Pocket Guide English Version FINAL A5

POCKET GUIDE TO INTEGRATED MANAGEMENT OF HIV, 2019
POCKET GUIDE TO INTEGRATED

MANAGEMENT OF HIV, 2019
i
ii
TABLE OF CONTENTS
TABLE OF CONTENTS ........................................................................... iii
LIST OF TABLES ................................................................................... vii
LIST OF FIGURES ................................................................................... x
Chapter 1: Guidelines on HIV prevention ............................................. 1
1.1 Post-Exposure Prophylaxis (PEP) ............................................. 1
1.1.1 PEP recommendations ............................................................ 1
1.1.2 Procedures for administering PEP: a case of rape ................... 3
1.1.3 PEP after occupational exposure to HIV .................................. 6
1.2 Pre Exposure Prophylaxis (PrEP or Pre-Exposure Prophylaxis) ..... 10
1.3 Positive Prevention (or Prevention in HIV-Positive People) ......... 12
1.3.1 Recommendations to improve HIV prevention among PLHIV
....................................................................................................... 13
Chapter 2 : Screening ......................................................................... 14
2.1 Overview ...................................................................................... 14
2.2 Screening procedures .................................................................. 15
2.3 Target Populations and Screening Frequencies ........................... 17
2.3.1 Target populations ................................................................ 17
2.3.2 Frequency of screening ......................................................... 18
2.3.3 Re-testing .............................................................................. 19
2.4 Screening Algorithm and Interpretation of Results ...................... 19
2.4.1 Screening Algorithm .............................................................. 19
2.4.2 Early diagnosis of HIV in exposed children ............................ 22
2.4.3 HIV testing in pregnant and lactating women ....................... 23
2.4.4 HIV testing in adolescents ..................................................... 23
2.4.5 HIV testing through "index cases" in the health facility or in
the Community .............................................................................. 23
2.4.6 HIV testing for blood transfusion .......................................... 24
2.5. Linkages between HIV testing and HIV prevention, care and
treatment ........................................................................................... 25
2.6. Screening quality assurance ........................................................ 30
Chapter 3: Elimination of Mother-to-Child Transmission of HIV ........... 32
3.1. Overview ..................................................................................... 32
3.2. Minimum package of services of the pregnant woman and
breastfeeding woman ........................................................................ 34
3.2.1. Package of services to offer to the pregnant woman ........... 34
iii
3.2.2. Package of services to be offered to HIV positive woman

after childbirth (Post-natal follow-up) ............................................ 36
3.2.3. ARV Treatment of Pregnant Woman or Breastfeeding HIV
Positive Woman ............................................................................. 39
3.2.4. ARV prophylaxis in exposed children (HIV-positive mother's
child) .............................................................................................. 40
3.2.5. Clinical and biological monitoring of HIV + pregnant or
breastfeeding woman .................................................................... 41
3.2.6 Management of Co-infections in Pregnant Women:
Tuberculosis, Viral Hepatitis B ........................................................ 42
3.2.7. HIV infection and family planning (FP) ................................. 43
3.3. HIV PMTCT strategies .................................................................. 44
Chapter 4: Management of the HIV-exposed child .............................. 45
4.1 Overview ...................................................................................... 45
4.2 Feeding the child born to a positive mother ................................ 48
4.2.1 Recommendations on the nutrition of children exposed to
HIV ................................................................................................. 48
4.2.2 Practical ways of feeding the exposed child .......................... 49
4.3 "Exit" Procedures of the Follow-up Program for Exposed Children
........................................................................................................... 50
Chapter 5: Initiation to Antiretroviral Treatment ................................. 51
5.1. .Stages of initiation of ARV treatment. ........................................ 52
5.1.1. Initial evaluation of the patient before ART initiation .......... 52
........................................................................................................... 52
5.1.2. WHO classification of patients by stage of clinical ................... 53
5.1.3. Patient classification according to the appropriate
differentiated model of care .............................................................. 54
5.1.4. Preparing the patient for ART .............................................. 56
5.1.5 Management to be done after ART preparation preparation ... 58
5.2 Monitoring of HIV after 1 year of ART .......................................... 60
5.2.1. Monitoring of stable and unstable persons living with HIV .. 60
5.2.1.1. Definition of “stable patient” and “unstable patient” ... 60
5.2.1.2. Tracking Stable and Unstable Patients ............................... 61
5.3. Special features of differentiated care by subpopulation ........... 66
5.4 Summary of Clinical and Biological Monitoring of PLHIV ............. 67
Chapter 6: ART in CHILDREN, ADOLESCENTS, and Adults ..................... 69
6.1 Overview ...................................................................................... 69
iv
6.2. First-line ART protocols ............................................................... 70

6.3. Second line ART protocols ........................................................... 72
6.4. Third Line ARV Protocols ............................................................. 73
6.5. Change of ARV treatment protocol ............................................. 73
6.5.1. Clinical, immunological and virological definitions of
treatment failure ............................................................................ 74
6.5.2. Interpretation of viral load ....................................................... 75
6.5.3. Management of therapeutic failure ..................................... 77
6.5.4 Management of treatment interruptions.............................. 79
Chapter 7. Observance, retention in care and psychosocial support .... 80
7.1. Assessment of compliance .......................................................... 80
7.2. Barriers to ART compliance ......................................................... 82
7.3 Counselling and treatment adherence support during the first six
months of ART.................................................................................... 84
7.3.1 Content of the 3 counselling sessions on improving observation
........................................................................................................... 86
7.3.2 Psychosocial support by population ...................................... 87
7.4 Retention of patients on ARV treatment ...................................... 91
Chapter 8: Detection Prevention and Management of Opportunistic
Diseases ............................................................................................. 93
8.1 Prophylaxis ................................................................................... 93
8.1.1 Cotrimoxazole prophylaxis treatment (CPT).......................... 93
8.1.2 Chemotherapy for tuberculosis prophylaxis with INH or
(Isoniazid preventive treatment).................................................... 94
8.2 Prevention and Management of TB / HIV Co-infection ................ 97
8.2.1 Tuberculosis search among PLHIV......................................... 97
8.2.2 Tuberculosis treatment in people with HIV ........................... 98
8.2.3- Time to initiation of TARV in a tuberculosis patient ........... 100
8.2.4 ARV protocols for HIV / TB co-infection .............................. 100
8.3. Inflammatory Immune Reconstitution Syndrome (IRIS) ............ 102
8.4. HIV co-infection / Viral hepatitis B and C .................................. 103
8.4.1. Vaccination against viral hepatitis in an HIV patient .......... 103
8.4.2. Treatment of HIV / Hepatitis B co-infection ....................... 104
8.5. HIV-HCV co-infection................................................................. 104
8.6. Management of Cryptococcus Meningitis (CM) in PLHIV .......... 104
8.7. Screening and Management of Pulmonary Pneumocystosis (PCP)
in PLHIV ............................................................................................ 105
v
8.8. Management of Toxoplasmosis in PLHIV .................................. 106

8.9. Other opportunistic infections .................................................. 108
8.9.1. Management of Candidiasis ............................................... 108
8.9.2. Management of Herpes Simplex Virus (HSV) Infection ...... 108
8.9.3. Management of Varicella Zoster Virus (VZV) Infection....... 109
Chapter 9: Detection and Management of NON-COMMUNICABLE
Diseases ........................................................................................... 110
9.1. Cardiovascular Disease (CVD) and Risk Factors ......................... 110
9.2. Management in case of diabetes .............................................. 111
9.3. Management in case of Cancer(s) ............................................. 112
9.4. Mental Health Problem in relation to HIV: Depression ............. 113
9.5. Drugs including Drug Abuse ...................................................... 114
9.6. Prevention of overweight and obesity in HIV patients receiving
Dolutegravir (DTG). .......................................................................... 114
Chapter 10: Coordination and Monitoring Evaluation ........................ 115
10.1 Coordination ............................................................................ 115
10.2 Monitoring and evaluation ....................................................... 115
vi
LIST OF TABLES
Table 1: Recommendations for Post exposure Prophylaxis .................... 2

Table 2: Importance of the risk based on the gesture............................. 3
Table 3 : Procedures for Administering Post-Exposure Prophylaxis........ 3
Table 4: Indication of PEP in case of AEBF ............................................... 6
Table 5: Recommendations for PEP within the frame of Occupational
Exposure .................................................................................................. 7
Table 6: Supporting an AEBF.................................................................... 8
Table 7: Recommendations for PrEP ..................................................... 10
Table 8: Prevention among PLHIV ......................................................... 12
Table 9: Principles for screening ............................................................ 14
Table 10: Principles for Screening location............................................ 15
Table 11: Pre and post-test counselling ................................................ 16
Table 12: Frequancy of screening an target populations ...................... 18
Figure 5: Algorithm screening children exposed from 0 to 18 months . 22
Table 13: Different type of link .............................................................. 26
Table 14: Link with HIV treatment Unit ................................................. 28
Table 15: Steps for quality assurance of screening tests ....................... 30
Table 16 : Factors Influencing MTCT...................................................... 33
Table 17: Main guidelines for counselling and testing of pregnant and
breastfeeding women............................................................................ 34
Table 18: Summary of interventions at each ANC ................................. 35
Table 19: Package of services for HIV + woman in postpartum period . 37
Table 20: Pregnant and/or breastfeeding woman follow up ................ 40
Table 21: Classification of MTCT risk ..................................................... 40
Table 22: Clinical and biological monitoring of pregnant or
breastfeeding women............................................................................ 41
Table 23: Management of Coinfections in pregnant women ................ 42
Table 24: Drug interactions of contraceptives with certain drugs ........ 43
Table 25: Schedule and package of follow-up services for children born
to HIV-positive mothers......................................................................... 46
Table 26: Method of feeding the exposed child .................................... 49
Table 27: WHO classification of HIV infection ....................................... 53
vii
Table 28: Classification of patients according to their clinical condition

............................................................................................................... 55
Table 29: Points to discuss when preparing for ART ............................. 56
Table 30: Classification of stable and unstable patients ....................... 60
Table 31: Follow-up of PLWHA under ART according to their "stable
patient" and "unstable patient" classification ....................................... 61
Table 32: Criteria for Defining Clinically Stable Children ....................... 62
Table 33: Criteria for defining clinically stable pregnant women .......... 63
Table 34: recommendations for the delivery of ARV treatments to
clinically stable patients......................................................................... 64
Table 35: Clinical and biological monitoring of PVVIH under TARV....... 67
Table 36: First-line ART protocols in the infected child ......................... 70
Table 37: First line ART protocols in Adults and adolescents (male sex)
............................................................................................................... 71
Table 38: First line ART protocols in Adults and adolescents (female sex)
............................................................................................................... 71
Table 39: 2nd line ART protocol *.......................................................... 72
Table 40: Summary of Different ARV Protocols for Naive Patients * .... 73
Table 41: Clinical, immunological and virological definitions of
treatment failure ................................................................................... 74
Table 42: side effects of ARVs................................................................ 76
Table 43: Goals and indications of a stress test..................................... 78
Table 44: Adherence assessment strategies ......................................... 81
Table 45: Evaluation of the compliance level according to the number
of tablets ................................................................................................ 82
Table 46: Barriers to adherence ............................................................ 83
Table 47: Content of adherence support sessions ................................ 86
Table 48 : Criteria for stopping and initiating CTX prophylaxis ............. 93
Table 49 : Posology of CTX according to the weight of children exposed
to HIV or infected with HIV .................................................................... 94
Table 50: Eligibility Criteria for INH ....................................................... 95
Table 51: Posology of INH prophylaxis by weight.................................. 95
Table 52: Criteria for Stopping or Resuming TPI.................................... 96
Table 53: Tuberculosis search among PLHIV ......................................... 97
Table 54: Tuberculosis treatment in people with HIV ........................... 98
Table 55: Time to initiation of TARV in a Tuberculosis patient ........... 100
viii
Table 56: Adaptation of ART in case of introduction of ant tuberculosis

treatment............................................................................................. 100
Table 57: ARV therapeutic protocols for anti-tuberculosis drugs ....... 101
Table 58: Evocative signs management of IRIS ................................... 102
Table 59: Vaccinations against viral hepatitis...................................... 103
Table 60: Management of Cryptococcus Meningitis ........................... 104
Table 61 : Management of Pulmonary Pneumocystosis ..................... 106
Table 62: Management of cerebral toxoplasmosis ............................. 107
Table 63: Management of oropharingeal candidiasis ......................... 108
Table 64: Management of candidal oesophagitis................................ 108
Table 65: Management of Herpes simplex virus infection .................. 108
Table 66: Management of Varicella Zoster virus infection .................. 109
Table 67: Assessing the Risks of Cardiovascular Disease ..................... 111
Table 68: Main Statines ...................................................................... 112
Table 69: Cancer management ............................................................ 113
Table 70: Management of depression ................................................. 113
Table 71: Coordination Activities......................................................... 116
Table 72: Data Collection Tools ........................................................... 117
ix
LIST OF FIGURES
Figure 1: PEP Algorithm for rape victims .................................................. 5
Figure 2: Algorithm for PEP in the frame of occupational exposure ........ 9
Figure 3: Key and Vulnerable Populations.............................................. 17
Figure 4: General Screening Algorithm .................................................. 20
Figure 5: Algorithm screening children exposed from 0 to 18 months .. 22
Figure 6: Principles of screening approach for HIV-exposed individuals
from an index case ................................................................................. 24
Figure 7: Screening Algorithm for Blood Transfusion ............................. 25
Figure 8: Initial evaluation of the patient before ART initiation ............. 52
Figure 9: What to do after preparation for TARV ................................... 58
Figure 10 : Algorithm for initiation of ART.............................................. 59
Figure: 11: Algorithm for the interpretation of plasma viral load .......... 75
Figure 12 : Counseling and adherence support during the first six
months of ART........................................................................................ 85
Figure 13: Accompanying Algorithm for Transition from Adolescent to
Adult Care Service .................................................................................. 92
x
CHAPTER 1: GUIDELINES ON HIV PREVENTION
In this chapter, only aspects of prevention related to the use of

antiretrovirals will be addressed.
Cameroon has opted for combined HIV prevention, putting together

biomedical interventions (PMTCT, TasP, PEP, PrEP), behavioural and
structural interventions in order to have the greatest impact on the
reduction of new infections. The combination of these interventions
as well as increasing their coverage in key and vulnerable populations
are essential for reducing the dynamics of contaminations.
1.1 Post-Exposure Prophylaxis (PEP)
PEP or emergency treatment is the short-term use of ARVs to prevent

transmission of the virus in an HIV-seronegative person after
potential occupational and non-occupational exposure.
The medical staff will assess the possible risk of HIV infection and the
relevance of prescribing PEP.
1.1.1 PEP recommendations
Guidelines on Post Exposure Prophylaxis are summarized in Table 1
below.
1
Table 1: Recommendations for Post exposure Prophylaxis

Conside-
Recommendations
rations
• Exposed individual with an HIV negative or unknown status,
• Exposure within 72 hours before visiting the health facility,
Eligibility
• High risk exposure (type AND material),
• Source subject with a positive or unknown HIV status.
• If the exposed subject is a breastfeeding woman,
• Continue breastfeeding. However, the child will not receive
ARV prophylaxis.
• To assess the relevance of prescribing PEP.
• Evaluate:
• The serological status of the exposed subject (rapid HIV test). If
the result is positive, PEP will not be prescribed but
antiretroviral therapy (ART).
Initial visit
• The serological status of the source person if possible. If the
source person is HIV seropositive, check if possible its viral load
and ARVs taken. PEP is recommended except in case of
undetectable viral load (VL).
• The time since the risky relationship (the assessment should be
done within 72 hours of exposure - ideally within four hours);
• The level of risk incurred (type of needle, penetration ...).
• TDF (300mg) / 3TC (300mg) / DTG (50mg) 1cp daily
ARV • In case of TDF contraindication (child <10kg, kidney failure)
regimen replace with ABC
Initiation • As soon as possible after exposure: within 4 hours, not after
72 hours
Duration • 28 days (give all the treatment at the first visit)
Dosage • Same dosage as ART. Adapt doses according to weight in
children
• 2nd and 3rd visits (Week2 and Week4 after the 1st visit):
Monitoring clinical and biological evaluation of ARV tolerance (side
(5 visits): effects). At each visit, the treatment may be adjusted,
Week2, continued or stopped.
Week4,
• Other visits: HIV test at week6, M3 and M6 after exposure.
2
Week6, M3
and M6
Counselling • Adherence, risk reduction, psychosocial, safe sex
• Screening and management of other STIs.
Other • Emergency contraception pill (after pregnancy test).
services
• Gender Based Violence (GBV).
Indications for ART prophylaxis depend on the degree of exposure

and the status of the source subject.
Source person: There are two types of source persons:
Person known as HIV Source person of unknown HIV

positive serology
• Look for previous • Ask for his agreement to
treatments, immune perform: Serology HIV, HBV, HCV
level, viral load and if necessary do a viral load.
If the source person is HIV negative, do not prescribe PEP
Table 2: Importance of the risk based on the gesture

Low risk of exposure High risk of exposure
Exposure to a large volume of potentially
Exposure to a small volume infectious blood or fluids, eg
of blood Contaminated blood transfusion
An injury with a solid needle Injury with a deep needle
Full needle stitch
Any superficial injury or
muco-cutaneous exposure Deep and intensive injury
Prick through a glove
1.1.2 Procedures for administering PEP: a case of rape

