On this page
Referral and warning signs
When to refer
- Suspected or confirmed treatment failure requiring resistance testing and/or switch to 3rd line ART (Specialised ART centres/Regional Referral Hospitals - RRH).
- Severe or complex Opportunistic Infections requiring specialist management (e.g., Cryptococcal meningitis, severe PCP, disseminated fungal/mycobacterial infections, CMV retinitis, CNS toxoplasmosis/lymphoma).
- Severe ARV toxicity requiring specialist evaluation (e.g., SJS/TEN, severe hepatitis, severe anaemia/neutropenia, persistent severe CNS toxicity).
- Management of Drug-Resistant Tuberculosis (DR-TB) co-infection (Designated DR-TB treatment centres).
- Management of complex co-morbidities (e.g., severe renal/liver disease, certain malignancies).
- Patients requiring Hepatitis B management beyond basic screening/prophylaxis.
- Confirmation of indeterminate infant HIV PCR results.
- Complex psychosocial issues requiring specialized support.
Red flags
- Signs/symptoms of severe OIs (e.g., headache/neck stiffness/altered consciousness - meningitis; severe respiratory distress/hypoxia - PCP; focal neurological deficits - toxo/PML/lymphoma).
- Signs of severe ARV toxicity (e.g., extensive blistering rash - SJS/TEN; jaundice/severe abdominal pain - hepatitis; severe pallor/fatigue - anaemia).
- Confirmed virological failure (>1000 copies/ml) despite adherence support.
- New onset WHO Stage 4 condition in a patient on ART > 6 months.
- Severe malnutrition or weight loss despite ART.
- Signs/symptoms suggestive of IRIS shortly after starting ART.
Signs and symptoms
- WHO Clinical Stage I: Asymptomatic, Persistent generalised lymphadenopathy.
- WHO Clinical Stage II (Mild): Moderate unexplained weight loss (<10%), Minor mucocutaneous manifestations (seborrheic dermatitis, popular pruritic eruptions, fungal nail infections, recurrent oral ulcerations, angular cheilitis), Herpes zoster, Recurrent upper respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis).
- WHO Clinical Stage III (Advanced): Unexplained severe weight loss (>10%), Unexplained chronic diarrhoea (>1 month), Unexplained persistent fever (>1 month), Persistent oral candidiasis, Oral hairy leukoplakia, Pulmonary tuberculosis, Severe bacterial infections (pneumonia, pyomyositis, empyema, bone/joint infection, bacteraemia, meningitis), Acute necrotizing ulcerative stomatitis/gingivitis/periodontitis, Unexplained anaemia (<8 g/dl), neutropenia (<0.5×10^9/L), or chronic thrombocytopenia (<50× 10^9/L).
- WHO Clinical Stage IV (Severe): HIV wasting syndrome, Pneumocystis jirovecii pneumonia (PCP), Recurrent severe bacterial pneumonia (>2 episodes/year), Toxoplasmosis of the brain, Cryptosporidiosis (>1 month diarrhoea), Chronic isosporiasis, Extrapulmonary cryptococcosis (including meningitis), Cytomegalovirus (CMV) infection (retinitis or other organs), Chronic HSV infection (>1 month), Progressive multifocal leukoencephalopathy (PML), Disseminated endemic mycosis (histoplasmosis, coccidioidomycosis), Candidiasis (oesophagus, trachea, bronchi, lungs), Disseminated non-tuberculous mycobacterial infection, Recurrent septicaemia (including non-typhoid salmonella), Extrapulmonary tuberculosis, Lymphoma (cerebral or B-cell non-Hodgkin), Invasive cancer of the cervix, Kaposi sarcoma, HIV encephalopathy, Atypical disseminated leishmaniasis, Symptomatic HIV-associated nephropathy or cardiomyopathy.
Risk factors
- Sexual intercourse with an HIV-infected person
- Transfusion with HIV-infected blood (esp. historical, 1975-1986)
- Mother-To-Child Transmission (pregnancy, delivery, breastfeeding)
- Use of HIV-contaminated sharp instruments (needles, surgical/dental equipment, razors, etc.)
