Reactive HIV Self-Test: Requires confirmatory testing
Prevention
Post-Exposure Prophylaxis (PEP):
Offer within 72 hours of potential HIV exposure
Refer to National HIV PEP Guidelines and Policy
Pre-Exposure Prophylaxis (PrEP):
Provides effective HIV prevention for HIV-negative individuals
Refer to ASHM Decision Making in PrEP Tool
Pre-Exposure Prophylaxis (PrEP) – Truvada
Taking Options for PrEP
Daily PrEP:
Regimen: One pill is taken every day.
Effectiveness: Provides continuous protection against HIV.
Who Should Use: Recommended for individuals at high ongoing risk of HIV.
On-Demand PrEP (Event-Driven PrEP):
Regimen:
Take two pills 2-24 hours before sex.
Take one pill 24 hours after the first dose.
Take another pill 24 hours after the second dose.
Effectiveness: Suitable for individuals with less frequent sexual activity or unpredictable risk.
When to Take PrEP
Daily PrEP: Should be taken every day at the same time for maximum effectiveness.
On-Demand PrEP: Follow the specified regimen before and after potential HIV exposure.
How to Take PrEP
Consistency: For daily PrEP, take it consistently at the same time each day.
With or Without Food: PrEP can be taken with or without food.
Missed Doses:
If a dose is missed, take it as soon as remembered if it’s within 12 hours of the usual time.
If more than 12 hours have passed, skip the missed dose and continue with the next scheduled dose.
Potential Side Effects and Risks
Common Side Effects:
Nausea
Headache
Fatigue
Diarrhea
Less Common Side Effects:
Kidney issues (e.g., increased creatinine levels)
Bone density loss
Management: Most side effects are mild and resolve over time. Regular monitoring can help manage and mitigate risks.
Ongoing Monitoring Needed
Initial Assessment:
Baseline HIV test to confirm negative status.
Kidney function test (e.g., serum creatinine).
Hepatitis B and C screening.
STI screening.
Regular Follow-Up:
Every 3 Months:
HIV test to confirm negative status.
Kidney function test.
STI screening.
Adherence and side effect assessment.
Every 6-12 Months:
Bone density monitoring (for those at risk).
Additional Monitoring:
More frequent monitoring if there are concerns about kidney function or if side effects occur.
HIV Management
Treatment:
ART should be initiated ASAP – in all children, adolescents, pregnant and breastfeeding women, and adults living with HIV, regardless of WHO clinical stage and CD4 cell count.
Refer to local HIV s100 prescribers and Antiretroviral Guidelines
Priority Initiation:
Children, adolescents, and adults with severe or advanced HIV clinical disease.
Adults with a CD4 count ≤ 350 cells/mm³.
Children < 5 years of age with WHO clinical stage 3 or 4, or CD4 count ≤ 750 cells/mm³.
Immediate Management:
Discuss U=U concept
People cannot pass HIV through sex when they have undetectable levels of HIV.
This prevention method is estimated to be 100% effective as long as the person living with HIV takes their medication as prescribed and gets and stays undetectable.
This concept known as Undetectable = Untransmittable (U=U)
Undetectable Viral Load: Less than 20 to 50 copies/mL (HIV RNA per milliliter of blood (copies/mL))
Provide support (peer navigation, counseling)
Avoid technical discussions initially
Inform sexual contacts of HIV status and offer PEP if needed
Complete comprehensive STI testing
Provide patient fact sheet
Notify health department
Viral Load for Monitoring Treatment
Routine Testing:
Viral load testing should be conducted at 6 and 12 months after ART initiation and every 12 months thereafter.
Patient Understanding and Adherence:
Viral load testing helps clients understand their HIV status and motivates adherence to treatment.
Adherence counseling should address the implications of a detectable or undetectable viral load.
CD4 Count:
Best predictor for disease status and immediate risk of death.
Should be used to identify those with advanced HIV disease.
All patients entering or re-entering care should receive a CD4 test at treatment baseline and as clinically indicated for unstable patients or those with advanced HIV disease.
CD4 Monitoring:
In settings where routine viral load monitoring is available, CD4 cell count monitoring can be stopped in individuals who are stable on ART and virally suppressed.
Management Recommendations:
Patients with advanced HIV disease (CD4 count below 200 cells/mm³) should receive a package of care as defined in the 2017 WHO Guidelines.
Additional tests include :
Cryptococcal Antigen Screening: For early detection and treatment of cryptococcal disease.
Tuberculosis Testing: To identify and manage co-infection with tuberculosis, which is common in individuals with advanced HIV diseas
Co-Infection with Hepatitis B/C: Seek specialist advice
Pregnancy: Start ART, seek specialist advice
Allergy to Treatment: Check HLA-B57 status before using abacavir
HIV Primary Illness: Urgent ART commencement
CD4 < 200 cells/μL: Urgent treatment, may need chemoprophylaxis (co-trimoxazole/fluconazole), seek specialist advice
Types of Treatment Failure
Virological Failure:
Viral load above 1,000 copies/ml based on two consecutive viral load measurements in a 3-month interval, with adherence support following the first viral load test, after at least six months of starting a new ART regimen.
