Part 2: HIV Treatment

 

3. Prioritization of Treatment Initiation 

Prioritization of antiretroviral therapy (ART) initiation is outlined in the chart to the right entitled, “CD4  provides guidance on when to start ART.” 6 

FLOWC-HIV CD4 Booklet Table 1 - Section 4

 

4. Rapid Initiation of ART

Recommendation for rapid initiation of ART People with no contraindication to rapid ART initiation should be fully informed of the benefits of ART and offered rapid ART initiation, including the option of  same-day initiation.7 Rapid ART start is especially important for people with very low CD4 cell count, for whom the risk of death is high.7 Although no longer a requirement for ART initiation, baseline CD4 cell count testing should be performed to determine whether the patient has advanced HIV disease.

5. Diagnosing Treatment Failure

Monitoring response to ART and diagnosing treatment failure in absence of viral load testing in individuals who are not stable on ART Viral load is recommended as the preferred monitoring approach to diagnose and confirm treatment failure.8 If viral load testing is not routinely available, CD4 count and clinical monitoring should be used to diagnose treatment  failure, with targeted viral load testing to confirm viral failure where possible.8

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.8 A patient is considered stable on ART based on the following criteria:8 on ART for at least one year, no current illnesses, good understanding of lifelong adherence, and evidence of treatment success (two consecutive viral load measurements below 1,000 copies/ml). 

6. Identifying Immunological Failure 

The role of CD4 in identifying immunological failure The 2016 WHO guidelines point out the role of CD4 in the identification of immunological failure for the decision to switch ART regimens:9

  • Adults and adolescents: CD4 count at or below 250 cells/ul following clinical failure OR persistent CD4 levels below 100 cells µ/L 
  • Children younger than 5 years: Persistent CD4 levels below 200 cells µ/L 
  • Children older than 5 years: Persistent CD4 levels below 100 cells µ/L

10. Treatment Adherence

Adherence support interventions The 2016 WHO Guidelines strongly recommend to provide adherence support interventions to people on ART.16   The following interventions demonstrated benefit in improving adherence and viral suppression:16 

  • Peer counselors 
  • Mobile phone text messages 
  • Reminder devices
  • Cognitive-behavioral skills training/medication adherence training
  • Fixed-dose combinations and once-daily regime

 

References

6. World Health Organization (2016): Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection; recommendations for a public health approach – 2nd ed., page xxxi.

7. World Health Organization (2017): Guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy, page 20. 

8. World Health Organization (2016): Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection; recommendations for a public health approach – 2nd ed., page xxxiv. 

9. World Health Organization (2016): Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection; recommendations for a public health approach – 2nd ed., page 131.1. 

16. World Health Organization (2016): Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection; recommendations for a public health approach – 2nd ed., page xlii.

 

 

FLOWC-HIV CD4 Poster overview - Section 4

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Twelve Steps To CD4 Testing

WHO Guidelines CD4 Testing​

The 2016 and 2017 World Health Organization (WHO) guidelines provide guidance on the diagnosis of human immunodeficiency virus (HIV) infection, the care of people living with HIV, and the use of antiretroviral (ARV) drugs for treating and preventing HIV infection.

12 Steps to CD4 Testing​ Part I: HIV Testing

The 2017 WHO guidelines point out that CD4 cell count testing at baseline for all people living with HIV remains important, because relying on clinical staging alone risks missing substantial numbers of people living with HIV with severe immune suppression.1 

12 Steps to CD4 Testing​ Part II: HIV Treatment

Recommendation for rapid initiation of ART People with no contraindication to rapid ART initiation should be fully informed of the benefits of ART and offered rapid ART initiation, including the option of  same-day initiation


12 Steps to CD4 Testing​ Part III: HIV & Opportunistic Infections

Co-trimoxazole prophylaxis is recommended for infants, children and adolescents with HIV, irrespective of clinical and immune conditions. Priority should be given to all children younger than 5 years old regardless of CD4 cell count or clinical stage.