- Exposure to HIV-infected materials through open wound/cut
- Present or past high-risk behaviour (multiple sexual partners)
- Loss of a spouse/partner from HIV disease
- Presence of other Sexually Transmitted Infections (esp. HSV-2)
- Being an uncircumcised man
- Being in an HIV-discordant sexual relationship/marriage
- Being a sexual contact of an index client
- Being a biological child of an HIV positive client
- Not knowing partner's HIV status
- Belonging to key, vulnerable, or priority populations (children, AGYW, pregnant/breastfeeding women)
Diagnosis
Clinical assessment
Clinical staging (WHO I-IV based on signs/symptoms/opportunistic infections) is performed at diagnosis, entry into care, ART initiation, and follow-up visits to guide care and monitor progression. Differential diagnosis includes TB, untreated diabetes, malnutrition, cancer, other chronic diseases.
Investigations
- HIV Testing Services (HTS): Mandatory pre/post counseling (except diagnostic/routine testing). Aim for early diagnosis and linkage. Targeted approaches used (Screening eligibility, Index Client Testing [ICT] including APN/KYCS, Social Network Strategy [SNS], HIV Self-Testing [HIVST]).
- Adults/Children >18 months: Serological (antibody) testing using National Serial Algorithm (Determine -> STAT-PAK -> SD BIOLINE tie-breaker). Re-test negative individuals after 3 months if recent exposure possible.
- MCH Settings: HIV/Syphilis Duo Kit used (See specific algorithm).
- Children <18 months: Virological testing (DNA-PCR) required due to maternal antibodies. Test at 6 weeks (or earliest opportunity). If positive, confirm and start ART. If negative and never breastfed, considered negative (confirm with serology at 18mo). If negative but breastfed, repeat PCR 6 weeks after cessation. (See Infant Testing Algorithm).
- CD4 Count: Measures immune compromise. Used for baseline assessment (esp. identifying advanced disease risk), not required for ART initiation.
- Viral Load (VL): Measures virus quantity in blood. Preferred method for monitoring ART response/failure. Done via DBS sample.
- Genotype Testing: Detects ARV drug resistance mutations. Useful for guiding 2nd/3rd line regimen choices (Specialised centres).
- Baseline Labs (Assess general health/complications): FBC (esp. if starting AZT), Urinalysis (esp. if starting TDF), Syphilis/Hepatitis B screening, LFTs/RFTs (if available), CrAg/Urine LAM (if CD4 <200), Sputum AFB/Xpert (if cough). Symptom-directed tests.
Diagnostic criteria
Confirmation of HIV infection via appropriate testing algorithm (Serological >18mo, Virological <18mo). Uganda's 'Test and Treat' policy mandates ART initiation upon diagnosis.
Management
Non-pharmacological management
- Pre-ART Measures: Prophylaxis against OIs (Cotrimoxazole - see pharmacological), Positive health interventions (Preventing transmission - condoms, safer sex; Disclosure support; Family planning linkage; Alcohol/risk reduction counseling).
- ART Initiation Assessment: Assess understanding, history, lifestyle, pregnancy risk/contraception, sexual risks/disclosure, OI history, current meds, psychosocial support needs.
- Physical Exam: Weight, nutrition, function, vital signs, targeted system exam (skin, oropharynx, nodes, lungs, abdomen, genitals, neuro).
- Adherence Support: Critical for success (>95% adherence needed). Develop adherence plan. Ongoing counseling.
- Differentiated Service Delivery (DSD): Tailoring frequency/modality of care based on patient stability after 1 year on ART (stable patients have spaced checks/fast track refills).
- Psychosocial Support: Emotional support, understanding implications, linkage to support groups/services (orphan care, income generation, home care), partner/family involvement strategies, managing stigma.
