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Caribbean Guidelines for the Care and Treatment of Persons with HIV Infection

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Caribbean Guidelines for the Care and Treatment of Persons with HIV Infection

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TABLE OF CONTENTS
Abbreviations
Acknowledgements
Foreword

(I) Comprehensive Management of Persons with HIV Infection

The Needs-Based Approach to Persons with HIV infection
Maximising Adherence to Antiretroviral Therapy
HIV Prevention in Care and Support Settings
Clinical Consultation Resources in the Caribbean

Appendix A: Sample Patient Adherence Risk Assessment Questionnaire
Appendix B: Epidemiology and Reporting of HIV/AIDS Cases in the Caribbean
Appendix C: CAREC HIV/AIDS Case Definitions and Staging System
Appendix D: WHO Staging System for HIV Infection and Disease in
Adults and Adolescents

(II) Common Clinical Manifestations of Undiagnosed HIV Infection

Common Dermatologic Manifestations of HIV Infection
Common Oral and Dental Manifestations of HIV Infection
Appendix A: Images of Common Manifestations of HIV Infection

(III) Special Considerations for the Caribbean: Management of the Patient with HIV and Sickle Cell Disease, Dengue, Malaria, or HTLV-1

HIV and Sickle Cell Disease
HIV and Dengue Fever
HIV and Malaria
HIV and HTLV-1

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(IV) Recommendations for Antiretroviral Therapy for Adults and Adolescents with HIV Infection

OVERVIEW OF ANTIRETROVIRAL THERAPY (ART)
Highly Active Antiretroviral Therapy (HAART)
Classes and Characteristics of ARVs
Principles of HAART: INITIAL THERAPY
Timing of HAART Initiation
Adherence
Treatment of Co-Morbid Opportunistic Infections (OIs)
Laboratory Monitoring Prior to Initiation of HAART
Selection of the Initial HAART Regimen
Selection of Individual Agents in the HAART Regimen
Patient Follow-Up and Monitoring After Initiation of Therapy

TREATMENT TOXICITY
Treatment Failure: Clinical Definition
Treatment Failure: Immunological Definition
Treatment Failure: Virologic Definition
SECOND-LINE AND SALVAGE ANTIRETROVIRAL THERAPY
HIV Resistance to Antiretroviral Therapy
Second-Line HAART Regimens
Salvage Therapy
HAART CONSIDERATIONS FOR PATIENTS WITH CO-MORBID DISEASES
Patients with HIV and Tuberculosis (TB)
Patients with HIV and Diabetes Mellitus
Patients with HIV and Chronic Liver Disease
Patients with HIV and Renal Disease
Patients with HIV and Other Sexually Transmitted Infections (STIs)
Patients with HIV and Neuropsychiatric Disorders
METABOLIC COMPLICATIONS OF HAART AND HIV INFECTION
Lactic Acidosis/Hepatic Steatosis
Lipodystrophy
Hyperlipidaemia
Insulin Resistance
Disorders of Bone Metabolism

TABLES
Table 1: General Recommendations of Initiation of HAART for HIV-Infected Adults and Adolescents
Table 2: Selected Factors that Influence Adherence
Table 3: ARVs for Treatment of HIV Infection
Table 4: Combination NRTI/NNRTI Tablets for Antiretroviral Therapy
Table 5: Preferred Initial HAART Regimens
Table 6: Alternative Initial HAART Regimens
Table 7: Common Adverse Drug Reactions Associated with First-Line HAART Regimens and Recommended
Drug Substitutions
Table 8: Second-Line Regimen Recommendations for Treatment Failure
Table 9: Drug Interactions with Tuberculosis Agents
Table 10: Selected Metabolic Complications in HIV
Table 11: Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
Table 12: Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
Table 13: Protease Inhibitors (PIs)
Table 14: Fusion Inhibitors
Table 15: Interactions between PIs
Table 16: Interactions between PIs and NNRTIs
Table 17: Drug Interactions between ARVs and Other Drugs
Table 18: Major Mutations Associated with Reduced Susceptibility to NRTIs
Table 19: Major Mutations Associated with Reduced Susceptibility to NNRTIs
Table 20: Major Mutations Associated with Reduced Susceptibility to PIs

