regular monitoring|- Co-morbidities e.g. diabetes mellitus, heart, chronic liver, and chronic kidney diseases - Poor adherence - Orphans and vulnerable children - Unsuppressed viral load - On 2nd or 3 line regimenrd - On recently changed regimen < 6months - Experiencing treatment failure|\n|Monitoring|- Does not require close monitoring at the facility level - Regular CD4+ cell count monitoring is unnecessary|- Close monitoring necessary at the facility level - CD4+ cell count monitoring may be required|\n\n*All mentally impaired or retarded PLHIV, including those with psychiatric manifestations should be classified as unstable, irrespective of the age, CD4+cell count or viral load; Unstable clients require closer monitoring and should receive facility-based care. They should not be devolved into any community model of differentiated ART delivery; Clients devolved to community-based models who become unstable should be referred back to the mainstream facility for closer monitoring.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - Page 154\n\n# Stable clients can be offered packages of care at the community level that do not include CD4+ cell count monitoring and also a reduction in the frequency of:\n\nClinical consultations to every 3-6 months\n\nARV drug refills and medication pickup to every 3 months\n\n# 9.2.4 Differentiated Service Delivery based on Sub-Populations\n\nThe various sub-populations of PLHIV considered for differentiated ART service delivery include:\n\n- Pregnant and breastfeeding women\n- Children\n- Adolescents and young people\n- Adult men and non-pregnant women\n- Key Populations (KPs)\n\n# 9.2.4.1 Differentiated Service Delivery for Pregnant and Breastfeeding Women\n\nThe facility-based DSD model of care is recommended for Pregnant and Breastfeeding women as it makes provision for safe delivery practices, promotes mother/baby pair, in addition to prevention of mother-to-child transmission and antiretroviral therapy.", "mimetype": "text/plain", "start_char_idx": 354891, "end_char_idx": 359592, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "a53ff8fa-43d7-4c48-b5a4-f1fc4a15e5e6": {"__data__": {"id_": "a53ff8fa-43d7-4c48-b5a4-f1fc4a15e5e6", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "290348b0-0903-42f6-9dee-89f395619ab9", "node_type": "1", "metadata": {}, "hash": "3915de3b0a5322fa0bfe5d8801930a7f136ac81d534172fa6403590d9ba67a8d", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "00592b08-271a-4179-85b5-664a5fb0b4c8", "node_type": "1", "metadata": {}, "hash": "5378bc95e5eac365cff651bf528a7be2d0106857770acb7143aaadd2fd61a654", "class_name": "RelatedNodeInfo"}}, "text": "Stability Criteria for Pregnant and Breastfeeding Women: The stability criteria for pregnant and breastfeeding women differs from the criteria for non-pregnant adults and children and is based on the viral load in the index pregnancy and previous PMTCT outcomes. A pregnant or breast-feeding woman is stated to be stable or unstable based on the criteria outlined in Table 9.4.\n\n|STABLE|UNSTABLE|\n|---|---|\n|Viral load &lt; 1000copies/ml in index pregnancy|Viral load &gt;1000copies/ml or unknown VL|\n|Has had a previous PMTCT experience and had a child with a HIV negative test result at 18 months|- Is a newly diagnosed PLHIV|\n| |- Is less than 20 years of age|\n| |- Has an obstetric or medical condition|\n| |- First PMTCT experience irrespective of ART status|\n| |- Previous PMTCT experience with a negative outcome|\n\nIt is recommended that pregnant and breastfeeding women be categorized into the following groups. This categorization will assist in deciding the most appropriate DSD model especially if a facility-based DSD model is not available in the environment.\n\n- It is recommended that stable pregnant and breastfeeding women should continue on DSD as appropriate to their peculiar situation. Their ART and antenatal clinic visits should be synchronized for those previously receiving care in a facility model of DSD. However, if she had been devolved into a community model of DSD, she should be linked to a health facility for antenatal services and to a health care provider-led group or mentor mother-led group for her drug pick up.\n- 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\n\n155\n\n# Recommendations for Differentiated Service Delivery for Women and Children\n\nFor breastfeeding women and children up to five years, at the secondary or tertiary facility level, it is important to ensure Prevention of Mother-To-Child Transmission (PMTCT) and safe delivery. Women who were on facility-based DSD models before delivery may choose to continue with it, but clinical consultation should be coordinated with Mother-Infant Pair (MIP) visits. Refills of ARV/medication should not go beyond 3 months.\n\n# Recommendations for Pregnant Women\n\n- Unstable pregnant women should be managed at a facility model of DSD.\n- Stable pregnant and breastfeeding women who were under a community model of DSD before pregnancy can continue to receive ARV/medication refills at the community level but should be connected to a facility for Antenatal Care (ANC).\n- Alignment of clinical visits and ARV/medication refills for the mother-infant pair is advised.\n- ARV/medication refills should not exceed 3 months.\n\n# Recommendations for Children\n\nChildren are often not adequately addressed in healthcare programs. It is suggested that the DSD model a child is under should align as much as possible with that of the mother or caregiver (if also on ART).\n\nChildren should be considered for enrollment into DSD from 5 years and above if they meet the criteria. They should be seen at primary treatment facilities within a maximum time frame of 3 months. If a child enrolled in DSD no longer meets the eligibility criteria, they should be promptly referred back to the primary treatment facility for review and ongoing management.\n\n# Special Scenarios\n\nIncarcerated children, those in boarding schools, and children of parents classified as Key Populations (KPs) should be categorized as stable or unstable based on specific criteria. Caregivers, lay providers, and school matrons should be able to collect ART drug refills for these children. Clinical consultations for children in boarding schools should align with school holidays as much as possible.\n\n- Unstable children should be managed at a facility model of DSD.\n- Stable children (from 5 years) can be under a community model of DSD, but ARV/medication refills should not be given for more than 3 months, and clinical visits should occur at the mainstream health facility every 3 months.\n\n# 9.2.4.3 Differentiated Service Delivery for Adolescents and Young People (AYP)\n\nDifferentiated service delivery for AYP focuses on the preferences and expectations of this sub-population. It aims at offering fewer intensive services to those who are stable on ART. Adolescents and young people with AHD at initiation should be provided with a package of care targeted to ensure stability within the first year of care. Stable clients on DSD who become unstable should be referred back to the mainstream facility for the continuum of care.\n\nIt is recommended that a family approach be adopted for stable AYP, whereby families receive same-day appointments, same-length ART refills or allowing one family member (rotated) to collect ART refills for other stable family members.", "mimetype": "text/plain", "start_char_idx": 359594, "end_char_idx": 364412, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "00592b08-271a-4179-85b5-664a5fb0b4c8": {"__data__": {"id_": "00592b08-271a-4179-85b5-664a5fb0b4c8", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "a53ff8fa-43d7-4c48-b5a4-f1fc4a15e5e6", "node_type": "1", "metadata": {}, "hash": "2afec7acad3487b8c6ec20f30086b48fc2347e7e9271a0738e9869fb97f46de3", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "8748db76-7138-4631-b69f-c177c46c7ccd", "node_type": "1", "metadata": {}, "hash": "c801d4f48fa38b564831c447983a90029f83c515cc3e39a7965e4228e727d6b2", "class_name": "RelatedNodeInfo"}}, "text": "# 9.2.4.3 Differentiated Service Delivery for Adolescents and Young People (AYP)\n\nDifferentiated service delivery for AYP focuses on the preferences and expectations of this sub-population. It aims at offering fewer intensive services to those who are stable on ART. Adolescents and young people with AHD at initiation should be provided with a package of care targeted to ensure stability within the first year of care. Stable clients on DSD who become unstable should be referred back to the mainstream facility for the continuum of care.\n\nIt is recommended that a family approach be adopted for stable AYP, whereby families receive same-day appointments, same-length ART refills or allowing one family member (rotated) to collect ART refills for other stable family members.\n\nThe principles of DSD models for AYP living with HIV should include the following:\n\n- AYP-centred (friendly, accessible, acceptable, affordable and stigma/discrimination-free)\n- Leverage on the existing adolescent support groups/clubs either at the facility or community\n- Preferably peer-led, especially amongst the older AYP\n- Adaptable (after school hours, weekends and holidays)\n- Pregnant adolescents should not be differentiated to community-based models\n\nDSD Modelling Approaches for AYP: These models outlined in Figures 9.3 and 9.4 below should be implemented primarily for stable adolescents whose ART refill should be every three to six months with clinical reviews completed at each visit. ART refills can also take place at the adolescents' club or support group meetings or within community ART groups. Where feasible, community volunteers should conduct monthly home visits to stable adolescents in community models. Unstable adolescents should have ART refills and clinical consultations conducted more frequently (one to two-monthly basis) at the facility.\n\nFigure 9.3: Building Blocks for DSD in AYP 10 \u2013 19 years\n\n|Receiving services|Delivering services|\n|---|---|\n|Young Adolescents|ART Clinician|\n|Caregivers and family|ART Nurse|\n|WHO|Adherence officer|\n| |Laboratory officer|\n| |Pharmacist|\n\nWHERE\n\n- Facility-based\n- - Out-of school clinic hours managed by HCWs\n- Weekend adolescent focused clinic\n- Using adolescent support groups\n- Adolescent clubs (peer-led)\n\nCommunity-based\n\nWHEN\n\n- ART initiation/fill\n- Laboratory tests\n- Clinical monitoring\n- Psychosocial support\n- Treatment of OI\u2019s\n- Adherence support\n- Linkage of caregivers to household economic empowerment and livelihood opportunities\n\n*For already mapped-out schools with established clinics\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n157\n\n# Figure 9.4: Building Blocks for DSD in AYP 20 \u2013 24 years\n\n|Receiving services|Delivering services|\n|---|---|\n|Young persons|ART Clinician|\n|Peers|ART Nurse|\n|WHO|Adherence officer|\n| |Laboratory officer|\n| |Pharmacist|\n|Facility-based|Community-based|\n|Support group|Community pharmacies|\n|Youth clubs|Adolescent community ART distribution groups|\n| |Higher institution-based clinics|\n\n# WHERE\n\n- ART initiation/fill\n- Laboratory tests\n- Clinical monitoring\n- Psychosocial support\n- Treatment of OI\u2019s\n- Adherence support\n- Linkage of caregivers to household economic empowerment and livelihood opportunities\n- Peer support\n- SMS adherence support\n- Youth Whatsapp platforms\n\n# WHEN\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\nIt is recommended that adult men and non-pregnant women who are stable on ART be differentiated to models of care that offer less frequent clinical consultations (3-6 months) and drug refills (3-6 months).\n\nRecommendations made below for service delivery in adults will be divided into those recommended at baseline, for those presenting well or with AHD and also for those who are stable or unstable after at least 1 year on ART.", "mimetype": "text/plain", "start_char_idx": 363635, "end_char_idx": 367518, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8748db76-7138-4631-b69f-c177c46c7ccd": {"__data__": {"id_": "8748db76-7138-4631-b69f-c177c46c7ccd", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "00592b08-271a-4179-85b5-664a5fb0b4c8", "node_type": "1", "metadata": {}, "hash": "5378bc95e5eac365cff651bf528a7be2d0106857770acb7143aaadd2fd61a654", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "c558b0e8-3b18-42f1-afef-6f0734840d33", "node_type": "1", "metadata": {}, "hash": "ae7d6b30c9e9944d673e81ea943478e87460d39f1b837b55bbc80b6d79d0fa11", "class_name": "RelatedNodeInfo"}}, "text": "Recommendations made below for service delivery in adults will be divided into those recommended at baseline, for those presenting well or with AHD and also for those who are stable or unstable after at least 1 year on ART.\n\n# Table 9.5: Packages of Care for Newly Diagnosed, Re-engaging or AHD Clients\n\n|Baseline Package of Care|Client Presenting Well|\n|---|---|\n|Who qualifies for the package of care|Client with WHO clinical stage 1 3 or 2 or CD4+ count > 200 cell/mm|\n|Who is the Service Provider|Healthcare workers trained to provide ART services (Clinician, Nurse, adherence counsellor, laboratory and pharmacy personnel) *|\n|Service Location|Approved health facilities|\n|Service Intensity (Packages Offered) and Service Frequency|Monthly for the first 2 months, thereafter 2-monthly for the first year.|\n|Advanced HIV Disease| |\n|Client with WHO clinical stage 3 or 4 or CD4+ count <200 cell/mm3| |\n|Healthcare workers trained to provide ART services (Clinician, Nurse, adherence counsellor, laboratory and pharmacy personnel)| |\n|Service Location|Approved health facilities|\n|Service Intensity (Packages Offered) and Service Frequency|Weekly/Bi-weekly in the first 1 month, Monthly for the first 2 months, thereafter 2-monthly for the first year|\n\n*For already mapped-out institutions with established clinics\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - 158\n\n# Baseline Package of Care\n\n|Monitoring|Client Presenting Well|Advanced HIV Disease|\n|---|---|---|\n|ART Refill Visits|Monthly for the first 2 months, thereafter 2-monthly for the first year.|Monthly for the first 2 months, thereafter 2-monthly for the first year.|\n|Laboratory monitoring|Laboratory monitoring tests may differ according to the level of the health care facility and should be done according to the schedule approved in the National Guidelines.|Laboratory monitoring tests may differ according to the level of the health care facility and should be done according to the schedule approved in the National Guidelines. Additional tests may be indicated based on diagnosed OIs.|\n|Ancillary services: psycho-social services, intensified adherence support chronic care/PHDP Services|At every clinic contact|At every clinic contact subsequently|\n\n*Adherence counselling/support and clinical screening for TB should be done at every clinic contact.\n\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\n|Package of Care| |Stable Client| | |\n|---|---|---|---|---|\n| |Service Location|Community models of DSD and Approved health facilities| | |\n| | |Service Intensity (Packages Offered) and Service Frequency|Less frequent \u2013 3 to 6 monthly| |\n| |Clinical consultations|Less frequent \u2013 3 to 6 monthly| | |\n| | |ART Refill Visits|Less frequent \u2013 3 to 6 monthly, VL monitoring annually, Cessation of CD4+ count monitoring if viral load testing is available| |\n|Ancillary services: psycho-social services intensified adherence support chronic care/PHDP Services|Aligned with clinic visit and ART refill| | | |\n|Unstable Client| | | | |\n| |Service Location|Approved health facilities| | |\n| |No devolvement till stable| | | |\n|Frequent - Monthly for 3 months or as indicated; subsequently as indicated.| | | | |\n|Frequent - monthly for 3 months; subsequently 2 monthly or as indicated VL monitoring at the end of 3 months after EAC for unsuppressed patients; subsequently according to National guidelines| | | | |\n|Monthly for 3 months or as indicated; subsequently aligned with clinic visits| | | | |\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 9.2.4.5 Differentiated Service Delivery for Key Populations\n\nKey populations (KPs) are defined as \u201cgroups who due to specific higher-risk behaviours, are at increased risk of HIV irrespective of the epidemic type or local context\u201d [1]. Internally Displaced Persons (IDPs), people in closed settings, fishing communities, truckers, marginalized or minority groups such as undocumented migrants, ethnic and sexual minorities etc. are also categorized as vulnerable and hard-to-reach populations.", "mimetype": "text/plain", "start_char_idx": 367295, "end_char_idx": 371520, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c558b0e8-3b18-42f1-afef-6f0734840d33": {"__data__": {"id_": "c558b0e8-3b18-42f1-afef-6f0734840d33", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "8748db76-7138-4631-b69f-c177c46c7ccd", "node_type": "1", "metadata": {}, "hash": "c801d4f48fa38b564831c447983a90029f83c515cc3e39a7965e4228e727d6b2", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "14a09a50-0bed-4733-b746-5389a1f64ed8", "node_type": "1", "metadata": {}, "hash": "47a2701a871eb17facf824d265293a7959537585311c47848a89bdae87e8ea34", "class_name": "RelatedNodeInfo"}}, "text": "Internally Displaced Persons (IDPs), people in closed settings, fishing communities, truckers, marginalized or minority groups such as undocumented migrants, ethnic and sexual minorities etc. 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 due to the following reasons:\n\n- The health-seeking behaviour of KPs is geared towards alternative structures that are community-based and not facility-based and this also means that identification of new cases will be at these alternative community structures.\n- Key Populations are also highly mobile in nature.\n- There are ancillary services uniquely demanded by KPs which include legal aid support, interventions for gender-based violence, Mental Health and Psychosocial Services (MHPSS). These are not provided under one roof or in most health facilities and this mitigates against KPs accessing and being retained in care at these health facilities.\n- The fear of stigmatization, discrimination and a criminalizing legal environment is also a huge challenge at the health facilities. An enabling environment (safe space) that provides the full complement of services required by this group is pertinent.\n\nBased on the above peculiarities the following models are advocated for service delivery to key populations:\n\n- One-Stop-Shop (OSS) strategy: This refers to the delivery of a comprehensive service package, under one roof, which is non-discriminatory, non-stigmatizing, safe, friendly and in a conducive environment.\n- Mobile ART teams (MART): These are trained healthcare service providers that often compose of at least 3 members namely; a clinician, a pharmacist and a laboratory scientist. These teams leverage on outreaches and designated hot spots to provide services to KPs.\n- Community Pharmacy (CP): These are pharmacies within the community used for ARV refills to maintain good adherence to ARVs and retention on ART.\n- Focal Service Providers (FSP): These are trained personnel who reside within the community and can easily be called upon to provide tailored services to KPs within their environment.\n- Peer-led support group meetings: This is a confidential platform where meetings are routinely held during which ART refills, adherence education/reinforcement and general social support are provided basically to strengthen retention in care. Guidance is also provided by experts during such meetings.\n- Key Population Friendly Health Facility: These facilities provide comprehensive services for KPs in a friendly and conducive environment. They ensure that all community-level DSD models for KPs are provided with a strong linkage to the Health facilities.", "mimetype": "text/plain", "start_char_idx": 371263, "end_char_idx": 374004, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "14a09a50-0bed-4733-b746-5389a1f64ed8": {"__data__": {"id_": "14a09a50-0bed-4733-b746-5389a1f64ed8", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "c558b0e8-3b18-42f1-afef-6f0734840d33", "node_type": "1", "metadata": {}, "hash": "ae7d6b30c9e9944d673e81ea943478e87460d39f1b837b55bbc80b6d79d0fa11", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "bdd91bc2-8834-4bd7-9c6c-8d017eb043d2", "node_type": "1", "metadata": {}, "hash": "20d8972f1974ff358db8f75dfc5b672000aacf7352f4ade13edd5d21659f90c6", "class_name": "RelatedNodeInfo"}}, "text": "These teams leverage on outreaches and designated hot spots to provide services to KPs.\n- Community Pharmacy (CP): These are pharmacies within the community used for ARV refills to maintain good adherence to ARVs and retention on ART.