Uganda guidelines for the treatment of HIV/AIDS

Clinical Stage I

Asymptomatic. Persistent generalised lymphadenopathy. Performance Scale 1: asymptomatic, normal activity.

Clinical Stage II

Moderate unexplained weight loss (< 10%). Minor mucocutaneous manifestations (seborrheic dermatitis, pruritic eruptions, fungal nail infections, recurrent oral ulcerations, angular cheilitis). Herpes zoster. Recurrent upper respiratory tract infections. Performance scale 2: symptomatic but normal activity.

Clinical Stage III

Unexplained severe weight loss (> 10%). Unexplained chronic diarrhoea for > 1 month. Unexplained persistent fever for > 1 month. Persistent oral candidiasis. Oral hairy leukoplakia. Pulmonary tuberculosis. Severe bacterial infections. Acute necrotizing ulcerative stomatitis. Unexplained anaemia (< 8 g/dl), neutropenia (< 0.5x10^9/L), chronic thrombocytopenia (< 50x10^9/L). Performance scale 3: Bed ridden for < 50% of the day during the last month.

Clinical Stage IV

HIV wasting syndrome. Pneumocystis jirovecii pneumonia (PCP). Toxoplasmosis of the brain. Cryptosporidiosis with diarrhoea for > 1 month. Extrapulmonary cryptococcosis including meningitis. Cytomegalovirus infection. Chronic oro-labial, genital or ano-rectal HSV for > 1 month. Progressive multifocal leukoencephalopathy (PML). Disseminated endemic mycosis. Candidiasis of oesophagus/trachea/bronchi/lungs. Disseminated non-tuberculous mycobacterial infection. Recurrent septicaemia. Extrapulmonary TB. Lymphoma. Invasive cervical cancer. Kaposi sarcoma. HIV encephalopathy. Symptomatic HIV-associated nephropathy or cardiomyopathy. Performance scale 4: Bed-ridden for > 50% of the day.

Index client testing (ICT) including Assisted Partner notification.

Testing for biological children (Know Your Child Status).

Targeted HIV testing to optimize case identification (key populations, contacts).

Test and Treat Policy

Provide lifelong antiretroviral therapy (ART) to ALL people living with HIV irrespective of CD4 count or clinical staging. Initiate ART on the same day if client is ready, or within 7 days for children/pregnant women, and within 1 month for adults.

First-Line ART (Adults, Adolescents >30kg, Pregnant/Breastfeeding)

Preferred: TDF + 3TC + DTG. Alternative if DTG contraindicated: TDF + 3TC + EFV400. Alternative if TDF contraindicated: TAF + FTC + DTG. Alternative if TDF/TAF contraindicated: ABC + 3TC + DTG.

First-Line ART (Children ≥20kg to <30kg)

Preferred: ABC + 3TC + DTG. Alternative if DTG contraindicated: ABC + 3TC + LPV/r (tablets). Alternative if ABC contraindicated: TAF + FTC + DTG (for children >6 years and >25kg).

First-Line ART (Children <20kg)

Preferred: ABC + 3TC + DTG. Alternative if intolerant or appropriate DTG formulations unavailable: ABC + 3TC + LPV/r Granules. Alternative if intolerant to LPV/r: ABC + 3TC + EFV (in children >3 years and >10kg).

Monitoring of ART

Schedule of visits: 1, 2, and 3 months from start of ART, then at 6, 9, 12 months. After 12 months, stable patients follow Differentiated Model of Care Delivery.

Drug Interactions — Rifampicin

Rifampicin lowers DTG levels. Action: Adjust DTG dose to twice daily. Do NOT co-administer Nevirapine (NVP) and rifampicin. If given with LPV/r, increase dose of RTV to achieve 1:1 ratio.

Drug Interactions — Oral Contraceptives / Implants

EFV, ATV/r, LPV/r, DRV, RTV increase metabolism of contraceptives. Action: Use additional barrier method or use Depo-Provera or IUDs.

Drug Interactions — Anticonvulsants (Carbamazepine, Phenytoin, Phenobarbital)

Decrease DTG levels by 30-70%. Action: Use valproic acid instead.

Drug Interactions — Metformin

DTG increases metformin levels (risk of hypoglycaemia/metabolic acidosis). Action: Close follow-up of electrolytes, BUN, Creatinine, RBS.

Diagnosis (<18 months)

Recommended test is virological (DNA-PCR). If mother is positive, do DNA PCR at 6 weeks of age or at an earlier opportunity. Start cotrimoxazole prophylaxis and Nevirapine syrup until HIV status is confirmed.

Diagnosis (>18 months)

Serial serological testing.