Pharmacological treatment
- Cotrimoxazole Prophylaxis (CPT): Give to ALL newly initiating ART, WHO stage 3/4, pregnant/breastfeeding, children/adolescents 0-15yrs, suspected treatment failure. Dose: Adult/Child >30kg: 960mg OD; Child <5kg: 120mg OD; 5-14.9kg: 240mg OD; 15-29.9kg: 480mg OD. Stop CPT in stable adults (>15yrs, on ART >1yr, suppressed VL, not pregnant, no stage 3/4 event). Restart if new pregnancy, failure, new stage 3/4. Alternative: Dapsone.
- TB Preventive Treatment (TPT): See TB section (TB002). E.g., 3HP (INH+Rifapentine weekly x3mo) or 6H (INH daily x6mo) after excluding active TB. Mandatory for PLHIV.
- Antiretroviral Therapy (ART): Goal is viral suppression, immune restoration, improved quality of life. Lifelong treatment. Initiate ASAP ('Test and Treat').
- Preferred 1st Line Regimens (Adults/Adolescents ≥30kg/Pregnant/Breastfeeding): TDF + 3TC + DTG.
- Alternative 1st Line (Adults/Adolescents...): TDF+3TC+EFV400 (if DTG contraindicated); TAF+FTC+DTG (if TDF contraindicated); ABC+3TC+DTG (if TDF/TAF contraindicated); TDF+3TC+ATV/r or LPV/r (if EFV/DTG contraindicated).
- Preferred 1st Line (Children 20-<30kg): ABC + 3TC + DTG.
- Preferred 1st Line (Children <20kg): ABC + 3TC + DTG.
- See UCG tables for detailed pediatric alternatives, dosing by weight band, and formulations (FDCs, granules, syrups).
- 2nd Line Regimens (After confirmed failure): Choice depends on failing regimen and resistance testing (if available). Often involves switching anchor drug class (e.g., NNRTI failure -> DTG or PI; DTG failure -> PI). Requires careful assessment and adherence support. See UCG tables.
- 3rd Line Regimens: Guided by resistance testing. Requires referral to specialized centres. May include newer drugs like DRV/r, RAL, ETV.
- Drug Interactions: Significant interactions exist (e.g., Rifampicin vs NNRTIs/PIs/DTG; PIs/NNRTIs vs hormonal contraceptives/statins/anti-epileptics; DTG vs metformin/polyvalent cations). Refer to UCG interaction tables. Adjust doses or choose alternatives.
- ARV Toxicity Management: Mild (reassure, symptomatic tx); Moderate (substitute drug within class or different class); Severe (stop offending drug, substitute); Severe Life-Threatening (e.g., SJS/TEN - stop all ARVs, manage event, restart modified regimen later). Monitor for specific toxicities (DTG: hyperglycemia/insomnia; EFV: CNS/rash/hepatitis; TDF: renal/bone; ABC: hypersensitivity; AZT: anaemia/lipoatrophy).
Monitoring
- Clinical: Assess at baseline, 1, 2, 3, 6, 9, 12 months, then per DSD model (stable: 3-6 monthly; unstable: monthly). Screen for OIs/STIs, pregnancy/FP needs, comorbidities, weight/nutrition, adherence, side effects, disclosure. Children: growth/development, school, behaviour.
- Laboratory: Viral Load (VL) is preferred monitoring tool. Schedule: Adults: Baseline (optional), 6mo, 12mo post-initiation, then annually if suppressed. Children/Adolescents: 6mo, 12mo, then 6-monthly if suppressed. Pregnant/Breastfeeding: Every 3 months. If VL >1000 copies/ml: Intensive Adherence Counseling (IAC) then repeat VL in 3-6mo. If still >1000, confirm failure, consider switch/resistance testing. If VL 201-999: IAC, repeat VL in 6mo (3mo if pregnant/BF).
- CD4 Count: Baseline to assess risk. Monitor if clinical stage 3/4 despite suppression or for stopping Crypto prophylaxis. Not routine for monitoring ART response if VL available.
- Other Labs: FBC (if on AZT), RFTs/LFTs (if indicated/on TDF), RBS (if on DTG/at risk), CrAg/LAM (if CD4<200), symptom-directed tests.
- Cervical Cancer Screening: Annually for women (VIA).