\n- Focal Service Providers (FSP): These are trained personnel who reside within the community and can easily be called upon to provide tailored services to KPs within their environment.\n- Peer-led support group meetings: This is a confidential platform where meetings are routinely held during which ART refills, adherence education/reinforcement and general social support are provided basically to strengthen retention in care. Guidance is also provided by experts during such meetings.\n- Key Population Friendly Health Facility: These facilities provide comprehensive services for KPs in a friendly and conducive environment. They ensure that all community-level DSD models for KPs are provided with a strong linkage to the Health facilities.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - 160\n\n# Table 9.7: Service Package and Level of Provision\n\n|Service Delivery Model|HTS|ART enrolment/Initiation|ARV refills (3,6 MMD)|STI screening /diagnosis|TPT/CPT|GBV intervention|Legal support services|Harm reduction (NSP, Overdose &wound management)|Harm Reduction (OST)|Hepatitis screening|TB screening (five questions using screening tool)|Cervical cancer screening|PMTCT (ANC/ART)|HIV exposed infant prophylaxis/ EID|\n|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|\n|Community Level| | | | | | | | | | | | | | |\n|Facility Level|OSS|MART|FSP|CP|Peer Support Group|HCP| | | | | | | | |\n| |\u00fc|\u00fc|\u00fc|\u00fc|\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| | | | | | | | | | | | | |\n| |\u00fc| | | | | | | | | | | | | |\n| |\u00fc|\u00fc|\u00fc|\u00fc|\u00fc|\u00fc| | | | | | | | |\n| |\u00fc| | | | | | | | | | | | | |\n| |\u00fc|\u00fc|\u00fc|\u00fc|\u00fc|\u00fc| | | | | | | | |\n| |\u00fc| | | | | | | | | | | | | |\n| |\u00fc| | | | | | | | | | | | | |\n\n# 9.2.5 Differentiated Service Delivery Based on Context\n\nThe context in which HIV services are offered takes into consideration the prevalence rates of HIV in these areas (high or low), whether the epidemic is concentrated, generalized or mixed and also the location (urban or rural), where services are offered. Unstable, challenging settings such as conflict regions, high migration areas and border towns also require specifically tailored interventions to ensure that affected populations can access quality HIV services within these challenging scenarios. Linkages to and sustained care may be hindered by distance, terrain, safety concerns, transportation costs and few, over-burdened health facilities with long waiting times. It is recommended that differentiated service delivery models take into consideration the context in which services are required in such communities and be tailored to the specific needs of these individuals.\n\n# 9.2.6 Integration of Service Delivery\n\nIt is recommended that facility and community-based sites leverage on differentiated service delivery models for ART and integrate other services. This is cost-effective in terms of human\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Family-Centred Differentiated Service Delivery\n\nFamily-centred DSD in the context of HIV services provides integrated services for family members at the same time (when), by the same healthcare provider (who) at the same venue (where). Family-centred care, though not new have had limited applicability. These interventions seek to align visits at facility or community level for family members, including children and adolescents to further improve efficiency, adherence, retention in care and virological suppression of patients. It also reduces the multiplicity of healthcare workers offering one family services, thereby reducing the frequency and intensity of contact with healthcare providers. It is recommended that implementation of DSD models provide an avenue to implement and scale-up family-centred interventions which have benefits for not only the patients and affected caregivers, but also the healthcare system itself.", "mimetype": "text/plain", "start_char_idx": 373025, "end_char_idx": 377205, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "bdd91bc2-8834-4bd7-9c6c-8d017eb043d2": {"__data__": {"id_": "bdd91bc2-8834-4bd7-9c6c-8d017eb043d2", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "14a09a50-0bed-4733-b746-5389a1f64ed8", "node_type": "1", "metadata": {}, "hash": "47a2701a871eb17facf824d265293a7959537585311c47848a89bdae87e8ea34", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "74ce8aca-8c4a-44ed-856d-b4a5f75531f1", "node_type": "1", "metadata": {}, "hash": "f91b76710b53ea1d0155c049212db5ee0f0472c6cebc137403bb0e427e19b423", "class_name": "RelatedNodeInfo"}}, "text": "This is cost-effective in terms of human\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Family-Centred Differentiated Service Delivery\n\nFamily-centred DSD in the context of HIV services provides integrated services for family members at the same time (when), by the same healthcare provider (who) at the same venue (where). Family-centred care, though not new have had limited applicability. These interventions seek to align visits at facility or community level for family members, including children and adolescents to further improve efficiency, adherence, retention in care and virological suppression of patients. It also reduces the multiplicity of healthcare workers offering one family services, thereby reducing the frequency and intensity of contact with healthcare providers. It is recommended that implementation of DSD models provide an avenue to implement and scale-up family-centred interventions which have benefits for not only the patients and affected caregivers, but also the healthcare system itself.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n162\n\n# Differentiated ART Service Delivery Models\n\n\u2022 Differentiated ART service delivery models are broadly classified as facility-based or community-based and all community-based models of service delivery should be linked to an approved facility.\n\n\u2022 It is recommended that all unstable PLHIV be managed at a facility model of DSD.\n\n\u2022 Stable clients can be offered and devolved to packages of care at the community level with a reduction in the frequency of clinical consultations and ARV/medication drug refills.\n\n\u2022 Alignment of consultation and refill visits for family members and integration of other services into differentiated ART service delivery models is recommended.\n\n# Standards for Quality HIV Service Delivery\n\nQuality is defined as the totality of features and characteristics of an entity that bears on its ability to satisfy a stated or implied need. The perception of the healthcare needs of a client or community will vary based on the views and perspectives of the client, service provider, society and the social, political and economic environment. Standards are seen as expectations of performance and help organizations understand how they can meet the diverse treatment needs of 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 prevention, testing, care and treatment across both public and private health facilities as well as at the community level. The need for streamlined standards for HIV service delivery across all strata of health care cannot be over-emphasized, bearing in mind the differences in unmet need across 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 involved to implement it. On the other hand, the simplest of systems can work very effectively if there is motivation and commitment on the part of those involved to improve the quality of care. Continuous quality improvement can therefore be achieved by encouraging a quality culture that is based on a common vision, purpose, understanding, values and principles.\n\n# Standards of Care\n\nThe standard care continuum for HIV extends from testing and counselling to care, treatment, and monitoring. The care continuum is not a \u201cone size fits all\u201d rather there are peculiarities for the various sub-populations, such as children, adolescents, key populations and pregnant/breastfeeding women. With more than 1.14 million (at 2019) PLHIV enrolled in care, it is important to employ strategies that strengthen linkages to care, retention in care and adherence to therapy to ensure that at least 95% of each of the various sub-populations of PLHIV achieve and sustain virological suppression.\n\nCertain strategies have been shown to strengthen/optimize the indices necessary to cater to the unmet need in HIV service delivery, key among them are:\n\nImproving Quality of Health Service Delivery\n\nQuality of care emphasizes that services should be effective in achieving desired health outcomes and that health care practices should be people-centred and safe. Efficient and effective HIV service delivery in Nigeria requires the following:\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n163\n\n# Health System Strengthening and Systemic Linkages\n\nHealth system strengthening and well-coordinated systemic linkages across primary, secondary, and tertiary health facilities as well as with community-based facilities, social support services, and support groups.\n\n# National Quality Evaluation and Accreditation Processes\n\nNational quality evaluation and accreditation processes for health facilities and health providers at both the facility and the community level aimed at:\n\n- Creating new service delivery sites at both facility and community levels\n- Reviewing existing facilities for potential designation as service delivery site\n- Assessing community capacity and identifying interventions to train and coordinate public education\n- Allocating new resources or reallocating existing scarce resources to HIV care\n- Overseeing national treatment programmes\n\n# Capacity Building\n\nCapacity building for healthcare providers at both the facility and community level and also of PLHIV for effective service delivery and communication.", "mimetype": "text/plain", "start_char_idx": 376163, "end_char_idx": 381598, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "74ce8aca-8c4a-44ed-856d-b4a5f75531f1": {"__data__": {"id_": "74ce8aca-8c4a-44ed-856d-b4a5f75531f1", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "bdd91bc2-8834-4bd7-9c6c-8d017eb043d2", "node_type": "1", "metadata": {}, "hash": "20d8972f1974ff358db8f75dfc5b672000aacf7352f4ade13edd5d21659f90c6", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "de21296b-ca4d-4077-8ca6-1672b328f78c", "node_type": "1", "metadata": {}, "hash": "67be684ba13c90f8fb7a000a36359d0d1811cfa15184f7fcb40f2cdbdb1415af", "class_name": "RelatedNodeInfo"}}, "text": "# National Quality Evaluation and Accreditation Processes\n\nNational quality evaluation and accreditation processes for health facilities and health providers at both the facility and the community level aimed at:\n\n- Creating new service delivery sites at both facility and community levels\n- Reviewing existing facilities for potential designation as service delivery site\n- Assessing community capacity and identifying interventions to train and coordinate public education\n- Allocating new resources or reallocating existing scarce resources to HIV care\n- Overseeing national treatment programmes\n\n# Capacity Building\n\nCapacity building for healthcare providers at both the facility and community level and also of PLHIV for effective service delivery and communication. Tasks must be clearly delineated, and performance expectations well defined.\n\n# Client Support and Informed Decision Making\n\nProviding information and supporting clients to make informed decisions about their health, their engagement with health care, and management of their health.\n\n# Appointment Systems and Tracking\n\nStrengthening existing patient appointment systems with acceptable frequency of clinic and medication refill visits and an efficient system for identification and tracking of PLHIV who default on their appointments.\n\n# Service Delivery Models and Quality Improvement\n\nAdoption of differentiated service delivery models and quality improvement strategies to reduce waiting and turnaround times in clinics, laboratories, and drug refill centers.\n\n# Integration of Services\n\nIntegrating the delivery of other services into HIV service delivery platforms as appropriate and relevant e.g. TB, hepatitis, STIs, mental health, substance abuse, NCDs, nutrition, and SRHS.\n\n# Quality Control\n\nQuality control for test kits, medications (including ARVs and OI drugs), and diagnostic equipment.\n\n# Data Management\n\nThe need to continually monitor and improve on perceived gaps in service delivery cannot be over-emphasized; therefore, continuous quality improvement should be integrated into routine service delivery. The framework in use in Nigeria for quality improvement programs is the NigeriaQual.\n\nFMOH and IPs\nState MP teams and IP QI teams\nSite and Network QI teams\nFigure 9.5: NigeriaQual Implementation Structure\n\n# NigeriaQual Components\n\n- Performance measurement\n- Indicator development, data collection, analysis and reporting\n- Quality management structure\n- Quality improvement teams at sites\n- Multidisciplinary management teams at facility, local government, state and federal government level\n- Quality improvement\n- Problem identification, prioritization, implementation of tests of change\n- Plan, Do, Study, Act (PDSA) cycle guides sustainable ongoing change\n\nReview the findings of your quality management system. Re-evaluate both the processes and the product.\n\n|PLAN|DO|ACT|CHECK|\n|---|---|---|---|\n|Begin the quality management process|Control; measure and monitor your outputs to ensure they meet expected criteria| | |\n|Identify areas where there is opportunity for improvement| | | |\n\nFigure 9.6: The Four Main Components of Quality Control Management\n\nIdentify your goals and baseline. Assemble internal resources. Determine quality standards and the requirements to meet those standards. Determine what procedures will be used to ensure criteria are being met, including training materials, policies, procedures, and documentation. Organize supporting documentation (ISO work instructions; documentation management system). Train employees on new processes. Deploy the quality management system.\n\n# Human Resource for Health\n\nThe inadequacy of the right number and mix of health workers to deliver quality ART services is a major obstacle to the achievement of universal access to quality HIV prevention, treatment, and care. Evidence-based interventions should be implemented to boost human resources for HIV service delivery. There is also the need to minimize staff attrition and incessant transfer of trained ART service providers. Additionally, there is a need for government and responsible agencies to consistently employ competent healthcare providers for the provision of ART services.\n\n# Training of Health Workers\n\nIt is recommended that:\n\n- All health workers and lay providers involved in the provision of HIV treatment and care should receive training prior to offering services and periodic re-training thereafter\n- Training of health workers and lay providers should conform with globally accepted standards for high-quality training\n- Training of health workers and lay providers should be conducted using nationally approved training curricula and manuals\n- Training curricula for the different cadres of healthcare providers, lay providers, peer educators, mentor mothers, etc., should be age and context-appropriate\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Task shifting and Task sharing\n\nTask shifting and task sharing involve the redistribution of tasks within health workforce teams that allows specialized health workers more time to focus on advanced clinical conditions while non-physician providers attend to more stable patients. It also makes it possible for lay providers to offer certain non-specialized services especially in community models of HIV service delivery. Task shifting and task sharing has enhanced linkage to care, addressed the high patient-to-doctor ratio, helped reduce the high default rates among patients already on ART, improved treatment adherence, patient satisfaction and also strengthened community systems.", "mimetype": "text/plain", "start_char_idx": 380826, "end_char_idx": 386429, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "de21296b-ca4d-4077-8ca6-1672b328f78c": {"__data__": {"id_": "de21296b-ca4d-4077-8ca6-1672b328f78c", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "74ce8aca-8c4a-44ed-856d-b4a5f75531f1", "node_type": "1", "metadata": {}, "hash": "f91b76710b53ea1d0155c049212db5ee0f0472c6cebc137403bb0e427e19b423", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "6f34babe-4cfe-4d28-803f-81fa7142e2d0", "node_type": "1", "metadata": {}, "hash": "71dec4a24bf80bf43bc98accf50332494f21ebc1ca51f920bb14bcb154cd7cc6", "class_name": "RelatedNodeInfo"}}, "text": "It also makes it possible for lay providers to offer certain non-specialized services especially in community models of HIV service delivery. Task shifting and task sharing has enhanced linkage to care, addressed the high patient-to-doctor ratio, helped reduce the high default rates among patients already on ART, improved treatment adherence, patient satisfaction and also strengthened community systems. Task shifting and sharing must be implemented with clear cut clarification of roles and assignments. It also requires mentorship and supportive supervision to ensure continuous quality improvement. The National Policy on Task Shifting provides guidelines and recommendations on task shifting and service provision and should be referred to for support in ensuring consistent quality of service delivery.\n\n# Standard Precautions\n\nThese are general guidelines to safeguard the various individuals involved in HIV service delivery, including healthcare workers, lay providers, clients and the community at large. In the day to day delivery of HIV services, there are safety measures that must be considered if optimal services are to be sustained; these include:\n\n# Infection Prevention and Control (IPC) Measures\n\nThese are measures/protocols put in place to ensure protection from infectious agents either as a result of nosocomial exposure or wide-spread infection at the community level. It is necessary to put in place protocols which will provide guidance in cases of infections of public health concern. In the case of HIV, it is necessary to prevent accidental infections, occupational infections and any widespread infection within a vulnerable sub population due to harmful practices or low level of awareness. There should be an established IPC policy in all health facilities in the private and public sectors to ensure the prevention of accidental/occupational exposure to blood, body fluids and airborne pathogens that may result in infection with HIV or any other infectious disease.\n\n# Standard Precautions\n\nThese are minimum infection prevention practices that should be observed by ALL health workers/lay providers in the provision of HIV services, regardless of suspected or confirmed infection status and include:\n\n- Hand Hygiene - Routine hand washing with soap and water before and after contact with each patient, regardless of the HIV status\n- Respiratory hygiene/cough etiquette\n- Use of barrier precautions including Personal Protective Equipment (PPE) such as gloves, gowns and masks etc.\n- Sharps Safety/Safe Injection Practices - Safe handling and disposal of sharp instruments and equipment, including needles and syringes\n- Clean and disinfected work surfaces\n\nFor more details, refer to the National Guideline for Continuity of HIV service delivery in the context of complex emergencies. It is recommended that ALL health facilities should provide the following for their workers:\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n166\n\n# 9.4 Nutrition\n\nNutritional interventions, both food-based approaches and micronutrient supplementation, are an essential component of comprehensive HIV care. Infection with HIV affects the nutritional status of PLHIV by causing increased energy requirements, metabolic alterations, reduced dietary intake and nutrient malabsorption. These eventually lead to weight loss, malnutrition and wasting in PLHIV. Malnutrition also affects the immune system in similar ways as HIV infection itself with abnormal B-cell responses, suppression of delayed hypersensitivity and decrease in CD4+ T-cells.\n\nGood nutrition contributes to an optimal nutritional status that enhances the wellbeing of the PLHIV at all stages of the disease and contributes to the prolongation of life. It requires the consumption of adequate both macronutrients (proteins, carbohydrates and fats) and micronutrients (vitamins and minerals).