• The victim must present herself within 72 hours of the
rape. PEP should be offered immediately.
• A3 voluntary
Table : Procedures
HIVfor Administering
test Post-Exposure
should be performed Prophylaxis
for any victim,
whether or not she receives PEP or not.
3
Table 3 : Procedures for Administering Post-Exposure Prophylaxis

Recommendations in case of sexual exposure
• Risk of transmission of HIV and other STIs.
• Importance of doing an HIV test to know one's status
before starting PEP.
• Importance of starting PEP as soon as possible.
• Importance of adherence to treatment should be
emphasized.
Counselling
• Common side effects of medicines should be explained.
• Victims should be informed of precautions to prevent
possible secondary transmission (eg to their sexual
partner or mother-to-child) until they are declared
seronegative to HIV six months after exposure.
• HIV, Syphilis, HBsAg,
Testing • Pregnancy
Within 72 hours:
o PEP : TDF/3TC/DTG during 28 days
o Emergency contraception
• Prophylaxis against STIs: Cefixime 400 mg (or
Ceftriaxone 250 mg) IM plus Metronidazole 2 g plus
Treatment Azithromycin 1g
• Hepatitis B vaccination if the patient is not already
immunized and no later than 21 days after the incident.
• If HBsAg is negative, vaccinate at 0, 1 and 3 to 6
months.
A Tetanus booster should be given
Psychological Throughout management.
support
Monitoring • At Day 3
visits • HIV test: week6, M3 and M6
Declare “SEXUAL ABUSE”
4
Sexually assaulted person
Collect History, Counseling on Pregnancy Risk,

STIs, Hepatitis, HIV and availability of prophylaxis
Medical consultation and

phlebotomy for the following tests:
HIV, HBsAg, pregnancy, syphilis.
Administer Tetanus vaccine.
Rape
Yes No
occurred
<72 hours
• Give ST prophylaxis • Give STI prophylaxis

• Give emergency • Emergency contraception?
contraception • Provide pre and post test
• Provide HIV pre and Refer for
counseling for HIV testing
post test counselling post • Explain that PEP is no longer
• Give PEP effective
traumatic
• Return to consultation after 3 days • Return to consultation after 3 days

• Start vaccination against HBV if • Start vaccination against HBV if negative
negative for Ac HVB
for Ac HVB
• Continue councelling on HIV risk
• Continue counselling on HIV risk
transmission
transmission
• Continue PEP during 28 days.
Follow-up visits at week 6, 3 months and 6 months

DECLARATION OF SEXUAL ABUSE
Figure 1: PEP Algorithm for rape victims
5
1.1.3 PEP after occupational exposure to HIV

- Healthcare providers have a risk of HIV infection after
accidental exposure to blood or body fluids of an HIV-
infected person.
- An accidental exposure to biological fluids (AEBF) is a contact

with blood or a contaminated biological fluid, during a break-
in (puncture or cut), or by a contact by projection on a
wound, an injured skin or mucous membrane. It exposes to a
risk of viral transmission (HIV, HBV, HCV ...).
- The risk of transmission after an AEBF is, on average, 0.30%

for HIV, 1.8% for Hepatitis C and 30% for Hepatitis B,
especially if the source person is untreated.
- HIV prophylaxis after an AEBF depends on:
• The severity of exposure and the nature of the biological fluid

responsible
• The serological status of the source person;
• The time between exposure and consultation.
Table 4: Indication of PEP in case of AEBF

Indications of PEP
Type
• Deep wound • Scalpel • Superficial injury
• Hollow •Puncture • Full needle
needle through glove • Cutaneous and mucosal
projection
Source HIV + or unknown HIV+ unknown

PEP Recommended NO
6
Table 5: Recommendations for PEP within the frame of Occupational

Exposure
Recommended for occupational exposure
• Risk of transmission of HIV and other STIs.
• Importance of doing an HIV test to know one's status before
starting PEP.
• Importance of starting PEP as soon as possible.
• Importance of adherence to treatment should be emphasized.
• Common side effects of medicines should be explained.
Counselling • Victims should be informed of precautions to prevent possible
secondary transmission (eg to their sexual partner or mother-to-
child) until they are declared HIV seronegative six months after
exposure.
Testing • HIV, HBsAg,
• Pregnancy
Within 72 hours:
o PEP with TDF/ 3TC/DTG for 28 days
Treatment o Emergency contraception
• Hepatitis B vaccination should be started as soon as possible if the
victim is not already immunized and no later than 21 days after the
incident.
o If HBsAg is negative, vaccinate at 0, 1 and between 3-6 months.
Psychological Identify the respective needs of psychological supports and address

support them.
Follow-up • At Day3
visits • HIV test: week 6, M3 and M6
Accompanying • Establishment of infection control committees

measures • Elaboration of measures to be taken in case of exposure to a
potentially infectious body fluid.
• Vaccination of health care staff against Tetanus and HVB
• Normal precautions (for example, avoid picking up or folding
needles, not putting all sharps in solid containers, etc.).
• Establishment and dissemination of clear SOPs to ensure
appropriate management after occupational exposure.
• Make ARVs for PEP available throughout in the Health Facility.
Declare the AEBL
7
- In the case of an AEBF, immediate action shoulds be taken

as indicated in the table below
Table 6: Supporting an AEBF

Immediate prophylactic measures
• Let the wound bleed without pressing, do not rub
Sting or accidental • Clean immediately with running water and mild soap;
skin injury or • Rinse thoroughly and dry, then
• Apply an antiseptic (at least 5 minutes) by soaking the
contact with
damaged area (if soaking impossible apply a dressing soaked in
damaged skin an antiseptic).
Antisepsis: dakin solute, 12% bleach, chlorhexidine diluted
1/10, 70% alcohol, polyvidone iodine dermal solution.
Eye projection • Rinse the eye thoroughly, preferably with normal saline or
otherwise with water for at least 5 or 10 minutes.
In case of exposure • Rinse the exposed area immediately with isotonic saline for
through the eyes, 10 minutes.
mouth and mucous • Antiseptic eye drops may also be used in case of exposure to
membranes the eyes.
• If none of these solutions are available, use clean water to
rinse thoroughly.
Consultation of urgent referring doctor (if possible less than 4 hours)
Information of the • Reassure the victim, Remove any feeling of guilty...
exposed subject • Inform: Risk HIV, HBV, HCV ....
• Prophylaxis: means and limits (TPE, Immunoglobulins ...)
• Condoms, no blood donation (until definitive knowledge of
the serological status)
This evaluation is done according to the severity of the
accident:
• Depth of injury (deep or shallow)
Assessment of • Needle type: deep for phlebotomy has higher risk than deep
transmission risks for injection which itself presents a risk greater than a full
needle. Stained or no blood?
• Wear gloves?
• Exposure deadline? consultation timeline?
• HIV and HBV status of the exposed?
• The degree of severity of the accident makes it possible to
decide on the need for ARV prophylaxis.
Follow-up with or without a prophylactic ARV treatment for 6 months
8
Health professional exposed to

potentially contaminated liquids
Wash the wound with soap and water. Collect

history and assess the risk of exposure
DO NOT OFFER PEP

Risk of high / low Non-injured skin, non-
exposure; Source contagious liquid, Source HIV
negative (offer counseling and
HIV positive or
psychosocial support)
Medical Examination and perform tests:

HIV (after consent), HBsAg and HBsAb, serum creatinine
Start PEP within 4 hours to ≤ 72 hours after exposure.
Administer Anti-Tetanus & HVB Vaccines in the absence
of vaccination. Declare the accident.
Neg HIV Pos

ativ test
Continue PEP for 28

days TDF (300 mg) + Offer
Refer for management of
3TC (300 mg) + DTG counselling &
HIV infection according
(50mg). support to national guidelines.
• Repeat the HIV Test at week6, M3 and M6

• Counsel to prevent possible secondary transmission
to sexual partner or from mother to child
• Check for drug tolerance on Day0 and week2
Figure 2: Algorithm for PEP in the frame of occupational exposure
9
1.2 Pre Exposure Prophylaxis (PrEP or Pre-Exposure Prophylaxis)

Pre-exposure prophylaxis (PrEP) is a complementary approach that is
part of the package of (diversified) strategies for preventing sexual
transmission of HIV. Adherence to PrEP is crucial for ensuring
protective benefits.
Table 7: Recommendations for PrEP

Recommendations
Do not prevent other STIs or unwanted pregnancies
Priority target populations: HIV Negative MSM and FSW aged above 21
years with continued risk of HIV exposure
• History of several episodes of STIs, or
Eligibility • Unprotected sex with at least two different partners in
criteria the last 6 months, or
• Consumption of psychoactive substances during sexual
intercourse.
• Risk assessment and eligibility criteria (according to
standard tools, eg MSM case)
• Prescription by a doctor (recommended protocol: TDF +
Terms of 3TC)
prescription • Taking ARVs continuously (daily) or intermittently (that
is, on demand in anticipation of a specific period of
sexual activity).
- In case of continuous intake, the optimal ARV activity
is obtained 7 days in men and 21 days in women
- Discontinued only in MSM and contraindicated in case
of HBV infection.
Duration • Until the risk is stopped or immediately if HIV
seroconversion or presence of a renal disorder
Medical • HIV testing: every 3 months

monitoring • Biological assessment: Renal function assessment every 6
months (TDF is contraindicated if Cl creatine <50 ml / min)
10
Initial visit 1 month visit 1 month visit

• Eligibility criteria • Research • STI and HIV
• Clinical examination for clinical testing
looking for suggestive signs of • Screening of
symptoms primary HIV TB
• Screening for HIV infection • Evaluate
and other STIs, TB, • Interpret compliance and
Hepatitis B and C; the results of risk factors
renal function the biological • Counselling
assessment; assessment for prevention
pregnancy test • Do the first (use of
• Look for a prescription condoms
contraindication to of PrEP
used ARVs
•Counselling
interview (check
adherence to PrEP)
Or • In approved health facilities (having the capacity and
required funding to provide a comprehensive set of
prevention services)
• DIC (Drop-in-Centres) who is linked to an approved health
facility (with trained staff)
• Discuss with the client the adoption of healthy lifestyles,

Other such as avoiding alcohol, tobacco and recreational drugs.
• Provide condoms and lubricants
Medical contraindications of PrEP

• HIV seropositivity or unknown HIV serology;
• Signs or symptoms of acute HIV infection;
• Renal problems (creatinine clearance <50 ml / min);
• Hypersensitivity to any of the active ingredients or product
excipients
11
1.3 Positive Prevention (or Prevention in HIV-Positive People)

This is the set of services to be offered to people living with HIV
(PLHIV) to reduce the risk of transmitting the virus to others
Essential services for prevention among PLHIV
Table 8: Prevention among PLHIV

Principle Effective prevention among PLHIV is based on multiple
approaches to the needs and rights of those infected and
affected by HIV (discordant couples, family).
Goals • Avoid HIV transmission
• Promote health
• Delay the disease progression
• Avoid resistance to ARV drugs (mutation)
Why ? • To prevent the spread of HIV to sexual partners and
exposed children (MTCT).
• Help PLHIV to adopt safe and reasonable behaviours.
Important • The sharing of the HIV status of an HIV + person to a
concepts person or organization can have beneficial or harmful
consequences
.• The notification of the partner (sexual or drug-injecting
partner) of a PLHIV to tell them about the potential risk of
HIV exposure and to encourage them to come for
counselling, testing and if necessary to have a treatment
for HIV.
Targets • PLHIV and their partners
• Family members of PLHIV
• People Living Prevention among PLHIV requires long-term care and
with HIV and direct links to other health services, including:
their partners • HIV counselling and testing for the family (spouse,
• Family descendants)
members of • PMTCT (if woman of childbearing age)
People Living • PF
with HIV. • ARV provision at the management unit
• STI management
• Diagnosis and treatment of viral hepatitis B and C
• Support for adherence by psychosocial agents or
community health workers
12
• Youth and adolescent health services (RH)

• Psychosocial support team
• Pre-exposure Prophylaxis (PrEP) for their partner
• Nutrition and diet advice including breastfeeding
women
• Mental Health
• Communication for behavioural change (CCC)
• Promoting healthy lifestyle behaviours
• Prevention of gender-based violence (GBV)
• Link Services
1.3.1 Recommendations to improve HIV prevention among

PLHIV
• Apply the principles of the "Patient Centred" approach to
care
• Combine strategies to create a trusting environment for
PLHIV.
• Protect and promote human rights and ethical principles,
including the right to privacy, confidentiality, informed
consent and the duty not to harm.
• Include measures to prevent the stigmatization and

discrimination of PLHIV, while always focusing on the special
needs and rights of PLHIV.
13
CHAPTER 2 : SCREENING
2.1 Overview
HIV testing is the initial step towards effective prevention and access
to appropriate care, as it enables early HIV diagnosis.
Cameroon has opted for "differentiated screening" based on:

o Integration of HIV testing services with other health services (eg
primary health care, antenatal care, immunization);
o Decentralization of HIV testing outside the hospital health system
o Delegation of tasks.
For more efficiency, this screening should target:

o Population groups: groups with high HIV prevalence (eg
Tuberculosis patients) ;
o Geographical area of the people most at risk: where the

populations are poorly served (locked areas, refugee camps ...).
Mandatory testing is not recommended. The patient voluntarily
decides to be tested after the test has been proposed. To respect
ethics, screening must respect the 5 WHO recommended principles.
Table 9: Principles for screening

Principles for a good screening: 5C
Informed Clients should be informed of the process and their
consent right to refuse testing
Confidentiality The content of the discussion between the provider
and the client must not be disclosed to a third party
Before the test is performed, the provider must offer
Advice appropriate advice
Correct results Provider must strive to provide quality screening
service and quality assurance mechanisms must be in
place to ensure accuracy of results
Connection(link) With prevention, care and treatment services
14
2.2 Screening procedures

Two approaches are used for screening:
o Provider-initiated HIV testing and counseling : The provider
should routinely offer HIV testing to all those arriving at the
facility, and to all accompanying adults, symptomatic or not
o Voluntary Counselling or Client-Initiated Counselling (VCT)

who goes to health facilities or OBC (with trained staff) to seek
screening can take place in a health facility or in the
community
Table 10: Principles for Screening location
HIV testing in the health facility HIV testing in the community

- In the community: "Hot Spot", OBC /
At all entry points: prenatal DIC, CMPJ / CS, places of cultural,
consultations, Maternity, sporting or religious grouping, points
vaccination, pediatrics, of affluence (markets), chieftaincies
tuberculosis, family - At home: family screening
Where?
planning, emergency, - Self-test *: Orientation test that a
consultation, nutrition, and client can perform on his own at
HIV treatment Centers, home. If the result is reactive, the
other ... client must then go to a health facility
for confirmation.
- Propose HIV testing to anyone who
- PITC or VCT
arrives through community
- Carring out the test interventions
- Reference/linkage to - Realization of the test
How? all HIV services of the
- Link / Reference to the HIV care
facility or to another
service in the same health facility or
facility according to the
to a health facility according to the
choice of the client
choice of the client
- Mobile health care teams (medical

By who ? -Medical teams
staff of the mobile unit)
15
- Non-medical trained - The advanced strategy (staff of the

providers (Psychosocial FOSA).
agents, Mother mentor ...) - Non-medical providers trained
(APS, ASCP, Mother mentor, ...)
- Reference linkage with health
facility for confirmation if the
result is reactive
- Adults, children, teenagers.
- Key populations (MSM, PS, detainees, ...) or vulnerable (truckers,
For who? refugees ...) 
- TB Membres family members
- The family of an index case
* The implementation of this screening approach will be gradual, focusing on
key populations (TS and their clients, MSM) while relying on pilot projects.
Counselling should be done before any screening. The stages of

counselling are listed in the table below:
Table 11: Pre and post-test counselling
Pre-test Counselling Post-test counselling
Goals • Aims to prepare the person for Interview in which the client
the HIV test. discovers his HIV test result
• Well conducted facilitates the (positive, negative or
announcement of the result. indeterminate)
Steps Step 1: To begin, the counsellor Address the following points:
introduces himself, explains his • Ensures the identity of the
role and reassures the person as client;
to the respect of the • reassure him of the
confidentiality. confidentiality of the
Step 2: Then, the counsellor interview;
addresses the different points: • Congratulates him for
• the person's knowledge of HIV coming back;
/ AIDS; • Briefly recall the initial
• The risk of the person's interview and inquire about
exposure to HIV and the the client's feelings during the
possibility of a risk reduction wait time;
plan; • Give the client the envelope
• Advantages of practicing HIV for the discovery of the result;
testing
16
• The meaning of HIV serology • Allow the person time to

tests; express their emotions
• The implications of the • Ensure the understanding of
screening result on the the result by the client;
person's life; • Encourage questions and
• The person's ability to cope give comprehensive answers;
with HIV and its • Explain clearly the meaning;
consequences;
• The informed consent of the NB: Pass the announcement
person regarding the phase, the interview
screening test; continues in different ways
• Possibly, the concept of depending on the result.
PMTCT;
• Family screening.
2.3 Target Populations and Screening Frequencies

2.3.1 Target populations
To improve screening efficacy, health care providers should prioritize
populations at high HIV risk, including key populations, vulnerable or
priority populations.
Figure 3: Key and Vulnerable Populations
17
Key populations: These are the populations most exposed to HIV.

