Bringing evidence based medicine to frontline health workers worldwide

1. D-Tree Bringing evidence based medicine to frontline health workers worldwide

2. Is this an emergency?  Unconscious  Bleeding  Seizure  Other Is the patient sick?  Yes  No 

3. Initation of new treatment?  Yes  No  Monitoring current treatment?  Side effects  Toxicities  Resistance  TB  IVDA  Adherence

4. How old is the patient?  1-6 mos  6-12 mos  1-5 yrs  5-10 yrs  10-20 yrs  20-45 yrs  45 + yrs  Sex of Patient:  Female  Male  Accepted definitions of HIV: CD4 < 200 TLC <1200 …. Documented HIV infection?  Yes  No 

5. WHO clinical stages of HIV disease: kids CLINICAL SYMPTOMS  Asymptomatic  Generalized lymphadenopathy  Unexplained chronic diarrhea  Sever persistent or recurrent candidiasis outside the neonatal period  Weight loss or failure to thrive  Persistent fever  Recurrent severe bacterial infection  AIDS-defining opportunistic infection  Severe failure to thrive  Progressive encephalopathy  Malignancy  Recurrent septicemia or meningitis Stage 1  Stage 2 Stage 3

6. WHO clinical stages of HIV disease: kids CLINICAL SYMPTOMS  Swollen glands  Diarrhea  Thrush  Weight loss  Persistent fever  Recurrent severe bacterial infection  AIDS-defining opportunistic infection  Failure to thrive  Progressive encephalopathy  Malignancy  Recurrent septicemia or meningitis  None of the Above Unexplained and over 2 weeks duration 

7. CD4 Testing Available  Yes  No 

8. Total lymphocyte count  more than 1200/mm3  less than 1200/mm3  Not available 

9. Recommendations NO TREATMENT In the absence of CD4 cell testing, asymptomatic HIV-infected patients (WHO stage I) should not be treated because there is currently no other reliable marker available in severely resource-constrained settings

10. Counselling/Teaching • Protected sex • Partner testing • Confidentiality • Breastfeeding • Transmission myths

11. How old is the patient?  1-6 mos  6-12 mos  1-5 yrs  5-10 yrs  10-20 yrs  20-45 yrs  45 + yrs  Sex of Patient:  Female  Male  Documented HIV infection?  Yes  No 

12. Initation of new treatment?  Yes  No  Monitoring current treatment?  Side effects  Toxicities  Resistance  TB  IVDA  Adherence

13. WHO clinical stages of HIV disease: adults and adolescents Clinical Stage I  Asymptomatic  Persistent generalized lymphadenopathy 

14. WHO clinical stages of HIV disease: adults and adolescents Clinical Stage II  Weight loss, < 10% body weight  Minor mucocutaneous manifestations (seborrheic dermatitis, prurigo, fungal nail infectons, recurrent oral ulcerations, angular chelitis)  Herpes zoster within last 5 years  Recurrent upper respiratory tract infections (ie bacterial sinusitis) AND/OR  Performance scale 2: symptomatic, normal activity 

15. WHO clinical stages of HIV disease: adults and adolescents Clinical Stage III  Weight loss >10% body weight  Unexplained chronic diarrhea > 1 month  Unexplained prolonged fever (intermittent or constant), > 1 month  Oral candidiasis (thrush)  Oral hairy leukoplakia  Pulmonary TB within last year  Severe bacterial infections (I.e. pneumona, pyomyositis) AND/OR  Performance Scale 3: bedridden <50% of the day during the last month

16. WHO clinical stages of HIV disease: adults and adolescents Clinical Stage IV  HIV wasting syndrome OR encephalopathy  pneumocystis carinii pneumonia  Toxoplasmosis of the brain  cryptosporidiosis with diarrhoea > 1 month  Extrapulmonary Cryptococcosis OR TB  CMV (not liver, spleen, lymph nodes)  HSV visceral, OR >1 mo mucocutaneous Progressive multifocal leukoencephalopathy  Disseminated endemic mycosis  Candidiasis, not thrush  Nontyphoid Salmonella septicaemia  Lymphoma  Kaposi’s AND/OR  Performance Scale 4: bedridden >50% of the day during the last month

17. WHO clinical stages of HIV disease: adults and adolescents Performance Scale  Asymptomatic  Symptomatic  Normal activity  Bedridden < 50% of the day during the last month  Bedridden > 50% of the day during the last month Scale 1  

18. HIV Wasting Syndrome?  weight loss of >10% of body weight PLUS  unexplained chronic diarrhea(>1 month) OR  chronic weakness and unexplained fever (>1 month)

19. HIV Encephalopathy? Clinical findings of disabling cognitive and/or motor dysfunction interfering with activities of daily living, progressing over weeks to months, in the absence of a concurrent illness or condition other than HIV infection which could explain the findings

20. CD4 Testing Available  Yes  No 

21. CD4 Count  above 200/mm3  below 200/mm3  has not been done  CD4 percentage  above 15%  below 15%

22. Total lymphocyte count  more than 1200/mm3  less than 1200/mm3  Not available 

23. Recommendations WHO stage II disease with CD4 count below 200/mm3 START ART

24. ART WHO stage II disease with CD4 count below 200/mm3 ZDV/3-TC/EFZ

25. Toxicities and Side Effects ZDV anemia EFZ associated CNS symptoms EFZ possible teratogenic NVP hepatoxicity and rash NsRTI metabolic side effects

26. Counselling/Teaching • Protected sex • Partner testing • Confidentiality • Breastfeeding • Transmission myths

27. Initation of new treatment?  Yes  No  Monitoring current treatment?  Side effects  Toxicities  Resistance  TB  IVDA  Adherence 

28. Symptoms of drug toxicities  Jaundice  Liver enlargement  Fatigue  Anorexia  Rash  Nausea  Vomiting  Abdominal Pain  Diarrhea  Sudden unexplained weight loss  Tachypnea  Dyspnea  Weakness  Fever  Myalgia  Pain, tingling or numbness of hands of feet   

29. Symptoms of Drug Rash  First 2-4 weeks of treatment  Erythematous  Maculopapular  Confluent  Most prominent on body and arms  Pruritic  Fever may be present  Mucosal involvement  Urticaria

30. Severe adverse effects of ARTs  Hepatitis  Pancreatitis  Stevens Johnson Syndrome  Pulmonary  Acute hypersensitivity reaction  Lactic Acidosis  Severe peripheral neuropathy 

31. Management  Discontinue all ARVs until symptoms resolve  Permanantly discontinue NVP  Once rash resolves, switch ARV to different class