THE REPUBLIC OF UGANDA

MINISTRY OF HEALTH

CONSOLIDATED GUIDELINES FOR THE

PREVENTION AND TREATMENT OF HIV
AND AIDS IN UGANDA

NOVEMBER 2022
THE REPUBLIC OF UGANDA
MINISTRY OF HEALTH

CONSOLIDATED GUIDELINES FOR THE

PREVENTION AND TREATMENT OF HIV
AND AIDS IN UGANDA

NOVEMBER 2022
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Contents
FOREWORD.............................................................................................................. xxii
ACKNOWLEDGMENTS........................................................................................xxiv
ABBREVIATIONS AND ACRONYMS.............................................................xxvii

1.0 INTRODUCTION..............................................................................1
1.1 CONTEXT......................................................................................................1
1.2 OBJECTIVES.................................................................................................2
1.3 TARGET AUDIENCE.................................................................................2
1.4 GUIDELINES DEVELOPMENT PROCESS........................................2
1.5 SUMMARY OF CHANGES IN 2022 HIV/AIDS GUIDELINES.....3

2.0 HIV TESTING SERVICES AND LINKAGE TO HIV CARE....... 12

2.1 INTRODUCTION..................................................................................12
2.2 PRINCIPLES OF HIV TESTING SERVICES (HTS).....................12
2.2.1 Guiding principles for HTS............................................................. 13
2.3 HIV TESTING SERVICES PROTOCOL..........................................14
2.3.1 HTS Cascade................................................................................... 16
2.4 HTS ELIGIBILITY SCREENING......................................................17
2.5 THE CONCEPT OF TARGETED HIV TESTING.......................18
2.5.1 Definition......................................................................................... 18
2.5.2 Why Targeted HIV testing?.............................................................. 18
2.5.3 Benefits of Targeted HIV testing...................................................... 18
2.5.4 Targeted HIV Testing approaches in Uganda.................................. 19
2.6 RESOLVING INCONCLUSIVE HIV TEST RESULTS ...............23
2.6.1 Resolving a second HIV inconclusive Test Result ........................... 23
2.6.2 Retesting for Verification ................................................................ 24
2.6.3 Resolving Discrepant results on retesting for Verification.............. 24
2.7 MODELS & APPROACHES FOR HIV TESTING SERVICES...24
2.8 HTS AT HEALTH FACILITIES..........................................................25
2.8.2 Diagnostic testing............................................................................ 26
2.8.3 Routine HIV testing ......................................................................... 26
2.8.4 Client-initiated testing and counseling (CITC)............................... 26
2.9 HTS At Community Settings................................................................ 26
2.9.1 Outreach HIV testing services......................................................... 27
2.9.2 Home Based HIV Counselling and Testing (HBHCT)..................... 27
2.9.3 HTS at the workplace....................................................................... 27

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2.9.4 HTS in Educational Institutions....................................................... 28

2.9.5 Mobile HTS...................................................................................... 28
2.9.6 Drop-In Centres (DICs) .................................................................. 28
2.10 INDEX TESTING .................................................................................28
2.10.1 Index testing .................................................................................. 28
2.10.2 Assisted Partner Notification (APN) ............................................. 29
2.10.3 Components of Assisted Partner Notification Services.................. 29
2.10.4 Target Populations for APN........................................................... 29
2.10.5 Principles of APN.......................................................................... 30
2.10.6 Partner Notification Methods........................................................ 31
2.10.7 APN Implementation Process ....................................................... 31
2.10.8 Adverse Events / Challenges in APN............................................. 32
2.10.9 Index client testing for biological
children/Know Your Child’s HIV Status ................................................... 33
2.10.10 Social Network Testing Strategy (SNS) ....................................... 33
2.10.11 Accreditation of Health facilities to offer index client testing services
35
2.11 HIV SELF-TESTING ............................................................................35
2.11.1 Guiding Principles for Implementation of HIVST......................... 36
2.11.2 Approaches to HIV self-testing ..................................................... 36
2.11.3 Target Populations for HIVST........................................................ 36
2.11.4 HIVST for PrEP and VMMC.......................................................... 37
2.11.5 HIV self-testing /Distribution Channels......................................... 37
2.11.6 Misuse and Adverse events associated with HIV self-testing......... 38
2.12 MATERNAL AND INFANT TESTING ..........................................38
2.12.1 Maternal and Child Health- HIV and Syphilis Testing Algorithm.38
2.12.2.HIV Testing Algorithm For Infants And Children Below 18 Months Of
Age/ Early Infant Diagnosis (EID) Cascade............................................ 39
2.13 RE-TESTING OF NEWLY IDENTIFIED HIV POSITIVE
PEOPLE....................................................................................................41
2.13.1 Retesting clients on ART................................................................ 41
2.13.2 Repeat Testing................................................................................ 41
2.13.3 Recent HIV Infection Surveillance ................................................ 43
2.15 LINKAGE TO HIV SERVICES...........................................................44
2.15.1 Community-Facility, Intra and Inter-facility linkages................... 45
2.15.2 Intra-facility linkage...................................................................... 45
2.15.3 Inter-facility linkage...................................................................... 45
2.15.4 Community-Facility Linkage ....................................................... 46
2.16 HIV TESTER AND SITE CERTIFICATION .................................48
2.16.1 Specific Objectives of Certification include: ................................. 48
2.16.2 Rationale of HIV Testing Certification ......................................... 48
2.16.3 National Certification Committee (NCC)...................................... 51
2.16.4 HIV Testing Certifying Body ......................................................... 51
2.16.5 Implementation of HIV Testing Certification................................. 51

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3.0 HIV PREVENTION SERVICES.....................................................55

3.1 INTRODUCTION..................................................................................55
3.2 BEHAVIORAL CHANGE AND RISK REDUCTION
INTERVENTIONS.................................................................................55
3.2.1 Interventions.................................................................................... 56
3.3 BIOMEDICAL PREVENTION INTERVENTIONS....................57
3.3.1 Comprehensive Condom Programming........................................... 58
3.3.2 Total Market Approach (TMA)........................................................ 58
3.3.3 Condom Distribution Guidelines..................................................... 59
3.3.4 Education, Promotion and Demand Creation................................. 60
3.3.5 Target Groups for condom use......................................................... 60
3.4 SAFE MALE CIRCUMCISION (SMC)...............................................61
3.5 POST-EXPOSURE PROPHYLAXIS FOR HIV...............................63
3.5.1 Types of HIV Exposure:................................................................... 63
3.5.2 Steps in Providing Post-Exposure Prophylaxis (PEP).................... 63
3.6 PRE-EXPOSURE PROPHYLAXIS (PrEP).......................................65
3.6.1 Oral PrEP........................................................................................ 65
3.6.2 Dapivirine Vaginal Ring (PrEP RING)........................................... 68
3.6.3 Formulation of the PrEP Ring......................................................... 68
3.6.4 PrEP Ring Effectiveness.................................................................. 69
3.6.5 PrEP Ring Use................................................................................. 70
3.6.6 Removing the PrEP Ring................................................................. 71
3.7 SWITCHING BETWEEN PREP METHODS.................................72
3.8 LONG-ACTING INJECTABLE CABOTEGRAVIR (CAB-LA).......72
3.8.1 New Recommendation 2021: Offering long acting injectable
cabotegravir for HIV prevention ............................................................. 72
3.8.2 Long acting injectable cabotegravir (CAB-LA) Initiation............... 72
3.8.3 Stopping CAB-LA............................................................................. 73
3.8.4 Service Delivery for CAB-LA........................................................... 73
3.9 TRANSFUSION OF SAFE BLOOD..................................................73
3.10 KEY AND PRIORITY POPULATION PROGRAMMING.........74
3.11 STRUCTURAL INTERVENTIONS...................................................74
3.12 PREVENTION AND MANAGEMENT OF GENDER-BASED
VIOLENCE..............................................................................................75
4.1 INTRODUCTION..................................................................................80
4.1.1 Pregnant and breastfeeding adolescent girls and young women.... 81
4.1.2 eMTCT Strategy............................................................................... 81
4.2 INTEGRATING eMTCT AND MATERNAL, NEWBORN, CHILD
AND ADOLESCENT HEALTH (MNCAH) SERVICES..............81
Figure 27: The eMTCT continuum of services......................................... 82

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4.3 SERVICES FOR NON-PREGNANT WOMEN..............................86

4.3.1 Primary Prevention of HIV Infection .............................................. 86
4.4 PREVENTION OF UNINTENDED PREGNANCIES,
CHILDBEARING NEEDS, AND SAFER CONCEPTION ........87
4.4.1 Recommendations for hormonal contraceptive use among women
at high risk of HIV infection- Medical Eligibility Criteria (MEC) for FP/
contraceptive methods.............................................................................. 92
4.4.2 Interactions between ART and Contraceptives................................ 92
4.5 DURING PREGNANCY......................................................................93
4.6 SERVICES TO BE PROVIDED DURING LABOUR AND
DELIVERY...............................................................................................99
4.7 SERVICES TO BE PROVIDED DURING THE POSTPARTUM
PERIOD...................................................................................................101
4.8 CARE OF THE HIV-EXPOSED INFANT/CHILD....................103
4.8.1 Visit schedule for HIV-Exposed Infants ........................................ 103
4.8.2 Healthcare Services for the HIV Exposed-Infants ........................ 103
4.9 HEALTHCARE SERVICES FOR INFANTS EXPOSED TO
SYPHILIS AND MANAGEMENT OF CONGENTIAL SYPHILIS
109
4.10 HEALTH CARE SERVICES FOR THE INFANTS EXPOSED TO
HEPATITIS B (PMTCT-HEPB).........................................................110
4.11 EPI/PMTCT/EID INTEGRATION................................................111
4.12 COMMUNITY PMTCT SERVICES..................................................114
4.12.1 Minimum Package of Community PMTCT Services ................... 114
4.12.2 Establishment of Community PMTCT Services .......................... 115
Establish coordination mechanism......................................................... 116
4.13 ALDOSCENT GIRLS AND YOUNG WOMEN (AGYW).........116
4.13.1 The Harmonised AGYW Service Package................................... 116
4.13.2 Prevention of Unintended Pregnancies among .......................... 121
4.13.3 Multisectoral approach................................................................ 122
4.14 MATERNAL, INFANT AND YOUNG CHILD FEEDING
GUIDELINES........................................................................................122
4.14.1 Introduction................................................................................. 122
4.14.2 Services Offered During Pregnancy............................................ 123
Initiatives to promote active Breastfeeding............................................ 124
4.14.3 Services Offered During Labour and Delivery............................ 124
4.14.4 Services Offered During the Postnatal Period............................ 125
Feeding a child 0-6 months ................................................................... 125
Feeding a child 6–12 months – Complementary Feeding...................... 125
Feeding a child 12–24 months................................................................ 126
Feeding a child 2-6 years....................................................................... 127
Additional Support Messages ................................................................ 127

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5.0 CARE AND SUPPORT FOR PEOPLE LIVING WITH HIV...... 129
5.1 MINIMUM SERVICE PACKAGE FOR PEOPLE LIVING WITH
HIV AND WHO CLINICAL STAGING.........................................129
5.2 DELIVERING HIV SERVICES FOR ADOLESCENTS.............131
5.2.1 Supporting Continuity in Care and Treatment............................... 138
5.2.2 Prevention of Interruption in Treatment........................................ 138
5.2.3 Tracing and re-engagement in care............................................... 140
5.2.4 Implementation considerations...................................................... 140
5.2.5 People interrupting treatment (less than 90 days)......................... 141
5.2.6 People interrupting treatment (more than 90 days)....................... 142
5.3 PREVENTION, SCREENING AND MANAGEMENT OF CO-
INFECTIONS AND NON-COMMUNICABLE DISEASES.....143
5.3.1 Management of Advanced HIV Disease........................................ 144
5.3.1.1 Definition of Advanced HIV Disease.......................................... 144
5.3.1.2 Background................................................................................. 144
5.3.1.3 Identifying individuals with Advanced HIV Disease.................. 144
5.3.1.4 Components of the package of care for PLHIV with advanced
disease..................................................................................................... 145
5.3.1.5 Package Of Care For Children With AHD ................................ 145
Treating severe pneumonia in children living with HIV ........................ 148
Treating severe bacterial infections ....................................................... 148
Treating Cryptococcal Meningitis in adolescents .................................. 148
Treating malnutrition in Children with HIV .......................................... 148
5.3.1.6 Package of Care for Adults with AHD ....................................... 149
5.3.1.7 Rapid ART Initiation................................................................... 151
5.3.1.8 People interrupting treatment (more than 90 days).................... 151
5.3.1.9 People interrupting treatment (less than 90 days)...................... 151
5.3.1.10 Adherence support.................................................................... 151
5.4 CO-INFECTION SCREENING, TREATMENT, AND
PREVENTION......................................................................................152
5.4.1 HIV and Tuberculosis.................................................................... 152
TB Screening........................................................................................... 156
Tools for systematic TB screening and diagnosis among people living with
HIV.......................................................................................................... 156
TB diagnosis in HIV-infected infants, children, adolescents and adults.156
TB Treatment ......................................................................................... 157
ART for TB/HIV co-infected patients ..................................................... 159
ART and TB treatment Drug interaction................................................ 163
Treatment of people with drug-resistant TB........................................... 166
TB PREVENTION .................................................................................. 167
TB Preventive Treatment (TPT).............................................................. 167
Algorithms to rule out active TB disease................................................ 167
Eligibility for TPT .................................................................................. 168
Timing of TPT in children....................................................................... 170

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Co-administration of DTG and TPT....................................................... 170

BCG vaccination..................................................................................... 172
5.4.2 HIV and Cryptoccoccal Infection.................................................. 174
Screening and management of early Cryptococcal disease................... 175
How to screen for Cryptococcal disease................................................ 175
For serum CrAg positive patients at facilities where lumbar
puncture can be performed..................................................................... 175
For serum CrAg-negative patients......................................................... 177
Diagnosis of Cryptococcal Meningitis................................................... 177
Treatment of Cryptococcal Meningitis................................................... 177
5.4.3 Pneumocystis Jiroveci Pneumonia................................................ 181
5.4.4 HIV and Hepatitis B....................................................................... 182
5.4.5 HIV and Histoplasmosis................................................................ 183
5.4.6 HIV and Aspergillosis ................................................................... 184
5.4.7 HIV and NON-COMMUNICABLE DISEASE............................... 185
5.4.7.1 Diabetes Mellitus (DM).............................................................. 186
Screening, Diagnosis and Management of Obesity................................ 190
5.4.7.2 Screening, Diagnosis and Management of Hypertension........... 191
5.4.7.3 Assessment and Management of Common
Mental Disorders Amongst PLHIV......................................................... 197
Assessment and management of depression........................................... 197
Procedure for mental Health assessment of Triage................................ 197
SAD PERSONS scale.............................................................................. 198
Scoring and interpreting AUDIT-C......................................................... 199
Management of Depression and Anxiety................................................ 200
Management of Alcohol and Substance Use Disorder........................... 201
Management of Mental Health Disorders using Group Support
Psychotherapy (GSP).............................................................................. 201
Interactions between ARVs and antidepressants.................................... 202
5.5 NUTRITION CARE AND SUPPORT FOR PLHIV....................203
5.5.1 Steps In Implementing NACS......................................................... 204
5.5.2 Dietary Recommendation For PLHIV .......................................... 206
5.5.2.1 Nutrition Support for PLHIV...................................................... 206
5.6 SEXUAL AND REPRODUCTIVE HEALTH SERVICES..........210
5.6.1 .Screening and Management of Sexually Transmitted Infections (STIS)
210
5.8 VACCINES FOR PEOPLE LIVING WITH HIV..........................213
5.9 PSYCHOSOCIAL CARE AND ADHERENCE SUPPORT FOR
PLHIV......................................................................................................214
5.9.1 Who Should Provide Psychosocial Support (PSS) to PLHIV?...... 215
5.9.2 Psychosocial Care and Support Service Package......................... 216
5.9.3 Adherence Preparation, Monitoring and Support......................... 218
5.9.4 Monitoring Adherence to ART....................................................... 223
5.9.5 Adherence Support......................................................................... 226

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

5.9.6 Intensive Adherence Counseling and Support for Patients with

Detectable Viral Load............................................................................. 227
5.9.7 Positive Health, Dignity and Prevention (PHDP)......................... 231
5.10 OVC CARE AND SUPPORT.............................................................232

6. ANTIRETROVIRAL THERAPY FOR PEOPLE LIVING WITH

HIV.................................................................................................. 234
6.1 THE GOAL OF ART............................................................................234
6.2 COMPOSITION OF ART...................................................................234
6.3 WHEN TO START ART......................................................................234
6.4 THE PROCESS OF STARTING ART..............................................234
6.5 FIRST-LINE ART REGIMENS FOR PATIENTS
INITIATING ART................................................................................236
6.6 SCREENING FOR RISK FACTORS PRIOR TO
INITIATING DGT...............................................................................237
6.6.1 Rationale for Using EFV400......................................................... 238
6.7 WHEN TO USE ALTERNATIVE FIRST LINE REGIMENS...238
6.8 PREGNANT AND BREATSFEEDING WOMEN NEWLY
INITIATING ON ART........................................................................239
6.8.1 When to use Alternative Firstline Regimens ................................. 239
6.9 WHEN TO USE ALTERNATIVE FIRSTLINE REGIMENS....241
6.10 RECOMMENDED FIRSTLINE REGIMEN FOR INITIATING
ART IN CHILDREN LESS THAN 20KG.......................................241
6.11 WHEN TO USE ALTERNATIVE FIRSTLINE REGIMENS ...241
6.12 MONITORING RESPONSE TO ART..............................................243
6.12.1 Clinical Monitoring .................................................................... 243
6.12.2 Laboratory Monitoring................................................................ 244
6.12.3 Frequency of viral load monitoring ............................................ 245
6.13 PHARMACOVIGILANCE..................................................................251
6.14 COMMON DRUG TOXICITIES IN HIV CARE.........................262
6.15 CHILDREN WITH A NON-SUPPRESSED VIRAL LOAD......274
6.16 WHAT REGIMEN TO SWITCH TO (SECOND LINE AND
THIRD LINE ART)..............................................................................274
6.16.1 Second Line ARVs In Adults And Adolescents ≥30Kg, Including
Pregnant and Breastfeeding Women ...................................................... 275
6.16.2 Second Line ARVs In Children ≥20Kg – 30Kg........................... 275
6.16.3 Second Line ARVs In Children <20Kg........................................ 276
6.16.4 Programmatic Drug Substitution on 2nd Line Regimens............ 278
6.17 THIRD-LINE ART REGIMENS.......................................................279