These are groups with the highest prevalence rates in a given
population who are generally socially marginalized and who are the
priority targets for HIV programs.
2.3.2 Frequency of screening

The recommendations on the frequency of screening of target
populations are summarized below.
Table 12: Frequancy of screening an target populations

Population
When to test
categories
General population • Once a year
• HIV test at first contact (even if it takes place in
the labor / delivery room), if negative repeat
Pregnant and every three months during the period covering
lactating women the rest of the pregnancy, childbirth and
breastfeeding;
Exposed infants (EI) • 1st PCR at 6/8 weeks after birth.
• If PCR 1 is negative and the child is not
breastfed, do not repeat PCR at 9 months, follow
up, then serology at 18 months;
• If PCR 1 is negative and child is breastfeed, do
PCR at 9 months or rather if clinical suspicion
• In case of indeterminate result, repeat PCR
within 4 weeks.
Exposed infants still • 6 weeks after stopping breastfeeding
under breastfeeding
HIV negative partner • Every 3 months until the HIV patient on ART has
in a serodiscordant viral suppression
relationship
• Make an initial test,at 3 months and then once a
TB patient year
Key populations (TS, • Test every 3 months if negative
MSM and IDUs)
18
Symptomatic STIs • Make an initial test, re-test every 4 weeks later

then for each new STI in according to the national
algorithm.
Recent risk exposure • At 1 month, 3 months and 6 months after
(AES, rape, condom ending PEP stop.
break, etc.)
In case of PrEP • Every 3 months
2.3.3 Re-testing
Re-testing consists of repeating HIV testing to ensure accurate
diagnosis just before initiating ART. This is the verification of positive
HIV status before treatment.
2.4 Screening Algorithm and Interpretation of Results

2.4.1 Screening Algorithm
In Cameroon it is a 2-test algorithm that is used before confirming any
result as positive.
The tests used are preferably rapid diagnostic tests (RDTs),

prequalified by the WHO and approved by the Ministry of Public
Health.
19
Figure 4: General Screening Algorithm
20
Results interpretation
Before doing an HIV test, the technician must ensure that the two
rapid tests recommended by the algorithm are available in the
laboratory.
• Negative result: Anti-HIV antibodies were not detected in the

client's blood.
In case of exposure to HIV, it is recommended to repeat the
test after one month in view of the window period.
• Positive result: Anti-HIV antibodies were detected in the
client's blood on the two rapid tests recommended by the
algorithm.
• Discordant result: On the same sample taken, the results of

the two rapid tests are opposite.
21
2.4.2 Early diagnosis of HIV in exposed children
Figure 5: Algorithm screening children exposed from 0 to 18 months

22
2.4.3 HIV testing in pregnant and lactating women

HIV testing of pregnant or breastfeeding women should be done at
each woman's contact with a health facility and at the same time as
screening for "Dual-testing" syphilis. The use of the combined test
"Duo test" will be preferred.
2.4.4 HIV testing in adolescents

It requires the creation of youth friendly health services (pleasant
atmosphere, adapted opening hours, customized teaching materials)
in the health facility and communities in ways to take into
consideration adolescents specific needs.
Before any sample is taken, counselling for testing should be done to

the parent / guardian.
• If the adolescent is over the age of 15 and has the criteria of a
"mature minor", their written consent must be obtained;
• If the adolescent is less than 15 years old, parent's or

guardian's written consent must be obtained
2.4.5 HIV testing through "index cases" in the health facility or

in the Community
This screening approach allows the provider to offer testing to
partners and family members of an HIV-positive patient identified as
an "index case".
The confidentiality and the will of "Case index" must always be

respected: its identity can be revealed only with its agreement and it
is the customer who chooses the level of disclosure of the
information in his entourage.
23
Figure 6: Principles of screening approach for HIV-exposed individuals

from an index case
2.4.6 HIV testing for blood transfusion
All blood donors must be advised / informed about HIV screening and
other diseases (viral hepatitis) before any blood collection.
HIV testing steps and counselling must be respected including
confidentiality.
Rapid tests to be performed are carried out in parallel, simultaneously

(as indicated in the national algorithm).
24
Figure 7: Screening Algorithm for Blood Transfusion
2.5. Linkages between HIV testing and HIV prevention, care and
treatment
The link is the process by which an HIV + tested patient in a hospital or
community is accompanied or referred to the service where the
infection will be managed, with the aim of initiation of ARV treatment.
The link to care services can be done:
- From the community to the health facility (screening
campaigns, door to door, screening from an index case ...)
- Within the health facility, from all services (gateways) to the

HIV management service.
25
✓ Link procedures (step by step)

• After appropriate post-test counselling, the newly diagnosed
HIV + client must be enrolled in a liaison registry (which must
be available at all gateways where HIV test is conducted
including at the community level).
• Also enter in this register, the patient contact and those of two
(2) of his relatives, as well as the plan of location of his home.
• The link is at several levels depending on screening patterns

and screening targets (see table below)
Table 13: Different type of link
Types Recommandations
Intra- The referral or physical attendant must ensure that HIV
healthcare positive people are registered in the TAR and that they
facility are on ART
Link between Follow the combined procedure (referral form of the
health facility HIV-positive person and telephone calls from the
treatment unit)
Community • Linkage providers should be involved in campaigns
link-health and follow up to link everyone who has a positive test.
facility or
• Follow the combined procedure to link HIV + people
to care.
Link between • In the health facility, apply the "intra-health facility"
blood link procedure;
transfusion & • In the case of a community blood donation campaign,
health facility apply the "Community – health facility" link procedure
described above
26
• For all HIV positive clients, the link must be made within
seven days maximum (in the same health facility) and within
30 days for referrals between health facility or the
community at the health facility
• Phone contacts of the managers of HIV care services, PSC and
focal points in HIV treatment Unit, PMTCT sites and others
should be made available to all actors of screening by the
RDPH / RTG-NACC for ease of reference and counter-
reference.
• Always allow the PLHIV to choose another CEP structure than

the screening site
27
Table 14: Link with HIV treatment Unit
FIXED Strategy ADVANCED Strategy

Where Community ( OBC the community (identity OBC, refugee camps, etc ...)
identity, refugee Community
camps, etc ...)
With who Health area management The teams of the mobile health unit
comittee
In the absence of PSC PSC participates in screening in the mobile
team
patient chosen to patient does not
be followed in the choose to be followed
care service in the care service
where the APS where the APS works
works
Responsible (in Healthcare provider of the FOSA, Psycho-Social Pediatric psycho-social escorts (APS) or
charge of in charge of rendering the result Counselors (CPS) of the adults of the UM team,
delivering the of the HIV test to the person HIV + UM team,
results)
28
Involved Psycho-Social SPC in charge of rendering the HIV test

persons Counselors (CPS) of the result to the HIV + person;
UM team,
Focal point in charge of
the link in the nearest
HIV care service or the
choice of the HIV +
person
Care link Use of the reference book / Combined procedure: Combined Combined procedure:
procedures to voucher made available to the HIV person reference procedure: reference form +
follow screening team to materialize the card + PEC phone calls reference sheet + physical
reference in addition to the physical accompaniment of the
physical support to the HIV care accompaniment person + telephone
service of the person calls from the PEC
service
29
2.6. Screening quality assurance

The steps for quality assurance of screening tests are described in the
table below:
Table 15: Steps for quality assurance of screening tests

Before testing During testing After testing
• Check daily storage • Follow safety • Clean and disposal of
temperature and ambient precautions for biohazardous waste
temperature biological hazards • Report results
• Make an inventory and • Identify the according to your SOP
ensure the date of validity of client • Document the results
the kits • Collect the • Collect, process and
• Check availability of rapid specimen transport samples for
testing device • Perform the confirmation
• Offer information about HIV test • Manage confirmation
/ AIDS testing • Interpret test test results
• Label the test device results • Participate in an
• Perform external quality external quality
control according to the assessment
manufacturer and site (periodically)
instructions.
• Record all necessary data,
such as kit lot number,
operator identity.
Some recommendations on quality control and related supervision:

• All quality control data should be regularly reviewed by the
quality manager responsible for the collection site.
• New test results should be analysed to determine if corrective
action can be taken if problems are identified.
• If the tests do not detect errors, sites should consider
discontinuing them.
30
• Any issues identified during supervisory visits should be

discussed immediately with on-site personnel and all
necessary follow-up activities, including training, should be
undertaken.
• The site visit must include observation of the tests with
samples of known reactivity (skill panels).
• On-site evaluation should occur at least twice a year at
established sites and at least quarterly for new sites or sites
with new staff. The frequency should be based on the initial
results and the need for corrective action.
• On-site visits should be informative and provide a mentoring

experience. The experience should not be punitive.
31
CHAPTER 3: ELIMINATION OF MOTHER-TO-CHILD

TRANSMISSION OF HIV
3.1. Overview
PMTCT is a set of interventions implemented to prevent children from
becoming HIV infected during pregnancy, birth, or breastfeeding. It
has four pillars:
• Prevention of HIV infection in women of childbearing age or
primary prevention (Pillar 1)
• Prevention of unwanted pregnancies in HIV-infected women
(Pillar 2)
• Prevention of mother-to-child transmission of HIV (Pillar 3)
• Treatment, care and support for infected women, their
partners, their children and their families (Pillar 4)
The risk of HIV transmission from mother to child is very low when the
infected mother is put on ARV treatment and has an undetectable viral
load. That is, the mother receives ARV treatment and has good
adherence to treatment.
The table below summarizes risk factors and mechanisms of HIV
transmission from mother to child by period.
32
Table 16 : Factors Influencing MTCT
Maternal Obstetrical Fetus / Breastfeeding Viral

Children modalities
• High VL • Episiotomy • Prematurity • unprotecte • Type of
• CD4 count • Early artificial • Hypotrophy d virus
down rupture of the • Firstborn breastfeed (25% for
• Advanced HIV membranes (twin ing (by HIV1 and
infection stage • Amniocentesis pregnancy) ARVs) 1% for
(AIDS) • Prolonged rupture • Oral diseases • Extended HIV2)
• Primo of membranes (˃ (candidiasis, breastfeed • Presence
infection 4h) stomatitis, ing of a
• Malnutrition • Instrumental ulcerations). • Mixed resistant
• Anemia delivery (eg by breastfeed virus.
• Presence of forceps or suction ing • Co-
STIs cup) • Breast infection
• Malaria • Vaginal birth injuries: (HVB,
• Other • Extended work mastitis, etc.)
infections (systematic use of nipple
(viral or the partogram) fissures,
microbial) • Maneuver by breast
external or internal abscess
version
HIV counselling and testing for pregnant women

• HIV testing and counselling for PMTCT should be done at each
woman's contact with the health care system according to the
national algorithm.
• Health personnel should encourage male partners of all

pregnant women to be tested for HIV.
The table below presents the main guidelines for HIV testing and
counselling for pregnant women.
33
Table 17: Main guidelines for counselling and testing of pregnant and
breastfeeding women
HIV counselling and testing for pregnant women
Where? • Health facility: Prenatal consultation, SA, CPON,
other services (Family planning, vaccination,
pediatrics)
• Community (home birth)
By who? • Health care providers, Psychosocial agents
• Prenatal consultation: 1st contact if unknown status
When? or negative for less than one month then at 3
months and 36 weeks (unless already tested
negative at 32-35 weeks)
• Labor room: if unknown or negative during prenatal
visits (≥ 3 months)
• Post partum: unknown status, then every 6 months
for the duration of breastfeeding if HIV (-)
• Pregnant and breastfeeding woman
Who? • Partner (notification of partners)
3.2. Minimum package of services of the pregnant woman and

breastfeeding woman
3.2.1. Package of services to offer to the pregnant woman
The table below describes the package of services to be offered to
pregnant women during prenatal consultations
34
Table 18: Summary of interventions at each ANC

Interventions Antenatal Antenatal Antenatal Antenatal
consultation 1 consultation 2 consulta- consulta-
tion 3 tion 4
Periods of visits 1st trimester: Any 2nd trimester: 3rd 4th
time before the 24-28 weeks trimester: trimester:
16th week 32-36 after 36
weeks weeks
Physical X X X X
examination
Basin X X
Assessment
Laboratory examinations
HIV test Pregnant woman Pregnant Repeat the test if the
and her partner if woman and her 1st HIV test was
HIV status is partner are not negative
unknown yet tested
Blood group, Rh Determine the ABO group and Rhesus factor from the first
consultation
Complete blood • If the patient shows signs of anemia (especially pallor) do
count, complete blood count
Hemoglobine • If Hb <11.5g / l, pregnant woman is anemic: double the dose
of iron and folate and give nutritional advice
Transaminases X X
Fasting blood X X
glucose
Urine Research glucose (research diabetes) and albumin at each visit
Syphilis Do TPHA / VDRL Do TPHA / VDRL if not done previously
Viral hepatitis Research HBsAg systematically to all pregnant women during the
1st ANC (or 1st contact antenatal care)
CD4 X X
lymphocytes
Viral load Do Viral load if Do Viral load at 3 months of initiation of
already ARV with a ART and then every 3 months
Viral load dating
back more than 3
months
Treatment and Prophylaxis
35
Vaccination Administer the first Administer the Give a dose of anti-

dose of anti- second dose of tetanus vaccine if
tetanus vaccine if Antitetanus necessary (if she has
not vaccinated vaccine (at least not received 2 doses
4 weeks after since the beginning of
the first visit) if pregnancy)
applicable
supplements Iron / folic acid: Give 1 cp of iron (200mg) and 1cp of folic acid
5mg daily. In case of anemia, double the dose
mebendazole Do not give during Give 1 cp to 500 mg in the 2nd or 3rd

the 1st trimester trimester of pregnancy
Intermittent Do not administer Give Sulfadoxine- Advise the

preventive until the 16th week Pyrimethamine 500mg / use of
treatment (IPT) of pregnancy, 25mg. LLINs
advise If the pregnant woman is
the use of Long HIV+, administer
Lasting Insecticides Cotrimoxazole (CTX) in place
Treated Mosquito of IPT
bed nets( LLINs) Advise the use of LLINs
CTX Give CTX at each visit if the pregnant woman is HIV +
ARVs Give ARVs as soon as possible after diagnosis regardless of the
term of pregnancy, CD4 count or clinical classification
Support for ART At each antenatal visit
adherence
Breastfeeding X X
advice
Childbirth X X
preparation
3.2.2. Package of services to be offered to HIV positive woman

after childbirth (Post-natal follow-up)
o Throughout postnatal follow-up period of the
mother-child pair, the risk of MTCT persists as long as
breastfeeding continues.
36
Table 19: Package of services for HIV + woman in postpartum period
Post natal follow-up of the mother

Periods of visits During the week following delivery From the 6th week to From the 6th to the
the 6th month 24th month
6 days after childbirth Once a month Every 3 months
• Screen for concomitant pathologies of the mother and treat them
Monitoring • Provide health education on maternal and child nutrition, immunizations, Family planning, hygiene, STI
prevention
• Promote dialogue with the partner within the couple and responsible parenthood
• Evaluation of ART compliance and support needed
Family planning • Advise on family planning and available methods and Start contraception if needed
• Examine the abdomen, vagina, cervix • Examine the abdomen, vagina, cervix
Physical • Examine baby's anterior fontanelle and umbilicus • Do a Pap smear
examination scarring
o Inform the client about danger signs to be monitored during the postpartum period and encourage
her to return to the health facility immediately.
Signs of danger o Mother: vaginal bleeding, convulsions, breathing difficulties, fatigue, fever, abdominal pain, pallor,
oedema, vaginal discharge,
o Baby: red or pus draining cord, refusal to suck, swollen eyes, sticky or draining pus, cold baby while it
is hot or warm baby while undressed, difficulty breathing, lethargy, pallor or yellow eyes, repeated
vomiting, convulsions
37
Nutritional • Take the infant's weight , height and head circumference then compare them to the values of a child of
evaluation his / her age,if malnutrition, nutritional support and / or referral
Tuberculosis Systematic
Research
Biological examination
HIV test Test the mother and her partner if unknown serology or negative test since more than 3 months.
Early diagnosis of • Diagnose HIV infection in the baby with DBS / PCR or POC / EID at 6 - 8 weeks
HIV in exposed • Continue the diagnosis process according to the national algorithm
children • Initiate any confirmed HIV-positive child to ART as soon as possible and ensure adherence to treatment
Viral load • Viral load every 3 months until breastfeeding stops.
Treatment and prophylaxis
Iron / folic acid Give 1 tablet of iron (200mg) + 1 tablet of folic acid (5mg) daily for 3 months. If anemia, double the dose
Mebendazole If the patient has not received during pregnancy, give Mebendazole (DU) at delivery and then every 6
months
IPT Advise the mother on the use of LLINs and, if necessary, give them when available
CTX Administer CTX to HIV + women • Administer CTX to HIV + women
• Administer the CTX to the exposed child from the
6th week until the diagnosis of non-contamination
ARV Initiate or continue ARVs to the HIV + mother and initiate nevirapine within the first 72 hours of life and
continue for 6 weeks
38
3.2.3. ARV Treatment of Pregnant Woman or Breastfeeding

HIV Positive Woman
• The goal of ART in HIV + pregnant women is threefold: (i)
Reduce viral load. (ii) restore and maintain the mother's
immune function and thereby improve her overall health; (iii)
Prevent Mother-to-Child Transmission of HIV
• The link of the pregnant or lactating woman between the HIV
diagnosis point and the initiation point of ARV therapy should
be done following the procedures described in the previous
chapter.
• Any HIV + pregnant woman (including the woman in the
delivery room) or breastfeeding woman should be started on
ART as soon as possible regardless of CD4 count or WHO
clinical stage (option B +)
Treatment protocols for PW and/or breastfeeding women
Preferred regimen:
• TDF/3TC/DTG 1 tablet once daily (If more than 8 weeks of

amenorrhea)
Alternative regimens:
• TDF/3TC/ EFV (600 or 400 mg) 1 tablet taken once daily
In case of treatment failure:
2nd line 3rd line

