HIV patients
These guidelines are for adults only; please refer to the HIV guidelines for further information
and information relevant to children.
HIV patients are some of the sickest patients on the ward.
First line of clerking/ ward entry should have HIV status.
It is important to know HIV status in all in patients in Malawi in Kamuzu Central hospital the
status of every patient should be known.
Status will fit into three categories
 Known positive
 Known negative (tested within three months)
 Refusing testing (try to persuade to have the test, it is in their best interest)
Remember newly infected individuals can take 3 months to until their test is positive.
If positive we then wish to know…

If they take ARV’s and for how long. It will take some time for them to have an effect
this depends on the degree of immunocompromise on starting treatment.

If they take Cotrimoxazole (CPT): this is used to prevent Pneumocystitis jiroverci
pneumonia.
If patients are not taking ARV’s they need to be staged according to WHO staging this is done
on the HIV related infections/conditions as so…
Stage 1:
 Asymptomatic patients
 Persistent generalized lymphadenopathy
Stage 2:
 Respiratory tract infections
 Recurrent (sinusitis, tonsillitis, otitis media, pharyngitis)
 Herpes zoster
 Angular cheilitis
 Oral ulcerations, recurrent
 Papular pruritic eruptions / Fungal nail infections
 Moderate weight loss <10%, unexplained
 Seborrhoeic dermatitis
Provided by T. Whitfield 2012
Stage 3:
 Fever, persistent unexplained, intermittent or constant, >1 month
 Oral hairy leukoplakia
 Pulmonary tuberculosis (current)
 Tuberculosis (PTB or EPTB) within the last 2 years
 Anaemia, unexplained < 8 g/dl
 Neutropaenia, unexplained < 500 /mm3
 Thrombocytopaenia, chronic < 50,000 /mm3
 Severe weight loss >10% and/or BMI <18.5kg/m2, unexplained
 Diarrhoea, chronic (>1 month) unexplained
 Oral candidiasis
 Severe bacterial infections (pneumonia, empyema, pyomyositis, bone/joint, meningitis,
bacteraemia)
 Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
 Hepatitis B or C infection
Stage 4:
 Pneumocystis pneumonia
 Candidiasis of oesophagus, trachea, bronchi or lungs
 Extrapulmonary tuberculosis
 Kaposi’s sarcoma
 HIV encephalopathy
 Cryptococcal meningitis or other Extrapulmonary cryptococcosis
 Disseminated non-tuberculous mycobacterial infection
 Cryptosporidiosis, chronic with diarrhoea
 Isosporiasis >1 month
 Disseminated mycosis (coccidiomycosis or histoplasmosis)
 Symptomatic HIV-associated nephropathy or cardiomyopathy
 Progressive multifocal leukoencephalopathy
 Cerebral or B-cell non-Hodgkin lymphoma
 HIV wasting syndrome (severe weight loss + persistent fever or
 severe weight loss + chronic diarrhoea)
 Bacterial pneumonia, recurrent severe
 Chronic herpes simplex infection (orolabial, genital / anorectal
 >1 month or visceral at any site)
 Cytomegalovirus infection (retinitis or infection of other organs)
 Toxoplasmosis of the brain
 Non-typhoidal Salmonella bacteraemia, recurrent
 Invasive cancer of cervix
 Leishmaniasis, atypical disseminated
Provided by T. Whitfield 2012
Cotrimoxoazole therapy (CPT)
This drug is used in all HIV positive adults to prevent PCP pneumonia, diarrhoea, malaria and
other HIV related diseases.
It is given as 480mg BD for life. Contraindications to CPT are…
 Jaundice
 Renal failure
 Developing Stevens-Johnson syndrome
 Pregnant women cannot take within 14 days of taking Sulfadoxine/Pyrimethamine
Starting Antiretroviral therapy
After staging anyone who is found to be stage 3 or 4 should be referred to start ARV therapy. In
addition ARVs should be given to all patients who are pregnant or breast feeding. CD4 count is
measured in patients who are unwell and do not meet stage 3/4 criteria, if the CD4 count is ≤
350cells/mm3 then the patient is eligible for ARV therapy.