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6.17.1 Eligibility for Third-Line ART...................................................... 279

6.17.2 When a patient on second line has suspected
resistance to secondline ART.................................................................. 279
6.17.3 Recommended third-line regimens for adults, adolescents and
children................................................................................................... 280
7 SERVICE DELIVERY APPROACHES......................................... 284
7.1 DIFFERENTIATED SERVICE DELIVERY (DSD)....................284
7.1.1 Core principles of differentiated service delivery.......................... 284
7.1.2 Why differentiated service delivery is needed................................ 285
7.1.3 The Target Groups For Differentiated Service Delivery................ 285
7.1.4 Building Blocks for Differentiated Delivery.................................. 285
7.1.5 The 5 A’s criteria to choosing a preferred DSD approach............ 286
7.1.6 Recommended differentiated services............................................ 287
7.1.7 Differentiated Care and Treatment Services ................................. 288
7.2 MULTI- MONTH PRESCRIPTIONS...............................................292
7.2.1 Frequency of clinical visits and ART pick up................................ 293
7.2.2 DSD for children and adolescents................................................. 293
7.2.3 DSD implementation in the context of ART optimization.............. 293
7.2.4 Provision of TPT Within DSD Models And Approaches ............... 294
7.2.5 TPT initiation................................................................................. 294
7.2.6 Monitoring clients on TPT............................................................. 294
7.2.7 How to Introduce DSD Models ..................................................... 295
7.3 COMMUNITY SYSTEMS AND STRUCTURES IN OPTIMIZING
DELIVERY OF HIV/TB SERVICES...............................................298
7.3.1 Coordination and Collaboration of all Community Stakeholders in
Delivery of Services to Communities...................................................... 299
7.3.2 Client-Centered Service Delivery ................................................. 301
7.3.3 Treatment Literacy ........................................................................ 304
7.4 INTEGRATING CONTINUOUS QUALITY IMPROVEMENT
INTO HIV CARE..................................................................................304
7.4.1 Steps to use CQI To Address HIV Services Delivery GAPS .......... 305
7.4.2 Monitoring of CQI Implementation............................................... 306
7.4.3 The following documents provide more
guidance on implementing CQI:............................................................. 306
7.4.4 Monitoring and Evaluation of the Strategy................................... 307
8 HEALTH PRODUCTS MANAGEMENT ................................... 309
8.1 INTRODUCTION................................................................................309
8.2 PRODUCT SELECTION, QUANTIFICATION AT THE
CENTRAL LEVEL ..............................................................................309

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8.3 FLOW FOR COMMODITIES USED IN THE PREVENTION,

CARE AND TREATMENT FOR HIV.............................................310
8.4 SELECTION OF HEALTH PRODUCTS AT FACILTY LEVEL .312
8.5 ORDERING AND REPORTING BY THE
HEALTH FACILITIES.........................................................................312
8.6 GUIDANCE ON ORDERING AND REPORTING FOR THIRD-
LINE ART MEDICINES.....................................................................314
8.7 ISSUING THIRD LINE ARVS TO FOLLOW-UP FACILITY ..315
8.8 GUIDANCE FOR STOCK MANAGEMENT
AT HEALTH FACILITY .....................................................................316
8.9 DISPENSING MEDICINES..............................................................316
8.10 RATIONAL MEDICINES USE.........................................................317
8.11 CRPDDP APPROACH ........................................................................320

9 MONITORING AND EVALUATION................................................ 322

9.1 INTRODUCTION................................................................................322
9.2 OVERVIEW OF HIV/AIDS PROGRAMME MONITORING.322
9.2.1 Pateint Data Recording................................................................. 322
9.2.2 Patient Data Reporting.................................................................. 322
9.2.3 Other programme data sources .................................................... 323
9.2.4 Programme Data Quality and Use................................................ 324
9.3 MONITORING ROLL OUT OF REVISED GUIDELINES.....324
9.3.1 Tracking progress of roll out.......................................................... 324
9.3.2 Supervision on implementation of revised guidelines.................... 324
9.3.3 Review of the guidelines................................................................ 325
9.3.4 Indicator matrix............................................................................. 325

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Annex 1: HIV-exposed infants visit schedule and care package.. 326

Annex 2: WHO staging for HIV infection and disease in adults and
adolescents..................................................................... 327
Annex 3: WHO staging for HIV infection and disease in infants and
children.......................................................................... 329
Annex 4: Intensified TB case finding guide.................................. 331
Annex 5: Algorithm for TB diagnosis in children......................... 332
Annex 6: Algorithm for TB diagnosis in HIV positive
adults and adolescents................................................... 333
Annex 7: Treatment algorithms for sexually transmitted diseases in
Uganda........................................................................... 334
Annex 8: Human resources for differentiated service delivery and
their roles........................................................................ 335
Annex 9: Home education/eating/exercise activities drugs/depres-
sion sexuality suicidality/safety assessment tool in adoles-
cents............................................................................... 339
Annex 10: Child health card........................................................... 342
Annex 11: Patient Health Questionnaire-9 (PHQ-9)..................... 343
Annex 12: ARV Dosing Tables....................................................... 344
Annex 13: Dosing of RUTF........................................................... 347
Annex 14: Suspected Adverse Drug Reaction Reporting form..... 348

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List of Tables
Table 1: Guiding principles for HIV Testing Services.............................................13
Table 2: HIV testing provision steps/protocol.........................................................15
Table 3: Screening questions for all children and adolescents <15 years .............20
Table 4: Principles of APN..........................................................................................30
Table 6: Categories of HIV-negative persons to retest at specified time points .41
Table 7: Schedule for the tracking of inter-facility linkages for HIV positive
individuals........................................................................................................46
Table 8: Schedule for follow-up/tracking community-facility-community linkages
for HIV positive individuals ........................................................................47
Table 9: Services for Behavioral Change and Risk Reduction................................56
Table 10: Process of providing safe male circumcision...........................................61
Table 11: Steps for Providing Post-Exposure Prophylaxis (PEP)..........................63
Table 12: The process of providing pre-exposure prophylaxis (PrEP).................65
Table 13: Gender-based violence (GBV) screening tool ........................................76
Table 14 : Minimum package for post-rape care services........................................78
Table 15: The PMTCT Strategy...................................................................................83
Table 16: Services for preventing HIV infection in women and girls of
reproductive age.............................................................................................86
Table 17: Childbearing, family planning/contraception, and safer conception
services for HIV-infected women of reproductive age...........................87
Table 18: Safer Conception .........................................................................................91
Table 19: Interactions between ART and Contraceptives.......................................93
Table 20: ANC and PMTCT Services for Pregnant Women..................................94
Table 21: eMTCT services during labour and delivery............................................99
Table 22: eMTCT services during the postpartum period....................................102
Table 23: HIV-exposed infant care services.............................................................104
Table 24: Syphilis treatment for infants ...................................................................109
Table 25: Integration of EID into EPI services.....................................................112
Table 26: HIV testing and prevention services for adolescent girls and young
women 10-24 years......................................................................................119
Table 27: Prevention of gender-based violence and post violence care.............120

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Table 29: Nutrition Counseling Messages for Pregnant Women.........................123

Table 30: Summary of Minimum Care Package for PLHIV.................................129
Table 70: Adolescent Friendly HIV Services...........................................................132
Table 71: Strategies for Preventing interruption in Treatment.............................139
Table 72: Re-engaging Adolescents after <90 days................................................142
Table 73: Re-engaging Adolescents after >90 days...............................................142
Table 31: Screening, diagnosis, treating and prevention components of the package
of care for children and adolescents with advanced HIV disease.......146
Table 32: Package of care for adults with advanced HIV disease.......................149
Table 35: .Anti-TB treatment regimens for infants, children, adolescents, and adults
157
Table 36: Dosage of Anti TB medicines by weight band for children................158
Table 37: Dosage of Anti TB medicines by weight band for adults....................158
Table 38: Dosage of Anti TB medicines by weight for children and adults.......159
Table 39: ART regimens for TB/HIV co-infected patients initiating First- and
Second -line ART.........................................................................................160
Table 40: ARV regimen substitutions for patients initiating TB treatment while
already on ART............................................................................................164
Table 41: TPT regimen for adolescents ≥ 15 years and adults on ART............169
Table 42: TPT regimen for children < 15 years on ART......................................169
Table 43: TPT dosing table.........................................................................................171
Table 33: Cotrimoxazole dosing................................................................................173
Table 34: Management of Cotrimoxazole hypersensitivity ..................................173
Table 44: Treatment regimen for non-meningeal Cryptococcal disease.............176
Table 45: Management of Cryptococcal Meningitis..............................................179
Table 46: Liposomal Amphotericin B dosing weight bands ................................181
Table 47: Flucytosine (5FC) dosing weight bands .................................................181
Table 49: Signs/symptoms, management and prevention of
Pneumocystis Jiroveci Pneumonia............................................................181
Table 48: Classification and Treatment regimen for disseminated Histoplasmosis
disease............................................................................................................183
Table 55: Sulfonylurea oral glucose lowering agents with starting and escalating
doses .............................................................................................................188
Table 56: Hypertension Treatment Protocol...........................................................192
Table 57: Interactions of hypertension medicine ..................................................195

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Table 58: Potential side effects of hypertension medicine ..................................196

Table 59: Psychotherapy and Medications for Anxiety and Depression ............200
Table 60: Interactions between ARVs and common antidepressants, and
recommended management.......................................................................202
Table 51: Seven steps approach for implementing NACS....................................204
Table 52: STI screening tool.......................................................................................210
Table 53: Eligibility criteria for cryotherapy/thermocoagulation.........................212
Table 54: HPV vaccine and dosing schedule...........................................................212
Table 61: Minimum Standards for Providing Psychosocial Support Services....216
Table 62: 5As for adherence preparation support..................................................219
Table 63: Checklist for developing an adherence plan...........................................221
Table 64: ART readiness assessment checklist........................................................222
Table 65: Question guide for reviewing an adherence plan..................................224
Table 66: Determining adherence levels from self-report and pill count and
recommended action...................................................................................225
Table 67: 5As for adherence support for people with non-suppressed viral load.227
Table 68: Positive health, dignity, and prevention intervention...........................232
Table 69: OVC Vulnerability screening tool............................................................233
Table 74: .Recommended first-line ARV regimens in Children, adolescents, adults
and pregnant or breastfeeding women ....................................................242
Table 75: Components of a comprehensive clinical assessment of PLHIV......244
Table 76: Follow-up lab tests and their clinical indication.....................................248
Table 77: Follow-up schedule for PLHIV and monitoring components............249
Table 83: Laboratory monitoring for Active Pharmacovigilance in non-sentinel
sites.................................................................................................................260
Table 84: Laboratory monitoring for Active Pharmacovigilance in sentinel sites.261
Table 85: Management of ARV side effects/toxicities..........................................263
Table 86: Symptomatic and Laboratory Severity Grading for common ADRs.264
Table 78:Toxicities/side effects of commonly used ARVs and recommended
substitutions..................................................................................................269
Table 79: Criteria for switching ART due to treatment failure.............................274
Table 80: Recommended NRTI sequence from first-line to second-line...........274
Table 81: First-Second- and third-line ART regimens for patients failing on
treatment: .....................................................................................................277

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Table 82: Drug interactions........................................................................................281

Table 88: Definition of the DSD Categories .........................................................289
Table 89: .Client categories for HIV Care and Treatment services under the various
differentiated categories..............................................................................290
Table 90: Stepwise approach to introduce differentiated
models of service delivery..........................................................................295
Table 93: Steps to use CQI to improvement HIV service delivery gaps............305
Table 94: New Formulations being introduced.......................................................309
Table95: How To Access Third Line ARV Medicines...........................................315
Table 96: Dosing for LPV/r 40/10mg Granules....................................................318
Table 97: Routine reports and their frequency........................................................323

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

List of Figures
Figure 1 : HIV continuum of Prevention and Care ..................................................3
Figure 2: Continuum of Linkage to Care and Prevention.......................................12
Figure 3: The HTS Protocol........................................................................................14
Figure 4: The HTS Process .........................................................................................17
Figure 5: Pediatric and Adolescent Eligibility Screening Tool for HIV Testing (18
months to 14 years)....................................................................................21
Figure 6: Eligibility Screening Tool for HIV Testing among adolescents and adults
(15 years and above)...................................................................................22
Figure 7: Serial HIV Testing Algorithm for testing persons above 18 months of age
in Uganda, 2022..........................................................................................23
Figure 8: Differentiated HIV Testing Services Models and Approaches for Uganda
25
Figure 9: Components of Assisted Partner Notification Services.........................29
Figure 10: APN Flow Chart.........................................................................................32
Figure 11: SNS Implementation – Four Phases........................................................34
Figure 12: Differences in SNS and Index Testing....................................................35
Figure 13: HIVST Distribution Channels .................................................................37
Figure 14: HIV Testing Algorithm using the HIV-Syphilis Duo Kit in MCH
Settings.........................................................................................................39
Figure 15:HIV testing algorithm for children <18 months of age.......................40
Figure 16: HIV Rapid Test for Recent Infection Interpretation............................44
Figure 19:Intra Health Facility Linkages for HIV Positive individuals ...............45
Figure 20: Tester Certification Process.......................................................................49
Figure 21: Site Certification Process...........................................................................50
Figure 22:Behavioral change risk assessment............................................................55
Figure 23: Overview of TMA System........................................................................59
Figure 24: Condom distribution flow chart...............................................................60
Figure 26: Four-question Screening Tool for GBV..................................................78
Figure 28: Management of HIV and Syphilis in Maternal and Child Health care
settings..........................................................................................................98
Figure 29: Algorithm for Hepatitis B screening and management in MCH........98

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 31: Assessment for High-Risk Mother-Infant Pairs...................................101

Figure 32: Tailored age-appropriate AGYW service package for impact...........117
Table 28: Family planning/contraception services for AGYW and emancipated
minors ........................................................................................................121
Figure 33: Symptom Screen and Advanced Disease Management Pathway......151
Figure 34: Algorithm for screening, diagnosis, and management of TB among
PLHIV .......................................................................................................153
Figure 35: Algorithm for the Diagnosis of TB in Children .................................154
Figure 36: One stop shop model for TBHIV service delivery.............................155
Figure 37: Follow up of a Neonate born to an HIV-positive Mother with Active
TB................................................................................................................172
Figure 38: Algorithm for screening and managing Cryptococcal disease...........176
Figure 39: ART timing with CCM.............................................................................178
Figure 42: Algorithm for Screening, Diagnosis and Management of Diabetes
Mellitus.......................................................................................................187
Figure 43: Treatment protocol for diabetes mellitus .............................................188
Figure 40: Contraindications for Metformin and Glibenclaminde......................189
Figure 44: DM Screening Algorithm for PLHIV Transitioning to DTG..........189
Figure 45: Screening for Complications with DM..................................................190
190
Figure 46: WHO classification of weight status and calculation of BMI...........191
Figure 47: Algorithm for diagnosis and management of hypertension .............192
Figure 48: Lifestyle Modification Counselling for Hypertension ........................194
Figure 49: Laboratory Monitoring for PLHIV on Hypertension Medications.195
Figure 50: Self-Reporting Questionnaire Screening Tool......................................198
Figure 51: Degree of Risk after Assessment using the SAD PERSON’s Scale.199
Figure 52: AUDIT-C tool for substance and alcohol use disorder......................199
Figure 53: Structure of GSP......................................................................................202
Figure 40: The Cycle of Under nutrition and HIV/AIDS...................................203
Figure 41: Algorithm for nutrition assessment, classification, and care plan of acute
malnutrition...............................................................................................209
Figure 54: Who to provide Psychosocial Support Services to PLHIV...............215
Figure 55: Flow-chart for offering IAC to non-suppressed Adult PLHIV........230
Figure 56: How to evaluate patients for ART initiation.........................................235

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 57: Screening Algorithm for PLHIV initiating or transitioning to DTG.238

Figure 58: VL testing algorithm for children, adolescents and adults for health
facilities using plasma and DBS samples .............................................246
Figure 59: Monitoring patients initiated or transitioned to DTG........................251
Figure 63: Steps and key players in Pharmacovigilance.........................................252
Figure 64: Showing reporting process of adverse drug reaction..........................254
Figure 65: Screening tool for Active Pharmacovigilance.......................................256
Figure 62: Third-Line ART Flow Chart...................................................................280
Figure 66: The building blocks for differentiated service delivery.......................286
Figure 67: Recommended differentiated HTS delivery models............................288
Figure 68: Recommended differentiated care and treatment service delivery models
and their respective target populations..................................................289
Figure 74: Functionalizing a Coordination Structure.............................................299
Figure 75: Integrated Community Service Delivery Model .................................301
Figure 76: Flow for Commodities used in the Prevention, Care and Treatment for
HIV..............................................................................................................310
Figure 77: Commodity Flow, Ordering and Reporting Timelines for PrEP, STI and
VMMC commodities................................................................................311
Figure 78: Administration of LPV/r 40/10mg Granules.....................................318
Figure 79: Flow for Commodities Under the CRPDDP Approach. ..................320

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

FOREWORD
The Government of Uganda promotes a combination of interventions to
manage a generalized HIV epidemic in the country. In the last two decades,
the AIDS Control Program has integrated antiretroviral therapy (ART) into
the comprehensive response to HIV prevention, care treatment, and support.

The 2016 version of the “Consolidated Guidelines for the Prevention and
Treatment of HIVand AIDS in Uganda” expanded the HIV “test and treat”
policy to all people diagnosed with HIV. The “test and treat” policy involves
providing lifelong ART to people living with HIV irrespective of CD4 or
WHO HIV clinical staging. In compliance with WHO recommendation, all
limitations on eligibility for ART among all people living with HIV were
removed: all populations and age groups became eligible for treatment.
In addition, we recommended HIV pre-exposure prophylaxis for HIV-
uninfected persons at substantial risk of HIV acquisition.

In the 2018 version of the “Consolidated Guidelines for the Prevention

and Treatment of HIV and AIDS in Uganda, we recommended optimizing
treatment by using Dolutegravir, in combination with Tenofovir and
Lamivudine as the preferred first-line for eligible people living with HIV.
We also provided guidance on HIV self-testing to increase access to testing
and there was a renewed focus on the screening and treating for syphilis in
pregnant women and their partners. In addition, we provided guidance on
service delivery modalities for g different client categories to catalyze the
pace towards achieving universal access to ART.