2 NRTIs + (ATV / r or DRV / r + DTG ± 1-2 NRTIs (After genotypic
LPV / r) resistance testing for optimization of ART)
Viral load monitoring for HIV+ pregnant and breastfeeding women
39
The table below describes the viral load monitoring for HIV+ pregnant
and breastfeeding women
Table 20: Pregnant and/or breastfeeding woman follow up

Post ART Postpartum (every 3 Every
Viral load
initiation months) year
- ANC1, if Viral load M3 32 – S6 M3 M6 M9 M12 annual
dating back more than 36 GA
3 months
- or during pregnancy
3.2.4. ARV prophylaxis in exposed children (HIV-positive

mother's child)
The risk of transmission in exposed children should be evaluated to
determine the duration of Nevirapine (NVP) administration.
The table below indicates the risk assessment criteria and duration of
ARV prophylaxis in exposed children.
Table 21: Classification of MTCT risk

Risk criteria Duration of
Dosage
classification prophylaxis EE
• Exposed child born to an Daily dose
High risk of HIV + woman who received NVP for 12 Weight * from
MTCT less than 4 weeks of ART weeks. 2000 to 2499 gr:
before delivery; 10 mg in one
• Exposed child born to an dose (1 ml)
HIV + mother whose viral Weight ≥ 2500 gr:
load was> 1000 copies / ml 15 mg in one
one month before delivery; dose (1.5ml)
• Exposed child whose
mother has been tested
HIV + during childbirth or
breastfeeding.
Low Risk of All other cases of HIV + NVP 6 weeks
MTCT pregnant or breastfeeding
women
* NB: With newborn with a low birth weight (<2000 gr), start with 2 mg / kg (0.2 ml
/ kg) per day until it reaches 2000 gr 1ml = 10mg of NVP
40
3.2.5. Clinical and biological monitoring of HIV + pregnant or

breastfeeding woman
The clinical and laboratory examinations of pregnant or
breastfeeding women infected with HIV are presented below.
Table 22: Clinical and biological monitoring of pregnant or

breastfeeding women
At ART Post ART Post-partum Every
initiation initiation year
M M M6 6th Every 3 M M M M
1 3 week months 12 15 18 24
Physical X X X X X X X X X X X
examination
Hepatitis B X
Screening
supply of X X X X X X X X X X X
ARV and CTX
Assessment X X X X X X X X X X X
and
adherence
support
Viral load X* X X** X** X** X* X* X* X* X**
* * * * *
*
creatinemia X X X X X X
Transaminase X X X X
s
Fasting X X X X
Blood Sugar
Hemoglobin X X X X X
Clinical and biological follow-up examinations of HIV-infected pregnant and
lactating women are presented below.
*: Exclusively for pregnant women already on ART before ANC1
**: For pregnant women and breastfeeding mothers screened for HIV + and
initiated on ART during the current pregnancy
41
Important:
After 6 months postpartum, and if the viral load is "suppressed" and

the client is clinically stable, she should benefit from multi-month
ARV dispensation (every 3 months) and Cotrimoxazole accompanied
by adherence advice
If the viral load is not "suppressed", a monthly dispensing of ARVs and

Cotrimoxazole should be continued, each time with an adherence
support session and the viral load measurement repeated after 3
monthly sessions
3.2.6 Management of Co-infections in Pregnant Women:

Tuberculosis, Viral Hepatitis B
Table 23: Management of Coinfections in pregnant women
Tuberculosis Viral hepatitis B

• TB should be eliminated in any • Screening for viral
HIV + pregnant woman hepatitis B should be
Research • Look for the following systematic in pregnant
symptoms: cough, fever, night women.
sweats, weight loss, enlarged
lymph nodes
• In case of tuberculosis, • Infants of HBsAg-
treatment is initiated before positive mothers with
initiation of antiretroviral hepatitis B should
therapy receive hepatitis B
Treatment • First line anti-TB drugs are safe vaccine within 24 hours
for pregnancy of birth
The ART protocol in these two situations (TB and Hepatitis B
virus) is the same: TDF / 3TC / EFV Cp fixed dose (1cp per day).
42
3.2.7. HIV infection and family planning (FP)

• FP counselling should always be provided to HIV + pregnant
women and as much as possible, contraceptives should be
provided locally.
• Integrating FP services into HIV services (VCT, PMTCT and
ARVs) and vice versa helps prevent unwanted pregnancies,
HIV re-infection and transmission
Table 24: Drug interactions of contraceptives with certain drugs
Options NNRTIs NRTIs LPV/r Anticon- antifungal

Contraception vulsants systemic
NVP EFV AZT, D4T, 3TC, ABC,
TDF
Condoms * * * * * *
COC ** ** * *** *** *
Progestin ** ** * *** *** *
implants ** ** * ** ** *
Injectables * * * ** ** *
DIU * * * * * *
*: Appropriate method; no interaction

**: Possibility of reducing the contraceptive effect or increasing the side
effects of hormonal methods (Add a backup method such as a condom to
alleviate a possible decrease in the contraceptive effect
***: Do not use the method (contra indicated)
43
3.3. HIV PMTCT strategies

• Integration of PMTCT and Neonatal and Infant Maternal
Health (MNCH): identifying women who need PMTCT at all
MNCH gateways (ANC, maternity, immunization service,
postnatal follow-up service, family planning service);
• The family-based approach to HIV infection: the HIV-infected
person already identified (woman, partner or child) as an
index to other family members (sexual partner and / or other
children);
• Delegation of tasks, decentralization of services that brings
health services closer to the population and alleviates the
lack of human resources in terms of quality and quantity;
• The implementation of option b + for pmtct: systematic

initiation of art in any pregnant or breastfeeding woman who
is hiv-positive regardless of her clinical or immunological
stage and nevirapine administration in neonates;
• Delegation of tasks, decentralization of services that brings

health services closer to the population and alleviates the
lack of human resources in terms of quality and quantity.
44
CHAPTER 4: MANAGEMENT OF THE HIV-

EXPOSED CHILD
4.1 Overview
The Exposed Infant (EI) is a child born to an HIV-positive mother. It is
said exposed as long as its HIV status has not been definitively
determined.
The objectives and expected results of the EA follow-up are

presented below.
follow-up • Ensure the best conditions for harmonious

Objectives for growth and development
exposed children • Determine your HIV status as soon as possible
• Link those who are confirmed to be HIV positive

to the ARV treatment service
Expected results of • The HIV status of any Exposed child is known as
the Exposed soon as possible.
children follow-up • Any confirmed child with HIV is linked to ARV
treatment
• All children receive clinical and psychological care

for optimal growth and development.
To achieve these results, the package of services below must be

delivered within the health facility according to the defined schedule
presented on the following page.
45
Table 25: Schedule and package of follow-up services for children born to HIV-positive mothers
At A 6th week From 6 weeks to 6 months From M6 to M18-24 (quarterly visit)

birth (monthly visit)
• Evaluate At each visit: • At each visit
adherence to • Look for concomitant • Research concomitant pathologies and treat
prophylactic ART pathologies and treat them
• Diagnose and treat them • Serology HIV at 9 months and confirmation by
concomitant • Screen for HIV infection PCR if positive serology
conditions Screen for by PCR • Serology HIV at 18 months or 6 weeks after
HIV infection by PCR • Link to the ART service if cessation of breastfeeding
• Link positive cases the child is infected with • Link to the ART service if the child is infected
to ART HIV with HIV
S10 S14 M5 M6 M9 M12 M15 M18 M21 M24

Prophylactic X
ARV
Psychosocial X X X X X X X X X X X X
support
46
Growth X X X X X X X X X X X X
monitoring
Monitor X X X X X X X X X X X X
psychomotor
development
Complete X X X X X X X X X X X X
clinical
examination
Food advice X X X X X X X X X X X X
Vaccination X X X X X
Initiate CTX Start Cotrimoxazole at 6 weeks of age and continue until confirmation of HIV non-infection
DNA PCR PCR at 9 months • After 18 months:
HIV diagnosis • If positive, affirm the diagnosis of HIV infection • If Pos., Make Serology according
in exposed and initiate ART confirmation PCR to the national
children • If negative, continue clinical follow-up and • If Neg, conclude algorithm for final
screening according to the national algorithm. negative test diagnosis of the
child.
Serology (9-18
months) if pos,
make confirmation
PCR
47
4.2 Feeding the child born to a positive mother

4.2.1 Recommendations on the nutrition of children exposed
to HIV
Baby feeding tips should:
• Begin during ANC and continue during successive follow-up
visits of the pregnant woman and at post-partum visits;
• Be adapted to the individual situation of his family and take
into account his uses, customs and beliefs;
• Include information on various feeding options (confers side

boxes below).
Breastfeeding option Artificial feeding option
• Define exclusive breastfeeding; • Ensure that the chosen

• Recall the advantages and artificial feed is acceptable,
disadvantages of breastfeeding; affordable, feasible, sustainable
• Clarify that the duration of and safe
exclusive breastfeeding is 6 • Acceptable: Lack of pressure of
months; any kind: partner, cultural,
• Identify the constraints that may family, etc.
hinder its proper implementation; • Feasible: The mother
• Define a mixed diet and explain understands how to prepare
its dangers; artificial milk and has all the
• Explain the dangers of mastitis or necessary equipment;
any breast infection;
• Affordable: Financial cost is
• Demonstrate the correct
accessible for the family;
breastfeeding position;
• Sustainable: Sustainable over
• Demonstrate the milk expression
technique; time;
• Express willingness to support the • Safe: Free from danger to the
implementation of the chosen child's life.
alimentation plan
48
The choice of feeding method is the sole responsibility of the mother

and her family. This decision is made in full knowledge of the facts,
after the enlightening by the health staff.
4.2.2 Practical ways of feeding the exposed child

Feeding modalities of the exposed child are developed below:
Table 26: Method of feeding the exposed child

Age Modalities
In the HIV-positive mother, encourage
Before 6 • Exclusive breastfeeding protected by ARVs
months OR
• Alternative feeding (artificial milk) up to 6 months of life if it is
affordable for the family.
Between • Continue breastfeeding and add adequate and balanced
6 and 12 supplementation.
months • Introduce one new food at a time and ensure tolerance before
introducing another new food.
• Milk remains at this age an essential food for infant feeding and
must receive at least half a litre each day in addition to feeding.
Beyond • In the exposed child in whom an HIV infection has been definitively
12 ruled out, breastfeeding will be discontinued and replaced by any
months other whole milk (cow's milk or commercial milk and then growth
milk) to prevent the child from an additional unnecessary risk of
contracting HIV infection.
• In addition to this milk, this child will be fed with family food whose
presentation will be adapted to its stage of development;
• For children with confirmed HIV infection, the provider will
encourage the mother to continue breastfeeding to allow her baby to
benefit for some time further from the nutritional benefits of breast
milk.
At each visit:
• Weight gain, height and head circumference
• Report of these measurements on the corresponding growth curves
• Assessment of nutritional status
49
4.3 "Exit" Procedures of the Follow-up Program for Exposed

Children
Exit follow-up methods are as follows:
• After 18 to 24 months of follow-up, the exposed child is

confirmed to be "not infected with HIV" by PCR, followed
by a serological test. He leaves the program to be followed
in the pool of young children in the context of child health
• During follow-up, the exposed child is confirmed to be

"infected with HIV". He is placed on ARV or referred for
treatment initiation and follow-up of antiretroviral treatment
in the structure closest to his place of residence.
• During the follow-up period, the exposed child is declared

"Lost to follow up" as all attempts to find him / her have
been unsuccessful. It is therefore removed from the list of
exposed children monitored in the health facility.
• During the follow-up period, the exposed child is "deceased".

It is therefore removed from the list of exposed children
monitored in the health facility.
In all cases, appropriate documentation of the "exit" modality of the

program must be made in the tracking register of exposed children
and the exit statement must be written at the end of the line of its
longitudinal follow-up.
50
CHAPTER 5: INITIATION TO ANTIRETROVIRAL

TREATMENT
As recommended by the WHO in the "Treatment for All" strategy,

anyone screened HIV + should be placed on antiretroviral (ARV)
treatment as soon as possible, as soon as the result of his HIV status
is announced.
Biological assessment is not a prerequisite for initiating ART. It should

not delay ARV
This treatment should be carried out by trained health care staff,

after a comprehensive clinical evaluation.
HIV infection is a chronic disease that, in the current state of

knowledge, requires regular treatment for life. Therefore, before
starting antiretroviral therapy, it is imperative to have in-depth
interviews with the patient about his or her willingness to be treated,
to be observant to treatment and to initiate for life.
The choice to accept, delay or refuse ART is ultimately the

responsibility of the patient or guardian (for the child or adolescent)
except in an emergency
51
5.1. .Stages of initiation of ARV treatment.

5.1.1. Initial evaluation of the patient before ART initiation
New PLHIV
The Patient for Treatment

Physical
examination
• Setting
parameters * Initiation to Treatment +
• Nutritional Prescription of biological
Evaluation examinations
Body Mass
Biological examination
Index (BMI):
Weight (kg) /
Systematic examinations: CD4 count,
Height (m2) NFS, fasting blood glucose, serum
• WHO creatinine,
classification Autres examens à faire en fonction de
• TB Active l’évaluation du patient
search
• Evaluation of
other OIs Follow-up visit to J15 for review of toxicity
• Evaluation of
Chronic Non-
communicable
Follow-up visit to D30 for readjustment of
Disease (CNCD)
ART-Clinical follow-up
Vaccine status
assessment
Figure 8: Initial evaluation of the patient before ART initiation
52
This evaluation also allows the patient to be classified according to

the stages defined by the WHO (Stage I, II, III and IV) and to
determine the appropriate model of care for this "Differentiated
Care" patient.
5.1.2. WHO classification of patients by stage of clinical

Table 27: WHO classification of HIV infection
WHO classification system for stages of HIV infection and illness in adults
and adolescents
Clinical stage I
1. Asymptomatic
2. Persistent generalized lymphadenopathy
Grade 1 of the activity scale: asymptomatic, normal activity
Clinical stage II
3. Weight loss <10% of body weight
4. Minor mucocutaneous disorders (seborrheic dermatitis, prurigo,
onycomycosis, recurrent oral ulceration, angular cheilitis)
5. Herpes infection in the last five years
6. Recurrent infections of the upper respiratory tract (bacterial sinusitis
And / or grade 2 of the activity scale: symptomatic, normal activity
Clinical Stage III

7. Weight loss> 10% of body weight
8. Unexplained chronic diarrhea> 1 month
9. Unexplained prolonged fever (intermittent or permanent)> 1 month
10. Oral candidiasis (thrush)
11. Hairy leukoplakia of the tongue
12. Pulmonary tuberculosis in the past year
13. Serious bacterial infections (ie pneumonia, pyomyositis)
And / or grade 3 of the activity scale: bed rest <50% of the day in the last month
Clinical stage IV
14. Cystic syndrome of AIDS, as defined by the Centers for Disease Control and
Prevention
15. Pneumocystis carinii pneumonia
53
16. Cerebral toxoplasmosis

17. Cryptosporidiosis with diarrhea> 1 month
18. Extrapulmonary cryptococcosis
19. Cytomegalovirosis with organ damage other than liver, splenic or
ganglionic
20. Herpes infection, mucocutaneous> 1 month, or visceral, whatever its
duration
21. Progressive multifocal leukoencephalopathy
22. Toute mycose endémique généralisée (telle que histoplasmose,
coccidioidomycose)
23. Candidiasis of the esophagus, trachea, bronchi or lungs
24. Generalized atypical mycobacteriosis
25. Non-Typhoid Salmonella Septicemia
26. Extrapulmonary tuberculosis
27. Lymphoma
28. Kaposi’s sarcoma
29. HIV encephalopathy, as defined by the Centers for Disease Control and
Preventionb
And / or grade 4 of the activity scale: bed rest> 50% of the day in the last
montha
a-AIDS Cachectic Syndrome : weight loss> 10% of body weight, plus chronic
diarrhea (> 1 month) or unexplained chronic asthenia and unexplained
prolonged fever (> 1 month).
B HIV encephalopathy: Clinical examination reveals cognitive and / or motor
dysfunction disrupting activities of daily living, ranging from several weeks to
several months, in the absence of disease or concomitant infection other than
HIV infection. HIV likely to report observations.
5.1.3. Patient classification according to the appropriate

differentiated model of care
Differentiated Services Delivery (DSD) or differentiated care is a

patient-centered approach to care. It consists of adapting services to
patient specific needs, preferences and expectations, in order to
facilitate access to care and adherence to treatment.
54
Differentiated care takes into account:

o Clinical status of clients: symptomatic, asymptomatic,
presence of comorbidity / co-infections, stable or unstable;
o The sub-population concerned: adults, children,

adolescents, pregnant and breastfeeding women, key
populations.
This approach requires, a prior assessment of the clinical,

psychological and other conditions. Patients to determine the level
and type of care they need and then offer them appropriate services.
As part of this approach, there are four (4) categories of patients as

described in the table below:
Table 28: Classification of patients according to their clinical condition
People living with HIV Main elements of differentiated care

People in good general Support for adherence and retention
condition
People with advanced Rapid clinical management to reduce mortality
disease risks and morbidity
Clinically stable people Less frequent clinical and biological monitoring
multi-month dispensing of ARVs through the
community model
Clinically unstable Intensive support for compliance, frequent
people measurement of viral load, switch to second- or
third-line ART if indicated, drug resistance
monitoring, etc.
Source: 2016 WHO Unified Guidelines
55
5.1.4. Preparing the patient for ART