ARV therapy
ART requires combining 3 different ARVs that act differently in order to avoid development
of drug‐resistant HIV. If possible try to keep the patient on a first line regime
1st line regimens:
Are easy to prescribe and easy to take, have a low risk of side effects and require no lab
monitoring for toxicity.
There are 6 different 1st line regimens if a patient has a significant side effect switch them to an
alternative 1st line regimen without delay. Alternative regimens are chosen by substituting only
the ARV responsible for the side effects.
2nd Line regimens:
These are a lifeline for patients who have confirmed treatment failure on 1st line
regimen (usually due to poor adherence in the past). Moving from 1st to 2nd line ART is called
switching.
2nd line regimes
o Contain a completely different class of ARVs (proteinase inhibitors)
o Are more complicated to prescribe and take
o Can have more side effects
o There are 3 different 2nd line regimens. The appropriate 2nd line regimen is
determined by the 1st line regimen that the patient was taking when failing.
3rd Line regimens:
Provided by T. Whitfield 2012
These are ‘salvage therapy’ and a last resort for patients failing on second line in
spite of good adherence. This requires confirmation of drug resistant virus using genetic
analysis in the lab. 3rd line can currently only be initiated on a study basis by a specialised
expert ARV clinician.
3rd line regimes
o Very expensive
o Can have more side effects and be difficult to take
Abbreviations of ARV’s
3TC Lamivudine
ABC Abacavir
AZT Zidovudine
d4T Stavudine
ddl Didanosine
EFV Efavirenz
LPV/r Liponivir/ritonavir
NVP Nevirapine
TDF Tenofivir
ZDV Zidovudine
Classification of ARVs
ARVs are classified according to their action…
Nucleoside reverse transcriptase inhibitors include: stavudine (d4T), zidovudine (AZT), abacavir
(ABC), lamivudine (3TC) and tenofivir (TDF).
Non-nucleoside reverse transcriptase inhibitors include: nevirapine (NVP) and efavirenz (EFV).
Protease inhibitors are liponivir and ritonavir (LPV/r).
Regimes for ARVs
Standard ARVs 1st line (Regimen 1 ‐ 6) and 2nd Line (Regimen 7 ‐ 9)
Regime 1
d4T 30mg /3TC 150mg /NVP 200mg
Indication
This is first line therapy except for those breast feeding, pregnant or already on TB therapy.
Provided by T. Whitfield 2012
This regime is started with a starter pack (gradual increase in drugs).
Contraindications to regime 1: Jaundice / hepatitis
Side effects:
Neuropathy
Hepatitis/ Skin rash
Lipodystrophy
Lactic acidosis
Treatment failure
Switch to regime:
2 5, 6, NS
3
5
5 NS
79
Regime 2
AZT 300mg / 3TC 150mg / NVP 200mg
This is standard for children under 15 years of age.
This regime is started with a starter pack
Contraindications to regime 2: Anaemia <8g/dl, Jaundice / hepatitis
Side effects:
Anaemia
Hepatitis/ Skin rash
Lipodystrophy
Lactic acidosis
Treatment failure
Switch to regime:
1 5, 6
43
5
5 NS
79
Regime 3
d4T 30mg / 3TC 150mg/EFV 600mg
Contraindications: History of psychiatric illness
Side effects:
Neuropathy
Hepatitis/Skin rash
Psychiatric disorder
Lipodystrophy
Lactic acidosis
Treatment failure
Switch to regime:
2 5, 6, NS
6
1 NS
5
5
7
Regime 4
AZT 300 mg /3TC 150mg /EFV 600mg
Contraindications: History of psychiatric illness, Anaemia <8g/dl
Side effects:
Anaemia
Lipodystrophy
Lactic acidosis
Provided by T. Whitfield 2012
Switch to regime:
35
5
59
Hepatitis/ Skin rash
Psychiatric disorder
Treatment failure
6
2 NS
79
Regime 5
TDF 300mg /3TC 300mg /EFV 600mg
This regime is 1st choice for pregnant women, breastfeeding women and adults already on TB
Treatment.