\n\n**Figure 9.7: Relationship between nutrition and HIV**\n\n# 9.4.1 Nutrition in HIV Positive Pregnant and Lactating Woman\n\nThe nutritional status of an HIV positive woman before, during and after pregnancy affects not just her health but also the outcome of the pregnancy and survival of the newborn. Anaemia may be more severe in HIV positive pregnant women, and severe anaemia (Hb &lt; 7g/dL) is associated with poor pregnancy outcomes and increased maternal and perinatal mortality. Extra nutrients are required during pregnancy to support the growth and development of the baby in utero.\n\n# 9.4.2 Nutrition in Children Living with HIV\n\nSuccessfully treating a child requires the commitment and involvement of a responsible caregiver. Parents and other family members of children living with HIV may themselves be\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\ninfected with HIV, and sub-optimal HIV care and treatment for family members could result in sub-optimal care for the child. Another challenge to optimal treatment is lack of nutritional support.\n\nThe nutritional needs of infants, young children, adolescents and adults alike should be adequately addressed during the initial evaluation, and it should be balanced with the need for their medication.", "mimetype": "text/plain", "start_char_idx": 386023, "end_char_idx": 391197, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6f34babe-4cfe-4d28-803f-81fa7142e2d0": {"__data__": {"id_": "6f34babe-4cfe-4d28-803f-81fa7142e2d0", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "de21296b-ca4d-4077-8ca6-1672b328f78c", "node_type": "1", "metadata": {}, "hash": "67be684ba13c90f8fb7a000a36359d0d1811cfa15184f7fcb40f2cdbdb1415af", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "f9f831ac-f9b9-4b1c-aa3c-0f3b9a7974eb", "node_type": "1", "metadata": {}, "hash": "c0e2adcfa06aa3c4ca0b4ed343c02f1ffddec968d1f01a23e778763602dab341", "class_name": "RelatedNodeInfo"}}, "text": "Anaemia may be more severe in HIV positive pregnant women, and severe anaemia (Hb &lt; 7g/dL) is associated with poor pregnancy outcomes and increased maternal and perinatal mortality. Extra nutrients are required during pregnancy to support the growth and development of the baby in utero.\n\n# 9.4.2 Nutrition in Children Living with HIV\n\nSuccessfully treating a child requires the commitment and involvement of a responsible caregiver. Parents and other family members of children living with HIV may themselves be\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\ninfected with HIV, and sub-optimal HIV care and treatment for family members could result in sub-optimal care for the child. Another challenge to optimal treatment is lack of nutritional support.\n\nThe nutritional needs of infants, young children, adolescents and adults alike should be adequately addressed during the initial evaluation, and it should be balanced with the need for their medication. It is important to ensure that nutritional counselling starts as soon as the diagnosis of HIV is made and is re-emphasized at each subsequent contact with healthcare providers at both the facility and the community level. All CLHIV should benefit from nutritional assessment, counselling and support (NACS).\n\nImproving the nutritional status of CLHIV should be based on scientific evidence, available local resources and expert opinion from clinical and programmatic experiences. Nutritional counselling, care and support requires the following steps:\n\n- Assessment of the specific circumstances of each CLHIV\n- Present nutritional status and diet\n- Identification of factors mitigating against and facilitating adequate dietary intake\n- Nutritional counselling to address specific areas identified during assessment and mutual agreements on the dietary plan based on available local resources\n- Monitoring and documentation of nutritional status\n\nStrategies and Guides for Improving and Monitoring the Nutritional Status of PLHIV\nDiet and Lifestyle\n\n- Eat a variety of foods that include proteins, carbohydrates, and a little good fat (nuts, avocado, fish, soybean)\n- Eat a diet high in fresh fruits and vegetables\n- Daily intake of lean, low-fat protein \u2013skinless chicken, fish, extra-lean meat, beans, groundnuts, soya beans, eggs and low-fat dairy products\n- Use salt sparingly\n- Ensure adequate water intake\n- Avoid alcohol and cigarette smoking\n- Limit simple sugars in sweets, soft drinks, cakes and foods with added sugar\n- Hygienically prepared food, drinking water and beverages\n- Nutrition education and counselling\n- Prompt treatment of OIs that interfere with nutrition (mouth disorders, diarrhoea etc)\n- Nutritional Support-macro/micronutrients\n- Regular exercise and physical activity\n- Economic empowerment\n\nMonitoring\n\n- Clinical assessment\n- History taking (intake, weight changes and growth, GI symptoms, and functional capacity)\n- Physical examination\n- Anthropometric measurements for growth monitoring in children\n- Height, Weight, BMI for age and Sex MUAC\n- Bodyweight changes in adults (BMI in 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- Waist -Hip Ratio\n- Biochemical measurements of metabolic parameters, serum proteins, and micronutrients\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 168\n\n# 9.4.3 Nutrition and Antiretroviral Therapy\n\nMetabolic complications associated with the use of some ART such as lactic acidosis, alterations in bone metabolism, derangement in blood glucose and lipid metabolism must be taken into consideration whilst planning an adequate diet for all PLHIV. Co-morbidities such as diabetes mellitus, cardiovascular and renal diseases may also require additional dietary modifications. An optimal nutritional status may enhance adherence to ART, its acceptability, effectiveness and ultimately virological suppression.\n\nNutritional support is an essential component of comprehensive HIV care. It is recommended that nutritional interventions, both food-based approaches and micronutrient supplementation (where applicable), are included as part of the routine care of infants, young children, adolescents and adults living with HIV and their family members.\n\n# 9.5 Service Delivery for Adolescents Living with HIV\n\nThere are about 120,000 adolescents (10-19 years) living with HIV (ALHIV) in Nigeria, with 70,000 (nearly 60%) being female [6]. Adolescents are a heterogenous group undergoing rapid developmental, emotional and social changes. Unique changes that occur during adolescence include: emerging autonomy but limited access to resources; dramatic increase in number and variety of social relations that could increase vulnerability; developing self and sexual identity, including capacity for self-direction; enhanced but evolving cognitive ability and greater impulsivity; and a gap between biological maturity and assumption of adult roles.", "mimetype": "text/plain", "start_char_idx": 390217, "end_char_idx": 395170, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "f9f831ac-f9b9-4b1c-aa3c-0f3b9a7974eb": {"__data__": {"id_": "f9f831ac-f9b9-4b1c-aa3c-0f3b9a7974eb", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "6f34babe-4cfe-4d28-803f-81fa7142e2d0", "node_type": "1", "metadata": {}, "hash": "71dec4a24bf80bf43bc98accf50332494f21ebc1ca51f920bb14bcb154cd7cc6", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "03e4ac44-fa49-4d5f-b06d-48aba85dcde9", "node_type": "1", "metadata": {}, "hash": "1511cbbd50ae46dc79f26d8580bb8cb18b9d99e8454099a93e9a4ea3b4623bb3", "class_name": "RelatedNodeInfo"}}, "text": "Nutritional support is an essential component of comprehensive HIV care. It is recommended that nutritional interventions, both food-based approaches and micronutrient supplementation (where applicable), are included as part of the routine care of infants, young children, adolescents and adults living with HIV and their family members.\n\n# 9.5 Service Delivery for Adolescents Living with HIV\n\nThere are about 120,000 adolescents (10-19 years) living with HIV (ALHIV) in Nigeria, with 70,000 (nearly 60%) being female [6]. Adolescents are a heterogenous group undergoing rapid developmental, emotional and social changes. Unique changes that occur during adolescence include: emerging autonomy but limited access to resources; dramatic increase in number and variety of social relations that could increase vulnerability; developing self and sexual identity, including capacity for self-direction; enhanced but evolving cognitive ability and greater impulsivity; and a gap between biological maturity and assumption of adult roles. Adolescents, therefore, have peculiar needs and challenges which have implications for their health and well-being.\n\nAddressing the distinct and diverse needs of adolescents living with HIV (ALHIV) to improve their HIV-related outcomes requires a comprehensive and integrated approach. Adolescent HIV services in Nigeria (where available) often have limited integration with other adolescent health services. Surveys and HIV program results have shown that over the years, adolescents living with HIV in Nigeria have been underserved and have significantly worse access to HIV testing, lower ART coverage, and lower viral load suppression rates compared to adults. They are at higher risk of loss to follow-up both before and after antiretroviral therapy initiation, with pregnant adolescents living with HIV and adolescent key populations particularly vulnerable. In 2014, the FMOH developed consensus guidelines to reconcile key ethical, legal and socio-cultural issues that pose serious challenges to the conduct of SRH research and access to HIV services. Globally, specific interventions, service delivery models and approaches tailored to the specific needs of adolescents have shown significant improvements in health outcomes for adolescents underscoring the need for the tailoring service delivery for adolescents living with HIV to their specific needs through what is now widely termed adolescent-friendly health services (AFHS).\n\n# 9.5.1 Adolescent Friendly Health Services\n\nAdolescent-friendly health services (AFHS) encompasses interventions, service delivery models and approaches tailored to the specific needs of adolescents. AFHS has the twin goals of promoting healthy development in adolescents, and the prevention and response to health problems if and when they arise.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n169\n\n# To make HIV services adolescent-friendly, the principles below should be followed\n\n|Equitable:|all adolescents, not just certain groups, are able to obtain the health services they need|\n|---|---|\n|Accessible:|adolescents are able to obtain the services that are provided|\n|Acceptable:|health services are provided in ways that meet the expectations of adolescent clients|\n|Appropriate:|the right health services that adolescents need is provided|\n|Effective:|the right health services are provided in the right way and make a positive contribution to the health of adolescents|\n\n# Package of services for adolescents living with HIV\n\nAdolescents living with HIV (ALHIV) need additional specific HIV-related services in addition to routine health services. Providing an appropriate package of services is one of the global standards for high-quality health services for adolescents. The package of services for ALHIV should be standardized and aligned with the principles of adolescent-friendly health services and the global standards for quality health-care services for adolescents (Fig 9.8). To ensure high-quality HIV services for adolescents in Nigeria, a package of HIV services for ALHIV is here defined and is recommended for implementation at health facilities and through referral links to other service delivery channels using a standardized approach.\n\n|Principle of adolescent-friendly health services|Global standards for quality health care services for adolescent|\n|---|---|\n|High quality HIV services for adolescents| |\n|Standardized package of services for ALHIV| |\n\nFigure 9.8: Key elements for high-quality adolescent HIV service delivery\n\n# Age-appropriate disclosure support\n\nDisclosure of HIV status is the process of informing a child or adolescent of his/her HIV status. It also refers to the adolescent sharing his/her HIV status with a family member, friend or significant other. Disclosure is not a one-time event, but rather a process that involves ongoing discussions about the disease as the child or adolescent matures cognitively, socially, emotionally, and sexually.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - 170\n\n# Phases of disclosure and age recommendations\n\n|No disclosure|There is no mention of any illness or HIV and no information is provided about HIV diagnosis.", "mimetype": "text/plain", "start_char_idx": 394138, "end_char_idx": 399361, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "03e4ac44-fa49-4d5f-b06d-48aba85dcde9": {"__data__": {"id_": "03e4ac44-fa49-4d5f-b06d-48aba85dcde9", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "f9f831ac-f9b9-4b1c-aa3c-0f3b9a7974eb", "node_type": "1", "metadata": {}, "hash": "c0e2adcfa06aa3c4ca0b4ed343c02f1ffddec968d1f01a23e778763602dab341", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "0fb8f16f-107c-4059-8128-46291c15f157", "node_type": "1", "metadata": {}, "hash": "1a1d55bddfdfe0bb6dff51c392ca7fd6dd7f1fd34533461077a742b47fd2e9f4", "class_name": "RelatedNodeInfo"}}, "text": "|Principle of adolescent-friendly health services|Global standards for quality health care services for adolescent|\n|---|---|\n|High quality HIV services for adolescents| |\n|Standardized package of services for ALHIV| |\n\nFigure 9.8: Key elements for high-quality adolescent HIV service delivery\n\n# Age-appropriate disclosure support\n\nDisclosure of HIV status is the process of informing a child or adolescent of his/her HIV status. It also refers to the adolescent sharing his/her HIV status with a family member, friend or significant other. Disclosure is not a one-time event, but rather a process that involves ongoing discussions about the disease as the child or adolescent matures cognitively, socially, emotionally, and sexually.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - 170\n\n# Phases of disclosure and age recommendations\n\n|No disclosure|There is no mention of any illness or HIV and no information is provided about HIV diagnosis. This is recommended for children aged 0-4 years.|\n|---|---|\n|Partial Disclosure|Children are given some but not all information about their illness. Information may be given on immunity and the need to take medicines in order to keep illness at bay. There is no mention of HIV or AIDS. This is recommended for children aged 5-8 years.|\n|Full Disclosure|Children are told the name of the illness (HIV and/or AIDS), disease-specific information (e.g., how the virus works, how it is transmitted), and how they acquired the disease. This is recommended for children/adolescents aged 9-12 years with the goal of completing full disclosure by age 10-12 years.|\n\n# Post-disclosure\n\nPeriod following disclosure, commonly described as early post-disclosure (first three to six months) and late post-disclosure (over six months) periods. The objective of post-disclosure evaluation and follow-up is to identify the feelings, perception, and degree of coping with the diagnosis and to prevent any complications after disclosure.\n\nAccidental disclosure occurs when someone talks about the HIV status of a child or adolescent without knowing that he/she is not aware of it. The service provider should carry out at least a partial disclosure of an HIV status to the child or adolescent when this occurs, and a readiness assessment and discussions with the parents or caregiver should be undertaken as soon as feasibly possible.\n\nDisclosure helps the child/adolescent to know the HIV diagnosis, infection, understand the disease process and health changes that could occur; develop strategies to lead a healthy life; and understand his/her responsibilities thereby promoting adherence to care and treatment, which is vital to achieving viral suppression. It has a positive long-term psychological impact and may improve social functioning and school performance. Both the health care team and caregivers should be involved throughout the disclosure process. Disclosure service provision should involve facility-based health care providers\u2014such as doctors, psychologists, nurses\u2014as well as social workers and community health workers.\n\n# Key considerations for successful disclosure:\n\n- Service providers and healthcare workers should build up trust and establish rapport with children and adolescents and their caregivers from the start of service delivery\n- The disclosure process should be aligned with recommended age guidance and should take the child's cognitive development into account, while remaining flexible and sensitive to the family's feelings and needs as they evolve through the phases of disclosure\n- An individual plan for disclosure should be developed for each child/adolescent and documented using a disclosure checklist/tracker as part of his/her medical records\n- The clinical team/care providers should provide intensive support and services to\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# caregivers who object to disclosing an adolescent's HIV diagnosis to address their concerns\n\n\u00a7 Beyond disclosure support by the healthcare team for informing an adolescent of his/her HIV status, support for onward disclosure to others such as family members, friend and significant other should be provided\n\n# 9.5.4 Psychosocial support for adolescents living with HIV\n\nHIV affects adolescents in various ways in addition to the peculiarities of adolescence. One of the gaps in the delivery of paediatric and adolescent HIV care and treatment services is the provision of psychosocial counselling to HIV infected/affected adolescents and their caregivers. Psychosocial support entails attendance to the emotional, psychological, social, spiritual, and practical needs of the adolescent within his/her current situation, family, environment and relationships. It is important for health care workers to receive adequate knowledge and skills needed to comfortably provide psychosocial counselling to HIV positive children/adolescents and their caregivers. There is also a need to provide on-going supportive counselling, to address care and treatment adherence issues.\n\nRecommendations for addressing gaps in the provision of psychosocial support for ALHIV:\n\n- Training of healthcare workers on the provision of psychosocial support to children and adolescents and their caregivers using a standard curriculum.", "mimetype": "text/plain", "start_char_idx": 398398, "end_char_idx": 403693, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "0fb8f16f-107c-4059-8128-46291c15f157": {"__data__": {"id_": "0fb8f16f-107c-4059-8128-46291c15f157", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "03e4ac44-fa49-4d5f-b06d-48aba85dcde9", "node_type": "1", "metadata": {}, "hash": "1511cbbd50ae46dc79f26d8580bb8cb18b9d99e8454099a93e9a4ea3b4623bb3", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "28e02e9b-68c8-4dea-983e-00c380d56686", "node_type": "1", "metadata": {}, "hash": "9ae96c0f6af2bc3bfa106b251379bf999ef7e677f540ac581179574a5059e0a5", "class_name": "RelatedNodeInfo"}}, "text": "One of the gaps in the delivery of paediatric and adolescent HIV care and treatment services is the provision of psychosocial counselling to HIV infected/affected adolescents and their caregivers. Psychosocial support entails attendance to the emotional, psychological, social, spiritual, and practical needs of the adolescent within his/her current situation, family, environment and relationships. It is important for health care workers to receive adequate knowledge and skills needed to comfortably provide psychosocial counselling to HIV positive children/adolescents and their caregivers. There is also a need to provide on-going supportive counselling, to address care and treatment adherence issues.\n\nRecommendations for addressing gaps in the provision of psychosocial support for ALHIV:\n\n- Training of healthcare workers on the provision of psychosocial support to children and adolescents and their caregivers using a standard curriculum.\n- Provision of child/adolescent centred counselling using appropriate SOPs and job aids. Service providers should bear in mind that each adolescent is unique and so should not generalize when providing support.\n- Provision of strength-based counselling for adolescents.\n- Psychosocial support should be available and accessible as part of the package of care at ART refill visits\n- Counselling should be provided based on the needs of the adolescents.