HIV education and adherence support are integrated into the initial
visit. All patients or patient’s guardians should have enough
information to be able to make an informed choice about starting ART.
Therapeutic education will be provided to the patient by health care
staff, psychosocial agents or counsellors (PSAs) and pharmacy staff at
all levels of the patient's circuit.
Treatment preparation should be appropriate to the patient's age,
sex, needs and clinical status. Adolescents and children specific needs
must also be taken into account
For a good patient preparation, it will be necessary to:
• Establish a good relationship with the patient (Create a
climate of trust, communicate clearly, guarantee
confidentiality, avoid judgments)
• Organize therapeutic education sessions (ETP): sensitization,

learning and patient psychosocial support regarding the
disease and the prescribed treatment.
Table 29: Points to discuss when preparing for ART

Components Points to discuss
• What is HIV?
HIV • How HIV is transmitted?
• Why partners and other family members need to
be tested?
• What is viral load?
Viral load • How many times does the viral load have to be
measured?
• Why do we need to have a viral load deleted?
• What is CD4?
CD4 • How many times should CD4 be dosed?
• What are the diminishing CD4s?
56
• What is ART?
ART • What are the benefits of ART?
• When to start ART?
• Does HAART cure?
• What is the duration of ART?
• What happens if:
Therapeutic • You stop your ART without medical advice
failure • Do not take your ART regularly
• Your resume is increasing
• You are in therapeutic failure
Side effects • What are the most common AEs?
(AE) • What to do if you have AEs?
• What is compliance?
Observance • What is the rate of ART?
• What can you do?
o Prevent to take your ART
o Help to respect the taking of your ART
• What can happen if you miss an appointment?
Nutrition • Why is food important?
• What can you do to improve your diet?
Monitoring • What is the rhythm of the visits
• What are the elements of monitoring
ART • Are you ready for ART today?
preparation
Follow-up • Exams to realize
plan • Medications to take today (ART, Cotrimoxazole ,
INH)
• When should you return to the health facility?
57
5.1.5 Management to be done after ART preparation preparation
Figure 9: What to do after preparation for TARV
58
o During the initial visit: Give the patient an laboratory exam

form for creatininemia if the prescribed protocol contains
Tenofovir (TDF) or the complete blood count if prescribed
protocol contains AZT.
o If the patient has mental health, addiction or other problems

that constitute major barriers to initiation and / or adherence
to ARV treatment, appropriate support should be provided
and readiness to start ART needs to be re-evaluated at
regular intervals.
Figure 10 : Algorithm for initiation of ART
59
5.2 Monitoring of HIV after 1 year of ART

5.2.1. Monitoring of stable and unstable persons living with
HIV
5.2.1.1. Definition of “stable patient” and “unstable
patient”
Table 30: Classification of stable and unstable patients

Adults Specific cases
UnStable patient Stable patient
The presence of at least The presence of all these Pregnant women:
one of these criteria indicators makes it if she was already
defines an unstable possible to define a on ART and stable
patient stable patient before the
• Patient at a very • Patient on ART for current
advanced stage (WHO more than 12 months; pregnancy
stage 3 or 4); • No active opportunistic
• On treatment for less infections including TB in Breastfeeding
than 12 months; the last 6 months; women: In case
• Presence of an active • Evidence of good of recent Viral
Opportunistic infections adherence to treatment load <1000 copies
(including TB) in the last 6 in the past 6 months / ml and early
months; (not missing any of the diagnosis of the
• Evidence of poor last 6 drug collection negative child
compliance during the last appointments in a between 6 and 8
6 months; period, even if it is a weeks
• Recent Viral load ≥ 1000 multi-month Teenager if stable
copies / ml; dispensation) ; and have
• Patients who have not • Recent Viral load ˂ psychosocial
completed their 6-month 1000 copies / ml; support
INH preventive treatment;
• BMI ˂ 18.5;
60
5.2.1.2. Tracking Stable and Unstable Patients
Table 31: Follow-up of PLWHA under ART according to their "stable

patient" and "unstable patient" classification
Unstable Patients Stable Patients
Where Health facility • health facility
• CBO (Community
Dispensation of ARVs)
Moni- • Every month • Clinic every 6 months
toring • Monthly ARV dispensing • Dispensation of ARVs
every 3 months
Care Monthly follow-up, however, additional Quarterly Follow-up
package visits are necessary in case of medical • Evaluation and Clinical
and / or psychological pathologies. follow-up / reassessment
• Evaluation and clinical and of stability criteria at each
paraclinical (biological) follow-up visit
according to guidelines • Prophylaxis with INH or
• Prophylaxis with INH or Cotrimoxazole
Cotrimoxazole • Systematic search for
• Systematic screening and tuberculosis
management of any Opportunistic • Adhesion assessment
infections • Therapeutic education
• psychosocial management • Assessment of viral load
• Intensification of therapeutic (once a year) or CD4 if viral
education load is not available every 6
• Assessment of tolerance and months
effectiveness of genotyping treatment • Renewal of prescription
as needed and supply of ARVs every 3
• Strengthening support for adherence months
• Refer patient for adequate
management if necessary
If the patient becomes "Stable" after If the patient become
HOW to XXX time, He is transferred to the unstable after sometime,
behave health facility or OBC for follow-up he returned to the health
according to the follow-up model facility for follow up
corresponding to "Stable" patients corresponding to unstable
patients
61
• No patient should be under pressure to receive ART at a

community distribution point or through an expedited
process
• Prescription renewal is in addition to ART, cotrimoxazole and
INH when applicable (indicated
• ART distribution points are health facilities or CBOs based on
patient preference, OAH systems and resources.
Table 32: Criteria for Defining Clinically Stable Children

Category Criteria Considerations
Age • Few dose adjustments after 2 years.
≥5 years
• Most vaccinations are performed.
Clinical Same criteria as • 12 months on ART.

criteria for adults
• Absence of malnutrition
• The disclosure of his / her seropositivity to

a child, appropriately according to his / her
Other non- Same treatment
age, encourages him to observe his / her
clinical regimen for
criteria more than 3 treatment durably.
months • Caregivers should be trained to begin this
revelation process when the child reaches
the appropriate age.
*Differentiated management adapted to stable patients is suitable for
children from the age of 2 years.
62
Table 33: Criteria for defining clinically stable pregnant women

Category Criteria considerations
Women on ART clinically stable at the time of conception
Already benefit from an ART Women must already meet
delivery model for clinically stable established clinical stability criteria.
subjects
Viral load <1000 The removal of viral load is critical to
copies / ml prevent MTCT.
since 3 months
ANC access Possibility to control that women
Possible control have access to antenatal care
additional Child exposed • Check that the exposed child has
clinical criterion to a negative benefited at 6 weeks from a PCR test
PCR at 6 weeks and received the result.
• Positive PCR may indicate
insufficient adherence and requires
intensified support for the mother
and infant.
Getting ART during pregnancy
Clinical criteria Same criteria as An HIV-tested woman who has been
for adults on ART during pregnancy
Possible Child exposed • Check that the exposed child has
additional to a negative benefited at 6 weeks from a PCR test
clinical criterion PCR at 6 weeks and received the result.
• Positive PCR may indicate
insufficient adherence and requires
intensified support for the mother
and infant.
63
Table 34: recommendations for the delivery of ARV treatments to clinically stable patients
Various Renewal of ART Clinical Consultations Psychosocial support

components prescriptions
when Every 3 to 6 months Every 6 months for pregnant or lactating Every month to every 6 months
women, adults and children over 5 years
where • FOSA (UPEC / CTA, • FOSA (UPEC / CTA, SMNI, CPN ...) • FOSA (UPEC / CTA, SMNI, CPN ...)
SMNI, CPN ...) • OBC • OBC
• OBC
who Healthcare Nurses, Midwives, Doctors Healthcare providers, APS,
providers, APS,
Pharmacy
what -Renewal of ART and Complies with directives: Peer Support Opportunities
MIO orders Clinical consultation including tuberculosis Counseling and support for
Monitoring screening and preventive treatment where caregivers to facilitate disclosure of
treatment appropriate HIV status
compliance Laboratory tests: measurement of CV and Assessment of factors that may
Control of the need CD4 affect adherence,
to refer the patient Prescription of ART until the next clinical Control of the need to refer the
to a clinician consultation PLHIV to a clinician
-children children
Start of the Dosage control and adjustment, if necessary
revelation Systematic review including verification of
64
procedure of the immunization status and tuberculosis

seropositivity screening Key populations
-Pregnant or teenagers Control of the need for legal advice
lactating women Assessment of mental health Combating violence and preventing
NCB Audit Pregnant or lactating women HIV, including reducing its harmful
-Key populations NCB Audit effects
HIV prevention and Key populations
risk reduction Screening for drug and alcohol use
HIV prevention, including reduction of its
harmful effects, screening and treatment of
STIs, viral hepatitis and tuberculosis
65
5.3. Special features of differentiated care by subpopulation

➢ Children
- Appointments must be made taking into account the school
calendar (school holidays, days and free hours) and according
to the appointments at tutor’s health facility ;
- For children aged 5 et 9, consultations for reneural of a TARV
prescription can take place gut side the health facilities , closed
to home and be provided by non-professional providers.
➢ Teens
- Their management must be done by staff trained in
adolescent care
- Health facilities should set up special "Teen" time slots
- Family planning benefits should be integrated into their
follow-up
➢ Pregnant and lactating women
- It is recommended to integrate their appointments with ANC
and HIV management and the follow-up of the infant exposed
to HIV, because the high frequency of the consultations in this
population, (ANC, CPON, and follow-up of the infant, routine
consultations for children less than 5 years) and various
consultation sites, help to promote the lost to follow up
phenomenon.
- As part of the family approachitis recommended to examine
members of
• family members (children, adolescents, pregnant or
breastfeeding women and parents / guardians) at the same
time
• For effective differentiated care, measures such as extending
pharmacy opening hours on certain days (during the day ...)
can be put in place.
• Differentiated care should be tailored to the unique needs of
each patient or group of patients, their clinical condition, and
the resources of the FOSA and the CBOs that depend on it.
66
5.4 Summary of Clinical and Biological Monitoring of PLHIV

Table 35: Clinical and biological monitoring of PVVIH under TARV
Week after Month M12 M18 M24
ART after ART
Appointment S2 S4 M2 M3 M4 M5 M6 Every 1 to 3 months Every 3 to 6
(RDV) depending on the months if stable
patient's stability patients
Physical X X X X X X X At all visits At all clinical visits
examination
Anthropometric X X X X X At all visits
measurements
Neurological X X X X X X X At all visits
examination
Nutritional X X X X X At all visits
Support
Psychosocial X X X X X At all visits
support
FTE and X X X X X X X At all visits

compliance
Drug toxicity At each visit using adapted tool
67
TB Research At each visit using the tool for intensive case search
CD4 test In case of need after
initiation of ART
Viral load Test X X X

Cryptococcus ag For adults or teenagers if CD4 <200
NFS, Hb X X X X
transaminases X X
Family Planning At every visit to women of childbearing age
Tips
creatinemia X X X X
Fasting blood X
glucose
Lipid profile X
HBsAg X
TPHA / VDRL X
Dipstick X X
68
CHAPTER 6: ART IN CHILDREN, ADOLESCENTS,

AND ADULTS
6.1 Overview
- ART is provided in health facilities equipped with resources

capable of dispensing this. "Treatment for All" strategy
recommends that ART should be routinely offered to all HIV +
patients (adults, adolescents and children) regardless of WHO
clinical stage or CD4 count.
- The goal of ART is to suppress viral replication (to achieve an

undetectable viral load) and restore the immunity of the
infected person. To this end, ART should be started as early as
possible to reduce the risk of morbidity and HIV-related
mortality.
- In addition, an undetectable viral load can reduce or even

reverse the transmission of HIV from one individual to another.
The prescription of ART is not an emergency. The patient must have

good preparation for treatment and expressed willingness to be treated.
- In order to relieve the burden of care, reduce the workload for

staff and the waiting times for patients during consultations,
the dispensing of ARVs should be done:
• Every month for unstable patients, new patients,

• Every 3 months for stable patients (refer to stable patient
classification, unstable patients)
69
• Every month, all patients put in the community through CBOs,

community ARV therapy groups,
- ART can only be delayed in the following situations:
• Patient refusal to start ART, or being in an unstable

psychological state
• Patient with acute and severe Opportunistic Infection
6.2. First-line ART protocols

- Treatment must be adapted to the type of virus (HIV-1, HIV-2),
clinical condition and lifestyle of the patient so that he/she is
observant in an optimal and sustainable way.
- It must be as powerful as possible in order to minimize
occurrence of resistance mutations.
Note: New protocols based on DTG and EFV 400mg are
included in the first-line preferential protocols while NVP-
based regimens will be phased out.
Below is a table summarizing the protocols according to the populations
Table 36: First-line ART protocols in the infected child

Populations 1st line 1st line Special
Preferential Alternative situations
treatment treatment
˃30kg (Children
ABC/3TC + DTG ABC/3TC + EFV** TDF/3TC + LPV/r
from 6 to 9 years)
Between 20 and
30 kg (Children ABC/3TC + DTG ABC/3TC + EFV AZT/3TC + LPV/r
from 3 to 6 years)
˂20 kg (Children ABC/3TC + LPV/r
˂3 years) AZT/3TC + LPV/r ABC/3TC + RAL
ABC/3TC + DTG*
• * If appropriate formulation (tablet or syrup available)
• * * Protocol of choice in children with TB / HIV co infection
NB: Do not double the dose of DTG in children, switch to ABC / 3TC + EFV
70
Table 37: First line ART protocols in Adults and adolescents (male sex)
Populations 1st line 1st line Alternative Special situations
preferential treatment
treatment
Adults and
adolescents TDF/3TC + EFV400
TDF/3TC/DTG AZT/3TC + EFV600*
(male sex) TDF/3TC/EFV600*
(> 10 years or> 30 kg)
* Depending on the availability of the formulation
Table 38: First line ART protocols in Adults and adolescents (female sex)
Populations 1st line preferen- 1st line
tial treatment Alternative
treatment
Adults and Pregnant and lactating women TDF/3TC/EFV600
adolescents TDF/3TC/DTG TDF/3TC/EFV400
More of childbearing age
(female sex)
(> 10 years On contraceptive and have
or> 30 kg) decide to take the TLD
Not on contraceptive / not
having access to
contraception and have
decide to take the TLD
after an informed choice
Child- Not on contraception and
bearing refusing to take the TLD
age after an informed choice
Not having access to
contraception and refusing
to take the TLD after an
informed choice TDF/3TC + PI/r
With desire for TDF/3TC/EFV400
motherhood and having
refused to take the TLD TDF/3TC/EFV600
after an informed choice
• Double the dose of DTG in children with TB/HIV co-infection, then stop the
second tablet of DTG two weeks after cessation of TB treatment
• Take 1tablet fixed combination of TDF/3TC/DTG per day (TDF 300mg, 3TC:
300mg, DTG: 50mg)
• If alternative regimen, TDF will be replaced by AZT (300mg). Take 1tablet of
AZT/3TC fixed combination and 1 tablet of DTG 50mg daily.
71
• EFV protocol, take 1 tablet of fixed combination TDF/3TC/EFV in the evening

(TDF 300mg, 3TC 300mg and EFV 600mg)
• In case of TB/HIV co-infection: take 1tablet of TDF/3TC/DTG in the morning
plus 1tablet DTG (50mg) in the evening for the duration of the TB treatment
ABC (Abacavir), AZT (Zidovudine), 3TC (Lamivudine), TDF (Tenofovir), EFV (Efavirenz),
ATV/r (ritonavir boosted Atazanavir), LPV/r (ritonavir boosted lopinavir), DTG
(Dolutegravir)
AVOID prescribing:
• DTG to women of childbearing age in the absence of effective
contraception
• EFV in case of psychiatric history or if child <3 years
• TDF if child <10 years
• AZT if anemia
• A Mono or Bitherapy
6.3. Second line ART protocols
The second-line protocol consists in using a new therapeutic class "PI:
Protease Inhibitor" boosted by ritonavir added to AZT / 3TC if TDF is
used in the first line or TDF / 3TC if AZT is used in the first line.
Table 39: 2nd line ART protocol *

Populations 1st line 2nd line
< 20 kg (< 3 years) • ABC /3TC + LPV/r  AZT/3TC + LPV/r
 ABC/3TC + DTG*
Between 20 and • ABC (AZT)/3TC + DTG  AZT (ABC)/3TC +
30 kg (3 to 9  ABC (AZT)/3TC + EFV ATV/r (LPV/r)
years)
>30 kg (10 to 19 • TDF/3TC/DTG ou  ABC (AZT)/3TC +
years)  TDF/3TC/EFV ATV/r (LPV/r)
Adults
72
6.4. Third Line ARV Protocols

Currently, the number of people requiring third line ART in Cameroon is
growing. Management of second- and third-line treatment failure cases
will be guided by resistance profile (genotyping). However, 3rd line
protocols should include new ARVs with proven HIV efficacy: 2nd
generation PIs (DRV / r), INI (RAL or DTG).
The therapeutic choice will take into account the viremia and sensitive
molecules available in the country.
Placing patients on third line ARV treatment is done exclusively in

Approved treatment centers of reference with expertise confirmed by
the National Program.
Table 40: Summary of Different ARV Protocols for Naive Patients *