Complications
- Opportunistic Infections (OIs): See WHO Staging. Common examples include Tuberculosis (TB), Cryptococcal Meningitis, Pneumocystis Pneumonia (PCP), Candidiasis, Herpes Zoster, severe bacterial infections.
- Malignancies: Kaposi Sarcoma, Lymphoma, Invasive Cervical Cancer.
- HIV Wasting Syndrome
- HIV Encephalopathy / HIV-associated neurocognitive disorders (HAND)
- HIV-associated Nephropathy (HIVAN)
- HIV-associated Cardiomyopathy
- Immune Reconstitution Inflammatory Syndrome (IRIS): Worsening of underlying OI after starting ART.
- ARV Drug Toxicity: See Management/Pharmacological.
- Non-Communicable Diseases (NCDs): Increased risk of cardiovascular disease, diabetes, kidney disease, liver disease, certain cancers.
- Mental Health Issues: Depression, anxiety.
Prevention
- Behavioural: Safer sex (condoms, partner reduction), avoid sharing sharps, delay sexual debut, avoid transactional/cross-generational sex, address GBV.
- Biomedical: Prevention of Mother-to-Child Transmission (PMTCT - see details within management), Safe Male Circumcision (SMC), ART as Prevention (U=U - Undetectable = Untransmittable), Post-Exposure Prophylaxis (PEP), Pre-Exposure Prophylaxis (PrEP), Blood safety, STI treatment, Safe injection practices, Infection control.
- Post-Exposure Prophylaxis (PEP): Short-term ARVs after potential exposure (occupational/non-occupational). Start ASAP (<72h). Assess eligibility, provide first aid, counseling, 28-day regimen (Adult: TDF+3TC+ATV/r; Child: ABC+3TC+LPV/r). Follow-up testing at 6wk, 3mo, 6mo.
- Pre-Exposure Prophylaxis (PrEP): ARVs for HIV-negative individuals at substantial risk. Screen for eligibility (risk assessment, confirm HIV neg, rule out acute HIV/Hep B issues, check renal function). Counsel on adherence/risk reduction. Prescribe daily oral TDF/FTC or TDF/3TC. Follow-up quarterly (HIV test, adherence, side effects, risk review). Discontinue if HIV+, low risk, non-adherent, side effects, or choice. PrEP Ring (Dapivirine) and Injectable Cabotegravir (CAB-LA) are emerging options.
Patient education
- Explain HIV diagnosis, Test and Treat policy, and lifelong nature of ART.
- Importance of strict adherence (>95%) to ART and OI prophylaxis (e.g., CPT).
- How ART works (viral suppression) and goals of treatment.
- Potential side effects of ARVs and when/how to report them.
- Importance of regular clinical and laboratory monitoring (especially VL).
- Strategies for preventing HIV transmission (condoms, U=U, partner testing).
- Disclosure options and support.
- Importance of screening for and treating OIs and STIs.
- Family planning options and safer conception methods if desired.
- Nutrition and healthy lifestyle advice.
- Infant feeding options and PMTCT principles for pregnant/breastfeeding women.
- Information on PEP/PrEP eligibility and use for partners/contacts if relevant.
Uganda-specific notes
Strict adherence to 'Test and Treat' policy. Emphasis on targeted HTS approaches. Use of specific national testing algorithms (Serial, Duo Kit, Infant PCR). DTG is the preferred anchor drug in 1st and 2nd line regimens. Differentiated Service Delivery (DSD) models implemented for stable patients. High prevalence of TB, Crypto, HBV co-infections require routine screening/management. CPT is crucial. eMTCT protocols are integrated into MCH services. PrEP and PEP availability/protocols follow national guidance. Resource limitations may affect VL/CD4/resistance testing frequency and 3rd line ART access.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 3 (HIV/AIDS and Sexually Transmitted Infections)
- Consolidated Guidelines for the Prevention and Treatment of HIV and AIDS in Uganda, MOH
(Referenced implicitly, latest version should be consulted)
- Technical Guidance on Pre-Exposure Prophylaxis for Persons at High Risk of HIV in Uganda, 2022
(Referenced for PrEP details)