The 2020 version of the “Consolidated Guidelines for Prevention and

Treatment of HIV in Uganda” reaffirmed optimizing ART by using
Dolutegravir-containing regimens as preferred first-line for all eligible
people living with HIV (including pregnant and breastfeeding adolescent
girls and women, and children). Further guidance was provided on service
delivery modalities for targeting different client categories to catalyze the
pace towards achieving epidemic control .The guidelines also emphasized
pharmacovigilance for screening, reporting and timely management of
adverse effects of medicines including ART and anti-TB drugs.

The 2022 revision of the “Consolidated Guidelines for Prevention and

Treatment of HIV in Uganda”, provides clear guidance on HIV prevention

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

options that include PrEP, eMTCT, Circumcision and HIV services with a
focus on case finding approaches. Furthermore, an updated, evidence-based
and simplified guide to ART optimization with DTG in all age groups and
sub populations and approaches to protect it from resistance through updated
treatment monitoring is being provided. The guidelines also emphasize
the management and integration of tertiary HIV in the general HIV care
continuum with a focus on Advanced HIV Disease, HIV drug resistance
and non-communicable diseases. Additionally, the guidelines also provide
updated guidance on key operational and service delivery issues with the aim
of increasing access to HIV services and strengthening the continuum of
HIV care

These guidelines provide a simplified framework for healthcare workers,

district health teams and Managers of different programs including HIV,
Tuberculosis Reproductive Maternal, Newborn Child and Adolescent
Health and Essential Medicines. They also act as a reference tool for
AIDS Development Partners, implementing partners, Training institutions,
Researchers, Civil Society Organizations and the entire community of people
living with HIV.

I call upon all Stakeholders in the fight against HIV in Uganda, to support
the successful implementation of these Guidelines.

---------------------------------------------------------------------------------------

Dr. Henry Mwebesa

DIRECTOR GENERAL HEALTH SERVICES

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

ACKNOWLEDGMENTS
The Ministry of Health thanks all the stakeholders who participated in the
Guidelines review and development. We thank the following chairpersons who
led the guidelines adaptation meetings in the different technical committees;
Prof. Moses Kamya (National HIV/AIDS Advisory Committee and Adult
ART Subcommittee), and Prof. Philippa Musoke (PMTCT and Paediatric
HIV Subcommittees). We also thank the organizations and individuals listed
below who participated in the Guidelines development process during the
adaptation meetings and the guidelines Writing Workshops.

Contributors:
Ministry of Health: D Henry Mwebesa, Patrick Tusiime, Charles Oyo
Akiya, Joshua Musinguzi, Susan Nabbada, Gerald Mutuungi, Annet
Nabaggala, Annet Nakigozi, Arthur Ahimbisibwe, Alisen Ayitewala, Barbara
Nanteza, Charles Kiyaga, Chris Okiira, Cordelia Katureebe, Christine
Katusiime, Carol Achola, Daniel Idipo, Dan Mawerere, Diina Kwariisima,
Doreen Ondo, Didas Tugumisirize, Ebony Quinto, Edward Katto, Eleanor
Namusoke, Emmy Muramuzi, Florence Nampala, Frank Mugabe, Geoffrey
Taasi, Gerald Pande, Ian Nyamitoro, Hakim Sendagire, Hasfa Lukwata,
Herbert Kadama, Hudson Balidawa, Ivan Kato Arinaitwe, Ivan Arinaitwe,
James Ochacacon, Jovah Praise, Juliet Cheptoris, Juliet Katushabe, Kenneth
Kalani, Laura Ahumuza, Linda Nabitaka, Lordwin Kasambula, Mark Agara,
Martin Nsereko, Maureen Mbabazi, Moorine Sekadde, Micheal Isabirye,
Mina Nakawuka, Miriam Nakanwagi, Morris Seru, Pamela Achii, Patrick
Twesigye, Peter Kyambadde, Peter Mudiope, Philip Kasibante, Promise
Mbonye, Proscovia Namuwenge Raymond Byaruhanga, Robert Majwala,
Ruth Nabbagala, Sam Balyejusa, Susan Wandera, Simon Kalyesubula, Simon
Muchuro, Samalie Namukose, Samuel Mutyaba, Vasta Kibirige, Victor
Bigira, Wilford Kirungi, Wilson Nyegenye, Viola Kasone and Zziwa Martin.
WHO: Kaggwa Mugagga, Hasfa Kasule and Rita Nalwadda. UNAIDS:
Jotham Mubabguzi UNICEF: Barbara Asire, Esther Nyamugisa Ochora,
CDC, Bill Elur, Daniel Bogere, Esther Nazziwa, Emilio Dirlikov, Grace
Namayanja, Jonathan Ntale, Jennifer Galbrach, Joseph Kabanda, Julius
Kalamya, Madina Apolot, Margaret Achom, Mary Naluguza, Phoebe
Namukanja, Rosemary Apondi, Samuel Wasike, Sophie Nantume, Stella
Alamo, Steven Baveewo, Thomas Nsibambi, and Deus Lukoye USAID:
Hilda Asiimwe, Jacqueline Calnan, Jennifer Namusobya, Miriam Mulungi,
Patrick Komakech, Immaculate Ddumba, Seyoum Dejene, Esther Karamagi

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Nkolo, Tamara Nsubuga-Nyombi, Fred Ntuuyo, Willy Kafeero, Sheila

Kyobutungi, Dalsone Kwarisiima, Gladys Tugume, Ismail Mbabali and
Daniel Kasozi. Department of Defence(DOD): Estella Birabwa and
Juliet Akao Clinton Health Access Initiative (CHAI): Amanda Williams,
Aston Nuwagira, Isaac Ikiring, Marvin Lubega, Robert Kirungi, Ronald
Kizito, Vennie Nabitaka,. Baylor Uganda: Adeodata Kekitiinwa, Denise
Birungi and Jackie Balungi. Elizabeth Glazer Pediatric AIDS Foundation
(EGPAF): Ange Kiyonga, Edward Bitarakwate, Caroline Tiri, Dan Mugisha,
Happy Betty, Mary Namubiru, Moses Luwunzu, Ronald Kamasi and Patrick
Serunjogi. Global fund FCO: Damian Rutazaana. ICWEA: Moriko Lillian
and Dorothy Namutamba Joint Clinical Research Centre (JCRC): Francis
Ssali. JCRC-PHAs: Moses Nsubuga (Super Charger). District Health
Officers, Makerere University College of Health Sciences: David Meya,
Ethel Nakimuli, Fred Semitala, Moses Kamya, Philippa Musoke, Sabrina
Kitaka, and Victor Musiime. Makerere University College of Health
Science Infectious Disease Institute (IDI): Andrew Kambugu, Mary
Mudiope, Joanita Kigozi, Martin Ssuna, Paul Kavuma, Peter Kalema and
Timothy Muwonge. Makerere University Joint AIDS Program (MJAP):
Isaac Kimera and Martin Muddu, Makerere University John’s Hopkins
University Collaboration (MUJHU): Emilly Lugolobi. Makerere
University School of Public Health: Rhoda Wanyenze, Violet Gwokyalya,
Makerere University Walter Reed Project (MUWRP): Anna Nakirijja,
Fred Magala and Monica Etima. MAMA’S Club: Lydia Mungherera.
Mbarara Regional Referral Hospital: Denis Nanseera, Alexa Namuli,
Winnie Muhinike. Medical Access: Sowedi Muyingo, Gerald Sebulime.
Medical Research Council (MRC)/UVRI: Christine Watera, Ivan
Namukoola, Joseph Lutakome and Josephine Birungi, Pontiano Kaleebu,
Monitoring and Evaluation Technical Support (METS): Alice Namale,
Edgar Kansiime, Evelyn Akello, Simon Muhumuza and Godfrey Timbihurira
Mildmay: Barbara Mukasa, Jane Nakaweesi, Stephen Watiti and Michael
Sonko. NAFOPHANU Stella Kentutsi. National Drug Authority: Victoria
Nabasa, Julius Mayengo, Paul Senoga. National Medical Store: Sande
Izidoro. TASO: Muhirwwe Ninsiima, Baker Bakashaba, Molly Rwankore,
Michael Etukoit and Obore Gilbert. Uganda Network of AIDS Service
Organizations (UNASO): Martha Kawala. UNYPA: Nicholas Nuwagaba.
UGANDA CARES: Agnes Bukirwa, Augustine Lubanga, Cecelia Natembo,
Kawoya Sulaimani, Samson Okumu. African Resource Center: LeBeau
Taljaard. Uganda Cancer Institute: Carol Nakisige. Other resource
persons: Vincent Kawooya, Jane Nabalonzi, Janet Nerima, Simon Peter

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Inyimai, Gabriel Kaddu, Peter Kiragga. Mulago Specialised Women and

Neonatal Hospital: Jolly Beyeza-Kashesya, RAND Corp: Glenn Wagner
Children’s Mercy Research Institute-University of Missouri-Kansas
City: Kathy Goggin, Emily Hurley, University of California Global
Health Institute: Deborah Mindry University of Kansas Medical Center:
Sarah Finocchario-Kessler, Augustina Delaney CDC Atlanta
Finally, we express our gratitude to the following organizations for the
financial support towards the guidelines review and development process:
World Health Organization-Uganda, Clinton Health Access Initiative-
Uganda, Global Fund, PEPFAR through CDC, DOD and USAID and
UNICEF.

---------------------------------------------------------------------------------------
Dr Joshua Musinguzi
PROGRAM MANAGER AIDS CONTROL PROGRAM

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

ABBREVIATIONS AND ACRONYMS

3TC Lamivudine
ABC Abacavir
ACTs Artemisinin-based combination therapies
AFHS Adolescent-friendly health services
AFP Alpha-fetoprotein
AIDS Acquired Immune Deficiency Syndrome
ALT Alanine Amino-Transferase
ANC Antenatal care
ARM Artificial rupture of membranes
ART Antiretroviral Therapy
ARV Antiretroviral medicines
AST Aspartate Aminotransferase
ATV/r Atazanavir/ritonavir
AZT Zidovudine
BCC Behavioral change communication
BCG Bacillus Calmette-Guerin
BP Blood pressure
CASA Community ART Support Agents
CBC Complete bloodcount
CBO Community-based organizations
CCLAD Community client-led ART Delivery
CD4 Cluster of differentiation 4
CDC Centers for Diseases Control and Prevention
CDDP Community drug distribution points
CDO Community Development Officer
CHEW Community Health Extension Worker
CITC Client-initiated Counseling and Testing
CM Cryptococcal meningitis
CMV Cytomegalovirus
COPD Chronic obstructive pulmonary disease
CPT Cotrimoxazole preventive therapy
CQI Continuous quality improvement
CrAg Cryptococcal Antigen
CSF Cerebral spinal fluid
CTX Cotrimoxazole

xxvii
DBS Dried blood spot
DM Diabetes mellitus
DNA Deoxyribonucleic Acid
DRV/r Darunavir/Ritonavir
DSDM Differentiated service Delivery Models
DTG Dolutegravir
EBF Exclusive breastfeeding
EFV Efavirenz
EGPAF Elizabeth Glaser Pediatric AIDS Foundation
eMTCT Elimination of Mother-To-Child HIV Transmission
ETV Etravirine
FBO Faith-Based Organizations
FP Family Planning
FPG Fasting Plasma Glucose
FTC Emtricitabine
GBV Gender-based violence
GFR Glomerular filtration rate
HBcAg Hepatitis B core antigen
HBHTC Home-based HIV testing and Counseling
HBsAg Hepatitis B surface Antigen
HBV Hepatitis B Virus
HCC Hepatocellular Carcinoma
HCIII Health Centre III
HCIV Health Centre IV
HCV Hepatitis C virus
HEI HIV-exposed infants
HIV Human immunodeficiency virus
HIVST HIV Self-Testing
HMIS Health Management Information Systems
HPV Human Papilloma Virus
HTS HIV Testing Services
IAC Intensive adherence counseling
ICF Intensified Case Finding
IFN Interferon
IGAs Income Generating Activities
IMNCI Integrated maternal, newborn and childhood illnesses
INH Isoniazid
IPD Inpatientdepartment
IPT Isoniazid Preventive Therapy
IRIS Immune reconstitution inflammatory syndrome
IRS Indoor residual spraying
ITC In-patient therapeutic center
LLINs Long-lasting insecticide-treated nets
IUD Intrauterine device
IYCF Infant and young child feeding
KP Key populations
LFTs Liver function tests
LMIS Laboratory management information system
LP Lumbar puncture
LPV/r Lopinavir/ritonavir
MAM Moderate acute malnutrition
MCH Maternal child health
MDR Multi-drug resistant
MOH Ministry of Health
MUAC Mid-upperarm circumference
NAC National ART Advisory Committee
NACS Nutrition assessment, counseling and support
NCD Non-Communicable Diseases
NDA National Drug Authority
NGO Non-government organization
NNRTI Non-nucleoside Reverse Transcriptase Inhibitor
NRTI Nucleoside Reverse Transcriptase Inhibitor
NVP Nevirapine
OI Opportunistic infection
OPD Outpatient department
OTC Outpatient therapeutic center
OVC Orphans and vulnerable children
PCR Polymerase chain reaction
PEP Post-exposure prophylaxis
PHDP Positive health dignity and prevention
PHQ Patient health questionnaire
PI Protease inhibitor
PITC Provider-initiated HIV testing and counseling
PJP Pneumocystis jiroveci pneumonia
PLHIV People living with HIV

xxix
PNC Postnatal care
PrEP Pre-exposure prophylaxis
PSS Psychosocial Support
PTT Prothrombin time
PWDs Persons with disabilities
PV Pharmacovigilance
QI Quality improvement
R Rifampicin
RAL Raltegravir
RFTs Renal function tests
RH Reproductive health
RMNCAH Reproductive Maternal Newborn, Child and Adolescent health
RUTF Ready-to-use therapeutic feeds
SAM Severe acute malnutrition
SBCC Socio-behavioral change communication
SFP Supplementary feeding programs
SMC Safe male circumcision
SP Sulfamethoxazole-pyrimethamine
SCC Safes Conception Counselling
SCM Safer Conception Method
STIs Sexually transmitted infections
TAF Tenofovir Alfenamide
TB Tuberculosis
TDF Tenofovir
TPHA Treponema pallidum hemagglutination assay
TUI Timed Unprotected Intercourse
USAID United States Agency for International Development
UTI Urinary tract infection
VCT Voluntary counseling and testing
VHT Village health team
VIA Visual inspection with acetic acid
VL Viral load
VMMC Voluntary medical male circumcision
WAOS Web-based ordering system
WFL/H Weight for length/height
WHO World Health Organization
YAPS Young People and Adolescent Peer Support(ers)
YCC Young child clinic

xxx
1.0 INTRODUCTION
1.1 CONTEXT
These 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. The goal of the Test and Treat Guidelines is to further expand
access to antiretroviral therapy (ART) and to optimize treatment for all
eligible adults and children .
The 2018 version of the Guidelines recommended optimizing ART using
a Dolutegravir-based regimen as the preferred first line for eligible PLHIV,
with consideration for rising levels of pre-treatment drug resistance to non-
nucleoside reverse transcriptase inhibitors (NNRTIs). These guidelines also
provided operational and service delivery guidance to districts and health
facilities to implement other new approaches including:
• HIV self-testing (HIVST) and assisted partner notification (APN),
• Effective integration of elimination of mother-to-child HIV transmission
(eMTCT) services into Reproductive Maternal, Newborn, Child and
Adolescent health services (RMNCAH),
• Differentiated service delivery, which reduces clinic visits and allows
community ART distribution to PLHIV who are stable on ART,
• Working with community structures to optimize delivery of HIV services;
and
• Retention, adherence to treatment, adolescent-friendly and responsive
health services.
The 2020 version of the Guidelines recommended the optimization of
ART using Dolutegravir-based regimens as preferred first line for all
eligible PHLIV. The Guidelines also recommended procedures for ARV
substitution in adults, adolescents, and children already on first-line ART
and recommended options for subsequent second- and third-line regimens.
These Guidelines also emphasized the importance of pharmacovigilance
(PV) and described the procedures for identifying, investigating, reporting,
and managing adverse effects of ART, anti-TB and other medications.
The objective of the 2022 Guidelines are:

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

1.2 OBJECTIVES
• To provide a standardized and simplified guide for offering HIV testing
services with a focus on case finding approaches.
• To provide additional PrEP options such as the Dapivirine ring and
injectable Cabotegravir, and for consolidating the existing prevention
methods: Behavior Change Communication, eMTCT and Safe Male
Circumcision.
• To provide an updated, evidence-based and simplified guide to ART
optimization with DTG in all age groups and sub populations and
approaches to protect it from resistance through updated treatment
monitoring.
• To provide updated guidance on the management and integration of
tertiary HIV in the general HIV care continuum with a focus on Advanced
HIV Disease, HIV drug resistance and Non-Communicable Diseases.
• To provide updated guidance on key operational and service delivery
issues with the aim of increasing access to HIV services and strengthening
the continuum of HIV care.

1.3 TARGET AUDIENCE

The primary audiences for these guidelines are:
• Healthcare workers and district health teams
• Program managers of HIV, Reproductive, Maternal, Newborn, Child and
Adolescent Health (RMNCAH) and TB programs as well as National
Medicines Warehouses, and
• AIDS Development Partners, Implementing partners, Training institutions,
Researchers, Civil Society Organizations and entire community of people
living with HIV.

1.4 GUIDELINES DEVELOPMENT PROCESS

These Guidelines were developed by a team of internal and external technical
experts, and with engagement of people living with HIV. The Guidelines
development process was comprehensive and involved adaptation and
approval of the Guidelines by the National ART Advisory Committee, and
Top Management of Ministry of Health. There were a series of Writing
Workshops and Peer Reviews with the guidance of a Consultant. The
adaptation of the Guidelines by the different subcommittees involved reviews
of evidence cited in the World Health organization Guidelines, presentation,
and review of local evidence with concurrence at all stages. We also received
technical support and peer review from external experts including those from

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

the World Health Organization, Centers for Disease Control and Prevention,
United States Agency for International Development, Clinton Health Access
Initiative and the Elizabeth Glaser Pediatric AIDS Foundation.