Population 1st line 2nd line 3rd line
Adults and NRTIs + DTG 2 NRTIs + (ATV/r DRV / r + DTG ± 1-2
adolescents or NRTIs (Whenever
2 NRTIs + EFV
(including pregnant possible, consider
LPV/r)
women and women genotyping for ART
of childbearing age) optimization)
* Special cases of co-infected patients are treated in the chapter of

opportunistic infections
6.5. Change of ARV treatment protocol

- Change of therapeutic regimen is indicated:
• In case of serious adverse effects or major toxicity to ARVs
• In case of therapeutic failure
Before considering changing a treatment, ALWAYS make sure the

patient is adherent.
73
6.5.1. Clinical, immunological and virological definitions of

treatment failure
Table 41: Clinical, immunological and virological definitions of treatment
failure
Types Characteristics
Clinical failure Children:
A new or recurrent clinical event indicating severe
or advanced immunodeficiency after 6 months of
effective treatment.
Adults and adolescents:
A new or recurrent clinical event indicating severe
immunodeficiency after 6 months of effective
treatment.
Immunological Adults and adolescents:
failure CD4 count equal to or less than 250 cells / mm3
following clinical failure or persistence of a CD4
count of less than 100 cells / mm3.
Children under 5:
Persistence of a CD4 count below 200 cells / mm3.
Aged over 5 years:
Persistence of a CD4 count less than 100 cells /
mm3
Virological Viral load> 1000 copies / ml determined by 2
failure consecutive measurements at 6-month intervals,
with support for compliance at the end of the first
virological test, at least 6 months after the start of
treatment (well conducted and well observed).
74
6.5.2. Interpretation of viral load
Figure: 11: Algorithm for the interpretation of plasma viral load
• Viral load measurement is the preferred monitoring method

for determining and confirming treatment failure.
• Viral load can be:
➢ Undetectable: CV <50 copies of RNA / ml, translating a
control of viral replication. This occurs in case of
effective ART
➢ Or Suppressed: CV <1000 RNA copies / ml, reflecting low
virus replication in progress. This low viral replication
indicates either: (i) a blip (transient elevation of the viral
load), (ii) a poor therapeutic compliance, or (iii) a
beginning of therapeutic failure;
75
Table 42: side effects of ARVs

ARV Major toxicity CAT
ABC • Hypersensitivity Do not use in the presence of this
gene
AZT • Anemia, neutropenia Substitute with TDF or ABC
• Lactic acidosis or severe
hepatomegaly with steatosis;
• Lipoatrophy or lipodystrophy;
myopathy
TDF • Chronic or acute renal disease Replace by AZT or ABC .Do not
(Fanconi syndrome) initiate TDF if CrCl <50ml/min,
• Decreased bone mineral uncontrolled hypertension, renal
density disease or uncontrolled diabetes
• Lactic acidosis or severe
hepatomegaly hepatic steatosis
INNTIs
EFV • Persistence of CNS disorders • Use EFV 400 or DTG
(vertigo, insomnia and
nightmares) or mental disorders • For severe hepatotoxicity, change
(anxiety, depression and mental to PI / r or an integrase inhibitor
confusion), Convulsion (DTG)
• Hepatotoxicity, gynecomastia
• Skin reactions or severe
hypersensitivity
NVP • Hepatotoxicity • In case of moderate
• Skin rash, hypersensitivity hepatotoxicity, replace with EFV
reaction (Stevens Johnson) including children aged 3 years and
over
• In cases of severe hepatotoxicity,
substitute with a different ARV class
such as IP / r or integrase inhibitor
76
ATV • ECG abnormalities (PR and QRS • Be careful when using medication
prolongation) that can lengthen QT
• Indirect hyperbilirubinemia • Substitute with LPV / r or DRV / r.
• Renal lithiasis • In case of contraindication to PI / r
and NNRTI failure, switch to
integrase inhibitors.
LPV/r • ECG abnormalities (PR and QRS Be careful when using medication
prolongation, torsade de that drug that can lengthen the QT
pointes) • If LPV / r is used in the first line in
• Hepatotoxicity, Pancreatitis; children use RAL or DTG if available
Diarrhea (children over 6 years old) otherwise
• Dyslipidemia EFV, NVP or ATV / r. If LPV / r is used
in the 2nd line in adults (failure to
NNRTIs), replace with an integrase
inhibitor (DTG).
DRV/r • Hepatotoxicity • Replace with ATV / r or LPV / r. If
• Severe skin reactions or used in the 3rd line, the options are
hypersensitivity limited.
• In case of hypersensitivity
substitute by a different class such
as anti-integrase.
DTG • Hepatotoxicity; hypersensitivity • Substitute with EFV or IP / r
reaction • Take tablet in the morning or
• Insomnia substitute by PI/r or RAL
• Depression
RAL • Rhabdomyolysis, myopathy, • Stop ARVs until symptoms stop
myalgia and replace with PI / r.
• Hepatitis
• Severe skin rash or
hypersensitivity reaction
6.5.3. Management of therapeutic failure

• In the face of a general therapeutic failure
- Follow up closely
77
- Evaluate compliance, tolerance, drug interactions, drug-diet

interactions, psychosocial issues.
- Strengthen adherence and therapeutic support sessions
- Review the patient's antiretroviral history to identify future
treatment options
• In front of a 2nd line failure
- Request a Genotypic resistance testing to ARVs and wait for the
result, keep the patient under the current protocol.
- Upon receipt of this test result, make a summary of the patient's
file and submit it to the regional committee for resistance to the
reference approved treatment centre for case study and
prescription of the 3rd line treatment regimen
Table 43: Goals and indications of a stress test

Goals Detect the presence of mutations on the viral genome that
reduce the sensitivity to ARVs, to guide the choice of future
ART
Indications • Confirmed virological failure to 2nd line ARV treatment in
adult patients;
• Confirmed virological failure under PI / r in children infected
following exposure to PMTCT;
• Suspicion of contamination with a resistant virus (Viral load
raised twice despite ART with DTG in an observant PLHIV,
therapeutic education)
• Seroconversion in PrEP before initiation of ART.
78
6.5.4 Management of treatment interruptions

- In case of ART interruption by the patient, support and assistance
to observance will be conducted by a counsellor trained for this purpose
In the event of interruption of ART by the provider for therapeutic

reasons (eg intolerance or serious adverse effect), the entire
combination must be discontinued in order to avoid the development
of resistance to the molecules maintained.
79
CHAPTER 7. OBSERVANCE, RETENTION IN CARE

AND PSYCHOSOCIAL SUPPORT
Principles
o Compliance improvement strategies need to be implemented as
soon as HIV is diagnosed (as part of post-test counselling and
linking to ART).
o Support for adherence should be personalized (adapted to each
patient) and continuous (continued throughout ART)
o The health facility should establish multidisciplinary teams
composed of clinicians, psychosocial staff (counsellor,
Psychosocial agents, social worker and psychologist), pharmacy
and laboratory staff to help patients obtain excellent
compliance.
o A viral load should not be repeated in case of persistent poor
compliance
- Compliance is the extent to which patients follow medical instructions

(appropriateness between medical prescription and use of the drug by
the patient)
7.1. Assessment of compliance
Adherence to ART should be assessed at each visit to treatment facilities
(Health facility, Community, etc.) by a trained provider by performing
one or more of the strategies described in the table below.
80
Table 44: Adherence assessment strategies

Strategies Technical Frequency
Counting • Ask the patient to bring all his pills with • At each visit until
tablets him during follow-up visits. confirmation of
• Calculate how many pills should remain viral suppression
based on the previous prescription date • Whenever health
and the prescribed amount, and compare worker suspects a
them to the number of pills remaining. complianceproblem
• Excess pills are supposed to be missed
doses.
Pharmacy • Compare the actual date with the • Each time you
records expected date of intake (depending on take
the number of pills dispensed during the medicine
last visit). • Whenever a
• If the actual date is health
later than expected, it is worker suspects a
assumed that the patient is compliance
missing doses equivalent to the problem
number of days late
Viral load • Follow the viral load monitoring See algorithm
algorithm.
Undetectable viral load is the best
confirmation available of
adequate adherence
Home • Observe where and how a patient
visits stores and takes medications and
evaluate if they have any extra
medications because of forgotten doses.
• Home visits can also provide a better
understanding of the patient's life
situation and specific barriers to
adherence.
- Unscheduled home visits should only be
performed if the patient has previously
consented to home visits (preferably at
the time of registration or initiation).
81
Table 45: Evaluation of the compliance level according to the number

of tablets
Missed % of Observance Actions required
doses per treatment
month taken
Taken Taken
once a twice a
day day
1 dose 1-3 >or= 95% Good Continue with support
doses and routine counselling
2-4 doses 4-8 85-94% Fair Assess barriers to
doses adherence and
strengthen counselling
Followed 2-4 weeks
>ou= 5 >or= 9 < 85% Bad Assess barriers to
doses doses adherence and
strengthen counselling
1-2 weeks follow-up
7.2. Barriers to ART compliance

Several factors (summarized below) lead to poor compliance. They are
related to the individual (patient), the drugs used or the health system.
82
Table 46: Barriers to adherence

Types of Different obstacles
factors
individual • Missed doses
• Changes in daily routines
• Mental health (depression)
• Lack of interest or desire to take medication
• Substance or alcohol consumption
• Multiple trips resulting in extended stays away from
home.
• domestic / domestic violence against the infected
person
• Lack of disclosure in the family and the child
• Cultural, traditional or spiritual beliefs
• Lack of funding / transportation to return to the
clinic
• To live alone ; lack of social support from family and
/ or friends
Illiteracy
• Poor understanding of ART regimen or ART efficacy
Drug- • Side effects
related • Complexity of dosing regimens and dietary
restrictions
• Taste
• Quantity of tablets
• Dosage frequency
• Refusal of the child
Linked to • Care provider workload
the system • Lack of transportation : distance from the health
of health center; insufficient access to refills
• Inability to pay the direct or indirect cost of care
• Work or school schedule
83
7.3 Counselling and treatment adherence support during the first six
months of ART
o Patients newly placed on ART should be particularly adherent to

ensure they achieve viral suppression within 6 months of
initiation.
o Increased adherence should be done in all patients with
compliance problems or in those with suspected treatment
failure. This involves counselling sessions.
o The minimum number of sessions recommended is three
sessions of enhanced adherence counselling, but additional
sessions may be added as needed.
o Ensure that the patient participates in all compliance
counselling sessions, and that they are done by the same
counsellor to ensure continuity; and that the session be
documented to track all identified issues.
84
Key messages for patients in the first six months of ART

• All new patients on ART need careful monitoring of adherence
• And support to ensure that they achieve viral suppression.
If no concerns about adherence If inadequate or poor adherence
Do counseling or group FTE or individual Do individual counseling or FTE support:

support: - Evaluate and eliminate potential barriers to
- Review the patient / TUTOR's knowledge adherence
of HIV and correct any gaps. - Review the patient / guardian's knowledge of
- Review patients '/ guardians' understanding HIV and address gaps
of antiretroviral therapy (dosing, timing, - Examine the patient / guardian's understanding
frequency) and address any gaps. of ART administration (dosage, timing,
- Explore any major or recent changes in the frequency)
life or daily routine of the patient / guardian - Cause any patient / guardian concern about
that could disrupt compliance antiretroviral, other medications, schedule of
- Update the patient's location and contact visits
information - Explore any major or recent changes in the life
- Encourage the patient / guardian to or daily routine of the patient / guardian that
continue the support systems discussed and could disrupt compliance
implemented before ART. - Update the patient's location and contact
information
- Examine the effectiveness of the support
Ask to do the first viral load at the follow-up visit with advice at the 6-month ART observance
Viral load Deleted: Viral

load˂1000 copies / ml Viral load not deleted: Viral load˃1000copies /
ml
- Continue adherence monitoring, - Discuss with the patient / guardian to
counselling and support despite viral develop a plan to assess barriers to adherence
suppression, but with lower intensity and - Reinforce compliance in the patient /
frequency. guardian through close follow-up
- After 12 months of treatment, these appointments
patients should also be evaluated for - Repeat the second viral load after 3 months
qualification as "stable patients" with less of good compliance
frequent visits to health facility, a multi-
month distribution of ARVs or community-
based, etc. - If result of the second CV increases
or does not change, carefully evaluate
- If result of the second CV goes down, the adherence and resolve any
continue the monitoring of the identified problems
therapeutic observance, the advice and - Confirm or diagnose the therapeutic
the support despite the result failure
- Repeat the resume after 6 months. - Change protocol (2nd line)
Figure 12 : Counseling and adherence support during the first six months of
ART
85
7.3.1 Content of the 3 counselling sessions on improving observation

The table below describes the essential elements of each of the 3
sessions designed to improve adherence.
Table 47: Content of adherence support sessions
Section 1 • Review the understanding of the viral load and discuss why the
viral load is high.
• Review the behavioural, emotional, and socioeconomic
barriers to adherence to treatment.
o Treatment skills
o Drugs: dosage, schedule, storage.
o Side effects
o Motivation
o Screening for mental health (screening for depression)
o Discuss patient support systems
• Help the patient develop an adherence plan to address
identified problems
Section 2 • Review the compliance plan for the first session and discuss
any potential issues.
• Identify other gaps and potential problems.
• Orientations and networking.
• Help the patient modify the compliance plan to solve the
identified problems.
Section 3 • Review the compliance plan for previous sessions and discuss
any potential issues.
• Identify other potential problems.
• Assist the patient in modifying the adherence plan to address
identified problems.
• Decision to repeat viral load based on current compliance: plan
to repeat
Viral load test after 3 months of good compliance
86
o If adherence challenges persist: plan more counselling sessions

on strengthening adherence
Section 4 • Discuss the results of the second Viral load
• Plan the management:
o If the viral load is now deleted: continue the current
treatment with increased adherence, repeat the viral
load after 6 months.
o Viral load is <1000 continue to monitor
7.3.2 Psychosocial support by population

7.3.2.1 Children and adolescents on ARV treatment
- The psychosocial support of children on ARV treatment is
essential to ensure the effectiveness of this treatment, because
the child must find a source of motivation to accept his
diagnosis, and take his treatment relentlessly;
- Each health facility should have a trained psychosocial care
team (clinical psychologists, social workers, socio-
anthropologists, peer educators, social educators, etc.);
- The psychosocial support system for children to be put in place
in health facilities includes the following elements:
o Systematic and personalized counselling of any child or parent
at each visit
o The announcement of the diagnosis of HIV infection of the child
at the appropriate age (begins around 7 - 8 years and ends
around 12 years)
o Support groups by age group (0 - 5 years old for parents, 6 - 9
years old, 10 - 14 years old and 15 - 19 years old)
o The regular organization of activities of "support groups"
87
o The organization of camps or study visits in services or

institutions that are of interest for the development of children
and in particular for adolescents.
o The system of the "education-pair" by implication of the
children or teenagers
o "champions" in the process of building and psychological
support of their peers
- A plan of psychological support and therapeutic education must
be developed.
This plan aims to help the patient and his entourage to:
o Understand his illness and treatment;
o Cooperate with caregivers;
o Live as healthy as possible;
o Maintain or improve the quality of life;
o Take care of his state of health;
o Acquire and maintain the resources needed to optimally
manage one's life with the disease.
- This plan includes four essential phases described below:
Phase What to do?
Initial education Timing of announcement of the diagnosis aims to
develop self-protection skills
Educational follow up Identification of the patient's educational needs
and their links with the therapeutic and care needs
Educational recovery Intervenes during an event considered important

for the patient as well as the caregiver
Assessment of patient Assessment of acquired skills. See national
transformation document on community care
88
➢ Disclosure or Announcement of HIV status to child or

adolescent
o Disclosure of HIV status to children is a CONTINUOUS process
that parents /care givers and health care providers must take
part in.
o It must be done in the context of a relationship / climate of trust
o It allows to involve the child or the teenager in his care in order
to facilitate his observance and to help him to live positively his
status
o Disclosure must be individualized taking into account the child /
youth, parent (s)/ guardian (s), family, household and
community.
o Partial or full age-appropriate disclosure is essential to ensure
sustained adherence to medications, especially as children grow
up in young adolescence.
✓ Serological status disclosure steps to children and adolescents

for young children (5-9 years)
• Provide simple information in a language that they can
understand
• Discuss the following points:
o Nature of the disease
o How they can take care of themselves
✓ For older children and adolescents (10-19 years)
• Provide information about their HIV status.
• Discuss and plan disclosure with parents.
• First determine what they already know (may ask if they
know
• Why they come to the center / have a blood test
89
• Need a correct assessment of the child

• The information must be specific
• Provide a moderate amount of information rather than
everything at once
• Help develop coping mechanisms
• Talk about who / what can others say
• Discuss all aspects of the disease:
o Basic nature of the HIV virus and disease progression
o Transmission and prevention
o Diagnosis and prognosis
o Drug resistance
o Live positively and normally
o Sexual health education
✓ In the teenager
• Establishment of a systematic therapeutic education
during educational sessions of the adolescent with his
parent, or adolescent alone, group sessions
• Follow-up beyond announcement of test results in
planned adolescent settings
• Prepare for the transition to adult management services
(see the following figure 13.)
7.3.2.2 Serological Status Disclosure or Announcement to

Pregnant Women
- Disclosure to pregnant women requires sharing one's status
with one or more people (spouse, children, parents, friends,
caregiver, employer or other person).
90
- It is important to promote the client's adherence to the

treatment, prevention and care plan.
- All patients should be encouraged to disclose their status to
family, sexual partners and community members.
- This disclosure cannot be made unilaterally by the provider without the
patient's consent
7.4 Retention of patients on ARV treatment