Appendix A: CHARACTERISTICS OF ARVS
Appendix B: DRUG-DRUG INTERACTIONS BETWEEN PIS AND NNRTIS
Appendix C: DRUG INTERACTIONS BETWEEN ARVS AND OTHER DRUGS
Appendix D: DRUGS THAT SHOULD NOT BE USED IN COMBINATION WITH
PIS OR NNRTIS DUE TO DANGEROUS DRUG INTERACTIONS
Appendix E: BASIC LABORATORY MONITORING FOR RECOMMENDED FIRST-LINE
REGIMENS

Appendix F: HIV RESISTANCE
Introduction
Resistance to Nucleoside Reverse Transcriptase Inhibitors (NsRTIs) and Nucleotide Reverse
Transcriptase Inhibitors (NtRTIs)
Resistance to NNRTIs
Resistance to PIs
Resistance Testing

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(V) Recommendations for the Treatment of Opportunistic Infections among Adults and Adolescents

The Effect of HAART on OIs and the Immune Reconstitution Syndrome
Initiation of HAART for the Treatment-Naïve Patient in the Setting of an Acute OI
Management of Acute OIs in the Setting of Recently-Initiated HAART
Treatment Recommendations: When to Initiate Therapy in the Setting of an Acute OI
Special Considerations in Pregnancy
Disease-Specific Recommendations

Appendix A: Summary of Pre-Clinical and Human Data on OI Drugs in Pregnancy
Appendix B: Treatment of AIDS-Associated OIs in Adults
Appendix C: Dosage Adjustment in Renal Insufficiency
Appendix D: Common Toxicities of Systemic Agents for Treatment of OIs
Appendix E: Significant Pharmacokinetic Drug-Drug Interactions for Drugs in the
Treatment of OIs

(VI) Recommendations for Adult and Paediatric Opportunistic Infections Prophylaxis

Prophylaxis to Prevent First Episode of Opportunistic Disease in Adults and
Adolescents with HIV Infection
Prophylaxis to Prevent Recurrence of Opportunistic Disease in Adults (After
Chemotherapy for Acute Disease) in Adults and Adolescents with HIV Infection
Recommendations for Use Of Specific Vaccines In Individuals with HV Infection
Prophylaxis to Prevent First Episode of Opportunistic Disease in Infants and Children with HIV Infection
Prophylaxis to Prevent Recurrence of Opportunistic Disease (After Chemotherapy for Acute Disease)
in Infants and Children with HIV Infection
Criteria for Starting, Discontinuing, and Restarting OI Prophylaxis for Adults with HIV Infection
Recommendations to Help Patients Avoid Exposure to or Infection with Opportunistic
Pathogens

(VII) Antiretroviral Therapy in Pregnant Women and Prevention of Mother-to-Child Transmission of HIV

Introduction and Background
General Recommendations Regarding the Antenatal Care of Pregnant Women with HIV Infection
PMTCT Antiretoviral Therapy Recommendations: Specific Scenarios
PMTCT Options and recommendations by Clinical Scenario: Discussion

Scenario A: Non-Pregnant Woman Who Needs ART for Her Own Health
Scenario B: Woman Who Is Already Receiving ART at the Time She Becomes Pregnant
Scenario C: Pregnant Woman, Not on HAART, Who Now Requires HAART for Her Own Health
Scenario D: Pregnant Woman Who Does Not Require HAART for Her Own Health
Scenario E: HIV-Infected Woman without Prenatal Care Who Presents in Labour
Scenario F: Woman of Unknown HIV Status Who Presents in Labour
Scenario G: Infants Born to Women Who Received No Antiretroviral Therapy for PMTCT Either
Prepartum or During Labour