Contraindications: History of psychiatric illness, Renal failure, Child under 12 years
Side effects:
Renal failure
Hepatitis/ Skin rash
Psychiatric disorder
Treatment failure
Switch to regime:
lower dose or 2
6
6 NS
8
Regime 6
TDF 300mg / 3TC 300mg/NVP 200mg
This regime starts with a starter pack.
Contraindications: Jaundice/Hepatitis, Renal failure, Child under 12 years
Side effects:
Renal failure
Hepatitis/ Skin rash
Treatment failure
Switch to regime:
lower dose or 2
5 NS
8
Regime 7
TDF 300mg / 3TC 300mg/ LPV/r 200/50
Contraindications: Renal failure, Child under 12 years
Side effects:
Renal failure
Nausea, vomiting
Switch to regime:
8
NS
Regime 8
AZT 300mg / 3TC 150mg /LPV/r 200/50
Contraindications: Anaemia <8g/dl
Side effects:
Anaemia
Nausea, vomiting
Provided by T. Whitfield 2012
Switch to regime:
7
NS
Conditions where different ARVs may be needed
Anaemia (<8g/dl)
Treatment can be started within 7 days of diagnosis with d4T/3TC/NVP
Active TB
Treatment should be started within 14 days of diagnosis
TB treatment + ARVs can be started on the same day if the patient is stable
Don’t delay either TBT or ARVs
Treatment: AZT/3TC/EFV or TDF/3TC/EFV
Jaundice
Refer to District or Central Hospital
Start ARVs after investigation and stabilisation
Treatment: d4T/3TC/EFV
1st trimester pregnancy
Start ARVs in the 2nd trimester with TDF/3TC/EFV
In labour (new HIV diagnosis)
Start ARVs as soon as possible with TDF/3TC/EFV
Renal failure
Refer to District or Central Hospital
Start treatment within 7 days of diagnosis with AZT/3TC/EFV
Monitoring ARVs
ARVs should be switched if there is no improvement in CD4 count or patient condition after 2
months of starting ARV therapy. ARVs should also be switched if the patient deteriorates and
CD4 count drops despite good compliance.
Serious side effects of ARVs
Patients should be told to stop ARVs and present to hospital immediately if they develop any of
the following symptoms…
 Yellow eyes/ skin
 Severe abdominal pain and vomiting
 Shortness of breath
 Blistering skin rash involving eyes, genitals or mouth
Provided by T. Whitfield 2012
Common complications of ARV treatment
Lactic acidosis
This severe life threatening condition occurs most commonly with stavudine (d4T) and
didanosine (ddI), though also with patients on zidovudine (AZT), abacavir and lamivudine (3TC).
It is more likely to occur in female patients and those who are pregnant or obese.
Symptoms of lactic acidosis include fatigue, stomach pain, nausea, vomiting and shortness of
breath, though symptoms can come on gradually. When assessing these patients increased
respiratory rate and tachycardia are early signs.
The diagnosis is made by measuring the pH of the blood and the lactate level though this is not
always possible in Malawi. A pH <7.35 or lactate > 5 mmol/L indicates a poor prognosis.
Individuals without any signs or symptoms may have asymptomatic hyperlactaemia in which it
may be simply appropriate to switch ARVs.
Treating lactic acidosis involves stopping all ARVs and giving IV fluids at 3 litres a day minimum
until symptoms settle.
Jaundice/ Hepatotoxicity
This is more common in those with pre-existing liver damage (Hepatitis B,C, alcoholics), renal
failure or those on protease inhibitor therapy.
Severe hepatotoxicity can occur with Nevirapine (NVP) but also with efavarenz (EFV) and
abacivir.
When treating these patients the ARVs must be stopped and other causes looked for (alcohol,
Gall stones etc). Treating what is found appropriately.