Immunological Failure:
Adults and Adolescents: CD4 count at or below 250 cells/mm³ following clinical failure or persistent CD4 levels below 100 cells/mm³.
Children Younger than 5 Years: Persistent CD4 levels below 200 cells/mm³.
Children Older than 5 Years: Persistent CD4 levels below 100 cells/mm³.
Clinical Failure:
Adults and Adolescents: New or recurrent clinical event indicating severe immunodeficiency after 6 months of effective treatment.
Children: New or recurrent clinical event indicating advanced or severe immunodeficiency after 6 months of effective treatment.
Contact Tracing
Important for preventing re-infection and reducing transmission
Responsibilities:
Diagnosing doctor initiates and documents contact tracing discussion
Focus on recent sexual or needle-sharing partners
Offer PEP within 72 hours of potential exposure
Refer to Australasian Contact Tracing Guideline for more information
Follow-Up
Close Follow-Up Post-Diagnosis:
Check psychosocial wellbeing
Review baseline investigations
Assess ART response if started
Long-Term Management:
Regular reviews by an HIV-experienced practitioner
Primary care by GP
Stable patients: follow-up every 3-6 months
HIV PREVENTION
at Risk:
Men who have sex with men
People who have sex with individuals from countries with a high rate of HIV infection
People who inject drugs
People who had tattoos or piercings overseas using unsterile equipment
People who have sex with individuals at high risk of HIV
Contributing Factors
Multiple STIs: Increases risk of HIV infection and transmission.
HIV Testing Recommendations
At Least Once a Year:
Gay and homosexually active men
People who inject drugs
Every Three Months:
Individuals with many sexual partners (more than 5 within 3 months)
Individuals having anal sex without a condom
Other High-Risk Groups:
People with multiple partners or recent partner change
Anyone diagnosed with an STI
People using pre-exposure prophylaxis (PrEP)
Sexual contacts of someone with HIV or at risk of HIV
Migrants from countries with a high rate of HIV
Pregnant women
Anyone with symptoms of HIV or an AIDS illness
Prevention advice
Condom Use: For anal and vaginal sex
Never Sharing Needles: Syringes or other injecting equipment
Sterile Equipment: For tattoos or piercings
Pre-Exposure Prophylaxis (PrEP): For high-risk HIV-negative individuals
Significantly reduces risk of getting HIV
Contains two antiretroviral medicines
Condoms should still be used
Antiretroviral Treatment:
For people with HIV to maintain low viral load
For HIV-positive women during pregnancy, childbirth, and breastfeeding to prevent mother-to-child transmission
Key Prevention Actions
HIV Testing: Regular testing for at-risk individuals to prevent transmission
Early Treatment: Start treatment early for better health outcomes and reduced transmission risk
Informing Partners: Sexual partners of those diagnosed with HIV should be tested urgently
Legal Responsibilities
Public Health Act 2010:
Individuals with HIV or other notifiable STIs must take reasonable precautions to prevent spread.
Reasonable Precautions Include:
Using a condom
Maintaining an HIV viral load of less than 200 copies/mL through effective treatment
Confirming that sexual partners are taking PrEP
Managing a Patient Who Won’t Notify Their Partner of a Positive HIV Result:
Counseling and Education:
Emphasize the importance of notifying partners for their health and safety.
Discuss the potential legal and ethical implications.
Support Services:
Offer support in notifying partners, including anonymous notification services.
Provide contact information for support groups and counseling.
Legal and Ethical Considerations:
Remind the patient of their legal obligation to prevent transmission.
Document the discussion and advice given.
Managing a Positive HIV Test Result in a Patient and Their Partner:
Immediate Care:
Provide emotional support and reassurance to both patients.
Discuss the positive result with empathy and confidentiality.
Partner Notification:
Facilitate partner notification with the patient’s consent.
Offer anonymous partner notification services if needed.
Testing and Treatment:
Recommend immediate HIV testing for the partner.
Start antiretroviral therapy (ART) as soon as possible for the patient.
Discuss the benefits of ART for both patients, including U=U (undetectable = untransmittable).
Ongoing Support:
Arrange follow-up appointments to monitor health and treatment response.
Provide access to counseling and support groups.
Educate both patients on maintaining an undetectable viral load and safe practices to prevent transmission.
Holistic Care:
Address other health concerns and comorbidities.
Provide comprehensive care, including mental health support and social services.
Legal and Ethical Considerations:
Ensure that both patients understand their rights and responsibilities regarding HIV disclosure and prevention.
Maintain confidentiality and document all discussions and actions taken.