\n- There should be multidisciplinary team involvement when providing psychosocial support to handle other issues like disclosure, nutritional support, mental health, caring for a sick caregiver etc.\n- Availability of peer support through individual engagement, peer support groups, virtual platforms etc. is important for adolescents.\n- Provision of access to basic education and literacy programs.\n- Provision of life skill coaching and empowerment which helps build their confidence and self-sufficiency.\n\nFor adherence support and SRH in adolescents, refer to the chapters on adherence and PMTCT respectively.\n\n# 9.5.5 Transitioning to adult care\n\nTransitioning is a purposeful, planned process to facilitate and support the movement of adolescents and young people from child/adolescent care- to adult-centred healthcare. A nationwide study reported that most secondary and tertiary health facilities in Nigeria transitioned adolescents to adult care at 15 or 18 years of age [31]. Less than 30% of facilities had an adolescent-specific clinic or transition policy, and most care was provided in a family-centred fashion.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - 172\n\n# 9.5.5.1 Organizing a Transition Plan\n\nTransition should involve a multidisciplinary team of paediatricians, adult physicians, nurses, social workers, adolescent peer mentors and mental health professionals where available. All healthcare facilities and providers should have a written standard plan in place to transition adolescents to adult care. This plan should include a schedule for the transition process initiated from early adolescence and engaging both the adolescent and the parents/caregivers. The plan should not be a \u201cone-size-fits-all,\u201d but should be flexible and tailored to clients' individual capacities, readiness, and developmental age. Caregivers should be active stakeholders in the transition process. Disclosure is important for successful transitioning and recommendations for disclosure 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 to adherence, retention and viral suppression addressed. During the transition process, adolescents should be empowered to take full responsibility for their health and commit to achieving good treatment outcomes. Some services may not be available at all levels of care and may require a referral.\n\n# 9.5.5.2 Key Considerations for the Transition Process\n\nTransitioning should be a continuous and seamless process rather than a \u201cone-off\u201d event that occurs with one meeting. Flexibility will ensure those involved in the process can recognize and respond to the unique needs of ALHIV. Informed decision-making is the key to mature self-care and is the overall goal of successful transitioning.", "mimetype": "text/plain", "start_char_idx": 402744, "end_char_idx": 407000, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "28e02e9b-68c8-4dea-983e-00c380d56686": {"__data__": {"id_": "28e02e9b-68c8-4dea-983e-00c380d56686", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "0fb8f16f-107c-4059-8128-46291c15f157", "node_type": "1", "metadata": {}, "hash": "1a1d55bddfdfe0bb6dff51c392ca7fd6dd7f1fd34533461077a742b47fd2e9f4", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "57680c96-f3a7-4cfd-af10-727c4b4a47eb", "node_type": "1", "metadata": {}, "hash": "b873a6539fdb3c93913d20213ca152cc15bcb5a49a4b46210024ea9a3ec2d532", "class_name": "RelatedNodeInfo"}}, "text": "Caregivers should be active stakeholders in the transition process. Disclosure is important for successful transitioning and recommendations for disclosure 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 to adherence, retention and viral suppression addressed. During the transition process, adolescents should be empowered to take full responsibility for their health and commit to achieving good treatment outcomes. Some services may not be available at all levels of care and may require a referral.\n\n# 9.5.5.2 Key Considerations for the Transition Process\n\nTransitioning should be a continuous and seamless process rather than a \u201cone-off\u201d event that occurs with one meeting. Flexibility will ensure those involved in the process can recognize and respond to the unique needs of ALHIV. Informed decision-making is the key to mature self-care and is the overall goal of successful transitioning. The following are key principles to guide the transition process:\n\n- Individualize the approach for each child and adolescent based on their developmental readiness\n- Identify HCWs to engage in the transition\n- Begin the process early, ensuring communication among the adolescent, caregivers, and the HCWs in the adult health care setting, before, during, and after\n- Develop and follow an individualized transition plan for each adolescent; in addition to developing an orientation plan in the adult health care setting;\n- Plans should be flexible to meet the adolescent's needs, and also should include provisions for any regressions that an adolescent may have\n- A checklist may be useful to develop such a plan\n- Use a multidisciplinary transition team including peers who are in the process of transitioning or who have transitioned successfully\n- Address comprehensive care needs of each adolescent, as part of the transition, including medical, psychosocial, and financial aspects of transitioning\n- Allow adolescents to express their opinions\n- Educate HIV care teams and staff about transitioning\n- Follow up transitioned adolescents in the adult clinic for 6 - 12 months to ensure adherence and retention in care\n\nThere may be various barriers to seamless transitioning at the provider, adolescent and family levels and these should be identified and addressed to minimize interruptions in care and treatment. Poor communication among all stakeholders forms one of the largest barriers.\n\n# 9.5.6 Peer-driven adolescent service delivery models\n\nMeaningful adolescent engagement is one of the standards for high-quality health services for adolescents. It entails intentionally involving adolescents in the planning, monitoring and evaluation of health services; inappropriate aspects of service provision; and in decisions regarding their care. It is essential that the meaningful participation and engagement of adolescent peers are encouraged and supported, and adolescents empowered and trained as effective peer educators, counsellors, trainers and advocates.\n\nWHO recently selected and profiled some adolescent peer-based models that are currently being implemented in multiple countries across sub-Saharan Africa which have shown evidence of improvement in linkage to care, adherence to antiretroviral therapy, retention in care, and viral suppression. Some of these models are being tested in Nigeria but are yet to be harmonized and evaluated. They include:\n\nAriel Adherence ClubsBaylor College of Medicine International Pediatric Aids Initiative Teen Club ProgrammeOperation Triple Zero (OTZ) ModelREACH (Re-engage Adolescents and Children with HIV) ProgrammeZvandiri Model\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n174\n\n# List of Contributors\n\nMs Bridget OnyebuchiMr Usman MohammedMr Sani Khalil A.Mrs Sanni KudiratProf. Lawal UmarDr Eugenia OfonduDr Egejuru UkabialaDr Olufunke BolajiDr Richard AmenyahDr Olumuyiwa OjoDr Helen SagayOdelola BabatunjiDr Uzoma EneMs.", "mimetype": "text/plain", "start_char_idx": 406001, "end_char_idx": 410008, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "57680c96-f3a7-4cfd-af10-727c4b4a47eb": {"__data__": {"id_": "57680c96-f3a7-4cfd-af10-727c4b4a47eb", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "28e02e9b-68c8-4dea-983e-00c380d56686", "node_type": "1", "metadata": {}, "hash": "9ae96c0f6af2bc3bfa106b251379bf999ef7e677f540ac581179574a5059e0a5", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "d167b9fc-757d-4e7e-8a12-cc0f87dc9a89", "node_type": "1", "metadata": {}, "hash": "2aeb3c47c10fffc315e8303c0a75649822e303c21a748b203f69a0d815cdcd01", "class_name": "RelatedNodeInfo"}}, "text": "Some of these models are being tested in Nigeria but are yet to be harmonized and evaluated. They include:\n\nAriel Adherence ClubsBaylor College of Medicine International Pediatric Aids Initiative Teen Club ProgrammeOperation Triple Zero (OTZ) ModelREACH (Re-engage Adolescents and Children with HIV) ProgrammeZvandiri Model\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n174\n\n# List of Contributors\n\nMs Bridget OnyebuchiMr Usman MohammedMr Sani Khalil A.Mrs Sanni KudiratProf. Lawal UmarDr Eugenia OfonduDr Egejuru UkabialaDr Olufunke BolajiDr Richard AmenyahDr Olumuyiwa OjoDr Helen SagayOdelola BabatunjiDr Uzoma EneMs. Dolapo T. OgundehinDr Adamu YakubuDr Ikechukwu AmamiloChiedozie NwaforDr Philip ImohiDr Majekodunmi OmololuoyeDr Eluke Francis BlessingDr Onyekwelu InnocentDr Otoyo Eskor ToyoDr Chidubem OraelosiDr Temi OmoleDr Honey D. OkpeDr Chinyerem Frances ImmanuelDr Emmanuel NwabuezeDr Torbunde NguaveseDr Nadia Sam-AguduDr Oladokun OluwatosinDr Kemi AkagwuDr Winifred EzeobiDr Chioma Helga Law-MadukaDr Dominic Umoru\n\n# Chapter 9\n\nAssistant Chief Scientific Officer, NASCPSenior Scientific Officer NASCPSenior Medical Laboratory Scientist NASCPCNO NASCPMember NTTA / Paediatrician ABUTH, ZariaMember NTTA / Dermatologist FMC OwerriMember NTTA / Paediatrician, Military Hospital, LagosMember NTTA / Paediatrician, FTH Ido EkitiFast Track Advisor UNAIDSNational Professional Officer (NPO) WHOTechnical Assistance- NTTP WHOLead, Integrated Service Delivery Team/HIV/AIDS-TB USAIDSenior Program Specialist HIV Care and Treatment CDCCare and Treatment Lead (Acting) USAIDDeputy Director, Public Health Programs US DoDSenior Technical Advisor CHAIAnalyst CHAIAssociate Director - Prevention, Care and Treatment FHI360Senior Technical Officer FHI360Technical Officer FHI360Associate Director FHI360Senior Technical Advisor, Prevention Care and Treatment FHI360Senior Technical Advisor APINSenior Technical Officer APINCare and Treatment Lead ICAPMedical Director AHFSenior Program Officer, Pediatric/Adolescent HIV IHVNSenior Technical Advisor, Pediatric and Adolescent HIV IHVNClinical Service Manager Paediatrics and Adolescent CIHPCSO PMTCT CIHPTechnical Advisor CCFNProgram Advisor Heartland AllianceMember NTTA/Paediatrician\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n175\n\n# 10. MONITORING AND EVALUATION\n\n|10.1 Introduction|177|\n|---|---|\n|10.2 Selection of Indicators|177|\n|10.3 Data Management|182|\n|10.4 HIV Data Dissemination and Use|184|\n|10.5 Human Resource for M&E|184|\n|10.6 HIV M&E Logistics|185|\n|10.7 Additional Strategies in M&E|185|\n|10.8 HIV Research|185|\n|10.9 Periodic monitoring of the implementation of the guidelines and content update|185|\n\n# 10.1 Introduction\n\nMonitoring and evaluation of the HIV programme enables the country to measure the level of effectiveness of interventions and linkages between services. This will enable the country track progress toward achieving its programme goals and set targets. It also provides data for informed decision-making on the programme and allocation of resources.\n\nThe M&E objectives include:\n\n- Monitoring programme performance across the domain of HIV prevention, treatment, care and support.\n- Improving data quality to inform decision making and programme planning.\n- Strengthening capacity in data management across all levels of implementation.\n- Improving data reporting from private, public and community level.\n- Strengthening and utilizing HIV surveillance and research.\n\nNew strategies in the management of HIV and co-infections, along with changes in the implementation environment call for a broadening of the M&E system in order to adequately measure and assess the impact of the interventions. In addition, routine monitoring shall be complemented by periodic systematic evaluations and programme reviews to assess the performance and impact of HIV programmes. Data triangulation, modeling and other analytic tools will be utilized to improve the accuracy and usability of HIV data.", "mimetype": "text/plain", "start_char_idx": 409369, "end_char_idx": 413386, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d167b9fc-757d-4e7e-8a12-cc0f87dc9a89": {"__data__": {"id_": "d167b9fc-757d-4e7e-8a12-cc0f87dc9a89", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "57680c96-f3a7-4cfd-af10-727c4b4a47eb", "node_type": "1", "metadata": {}, "hash": "b873a6539fdb3c93913d20213ca152cc15bcb5a49a4b46210024ea9a3ec2d532", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "152adb26-e7d9-4d13-a9dc-9a8bc02f47b0", "node_type": "1", "metadata": {}, "hash": "3d542fa5edd66a701cd26b7e35d5a5df71fdb186e4c17a68d6f1430435e7e51b", "class_name": "RelatedNodeInfo"}}, "text": "This will enable the country track progress toward achieving its programme goals and set targets. It also provides data for informed decision-making on the programme and allocation of resources.\n\nThe M&E objectives include:\n\n- Monitoring programme performance across the domain of HIV prevention, treatment, care and support.\n- Improving data quality to inform decision making and programme planning.\n- Strengthening capacity in data management across all levels of implementation.\n- Improving data reporting from private, public and community level.\n- Strengthening and utilizing HIV surveillance and research.\n\nNew strategies in the management of HIV and co-infections, along with changes in the implementation environment call for a broadening of the M&E system in order to adequately measure and assess the impact of the interventions. In addition, routine monitoring shall be complemented by periodic systematic evaluations and programme reviews to assess the performance and impact of HIV programmes. Data triangulation, modeling and other analytic tools will be utilized to improve the accuracy and usability of HIV data.\n\n# 10.2 Selection of Indicators\n\nIn 2017, the country adopted WHO global indicators for M&E reporting of the HIV programme. The categories of national indicators relate to the following:\n\n- HIV testing services\n- Treatment and care for pregnant and breastfeeding women (prevention of mother-to-child transmission (PMTCT)\n- Paediatric, adolescent and adult HIV treatment and care\n- Advanced HIV disease\n- TB/HIV co-infection\n- Other comorbidities and co-infections\n- Post-exposure prophylaxis (PEP) and Pre-exposure prophylaxis (PrEP)\n- Services for key populations\n- Linkage, enrolment and retention in care\n- Toxicity monitoring\n- HIV drug resistance (HIV-DR)\n- Viral suppression and\n- Impact evaluation (mortality, prevalence and incidence)\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Table 10.1: MONITORING AND EVALUATION FRAMEWORK\n\n|DATA|FREQUENCY|INDICATORS|DEFINITION|Disaggregation|RESPONSIBLE|How often|SOURCE|\n|---|---|---|---|---|---|---|---|\n|IMPACT INDICATORS| | | | | | | |\n|% of annual AIDS death among PLHIV during the reporting period.|Annually|N: Number of annual AIDS deaths among PLHIV. D: Estimated number of PLHIV.|Age (<1, 1\u20134, 5\u20139, 10-14, 15\u201319, 20\u201324, 25-49, 50+ years); sex|Programme Data. Spectrum.|STATE/FMOH| | |\n|Number of new infections averted|Annually|N&D: Number of new infections averted|Age (<1, 1\u20134, 5\u20139, 10-14, 15\u201319, 20\u201324, 25-49, 50+ years); sex|Spectrum.|STATE/FMOH| | |\n|OUTCOME INDICATORS| | | | | | | |\n|% PLHIV on ART who are virally suppressed at 6 months of initiation|Bi-annually|N: Number of PLHIV who are virally suppressed at 6 months on ART. D: Number of PLHIV on ART that received a VL test result at 6 months of initiation on ART|Age (<1, 1\u20134, 5\u20139, 10-14, 15\u201319, 20\u201324, 25-49, 50+ years); sex|Programme Data (PMM Tools).|STATE/FMOH| | |\n|% of PLHIV on ART who are virally suppressed at 12 months of initiation|Annually|N: Number of PLHIV who are virally suppressed at 12 months on ART. D: Number of PLHIV on ART that received a VL test result at 12 months of initiation on ART|Age (<1, 1\u20134, 5\u20139, 10-14, 15\u201319, 20\u201324, 25-49, 50+ years); sex|Programme Data (PMM Tools).|STATE/FMOH| | |\n|% of PLHIV on ART who are retained on ART at 6 months of ART initiation|Bi-annually|N: Number of PLHIV who are retained on ART at 6 months after initiation during the reporting period. D: Number of PLHIV initiating ART up to 6 months before the beginning of the reporting year. (This includes those who have died since starting therapy, those who have stopped therapy and those lost to follow-up as of month 6.", "mimetype": "text/plain", "start_char_idx": 412258, "end_char_idx": 415958, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "152adb26-e7d9-4d13-a9dc-9a8bc02f47b0": {"__data__": {"id_": "152adb26-e7d9-4d13-a9dc-9a8bc02f47b0", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "d167b9fc-757d-4e7e-8a12-cc0f87dc9a89", "node_type": "1", "metadata": {}, "hash": "2aeb3c47c10fffc315e8303c0a75649822e303c21a748b203f69a0d815cdcd01", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "7538fc80-39bd-4699-add9-4e3b386ae671", "node_type": "1", "metadata": {}, "hash": "23671bd5b47117d8e9d48976c7f3e1f4a606e949fb40d4a15487125d6a677abe", "class_name": "RelatedNodeInfo"}}, "text": "D: Number of PLHIV on ART that received a VL test result at 12 months of initiation on ART|Age (<1, 1\u20134, 5\u20139, 10-14, 15\u201319, 20\u201324, 25-49, 50+ years); sex|Programme Data (PMM Tools).|STATE/FMOH| | |\n|% of PLHIV on ART who are retained on ART at 6 months of ART initiation|Bi-annually|N: Number of PLHIV who are retained on ART at 6 months after initiation during the reporting period. D: Number of PLHIV initiating ART up to 6 months before the beginning of the reporting year. (This includes those who have died since starting therapy, those who have stopped therapy and those lost to follow-up as of month 6.)|Age (<1, 1\u20134, 5\u20139, 10-14, 15\u201319, 20\u201324, 25-49, 50+ years); sex|Programme Data (PMM Tools). Cohort Analysis|SMOH/FMOH| | |\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - Page 178\n\n# % of PLHIV on ART who are retained on ART at 12 months of ART initiation\n\n|Age|N|D|Programme|Annually|SMOH/FMOH|\n|---|---|---|---|---|---|\n|<1|Number of PLHIV alive and on ART at 12 months of ART initiation| | | | |\n|1-4| | | | | |\n|5-9| | | | | |\n|10-14| | | | | |\n|15-19| | | | | |\n|20-24| | | | | |\n|25-49| | | | | |\n|50+| | | | | |\n\n# OUTPUT INDICATORS\n\n|Number counselled, tested for HIV|Age|N|D|Programme|N&D|NABi-annually|SMOH/FMOH|\n|---|---|---|---|---|---|---|---|\n|and received results during the reporting period.|<1| | | | | | |\n| |1-4| | | | | | |\n| |5-9| | | | | | |\n| |10-14| | | | | | |\n| |15-19| | | | | | |\n| |20-24| | | | | | |\n| |25-49| | | | | | |\n| |50+| | | | | | |\n\n# % of infants born to HIV-positive women receiving a DNA-PCR test for HIV within 2 months of birth\n\n|N|D|Programme|Bi-annually|SMOH/FMOH|\n|---|---|---|---|---|\n|Number of HIV-exposed infants who received EID/DNA-PCR test for HIV within two months of birth during the reporting period.| | | | |\n\n# % of HIV Exposed babies who tested for HIV within 18 months of birth by Rapid Test\n\n|N|D|Programme|Bi-annually|SMOH/FMOH|\n|---|---|---|---|---|\n|No.", "mimetype": "text/plain", "start_char_idx": 415349, "end_char_idx": 417296, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "7538fc80-39bd-4699-add9-4e3b386ae671": {"__data__": {"id_": "7538fc80-39bd-4699-add9-4e3b386ae671", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "152adb26-e7d9-4d13-a9dc-9a8bc02f47b0", "node_type": "1", "metadata": {}, "hash": "3d542fa5edd66a701cd26b7e35d5a5df71fdb186e4c17a68d6f1430435e7e51b", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "7583dec9-c673-4686-b2a8-c38682e9d3bf", "node_type": "1", "metadata": {}, "hash": "939febb2c686e9cec9530a53b0aef2937f234a488b1bd4c195cb72d90fafdeee", "class_name": "RelatedNodeInfo"}}, "text": "of HIV Exposed babies who tested for HIV within 18 months of birth by Rapid Test during the reporting period.| | | | |\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n179\n\n# % of persons who test\n\n|N: Number of persons who test|Programme|Annually|SMOH/ FMOH|\n|---|---|---|---|\n|D: Number of persons counselled tested.|Spectrum|and received|Proportion of newly diagnosed|\n\n# N:Number of newly diagnosed PLHIV\n\n|Programme|Bi-annually|SMOH/ FMOH|Data (PMM|\n|---|---|---|---|\n|HIV-positive PLHIV newly|enrolled in clinical care during|& PME|enrolled in clinical care during|\n|the reporting period.Tools).|the reporting period|D: Number of newly diagnosed PLHIV|N:Number of positive PLHIV who|\n\n# % of positive PLHIV who\n\n|Age (<1, 1\u20134, 5\u20139,|Programme|SMOH/ FMOH|Bi-annually|\n|---|---|---|---|\n|received at least one of the following|received clinical assessment|10-14, 15\u201319, 20\u2013|Data (PMM|\n|clinical24, 25& PME49, 50+\u2013|(WHO staging) OR CD4+count|assessment (WHO staging) OR CD4+|years); sex|\n|count OR viral load OR current on|treatment during the reporting|on treatment|period.