1.5 SUMMARY OF CHANGES IN 2022 HIV/AIDS

GUIDELINES
Figure 1 : HIV continuum of Prevention and Care

Chapter 2- HIV TESTING SERVICES- Prioritize case finding

approaches

HIVST
Prioritize Case finding;
• Consent now 15 years and above.
• Target populations to include adolescent Optimized PITC,
girls, Adolescent Girls, Youths and
Scale up, HIVST
Women
• Blood based HIVST now in use Index Testing,
INDEX TESTING Recency,
• Biological Children recommended aged Linkages
between 18 months to 19 years
focused Community Testing

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• If using Caregiver-assisted oral screening to conduct index testing for

biological children, then recommended ages are 2 years to 14 years.
• HFs offering ICT assessed annually and accredited to ensure adherence to
minimum standards around the 5Cs
LINKAGE
• Intra-facility linkage revised to 7 days or on the same day,
• Inter-facility and community linkages is at 14 days
• HIV tester and site certification
• Guidance provided on the verification and confirmation of the
requirements needed for HIV testers and sites certification.
Chapter 3: PRE-EXPOSURE PROPHYLAXIS FOR HIV
PREVENTION

Recommended Use of
• Dapivirine vaginal ring
• Injectable cabotegravir (LA-CAB
Dapivirine vaginal ring and Injectable Carbotegravir may be offered as an
additional prevention choice for people at substantial risk of HIV infection
as part of combination prevention approaches
Chapter 5: CARE AND SUPPORT FOR PLHIV- TB SCREENING
AND DIAGNOSIS

Systematic screening for TB among People living with HIV

• PLHIV should be systematically screened for TB disease at each visit to a
health facility with a combination of;
• Intensified Case finding ( ICF)- form
• C-Reactive Protein(CRP) and or CXR
Chapter 5: INITIATING ART AMONG PLHIV WITH TB

Treatment for drug sensitive TB ,

ART should be started at two weeks of initiating TB treatment, regardless
of CD4 cell count, among people living with HIV (Except when signs and
symptoms of meningitis are present)
Treatment of people with drug-resistant TB
• all people with HIV and drug-resistant TB, requiring second-line anti-TB
drugs irrespective of CD4 cell count, should start ART as early as possible
(within the first eight weeks) following initiation of anti-TB treatment

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

TB Preventive Treatment Options

• Use of 3HP (RPT + INH)
• 6H also in practice
Chapter- 5: ART timing with CCM
Chapter- 5: ART timing with CCM

Chapter- 5: CARE AND SUPPORT FOR PLHIV- Mgt of CCM-

Table 45 with details

Induction phase; (2 weeks) - Recommended:

• Amphotericin B liposomal single high dose (10mg/kg) + Flucytosine
(100mg/kg/day in four divided doses) + Fluconazole 1200mg/ day for
14 days OR
• Amphotericin B deoxycholate (1mg/kg/day) + Flucytosine (100mg/kg/
day in four divided doses) for 1 week, followed by 1 week of fluconazole
(1200 mg/day for adults, 12 mg/kg/day for children and adolescents). OR
• Fluconazole (1200 mg daily for adults, 12 mg/kg/day for children and
adolescents) + Flucytosine (100 mg/kg/day, divided into four doses per
day. OR
• Amphotericin B deoxycholate (1mg/kg/day) + high-dose Fluconazole
1200mg/day.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Chapter 6: TERTIARY HIV MGT, AGING WITH HIV,

INTERGRATION OF NCDs IN HIV MANAGEMENT

Consolidate and Scale Up Efforts On

• HIV Drug Resistance
• AHD- (CCM, TB/HIV, Severe Bacterial Infection, Histoplasmosis)
• CaCx Mgt
• Hypertension and DM Mgt Intergration In HIV Mgt
• Mental Health Mgt Intergartion In HIV Care
Chapter 7: TB 74: Recommended first-line ARV regimens in
Children, adolescents, adults and pregnant or breastfeeding
women
Pregnant and breastfeeding women:
Adults and TAF + FTC +
adolescents ≥ DTG or TDF TDF + 3TC + EFV400 or TAF + FTC
30Kg + 3TC + DTG +EFV400
If DTG is contraindicated1: TDF + 3TC +
EFV400 or TAF + FTC +EFV400
If TDF or TAF is contraindicated2: ABC +
3TC +DTG
Pregnant and TAF +FTC +
If both TDF or TAF and DTG are
breastfeeding DTG or TDF
contraindicated: ABC +3TC +EFV400
women +3TC+ DTG
If EFV and DTG are contraindicated:
TDF +3TC + ATV/r or TAF + FTC
+ATV/r or ABC + 3TC + ATV/r
If DTG is contraindicated: ABC + 3TC +
LPV/r (tablets)
Children ABC + 3TC +
If ABC is contraindicated: AZT + 3TC +
≥20Kg- DTG or TAF
DTG or
<30Kg +FTC + DTG
TAF + 3TC + DTG (TAF in children> 6
years and ≥25Kg)
If intolerant or appropriate DTG
formulations are not available:
ABC +3TC + LPV/r (syrup, pellets, or
Children ABC + 3TC + tablets).
<20Kg DTG If intolerant to LPV/r: ABC + 3TC + EFV
(in children > 3 years and >10Kg)
If ABC is contraindicated: AZT + 3TC +
DTG or LPV/r

6
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Chapter 7: ART FOR PLHIV: MONITORING RESPONSE TO

ART- VL
• 6 months after ART initiation,
• then 12 months after ART initiation,
• and thereafter when established on ART
• 1 year for adults;
• 6 months for children & adolescents 0-19 years;
• and 3 months for pregnant and lactating women
• POC- VL testing may be used to monitor treatment.
• HIV DR recommended for all PLHIV to guide the next course of
treatment
• Incase more than one drugs are susceptible then refer to ART tables to
choose the preferred or alternative drug
Chapter 7

7
Chapter 6: Tb 81: Failing First line, Recommended Second- and third-line ART regimens for Pts
Recommended second
Failing first line Alternative second line
Population line regimen; guided by Third line regimens

8
regimens regimen
HIV DR
TAF + FTC + EFV or
TDF + 3TC+EFV or AZT+3TC+ DRV/r or
AZT+3TC+DTG
Adults and ATV/r
TDF+3TC+NVP
adolescents TAF + FTC + DTG or
AZT+3TC+DRV/r AZT+3TC+ATV/r
≥ 30Kg, TDF+3TC+DTG
including AZT+3TC+NVP , All third line regimens
pregnant and AZT+3TC+EFV , TAF + FTC + DTG or TAF + FTG + ATV/r or to be guided by HIV DR
breastfeeding ABC/3TC/NVP ABC+ TDF+3TC+DTG TDF+3TC+ATV/r resistance testing.
women 3TC+ EFV In case of susceptibility
AZT+3TC+DTG , TAF+ FTC + DRV/r or TAF+ FTC +ATV/r or to all drugs, use the table
ABC+3TC+DTG TDF+3TC+ DRV/r TDF+3TC+ATV/r to guide the preferred or
ABC+3TC+EFV , alternative choices.
AZT+3TC+DTG AZT+3TC+LPV/r
ABC+3TC+NVP
NOTE: For details on
ABC+3TC+LPV/r AZT+3TC+DTG AZT+3TC+ DRV/r
the third-line ART, please
Children ABC+3TC+DTG AZT+3TC+DRV/r AZT+3TC+LPV/r see the third-line ART
AZT+3TC+EFV , TAF + FTC + DTG or TAF+ FTC +LPV/r or implementation guides.
≥ 20Kg - AZT+3TC+NVP ABC+3TC+DTG ABC+3TC+LPVr
<30Kg TAF + FTC +DTG or TAF+ FTC + DRV/r or
AZT+3TC+LPV/r
ABC+3TC+DTG ABC+ 3TC+DRV/r
TAF+FTC + DRV/r or TAF + FTC +LPV/r or
AZT+3TC+DTG
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

ABC+3TC+ DRV/r ABC+3TC+ LPV/r

Children ABC+3TC+EFV , AZT+3TC+DTG AZT+3TC+LPV/r
<20Kg ABC+3TC+NVP
ABC+3TC+LPV/r AZT+3TC+DTG AZT+3TC+DRV/r
ABC+3TC+DTG AZT+3TC+ DRV/r AZT+3TC+ LPV/r
AZT+3TC+EFV , ABC+3TC+DTG ABC+3TC+LPV/r
AZT+3TC+NVP
AZT+3TC+LPV/r ABC+3TC+DTG ABC+3TC+DRV/r
AZT+3TC+DTG ABC+3TC+ DRV/r ABC+3TC+ LPV/r
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Chapter 7: DIFFERENTIATED SERVICES DELIVERY

• All PLHIV are eligible for differentiated Care and Treatment within or
outside HFs
• People established on ART should be offered refills of ART lasting 3–6
months, preferably every six months if feasible.
• ART can be initiated out of the HFs with possible 6 MMD
• Regions supported by IPs should implement interventions to trace people
who have disengaged from care and provide support for re-engagement

Chapter 7: Recommended Differentiated HIV Treatment and

Care Models and Approaches
Category of Recipient of Care
• PLHIV newly identified and or re-engaging in care when clinically well
• PLHIV newly identified and or re-engaging in care with advanced HIV disease
• PLHIV established on ART and or with controlled chronic illnesses / NCDs.
• PLHIV with uncontrolled chronic illness / NCDs, and any Drug limiting toxicities
• PLHIV with treatment failure
Treatment at Facility or in Community
Group Model Individual Model

Group models Individual models Individual model

Group models Managed based in community
Managed by based at facilities
by HCW
client Examples
Examples CRPDDP
Examples
Examples FTDR Drop in centers
FBG (e.g. FSG, Viraemia
CCLAD FBIM (e.g. Peer led models (e.g. YAPS,
clinics, G-ANC)
CLDDP Adolescent centers) Home ART delivery)
CDDP

Chapter 7: Definition of the Client Categories for Differentiating

HIV Care and Treatment
❑ PLHIV newly ❑ PLHIV newly ❑ PLHIV Established on ART and or with ❑ PLHIV with ❑ PLHIV with
identified and or identified and or Controlled chronic illnesses / NCDs Treatment Failure uncontrolled
re-engaging in re-engaging in chronic illness
care with care when / NCDs and
Advanced HIV clinically well any Drug
disease limiting
toxicities
✓ CD4 <200 ✓ CD4≥ 200 ✓ Receiving ART for at least 6 months ✓ 2 consecutive Non ✓ FBG ≥ 7mmol
cells/mm3 Cells/mm3 ✓ No current illness suppressed VL ≥ ✓ RBG ≥ 11mmol
✓ WHO stage 3 or ✓ WHO stage 1 ✓ Controlled chronic health conditions 1000 copies ✓ HTN ≥
4 at and 2 ✓ Good understanding of lifelong ✓ Has current or 140/90mmhg
presentation for adherence history of WHO ✓ SRQ≥ 6
care ✓ Evidence of treatment success (at stages 3 or 4 event ✓ Audit-C > 3
✓ Children < 5 least one suppressed VL in the last 6 within the past one ✓ HPV/VIA
years months) year. positive clients
✓ No ART limiting drug toxicity

9
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Chapter 7:..The 5 A’s criteria to choosing a preferred DSD approach.

Assess
Explain the purpose of the session
Assess the client’s barriers to adherence to DSD approaches
Assist
Evaluate the underlying causes of the identified barriers
Identify client-specific strategies to overcome identified barriers
Discuss the pros and cons of each strategy/option(s)
Advise
Give necessary information about the different approaches
Review benefits of good adherence in relation to DSD
Discuss consequences of non-adherence
Agree on
Agree on the client’s action points to address the key barriers
Evaluate each action point
The document agreed upon action points
Arrange
Summarize the session
Arrange for ART refill in the agreed upon approach
Schedule and Document the next appointment date on the visit session form
Refer and link to other services as appropriate

Chapter 7: Moving towards an integrated service delivery approach to micro-plan for most
vulnerable individuals, promote person-centered care, and efficiencies

AIM: Prevent transmission,

address mortality and provide
holistic support.
Data-driven micro-
planning
by multi-disciplinary AUDIT TOOL
teams to facilitate bi-
directional facility-
community linkage

Community attachment
10 households to one
Community Health Worker
AUDIT TOOL
Address service delivery gaps
at the household level

16

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Chapter 8: Integrating CQI into HIV services

• Establish health facility QI team

• Set up HIV work improvement teams (WIT)
• Identify gaps
• Gap analysis to get root causes
• Develop possible solutions
• Prioritizing solutions to address performance gaps
• Developing improvement projects using the documentation journal

Chapter 8: COMMODITY FLOW DIAGRAM

Chapter 8: NEW FORMULATIONS INTRODUCED

Dolutegravir/Emtricitabine/Tenofovir
Darunavir/Ritonavir 400/50mg (DRV/r
alafenamide 50/200/25mg
400/50mg)
(TAF/FTC/DTG 25/200/50mg)
Pack size

30 tablets Pack size: 60 tablets

90 tablets

Lopinavir/Ritovir 40/10MG Granules-Pack of 120

11
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.0 HIV TESTING SERVICES

AND LINKAGE TO HIV
CARE
2.1 INTRODUCTION
HIV testing is the entry point to HIV prevention, care, treatment, and
support services. The aim of HIV testing services (HTS) is to promptly
identify HIV status to ensure early linkage to prevention, treatment, and
support services. Data from the UPHIA of 2020 indicate that, only 81%
of the estimated 1.45 million HIV-positive persons aged 15 years and above
knew their HIV serostatus, 96% of those were on ART, and 92% of those
on ART were virally suppressed. To improve access and efficiency, HIV
testing services (HTS) should be made available to all persons at risk of HIV
infection using cost-effective and high-impact approaches. Because only 19%
of PLHIV aged 15 years and above do not know their status, HTS should
be differentiated to sub populations and geographical locations to identify
those remaining cases.
HTS delivery includes a range of activities and services that are described on
the pathway in Figure 2 below. This section guides the provision of quality
HTS for reaching populations most at risk of HIV. Health workers should
use this guidance alongside the National HIV Testing Services Policy and
Implementation Guidelines 2022.
Figure 2: Continuum of Linkage to Care and Prevention

Adopted from WHO consolidated guidelines on HTS, 2015.

2.2 PRINCIPLES OF HIV TESTING SERVICES (HTS)

2.2 PRINCIPLES OF HIV TESTING SERVICES (HTS)
HTS delivery shall be non-discriminatory and offered using a public health approach
HTS
thatdelivery
observesshall be (Confidentiality,
the 5Cs non-discriminatory andCounselling,
Consent, offered using a public
Correct health
test result and
Connection to appropriate services) irrespective of HTS approach. These
approach that observes the 5Cs (Confidentiality, Consent, Counselling, principles are
described below:

2.2.1 Guiding principles for HTS

12Table 1: Guiding principles for HIV Testing Services
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Correct test result and Connection to appropriate services) irrespective of

HTS approach. These principles are described below:
2.2.1 Guiding principles for HTS

Table 1: Guiding principles for HIV Testing Services

Consent  • All persons ≥12 years can consent to HTS on their
own. For children under 12 years of age, HIV testing shall
be done with the knowledge and consent of parents/
guardians.
• Mandatory testing should not be implemented. 
• Written consent shall be obtained for HIV testing.
• For HIV Self Testing, verbal consent shall be sufficient.
Confidenti- • All providers should ensure privacy during HTS provi-
ality  sion.
• All information discussed with clients should not be dis-
closed to another person without the client’s consent. 
• Confidentiality in the context of HIV Self Testing should
be maintained  around the distribution of HIV self-test
kits, testing and shared HIV self-test result.
• Shared confidentiality shall be acceptable if it’s in the best
interest of the client.
Counseling  • All persons accessing HTS should be provided with quality
counseling before and after testing as per HTS protocol.
• Quality counselling should be non-judgmental and client
centered.
• Provide adequate information before and after HIV Self
Testing to individuals through health worker demonstra-
tions, demonstration videos and print material, among oth-
ers.
Correct • HTS providers should adhere to the National Testing Al-
results  gorithm and must follow the Standard Operating Proce-
dures for HIV testing to ensure that clients receive correct
HIV test results.
Connec- • Providers should link HTS clients to appropriate HIV
tion/  prevention, treatment, care and support services. 
linkage to • Linkage should be done within 7 days (within the same
care facility) and within 14 days if referred to another facility
or from the community.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.3 HIV TESTING SERVICES PROTOCOL

The HTS protocol describes the minimum steps that shall be followed in
order to provide quality and effective HTS. For HTS to be complete, the
following key steps must be undertaken (see Figure 3):
• Demand creation/ health education
• HTS eligibility/Pre-test counseling/ information giving
• Testing for HIV
• Post-test Counseling
• Linkage into prevention, treatment, care and support services
Figure 3: The HTS Protocol

Demand creation/ health education

HTS eligibility and Pre-test counselling for all clients

All clients initiated by service All self-referred clients (CICT)

provider (PITC)

Individual, couple, group counselling/information giving

Clients who decide to test Clients who decide not to test

Consent obtained Provide counselling and encourage

testing

Sample collection and HIV test performance

Results giving and Post-test counselling

Appropriate referral and linkage to prevention, treatment, care and support

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

HTS service provision should follow the steps described in Table 2 below.
Table 2: HIV testing provision steps/protocol
Activity Description
1 Demand Demand creation refers to using communication
Creation approaches that influence attitude, perceptions, and
social norms to generate demand and utilization of
HTS.
In order to address behavioral and structural
barriers for HTS, a strategic mix of approaches
that include mass media, social media, interpersonal
communication, community dialogues, edutainment
and use of champions/ peer mobilisers/ satisfied
users should be utilized.
2. Pre-test • Re-assurance about confidentiality
information • Benefits of testing for HIV
and • Information pertaining to the modes of HIV
counseling/ transmission
Risk • Assessment for client risks
assessment • Possible results and their implications
• A brief procedure of the HIV testing process
• The potential for incorrect results if a person
already on ART is tested
• An explanation of the informed consent form
and possibility of opting out
• Other relevant information as the counsellor may
deem necessary
3. HIV testing This can be either an HIVST and/or following
the national testing algorithm. Will be done using
blood or oral fluid.
For those below 18 months, a DNA PCR test
will be done and those above 18 months an
antibody test will be done. Refer to the HIV testing
algorithms for the different age groups.
For more details on HIV testing, refer to the
HIV Testing Services Policy and implementation
guidelines 2022

15
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

4. Post-test Assess readiness to receive results. Give results

counseling simply and clearly. Address concerns, conduct
(individual/ risk reduction, encourage disclosure, and partner
couple) testing. Provide information on HIV prevention,
care, treatment and support services; complete the
HTS card and HTS register.
5. Linkage Link to appropriate HIV prevention, treatment,
to HIV care and support services. Complete/fill the HIV
Prevention, comprehensive referral form, Linkage and Pre-
Treatment, ART Register and other appropriate tools.
Care, and
support
Services

Note: Counselling for children should be age appropriate.

• For children aged below 12 years: Counselling should be
offered to the parent/guardian. The child should only attend the
counselling session if the parent/guardian finds it appropriate for
him/her to participate.
• For children aged 12 years and above: Individual counselling
should be offered to the child unless the child prefers to have the
parent/guardian to participate in the counselling session.
2.3.1 HTS Cascade

In Uganda, the HTS cascade shall follow the steps depicted in Figure 4
below.