The HIV care cascade includes: HIV testing, linkage and retention in care,
initiation of antiretroviral therapy and antiretroviral retention and viral
suppression
Fundamental elements of a good retention in care and ARV treatment

o Improvement of services quality offered in the health facility
(reception, respect, communication with patients, etc.)
o Organization of services within the health facility (patient
circuit, combined parent / child visits, provision of services
beyond usual hours of service, etc.).
o Use of retention agents or psychosocial coaches (APS) to whom
should be assigned the responsibility of daily monitoring of
PLWAs. Each agent has a cohort of patients
o Use of appointment tracking register (retention) with names,
addresses and telephone numbers of patients
o Establishment of "youth-friendly" services, including dedicated
spaces, trained staff ...,
o Organization of "Support Group" activities for children,
adolescents and others
91
Figure 13: Accompanying Algorithm for Transition from Adolescent to

Adult Care Service
92
CHAPTER 8: DETECTION PREVENTION AND

MANAGEMENT OF OPPORTUNISTIC DISEASES
8.1 Prophylaxis
The prevention of opportunistic infections by chemoprophylaxis is a
strategy that aims to use, in PLHIVs, drugs to reduce the risk of
opportunistic infections (primary prophylaxis) or the reoccurrence of a
previously treated and controlled infection (prophylaxis secondary).
8.1.1 Cotrimoxazole prophylaxis treatment (CPT)
The criteria for initiation and discontinuation of CTX prophylaxis are
given in the table below.
Table 48 : Criteria for stopping and initiating CTX prophylaxis
Target
Goals Criteria for initiation Stopping criteria
person
In the It protects o From the 6th week of o Until the risk of
newborn against: life HIV transmission
exposed to • Pneumocystis has stopped and
HIV pneumonia (PCP), HIV infection is
•Toxoplasmosis, completely ruled
• Diarrhea caused out.
by Isospora belli
Children and o Regardless of CD4 o CD4>
and adults Cyclospora spp. count after confir- 350 /
HIV + • Malaria and mation of HIV infection mm3
• Certain bacterial o
infections, including
HIV + o Whatever the level of o Viral load
bacterial
pregnant CD4 unless the removed
pneumonia and
women pregnant woman is on o Undesirable
urinary tract
IPT with Sulfadoxine o effects *
Pyrimethamine
In case of allergy to CTX, Dapsone 100 mg once a day.
93
• Dosage of CTX for prophylaxis
Table 49 : Posology of CTX according to the weight of children exposed

to HIV or infected with HIV
Weight Dosage mg / d Oral suspension Adult Cp
(based on 4 mg 240mg / 5ml 480mg
TMP / kg)
< 5 kg 16 to 20 mg per 2.5 ml ¼ cp
day
5 – 15 kg 40 mg 5 ml ½ cp
16 – 20 kg 60 mg 10 ml 1 cp
21 – 30 kg 80 mg 10 ml 1 cp
>30 kg 160 mg - 1 cp
8.1.2 Chemotherapy for tuberculosis prophylaxis with INH or

(Isoniazid preventive treatment)
- IPT and antiretroviral therapy can be initiated safely at the same

time in people living with HIV.
- Isoniazid is safe during pregnancy, breastfeeding.
- One negative screening is enough to start prophylaxis.
- People who start IPT should be warned of possible side effects
of isoniazid: (i) hepatitis, (ii) peripheral neuropathy and (iii) rash.
94
Table 50: Eligibility Criteria for INH

Children Adults
• Child in close contact with • PLHIV with no signs /
a contagious TB case: symptoms of active TB (no
o All children under the age of cough, no fever, no weight
0-5 (infected or uninfected). loss, no night sweats)
o All children infected with
HIV up to 15 years old. • No contraindication to INH
• If asymptomatic for tuberculosis. (psychosis, convulsions,
• And having no contraindications neuropathies)
to INH. • No side effects to INH
Table 51: Posology of INH prophylaxis by weight
Slice of Daily dosage of INH • INH at 5 mg / kg / day
weight (kg) (100 mg cp) • Pyridoxine (Vitamin B6) at 25 mg
2 – 3,4 1/4 cp / day (or 12.5 mg / day if <3kg).
3,5 - 4,9 1/2 cp • Remember: The maximum
5 – 7,4 3/4 cp dose of isoniazid
7,5 – 9,9 1 cp should not exceed 300 mg
10 – 14,9 1 ½ cps • Duration: 6 months
15 – 19,9 2 cps
20 – 29,9 3 cps
≥ 30 3 cps
NB: People who start IPT should be warned of possible side effects of
isoniazid: (i) hepatitis, (ii) peripheral neuropathy and (iii) rash.
The table below summarizes the different conditions for evaluating the
shutdown or recovery of INH.
95
Table 52: Criteria for Stopping or Resuming TPI

Scenario Actions
Suspicion of Stop INH immediately and refer the PLHIV to a
active TB comprehensive TB case management facility.
Poor If INH is temporarily discontinued for less than 3
compliance months, the provider should:
with INH - Investigate the reasons for discontinuing treatment;
prophylaxis - Counsel the patient on the importance of IPT;
- Look for signs/symptoms suggestive of active TB
o If asymptomatic and no signs of TB, continue IPT and
add missed doses of INH for a total duration of 6
months.
Interruption of INH for more than 3 consecutive
months:
- Stop INH
- Investigate reasons for discontinuation
- Counsel the patient on the importance of IPT
- Look for signs/symptoms suggestive of active TB
o If asymptomatic and no signs of TB, restart IPT for 06
months
- Any interruption of treatment for the second time: Stop
INH regardless of the duration of the interruption.
Translated with www.DeepL.com/Translator (free
version)
Hepatotoxicity • Investigate and discontinue INH if active TB is
confirmed
Skin rash • Mild, stop INH until rash disappears and restart
under supervision
• Severe, stop INH immediately and refer to hospital
urgently
96
Peripheral • Assess severity and speed of progression.

neuropathy • Inform patient that neuropathy may be due to HIV
and/or INH.
• Inform the patient that the neuropathy will cease
when INH therapy is stopped.
• If symptoms of neuropathy are mild, continue INH,
counsel and treat
o Increase pyridoxine dose from 25 to 100 mg
daily
o For adults, prescribe amitryptiline 25 mg to be
taken at night if neuropathy unbearable.
• If difficulty walking or excessive pain: stop INH and
treat
8.2 Prevention and Management of TB / HIV Co-infection

8.2.1 Tuberculosis search among PLHIV
The active search for TB is done through a checklist and is based on the
elements described below.
Table 53: Tuberculosis search among PLHIV
Approach Elements
The clinic Signs and Symptoms (Cough, Fever, Night sweats, Weight
loss and appetite, Asthenia, Fatigue, Dyspnoea, Chest
pains, Haemoptysis)
In PLHIV, the presence of only one of the signs
mentioned above should already make people suspect
Bacilloscopy • Essential examination.
(bacteriological • The excretion of Koch bacillus being intermittent, it is
diagnosis) recommended to carry out 2 consecutive sputum. A
single positive smear result is sufficient to establish that
a patient has smear-positive TB and start treatment
The GenXpert • Molecular technique for rapid diagnosis of TB and
(MTB / RIF) • susceptibility testing for rifampicin
The LAM TB • Rapid diagnostic tests recommended by WHO (WRD)
97
• Detects TB bacilli with sensitivity and specificity that are

comparable to those of GenXpert but do not detect
resistance to Rifampicin.
X-ray • Does not provide certainty because pulmonary TB can
take many forms of radiological abnormalities.
Culture • Reserved for patients with GenXpert RR+ tests and for
follow-up of MDR patients
o TB signs should be systematically investigated at each visit /

appointment with the PLHIV.
o In The presence of a single sign the health care provider should
think of TB.
8.2.2 Tuberculosis treatment in people with HIV
Table 54: Tuberculosis treatment in people with HIV

Category Treatment schemas
New TB case • Patients who have never been treated
before with TB drugs or treated for
less than a month
• Duration of 6 months of treatment 2
{RHEZ} / 4 {RH} in two phases:
o Intensive phase comprising 4 molecules (RHEZ),
duration 2 months;
o Continuation phase with 2 molecules
(RH), duration 4 months
98
Reprocessing(*) • Patients who have previously taken anti-TB drugs for a

month or longer and have either a relapse, a treatment
failure or been lost to follow-up.
• Patients who have previously taken anti-TB drugs for a
month or longer and have either a relapse, a treatment
failure or been lost to follow-up.
• Total duration of 6 months: 6 {RHEZ}
in two phases separated by the
monitoring work up:
o 3 months of daily RHEZ intake
 Follow-up report (continuation
decision following Xpert's result)
o 3 months of daily intake of RHEZ
Other cases • The sick ones
- Without clear antecedents of
previous TB treatment
- Having already been treated but have
smear / culture negative for
pulmonary tuberculosis or (TPB-)
show extra-pulmonary tuberculosis
(PET)
• Same treatment regimen as new cases
(*) Categorize as reprocessing and treat as such after a rifampicin-sensitive

GenXpert test
99
8.2.3- Time to initiation of TARV in a tuberculosis patient

Table 55: Time to initiation of TARV in a Tuberculosis patient
Criteria for diagnosing Time to initiate ART
TB in PLHIV
CD4 <50 / mm3 *, • Start ART within 2 weeks after starting anti-TB
treatment
CD4 > 50/mm3 • Start ART within 2 to 8 weeks of starting TB
treatment
• Start ART 2 to 4 weeks after starting second-line
Multi-resistant TB
TB treatment
HIV + pregnant • Start Tuberculosis Treatment on the same day
woman with active TB • Then begin ART two (2) weeks later.
Tuberculosis • Start ART 8 weeks after starting TB treatment
meningitis regardless
of CD4 count
* Take into account the risk of IRIS when ART is introduced early and at a low
CD4 count. Systemic corticosteroid therapy may be considered to treat
symptomatic IRIS at a dose and for a duration that will depend on the
therapeutic response.
8.2.4 ARV protocols for HIV / TB co-infection

If TB is found in a patient already on ART, the treatment should be
adjusted as described in the following tables:
Table 56: Adaptation of ART in case of introduction of ant tuberculosis

treatment
Age ARV diet
< 3 years • LPV / r or DTG
3 to 10 years (≥ 10 kg) • Maintain protocols based on DTG, EFV or LPV / r
Adolescents> 35 kg or • Maintain protocol based on EFV or LPV / r OR
adults • Substitute by DTG
In the case of LPV /r, do not double the dose of LPV/r, Ritonavir should be
added to obtain an LPV/r ratio of 1:1.
If DTG, double the dose of DTG in children, then stop the second DTG tablet 2
weeks after ending TB treatment.
100
NB: Children ≥ 3 years of age and exposed to NVP for 6 weeks or

more (PMTCT) should be initiated with ABC + 3TC + LPV / r
Table 57: ARV therapeutic protocols for anti-tuberculosis drugs

1st line 2nd line
Infants and children ABC + 3TC + LPV/r
• Expert opinion
<3 years old (or <10 AZT + 3TC + DTG • ABC + 3TC + LPV / r plus
kg) Ritonavir ;
• 2 weeks after stopping TB, stop
2nd dose of Ritonavir
Children ≥ 3 years ABC + 3TC + DTG • AZT + 3TC + LPV /r plus
(and ≥ 10 kg) Ritonavir ;
• 2 weeks after stopping TB, stop
2nd dose of Ritonavir
Adults and TDF + 3TC + DTG • TDF + 3TC + LPV/r or AZT +
adolescents ≥ 13 or TDF+3TC+EFV 3TC + LPV /r plus Ritonavir;
years (and> 35 kg)
Pregnant women or TDF + 3TC + EFV • AZT +3TC+ LPV/r
FAP
HVB / HIV co- • Always maintain TDF-based protocols
infection
• Special case of pregnant woman

All mothers, including those on TB treatment and / or HIV-infected,
should be encouraged to breast-feed.
➢ Management of an infant born to a mother with tuberculosis
- Perform a clinical examination including examination of the
abdomen
- Look for the following signs and symptoms;
o Respiratory frequency ≥60 / min or difficulty breathing
o Feeding problem or low weight gain
o Abdominal distention, hepatomegaly or splenomegaly
o Jaundice
101
• Perform the Postnatal examination of the placenta for

calcification (if placental calcifications, endometrial specimens
should be obtained within 72 hours of delivery and sent to the
laboratory for Koch bacillus culture and histological
examination).
8.3. Inflammatory Immune Reconstitution Syndrome (IRIS)

It can manifest itself a week or several months after the introduction of
ART.
This is the worsening of the clinical status of HIV-positive patients
occurring after initiation of ART, as the immune system begins to rebuild
and induces inflammatory reactions that explain the clinical
manifestations.
Table 58: Evocative signs management of IRIS

How to diagnose IRIS during How to support IRIS?
tuberculosis?
Exclusion diagnosis
Other possible causes of clinical • Most patients can be treated on
worsening of tuberculosis should be an outpatient basis
excluded, namely: • Non-steroidal anti-inflammatory
• Multidrug-resistant tuberculosis drugs can be prescribed
• Alternative diagnoses such as • ART should be continued unless
bacterial pneumonia, there is a risk of life-threatening
pneumocystosis, Kaposi's sarcoma, • If life threatening, the patient
etc. should be hospitalized urgently
• Poor adherence to treatment • Corticosteroid therapy may be
• Malabsorption necessary for severe reactions.
• Drug toxicity
102
o IRIS due to TB is rarely fatal.

o ART should not be delayed in patients with low CD4 counts to
prevent TBI IRIS because mortality is high when ART is delayed.
8.4. HIV co-infection / Viral hepatitis B and C
HIV infection in HCV + and / or HBV / HDV + patients promotes the

occurrence of chronic forms and a rapid progression to complications
(cirrhosis and hepatocellular carcinoma).
ART is recommended for all HIV + coinfected with HBV regardless of CD4
count. It must contain Tenofovir + Lamivudine (TDF / 3TC) or Tenofovir
+ Emtricitabine (TDF / FTC)
In case of therapeutic failure in co-infected HIV-HBV patients, maintain
TDF + 3TC if possible and add an IP / r.
8.4.1. Vaccination against viral hepatitis in an HIV patient
Table 59: Vaccinations against viral hepatitis

vaccine How
Hepatitis • PLHIVs co-infected with HBV and / or HCV;
A vaccine • After checking for the absence of anti-HA antibodies;
• Less effective if CD4 is less than 200/mm3;
• If low CD4 (<200 / μL) and uncontrolled Viral load, ART should
be started before immunization is used.
Hepatitis B • The presence of isolated anti-HBc IgG (HBs neg, anti-HBc (+)
vaccine and anti-HBs neg) is not recommended.
• Revaccination should be considered in HIV-infected persons
with a suboptimal response to a first anti-HBV vaccination (Anti-
HBs Ab <10 IU / L).
103
8.4.2. Treatment of HIV / Hepatitis B co-infection

ART is recommended in all HIV + people infected with HBV regardless of
CD4 count.
It must contain Tenofovir + Lamivudine (TDF / 3TC) or Tenofovir +
Emtricitabine (TDF / FTC). In case of therapeutic failure in co-infected
HIV-HBV patients, maintain if possible TDF + 3TC and add an IP / r to HIV
+ co infected patient
8.5. HIV-HCV co-infection

- The goal here is to achieve an undetectable HIV viral load on
antiretroviral therapy because it is associated with a lower
progression of liver fibrosis.
- ART is instituted as in any HIV + patient, with closer hepatic
monitoring
8.6. Management of Cryptococcus Meningitis (CM) in PLHIV

Table 60: Management of Cryptococcus Meningitis
Management of Cryptococcus Meningitis
Diagnosis: Treatment Prophylaxis
Positive microscopy • Attack treatment: primary prophylaxis
OR detection of Systematic antifungal is
o Liposomal
Cryptococcus recommended in PLHIV with
amphotericin B (3
neoformans (Ag Cr) CD4 <200 / mm3 before ART
mg / kg once daily
antigen in serum, is recommended only in the
IV) + Fluconazole 400
plasma, or CSF culture. following situations:
mg twice daily 14
Cryptococcal Serum days then perform • Positive cryptococcal serum
Ag Research in PVVIH lumbar puncture ag
with a CD4 count <200 (PL): if sterile CSF
• Diagnosis of CM eliminated
cells / mm3 is culture, switch to
by CSF examination
required. oral therapy
104
• If serum Ag • Consolidation It is as follows: Fluconazole 1

detection, eliminate treatment x 800 mg 1x / day for 2 weeks
CM by CSF then 1 x 400 mg daily for 8
o Fluconazole 400
examination. weeks
mg 1 cp daily oral
• If CM diagnosis is (loading dose 1 x 800 Secondary Prophylaxis /
discontinued, mg on day 1) Maintenance Treatment
prophylactic
8 weeks. PL repeated • Fluconazole 200 mg / day
treatment with
until opening orally for a duration of 12
Fluconazole 800 mg
pressure <20 cm months
once daily for two
H2O
weeks is Consider stopping: if CD4
recommended, prior count> 200 cells / mm3 on 2
to initiation of ART, to successive samples at 6
reduce the risk of month intervals and viral load
unmasking IRIS. suppressed / undetectable
for 3 consecutive months
8.7. Screening and Management of Pulmonary Pneumocystosis (PCP)

in PLHIV
Pneumocystis pneumonia is an infection caused by a parasite,
Pneumocystis jiverocii. It occurs in patients with advanced
immunodepression and indicates progression to AIDS disease.
105
Table 61 : Management of Pulmonary Pneumocystosis