|\n\n# D: Estimated number of PLHIV.", "mimetype": "text/plain", "start_char_idx": 417297, "end_char_idx": 418425, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "7583dec9-c673-4686-b2a8-c38682e9d3bf": {"__data__": {"id_": "7583dec9-c673-4686-b2a8-c38682e9d3bf", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "7538fc80-39bd-4699-add9-4e3b386ae671", "node_type": "1", "metadata": {}, "hash": "23671bd5b47117d8e9d48976c7f3e1f4a606e949fb40d4a15487125d6a677abe", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "d7d83cd6-cb9d-4ffa-aa21-158a96ad25cd", "node_type": "1", "metadata": {}, "hash": "4077a0dde6800cc6c6d26a4fd73028a488e32f5f4e80f97c0dd019b0e1c6adec", "class_name": "RelatedNodeInfo"}}, "text": "Facility-based denominator:\n\n|Number of PLHIV newly|N & D:N/A|Age (<1, 1\u20134, 5\u20139,|Programme| |\n|---|---|---|---|---|\n| |started on ART during the|reporting period.|10-14, 15\u201319, 20\u2013|Data (PMM|\n|24, 25& PME49, 50+\u2013|years); sex|Tools).| | |\n\n# ART coverage among PLHIV\n\n|N:Number of PLHIV currently|Age (<1, 1\u20134, 5\u20139,|Programme|SMOH/ FMOH|\n|---|---|---|---|\n|receiving ART.|10-14, 15\u201319, 20\u2013|Data (PMM|24, 25& PME49, 50+\u2013|\n|D: Estimated number of PLHIV|years); sex|Tools).| |\n\n# % of PLHIV in care (including\n\n|N:Number of PLHIV enrolled in HIV care|Age (<1, 1\u20134, 5\u20139,|Programme|SMOH/ FMOH|\n|---|---|---|---|\n|whose TB status was assessed and recorded|PMTCT) who were clinically|10-14, 15\u201319, 20\u2013|Data (PMM|\n|at their last visit during the reporting period.|screened for TB in HIV care and|24, 25& PME49, 50+\u2013|D: Total number of PLHIV currently|\n|treatment settin gs during the|years); sex|reporting period.| |\n\n# % of PLHIV Enrolled in HIV Care\n\n|N|Programme|Bi-annually|SMOH/ FMOH|\n|---|---|---|---|\n|Total number of PLHIV enrolled in care|who have Active TB Disease.|who have active TB disease during the reporting period.| |\n|Age (<1, 1 \u20134, 5\u20139, 10-14, 15 \u201319, 20 \u201324, 25& 50+ years); sex|Data (PMM Tools).| | |\n|D|Total number of PLHIV currently in HIV care who were screened for TB during the reporting period| | |\n\n# ART coverage among HIV-Positive New and Relapsed TB PLHIV\n\n|N|Programme|Bi-annually|SMOH/ FMOH|\n|---|---|---|---|\n|Total number of HIV-positive new and relapsed TB PLHIV started on TB treatment|during TB Treatment.|during the reporting period who are already on ART or started on ART during TB treatment.| |\n|Age (<1, 1 \u20134, 5\u20139, 10-14, 15 \u201319, 20 \u201324, 25& 50+ years); sex|Data (PMM Tools).| | |\n|D|Total number of HIV-positive new and relapsed TB PLHIV registered during the reporting period| | |\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n181\n\n# Data Management\n\nHIV data management is a process that includes the collection, collation, analysis, dissemination and use of HIV data for planning and implementing HIV services. The data is disaggregated by age, sex, location (LGA, state and national), breastfeeding and pregnancy status to improve decision making.\n\n# Data Collection\n\nRoutine HIV data is collected through both paper-based and electronic platforms. Efforts are to be geared towards strengthening the platforms to improve the quality of data.\n\nPatients' information is collected using 2 types of tools:\n\n1. Patient Management and Monitoring (PMM) tools2. Programme Monitoring and Evaluation (PME) tools.\n\nPMM tools are used to collect data on individual patients and help in improving the management of PLHIV. The tools are available at every point of HIV service delivery. This information is monitored over time and enables healthcare providers to assess a patient's response to treatment.\n\nPME tools are used to track the progress of services provided to PLHIV. The data can be used to routinely monitor and evaluate the effectiveness, efficiency and acceptability of HIV service provision at all levels of healthcare.\n\nHCWs at service delivery points should ensure proper documentation of all HIV services provided. Facility M&E staff are responsible for the collection of data from all service delivery points for monthly reporting.\n\nIn general, the emphasis will be on using the PMM/PME tools to continuously inform HIV programming. Process and outcome evaluations will be periodically conducted to assess programme performance for informed decisions.", "mimetype": "text/plain", "start_char_idx": 418427, "end_char_idx": 421944, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "d7d83cd6-cb9d-4ffa-aa21-158a96ad25cd": {"__data__": {"id_": "d7d83cd6-cb9d-4ffa-aa21-158a96ad25cd", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "7583dec9-c673-4686-b2a8-c38682e9d3bf", "node_type": "1", "metadata": {}, "hash": "939febb2c686e9cec9530a53b0aef2937f234a488b1bd4c195cb72d90fafdeee", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "879c98e2-123e-4997-90a7-7aee15f0dbf3", "node_type": "1", "metadata": {}, "hash": "71d8853dfe6236cff164e13f1f095576a9190cbe9362f4b67978e9abddbbfdfc", "class_name": "RelatedNodeInfo"}}, "text": "Patient Management and Monitoring (PMM) tools2. Programme Monitoring and Evaluation (PME) tools.\n\nPMM tools are used to collect data on individual patients and help in improving the management of PLHIV. The tools are available at every point of HIV service delivery. This information is monitored over time and enables healthcare providers to assess a patient's response to treatment.\n\nPME tools are used to track the progress of services provided to PLHIV. The data can be used to routinely monitor and evaluate the effectiveness, efficiency and acceptability of HIV service provision at all levels of healthcare.\n\nHCWs at service delivery points should ensure proper documentation of all HIV services provided. Facility M&E staff are responsible for the collection of data from all service delivery points for monthly reporting.\n\nIn general, the emphasis will be on using the PMM/PME tools to continuously inform HIV programming. Process and outcome evaluations will be periodically conducted to assess programme performance for informed decisions.\n\nThe following are current tools used for M&E in the national HIV programme:\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n182\n\n# Table 10.2: Tools used for M&E in the national HIV programme\n\n|HTS|PMTCT|\n|---|---|\n|PMM|PME|\n|-Client Intake form|- PMTCT Monthly Summary form|\n|-Request & Result 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 Worksheet|-Partner Register|\n|- Referral Register|-PMTCT Delivery Register|\n|- HTS Monthly Summary form| |\n\n|ART| |\n|---|---|\n|PMM| |\n|- Care card| |\n|- Adult Initial Clinical Evaluation form| |\n|- Paediatric Initial Clinical Evaluation form| |\n|- Lab Order & Results form| |\n|- Pharmacy Order form| |\n|- HIV Care & Treatment transfer form| |\n|- Client Tracking & Termination form| |\n|PME| |\n|-Care card| |\n|-Enrolment Register| |\n|-ART Register| |\n|-ART monthly summary form| |\n|-Pharmacy Daily Worksheet| |\n|-HIV Care & Treatment Client Tracking Register| |\n|-Post Exposure Prophylaxis Register| |\n|-Cohort analysis report| |\n\n# 10.3.2 Data Security, Collation & Reporting Flow\n\nHandling of PMM/PME tools requires confidentiality and efficiency to give the clients a sense of security. A filing system for HIV programme records should be developed and followed within each facility. All records should be kept confidential and stored in a secure room with lockable cabinets. Backup records should be secured from damage or loss.\n\nAt the end of each month, routine HIV programme data should be validated for quality and collated into monthly summary forms. Completed monthly summary forms should be forwarded to the Local Government Area (LGA), where data from all the HIV sites in the LGA are collated and transmitted to the State Ministry of Health and District Health Information System (DHIS).\n\nAt State M&E review meetings HIV data should be validated, collated and analysed by all relevant HIV programme stakeholders. States should in turn forward to the NASCP of the FMOH.\n\nThe respective health authorities at the various levels will have responsibility for reporting to the HIV and AIDS coordinating authorities at the various levels (i.e. health facility to LGA to State MOH to FMOH).\n\nFacilities can now upload information on the monthly summary forms directly on the DHIS. Validation is conducted by the L.G.A. and the State. The information can be viewed at the local, state and national level. With the electronic medical record (EMR) system, facilities upload patient-level data into the National Data Repository (NDR) which can be reviewed for quality at all levels and analysed by stakeholders. Electronic data record should be stored and secured in a\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# HIV Program Data Flow Chart\n\nNational DHIS\n\n|National level|Sent|\n|---|---|\n|State level|DHIS 2|\n|LGA|Cascade|\n|Paper Based Tools|Patient Level Data|\n| |Health Facilities|\n\nFigure 10.1 \u2013 Data Flow Chart for HIV reporting\n\nNational Data Repository\n\nElectronic Medical Records (EMR)\n\n10.4 HIV Data Dissemination and Use\n\nThe significance of data cannot be fully realized until it is disseminated to all relevant stakeholders for effective planning and decision making. The dissemination of HIV data and information products will be via regular fact sheets, bulletins, report and official social media platforms. Also validated data are shared with the states biannually as a way of feedback.", "mimetype": "text/plain", "start_char_idx": 420894, "end_char_idx": 425473, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "879c98e2-123e-4997-90a7-7aee15f0dbf3": {"__data__": {"id_": "879c98e2-123e-4997-90a7-7aee15f0dbf3", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "d7d83cd6-cb9d-4ffa-aa21-158a96ad25cd", "node_type": "1", "metadata": {}, "hash": "4077a0dde6800cc6c6d26a4fd73028a488e32f5f4e80f97c0dd019b0e1c6adec", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "5c6b3a8c-8bae-439f-be40-f2680b092249", "node_type": "1", "metadata": {}, "hash": "6b71a87ecada8330b03b77bf9943bd01c8f0840b77d5a62bfae5d9c0a2d6f215", "class_name": "RelatedNodeInfo"}}, "text": "Electronic data record should be stored and secured in a\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# HIV Program Data Flow Chart\n\nNational DHIS\n\n|National level|Sent|\n|---|---|\n|State level|DHIS 2|\n|LGA|Cascade|\n|Paper Based Tools|Patient Level Data|\n| |Health Facilities|\n\nFigure 10.1 \u2013 Data Flow Chart for HIV reporting\n\nNational Data Repository\n\nElectronic Medical Records (EMR)\n\n10.4 HIV Data Dissemination and Use\n\nThe significance of data cannot be fully realized until it is disseminated to all relevant stakeholders for effective planning and decision making. The dissemination of HIV data and information products will be via regular fact sheets, bulletins, report and official social media platforms. Also validated data are shared with the states biannually as a way of feedback. Data use should be encouraged at all levels especially at the health facilities where these data are generated, to improve patient management and monitoring.\n\n10.5 Human Resource for M&E\n\nThe relevant human resource for monitoring and evaluation should be employed at all levels to support data management. The FMOH in collaboration with relevant stakeholders will ensure training and retraining of healthcare workers, local government and state officers on data management and use.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - 184\n\n# 10.6 HIV M&E Logistics\n\nNational M&E tools and infrastructure should be made available to all sites delivering HIV services to facilitate service documentation and reporting of routine data. Indicator Reference Sheets and User Guides should be made available to end-users to aid understanding of programme indicators and also help in the completion of M&E tools.\n\n# 10.7 Additional Strategies in M&E\n\nAs the country makes progress towards epidemic control, the need to put in place innovative strategies in monitoring and evaluating national HIV health sector response has become highly imperative. This enables evidence-based planning, resource allocation and decision making in line with innovations within the response. Some of the innovative strategies include the introduction of case-based surveillance, mortality surveillance and recency surveillance.\n\n- The case-based surveillance allows a shift from aggregate reporting to focus on individual follow up from the time of identification of a new case to retention in care and even death. This longitudinal form of data collection is used to track clinical outcomes and monitor the quality of linkage to care.\n- Recency surveillance provides insight into the timeline of an individual's HIV infection. This information is important to public health because of the ability to use such data for targeted interventions, programmatic shifts and to achieve epidemic control.\n- The mortality surveillance also determines the distribution, trends and patterns of leading causes of death attributable to HIV among people receiving ART in the program.\n\nAdditional M&E tools are being developed to capture data on Recency testing, Self-testing, PrEP, AHD and DSD.\n\n# 10.8 HIV Research\n\nThe National HIV research policy and agenda seeks to inform HIV implementation and formative research that provide evidence-based data to improve the effectiveness and efficiency of HIV programme management in Nigeria. Research programmes will be prioritized to identify cost-effective mechanisms for HIV treatment, care, and support. It should also prioritize research that promotes the reduction of HIV risk behaviours among key, vulnerable and general populations, enhance prevention programmes, strengthen basic and implementation research, clinical trials, social science research and systematic reviews.\n\n# 10.9 Periodic monitoring of the implementation of the guidelines and content update\n\nHIV medicine is a dynamic speciality with continuously emerging evidence and innovations that optimize prevention, treatment and care of PLHIV. Consequently, this necessitates periodic updates to these guidelines. In addition, there is also a need to monitor and evaluate the level of implementation of these guidelines at service delivery points with the aim of re-strategizing for effective programme implementation. It is recommended that FMOH should take the lead with the support of all stakeholders to ensure regular reviews and update of these guidelines.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# List of Contributors\n\n|Dr Uba Sabo|Assistant Director, PREP/STI NASCP|\n|---|---|\n|Dr Onifade Bodunde|Senior Medical Officer II, HIV Data Manager NASCP|\n|Mr Adebayo Adesina|Senior Scientific Officer, M&E NASCP|\n|Dr Yewande Olaifa|Assistant Director NACA|\n|Dr Tolulope Oladele|Assistant Director, Health Sector Response Support NACA|\n|Prof.", "mimetype": "text/plain", "start_char_idx": 424660, "end_char_idx": 429429, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "5c6b3a8c-8bae-439f-be40-f2680b092249": {"__data__": {"id_": "5c6b3a8c-8bae-439f-be40-f2680b092249", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "879c98e2-123e-4997-90a7-7aee15f0dbf3", "node_type": "1", "metadata": {}, "hash": "71d8853dfe6236cff164e13f1f095576a9190cbe9362f4b67978e9abddbbfdfc", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "b90a87b5-5e8d-464b-9cae-c3a7030cc97d", "node_type": "1", "metadata": {}, "hash": "8f4516ddf6f93b51f1aaaccfb10b237b9534425efd4843808875bbd5296d7b1d", "class_name": "RelatedNodeInfo"}}, "text": "Consequently, this necessitates periodic updates to these guidelines. In addition, there is also a need to monitor and evaluate the level of implementation of these guidelines at service delivery points with the aim of re-strategizing for effective programme implementation. It is recommended that FMOH should take the lead with the support of all stakeholders to ensure regular reviews and update of these guidelines.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# List of Contributors\n\n|Dr Uba Sabo|Assistant Director, PREP/STI NASCP|\n|---|---|\n|Dr Onifade Bodunde|Senior Medical Officer II, HIV Data Manager NASCP|\n|Mr Adebayo Adesina|Senior Scientific Officer, M&E NASCP|\n|Dr Yewande Olaifa|Assistant Director NACA|\n|Dr Tolulope Oladele|Assistant Director, Health Sector Response Support NACA|\n|Prof. Musa Babashani|Member NTTA / Physician AKTH Kano|\n|Dr Elon W. Isaac|Senior Lecturer Paediatrics / College of Medical Sciences, GSU Gombe|\n|Chika Obiora-Okafo|Director Monitoring & Evaluation FHI360|\n|Dr Augustine Idemudia|Associate Director; Monitoring & Evaluation FHI360|\n|Dr Levy-Braide Boma|Senior Analyst CHAI|\n|Omaye Victoria Negedu|Senior Analyst CHAI|\n|Dr Akanmu|Analyst CHAI|\n|Muhammad-Mujtaba| |\n|Olusegun Adewole|Technical Officer APIN|\n|Dr Abiodun Hassan|Technical Director FHI360|\n|Dr Chizoba Mbanefo|Technical Director CRS|\n|Oyedokun Aliu Ope|Medical Officer II, NASCP|\n|Nkechi Okoro|M&E Officer NEPWHAN|\n|Ijeoma Amazue|US DoD|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n186\n\n# REFERENCES\n\n|[1]|World Health Organisation, \u201cConsolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection,\u201d WHO, 2016.|\n|---|---|\n|[2]|O. Agbaji , P. Agaba , K. Falang , A. Onu, M. Muazu and J. Idoko, \u201cPredictors of impaired renal function among HIV infected patients commencing highly active antiretroviral 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 exposure to tenofovir disoproxil fumarate-containing antiretroviral therapy is associated with renal impairment in an African cohort of HIV-infected adults,\u201d vol. 18, pp. 1-9, 2019.|\n|[4]|World Health Organisation, \u201cGLOBAL TB REPORT,\u201d WHO, 2018.|\n|[5]|National Population Commission Nigeria, \u201cNigeria Demographic Health Survey,\u201d NPC, 2018.|\n|[6]|National Agency for the Control of AIDS, \u201cNational HIV strategy for adolescents and young people 2016-2020,\u201d NACA, 2016.|\n|[7]|UNAIDS, \u201c90-90-90 An ambitious treatment target to help end the AIDS epidemic,\u201d UNAIDS, 2014.|\n|[8]|Federal Ministry of Health Nigeria, \u201cNigeria HIV/AIDS Indicator and Impact Survey,\u201d FMOH, 2018.|\n|[9]|National Agency for the Control of AIDS, \u201cNATIONAL AGENCY FOR THE Cnational 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, Rising HIV prevalence among men who have sex with men in Nigeria: A trend analysis.,\u201d BMC Public Health, vol. 1, no. 19, pp.", "mimetype": "text/plain", "start_char_idx": 428605, "end_char_idx": 431658, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "b90a87b5-5e8d-464b-9cae-c3a7030cc97d": {"__data__": {"id_": "b90a87b5-5e8d-464b-9cae-c3a7030cc97d", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "5c6b3a8c-8bae-439f-be40-f2680b092249", "node_type": "1", "metadata": {}, "hash": "6b71a87ecada8330b03b77bf9943bd01c8f0840b77d5a62bfae5d9c0a2d6f215", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "bce74d45-e99d-4a9f-ab2e-7d93c88d1d68", "node_type": "1", "metadata": {}, "hash": "511fa01c8c2899f1373848d4f0bd6c17d8d021874d7cb8d17977e23d74aaaa69", "class_name": "RelatedNodeInfo"}}, "text": "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 initiation of antiretroviral therapy,\u201d WHO, 2017.|\n|[13]|Federal Ministry of Health, \u201cNational Tuberculosis and Leprosy Control Programme report,\u201d NTBLCP, 2019.|\n|[14]|World Health Organisation, \u201cGuidelines for the diagnosis, prevention and management of cryptococcal disease in HIV-infected adults, adolescents and children: supplement to the 2016 consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection.,\u201d WHO, 2018.|\n|[15]|Gomerep S, Idoko J and Ladep N, \u201cFrequency of cryptococcal meningitis in HIV-1 infected patients in north central Nigeria.,\u201d Nigerian Journal of Medicine. 2010; 19(4): , 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 meningitis in Nigeria, one-step at a time; the impact of training.,\u201d PLoS One, vol. 15, no. 7, 2020.|\n|[17]|Uneke C, Duhlinska D and Njoku M, \u201cSeroprevalence of acquired toxoplasmosis in HIV- infected and apparently healthy individuals in Jos, Nigeria.,\u201d Parassitologia. 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 Kaplan J,\u201cCurrent epidemiology of Pneumocystis pneumonia,\u201d Emerg Infect Dis., vol. 10, no. 10, pp. 1713-20, 2004.|\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n187\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n[19] Ogba, Ofonime, Abia-Bassey, Lydia, Epoke and James, \u201cThe relationship between opportunistic pulmonary fungal infections and CD4 count levels among HIV seropositive patients in Calabar, Nigeria,\u201d Royal Society of Tropical Medicine, 2013.