16
2.3.1 HTS Cascade
In Uganda, the HTSConsolidated Guidelines
cascade shall for the
follow the Prevention
steps depictedand
in Treatment of HIV and Aids in Uganda - 2022
Figure 4 below.
Figure 4: The HTS Process

Figure 4: The HTS Process

Demand Creation HTS Promotion

Facility
HTS Entry Point

Community

CICT
HTS Approach

PICT

Pre-test Counselling/
Information giving

HTS Protocol HIV Testing

Post-test
Counselling

Prevention Services
Linkage & Referral

Care, Treatment and

Support

2.4 HTS ELIGIBILITY SCREENING

9
The following clients shall be screened for eligibility before HIV testing:
1. Adults and children in OPD Community
2. Clients seeking Voluntary Medical Male Circumcision
3. In-patients due to trauma and partners of pregnant and breast-feeding
women
The following clients may not require screening before testing and these
include:
1. Presumed/diagnosed TB clients
2. Malnourished individuals
3. In-patients
4. Clients with current STIs

17
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

5. Pregnant and breastfeeding women

6. Sexual offenders and survivors
7. Blood donors
8. Body tissue and organ donors
To optimize HTS, eligibility screening tools shall be utilized at both facility
and community settings. This should be conducted using either paediatric &
adolescent or adult screening tools that have been developed and validated.

2.5 THE CONCEPT OF TARGETED HIV TESTING

2.5.1 Definition

Targeted HIV testing is the process by which HTS is focused on an individual

or group of individuals who are at high risk of HIV acquisition. It requires
HTS providers to follow a set criterion (risk factors) to determine eligibility
of an individual or groups of individuals prior to HIV testing.
2.5.2 Why Targeted HIV testing?

To optimize HIV case identification and linkage to care and prevention

services, it is critical that the HTS program adopts a mix of effective and
cost-effective innovations and approaches as recommended in the National
Plan for Optimizing HIV Testing Services in Uganda, 2020/21-2022/23.
Based on the dynamics of the HIV epidemic in Uganda, specific risk factors
that drive the epidemic have been identified. HTS delivery shall be focused
on populations that are particularly at high risk of HIV acquisition.
These include:
1. Being in a sexual relationship with multiple concurrent partners
2. Belonging to a key, vulnerable or priority population (e.g., children,
adolescent girls and young women, pregnant or breastfeeding women)
3. Being a sexual contact to an index client
4. Being a biological child to an HIV positive client
5. Not knowing your partner’s HIV status
6. Being in a serodiscordant relationship
2.5.3 Benefits of Targeted HIV testing
• Prompt identification for population groups with high incidence
• Maximizes use of testing resources
• Permits health facilities to focus their activities on high-risk populations
• Yields a higher positivity rate than routine or conventional testing

18
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• Reduces workload and improves outcomes from constrained health

workforce
2.5.4 Targeted HIV Testing approaches in Uganda

In Uganda, targeted HIV testing is also referred to as ‘’risk-based testing’’

where HTS delivery focuses on people who are at increased risk of acquiring
HIV. The following approaches are utilized in risk-based testing to optimize
HIV case identification and linkage:
• Screening for HIV testing eligibility for children, adolescents and adults
• Index client testing (ICT), including Assisted Partner notification (APN)
and testing for biological children/ Know Your Child Status (KYCS).
• Social Network Strategy (SNS)
• HIV Self-Testing (HIVST)
HIV Testing Eligibility Screening Tool for Children and
Adolescents (18 months-14 years)
Guide for health workers
Purpose: This guide describes how to use the HIV testing eligibility screening
tool and job aid.
Applicability: This guide is applicable to all personnel involved in screening
children and adolescents aged 18 months to 14 years for eligibility to test for
HIV.
Procedure and instruction: The eligibility screening tool will be
administered either directly to adolescents aged 12 years and above or to the
caregivers of children aged below 12 years. Follow the instructions below:
i) Create rapport with the child/adolescent and caregiver.
ii) Assure confidentiality of all information being shared during the
process of eligibility screening.
iii) Be alert in observing both verbal and non-verbal communication from
the child/adolescent and/or caregiver during screening. Provide a
conducive environment for the child/adolescent and/or caregiver to
speak freely.
iv) Clarify any questions/issues/concerns to the child/adolescent and/or
the parent/caregiver.
v) Be empathetic.

19
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Table 3: Screening questions for all children and adolescents

<15 years
No Screening Guidance
Question
1 Is the child’s Ask the mother whether she knows her current HIV
mother HIV status. If the mother is not present, ask if the child or
positive? caregiver knows the HIV status of the child’s mother. The
response may be ‘Yes’ or ‘No.’ If the mother’s HIV status
is known, ask if positive or negative. If the mother’s HIV
status is positive, test the child for HIV. If the mother’s
HIV status is negative or not known, continue to ask
questions 2-6 as shown below.
2 Has the The answer to this question is ‘Yes’ if there has been
child/have any change in the health condition, even if it is relatively
you been minor. Ask if the child received medication or made a
sick in the clinic visit in the last 3 months, or if they were bedridden
last three or not playing.
months?
3 Has the You may need to ask this question in two parts:
child/have 1) If there was any skin problem (e.g., rash, itching and/or
you had sores) and 2) If these were recurrent.
recurring
Observe the child for any skin rash and/or scars
skin
suggestive of a previously treated skin rash. If child/
problems?
caregiver reports 1 or 2 isolated incidents of a skin
problem that disappeared on its own or with treatment,
select ‘No’ to this question.
4 Has the Weight loss may not be easy to determine. Use different
child/have examples to describe weight loss, such as a decrease in
you lost body size, muscles, and/or loose or sagging clothes.
weight in Choose either ‘Yes’ or ‘No’ depending on whether
the last few the child has lost weight in the last 3 months. If the
months? respondent is ‘Not sure’, the answer is likely to be ‘No’.
5 Has the Establish if the child has ever had or been treated for TB.
child/have Select ‘Yes’ if child has ever been diagnosed or treated for
you ever had TB. Select ‘No’ if TB was suspected but not confirmed,
TB? or a persistent cough is reported, or if child reports
that ‘I think I was treated for TB, but not sure’, or if the
caregiver reports this on behalf of the child.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

No Screening Guidance
Question
6 Is the child/ A child or caregiver may not easily be able to tell what
are you growing well means. To assess if a child is growing well,
growing ask if the child’s height, weight or milestones compare
well? with those of other children in the same class or of the
same age or not.
Determine if the child/adolescent is eligible for an HIV test using the tool
below:
Selecting children that should be tested: For each screening question on the
right, a “YES” response for the first four questions and “NO” for the last
question are shaded in gray because of their significance in determining if a
child should be tested.
• If the answer to the question, “Is the child’s mother HIV-positive?” is
‘Yes’, test the child for HIV.
• If the answer to the question, “Is the child’s mother HIV-positive?” is
‘No’ or ‘I don’t know’, ask the set of 5 questions to the right.
• If 2 or more responses to the 5 questions on the right shaded in gray are
selected, test the child for HIV.
Figure 5: Pediatric and Adolescent Eligibility Screening Tool
for HIV Testing (18 months to 14 years)

21
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 6: Eligibility Screening Tool for HIV Testing among adolescents and
adults (15 years and above)

THE HIV TESTING ALGORITHM FOR PERSONS AGED

18 MONTHS AND ABOVE
The HIV testing algorithm for persons aged 18 months and above is in
Figure 7 below. Note: if the child is still breastfeeding at 18 months or above
and the HIV test is negative, a final test should be done 3 months after the
child stops breastfeeding. See Figure 15 for the testing algorithm for infants
<18 months.

22
Note: if the child is still breastfeeding at 18 months or above and the HIV test is
negative, a final test should be done 3 months after the child stops breastfeeding. See
Figure 15 for the testing algorithm for infants <18 months.
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022
Figure 7: Serial HIV Testing Algorithm for testing persons above 18
months of age in Uganda, 2022
Figure 7: Serial HIV Testing Algorithm for testing persons
above 18 months of age in Uganda, 2022
Screening Test
DETERMINE

Non-Reactive Reactive

Report HIV Negative Confirmatory Test

STAT-PAK

Non-Reactive Reactive

Tie-Breaker Test Report HIV

SD BIOLINE
Positive

Non-Reactive Reactive

Report HIV Negative Report as INCONCLUSIVE

Re-test after 14 days
15

The HIV testing algorithm for persons aged 18 months of age and above
recommends: Determine as the screening test, Stat-Pak as the confirmatory
test and SD Bioline as the third test (tie-breaker). A reactive test on SD
Bioline is reported as inconclusive.
Note: An inconclusive result on the national HIV testing algorithm
does not deem SD Bioline an inferior test assay.

2.6 RESOLVING INCONCLUSIVE HIV TEST RESULTS

2.6.1 Resolving a second HIV inconclusive Test Result

For clients whose results are Inconclusive after the recommended 14 days
following a first inconclusive test result, a sample should be collected, labelled
“2nd INC” and sent to the national HIV reference laboratory (UVRI) for
testing. A result will be sent back as either POSITIVE or NEGATIVE.
Sample and result transportation will utilize the existing hub system.

23
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.6.2 Retesting for Verification

A retest for verification is not performed to assess the competency of the

first tester but it is a quality measure to ensure that a client who is enrolling
in HIV Care is TRULY HIV positive.
The re-test for verification shall be performed by a health worker (tester),
other than the one who performed the first test and using a different blood
sample drawn from the same individual (client). Retesting for verification
shall be performed at the point of ART Initiation. This may be performed
at the Mother Baby Care Point (MBCP), HIV/ART clinic or laboratory. The
respective national HIV testing algorithm must be followed during retesting
for verification (same algorithm in test event 1 and 2).
2.6.3 Resolving Discrepant results on retesting for
Verification

For clients whose results are NEGATIVE on retest for verification, samples
should be collected, labelled “Discrepant” and sent to the national HIV
reference laboratory (UVRI) for testing. A result will be sent back as either
POSITIVE or NEGATIVE. Sample and result transportation will utilize the
existing hub system.
Note: Before discrepant results are sent to national HIV reference laboratory
(UVRI), rule out errors at facility level such improper handling of samples or
testing kits and personnel incompetence. To ensure accuracy and reliability
of HIV test results, the World Health Organization recommends this for all
HIV antibody tie breaker tests. Therefore, the final HIV test result in the
HTS client card, HTS Register, and the Daily Activity Register should be
recorded as: NEGATIVE, POSITIVE, or INCONCLUSIVE.

2.7 MODELS & APPROACHES FOR HIV TESTING

SERVICES
To improve access and efficiency of HTS, a mix of health facility and
community-based models should be utilized. Under each of these models,
the two main approaches for HTS will include: provider-initiated HIV testing
and counseling (PITC) and client-initiated testing and counseling (CITC). The
figure below provides a diagrammatic flow of HTS models and approaches
in Uganda. HIV Self Testing shall be provided as an additional testing option
across both testing models. Reporting for HTS shall be synchronized and
aligned to these models to track efficiency of each.

24
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.8 HTS AT HEALTH FACILITIES

Within the decentralized health system, HTS shall be offered up to HC II
level. At HC IIs, HTS should be offered under supervision of higher-level
health facilities. Both PITC and CICT shall be provided in health facilities by
either the conventional HIV testing using the national algorithm or HIVST.
Provider-initiated HIV testing and counseling (PITC)
PITC should be conducted in either a health facility or community setting
and is initiated by a health worker.
Figure 8: Differentiated HIV Testing Services Models and
Approaches for Uganda

In this approach, health workers should screen for eligibility as a standard

of care to clients. Adequate information should be provided to clients
In this approach, health workers should screen for eligibility as a standard of care to
about the benefits of testing to enable them to make an informed decision.
clients. Adequate information should be provided to clients about the benefits of testing
Service
to enable delivery points
them to make for PITC
an informed include
decision. ServiceMaternal andforChild
delivery points PITC Health,
include adult
and paediatric
Maternal in-patient
and Child Health, adultwards, TB clinics,
and paediatric nutrition
in-patient wards, TB units,
clinics,family planning
nutrition
clinics, Sexually
units, family Transmitted
planning Infections
clinics, Sexually clinics,
Transmitted Out Patient
Infections Department
clinics, Out Patient and
Department
clinics and clinics
managing managingofsurvivors
survivors sexual ofabuse.
sexual See
abuse. See section
section 6.5 6.5in in
thethenational
national HTS policy and implementation guidelines 2022 for details on integration of
HTS policy and implementation guidelines 2022 for details on integration of
HTS. PITC shall include diagnostic testing as well as routine testing.
HTS. PITC shall include diagnostic testing as well as routine testing.

25
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.8.2 Diagnostic testing

This shall be carried out on individuals as deemed necessary by the attending

health care team with the purpose of better patient management. Such
situations may include symptomatic, unconscious, very sick and mentally
impaired patients. Through PITC, the patient or attendant should be given an
opportunity to know his/her status to promote adherence; prevent further
transmission and enhance psychosocial support for the patient.
2.8.3 Routine HIV testing

This shall be carried out for individuals likely to cause a risk of HIV infection
to others. The following individuals shall be offered routine testing in
reference to the Uganda HIV prevention and Control Act 2014:
• Pregnant and breastfeeding women
• Partners of pregnant and breastfeeding women
• Donors of blood, body tissue and organs.
• Sexual offenders and survivors
2.8.4 Client-initiated testing and counseling (CITC)

In this approach, individuals and couples willingly seek HTS either from the
health facility or a preferred community setting and follow the approved
HTS protocol. CICT should be offered to individuals or couples after risk
screening.
2.9 HTS At Community Settings

HTS in communities will aim to serve populations that would otherwise

not attend facility-based HTS. Services should be offered in homes, social
gatherings, education establishments, DICs, safe spaces and at workplaces
by either using the conventional HIV testing or HIV Self Testing national
algorithm.
Programs offering HTS at community level shall ensure that follow-up and
linkage to prevention, care, treatment and other support services follow
respective protocols.
HTS in community settings shall aim to offer an integrated package of
primary health care services, including STI screening and management, child
health services and other health promotion interventions. Recording and
reporting community HTS will utilise Ministry of Health reporting tools.
HTS at community level should be offered in the ways as listed below:

26
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.9.1 Outreach HIV testing services

Outreach HTS can be offered by higher to lower-level health facilities or

to communities through planned and regular visits to the outreach sites or
through community camping where outreach sites are inaccessible.
Note: HTS outreaches for general populations as well as during public
campaigns are discouraged.
2.9.2 Home Based HIV Counselling and Testing (HBHCT)

HBHCT shall follow two main models:

• Door-to-door testing for all consenting individuals, couples or families in
a specified geographic area.
• Index client contact tracing and testing that is offered to households with
a consenting PLHIV or person with active or presumptive TB (index
client).
Door-to-door testing may be implemented ONLY in high HIV prevalence
settings or communities for key populations such as, hotspots for sex workers,
men who have sex with men, or through the snow-ball approach.
HBHCT should be arranged in collaboration with existing health facilities
and community support groups to ensure on-going care for persons who are
offered HTS. HBHCT should offer the benefits of supported disclosure and
adherence to ART and other medications.
2.9.3 HTS at the workplace

Workplace HTS conveniently provides HIV testing to individuals at their

place of work. These are usually individuals whose work schedules do not
permit them to leave their workplaces in search of health care. Workplace
testing should be implemented with high levels of uptake and linkage to care
and prevention services, particularly in high burden settings. Providers should
ensure confidentiality, non-coercion and effective linkage to prevention, care,
treatment and support services.
Employers in Uganda should mainstream the provision of HTS to employees
and their families in the workplace as an integral component of staff welfare.
HIV testing services at workplaces should be offered within the workplace in
collaboration with health facilities that provide care treatment and prevention
services.

27
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.9.4 HTS in Educational Institutions

HIV testing services in educational establishments should address sexually

active youth in the context of sexual health education and behaviour
change interventions. Provision of HTS in education institutions in Uganda
should be done according to the National School Health Policy. HTS at the
educational institutions should be implemented with high levels of uptake
and linkage to care and prevention services
2.9.5 Mobile HTS

HTS is offered by mobile teams at hotspots for key and priority populations.
2.9.6 Drop-In Centres (DICs)

Drop-in Centres (DICs) are service delivery points targeting special

sub-populations (Key Populations, Priority Populations and Vulnerable
Populations), who would otherwise fail to access health services including
HTS. These can be established by Community Based Organisations or
Ministry Of Health together with its partners. Members of the general
population should not be denied services at these sites.
The objectives of Drop In Centres are to promote and improve the quality of
life through building capacity and skills empowerment, creating an enabling
environment, establishing linkages with existing health services, Non-
Government Organizations, Community Based Organizations and other
welfare and development programs, and protecting and promoting the rights
of the Key Populations, Priority Populations and Vulnerable Populations.
For Key Populations, Priority Populations and Vulnerable Populations, a
growing number of Community Based Organizations are utilising Drop In
Centres to provide HTS.

