Goal of this chapter. 6.1 Introduction Good practices for linkage to care General care for people living with HIV 84

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1 Clinical guidelines across THE CONTINuUM OF CARE: LINKING PEOPLE DIAGNOSEd WiTH hiv infection to hiv care and treatment Introduction Good practices for linkage to care General care for people living with HIV Preparing people living with HIV for What to expect in the first months of 88 Goal of this chapter To provide an overview of issues and interventions related to general HIV care for individuals from the time that they are diagnosed with HIV infection to the time that they are initiated on, including practices for linking people diagnosed with HIV infection to HIV care and treatment, the components of a general care package, and preparing individuals for starting.

2 86 Consolidated guidelines on the use of antiretroviral drugs for treating and preventing hiv infection 6. The continuum of care: linking people diagnosed with HIV infection to HIV care and treatment 6.1 Introduction It is critical for people living with HIV to enrol in care as early as possible. This enables both early assessment of their eligibility for and timely initiation of as well as access to interventions to prevent the further transmission of HIV, prevent other infections and comorbidities and thereby to minimize loss to follow-up. The 2012 WHO strategic HIV testing and counselling programme framework (1) especially emphasizes the importance of ensuring linkage between HIV testing and counselling programmes and prevention, treatment, care and support services. 6.2 Good practices for linkage to care Interventions to improve linkage to care need to be more rigorously evaluated. However, several systematic reviews and observational studies suggest that several good practices can improve linkage to care (2 4). These include integrating HIV testing and counselling and care services; providing on-site or immediate CD4 testing with same-day results; assisting with transport if the site is far from the HIV testing and counselling site; involving community outreach workers to identify the people lost to follow-up; ensuring support from peers or expert patients; and using new technologies, such as mobile phone text messaging. 6.3 General care for people living with HIV Countries should establish a package of general HIV care interventions, in addition to, for people living with HIV to reduce HIV transmission, prevent illness and improve their quality of life. Not all people living with HIV are eligible for and, of those eligible, not all will be able to access immediately. Others may choose to defer to later. Enrolment in care provides an opportunity for close clinical and laboratory monitoring and early assessment of eligibility for and timely initiation, and aims to minimize loss to follow-up. Many care interventions are relevant across the full continuum of care, including HIV-exposed individuals and people living with HIV before initiating, and during. General care includes basic HIV prevention, promoting the health of people living with HIV and the screening, prophylaxis and management of HIV-related coinfections and comorbidities. WHO has produced summary guidance on general care and prevention interventions (5 7), and in 2008, recommended a package of 13 prevention interventions for adults and adolescents living with HIV in resource-limited settings (5). These include (1) psychosocial counselling and support; (2) disclosure and partner notification; (3) co-trimoxazole prophylaxis; (4) TB counselling, screening and preventive therapy; (5) preventing common fungal infections; (6) preventing sexually transmitted infections and supporting reproductive health needs, including prevention of and screening for cervical cancer; (7) malaria (co-trimoxazole, bed-nets and preventing malaria among pregnant women); (8) selected vaccine-preventable diseases; (9) nutrition; (10) family planning; (11) PMTCT; (12) needle and syringe programmes for people

3 6. The continuum of care: linking people diagnosed with HIV infection to HIV care and treatment 87 who inject drugs; and (13) water, sanitation and hygiene. A general care package will vary according to the epidemic type, populations affected and prevalence of coinfections, other comorbidities and health conditions. Table 6.1 provides an overview of elements of a general care package for people living with HIV. Section 8.1 summarizes key recommendations from existing WHO guidelines on the screening, prophylaxis and timing of with the most common coinfections, comorbid conditions and other health conditions. Table 6.1 Overview of key elements of general care over the continuum of HIV care for people living with HIV Service General care WHO clinical staging Past and current HIVrelated conditions Pregnancy status Family planning and Contraception PMTCT Support for disclosure and partner notification HIV diagnosis enrolment into care initiation of Stable while receiving treatment failure and switching regimen Comment and crossreferences Annex 1 Section Sections and Section The continuum of care: linking people diagnosed with HIV infection to HIV care and treatment Risk reduction counselling and combination HIV prevention approaches Screening for, preventing and managing comorbidities and noncommunicable diseases Screening for and managing mental health problems and substance use Section Section Sections and Psychosocial counselling and support

4 88 Consolidated guidelines on the use of antiretroviral drugs for treating and preventing hiv infection Table 6.1 (continued) Service HIV diagnosis enrolment into care initiation of Stable while receiving treatment failure and switching regimen Comment and crossreferences General care Managing pain and symptoms Nutritional assessment and counselling Nutritional, growth and development assessment in children and adolescents Section Section Sections and Infant and child feeding Preventing and treating coinfections Co-trimoxazole preventive therapy Intensified TB casefinding Isoniazid preventive therapy Screening for cryptococcal infection and fungal prophylaxis Screening for hepatitis B and C Malaria prevention (insecticide-treated bed-nets and prophylaxis) Screening for sexually transmitted infections Prevention of and screening for cervical cancer Section Section Section Section Section Section Section Section 8.1.7