Stevens-johnsons syndrome
This is a blistering skin rash present on most of the surfaces of the skin and involving the mouth,
eyes and genitals. This condition can be caused by other illnesses such as streptococcal
infection or diabetic drugs. The common cause in Malawi is due to Nervirapine (NVP) therapy
though cotrimoxazole (CPT) can also cause this condition.
To treat Stevens-Johnson syndrome stop all ARV treatment, ensure the patient is fully hydrated
with good urine output, (usually given IV fluid at least 3L per day). Antibiotics such as
cefuroxime1g bd are given to cover skin infection and the eyes are covered with tetracycline
eye ointment. Potassium per manganite soaks are also prescribed to prevent skin infection.
Provided by T. Whitfield 2012
Immune reconstitution syndrome (IRS)
This is caused when the immune system becomes over-aggressive as it recovers due to ARVs
and attacks an already existing infection. This usually occurs within days to week of starting
ARVs. Often immune reconstitution syndrome can unmask a previously unknown infection or
worsen a disease that was improving.
Common infections in IRS
 TB
 Kaposi sarcoma
 Cryptococcal Meningitis
 Herpes zoster
 Hepatitis
Treat the underlying infection and continue the ARVs.
Psychiatric disorders
Efavirenz (EFV) can cause a range of psychiatric disorders from insomnia to severe dellusions
this is especially likely if there is pre-existing psychiatric disorder. It should be withdrawn in
people with psychiatric disorders. Abacavir and lamivudine(3TC) should also be avoided in
people with psychiatric disorders.
Peripheral Neuropathy
This is a common side effect of Stavudine (d4T), didanosine (ddI) and zidovudine (AZT). The
patient will complain of numbness from the feet upwards, they should have their ARV regime
switched.
HIV related illness
Skin and mucosal problems
Dermatophytes
This is a fungal rash usually found on hairy or sweaty regions of the skin such as the groin, axilla,
scalp and face. This condition can occur in non-reactive patients but is more common in HIV.
Provided by T. Whitfield 2012
The rash is often itchy, greasy and scaly. It is treated with an antifungal cream such as
clotrioxazole or miconazole in the first line and with ketoconazole tablets 200mg BD 7days if
these are ineffective.
Candida oral/oesophageal
This presents with white/red plaques anywhere in the mouth cavity. Oesophageal candidiasis
will cause pain and difficulty swallowing (dysphagia).
Oral candidiasis may be treated first patients treat with nystatin solution 4ml QID for 10-14
days. If there is persistent candidiasis or a suggestion of oesophageal candidiasis then
fluconazole 200mg for 14 days should be given.
Herpes Zoster
Chicken pox is primary disease causing widespread vesicular rash.
Can remerge as shingles in immunocompromised, this follows a dermatomal distribution
(doesn’t cross the patients midline) and begins with pain followed by the rash.
Look for secondary infection especially if it involves the eyes. The shingles is caught before the
blisters burst then acyclovir 800mg 5 times a day for 7 days can improve symptoms.
Tinea corporis, cruris, pedis
Round red plaques with a scaly edge on the body, head or feet but may be widespread across
the body.
Treat with Whitfield’s ointment, Gentian-violet paint or clo-trimazole cream twice daily for 3-4
weeks. Griseosulfin tablets 500mg bd for 3-4 weeks can be used as second line if no response.
Neurological problems
Meningitis
All below present with the symptoms of meningitis such as headache, neck pain, reduced GCS,
seizures and photophobia.
Ensure airway ABV approach in all patients and if confusion/fits/ ↓GCS ensure blood sugar
checked.
Acute bacterial meningitis
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The symptoms and presentation are as above. Always suspect this in patients with low GCS and
treat immediately if any suspicion.
Treatment is cefuroxime 2g bd with lumbar puncture to confirm diagnosis.
TB meningitis
This is more common in immunosuppressed individuals and has a poor prognosis.
It is difficult to confirm a diagnosis of TB meningitis, on LP acid fast bacilli are rarely seen there
is elevated lymphocytes, low sugar and raised protein.