2.10 INDEX TESTING

2.10.1 Index testing

Index testing involves tracing contacts of index HIV- positive clients and
offering them testing services. Examples of these approaches include:
i) Assisted partner notification (APN)
ii) Index client testing for biological children/ Know Your Child Status
(KYCS)

28
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.10.2 Assisted Partner Notification (APN)

APN is part of a comprehensive array of services offered to persons infected

with HIV or Sexually Transmitted Diseases and their partners. APN is a
process through which HIV-positive index clients are interviewed to elicit
information about their sexual partners, who can then be confidentially
notified of their possible exposure or potential risk and offered HTS. Index
clients should be encouraged to notify past partners, in addition to current
partners, and engage them in testing services. APN is voluntary, confidential,
client-centred, and free, for both the index client and his/her partner(s).
addition
For to currentinformation
additional partners, and refer
engagetothemtheinHTS
testingPolicy
services.
andAPN is voluntary,
Implementation
confidential, client-centred, and free, for both the index client and his/her partner(s).
Guidelines 2022.
For additional information refer to the HTS Policy and Implementation Guidelines 2022.
2.10.3 Components of Assisted Partner Notification Services
2.10.3 Components of Assisted Partner Notification Services
APN includes,partner
APN includes, partner elicitation
elicitation and notification,
and notification, counselling
counselling andfortesting
and testing HIV for
HIV linkage to HIV care, treatment, prevention and other services as
linkage to HIV care, treatment, prevention and other services as shown in the figure shown
in the figure below.
below.
Figure 9: Components of Assisted Partner Notification
Figure 9: Components
Servicesof Assisted Partner Notification Services

2.10.4 Target Populations for APN

2.10.4 Target Populations for APN
The
The target
target populations
populations forfor APN
APN areare individuals
individuals aged aged 15 and
15 years years andwith
above above with
high
high likelihood to transmit HIV to their partner(s).
likelihood to transmit HIV to their partner(s).
These include:
These include:
• All persons newly diagnosed with HIV including those on ART for less than 6
months
• PLHIV on ART with an identified risk (e.g., new sexual partner(s), People Who Use
and Inject Drugs sharing contact(s), or STI diagnosis.)
• On ART but non- virally suppressed 29
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• All persons newly diagnosed with HIV including those on ART for less
than 6 months
• PLHIV on ART with an identified risk (e.g., new sexual partner(s), People
Who Use and Inject Drugs sharing contact(s), or STI diagnosis.)
• On ART but non- virally suppressed (including individuals with VL>200
copies/ml and 400 copies/ml for plasma and DBS respectively)
• Adolescents living with HIV below 15 years of age who are sexually active
and meet any of the above criteria
2.10.5 Principles of APN

The principles of APN as stipulated in table 3 below include: voluntary and

non-coercive; free; non-judgemental; confidential; client centred and focused;
comprehensive and integrative; culturally and linguistically appropriate; and
available and accessible to all clients.
Table 4: Principles of APN
Voluntary and APN is never coercive or mandatory and always relies
non- coercive on the willing participation of HIV-infected persons
and their partners. Providers should encourage patient
participation in APN by fostering rapport and an
atmosphere of trust and mutual respect. All service
recipients should be informed of benefits and risks
from participating in APN.
Confidential All information (both print and electronic) regarding
index clients and their partners should be kept
strictly confidential and not accessible or disclosed
to anyone other than those who are authorized to
have access (APN providers and their supervisors).
Strict adherence to confidentiality should be followed
during attempts to contact the patient, initial interview,
notification of partners and subsequent contacts and
re-interviews.
During attempts to locate and schedule an interview
with a patient, the APN provider should not disclose
to anyone other than the patient the reason for locating
the patient. The HIV status or any other potential
HIV-identifying information is discussed with only the
patient and authorized public health staff.

30
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Client-centered All communication with patients should be centered

and focused on the needs of the patient. The APN process should
be tailored to the behaviors, circumstances, and
specific needs of each patient.
Comprehensive APN staff should be part and parcel of health services
and Integrative that are integrated to the greatest extent possible for
persons with HIV infection or other STDs and their
partners.
Available and APN staff should be available for persons who test
accessible to all HIV positive. All individuals who test positive should
clients be informed of the option of obtaining APN without
disclosing their identity or having their HIV test
result disclosed. If the patient decides to participate
in APN, the HIV counseling and testing provider
trained on APN can provide APN at a place and time
convenient to the patient. Partners of a person with
HIV are notified of their HIV risk and are informed
of anonymous and confidential testing options.
2.10.6 Partner Notification Methods

There are four notable partner notification methods as described below:

1. Provider Referral = The HTS provider will contact the partner(s) of
an index client, and offer them HTS.
2. Client Referral = The index client informs their partner(s) about the
need for them to test for HIV.
3. Contact Referral = The index client and HTS provider shall work
together to notify the index client’s partner(s). The index client shall be
given 14 days to inform their partner(s) of the need to test for HIV. If
after 14 days the index client has not yet informed his/her partner(s)
the HTS provider shall contact the partner(s) and offer HTS.
4. Dual Referral = The HTS provider will sit with the index client and
their partner(s) and discuss the need for HIV testing.
2.10.7 APN Implementation Process

The following steps shall be involved in the delivery of APN services:

Step 1: Index client Identification
Step 2: Index Client Interview and Elicitation
Step 3: Partner Notification

31
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

a) Index client Notification

b) Assisted/Provider Notification
Step 4: Partner Counselled and Referred to or Linked to Care Services:
Step 5: Case Closure
Figure 10: APN Flow Chart

2.10.8 Adverse Events / Challenges in APN

2.10.8 Adverse Events / Challenges in APN
During
During APN implementation,adverse
APN implementation, adverseevents
eventsmaymayarise
arise and
and therefore
therefore APN
APN staff should
staff should follow appropriate national implementation Guidelines and
follow appropriate national implementation Guidelines and Protocols to mitigate them.
Protocols to mitigate them. The common adverse events include index
The common
clients’ adverseofevents
acceptability APNinclude index
services, theclients’ acceptability
potential of APN
for patient abuseservices,
or the
potential
harm for patient
resulting fromabuse or harm
partner resultingand
notification, fromthepartner notification,
potential negativeand the potential
effects
on relationships between patients and their partners including physical,
negative effects on relationships between patients and their partners including physical,
social, economic, and emotional harm.
social, economic, and emotional harm.
All APN providers shall be trained on the how to access and mitigate adverse
events that impact implementation of APN services. Such training shall
All APN
cover, providers
among others:shall be trained on the how to access and mitigate adverse events
• that impact implementation
Maximizing acceptabilityofofAPNAPNservices.
among Such trainingand
patients shallminimizing
cover, among
theothers:
negative effects resulting from notifying partners of their risk.
• Maximizing acceptability of APN among patients and minimizing the
negative effects resulting from notifying partners of their risk.
32
• Risks associated with home/field visits and how to assess the safety of each
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• Risks associated with home/field visits and how to assess the safety of
each situation.
• Following appropriate safety Policies and Guidelines regarding field or
home visits which should emphasize safety as a priority.
• Keeping supervisors and/or colleagues aware of their field visit
appointments and locations.
• Counseling and communication skills.
2.10.9 Index client testing for biological children/Know Your
Child’s HIV Status

HIV positive clients and /or TB patients in care should be mobilized to bring
their biological children and other household members whose HIV status is
unknown for HIV testing. This also applies to HIV exposed infants whose
mother accesses postnatal care (PNC), young child clinics (YCCs), family
planning (FP) and/or gynecological services e.g., STI or cervical cancer
screening.
When conducting partner services, it is also important to offer HIV testing
services to the biological children (2 -19 years) of the HIV-positive client,
when their HIV status is unknown. Index testing shall also be offered to
nonbiological children (2 -19 years) not born to the index client but living
in the same household. In all settings biological children of a parent with
HIV should be routinely offered HTS and if found to have HIV or to be at
high risk for infection through breastfeeding, should be linked to services for
treatment or prevention.
2.10.10 Social Network Testing Strategy (SNS)

Social network strategy (SNS) is a case-finding strategy that uses social

network connections to locate individuals at high risk for HIV. SNS can be
particularly useful in finding Key Populations and others who are at risk for
HIV.
Social network strategy addresses some of the challenges in scaling up HIV
partner services among Key Populations and other high-risk individuals,
particularly issues of confidentiality. By addressing confidentiality concerns,
Social network strategy broadens the reach of partner services to include
both HIV-positive and HIV-negative members of Key Populations and
other high-risk individuals, their partners, social contacts and networks and
other persons who are at risk of HIV but do not have easy access to HTS.

33
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Underlying assumption – people in the same social network share similar risk
behaviours for HIV
The overall SNS strategy is aimed at enlisting HIV-positive and high-risk
HIV negative persons (recruiters) who identify individuals from their social
networks for HTS.
SNS shall be implemented using the following appropriate tools:
• Standard Operating Procedures (SOPs)
• Facility registers
• Periodic reporting templates
Social network strategy processes shall involve training of health workers,
identification of facility-based focal persons, identification of eligible high-
risk clients including Key Populations and other high-risk individuals,
for each social contact, developing appropriate notification plan(s) for the social conta
conducting risk assessment for each social contact, developing appropriate
(time, method, means of contact) to ensure he/she receives an HIV test.
notification plan(s) for the social contact (time, method, means of contact)
to ensure he/she receives an HIV test.
Note:
Note: i) Social contacts being tested should be linked to appropriate care, treatment
i) Social contacts being tested should be linked to appropriate care,
prevention and support services
treatment, prevention and support services
ii) All ii) named social social
All named contacts will be
contacts willsubjected totothe
be subjected the HTS screeningtools
HTS screening
tools
SNS shall be implemented following four phases as illustrated in figure 8 below.
SNS shall be implemented following four phases as illustrated in figure 8
below.
Figure 11: SNS Implementation – Four Phases
Figure 11: SNS Implementation – Four Phases

Figure 12: Differences in SNS and Index Testing

34
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 12: Differences in SNS and Index Testing

Figure 12: Differences in SNS and Index Testing

2.10.11 Accreditation of Health facilities to offer index client

testing services 28

Index client testing (ICT) services should meet the HTS ethical principles
of the 5Cs which include consent, confidentiality, counselling, correct test
results and connection to HIV prevention, care, treatment and support
services. Health facilities (sites) offering Index client testing services should
ensure that appropriate systems are in place for testing, identification and
responding to clients who disclose and fear or experience IPV from (a)
partner(s). Mechanisms must be in place to monitor and address adverse
events arising from the provision of Index client testing services.
The assessment for Index client testing shall be conducted using the minimum
standards checklist provided by OGAC as it meets all the essential elements
for quality Index client testing. The tool consists of 5 sections; however,
section one (1) which consists of 33 checklist scores shall be the minimum
for accreditation.
For details on accreditation on Index client testing services, refer to
the HTS policy and implementation guidelines 2022

2.11 HIV SELF-TESTING

HIV self-testing (HIVST) is a process in which a person collects his or her
own specimen (oral fluid or blood) and then performs a test and interprets
the result, often in a private setting, either alone or with someone he or
she trusts. Prior to offering HIV self-testing, clients shall be screened for

35
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

eligibility according to the HTS screening protocol. HIV self-testing is a

screening test (test for triage) and is not sufficient to make an HIV-positive
diagnosis. Therefore, a reactive (positive) self-test result should be confirmed
using the validated national testing algorithm by a trained HTS provider.
HIVST results shall be reported and documented accordingly.
2.11.1 Guiding Principles for Implementation of HIVST

The 5C’s guiding principles should be followed while delivering HIVST

services: (Refer to Table 4 principles of APN testing)
2.11.2 Approaches to HIV self-testing

HIV self-testing will be provided through two main approaches:

Directly Assisted self-testing
A trained provider (a health worker, distributor or peer) supervises/assists
an individual in performing the HIV self-testing. This involves an in-person
demonstration before or during HIV self-testing, on how to perform the
self-test and interpret results. This is in addition to the manufacturer-
supplied instructions for use and other materials. Caregivers can directly
assist children 18 Months -14 years to administer a self-test, if oriented by a
trained provider.
Unassisted Self-Testing
Individuals are given HIV self-testing kits and they conduct the test and
interpret results without any supervision or assistance from a trained provider
(health provider, distributor or peer). However, general information on how
to conduct the test should be made available to the user with additional
manufacturer’s instructions, telephone hot line, instructional videos, leaflets,
social media and other internet-based links.
2.11.3 Target Populations for HIVST

The following population groups will be prioritized for HIV self-testing in

Uganda:
• Children 2 -14 years (caregiver assisted oral screening)
• Adolescent Girls & Young Women & Boys (AGYWB)
• Individuals above 50 years and above
• Men including partners of pregnant women and lactating mothers
• Key populations and priority populations
• General population (through the private sector)

36
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.11.4 HIVST for PrEP and VMMC

Blood-based HIVST is an alternative for PrEP refill in case of absence of

the national HTS standard recommended in patients on PrEP.
All individuals presenting for VMMC will now be tested for HIV regardless
of age and risk.
2.11.5 HIV self-testing /Distribution Channels

HIV self-testing will be implemented through different distribution channels

targeting different populations in the public and private sectors. Figure 8
shows the distribution channels that will be used to implement HIV self-
testing. Additional evidence based channels may be adopted.
HIV self-testing kits may be distributed through primary or secondary
modes both at the facility or community. For primary distribution, HIV
self-testing kits will be distributed to primary recipients for self-use. With
secondary distribution a primary client will take the HIV self-testing kit to
their partner(s) or social contacts along with instructional materials on how
to use them. Additional informational for linkage and treatment should also
be provided.
Figure
Figure 13: 13: Distribution
HIVST HIVST Distribution Channels
Channels

2.11.5 Misuse and Adverse events associated with HIV self-testing

Misuse and adverse events associated with HIVST should be assessed pre-and post-
distribution:

• Individuals who disclose any form of violence by an intimate partner or social

contact should be offered immediate support. Health care providers should offer
first line support when clients disclose violence.
37
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.11.6 Misuse and Adverse events associated with HIV self-

testing

Misuse and adverse events associated with HIVST should be assessed pre-
and post-distribution:
Individuals who disclose any form of violence by an intimate partner or
social contact should be offered immediate support. Health care providers
should offer first line support when clients disclose violence.
Do not provide HIV self-testing kits for secondary distribution to clients
experiencing intimate partner violence. Partners of individuals experiencing
intimate partner violence should be offered alternative HIV testing services.
A person testing negative is advised to re-test as per the national retesting
guidelines.
The HIV Self Testing is NOT suitable for users who are taking antiretroviral
treatment (ART)
There should be a system (framework) in place to report and document
adverse events experienced during the provision of HIVST services.
Providers experiencing adverse events should equally be offered first line
support.
These events should be appropriately reported and documented using the
standardised HMIS tools.

2.12 MATERNAL AND INFANT TESTING

2.12.1 Maternal and Child Health- HIV and Syphilis Testing
Algorithm

Within Maternal and Child Health settings, the HIV/syphilis duo test kit will
be used as a screening test for both women and their partners. Stat-Pak shall
be used for HIV test confirmation. Women who are already known HIV
positive will still need to test for syphilis using the single rapid syphilis test as
depicted in Figure 14 below.
For samples that react on HIV syphilis duo but do not react on Stat-Pak the
tester shall utilize the national HIV testing algorithm.. Index testing should
be provided for those testing positive for HIV and/or syphilis.

38
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 14: HIV Testing Algorithm using the HIV-Syphilis Duo

Kit in MCH Settings

2.12.2 HIV Testing Algorithm For Infants And Children

Below 18 Months Of Age/ Early Infant Diagnosis (EID)
Cascade

In sub-Saharan Africa approximately half of perinatally infected and a

quarter of infants infected through breastfeeding will die before their second
birthday, compared to <5% infant mortality in HIV-exposed uninfected
infant1. The cascade of care required for optimally effective EID programs,
essentially has two primary goals:
1. Correctly inform caregivers of infant infection status, and
2. Link all HIV-infected infants to care and ART.
Diagnosing HIV among infants is prudent and should be done at 4-6 weeks
or at the earliest opportunity thereafter. All infants diagnosed with HIV
should be initiated on ART immediately to reduce morbidity and mortality.
A virological test (DNA/PCR) is recommended for determining HIV status
in infants and children below 18 months of age. The sample for testing
should be collected using dried blood spot (DBS) specimens.
2.12.3 HIV testing schedule for infants
1 Davies M-A et al. Survival of HIV-1 vertically infected children. Curr Opin HIV AIDS
2016; 11(5): 455-464.

39
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

The 1st DNA/PCR test should be done at four to six weeks of age or the
earliest opportunity thereafter. A 2nd DNA/PCR test has been introduced at
9 months of age for all infants irrespective of breastfeeding status. The 3rd
PCR should be done 6 weeks after cessation of breastfeeding. Interpretation
of the results and further testing are guided by the testing algorithm in Figure
15 below.
A positive DNA/PCR test result indicates that the child is HIV-positive.
All infants with a positive DNA/PCR test result should be initiated on
ART immediately and another blood sample should be collected on the day
of ART initiation to confirm the positive DNA/PCR HIV test result. A
negative 1st DNA/PCR test result means that the child is HIV-negative but
could become infected if they are still breastfeeding. Infants testing HIV-
negative on the first DNA/PCR should be retested using DNA/PCR at 9
months of age irrespective of breastfeeding status and retested again at six
weeks after cessation of breastfeeding. Infants with negative third DNA/
testPCR test have
should should haverapid
a final a final rapid antibody
antibody test performed
test performed at 18using
at 18 months months
the
using the national HIV testing
national HIV testing algorithm. algorithm.
Figure
Figure 15:
15: HIV HIValgorithm
testing testing algorithm for children
for children <18of
<18 months months
age of age

Note:40A rapid HIV antibody test can be used to establish if an infant is exposed to HIV
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Note: A rapid HIV antibody test can be used to establish if an infant is

exposed to HIV before the age of 18 months. This can be done if the infant
doesn’t present at the health facility with the biological mother. A reactive
HIV rapid antibody test will confirm exposure to HIV but not HIV infection.
In that case, if the HIV test is reactive, a DNA PCR sample should be taken
as explained above to establish if the infant is HIV-positive or not.