General Recommendations for Management of the HIV-infected Mother during Labour and Delivery
Recommendations Regarding Breastfeeding and Postpartum Management of the Mother

TABLES
Table 1: PMTCT Options and Recommendations by Clinical Scenario
Table 2: Selected clinical Trials of Prophylactic ARV Regimens for PMTCT

APPENDICES
Appendix A: Dosing of ARVS inPMTCT regimens
Appendix B: Efficacy of PMTCT interventions: summary of the evidence
Appendix C: Managinf the risks of resistance assoiciated with PMTCTregimens
- Resistance to AZT
- Resistance to 3TC
- Resistance to NVP
- Potential Strategies to Reduce the Risk of NVP Resistance Associated with PMTCT Regimens
- Implications for Women Initiating HAART who received SD NVP or 3TC in the Past
- Implications for Women who have received SD NVP in the past and are now Pregnant again
Appendix D: Risks of antiretroviral therapy in pregnany
Appendix E: Antiretroviral drug pharmacokinetic and toxicity data in human pregnany and
recommendations for use for treatment of pregnant women with HIVinfection

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(VIII) Care of Children Born to HIV-Infected Mothers

Recommendations for Management of Mothers with HIV Infection During Labour and Delivery
Recommendations Regarding Breastfeeding
Recommendations for Management of Infants Born to Mothers with HIV Infection
Appendix A: WHO Clinical Case Definition for Pediatric AIDS
Appendix B: WHO Staging System for HIV Infection and Disease in Children
Appendix C: 1994 CDC Revised Human Immunodeficiency Virus Paediatric
Classification System: Clincal Categories
Appendix D: Interventions to Reduce the Risk of MTCT: Summary of the Evidence

(IX) Care Of The HIV-Infected Child, Including Considerations Of Antiretroviral Therapy

Background
Diagnosis and Classification of Paediatric HIV/AIDS
OI Prophylaxis and Immunisations
Initiation of HAART in Paediatric Patients: General Considerations
Recommendations for Initiation of HAART in Resource-Constrained Settings: WHO
Guidelines
Recommendations for Initiation of HAART in Resource-Full Settings: NIH and CDC
Guidelines
Practical Considerations for the Caribbean
Adherence
Recommended Initial Paediatric HAART Regimens
Second-Line and Salvage Antiretroviral Therapy
Paediatric Antiretroviral Therapy Drug Formulary for the Caribbean

Appendix A: Considerations on Specific Drugs
Appendix B: Currently Available ARVs for Paediatric Use
Appendix C: Classification of Paediatric HIV/AIDS

(X) Diagnosis and Treatment of Opportunistic Infections (OIs) Among HIV-Exposed and Infected Children

Disease-Specific Recommendations
Appendix A: Recommendations for Treatment of OIs in HIV-Exposed and Infected
Caribbean Infants and Children

(XI) Post-Exposure Prophylaxis

Occupational exposure to HIV
Risk of Transmission Associated with an Occupational Exposure
Efficacy and Timing of PEP
Risks and Benefits of PEP
PEP Regimens
Recommendations for Management of Occupational Exposures to HIV
Follow-Up
PEP FOLLOWING SEXUAL EXPOSURE TO HIV

PEP SCENARIOS AND RECOMMENDATIONS
Needlestick Involving HIV-Infected Source Patient
Exposure Involving a Source Patient Whose HIV Status Is Not Known
Exposed Healthcare Worker with a Positive Baseline HIV Test
Exposure Involving Sexual Assault

TABLES
Table 1: Variables that Likely Increase Risk of HIV Transmission in Occupational Exposures
Table 2: PEP Management Recommendations: Percutaneous (Needlestick) Exposures
Table 3: PEP Management Recommendations: Mucocutaneous or Non-Intact Skin Exposures
Table 4: Average Per-Exposure Risk Associated with Exposures to HIV

FIGURES
Figure 1: Recommendations for Antiretroviral Post-exposure Prophylaxis for Non-occupational
Exposure to HIV...........................................................................................

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