The biggest clue for diagnosis is a history of progressive illness with fever and night sweats over
a few weeks. Chest x-ray may be appropriate to look for pulmonary TB.
Treatment for TB meningitis is 9/12 of standard TB therapy. Steroids at a dose of prednisolone
1mg/kg/day for one month should be given and then tailored down over several weeks.
sterioscan be given to improve the GCS.
Cryptococcal Meningitis (CCM)
This occurs soley in immunocompromised individuals the onset of symptoms is gradual over
several weeks. The opening pressure on lumbar puncture is very high and often squirts across
the room.
The diagnosis is made by india ink staining of yeasts in the CSF or positive CRAG antigen in the
CSF or blood.
Treating CCM is with fluconazole 1200mg od for 2/52, then 800mg for 8/52 then 200mg od for
life. Amphoteracin B 1mg/kg od every day for 7 days can also be added to this regime if
available but can cause renal failure so ensure U+E checked beforehand. Repeat LPs can be
done daily to relive symptoms of raised ICP, up to 20ml taken each time.
Space occupying lesions
These occur more commonly in HIV they present with focal neurology often like a stroke with
weakness/numbness on one side of the body but with a more gradual onset, headache,
vomiting and fits.
Space occupying lesion is best confirmed by CT or MRI scan, unfortunately this is not possible in
most instances in Malawi.
Provided by T. Whitfield 2012
Steriods can be used to reduce cerebral oedema in life saving situations though they can cause
false recovery of symptoms making people believe their treatment is working when another
diagnosis should be sought.
Common causes of space occupying lesion in HIV patients are
Toxoplasma: Tested for with toxoplasma antigen test, it is likely if the CD4 count <50cells/mm3.
It is often treated blindly in patients with suspected SOL and CD4 count <150 cells/mm 3.
Toxoplasma is treated with Sulphadiazine and pyrimethamine (SP) 4 tablets Bd then 2 tablets
BD for at least four weeks.
Cryptococcoma: diagnosed and treated as for cryptococcal meningitis.
Lymphoma: often disseminated lymphadenopathy, needs to be diagnosed on biopsy, can look
similar to Tuberculoma.
Tuberculoma: Difficult to diagnose without TB elsewhere in the body. Often it is treated when
the there is evidence of TB elsewhere. If the CD4 count>150 cells/mm3 or there is no response
to SP then TB treatment can be tried.
Respiratory problems
Bacterial pneumonia
The patient will have symptoms of a productive cough of green sputum with shortness of
breath and fever. Chest x-ray will show consolidation/infiltrates confined to a specific lung area,
unless atypical pneumonia which can show reticulo-nodular shadowing in the upper lobes.
White cell count is usually elevated.
If there is severe pneumonia then treat intravenously with cefuroxime 1g od or x-pen 3MU TID
and chloramphenicol 1g TID. Severe pneumonia often needs oxygen.
Mild pneumonia may be treated with oral antibiotics such as amoxicillin 500mg TID adding
erythromycin or doxycycline if ineffective.
Pneumocystis jiroveci (carinii) pneumonia (PCP)
This disease tends to characterized by progressive shortness of breath over a few weeks with a
dry cough or fever. Chest x-ray will show a ground glass appearance initially focused around
the hilar region.
Provided by T. Whitfield 2012
Cd 4 count will be < 200 cells/mm3 and the white cell count tends to be normal. If the diagnosis
is uncertain between PCP and bacterial pneumonia then it is appropriate to treat both.
PCP is treated with oxygen to improve sats, co-trimoxazole (CPT, Bactrim) 4x 480mg tablets TID
for 21 days followed by a life time of preventative CPT (480mg bd). 40mg prednisolone is given
bd for 5 days then od for five days then 20mg for five days then gradually weaned down by 5mg
every 3 days.
Second line therapies for PCP include clindamycin 300mg tid for 3 weeks or primaquinine
300mg od for 3 weeks.
Tuberculosis
This presents with a chronic cough productive often bloody cough with TB symptoms such as
weight loss, fever and night sweats.