2.13 RE-TESTING OF NEWLY IDENTIFIED HIV

POSITIVE PEOPLE
All newly identified HIV positive people, should be retested before initiating
ART. This should be performed by a different tester using the approved
national HIV testing algorithm at the ART initiation site/ care point. Table 6
below shows the categories of people to retest at specified time-points.
2.13.1 Retesting clients on ART

Retesting clients on ART is not recommended because most of these clients

turn out with false HIV negative results.
2.13.2 Repeat Testing

Repeat testing should be conducted in specified circumstances to rule out

laboratory or transcription errors and either to rule in or rule out sero-
conversion. This could be followed by supplemental testing where additional
assay(s) not used in the first testing algorithm may be used on the same
specimens to obtain more information about the HIV test result.
Repeat testing for individuals thought to be in the window period is needed
ONLY for those who report specific recent risk.
Table 6: Categories of HIV-negative persons to retest at
specified time points
Population category When to re-test
Individuals exposed to Four weeks after the 1st test
HIV within four weeks
before HIV testing
Key populations Depending on risk of exposure in the past 3
months
HIV-negative partners Depending on risk of exposure in the past 3
in discordant couples months

41
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Pregnant women 1st trimester/1st ANC visit, again in the 3rd

trimester for negative or unknown status women,
with catch-up during labor or delivery for any
women who missed HIV tests during ANC.
Breastfeeding women Every three months until three months after
cessation of breastfeeding. Align retesting to child
immunization schedule as possible.
Confirmed and Four weeks after the 1st test
presumptive TB Patients
TB, Hepatitis and STI Four weeks after testing
patients
PEP clients At one month, three months and six months after
completing the PEP course
PrEP Depends on risk of exposure in the past 3
months
HIV-exposed infants 4-6 weeks, 9 months of age, six weeks after
(HEIs) cessation of breastfeeding and at 18 months of
age
Children who are still 3 months after cessation of breastfeeding
breastfeeding beyond
18 months of age
INCONCLUSIVE 14 days after the last test
results
Children and Risk based with exceptions explained earlier in
adolescents (2-14years) these guidelines
Family planning clients Risk based
Sexual offenders and Four weeks after the 1st test
survivors of SGBV
Index testing-Sexual Four weeks after the 1st test
partners
Blood, Tissue Four weeks after the 1st test
donors
General Population Once a year depending on risk of exposure for
the duration in which they have not had an HIV
test > 3 months

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.13.3 Recent HIV Infection Surveillance

All newly-diagnosed HIV cases by the national HIV testing algorithm

aged 15 years or older will be tested for HIV recent infection and routinely
monitored by demographic and risk characteristics, Justification: As Uganda
moves closer towards reaching 95-95-95 goals and sustained epidemic
control, it is important to have individual-level data to monitor trends in the
actual number of newly-diagnosed individuals with HIV. Also, information
on the timing of HIV infection using tests for recent infection among newly-
diagnosed persons provide important information on where and among
whom recent transmission is occurring to guide rapid public health response
efforts. These data will allow Uganda to better target HIV prevention
programs to subpopulations and locations with a high burden of HIV and
ongoing transmission.
Implementation guidance: HIV recent infection testing will be conducted
at the health facility as well as the community level. At the facility, recent
infection testing will be done at the HTS and Key Populations friendly service
delivery points. At the community level, HIV recent infection testing will be
integrated in the HTS outreach services and conducted at the outreach HTS
service delivery points targeting key populations.
Eligible clients will be consented before testing for HIV recent infections.
During the consenting process, clients will be provided with information
on the purpose, risks, benefits, confidentiality and voluntary nature of
participation. They will also be informed that their results will not be returned.
In testing for HIV recent infections, a point- of-care rapid test for recent
infection (RTRI) or any other approved assay will be used to test HIV recent
infection. Whole blood, plasma or serum may be used in conducting recent
infection testing.
Interpretation of HIV Rapid Test for recent infection will follow the guidance
depicted in Figure 14 below.
Recency testing data collection and use: Data on recent infection testing will
be collected using approved HTS card, HTS addendum and HTS register.
Collected data will be entered in Electronic Medical Record system and
uploaded to the central server hosted by Central Public Health Laboratory
(CPHL). This data will used for surveillance and public response only and
not used for diagnostic purposes

43
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 16: HIV Rapid Test for Recent Infection Interpretation

V-Control line; V-Positive verification line; VL-Long term line

Recent infection testing algorithm (RITA): As part of laboratory quality

control, clients who consent for point of care testing for recency are also
consent to provide extra blood sample for shipment to Uganda Virus Research
Institute (UVRI) for Viral Load testing and re-testing. RITA combines results
of recent infection assay and viral load for final interpretation of recency
status. Specimens that test recent on RTRI with a viral load result ≥1,000
copies/mL, will be classified as a RITA recent infection while specimens
that test recent on RTRI with a viral load result <1,000 copies/mL will be
classified as a RITA Long term infection. Including the additional VL reduces
misclassification of an infection as a recent infection when the infection is
actually long term.

2.15 LINKAGE TO HIV SERVICES

Linkage refers to an act of connecting an individual from one point of care
to another. The second 95 in the UNAIDS fast-track targets of 95-95-95 by
the year 2030 is “linkage of 95% of HIV positive individuals to treatment”.
Without effective strategies that ensure linkage and enrolment in care, the
effect of HTS in reducing HIV transmission, morbidity and mortality cannot
be fully realized. It is therefore the mandate of the HTS program to ensure
identification and linkage of HIV positive individuals to care, treatment,
support and prevention services.
HTS providers should address barriers to linkage to ease the process for
PLHIV. Barriers may include:
• Client factors such as feeling healthy, depression, lack of social or family
support and fear of disclosure
• Social or cultural factors such as stigma and discrimination
• Structural or economic factors; including legal issues and lack of
transportation, health system barriers, such as poor referrals, stigmatizing
or unfriendly services and long waiting times in facilities

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.15.1 Community-Facility, Intra and Inter-facility linkages

Linkage of HTS clients can be inter-facility, intra-facility or community-

facility.
2.15.2 Intra-facility linkage

Intra-facility linkage refers to connecting a client from one point of care to

another within the same facility. Intra-facility linkage should be encouraged
for facilities that are accredited to offer HIV treatment. However, clients
should be given an opportunity to choose the most appropriate facility to
receive care, treatment or prevention services from. All intra-facility linkages
shall be on the same day and where not possible, should be effected within
7 days.
The process of linkage within the same health facility is described in Figure
19 below.
Figure 19: Intra Health Facility Linkages for HIV Positive individuals

2.15.3 Inter-facility linkage

Inter-facility linkage refers to connecting clients from one facility to another

facility for HIV treatment, care, and support services. The referring facility
should track all HIV-positive clients referred to other facilities and ensure

45
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

they are enrolled in HIV care and treatment within 14 days, using the tracking
schedule described in Table 7 below.
Table 7: Schedule for the tracking of inter-facility linkages
for HIV positive individuals
Timeline Action
Day 1 • A client diagnosed HIV positive and referred to the
(referral day) facility of choice.
• Linkage facilitator documents clients’ contacts.
• Linkage facilitator obtains client’s consent for home
visiting.
• Linkage facilitator introduces the client to community
health worker.
Week 1 • Linkage facilitator calls a client or the contact in the
health facility where the client was referred to.
• If client reached the new facility, document complete
linkage.
• If the client didn’t reach the new facility by week 1, the
community health worker (VHT) visits client’s home to
remind about the referral.
Week 2 • Linkage facilitator calls client or new facility to confirm
if the VHT visit to client’s home made any impact.
If client reached the new facility, document complete
linkage.
• If the client didn’t reach the new facility, the linkage
facilitator visits client’s home to discuss reasons for the
client’s failure to reach the referral point.
• Linkage facilitator calls client or facility to confirm if
client reached. If yes, document linkage as complete. If
no, document as lost.
2.15.4 Community-Facility Linkage

Community-facility linkage refers to connecting a client in the community to

a health facility for HIV, treatment, care, prevention, and support services.
HTS programs shall work with peer leaders, expert clients, YAPS, VHTs
and CHEWs to create demand for community HIV testing approaches,
referral and follow up of all individuals for appropriate services. Linkage
from community to facility shall be done within 14 days. The process of
community-facility linkage is described in Table 8.

46
Table 8: Schedule for follow-up/tracking community-facility-
community linkages for HIV positive individuals
Timeline Action
Day 1 - A client is diagnosed HIV positive and referred to the
(referral preferred facility using the HIV Comprehensive Referral
day) form.
- A copy of the referral form is given to the CHEW who
documents the address and contact information into the
follow-up register, schedules an appointment for facility visit
and obtains client’s consent for home visiting.
- The HIV Comprehensive Referral form copy should be
delivered to the facility where the client has been referred.
Week 1 -The organization doing community testing should call
the client or the contact in the health facility where the
client was referred. If client reached the facility, document
complete linkage.
-The health facility linkage facilitator identifies referred
clients who have come to the facility and documents those
referrals as linked/complete.
- The facilitator notifies the CHEW of all clients who have
not yet been linked.
-The CHEW visits client’s home to ascertain reasons for
failure to reach the facility and makes a new appointment for
facility visit.
-The CHEW documents the outcome of the visit and
notifies the health facility team.
Week 2 -The health facility linkage facilitator ascertains if the client
was linked and notifies CHEW of the pending clients
-The CHEW makes a final visit to client’s home; discusses
reasons for failure to reach the facility; makes a final
appointment if the client is willing or documents outcome
(refused, not ready, relocated, etc.). If the client has not yet
decided to enrol in care, the CHEW will continue to contact
and encourage them to seek care. A client is lost to linkage if
he/she is not in care within 14 days of HIV diagnosis.
This process should be replicated for clients identified in the facility and
linked to community for other support services.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.16 HIV TESTER AND SITE CERTIFICATION

Certification is the process by which an independent and authorized agency
assesses the quality system of a facility/site, competency of a provider based
on certain pre-defined standards. Certification gives formal recognition that
a facility/site or tester is authorized to carry out a specific task such as HIV
rapid testing for diagnosing HIV infections.
2.16.1 Specific Objectives of Certification include:

Ensuring adherence to national standards of delivering HIV rapid testing

Ensure availability of competent personnel for HIV rapid testing
Ensure conformity of sites to national standards for quality results
2.16.2 Rationale of HIV Testing Certification

HIV rapid tester (Figure 20) and site certification (Figure 21) shall be key
strategies to enhance the quality of HTS.
Despite many interventions to strengthen quality of HIV testing, gaps in
quality assurance still exist including capacity of trained staff, unavailability
of testing supplies, lack of post-market surveillance practices, deviation from
testing procedures, low participation and performance rates in proficiency
testing programs and under-utilization of testing data for timely corrective
actions. A national certification program for HIV rapid testing may prove
to be not only a healthcare cost saving approach, but also an expansion of
quality of care.
It also provides clinical governance to support health care providers involved
in testing by creating an enabling environment for health-care providers to
be accountable for providing the quality of HIV Rapid testing services and
safeguarding high standards of care and excellence in clinical care.
Implementation and maintenance of HIV rapid testing site and tester
certification program adds credibility to any testing site, provides the means
to ensure and monitor adherence to quality standards and instills confidence
in the results for patient care. This program provides an umbrella under
which all aspects of quality HIV testing shall be gathered and continuously
monitored.

48
Figure 18: Tester Certification
Consolidated Guidelines for theProcess
Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 20: Tester Certification Process

42

49
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 19: Site Certification Process

Figure 21: Site Certification Process

50
2.16.3 National Certification Committee (NCC)
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

2.16.3 National Certification Committee (NCC)

This shall be a multi-sectorial committee that is independent of the assessors

with diverse membership to increase objectivity, minimize bias and address
conflict of interest. It shall be comprised of technical personnel from the
following institutions: UVRI, Allied Health Professional council (AHPC),
CPHL, Uganda Medical Laboratory Technologist Association (UMLTA),
ACP, Quality Assurance Department (QAD), Civil Society Organizations
(CSOs), Ministry of Trade - National Bureau of standards (UNBS), Ministry
of Education, testers, Academia, NDA, Private practitioners, Uganda
Healthcare Federation, Uganda National Health Consumer Association
(UNHCO) and PLHIV Networks. Members serving on this committee shall
be assigned by the Director-General, Health Services (DGHS), MOH and
will serve for a three-year term before new members are nominated. The
recommending authority upon satisfactory performance may renew the
three-year term for each member of the independent certification committee.
2.16.4 HIV Testing Certifying Body

The National HIV Reference Laboratory (NHRL)/UVRI shall have the

mandate from MOH to conduct quality assurance for HIV rapid testing in
Uganda. UVRI shall be the Certifying Body for HIV rapid testing sites and
testers. It shall work closely with the MOH/ACP and the QAD of MOH in
fulfilling its role.
2.16.5 Implementation of HIV Testing Certification

Implementation of the HIV Testing Certification shall include a process

of assessments/audits of the testers and testing sites, certification,
decertification, recertification, monitoring and evaluation.
Certification shall ensure maintenance of standards and reliability of results
generated to support clinical and public health activities by the HIV testing
point (site) and HIV rapid tester (HIVRT). Both HIVRT and site certification
shall be valid for a period of not more than two years.
Refer to HTS Policy and Implementation Guidelines 2022 on details
for HIV Rapid Testing Certification.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Box 2: Key Highlights in HIV Testing Services and linkage to

HIV care

• Utilize a strategic mix of facility-based

and community-based HIV testing models to increase access.
• Optimize HTS to appropriately and efficiently target undiagnosed people
living with HIV- especially men, adolescents and children.
• High HIV burden and risk populations for HTS include priority
populations (PPs), vulnerable populations (VPs), key populations (KPs).
• HTS Optimization strategies include: screening for HIV testing eligibility
(risk-based testing), Index Client Testing [APN/ testing for biological
children/Know Your Child’s HIV Status (KYCS)], SNS and HIVST.
• Index Client Testing services shall be provided with adherence to minimum
standards to meet expectations of the consumers and community. All
health facilities offering Index Client Testing (and APN) will be assessed
annually and accredited to ensure adherence to minimum index testing
standards.
• HIV self-testing with oral-fluid and blood-based kits shall be offered as
an additional approach to HIV testing services in Uganda. Persons aged
2 years and above shall be considered for HIVST depending on eligibility.
HIV self-testing is a screening test and is not sufficient to make an HIV-
positive diagnosis. Therefore, a reactive (positive) self-test result should be
confirmed using the national testing algorithm.
• HIV rapid testing shall be conducted in accredited sites by certified testers.
Sites and testers that do not meet the minimum standards for accreditation
shall be supported to attain accreditation status before being permitted to
provide HTS
• Amid public health emergencies such as the COVID-19 pandemic, HTS
implementation shall follow national guidance on Infection, Prevention
and Control measures and ensure continuity of services.
• All intra-facility linkages shall be on the same day and where not possible,
should be within 7 days; inter-facility and community linkages should be
completed within 14 days. Community and inter-/intra-facility networking
and collaborations should be promoted for effective linkages of clients.
All HTS points should have a regularly updated referral directory of
community and institutional prevention, care and support services.
HTS providers should refer HIV Negative persons to appropriate HIV
prevention services. All referrals and linkages should be documented using
appropriate national data collection tools (HIV Comprehensive Referral
and Linkage Form, Linkage and pre-ART register).

52
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• HTS being the entry point for all HIV & AIDS related support, care
and prevention services, will contribute to the HIV&AIDS surveillance
function for public health action. HTS will also contribute to: HIV
Recency Infection Surveillance, HIV case-Based surveillance, ANC
Sentinel surveillance and Periodic Surveys.
• All individuals diagnosed as HIV-positive in communities or facilities
should be linked into care and treatment. Linkage is considered successful
when an HIV positive individual is enrolled into care and treatment.
Guidance on specific policy changes:
• Re-testing for verification: All newly diagnosed individuals should
be retested before ART initiation (with the exception of infants <18
months).
• All babies testing HIV-positive at DNA/PCR HIV testing should be re-
tested, but ART should initiated immediately. A confirmatory sample
DBS should be collected on the same day the child is initiated on ART.
• Perform risk screening, apply appropriate HTS screening tool to various
age groups for clients seeking VMMC.
• Test all pregnant women at first ANC. Retest all pregnant women who
are negative or unknown at third trimester. If a previous test is missed,
test at labor and delivery.
• Social network testing (SNS) should be implemented as a form of index
testing.
• Testing every 3 months for KPs & PPs should be based on risk. Assess
for risk every 3 months and test for HIV if there is exposure risk in the
last 3 months.
HIV Self Testing (HIVST):
• HIVST kits are available off the counter for the public in pharmacies
countrywide.
• Testing for lactating mothers: Retest all HIV negative breastfeeding
mothers every 3 months until cessation of breastfeeding (no risk
screening). Align re-testing to immunization schedule where possible.
• Age for APN: All individuals ≥ 18 years are eligible for APN. Individuals
<18 years should be considered for APN if sexually active.
• Risk-based HIVST will target HIV negative KPs, PPs, men, adolescents,
and index clients through APN.

53
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• HIVST in MCH should be non-discriminative: all mothers whose

sexual partners are of unknown HIV status and have not come to
the facility for testing should receive HIVST kits to deliver to their
partners if they consent.
• Men in the general population should also be targeted for HIVST.
• Caregiver assisted oral screening for children aged 2-14 years and
HIVST for adolescents aged 15-19 years shall be implemented upon
guidance by MOH.
• HIV test kits made for professional use should only be sold on
wholesale basis and not as single self-test devices. Selling these test kits
to individuals for the purpose of self-testing is prohibited and should
be discouraged. Only approved HIV self-testing kits should be sold
over the counter to the public. Currently, Oraquick, Sure-check and
INSTI have been evaluated and approved for use in Uganda.
• HIV syphilis DUO testing for key and priority populations, including
pregnant and breastfeeding women, using the approved national
algorithm shall be considered upon availability of HIV/syphilis DUO
commodities.

54
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

3.0 HIV PREVENTION

SERVICES
3.1 INTRODUCTION
3.0 HIV PREVENTION SERVICES
In Uganda, the HIV epidemic is driven by multiple behavioral, biomedical and
3.1 INTRODUCTION
structural factors. As such there is no single HIV prevention intervention that
In Uganda, the HIV epidemic is driven by multiple behavioral, biomedical and
isstructural
enough factors.
to prevent all HIV transmissions. The country, therefore, adopted
As such there is no single HIV prevention intervention that is enough
atocombination HIV prevention
prevent all HIV transmissions. Theapproach
country,which usesadopted
therefore, a mix of biomedical,HIV
a combination
behavioral and structural
prevention approach interventions
which uses to meet the
a mix of biomedical, HIV prevention
behavioral and structural
needs of the topopulation
interventions meet the HIVto prevention
have the greatest
needs of possible impact
the population on reducing
to have the greatest
new infections.
possible impact onThis chapter
reducing newwill provide
infections. Thisguidance onprovide
chapter will how toguidance
implement
on how
interventions
to implementthat reduce newthat
interventions HIVreduce
infections
new among children,among
HIV infections adolescents,
children,
adolescents,
young young
people, people,
adults, andadults,
key andandpriority
key andpopulations.
priority populations.