[20] Oladele R, Anyanlowo O, Richardson M and Denning D, \u201cHistoplasmosis in Africa: An emerging or a neglected disease? . 2018 Jan 18;12(1):e0006046. doi:,\u201d PLoS Negl Trop Dis, vol. 12, no. 1, 2018.[21] Oladele R, Toriello C, Ogunsola F, Ayanlowo O, Foden P and Fayemiwo A, \u201cPrior subclinical histoplasmosis revealed in Nigeria using histoplasmin skin testing,\u201d PLoS ONE, vol. 13, no. 5, pp. 1-11, 2018.[22] Adeyemi A, Sulaiman A, Solomon B, Chinedu O and Victor I, \u201cBacterial bloodstream infections in HIV-infected adults attending a Lagos teaching hospital,\u201d J Health Popul Nutr, vol. 28, no. 4, pp. 318-26, 2010.[23] Ogunsola F, Arewa D, Akinsete I, Oduyebo O, Akanmu A and Odugbemi T, \u201cAetiology of bacteraemia among adult AIDS patients attending Lagos University Teaching Hospital (LUTH), Lagos, Nigeria.,\u201d Niger Postgrad Med J, vol. 16, no. 3, pp. 186-92, 2009.[24] Ford N et al, \u201cManaging Advanced HIV Disease in a Public Health Approach.,\u201d Clinical Infectious Diseases, 2018.[25] Agaba P, Meloni S, Sule H, Agbaji O, Ekeh P, Job G, Nyango N, Ugoagwu P, Imade G, Idoko J and Kanki P, Patients who present late to HIV care and associated risk factors in Nigeria. HIV medicine, vol. 15, no. 7, pp. 396-405, 2014 .", "mimetype": "text/plain", "start_char_idx": 431644, "end_char_idx": 434742, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "bce74d45-e99d-4a9f-ab2e-7d93c88d1d68": {"__data__": {"id_": "bce74d45-e99d-4a9f-ab2e-7d93c88d1d68", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "b90a87b5-5e8d-464b-9cae-c3a7030cc97d", "node_type": "1", "metadata": {}, "hash": "8f4516ddf6f93b51f1aaaccfb10b237b9534425efd4843808875bbd5296d7b1d", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "8b42d6ab-1729-4f6f-ace2-6b4e2b7cc9b3", "node_type": "1", "metadata": {}, "hash": "5df59cf69bf85ddc723bfb03432276570d55eb922a699bacdcb08cbd9b0604d2", "class_name": "RelatedNodeInfo"}}, "text": "16, no. 3, pp. 186-92, 2009.[24] Ford N et al, \u201cManaging Advanced HIV Disease in a Public Health Approach.,\u201d Clinical Infectious Diseases, 2018.[25] Agaba P, Meloni S, Sule H, Agbaji O, Ekeh P, Job G, Nyango N, Ugoagwu P, Imade G, Idoko J and Kanki P, Patients who present late to HIV care and associated risk factors in Nigeria. HIV medicine, vol. 15, no. 7, pp. 396-405, 2014 .[26] World Health Organisation, \u201cLatent TB Infection: Updated and consolidated guidelines for programmatic management.,\u201d WHO, 2018.[27] World Health Organisation, \u201cOperational handbook on tuberculosis: module 1: prevention: tuberculosis preventive treatment,\u201d WHO, 2020.[28] Nakimuli-Mpungu E, Wamala K, Okello J, Ndyanabangi S, Kanters S and Mojtabai R, \u201cProcess Evaluation of a Randomized Controlled Trial of Group Support Psychotherapy for Depression Treatment Among People with HIV/AIDS in Northern Uganda,\u201d Community Ment Health J, vol. 58, no. 3, p.991\u20131004., 2017.[29] Elbrit D, Mahlab-Guri K, Bezalel-Rosenberg S, Gill H, Attali M and Asher I, \u201cHIV-associated neurocognitive disorders (HAND),\u201d Isr Med Assoc J., vol. 17, no. 1, pp. 54-9, 2015.[30] World Health Organisation, \u201cConsultation on HIV differentiated service delivery models for specific populations and settings: Pregnant and breastfeeding women, children, adolescents and key populations,\u201d WHO, 2016.[31] Badejo O, Menson W, Sam-Agudu N, Pharr J, Erekaha S and Bruno T, \u201cPediatric to adult healthcare transitioning for adolescents living with HIV in Nigeria: A national survey,\u201d PLoS ONE, vol. 13, no. 6, pp. 1-13, 2018.\n\n# APPENDIX\n\n1.1 Objectives of the Guidelines\n\n1.2 Epidemiology of HIV in Nigeria\n\n1.3 Natural History of HIV\n\n# Appendix 1: Commonly used Adult and Paediatric ARV Formulations and Dosage\n\n|Generic name|Dose|\n|---|---|\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 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 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 (\"Double dose\" LPV 800 mg/ + ritonavir 200 mg twice daily or \"super boosted\" with LPV 400 mg/ + ritonavir 100 mg twice daily plus additional doses of RTV 300 mg twice daily), with close monitoring. In the presence of rifabutin, no dose adjustment required.", "mimetype": "text/plain", "start_char_idx": 434363, "end_char_idx": 437384, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8b42d6ab-1729-4f6f-ace2-6b4e2b7cc9b3": {"__data__": {"id_": "8b42d6ab-1729-4f6f-ace2-6b4e2b7cc9b3", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "bce74d45-e99d-4a9f-ab2e-7d93c88d1d68", "node_type": "1", "metadata": {}, "hash": "511fa01c8c2899f1373848d4f0bd6c17d8d021874d7cb8d17977e23d74aaaa69", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "85f8bfe6-b093-4cb8-9a2a-d8d05265e257", "node_type": "1", "metadata": {}, "hash": "31221faf2ed2ce78b0a2b25611dcd12e74e89ae5ed7d956018ddfcfed4252444", "class_name": "RelatedNodeInfo"}}, "text": "In the presence of rifabutin, no dose adjustment required. Rifapentine 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 twice daily) and RAL (800 mg twice daily), with close monitoring. In the presence of rifabutin or rifapentine, no dose adjustmentis required.| |\n\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 adolescents living with HIV weighing at least 25 kg.\n\nb DTG 50 mg and TLD (Tenofovir 300 mg, Lamivudine 300 mg, Dolutegravir 50 mg fixed dose combination) can be used once daily in adolescents living with HIV weighing at least 30 kg.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Table 1.2: Dosing of optimal pediatric ARVs\n\n|Formulation|3\u20135.9 kg|6\u20139.9 kg|10\u201314.9 kg|15\u201319.9 kg|20\u201324.9 kg|25\u201329.9 kg|\u226530 kg| | | | | | | |\n|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|\n| |A|P|A|P|A|P|A|P|A|P|AM|PM|AM|PM|\n|ABC/3TC 120/60mg scored dispersible tablet|1|1.5| |2|2.5|3|(600/300 mg)|(600/300 mg)| | | | |1 adult tab|1 adult tab|\n|LPV/r 40/10 mg pellets (capsules)|2|2|3|3|4|4|5|5|6|6|-|-|-| |\n|LPV/r 40/10 mg granules (sachets)|2|2|3|3|4|4|5|5|6|6|-|-|-| |\n|LPV/r 100/25 mg tablets| | | | |2|1|2|2|2|2|3|3|3|3|\n|4-in-1 ABC/3TC/LPV/r 30/60/40/10 mg (capsules)|2|2|3|3|4|4|5|5|6|6|-|-|-| |\n|DTG 5 mg dispersible tablets|2|3|4| |5|-|-|-|-|-|-|-|-| |\n|DTG 10 mg scored dispersible tablet|0.5|1.5| |2|2.5|-|-|-|-|-|-|-|-| |\n|DTG 50 mg tablet|-|-|-|-|1|1|1|1| | | | | | |\n|TDF/3TC (or FTC)/DTG 300/300 (or 200)/50 mg tablet|-|-|-|-|-|-|-|-|-|-|1| | | |\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n191\n\n|Drug|Strength of paediatric tablets|Number of tablets by weight band morning and evening|Strength of adult tablet|Number of tablets by weight band|\n|---|---|---|---|---|\n|Tablet 300 mg/150 mg/30 mg (dispersible)|60 mg/30 mg/15 mg|1 AM, 1 PM|2|2 AM, 2 PM|\n|Tablet 300 mg/150 mg/60 mg/30 mg/50 mg|60 mg/30 mg/20 mg|1 AM, 1 PM|2|2 AM, 2 PM|\n|Tablet 600 mg/300 mg/60 mg/30 mg (dispersible)|60 mg/30 mg|1 AM, 1 PM|2|2 AM, 2 PM|\n|Tablet 600 mg/300 mg/120 mg/60 mg|60 mg/30 mg|1 AM, 1 PM|2|2 AM, 2 PM|\n\nFor 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 metabolize medications.", "mimetype": "text/plain", "start_char_idx": 437326, "end_char_idx": 439866, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "85f8bfe6-b093-4cb8-9a2a-d8d05265e257": {"__data__": {"id_": "85f8bfe6-b093-4cb8-9a2a-d8d05265e257", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "8b42d6ab-1729-4f6f-ace2-6b4e2b7cc9b3", "node_type": "1", "metadata": {}, "hash": "5df59cf69bf85ddc723bfb03432276570d55eb922a699bacdcb08cbd9b0604d2", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "c9bed0f4-7f44-4755-8517-eed6d7e265ff", "node_type": "1", "metadata": {}, "hash": "e2ed72ab5efc56cec9d15d6512cfd7db4a530501b96daddf790554ab7255e260", "class_name": "RelatedNodeInfo"}}, "text": "For infants 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 appropriate dosing of ARVs in preterm and low birth weight infants.\n\nPlease note that this regimen and formulation is no longer recommended and should only be used in special circumstances where other age-appropriate formulations are not available. 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|Drug|Strength of paediatric tablet|Strength of adult tablet or capsules|3\u20135.9 kg|6\u20139.9 kg|10\u201313.9 kg|14\u201319.9 kg|20\u201324.9 kg|25\u201334.9 kg|\n|---|---|---|---|---|---|---|---|---|\n|Tablet (scored) 200 mg|-|-|1|1.5\u20132|EFV mg| | | |\n|Tablet (dispersible) ABC / 3TC 1 mg|2|3|4|5|6|60/30 mg|600 mg/300 mg| |\n|Tablet (dispersible) ABC/3TC 1 mg|1|1.5|2.5|3|120/60 mg| | | |\n|Tablet 25 mg|-|-|-|-|25 mg|1 TAF| | |\n|Capsules 100 mg|-|2|2|-|300 mg|1 ATV| | |\n|Capsules 200 mg|-|1|1|-|-|600 mg|1 DRV| |\n|Tablet 150 mg|-|-|-|4|4|-|100 mg|1 RTV|\n|Tablet 50 mg|-|-|-|2|2|-|-|-|\n|Film-coated Tablet|-|-|-|-|-|150 mg|1 DTG 50 mg| |\n\nSee 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 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 appropriate dosing of ARVs in preterm and low birth weight infants.\n\nEFV is not recommended for children younger than 3 years and weighing less than 10 kg.\n\nAt 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 (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 least 25 kg.\n\nATV 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# 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/ packet) with 80 mg of RTV oral solution (1 ml).\n\nhttps://www.accessdata.fda.gov/drugsatfda_docs/label/2018/021567s042,206352s007lbl.pdf\n\nA 300 mg dose for 25-29.9 kg is recommended on the basis of findings from the PRINCE-2 study8\n\nDRV 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 from 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.\n\nRTV 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).", "mimetype": "text/plain", "start_char_idx": 439867, "end_char_idx": 443122, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c9bed0f4-7f44-4755-8517-eed6d7e265ff": {"__data__": {"id_": "c9bed0f4-7f44-4755-8517-eed6d7e265ff", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "85f8bfe6-b093-4cb8-9a2a-d8d05265e257", "node_type": "1", "metadata": {}, "hash": "31221faf2ed2ce78b0a2b25611dcd12e74e89ae5ed7d956018ddfcfed4252444", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "c5155a8f-80ac-48fd-af2a-8608883da8d9", "node_type": "1", "metadata": {}, "hash": "73de05b3ff3d30e08ee76d4c1f30efb6215299db5a2ce3e23bd8bc635e180820", "class_name": "RelatedNodeInfo"}}, "text": "https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/021567s042,206352s007lbl.pdf\n\nA 300 mg dose for 25-29.9 kg is recommended on the basis of findings from the PRINCE-2 study8\n\nDRV 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 from 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.\n\nRTV 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).\n\nAt 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 (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 current 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 and 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 experience, 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 current limited experience with this dosing. All children over 20kg receiving 50mg FCT will continue to be followed up in ODYSSEY and toxicity data collected.", "mimetype": "text/plain", "start_char_idx": 442429, "end_char_idx": 444270, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "c5155a8f-80ac-48fd-af2a-8608883da8d9": {"__data__": {"id_": "c5155a8f-80ac-48fd-af2a-8608883da8d9", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "c9bed0f4-7f44-4755-8517-eed6d7e265ff", "node_type": "1", "metadata": {}, "hash": "e2ed72ab5efc56cec9d15d6512cfd7db4a530501b96daddf790554ab7255e260", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "9d0b650f-f03a-4211-af68-5e0780e74f58", "node_type": "1", "metadata": {}, "hash": "3d46bb0898f75a26f23a81da1530a81d67c634b4e032f410d0dc21d110605f0f", "class_name": "RelatedNodeInfo"}}, "text": "In January 2019 the PAWG reviewed and 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 experience, 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 current 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 more 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\n\n194\n\n|Drug|Strength of paediatric weight band|Number of tablets or MLS by weight band morning (AM) and evening (PM)|Strength of adult tablet|Number of tablets by weight band| | | | | | |\n|---|---|---|---|---|---|---|---|---|---|---|\n|3\u20135.9 kg|6\u20139.9 kg|10\u201313.9 kg|14\u201319.9 kg|20\u201324.9 kg|25\u201334.9 kg|AM|PM|AM|PM| |\n|Tablet (dispersible) 60AZT|1|1.5|2|2.5|3|3|1|1|300 mg|11 mg|\n|Tablet (dispersible) 60ABC|1|1.5|2|2.5|3|3|1|1|300 mg|11 mg|\n|Tablet (dispersible) 50|1|1.5|2|2.5|3|3|2|2|200 mg|11 mg|\n|Tablet 100 mg/25 mg|-|-|-|2|1|2|2|2|2|3|\n|Pellets 40 mg/10 mg|2|2|3|3|4|4|5|5|6|6|\n|Granules 40 mg/10 mg|2|2|3|3|4|4|5|5|6|6|\n|Tablet 75 mg|-|-|-|-|5|5|5|5|400 mg|11 mg|\n|Tablet 25 mg|-|-|-|-|2|2|2|2|RTV|e|\n|Tablet 50 mg|-|-|-|-|1|1|1|1|-|-|\n|Chewable tablets 25 mg|1|1|2|3|4|6|6|-|RAL|f|\n|Chewable tablets 100 mg|-|-|-|-|-|-|1|1.5|-|-|\n\n# Liquid Formulations\n\n|Medication|Concentration|6 ml|9 ml|12 ml|\n|---|---|---|---|---|\n|AZT|10 mg/ml|6 ml|9 ml|12 ml|\n|ABC|20 mg/ml|3 ml|4 ml|6 ml|\n|3TC|10 mg/ml|3 ml|4 ml|6 ml|\n|NVP|80/20 mg/ml|1 ml|1.5 ml|2 ml|\n|LPV/r|100 mg/ml|2.5 ml|3.5 ml| |\n|RTV|80 mg/ml|0.5 ml|0.6 ml| |\n|10 mg/mL (Oral granules for suspension: 100 mg/sachet)| |3 ml|5 ml|8 ml|\n\nSee 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 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 and low birth weight infants.\n\nNVP 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 suggested that younger children have a lower risk of toxicity, and consideration can be given to starting with a full dose. Please note that this regimen is no longer recommended and should only be used in special circumstances where other age-appropriate formulations are not available.\n\nLPV/r liquid requires a cold chain during transport and storage.", "mimetype": "text/plain", "start_char_idx": 443682, "end_char_idx": 446645, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "9d0b650f-f03a-4211-af68-5e0780e74f58": {"__data__": {"id_": "9d0b650f-f03a-4211-af68-5e0780e74f58", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "c5155a8f-80ac-48fd-af2a-8608883da8d9", "node_type": "1", "metadata": {}, "hash": "73de05b3ff3d30e08ee76d4c1f30efb6215299db5a2ce3e23bd8bc635e180820", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "e44a04e9-7750-4cde-a5ab-ec31dadcd9f4", "node_type": "1", "metadata": {}, "hash": "c34fb822d05e5f0c2e6ea3f53930fde09a7ab62bc3231187a6a8d07cc60c9f00", "class_name": "RelatedNodeInfo"}}, "text": "Doses for this age group are reduced to account for the decreased ability to excrete and metabolize medications. For infants 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 and low birth weight infants.\n\nNVP 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 suggested that younger children have a lower risk of toxicity, and consideration can be given to starting with a full dose. Please note that this regimen is no longer recommended and should only be used in special circumstances where other age-appropriate formulations are not available.\n\nLPV/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 200/50 tablet could be used for patients 14-24.9 kg (1 tab am and 1 tab pm) and for patients 25-34.9 kg (2 tab am and 1 tab pm). LPV/r pellets formulation should not be used in infants younger than 3 months. More details on the administration of LPV/r pellets can be found at https://www.who.int/hiv/pub/toolkits/iatt-factsheet-lopinavir-ritonavir/en/. This dosing schedule applies to equivalent solid dosage forms such as LPV/r granules which can be used from 2 weeks of age. Since supply is currently constrained, both pellets and granules should be discouraged for children above 14 kg who should receive LPV/r 100/25mg tablets instead. Info on LPV/r formulations for children available at: https://www.arvprocurementworkinggroup.org/lpv-r-supply\n\nDRV, 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 formulation) in children 15 to 30 kg. RTV 100 mg tablets can be used as a booster if lower-strength RTV tablets are not available. This is based on limited experience suggesting good acceptability and tolerability. But no efficacy data.\n\nRTV should only be used at this dose as a boosting agent in combination with ATV or DRV.\n\nRAL granules are approved from birth. Feasibility and acceptability of such formulations have not been widely investigated and concerns have been raised regarding administration in resource-limited 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 children older than 4 weeks and weighing at least 3 kg. This was largely based on in vitro data on solubility and bioequivalence between tablets and granules as well as considering the limited availability 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 in rural settings is feasible as long as supported with adequate training and counseling.", "mimetype": "text/plain", "start_char_idx": 445754, "end_char_idx": 448896, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "e44a04e9-7750-4cde-a5ab-ec31dadcd9f4": {"__data__": {"id_": "e44a04e9-7750-4cde-a5ab-ec31dadcd9f4", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "9d0b650f-f03a-4211-af68-5e0780e74f58", "node_type": "1", "metadata": {}, "hash": "3d46bb0898f75a26f23a81da1530a81d67c634b4e032f410d0dc21d110605f0f", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "6232c831-6164-4503-bd1d-56cd5088a779", "node_type": "1", "metadata": {}, "hash": "c84a54d7e89b13a7626a7cd7b382aa30c7eb23f1bd725319614ded102c67b569", "class_name": "RelatedNodeInfo"}}, "text": "But no efficacy data.\n\nRTV should only be used at this dose as a boosting agent in combination with ATV or DRV.\n\nRAL granules are approved from birth. Feasibility and acceptability of such formulations have not been widely investigated and concerns have been raised regarding administration in resource-limited 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 children older than 4 weeks and weighing at least 3 kg. This was largely based on in vitro data on solubility and bioequivalence between tablets and granules as well as considering the limited availability 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 in rural settings is feasible as long as supported with adequate training and counseling.\n\n|Drug|Strength of oral liquid|2-3 kg|3-4 kg|4-5 kg| | | | |\n|---|---|---|---|---|---|---|---|---|\n|AZT|10 mg/mL|1 mL|1 mL|1.5 mL|1.5 mL|2 mL|2 mL| |\n|NVP|10 mg/mL|1.5 mL|1.5 mL|2 mL|2 mL|3 mL|3 mL| |\n|3TC|10 mg/mL|0.5 mL|0.5 mL|0.8 mL|0.8 mL|1 mL|1 mL| |\n|80/20 mg/mL|0.6 mL|0.6 mL|0.8 mL|0.8 mL|1 mL|1 mL| | |\n|LPV/r|Granules 40 mg/10 mg sachet| |2|2|2|2| | |\n|10 mg/mL|CCC|&lt;1 week|0.4 mL (once daily)|0.5 mL (once daily)|0.7 mL (once daily)| | | |\n| |(Oral granules for RAL suspension: 100 mg/sachet)|&gt;1 week|0.8 mL|0.8 mL|1 mL|1 mL|1.5 mL|1.5 mL|\n\nPK 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 addition, 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 will be updated when more evidence is available from ongoing trials.\n\nDo not use LPV/r solution in infants aged &lt;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 https://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 developed 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 kg. 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.\n\nRAL 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/isentress/isentress_pi.pdf) and twice a day afterwards.\n\n# Appendix 2: Mental Health Screening\n\nMental Health Screening for HIV Infected Patients According to the New York state Department of Health AIDS Institute\n\nAll HIV-infected patients should receive baseline and ongoing assessment of the following:\n\n- Mental health disorders:\n- Depression (every visit)\n- Anxiety (at least annually)\n- Post-traumatic stress disorder (at least annually)\n- Cognitive function (at least annually)\n- Sleep habits and appetite (every visit)\n- Psychosocial status (at least annually)\n- Suicidal/violent ideation (every visit)\n- Alcohol and substance use (at least annually)\n\nScreening Questions to Identify Depression in HIV infected patients:\n\n- In the past year, were you ever on medication or antidepressants for depression or nerve problems?