Chest x-ray may show widespread dense consolidation or cavitation in the presence of a patient
who looks not too unwell. A reticulo-nodular (small spotty) pattern can be seen in patients with
millary TB. Pleural effusion is very common in TB and when tapped will show an exudate with a
lymphocyte predominance.
TB is treated with regular TB combined medication regime for 6 months.
Gastrointestinal problems
The Malawi HIV guidelines recomned a stepwise approach to managing HIV patients with
diarrhoea.
The first priority in management is to correct dehydration by giving oral rehydration salts
5ml/kg every 4 hours and after every episode of diarrhea or IV fluids if severe dehydration or
unable to drink.
Step 1:
This involves treating all bacterial causes of diarrhea as well as isopora and ciclospora.
In HIV patients bacterial diarrhoea is commonly caused by Salmonella, Shigella, typhoid and
Campylobacter all of which can cause bloody diarrhea, fever and abdominal pain.
Treat these individuals with co-trimoxazole 960 mg TID for 7 days. If bacterial diarrhea is
suspected and no improvement seen give ciprofloxacin 500mg bd.
Step 2:
Treats amoebic dysentery, giardia, microspore and clostridium diarrhoeas
Amoebic dysentery produces chronic bloody diarrhea with abdominal pain but no fever.
Provided by T. Whitfield 2012
Giardia causes a persistent watery diarrhea going on for several weeks
Treatment for these organisms is with metronidazole 400-500mg TID for 7-14 days.
Step 3:
Treats microspore and helminth causes of diarhoea and involves giving albendazole 400mg BD
for 14 days.
Malignancy in HIV
Kaposi Sarcoma
This condition is characterised by single or multiple purple patches or nodes mainly mouth,
skin, conjunctiva, lung, and gastrointestinal tract. There may be enlarged lymph nodes or
oedema present also.
The diagnosis is usually clear given skin and oral mucosal findings. Consider KS even without
skin or oral lesions if no response to TB therapy within 4 weeks
The treatment of KS involves analgesia, symptomatic relief and ARVs. If chemotherapy is
needed depends on the stage of the KS.
For KS stage T0 (skin KS without oedema) chemotherapy can be delayed and only given if there
is no improvement after 3 months on ARVs
For KS stage T1 (KS in mouth or internal organs, nodular skin KS, skin KS with oedema):
Immediate chemotherapy is needed.
Contraindications for chemotherapy:
 Severe PN
 Hb<10g/dl
 Platelet count <50/mm3
 Jaundice
 Pregnancy
1st Line chemotherapy: Vincristine
Each cycle consists of 6 doses. It must not leak when given IV as infiltration into the tissues
causes burns, document therapy and response in the patients health passport. Look for
progress of the lesions at every visit. The dose is 2mg IV.
Provided by T. Whitfield 2012
Review the progress after each cycle, stop the chemotherapy if there is severe neuropathy or
constipation. If the lesions have cleared the therapy can also be stopped. If the lesions are
improving give another cycle if there is no improvement or worsening disease give second line
therapy.
1) Initial cycle:
1 dose every 7 days for 6 weeks
2) Second cycle:
1 dose every 14 days for 12 weeks
3) Final cycle:
1 dose every 28 days for 6 months
2nd Line chemotherapy: Vincristine and Bleomycin
Over a life time an adult can have no more than 400 units of Bleomycin.
Bleomycin should be stopped immediately if any sign for lung fibrosis (incl. cough, shortness of
breath) are seen.
Bleomycin is given in one combined dose of 15 units every 14 days until 400 units is reached or
until a good response is seen.
The patient will receive vincristine at the appropriate cycle at the same time.
The patient will need to be referred for 3rd line chemotherapy (doxorubicin) if there is still little
response this is to be done at a specialist centre.
Cervical cancer
There are no early symptoms of cervical cancer therefore active screening is needed in all HIV
patients. The patient should be referred to gynaecology clinic if there is abnormal vaginal
discharge, pain during sex or abnormal bleeding.
Provided by T. Whitfield 2012