5 6. The continuum of care: linking people diagnosed with HIV infection to HIV care and treatment 89 Table 6.1 (continued) Service Assessing for vaccine-preventable diseases Preparing people for HIV diagnosis enrolment into care initiation of Stable while receiving treatment failure and switching regimen Comment and crossreferences Section Section Preparing people living with HIV for Preparing, assessing and supporting adherence Sections 6.4 and 9.2 Current medications See section Preparing people living with HIV for Before people start, it is important to have a detailed discussion with them about their willingness and readiness to initiate, the ARV regimen, dosage and scheduling, the likely benefits and possible adverse effects and the required follow-up and monitoring visits. For children with HIV, this conversation should directly involve the carer and include discussion about disclosing their HIV status (see Chapter 5). Retesting all people living with HIV before initiating is good practice to ensure correct diagnosis of HIV infection. Initiation of should always consider nutritional status, any comorbidities and potentially interacting medications for possible contraindications or dose adjustment. The choice to accept or decline ultimately lies with the individual person or his or her caretaker, and if they choose to defer initiation, can be offered again at subsequent visits. If there are mental health, substance use or other problems that are major barriers to adherence, appropriate support should be provided, and readiness to initiate should be reassessed at regular intervals. A wide range of patient information materials as well as community and peer support can help the person s readiness and decision to start therapy. People starting treatment and carers should understand that the first regimen offers the best opportunity for effective viral suppression and immune recovery, and that successful requires them to take the medications exactly as prescribed. They should be advised that many adverse effects are temporary or may be treated, or that substitutions can often be made for problematic ARV drugs. (See section 9.2 for strategies to support adherence to an regimen.) People receiving and carers should also be asked regularly about any other medications they take, including herbal remedies and nutritional supplements. People receiving should understand that, while the ARV drugs reduce the risk of HIV transmission, they cannot be relied on to prevent other people from acquiring infection. They should be given advice on safer sex (including condom use) and avoidance of other high-risk activities, such as sharing of injecting equipment, to prevent transmitting HIV to other people.

6 90 Consolidated guidelines on the use of antiretroviral drugs for treating and preventing hiv infection 6.5 What to expect in the first months of Although taking is a lifelong commitment, the first six months of therapy are especially important. Clinical and immunological improvement and viral suppression are expected when individuals adhere to, but opportunistic infections and/or immune reconstitution inflammatory syndrome (IRIS) may develop, as well as early adverse drug reactions, such as drug hypersensitivity, especially in the first three months of. significantly decreases mortality overall, but death rates are also highest in the first three months of. These complications are commonest when the people starting already have advanced HIV disease with severe immunodeficiency and existing coinfections and/or comorbidities, severely low haemoglobin, low body mass index and very low CD4 counts or are severely malnourished (8,9). CD4 recovery In most adults and children, CD4 cell counts rise when is initiated and immune recovery starts. Generally, this increase occurs during the first year of treatment, plateaus, and then continues to rise further during the second year (10). However, severe immunosuppression may persist in some individuals who do not experience a significant rise in CD4 cell count with treatment, especially those with a very low CD4 cell count when initiating. Failure to achieve some CD4 recovery should alert the health care provider to potential adherence problems or primary non-response to, and consideration should be given to continue prophylaxis for opportunistic infections such as co-trimoxazole preventive therapy. Immune reconstitution inflammatory syndrome (IRIS) IRIS is a spectrum of clinical signs and symptoms thought to be associated with immune recovery brought about by a response to. It is a widely recognized phenomenon that occurs among 10 30% of the people initiating, usually within the first 4 8 weeks after initiating therapy (11,12). It may present in two different ways: paradoxical IRIS, when an opportunistic infection or tumour diagnosed before initially responds to treatment but then deteriorates after starts; or unmasking IRIS, in which initiating triggers disease that is not clinically apparent before. It should be considered only when the presentation cannot be explained by a new infection, expected course of a known infection or drug toxicity. The clinical spectrum is diverse, and IRIS has been reported for many different infections, tumours and non-infectious conditions (11,12). The most serious and life-threatening forms of paradoxical IRIS are for TB, cryptococcosis, Kaposi s sarcoma and herpes zoster. BCG vaccine associated IRIS (localized and systemic) may occur in infants infected with HIV in settings where BCG immunization is routine. A low CD4 + cell count (<50 cells/mm 3 ) at initiation, disseminated opportunistic infections or tumours and a shorter duration of therapy for opportunistic infections before starts are the main risk factors (11,12). IRIS is generally self-limiting, and interruption of is rarely indicated, but people may need to be reassured in the face of protracted symptoms to prevent discontinuation of or poor adherence to. The most important steps to reduce the development of IRIS include: earlier HIV diagnosis and initiation of before a decline to below 200 CD4 cells/mm 3 ; improved screening for opportunistic infections before, especially TB and Cryptococcus; and optimal management of opportunistic infections before initiating. Timing of in people with opportunistic infections requires balancing a greater risk of IRIS after early initiation against continuing high mortality if is delayed. Chapter 8 summarizes existing WHO recommendations for the optimal timing of among people with TB (see section 8.1.2) and cryptococcal disease (see section 8.1.3) based on evidence from randomized clinical trials.