\n- In the past year, was there ever a time when you felt sad, blue, or depressed for more than 2 weeks in a row?", "mimetype": "text/plain", "start_char_idx": 447921, "end_char_idx": 451825, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6232c831-6164-4503-bd1d-56cd5088a779": {"__data__": {"id_": "6232c831-6164-4503-bd1d-56cd5088a779", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "e44a04e9-7750-4cde-a5ab-ec31dadcd9f4", "node_type": "1", "metadata": {}, "hash": "c34fb822d05e5f0c2e6ea3f53930fde09a7ab62bc3231187a6a8d07cc60c9f00", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "8b349233-f4a6-417f-a745-551c92561564", "node_type": "1", "metadata": {}, "hash": "e99ec1618263858feedd9b3082b24a81ff741f16bd5e481577659603d3d57748", "class_name": "RelatedNodeInfo"}}, "text": "# Appendix 2: Mental Health Screening\n\nMental Health Screening for HIV Infected Patients According to the New York state Department of Health AIDS Institute\n\nAll HIV-infected patients should receive baseline and ongoing assessment of the following:\n\n- Mental health disorders:\n- Depression (every visit)\n- Anxiety (at least annually)\n- Post-traumatic stress disorder (at least annually)\n- Cognitive function (at least annually)\n- Sleep habits and appetite (every visit)\n- Psychosocial status (at least annually)\n- Suicidal/violent ideation (every visit)\n- Alcohol and substance use (at least annually)\n\nScreening Questions to Identify Depression in HIV infected patients:\n\n- In the past year, were you ever on medication or antidepressants for depression or nerve problems?\n- In the past year, was there ever a time when you felt sad, blue, or depressed for more than 2 weeks in a row?\n- In the past year, was there ever a time lasting more than 2 weeks when you lost interest in most things like hobbies, work, or activities that usually give you pleasure?\n\nScreening Questions to Identify Anxiety in HIV infected patients:\n\n- In the past year, did you ever have a period lasting more than 1 month when most of the time you felt worried and anxious?\n- In the past year, did you have a spell or an attack when all of a sudden you felt frightened, anxious, or very uneasy when most people would not be afraid or anxious?\n- In the past year, did you ever have a spell or an attack when for no reason your heart suddenly started to race, you felt faint, or you couldn't catch your breath?\n\nScreening Questions to Identify Post Traumatic Stress Disorder in HIV infected patients:\n\n- During your lifetime, as a child, or adult, have you experienced or witnessed traumatic event(s) that involved harm to yourself or others?\n- If \u201cyes\u201d:\n- In the past year, have you been troubled by flashbacks, nightmares, or thoughts of the trauma?\n- In the past 3 months, have you experienced any event(s) or received information that was so upsetting it affected how you cope with everyday life?\n\nScreening Questions to Identify Mania in HIV infected patients:\n\n- In the past year, when not high or intoxicated, did you ever feel extremely energetic or irritable and more talkative than usual?\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Appendix 3: Energy and Nutritional Recommendations for PLHIV\n\n|MACRONUTRIENT INTAKE| | |\n|---|---|---|\n|Normal Energy Requirements for Health:| | |\n|Carbohydrates - 45% to 65% of total energy intake| | |\n|Protein - 10% - 30% of total energy intake| | |\n|Fat - 20% to 35% of total energy intake| | |\n|Children|Adults|Pregnant and Lactating Women|\n|A 10% increase in energy intake is recommended to maintain growth in asymptomatic children.|A 10% increase in energy intake is recommended to maintain body weight and physical activity in asymptomatic HIV-infected adults.|The recommended energy intake for HIV-infected adolescents and pregnant and lactating women should be the same as their HIV negative counterparts.|\n|A 50% - 100% increase in energy intake over established requirements for healthy uninfected children is recommended in children who have weight loss.|A 20% - 30% increase in energy intake is recommended during symptomatic disease or opportunistic infections to maintain body weight.|Additional energy requirement during pregnancy and lactation: 1st Trimester = 90kcal/day 2nd Trimester = 300kcal/day 3rd Trimester = 450kcal/day Lactation = 500kcal/day|\n\n|MICRONUTRIENT INTAKE| | |\n|---|---|---|\n|People LHIV require extra vitamins and minerals to help repair and heal damaged cells. Consumption of a healthy diet may be insufficient to correct nutritional deficiencies in PLHIV and supplementation may be required.", "mimetype": "text/plain", "start_char_idx": 450940, "end_char_idx": 454713, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "8b349233-f4a6-417f-a745-551c92561564": {"__data__": {"id_": "8b349233-f4a6-417f-a745-551c92561564", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "6232c831-6164-4503-bd1d-56cd5088a779", "node_type": "1", "metadata": {}, "hash": "c84a54d7e89b13a7626a7cd7b382aa30c7eb23f1bd725319614ded102c67b569", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "76bb6dfa-1357-482d-876c-e5e182e4d76c", "node_type": "1", "metadata": {}, "hash": "57b8ffe89eda9164fb025afb71edffce3ac4ffea7af438b8611b974b4e2836ab", "class_name": "RelatedNodeInfo"}}, "text": "Consumption of a healthy diet may be insufficient to correct nutritional deficiencies in PLHIV and supplementation may be required. The following vitamins can be found in the foods listed:| | |\n|Vitamin A and beta-carotene: dark green, yellow, orange, or red vegetables and fruit; liver; whole eggs; milk| | |\n|Vitamins B: meat, fish, chicken, grains, nuts, white beans, avocados, broccoli, and green leafy vegetables| | |\n|Vitamin C: citrus fruits| | |\n|Vitamin E: green leafy vegetables, peanuts, and vegetable oils| | |\n| |Selenium: whole grains, nuts, poultry, fish, eggs, and peanut butter| |\n| |Zinc: meat, poultry, fish, beans, peanuts, milk and other dairy products| |\n|Children| |Pregnant and Lactating Women|\n|Vitamin A Supplementation|Vitamin A Supplementation| |\n|In keeping with WHO recommendations, 6 month to 60 month-old exposed/infected children born to HIV-infected mothers living in resource-limited settings should receive periodic (every 4\u20136 months) vitamin A supplements (100,000 IU for infants 6 to 12 months and 200,000 IU for children >12 months)|Daily vitamin A intake by HIV-infected women during pregnancy and lactation should not exceed the RDA. In areas of endemic vitamin A deficiency, a single high-dose of vitamin A (200,000 IU) is recommended to be given to women as soon as possible after delivery, but no later than six weeks after delivery.| |\n| |Iron Folate Supplementation| |\n|To prevent anaemia, WHO recommends daily iron-folate supplementation (400 \u00b5g of folate and 60 mg of iron) during six months of pregnancy, and twice-daily supplements to treat severe anaemia. Available data do not support a change in this recommendation for women living with HIV| | |\n\n# Appendix 4: Recommended activities for adolescent HIV service delivery\n\n|Global standard|Description|Recommended activities|\n|---|---|---|\n|1. Adolescents\u2019 health literacy|The health facility implements systems to ensure that adolescents are knowledgeable about their own health and they know where and when to obtain health services|- Training of peer supporters and adolescents living with HIV (ALHIV) in HIV prevention, sexual and reproductive health, mental health and life skills\n- Developing job aides on HIV testing, care and treatment, viral load monitoring, adherence counselling and contraceptive information and provision specific to adolescents\n- Peer supporters and treatment literacy staff address HIV knowledge and adherence concerns of adolescents\n|\n|2. Community support|The health facility implements systems to ensure that parents, guardians and other community members and community organizations recognize the value of providing health services to adolescents and support such provision and the utilization of services by adolescents|- Facilities create strong linkages with bi-directional referral to community-based services such as orphans and vulnerable children (OVC), gender-based violence prevention and support, social and legal protection, vocational training etc. through partnerships\n- Facilities and relevant community-based organizations (CBOs) establish formalized relationships (e.g. through memoranda of understanding) for shared implementation, monitoring and reporting whenever feasible\n- Facilities participate and support the training of community service providers as appropriate\n- Provision of community-based support for both ALHIV and their caregivers\n- Conducting sensitization sessions within schools to eliminate stigma and promote testing, adherence and retention by school attending ALHIV\n|\n|3. Appropriate package of services|The health facility provides a package of information, counselling, diagnostic, treatment and care services that fulfils the needs of all adolescents. Services are provided in the facility and through referral links and outreach|- Standard operating procedures and job aids developed and implemented to provide standard and simplified information on the package of services for adolescents\n- Constitute a multidisciplinary mentorship team on capacity-building for the needs of the adolescents\n|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 4. Providers\u2019 Competencies\n\nHealth-care providers demonstrate the technical competence required to provide effective health services to adolescents. Health-care providers and support staff respect, protect, and fulfill adolescents\u2019 rights to information, privacy, confidentiality, non-discrimination, non-judgmental attitude, and respect.\n\n# 5. Facility Characteristics\n\nThe health facility has convenient operating hours, a welcoming and clean environment, and maintains privacy and confidentiality. It has the equipment, medicines, supplies, and technology needed to ensure effective service provision to adolescents.", "mimetype": "text/plain", "start_char_idx": 454582, "end_char_idx": 459343, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "76bb6dfa-1357-482d-876c-e5e182e4d76c": {"__data__": {"id_": "76bb6dfa-1357-482d-876c-e5e182e4d76c", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "8b349233-f4a6-417f-a745-551c92561564", "node_type": "1", "metadata": {}, "hash": "e99ec1618263858feedd9b3082b24a81ff741f16bd5e481577659603d3d57748", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "9ae909bd-db93-45cf-816d-a40112115c04", "node_type": "1", "metadata": {}, "hash": "6aebee18943109f8bc78334ded0e598901fede8fa7f89b4263fbfd393b1bb70a", "class_name": "RelatedNodeInfo"}}, "text": "Services are provided in the facility and through referral links and outreach|- Standard operating procedures and job aids developed and implemented to provide standard and simplified information on the package of services for adolescents\n- Constitute a multidisciplinary mentorship team on capacity-building for the needs of the adolescents\n|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# 4. Providers\u2019 Competencies\n\nHealth-care providers demonstrate the technical competence required to provide effective health services to adolescents. Health-care providers and support staff respect, protect, and fulfill adolescents\u2019 rights to information, privacy, confidentiality, non-discrimination, non-judgmental attitude, and respect.\n\n# 5. Facility Characteristics\n\nThe health facility has convenient operating hours, a welcoming and clean environment, and maintains privacy and confidentiality. It has the equipment, medicines, supplies, and technology needed to ensure effective service provision to adolescents.\n\nAge band clinic appointment and flexible opening hours outside regular clinic hoursA safe space for adolescent HIV care and psychosocial support discussions, and peer interactionsScheduling of multidisciplinary teams to provide various services including counseling, antiretroviral medicine refill, viral load testingDevelopment and adherence to infection prevention and control policies\n\n# 6. Equity and Nondiscrimination\n\nThe health facility provides high-quality services to all adolescents regardless of their ability to pay, age, sex, marital status, education level, ethnic origin, sexual orientation, or other characteristics.\n\nServices provided free of charge with no out-of-pocket expensesClient satisfactory survey done periodically to get feedback for improvementInvolvement and collaboration by multi-layered and multisectoral agencies, including social protection services and government health ministries/agencies at all levels\n\n# 7. Data and Quality Improvement\n\nThe health facility collects, analyses, and uses data on service utilization and quality of care, disaggregated by age and sex, to support quality improvement. Health facility personnel are supported in participating in continual quality improvement.\n\nDevelop and implement standard data collection tools at the facility level and a reporting template that capture age, sex, and outcomesEstablish quality improvement teams at health facilities and build their capacity to use dataQuality improvement teams to routinely review disaggregated data, identify, test, and implement appropriate solutions\n\n# Adolescents\u2019 Participation\n\nAdolescents are involved in planning, monitoring, and evaluating health services and in decisions regarding their care and in certain appropriate aspects of service provision.\n\nInvolvement of peer supporters/educators in relevant facility health team activities and meetings such as case reviews and advocacy for adolescent-friendly health services.\n\nTraining of peers to be self-health managers, to motivate self and others, and to be a source of positive peer pressure to others.\n\nDeveloping viable and effective mechanisms for harnessing input and feedback from adolescents on the planning, implementation, monitoring, and evaluation of services provided.\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Appendix 5: Guide on Age Appropriate Disclosure for Children and Adolescents\n\n|Age characteristics|Stage of Disclosure|Provider Action|\n|---|---|---|\n|0 - 4 years|No disclosure|At this stage, no disclosure is done since the child is too young to understand about HIV|\n|5 - 8 years|Partial disclosure|At this age, the child can understand a lot. Define the virus as a germ and the CD4+ as the soldier in the body that keep fighting and one has to take the drugs to strengthen the soldiers in the body. Full disclosure is important since most children at this stage are able to understand more about HIV and would have heard about HIV as part of formal education at school. Follow the following stages in the disclosure process: Stage 1: Assessing the child social support system to ensure the availability of sufficient support once disclosure is completed. Stage 2: Assess the child's prior knowledge about HIV/AIDS including information given at school, any myths and misconceptions. Offer or reinforce accurate information. Stage 3: Use an imaginary exercise or story to assess a child's reaction to disclosure.|\n|9 to 12 years|Post-disclosure (3-6 months after full disclosure)|Find out from the parent/guardian if they have observed anything after disclosure, e.g. behavior change: - Introduce the child to tell their story and emerge as a hero (a comic book may be a useful aid). - Link the child to a support group or with an older child who has been disclosed to.", "mimetype": "text/plain", "start_char_idx": 458313, "end_char_idx": 463150, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "9ae909bd-db93-45cf-816d-a40112115c04": {"__data__": {"id_": "9ae909bd-db93-45cf-816d-a40112115c04", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "76bb6dfa-1357-482d-876c-e5e182e4d76c", "node_type": "1", "metadata": {}, "hash": "57b8ffe89eda9164fb025afb71edffce3ac4ffea7af438b8611b974b4e2836ab", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "803f17f4-2e43-4d79-8393-ff8901454137", "node_type": "1", "metadata": {}, "hash": "16a2961769ecbf504c498c79959d904ca5f9a7d55da05b3c753293f1980b34eb", "class_name": "RelatedNodeInfo"}}, "text": "Follow the following stages in the disclosure process: Stage 1: Assessing the child social support system to ensure the availability of sufficient support once disclosure is completed. Stage 2: Assess the child's prior knowledge about HIV/AIDS including information given at school, any myths and misconceptions. Offer or reinforce accurate information. Stage 3: Use an imaginary exercise or story to assess a child's reaction to disclosure.|\n|9 to 12 years|Post-disclosure (3-6 months after full disclosure)|Find out from the parent/guardian if they have observed anything after disclosure, e.g. behavior change: - Introduce the child to tell their story and emerge as a hero (a comic book may be a useful aid). - Link the child to a support group or with an older child who has been disclosed to. NB: Find out how the child is doing at every visit after full disclosure.|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Appendix 6: Self-management timeline for transitioning ALHIV\n\n|Age|From 10-12 years|From 13-16 years|From 17-19 years (Capacity to transition)|\n|---|---|---|---|\n|Individual growth and environmental support: Encouraging healthy decisions|Psycho-social support|Psycho-social support|Psycho-social support|\n| |Link to relevant support groups and programs|Link to relevant support groups and programs|Link to relevant support groups and programs|\n| |Support mentorship of younger positive adolescents|Support mentorship of younger positive adolescents|Support mentorship of younger positive adolescents|\n| |Sexual and reproductive health, positive health and prevention|Sexual and reproductive health, positive health and prevention|Sexual and reproductive health, positive health and prevention|\n| |Answer any questions that emerge honestly and truthfully|Link to an adolescent-friendly reproductive health provider and clinics, review sexuality issues and safe sex practices, refer for regular sexual health check-ups, discuss HIV prevention methods|Continue sexuality conversations, encourage questions about HIV, pregnancy, and sexuality, refer for regular sexual health check-ups, discuss HIV prevention methods|\n| |Substance use|Substance use|Substance use|\n| |Discuss substance use and how it can impact health|Discuss the links between sexually risky behaviours, substance abuse, and poor health outcomes; assess if using substances and what triggers use|Discuss the links between sexually risky behaviours and substance abuse, and poor health outcomes; assess if using substances and what triggers use|\n| |Future planning|Future planning|Future planning|\n| |Initiate conversation about future goals (work, school, etc.", "mimetype": "text/plain", "start_char_idx": 462352, "end_char_idx": 465017, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "803f17f4-2e43-4d79-8393-ff8901454137": {"__data__": {"id_": "803f17f4-2e43-4d79-8393-ff8901454137", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "9ae909bd-db93-45cf-816d-a40112115c04", "node_type": "1", "metadata": {}, "hash": "6aebee18943109f8bc78334ded0e598901fede8fa7f89b4263fbfd393b1bb70a", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "07c9d249-39c2-400e-889f-3f0e1879b3f1", "node_type": "1", "metadata": {}, "hash": "21e85fcafe66e245e6ba3d05b06b9cf98d8d31d9283c5d13441724690f480deb", "class_name": "RelatedNodeInfo"}}, "text": ")|Promote peer education opportunities, connect ALHIV with relevant NGOs|Connect ALHIV to job training, vocational training, and continued education opportunities|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Clinical support: Providing or facilitating referrals for needed services\n\n- Self-care\n- Support caregivers to disclose to the adolescent if not already done\n- Talk to the child to start mapping out the transition timeline after disclosure\n- Build a schedule/calendar with the adolescent to strengthen adherence to treatment and retention\n- Discuss and address transport barriers and other issues that hinder Clinic and ART adherence\n- Clinical management\n- Talk about HIV and prevention measures\n- Begin to explain medications and reinforce adherence messages\n- Talk about adherence issues\n- Link to counselling (including lay or peer) for any mental health issues\n- Talk to the adolescent about diagnosis, medications, appointment keeping, and adherence\n- Help identify appropriate adult providers/clinics\n- Solicit questions about care, treatment, and potential future changes in treatment\n- Link to counselling (including lay or peer) for any mental health issues\n- Ensure that viral load suppression (<1000 copies/ml) is achieved within the last one year prior to completion of transitioning to adult care\n- Follow up with transitioned adolescents 6 months to ensure adherence and retention in care\n\n# NATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n205\n\n# 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 for TB Preventive Therapy| |\n|---|---|\n|Children aged \u2265 12 months living with HIV * - Screen for TB with any one of the following symptoms: - Weight loss or poor weight gain\n- Fever\n- Current cough\n- History of contact with a person with TB\n| |\n|No Assess for contraindications to TPT - No\n- Defer