Management of pulmonary pneumocystosis
Diagnosis: Treatment Prophylaxis
• Presumptive: CD4 Treatment for at least 21 Primary Prophylaxis
count <200 / mm3 AND days and secondary • Any PLWHA with
dyspnea / desaturation prophylaxis CD4 count ≤ 500
with exertion and cough • Cotrimoxazole (TMP mm3
AND radiology (miliary
image) compatible / SMX): 3 x 5 mg / kg / • Stop if you have an
without obvious signs of day not exceeding 12 vials immune restoration
bacterial pneumonia / day IV (severe or CV deleted /
AND response to forms) and 6 cps at undetectable for
treatment. 800mg / d orally more than 3 months
Definition: cough and (moderate forms) + • Cotrimoxazole: 1cp
dyspnea on exertion prednisone within 72
hours after CTX initiation double dose
AND diagnosis based on (800/160) 3x / week
cytological examination for a duration of 05 days,
of if Pa02 <10 or 1cp single dose
kPA or <70 mmHg (400/80) 1x / d
sputum (80%
sensitivity), (eliminate TB before any • Alternative
bronchoalveolar lavage corticosteroids) o Atovaquone (1500
(sensitivity> 95%) or • Allergy at Cotrim mg / day in a PO
biopsy of o Atovaquone oral with meal) +/-
bronchoscopically suspension 2 x 750 mg / Pyrimethamine (75
collected respiratory day po (with a meal) or
tissues (sensitivity> 95%) mg 1x / week) +
Dapsone 1 x 100 mg / day Folic Acid (25-30 mg
po Look for G6PD 1x / week)
Deficiency
8.8. Management of Toxoplasmosis in PLHIV

Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii. In
PLHIV, clinical manifestations occur as part of an endogenous
reinfestation (reactivation of cysts remaining in the quiescent state).
Toxoplasmosis occurs with CD4 count <200 / mm3 and in the absence
of specific prophylaxis.
106
The most common locations of toxoplasmosis during HIV infection are

cerebral toxoplasmosis and toxoplasmic chorioretinitis.
Table 62: Management of cerebral toxoplasmosis
Management of Cerebral Toxoplasmosis
Diagnosis Treatment Prophylaxis
Clinical Cure : • Primary and
picture: Acute • Attack treatment of 6 weeks. secondary
associated with • The evolution of cerebral toxoplasmosis is prevention is
low fever or rapidly favorable under adapted treatment. In done by
low fever, the absence of a favorable evolution, the
headache, cotrimoxazole.
diagnosis must be reconsidered.
seizures, • Secondary
• 1st intention: prophylaxis
sometimes
cautiousness. o Pyrimethamine (MALOCIDE 100 mg on the 1st can be
and 2nd day then 1 mg / kg / day or 50 to 75 mg
Brain imaging stopped if the
/ day) + Sulfadiazine (ADIAZINE 100 mg / kg /
(CT and MRI) CD4 count>
day, divided into 4 doses with a maximum of 6 g
without and 200 / mm3.
/ day) + Folinic acid (LEDERFOLINE, 25 mg / day).
with contrast
medium). o In case of intolerance to sulphonamides,
replace Sulfadiazine with Clindamycin
NB: Serology is
(Dalacin 2.4 g / day in 3 to 4 IV or PO doses).
of interest only
if it is negative • Alternative
because it Cotrimoxazole 960mg: 2cp x 3 / d or equivalent
eliminates the 75/15 mg / kg / day in children.
diagnosis. Adjuvant measures:
• Anticonvulsivant treatment if antecedent or
presence of crisis
• Corticotherapy in case of mass syndrome or
significant peri-lesional edema.
Motor physiotherapy should be started early if
motor deficit.
107
8.9. Other opportunistic infections

8.9.1. Management of Candidiasis
Table 63: Management of oropharingeal candidiasis
1st-line treatment of oropharyngeal candidacies
Fluconazole: 50-100 mg / day po until improvement (5-7 days)
or Amphotericin B: 3-6 lozenges at 10 mg / day or oral suspension 1-2 g /
day (in 2-4 doses)
Itraconazole : 100-200 mg 1-2g/ day (fasting oral solution)
Table 64: Management of candidal oesophagitis

Management of candidal esophagitis
Presumptive diagnosis: Recent onset of dysphagia and Oropharyngeal
candidiasis
Certainty diagnosis: endoscopy with biopsy (Histology)
Fluconazole: 400 mg / day po or 400 mg / day in loading dose then 200 mg
/ day, 10-14 days
Or Itraconazole: 1-2 x 100-200 mg / d (fasting oral solution) then 50 mg / d
iv during 10-14 days.
8.9.2. Management of Herpes Simplex Virus (HSV) Infection

The clinical appearance of the lesions is unreliable.
Table 65: Management of Herpes simplex virus infection
Management of Herpes simplex virus infection
Diagnosis: antigen test / PCR / smear culture / CSF / biopsy.
Genital VSH / cutaneous mucus
• 1st thrust: 7-10 days or until lesions heal
o Valacyclovir: 1000 mg x 2 / day po or
o Famciclovir: 500 mg x 2 / day po or
o Acyclovir: 400-800 mg x 3 / day in
• Recurrence (> 6 relapses / year): chronic suppressive treatment
o Valacyclovir: 500 mg x 2 / day in
108
Severe mucocutaneous lesions

• Acyclovir: 5 mg / kg / day in 3 IV doses (switch to oral route
after regression of lesions)
Cutaneous mucosal lesions resistant to acyclovir:
• Foscarnet: 80-120 mg / kg / day IV in 2 to 3 doses until clinical response
8.9.3. Management of Varicella Zoster Virus (VZV) Infection

Table 66: Management of Varicella Zoster virus infection
Diagnosis: typical clinical appearance with / without antigen test
OR antigen test / PCR / smear culture / CSF / biopsy
Treatment
Primary infection valacyclovir 3 x 1000 5-7 days
(chickenpox) mg/days po
Zona: Not valacyclovir 3 x 1000 7-10 days
disseminated mg/days po
or 3 x 500 7-10 days
Famciclovir mg/days po
Zona: acyclovir 3 x 10 10-14 days
Disseminated mg/kg/days iv
Encephalitis acyclovir 3 x 10-15 14.21 days
(including mg/kg/days
vasculitis)
109
CHAPTER 9: DETECTION AND MANAGEMENT OF

NON-COMMUNICABLE DISEASES
PLHIV are at high risk of developing a number of chronic non

communicable diseases (NCDs) including cardiovascular diseases,
diabetes, chronic respiratory diseases and certain types of cancer.
The recognized risk factors are:
- Exposure to and toxicity to ART (including PIs)
- HIV itself, as well as immune dysfunction and inflammation,
associated with HIV or co-infections (eg, CMV, HCV).
- Excessive weight gain, especially in patients under protocol
including Dolutegravir (DTG)
9.1. Cardiovascular Disease (CVD) and Risk Factors
- The options for modifying ART include
o Replace the IP / r with an NNRTI, RAL or another IP / r that

does not provide any metabolic abnormalities,
o Consider replacing ZDV or ABC with TDF or using a non-NRTI

regimen.
110
Table 67: Assessing the Risks of Cardiovascular Disease

Situation Tips or Actions
Smoking Smokers should be aware of the benefits of smoking
cessation: reduced risk of developing smoking-related
diseases, slowing the progression of existing smoking-
related diseases, and increased life expectancy by an
average of ten years.
Blood • Blood pressure must be maintained <140/90
pressure • Repeated measurements of blood pressure should be
used for classification.
Consider taking anti-hypertensives targeting
<130/80 if necessary after initiating sports activities as
well as dietary rules.
Blood Sugar Type 2 diabetes may be underestimated by HbA1c values
in HIV-positive and ARV-treated patients, particularly
when treatment includes ABC.
Dyslipidemia A high level of LDL-c is associated with an increased risk of
cardiovascular disease.
Optimal Standard
Total < ou = 4 (155) < ou = 5 (190)
cholesterol
LDL < ou = 2 (80) < ou = 3 (115)
9.2. Management in case of diabetes

A joint management with a diabetologist is recommended:
o Glycemic control (HbA1c <6.5-7% without hypoglycaemia,
fasting glucose between 4-6 mmol (73-110 mg / dl), prevention
of long-term complications;
o Treatment with acetylsalicylic acid (75-150 mg / day) should be
considered in any diabetic patient with a high CVD risk;
111
o Screening for diabetic nephropathy and retinopathy is identical

to that performed in the non-HIV diabetic population;
o In PLHIVs on ART, cardiovascular risk factors should be

evaluated, and if appropriate treatments should be proposed as
well as lifestyle modification measures;
o Metformin may aggravate lipodystrophy. Similarly, a dose
reduction should be considered in people with moderate to
moderate CKD, or those who receive DTG;
o Anyone with proven cardiovascular disease or type 2 diabetes
or high risk of cardiovascular disease should be placed on statins
regardless of serum lipid levels.
Table 68: Main Statines

With IP With INNTI
Atorvastatin: Start at low dose (v) (max: Consider higher
10-80 mg / day 40 mg) doses
Pravastatin: 20-80 mg / Consider higher doses Consider higher
day doses
Side effects of statins: Gastrointestinal disorders, headache, insomnia,
rhabdomyolysis (rare) and toxic hepatitis
9.3. Management in case of Cancer(s)

o All women with HIV should have cervical cancer screening and
regular follow-up.
o Vaccination against Papilloma virus and the management of
cervical cancer is similar to what is done in people who are not
infected with HIV.
112
Table 69: Cancer management

Problem People Comple- Screening Comments
mentary frequency
exam
Anal MSM Rectal touch 1-3 years Anoscopy if
cancer People with HPV- +/- anal normal
associated cytology anal
dysplasia cytology
Breast Women aged 50- Mammo- 1-3 years
cancer 70 graphy
Cervical HIV-positive Cervical 1-3 years HPV
cancer women> 21 years smear screening
old or having an can be
activity
Colorect People between Blood 1-3 years
al Cancer 50 and 80 years culture
of age
Hepatoc People with Ultrasound Every 6
ellular cirrhosis and (alpha months
carcinom those co-infected fetoprotein)
a with HBV or at
high risk of HCV
infection
9.4. Mental Health Problem in relation to HIV: Depression
Table 70: Management of depression

Depression
Screening and diagnosis:
• Pervasive sadness and lack of interest in daily activities
• Loss of appetite, weight loss
• Insomnia with early waking, severe fatigue, difficulty concentrating or
making decisions
• Suicidal ideation (EFV is associated with a higher risk of suicidal risk)
113
Exclude any other cause of depression: announcement of seropositivity,

hypothyroidism, intolerance to efavirenz (associated with insomnia,
nightmares, memory loss), recent death of a family, etc.
care and support :
• Replace EFV with another ARV for people with a diagnosis of depression
• Medication is recommended for people with suicidal thoughts, repeated
episodes of depression, and insufficient response to psychological support
• All antidepressant patients also receive psychological support.
• The duration of treatment varies from 3 to 6 months, but some will require
long-term treatment.
• Weekly consultations in the first month are required to monitor symptoms,
side effects and drug renewal. Treatment should always be stopped gradually
9.5. Drugs including Drug Abuse

The use of alcohol or other drugs is a common reason for poor
compliance. Drug management involves regular support counselling.
The pathologies encountered are (i) dependence, (ii) depression and (iii)
acute psychosis
9.6. Prevention of overweight and obesity in HIV patients receiving

Dolutegravir (DTG).
DTG will not be administered if BMI> 30.
114
CHAPTER 10: COORDINATION AND MONITORING

EVALUATION
10.1 Coordination
- To achieve the objectives of this guide, a good coordination of
activities is essential between the various actors:
o CTG / RTG / NACC (National AIDS Control Committee)
o Technical and Financial Partners and
o Implementing partners,
o Ministry of Public Health,
o HIV management structures
- Coordination activities are summarized in Table 71
10.2 Monitoring and evaluation

- Follow-up activities are done thanks to:
o Validated indicators at national level and integrated into data
collection tools
o Reporting that integrates screening data, HIV management and
viral load suppression
o Regular analysis of data at all levels of the pyramid
o Formative supervision from higher to lower level
- The data collection tools used are grouped in Table 72
115
Table 71: Coordination Activities

Levels Activities Role / Goals
Strategic Quarterly - Good implementation of activities
meetings - Discussion of the results obtained after
between NACC, the implementation of the strategy,
PTF and the - Identification of bottlenecks and
Ministry of proposed solutions
Public Health - Allows synergy of action between
technical and financial partners.
Decentralization - Continue the decentralization of care to
Medicalised Health Centers, Integrated
health centers, CDT
- Organize the management sites
/Approved treatment centers support
system (tutorial),
etc ...
- Strengthen the delegation of tasks
between the health facilities at different
levels according to the national delegation
of duties guide
Capacity Organize the training of the actors on the
Building ground on the dispensing of the ARVs and
the assumption of responsibility of the
AEs
Inputs Supply Organize the supply system and input
management
Operatio Quarterly - Organized by UPEC / CTA coordinators
nal meetings of the - Multidisciplinary team - Discussion
FOSA Retention platform of the organization of the
Committees strategy in the health facility, results
monitoring and supervision of activities in-
house (availability of inputs, operation of
APS ...)
Health facility - Organize services to ensure systematic
support post-natal follow-up of mother-child and
children exposed to HIV
- Create a space for children and
adolescents, support groups
116
- Prepare the transition of adolescents to

adult ARV services;
Capacity - Provide on-site continuing training for
Building medical and paramedical providers
Health facilities to support ARVs with the support of
with the management sites and Approved
support of SSD treatment centers tutors;
and DRSP
Table 72: Data Collection Tools

Topics Collection Tools
HIV testing ➢ For input supply
o Physical inventory records,
o Stock cards,
o Monthly "Purchase Order" notebook,
o Delivery and receipt slip,
o Input usage reports,
o Inventory of stocks or expired /
Spoiled quantities.
➢ For the organization and reporting of
screening activities:
o Medical record of the exposed child;
o Consultations register at the front doors
Index cases registrer;
o Monthly summary of HIV screening data;
o Reference sheet;
o Quality assurance record
Patient - Notebooks with reference vouchers of HIV +
reference patients from screening to the ARV management
structure;
- Appointment book;
HIV treatment - National guidelines for HIV care;
with ARVs - Medical record of the HIV patient
117
- Appointment log book schedule;

- ART register;
- ARV dispensing register;
- Active search of patients under ART register (Tracking
log book);
- Support group register (eventually);
- Patient transfer card
118

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POCKET GUIDE TO INTEGRATED MANAGEMENT OF HIV, 2019

POCKET GUIDE TO INTEGRATED

3.2.2. Package of services to be offered to HIV positive woman

6.2. First-line ART protocols ............................................................... 70

8.8. Management of Toxoplasmosis in PLHIV .................................. 106

Table 1: Recommendations for Post exposure Prophylaxis .................... 2

Table 28: Classification of patients according to their clinical condition

Table 56: Adaptation of ART in case of introduction of ant tuberculosis

CHAPTER 1: GUIDELINES ON HIV PREVENTION

In this chapter, only aspects of prevention related to the use of

Cameroon has opted for combined HIV prevention, putting together

PEP or emergency treatment is the short-term use of ARVs to prevent

Table 1: Recommendations for Post exposure Prophylaxis

Indications for ART prophylaxis depend on the degree of exposure

Source person: There are two types of source persons:

Person known as HIV Source person of unknown HIV

Table 2: Importance of the risk based on the gesture

1.1.2 Procedures for administering PEP: a case of rape

Table 3 : Procedures for Administering Post-Exposure Prophylaxis

Sexually assaulted person

Collect History, Counseling on Pregnancy Risk,

Medical consultation and

Administer Tetanus vaccine.

• Give ST prophylaxis • Give STI prophylaxis

• Return to consultation after 3 days • Return to consultation after 3 days

Follow-up visits at week 6, 3 months and 6 months

Figure 1: PEP Algorithm for rape victims

1.1.3 PEP after occupational exposure to HIV

- An accidental exposure to biological fluids (AEBF) is a contact

- The risk of transmission after an AEBF is, on average, 0.30%

- HIV prophylaxis after an AEBF depends on:

• The severity of exposure and the nature of the biological fluid

• The serological status of the source person;

• The time between exposure and consultation.

Table 4: Indication of PEP in case of AEBF

Source HIV + or unknown HIV+ unknown

Table 5: Recommendations for PEP within the frame of Occupational

Psychological Identify the respective needs of psychological supports and address

Accompanying • Establishment of infection control committees

- In the case of an AEBF, immediate action shoulds be taken

Table 6: Supporting an AEBF

Health professional exposed to

Wash the wound with soap and water. Collect

DO NOT OFFER PEP

Medical Examination and perform tests:

Neg HIV Pos

Continue PEP for 28

• Repeat the HIV Test at week6, M3 and M6

Figure 2: Algorithm for PEP in the frame of occupational exposure

1.2 Pre Exposure Prophylaxis (PrEP or Pre-Exposure Prophylaxis)

Table 7: Recommendations for PrEP

Medical • HIV testing: every 3 months

Initial visit 1 month visit 1 month visit

• Discuss with the client the adoption of healthy lifestyles,

Medical contraindications of PrEP

1.3 Positive Prevention (or Prevention in HIV-Positive People)

Essential services for prevention among PLHIV

Table 8: Prevention among PLHIV

• Youth and adolescent health services (RH)