TPT until problem resolved\n|Yes Investigate for TB and other diseases - Other Diagnosis\n- Not TB\n- TB\n|\n|Administer TPT - Screen regularly for TB at each encounter with the patient\n| |\n\n*All infants <1 year should only be given TPT if they have a history of household contact with a TB case and do not have active TB after evaluation\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - Page 206\n\n# Figure 7.2: Algorithm for screening Adult and Adolescent Living with HIV (including pregnant PLHIV) for TB Preventive therapy\n\n|All Adults and Adolescents living with HIV| | |\n|---|---|---|\n| |Screen for TB with any one of the following symptoms:|Current cough|\n| |Fever| |\n|No|Weight loss| |\n| |Night sweats| |\n|No| |Yes|\n|Assess for contraindications to TPT|Investigate for TB and other diseases| |\n|No| |Yes|\n|Defer TPT until problem resolved|Give Appropriate Treatment and consider TPT| |\n|Administer TPT|Follow up and Treat| |\n| |Screen regularly for TB at each encounter with the patient| |\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - Page 207\n\n# Figure 7.3: Algorithm for Diagnosing TB in Children and Adolescent\n\nPresume TB in a child living with HIV if any of the following is present:\n\n- Current cough\n- Unexplained fever\n- Weight loss or failure to gain weight\n- History of contact with an adult TB\n- Features of Extra-pulmonary TB\n\nIf specimen is available:\n\n- Collect appropriate specimen (e.g. sputum, stool, lymph node/gastric aspirate, cerebrospinal fluid, abscess/pus and other body fluids) for Xpert MTB/RIF assay OR collect sputum only for Truenat MTB/RIF test\n\nIf specimen is unavailable (e.g. presumptive EPTB) or MTB not detected:\n\n- History of contact with TB patient or positive Mantoux test\n- Physical signs suggestive of TB\n- TB suggestive imaging features (e.g.", "mimetype": "text/plain", "start_char_idx": 465017, "end_char_idx": 468788, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "07c9d249-39c2-400e-889f-3f0e1879b3f1": {"__data__": {"id_": "07c9d249-39c2-400e-889f-3f0e1879b3f1", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "803f17f4-2e43-4d79-8393-ff8901454137", "node_type": "1", "metadata": {}, "hash": "16a2961769ecbf504c498c79959d904ca5f9a7d55da05b3c753293f1980b34eb", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "6384850b-88e2-45f1-9857-984e8d1026df", "node_type": "1", "metadata": {}, "hash": "6e5e96e0dd5e01d045de488942dd63a856c18b8462d57b307a141c417c6ab637", "class_name": "RelatedNodeInfo"}}, "text": "sputum, stool, lymph node/gastric aspirate, cerebrospinal fluid, abscess/pus and other body fluids) for Xpert MTB/RIF assay OR collect sputum only for Truenat MTB/RIF test\n\nIf specimen is unavailable (e.g. presumptive EPTB) or MTB not detected:\n\n- History of contact with TB patient or positive Mantoux test\n- Physical signs suggestive of TB\n- TB suggestive imaging features (e.g. chest x-ray and computed tomography scan)\n\nTreat as Drug Susceptible TB (DS-TB) if child is not a contact of DR-TB case\n\n| |MTB detected, RIF detected|MTB not detected, RIF resistance detected|MTB not detected, RIF resistance not detected|\n|---|---|---|---|\n|If only one of three features present|Refer to Medical Officer|Refer to Medical Officer|Refer to Medical Officer|\n|If two or more features present **|Review after 2 - 4 weeks|Review after 2 - 4 weeks|Review after 2 - 4 weeks|\n\nIf child is ill: Refer to Medical Officer\n\nIf child is well: Review after 2 - 4 weeks\n\nPresume DR-TB if in addition to symptoms of TB, the child has any of the under-listed risk factors:\n\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 - 12 months)\n- Not improving after 2 months of DS-TB treatment\n\n*Clinical diagnosis is recommended if all effort at bacteriological confirmation using Xpert MTB/RIF assay/Truenat test (or Urine LF-LAM assay in PLHIV with advanced disease) is not possible\n\n**In settings where there is no doctor (e.g. hard to reach areas), the trained health care worker can make a diagnosis of TB and commence anti-TB treatment\n\n***Treat as DR-TB if child is a contact of DR-TB case\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\nFigure 7.4: Algorithm TB in Diagnosis in AdultsNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020209\n\n# Appendix 8: Global Standards for Quality Health-Care Services for Adolescents\n\n|Adolescents\u2019 health literacy|Standard 1 - The health facility implements systems to ensure that adolescents are knowledgeable about their own health, and know where and when to obtain health services.|\n|---|---|\n|Community support|Standard 2 - The health facility implements systems to ensure that parents, guardians and other community members and community organizations recognize the value of providing health services to adolescents and support such provision and the utilization of services by adolescents.|\n|Appropriate package of services|Standard 3 - The health facility provides a package of information, counselling, diagnostic, treatment, and care services that fulfils the needs of all adolescents. Services are provided in the facility and through referral linkages and outreach.|\n|Providers\u2019 competencies|Standard 4 - Health-care providers demonstrate the technical competence required to provide effective health services to adolescents. Both healthcare providers and support staff respect, protect and fulfil adolescents\u2019 rights to information, privacy, confidentiality, non-discrimination, non-judgmental attitude, and respect.|\n|Facility characteristics|Standard 5 - The health facility has convenient operating hours, a welcoming and clean environment and maintains privacy and confidentiality. It has the equipment, medicines, supplies, and technology needed to ensure effective service provision to adolescents.|\n|Equity and non-discrimination|Standard 6 - The health facility provides quality services to all adolescents irrespective of their ability to pay, age, sex, marital status, education level, ethnic origin, sexual orientation, or other characteristics.|\n|Data and quality improvement|Standard 7 - The health facility collects, analyses and uses data on service utilization and quality of care, disaggregated by age and sex, to support quality improvement. Health facility staff is supported to participate in continuous quality improvement.|\n|Adolescents\u2019 participation|Standard 8 - Adolescents are involved in the planning, monitoring, and evaluation of health services and in decisions regarding their own care, as well as in certain appropriate aspects of service provision.|\n\n1 Service provision in the facility should be linked, as relevant, with service provision in referral level health facilities, schools, and other community settings.", "mimetype": "text/plain", "start_char_idx": 468408, "end_char_idx": 472754, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "6384850b-88e2-45f1-9857-984e8d1026df": {"__data__": {"id_": "6384850b-88e2-45f1-9857-984e8d1026df", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "07c9d249-39c2-400e-889f-3f0e1879b3f1", "node_type": "1", "metadata": {}, "hash": "21e85fcafe66e245e6ba3d05b06b9cf98d8d31d9283c5d13441724690f480deb", "class_name": "RelatedNodeInfo"}, "3": {"node_id": "886d0981-c66f-428d-8126-fb0c816909b4", "node_type": "1", "metadata": {}, "hash": "85caa5fd2baaed23bce91a0dd68cc18dba72ed1e91a077473adc65282799a45f", "class_name": "RelatedNodeInfo"}}, "text": "It has the equipment, medicines, supplies, and technology needed to ensure effective service provision to adolescents.|\n|Equity and non-discrimination|Standard 6 - The health facility provides quality services to all adolescents irrespective of their ability to pay, age, sex, marital status, education level, ethnic origin, sexual orientation, or other characteristics.|\n|Data and quality improvement|Standard 7 - The health facility collects, analyses and uses data on service utilization and quality of care, disaggregated by age and sex, to support quality improvement. Health facility staff is supported to participate in continuous quality improvement.|\n|Adolescents\u2019 participation|Standard 8 - Adolescents are involved in the planning, monitoring, and evaluation of health services and in decisions regarding their own care, as well as in certain appropriate aspects of service provision.|\n\n1 Service provision in the facility should be linked, as relevant, with service provision in referral level health facilities, schools, and other community settings.\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020 - Page 210\n\n# Appendix 9: Pharmacovigilance or Drug and Therapeutic Committees (PVC) - Terms of Reference\n\nThere should be the existence of a functional Pharmacovigilance or drug and therapeutic committee at the facility level, which meets regularly to provide oversight, review all the documented/reported cases of ADRs and advise on the management of such patients. The committee should be comprised minimally of a clinician, Pharmacist, Nurse, Adherence counselor, and a Lab scientist; may also include data/record officer, Mentor mother and other support staff where available.\n\n# Terms of Reference of the PVC or DTC\n\nThe Pharmacovigilance or Drug and Therapeutic committee will hold regular meetings in pursuant of their roles and responsibilities as stated below. If necessary, the committee will need to enforce mandatory attendance to accomplish the functions of the committee. Minutes and MOVs need to be prepared for each meeting and distributed to the appropriate departments. Finally, all goals, terms of reference, policies, decisions, and other actions of the PVC or DTC should be documented, and the records kept.\n\n# Roles and Responsibilities\n\nThe responsibilities of the PVC or DTC include but are not limited to \u2013\n\n|1.|Medication advisory role to the facility|On VL optimization and results review, pharmacovigilance & management activities, regimen switch and substitutions decisions etc.|\n|---|---|---|\n|2.|Identifying drug use problems and promoting rational drug use.|Through examinations of reports such as Medication error reports; Drug-drug interactions; VL reports for treatment failure (unsuppressed clients to be considered for EAC and decision to switch); ADR reports, etc.|\n|3.|Promoting interventions that improve drug use such as education program (e.g., CME, bulletin publication, in-service training) and managerial program (such as conduct Drug Use evaluation).| |\n|4.|Promoting pharmacovigilance activities by encouraging, monitoring, assessing, reporting, and prevention of ADRs and other medication related problems:|To review the availability and adequacy of tools (ADR Screening form, NAFDAC yellow/ADR reporting form), and the skills of HCWs to monitor and report ADR at the facility. Liaise with supporting Implementing Partners, state LMCU, or other partners to address identified gaps in Pharmacovigilance monitoring and reporting at the facility level. Ensure the documentation, collation, and routine reporting of identified ADRs from the facility to the National Pharmacovigilance Centre (NPC) managed by NAFDAC.", "mimetype": "text/plain", "start_char_idx": 471691, "end_char_idx": 475379, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}, "886d0981-c66f-428d-8126-fb0c816909b4": {"__data__": {"id_": "886d0981-c66f-428d-8126-fb0c816909b4", "embedding": null, "metadata": {}, "excluded_embed_metadata_keys": [], "excluded_llm_metadata_keys": [], "relationships": {"1": {"node_id": "570e4a23-736a-4937-afc6-0790d7ab44a1", "node_type": "4", "metadata": {}, "hash": "eca99945416e34313cf3a06133930f72c70a6b40c467ed9df436405d39f06d7d", "class_name": "RelatedNodeInfo"}, "2": {"node_id": "6384850b-88e2-45f1-9857-984e8d1026df", "node_type": "1", "metadata": {}, "hash": "6e5e96e0dd5e01d045de488942dd63a856c18b8462d57b307a141c417c6ab637", "class_name": "RelatedNodeInfo"}}, "text": "Liaise with supporting Implementing Partners, state LMCU, or other partners to address identified gaps in Pharmacovigilance monitoring and reporting at the facility level. Ensure the documentation, collation, and routine reporting of identified ADRs from the facility to the National Pharmacovigilance Centre (NPC) managed by NAFDAC. Provide guidance to community pharmacies and other out of facility DSD models, to ensure that the capacity and tools are available to monitor and report ADRs among the patients they serve.|\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\n# Appendix 10: NAFDAC ADR Form\n\nANNEXURE\nPVPMS-003-01\n\nNational Agency for Food and Drug Administration and Control (NAFDAC)\n\nCorporate Headquarters\n\nPlot 2032 Olusegun Obasanjo\n\nWuse Zone, Abuja\n\nNAFDAC National Pharmacovigilance Centre\n\n# PATIENT INFORMATION\n\n|Patient's Full Name:| |Initials (In Confidence):|\n|---|---|---|\n|Weight (kg):| | |\n|Female:| | |\n|Male:| | |\n|Date of Birth (e.g., 03 May 1925):| | |\n\nHospital Treatment Centre\n\nPatient Record No:\n\n# ADVERSE EVENT\n\nDescribe Event:\n\nSeriousness of Adverse Event (Check all that apply):\n\n- Death (Include date - dd-mmm-YYYY)\n- Life-threatening\n- Hospitalization - Initial\n- Hospitalization - Prolonged\n- Disability - Permanent Damage\n- Congenital Anomaly/Birth Defects\n- Required Intervention to Prevent Permanent Impairment/Disability (Devices)\n- Others (Specify)\n\nOutcomes:\n\n- Recovering fully\n- Recovered\n- Unknown\n- Others (Specify)\n\n|Onset Date:| |Stop Date of Event:|\n|---|---|---|\n| | | |\n\nSUSPECTED DRUG (Including Biologicals, Traditional/Herbal Medicines, Cosmetics)\n\n|Product Details (Name and other details as per product label/sample if available):| | |\n|---|---|---|\n|Brand Name:| |Batch No:|\n|Generic Name:| |NAFDAC:|\n|Name and Address of Manufacturer:| | |\n|Expiry Date:| | |\n\nNATIONAL GUIDELINES FOR HIV PREVENTION TREATMENT AND CARE 2020\n\nSERIAL NO:\n00024981\n\nNAFDAC USE ONLY\n\nIndications for Use (Diagnosis)\n\n|Dosage|Frequency|Route|Administration|\n|---|---|---|---|\n|Date Medication Started (dd-mmm-YY)| |Date Medication Stopped (dd-mmm-YYYY)| |\n\nReaction Stopped After Drug Withdrawal\n\nReaction Reappeared After Drug Reintroduction?\n\n- Doesn't apply\n- Doesn't apply\n\n# CONCOMITANT MEDICINES\n\n(medicines taken within the months including herbal and self-medication)\n\nBrand Name\nGeneric Name\nDosage\nRoute\nDate Started\nDate Stopped\nReason for Use\n\n# RELEVANT TESTS\n\nLABORATORY DATA WITH DATES\n\n# OTHER RELEVANT HISTORY\n\nIncluding Preexisting Medical Conditions:\n\n- Pregnancy\n- Alcohol use\n- Smoking\n- Liver Problems\n- Kidney Problems\n- Allergies\n- Others (Specify)\n\n# REPORTER\n\nName and Address:\n\nLast Name:\n\nFirst Name:\n\nAddress:\n\nCity:\n\nState:\n\nCountry:\n\nDate:\n\nPhone No:\n\nEmail:\n\nHealth Professional?\n\nOccupation:\n\n212", "mimetype": "text/plain", "start_char_idx": 475046, "end_char_idx": 477835, "text_template": "{metadata_str}\n\n{content}", "metadata_template": "{key}: {value}", "metadata_seperator": "\n", "class_name": "TextNode"}, "__type__": "1"}}, "docstore/ref_doc_info": {"570e4a23-736a-4937-afc6-0790d7ab44a1": {"node_ids": ["1be39814-a249-4beb-9742-aedeeac8f9cf", "c917afa3-7e9c-4051-893e-cde6a22e2eae", "182c0ea7-396b-4837-8599-6d6dbacb7005", "7f05d90e-6603-4c55-9d6d-ff1c1cb022aa", "71cda16c-eddb-417f-b65b-76e85b24a519", "dedf3b6c-5868-40ea-82a7-4fdadfcab74a", "3b1708a5-0d86-4d65-bb50-0ca163399c44", "aa183659-830b-4122-8951-3129dedfea68", "6f3454a0-948f-4cde-ad10-1b6aed794ed9", "6169792c-ef1d-450c-9d2f-f02eb3edd3ed", "0cf5611b-e367-4e1d-94fb-a204337f5b59", "0d807e4e-524c-4de5-a445-65f2645055ff", "773bb3cd-87f0-4aea-a0eb-9bf3ca65f2eb", "de65c2a1-97ff-4bfa-b7d0-52e200af1b61", "ebc6c790-a421-45e6-beef-4782eeb79856", "856b62f2-43df-4a71-9419-06d1bbd3e7de", "c60d14ec-6b32-4dd3-a838-59461c2b8ced", "b132e3cd-9e1c-4143-be38-aabfe6f039a4", "e9fe0eaa-658a-4901-9617-57d195b286d8", "08444e6b-7299-445d-a579-45b38638d531", "adc25c12-2748-4636-b682-3bcc9ef0ae8e", "c268ce2d-dad5-4184-b4cb-bc43a8b97797", "bb428944-f860-48cc-a583-35e574e586c7", "acdae45e-cd3e-4340-988f-6cf0b86bfecf", "6b58603d-7cc7-4197-a17c-e3384af73d0c", "fc58a0be-8fc8-46cc-9913-79372ec5b371", "0a6de4b6-cc5d-49b2-9567-661e61fabf4b", "b1238e3b-068e-4192-b862-93fe607a37a2", "8487c36f-b154-409c-a194-cb38a34c6bd9", "e8ee475d-e9bf-4041-9054-d827b164f4ea", "66be3a16-0a4d-4efb-9177-b28c373a4da0", "3d134476-b69b-4975-9bde-35e3df8da770", "2cf1d939-3565-4dd1-92c4-576e43cf56ab", "225bc172-e222-4e71-9928-e96ee21d9b62", "a2c58816-600c-4345-a8da-1b43314b1eeb", "da01d3e5-5774-4c96-9db6-de87248ba4aa", "8391fb3d-0f9f-40b3-b7ab-28325bcb41f7", "768ad6e1-bb2e-4e0f-aae0-9326cb0d503a", "2992863a-e3a3-4e28-8567-ccb60ad5988f", "934e5e60-8fbc-43eb-9667-95508dbc9dd4", "4faedd18-3ed4-44f5-92de-f8a37a477e3e", "48f6c872-48e2-4d22-b01d-6346cd593416", "8f48c9af-cc4a-45d3-9812-9e18b74cdf4e", "9c44f389-1d28-4f71-980c-1578e1550fb0", "768fa145-742c-4763-bd70-f252de065582", "fdd30f91-0a54-4d84-94e5-412656dae5c5", "a315f0f8-af27-4fe6-9ef2-9a99355e67b8", "d0ffd61a-1fc6-4dab-8563-dc6e70406c15", "9981c837-beee-49a4-8d2c-6736cfc6d7a1", "4e1f0313-44ae-46b8-bf73-f311cc8c925c", "aacb9127-6773-42f8-b854-3a8e54a53d3d", "72952e09-0f8b-4b41-b5d4-6f5e3200be74", "ee5d725b-c1de-48fc-9442-38f9a8c36c3d", "1ebd72d6-6e31-4687-b953-e3498e8d9d8f", "864e3900-17ba-4043-a25f-a69360de0f97", "24871fd0-80bb-4a0c-9dbd-2a8090bb673e", "3371b69f-ec01-4528-8ee5-1826662a7257", "5b885312-bf3e-4bc2-a08b-1c30acc44439", "536c8729-832f-4e37-9270-19eb6521c97b", "52e81834-d79f-4d6d-a8dd-c04bc659c89a", "8b178d80-74e9-4171-8b00-8ca7e99f88b5", "51a3eb4e-c195-495a-a7f8-c1b5a59175d6", "2876bcad-2f09-462d-a10c-aa1150e1bdd8", "3a0597d5-512e-4e79-a2da-fe54414a9754", "c96ea4c9-bf74-473e-827c-4a29733b79e3", "fb741f10-a41a-410a-9761-620d24c25529", "5b859628-c49c-4c48-b6a0-3541bd556f53", "d0b319aa-5b24-4d0d-bb9b-3356f697502f", "6e46d6e4-6b98-4c16-af94-d1ce52418406", "2e499b5c-095f-419a-820c-e70d05e34ad7", "30cf4aa4-357a-40fc-a302-e0e8142f0c01", "384b5810-f3a7-4f0e-808f-1abbfa534112", "92acaea4-c99a-492e-8889-875fc6ce9912", "762ac6ee-aa2e-4595-ad5b-1b5f0316bda4", "b58857f8-fbee-4ff9-8e32-023953efe7d7", "724d4268-deac-488c-99f6-2e31a05009f4", "05cbce19-bc3f-4963-83d6-1e77bd17790d", "72e340aa-8865-485a-8d95-ce8cb86298c9", "7aa2b209-d355-4edf-a025-663585c6d543", "1c8e8c27-a0a7-4d07-aca4-0a372248627a", "7d76622d-c052-4fc8-bea4-39b920d597ea", "74aa6c80-4fa6-4e5a-ab61-5459f39e9521", "9a62be8c-002e-423c-ad65-b85bad865c4f", "4a14b673-b704-4c53-bf82-86a2a9d82b04", "bc9e66bf-23a6-47c7-9920-d18d7903002f", "78c000b2-808a-46fc-8390-486722342cf7", "abef2aa6-0090-461e-982c-e8880353d9f8", "a0ea8a83-92f2-421f-b583-e5d04834c259", "eeb1cdda-7b65-47d1-b142-5d532ac85cab", "c5ef7c56-7463-4737-9006-a4125c33a909", "1922b9cb-3833-488e-a0c4-c6ff0f6b1b99", "b4386fec-b92e-4f31-99f0-c1000563c82a", "049328b1-bbcb-4bae-a28c-c5eaf96cf908", "4e1172eb-ec42-4e8d-84f2-9500acb0c007", "89805267-89b6-4d46-93ec-c90570ad8da3", "e6e74683-1f88-4425-9346-ccf52b68098a", "fd13c817-0bd5-48ed-9c7e-889bea17e88b", "ca780269-c4fe-4975-9c0e-6ea659664995", "fc4c2773-3865-4163-a103-276e0408ca85", "34c80094-8287-4c44-bc16-088a133f62f0", "e3fc83c3-658e-4bc1-8184-4af3df01af48", "9bb1b86d-d3ae-41b4-bd0f-1c54ec21a3c4", "ee1887b0-dfd0-4074-ab4b-290b1cfe94c6", "adbe517d-f0bc-4ad4-a660-6b852988e564", "719b0511-e145-4652-b14e-bc6a1aeeaa19", "7bd8ebd7-cbab-48e0-afaf-7691de62ea33", "290348b0-0903-42f6-9dee-89f395619ab9", "a53ff8fa-43d7-4c48-b5a4-f1fc4a15e5e6", "00592b08-271a-4179-85b5-664a5fb0b4c8", "8748db76-7138-4631-b69f-c177c46c7ccd", "c558b0e8-3b18-42f1-afef-6f0734840d33", "14a09a50-0bed-4733-b746-5389a1f64ed8", "bdd91bc2-8834-4bd7-9c6c-8d017eb043d2", "74ce8aca-8c4a-44ed-856d-b4a5f75531f1", "de21296b-ca4d-4077-8ca6-1672b328f78c", "6f34babe-4cfe-4d28-803f-81fa7142e2d0", "f9f831ac-f9b9-4b1c-aa3c-0f3b9a7974eb", "03e4ac44-fa49-4d5f-b06d-48aba85dcde9", "0fb8f16f-107c-4059-8128-46291c15f157", "28e02e9b-68c8-4dea-983e-00c380d56686", "57680c96-f3a7-4cfd-af10-727c4b4a47eb", "d167b9fc-757d-4e7e-8a12-cc0f87dc9a89", "152adb26-e7d9-4d13-a9dc-9a8bc02f47b0", "7538fc80-39bd-4699-add9-4e3b386ae671", "7583dec9-c673-4686-b2a8-c38682e9d3bf", "d7d83cd6-cb9d-4ffa-aa21-158a96ad25cd", "879c98e2-123e-4997-90a7-7aee15f0dbf3", "5c6b3a8c-8bae-439f-be40-f2680b092249", "b90a87b5-5e8d-464b-9cae-c3a7030cc97d", "bce74d45-e99d-4a9f-ab2e-7d93c88d1d68", "8b42d6ab-1729-4f6f-ace2-6b4e2b7cc9b3", "85f8bfe6-b093-4cb8-9a2a-d8d05265e257", "c9bed0f4-7f44-4755-8517-eed6d7e265ff", "c5155a8f-80ac-48fd-af2a-8608883da8d9", "9d0b650f-f03a-4211-af68-5e0780e74f58", "e44a04e9-7750-4cde-a5ab-ec31dadcd9f4", "6232c831-6164-4503-bd1d-56cd5088a779", "8b349233-f4a6-417f-a745-551c92561564", "76bb6dfa-1357-482d-876c-e5e182e4d76c", "9ae909bd-db93-45cf-816d-a40112115c04", "803f17f4-2e43-4d79-8393-ff8901454137", "07c9d249-39c2-400e-889f-3f0e1879b3f1", "6384850b-88e2-45f1-9857-984e8d1026df", "886d0981-c66f-428d-8126-fb0c816909b4"], "metadata": {}}}}