3.2 BEHAVIORAL
3.2 BEHAVIORAL CHANGE AND CHANGE AND RISK
RISK REDUCTION REDUCTION
INTERVENTIONS
Behaviour change starts with a risk assessment.
INTERVENTIONS
Behaviour change starts
Figure 20: Behavioral withrisk
change a risk assessment.
assessment
Figure 22: Behavioral change risk assessment
Risk Assessment
(interventions, materials & tools)

Increased Risk Perception

Partner
Tracing
- VE
Result HTS +VE
Result
Partner
Tracing

Start Treatment
Stigma Reduction

Risk Reduction Plan

• Abstinence
• Condom use
Risk Reduction
• MCP
• SMC
• TB
• STIs ART Adherence
• Alcohol
• GBV/ violence
• Child Protection
VLM - Demand

Provider IPC skills and customer care

3.2.1 Interventions
The priority of behavioral interventions is to delay sexual debut; reduce unsafe sex
(including concurrent sexual partnerships), discourage cross-generational and
transactional sex and promote consistent condom use. Table 9 below describes services
for behavioral change and risk reduction.
55
47
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

3.2.1 Interventions

The priority of behavioral interventions is to delay sexual debut; reduce

unsafe sex (including concurrent sexual partnerships), discourage cross-
generational and transactional sex and promote consistent condom use.
Table 9 below describes services for behavioral change and risk reduction.
Table 9: Services for Behavioral Change and Risk Reduction.
Area Guidance
Service a. Each health facility/program should have a focal per-
delivery son for HIV prevention
b. All staff offering HIV prevention services need to be
trained, including training in Gender and Sexuality Di-
versity (GSD)
c. Utilize peer-led models for priority key populations in-
cluding young people
d. Outreaches & Drop-in Centers for key and priority pop-
ulations
e. Job aides to support standardization for quality assur-
ance
f. Linkage and follow-up between facility and community
is important
g. Promote youth and key population friendly services
Risk assess- a. Assess sexual behavior of the client (ask if condoms are
ment for used, frequency, the number of partners, transactional
client sex/sex work) and if the client is involved in transac-
tional sex/sex work encourage correct and consistent
condom use.
b. Discuss knowledge of partner HIV status and sexual
behavior.
c. Assess for STIs and link to treatment.
d. Asses for gender-based violence (GBV)
e. Discuss sexual and reproductive health services and link
to services as appropriate.
f. Offer HTS to sexually active clients who have not tested
in the last 12 months or have had unprotected sex in last
three months.
g. Conduct psychosocial assessment

56
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Area Guidance
Provide so- a. Build a lifestyle of prevention among young people
cio-behav- b. Discuss delay of sexual debut in children and adoles-
ioral change cents (abstinence)
communica- c. Discuss correct and consistent condom use and offer
tion (SBCC) condoms as appropriate.
and link to d. Discourage multiple, concurrent sexual partnerships and
services as promote faithfulness to a partner of known HIV status.
appropriate e. Discourage cross-generational and transactional sex.
f. Discourage risky cultural practices such as widow inher-
itance, wife replacement and child marriages.
g. Identify, refer and link clients to other available services
at facility and community level.
h. Assess for violence, (physical, emotional, or sexual); if
client discloses sexual violence, assess if the client was
sexually assaulted and act immediately.
i. (See Section 3.12 for GBV case management and Sec-
tion 3.5 for PEP)
Condom a. Discuss self risk assessment with the client
promotion b. Discuss correct and consistent condom use as an option
and provi- for risk reduction
sion c. Discuss the different types of condoms (rubber, nitrile,
polyurethane, etc.)
d. Discuss benefits of male and/or female condom use
e. Clarify any questions and dispel myths around condoms
f. Demonstrate how to use male and female condoms us-
ing appropriate tools (e.g. the O cube or cervical model
for female condoms and the dildo for male condoms.)
g. Demonstrate negotiation skills for safer sex
h. Allow the client to role play negotiation skills for safer
sex and how to introduce condoms in a relationship.
i. Provide condoms to the client and information on where
to access more

3.3 BIOMEDICAL PREVENTION INTERVENTIONS

The key biomedical interventions include STI screening and treatment,
eMTCT, safe male circumcision (SMC), ART for prevention, PEP, PrEP,
condom use and blood transfusion safety. Key and priority populations

57
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

in particular should receive STI screening and treatment. This section will
discuss condom programming, SMC, PEP and PrEP, blood transfusion
safety. Other biomedical interventions will be discussed in other chapters
including: eMTCT (Chapter 4),ART (Chapter 8) and STI screening and
treatment (Section6.14.1).
3.3.1 Comprehensive Condom Programming

Condom programming for HIV prevention is a means of ensuring that all

sexually active persons at risk of HIV and/or unintended pregnancies are
motivated to use condoms, have access to quality condoms, and can use
them correctly and consistently. Condoms are the only prevention tools
that offer triple protection from HIV, STIs and unintended pregnancies.
The protection from condom use is over 85% when used correctly and
consistently. The Ministry of Health has a condom program which addresses
demand, supply, and support for male and female condom utilization, as a
means of protection from STIs/HIV and unintended pregnancies.
People Centered and Data Driven with active demand creation and
sustenance interventions. More information can be accessed in the National
Comprehensive Condom Programming Strategy and Implementation Plan
(2020-2025).
3.3.2 Total Market Approach (TMA)

The Ministry of Health advocates for TMA to ensure availability of

condoms to all sectors of the population. With the TMA, free condoms
will target those who are unable to pay and disadvantaged/ vulnerable
population segments, while the higher wealth quintile population segments
of the community will either buy subsidized condoms from social marketing
or high end Commercial Sector condoms.
The Total Market Approach seeks to maximize market Efficiency, Equity
and Sustainability through the Coordination of the Public, Social Marketing,
Private Cost Recovery and the Commercial Sectors. This Coordination is to
be accompanied by Market Research and Segmentation, for equitable service
delivery to the target populations.

58
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022
Figure 21: Overview of TMA System
Figure 23: Overview of TMA System
TMA Health System Actors

PUBLIC NGO-SMO

TMA

PNFP
COMMERCIAL

ACP-NCCC-MoH

3.3.3 Condom Distribution Guidelines

3.3.4 Condom Distribution Guidelines
The The
One OneWarehouse One Health
Warehouse facility (OWOH)
One Health policy forpolicy
facility (OWOH) distribution
for distribution
of RH commodities including Condoms was introduced (2019)
commodities including Condoms was introduced (2019) whereby National whereby
National
StoresMedical
can onlyStores can onlycommodities
distribute distribute commodities to public
to public Health Healthand the Alt
facilities
facilities and the Alternative Distribution System distributes to the PNFP
Distribution System distributes to the PNFP Health Facilities. However Publi
Health Facilities. However Public Sector Condoms are to be made more
Condoms
available are to be to
and accessible made
the more
users available and accessible
through Health Facilitiestoand
thegeo-
users through
mappedFacilities and and
Hot Spots geo-mapped Hot Spots
non-traditional and non-traditional
pick points at Community level.pick points at Com
level.
The guidelines specify the condom flow, reporting line as well as the roles of
Thestakeholders
various guidelines atspecify theDistrict,
National, condomHealthflow, facility
reporting
and line as welllevel.
community as the roles of
stakeholders
The Guidelines alsoathighlight
National,theDistrict, Health
importance of facility and community
forecasting, proper storage,level. The Gu
records
alsokeeping, reporting
highlight and the use
the importance of effective distribution
of forecasting, mechanisms.
proper storage, records keeping, r
All data
andcollection
the use ofis to be reported
effective through the
distribution MOH recommended
mechanisms. system. is to be r
All data collection
Morethrough
information can be accessed from the National Condom Distribution
the MOH recommended system. More information can be accessed f
Guidelines – October 2021.
National Condom Distribution Guidelines – October 2021.

59
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 22:24:
Figure Condom distribution
Condom flow chartflow chart
distribution

3.3.4 Education,
3.3.5 Education, Promotion
Promotion and
and Demand Demand Creation
Creation
Government Policy states that Condom distribution should be accompanied with
Government Policy&states
relevant information thatforCondom
education the targetdistribution
populations. should be accompanied
Please take note of Table 6: on Condom Promotion and provision Services for Behavior
with relevant information & education for the target populations.
Change and Risk Reduction for clients who opt to use Condoms.
Please take note
In addition, of Table
Condom 6: on Condom
Programming Promotion
requires vibrant anddemand
Condom provision Services
creation and
sustenance interventions to improve uptake and use of Condoms, for triple
for Behavior Change and Risk Reduction for clients who opt to use Condoms. protection.

In
3.3.6addition, Condom
Target Groups Programming
for condom use requires vibrant Condom demand
The following
creation andhave been identified
sustenance as target populations
interventions and include
to improve the populations
uptake and use of at
high risk of HIV transmission or acquisition, such as:
Condoms, for triple protection.
1 Adults and youth engaged in multiple concurrent sexual partnerships.
3.3.5
2 MenTarget Groups
and women for condom
who engage use sex and their partners.
in transactional
3 Adults working away from home such as transport and migrant workers,
The uniformed
followingpersonnel,
have been identified
fisher as target
folk, boda-boda populations and include the
riders.
populations
4 People whoat high
injectrisk
drugsofand
HIVmentransmission or acquisition,
who have sex with men. such as:
1. 5 Adults
Adultsandandyouth
youthwho access in
engaged family planning/contraception
multiple concurrent sexual clinics or service
partnerships.
delivery points.
2. Men and women who engage in transactional sex and their partners.
6 Discordant couples.
3. 7 Individuals
Adults working away from home such as transport and migrant
taking PEP or on PrEP, as well as women using the Dapivirine Ring
workers, uniformed personnel, fisher folk, boda-boda riders.
51
4. People who inject drugs and men who have sex with men.
5. Adults and youth who access family planning/contraception clinics or
service delivery points.
6. Discordant couples.
7. Individuals taking PEP or on PrEP, as well as women using the
Dapivirine Ring

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

3.4 SAFE MALE CIRCUMCISION (SMC)

The Government of Uganda is promoting Safe Male Circumcision (SMC)
as an important intervention for HIV prevention. Male circumcision is
the surgical removal of the foreskin of the penis. SMC reduces the risk of
HIV acquisition among circumcised men by approximately 60%. Table 10
describes the process involved in providing SMC.
Table 10: Process of providing safe male circumcision
Process Description
Priority groups• All healthy males including infants, although focus is
for SMC on pivotal age of 15-45 years
Recommended • Conventional surgery using the dorsal slit method and
methods for Shangring for adults; Mogen clamp for infants
SMC WHO pre-qualified devices
Eligibility • Screen for STIs: If STIs are present defer the
Screening for circumcision and treat the STIs (See Section 9.1.1)
SMC • Tetanus immunization status:
• all clients adolescents and adults men seeking SMC
servies should get one Tetanus dose before the
procedure regurdless of the circumcision method
• Administer three dose TT vaccination schedule for
both conventional and device methods: First TT
shot on day 0, 2nd TT shot on day 28 and 3rd TT
shot after 6 months.
• MoH recommends one TT dose for both
conventional and device method but recommends
the man to have the 2nd and 3rd dose for longer
protection against tetanus infection
• Penile abnormalities: If there are any penile
abnormalities, refer for specialist care.
• Bleeding disorders: If there is a history of bleeding
disorders, defer SMC and refer for specialized care.
• Existence of chronic disease conditions such as
diabetes or hypertension: Defer SMC and refer to the
nearest hospital.
Consent/assent • All clients should receive information regarding SMC
and understand the benefits and risks of SMC.
• The client should provide consent/assent prior to SMC
procedure.

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HIV Testing • All SMC clients should be offered HTS, though clients
may opt out.
• A positive HIV test is not a contraindication to
circumcision.
• Initiate ART in men and adolescents who test positive.
Follow up after • Following conventional surgery: at 48 hours, seven
SMC days, 14 days and at six weeks
• Following device circumcision: follow the manufacturer
guidance for device used
Refer to the SMC Guidelines for details
The following guidance has been added:
• Age: Ideally all males should be circumcised regardless of the age. SMC
should be integrated in the main health services especially in health HCIVs
and hospitals for sustainability.
• Accreditation: Unlike many other HIV prevention interventions that
targets infected people, SMC targets health men. So the quality of the
services should really be a priority. All sites that offer SMC should at
least meet the minimum standards and this is ensured only when sites are
accredited every 12 months.
• Devices: Over the years, a lot of innovations have been implemented to
ensure scale-up of SMC services. Devices are on pf those innovations that
have really helped in creating high demand among the laggards. Currently
Shangring is highly acceptable among Ugandan males due to the fact that
there is no injection, no sutures and the client returns once. On the other
hand, the disposable kits have quality and waste disposal challenges and
the re-usable kits main challenge is sterility.
• Tetanus: In the past tetanus infection caused fatal adverse events and this
lead to a tetanus policy in the SMC program. MoH conducted a study about
tetanus infection among circumcision clients and recommended one TT
shot for every client before the procedure and there after recommended
for all the clients to get 2nd and 3rd doses after 28 days and 6 months
respectively.
• Adverse Events: MoH recommends for an adverse event rate to be less
than 1% among circumcised men. All severe adverse events should be
reported to MoH within 48 hours for audit but the notifiable should be
immediately to the national SMC coordinator for proper management,
audit and documentation.

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3.5 POST-EXPOSURE PROPHYLAXIS FOR HIV

Post Exposure Prophylaxis (PEP) for HIV is the short-term use of ARVs to
reduce the likelihood of acquiring HIV after a potential exposure. The main
desired outcome is to provide quality PEP services to all the eligible clients.
It is also important to prevent exposures to blood and body fluids among
healthcare workers and clients, by complying with Infection Prevention
and Control Standard Precautions. It is equally critical that all the key PEP
stakeholders are effectively engaged and coordinated to improve PEP service
demand and utilization.
3.5.1 Types of HIV Exposure:

Occupational exposures occur in the health care settings and include

SHARPS, e.g., needlestick injuries and splashes of body fluids to the skin
and mucous membranes.
Non-occupational exposures include sexual assault (rape and defilement),
road traffic accidents, unprotected sex with an HIV infected person,
unprotected sex with a person of unknown HIV status.
3.5.2 Steps in Providing Post-Exposure Prophylaxis (PEP)

Health facilities providing PEP must have trained healthcare workers on

infection prevention and control including management of PEP. The
healthcare workers should use the steps in Table 11 to assess clients for PEP
eligibility and provide PEP.
Table 11: Steps for Providing Post-Exposure Prophylaxis
(PEP)
Step Description
Step 1: Conduct a rapid assessment of the client to assess exposure and
Clinical risk and provide immediate care.
Assessment a. Occupational exposure:
and b. After a needle stick or sharp injury
Providing c. Do not squeeze or rub the injury site
First Aid d. Wash the site immediately with soap and water.
e. Don’t use strong, irritating antiseptics (like bleach or iodine)
f. After a splash of blood or body fluids in contact with intact skin
g. Wash the area immediately
h. Don’t use strong, irritating antiseptics (like bleach or iodine)
For exposure-specific injuries, refer to the PEP Guidelines

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Step Description
Step 2: Provide PEP when:
Eligibility a. Exposure occurred within the past 72 hours; and
assessment b. The exposed individual is not infected with HIV; and
c. The ‘source’ is HIV-infected, has unknown HIV status or is
high risk
d. Do not provide PEP when:
e. The exposed individual is already HIV-positive
f. The source is established to be HIV-negative
g. Individual was exposed to bodily fluids that do not pose a
significant risk (e.g. tears, non-blood-stained saliva, urine,
sweat)
h. Exposed individual declines an HIV test
Step 3: Counsel on:
Counseling a. The risk of HIV from the exposure
and support b. Risks and benefits of PEP
c. Side effects of ARVs (see Table 60)
d. Enhanced adherence if PEP is prescribed
e. Importance of linkage for further support for sexual assault
cases
Step 4: a. PEP should be started as early as possible, ideally within first
Prescription 2 hours but not beyond 72 hours after exposure
b. Recommended regimens include:
i) Adults and adolescents weighing>30Kg:
ii) Preferred: TDF+3TC+DTG or TAF+FTC+DTG
iii) First Alternative: TDF+3TC+ATV/r or
TAF+FTC+ATV/r
iv) Second Alternative: TDF+3TC+EFV or
TAF+FTC+EFV
v) Children weighing <30kg
vi) Preferred: ABC+3TC+LPV/r
Alternative: ABC+3TC+DTG
b. A complete course of PEP should run for 28 days
c. Do not delay the first doses because of lack of baseline HIV
test or any reason
d. Document the event and patient management in the PEP
register (ensure confidentiality of patient data).

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Step Description
Step 5: Review client after one week for adherence support.
Provide Discontinue PEP after 28 days.
follow-up Perform follow-up HIV testing at one month, three and 6 months
after exposure.
Counsel and link to HIV clinic for care and treatment if HIV-
positive.
Provide prevention education and risk reduction counseling if HIV-
negative.
Refer to National Policy guidelines on Post Exposure Prophylaxis for HIV,
Hepatitis B and Hepatitis C, November (2013).
3.6 PRE-EXPOSURE PROPHYLAXIS (PrEP)
Definition: PrEP is the use of ARV drugs by HIV uninfected persons to
prevent the acquisition of HIV before exposure to HIV. Table 12 describes
processes involved in offering PrEP.
3.6.1 Oral PrEP

Table 12: The process of providing pre-exposure prophylaxis

(PrEP)
Process Description
Screening PrEP provides an effective additional biomedical prevention option for
for risk of HIV-negative people at substantial risk of acquiring HIV infection. These
HIV include people who:
• Live in discordant sexual relationships
• Have had unprotected vaginal sexual intercourse with more than one
partner of unknown HIV status in the past six months
• Have had unprotected anal sexual intercourse in the past six months
• Have had sex in exchange for money, goods or a service in the last six
months
• Use or abuse of drugs especially injectable drugs in the last six months
• Have had more than one episode of a STI within the last twelve months
• Are part of a discordant couple, especially if the HIV-positive partner is
not on ART or has been on ART for less than six months or not virally
suppressed.
• Recurrent PEP users (PEP use >3 times a year).
• Are members of key or priority populations who are unable or unwilling
to achieve consistent use of condoms.
NB: Eligibility is likely to be more prevalent in populations such as dis-
cordant couples, sex workers, fisher folk, long-distance truck drivers, men
who have sex with men (MSM), uniformed forces, and adolescents and
young women including pregnant and lactating AGYW.

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Process Description
Screening • After meeting the substantial risk for HIV criteria:
for PrEP • Confirm HIV-negative status using the national HTS algo-
eligibility rithm
• Rule out signs and symptoms of acute HIV infection
• Assess for hepatitis B infection: if negative, patient is eligible
for PrEP; if positive, refer patient for Hepatitis B manage-
ment.
• Note: HEP B positive test is not a contraindication for ini-
tiating PrEP, however, precaution needs to be taken when
making a decision to stop PrEP to avoid HEP B viral load
flare.
• Creatinine test and creatinine clearance calculation using
GFR formula is done. Do not offer PrEP if Creatinine clear-
ance is less than 1.2mg/dl.
• Note: Absence of this should not delay PrEP initiation in
persons with no signs and symptoms of renal impairment.
If available, creatinine test can be done at initiation and re-
peated every 6 months.
• Assess for contraindications to TDF/FTC or TDF/3TC.
Steps to • Provide risk-reduction and PrEP medication adherence
initiation of counseling:
PrEP • Provide condoms and education on their use
• Initiate a medication adherence plan
• Prescribe a once-daily pill of TDF (300mg) and FTC (200mg)
or TDF (300mg)/ 3TC (300mg)
• Initially, provide a 1-month TDF/FTC or TDF/3TC pre-
scription (1 tablet orally, daily) together with a 1-month fol-
low-up date
• Counsel client on side effects of TDF/FTC or TDF/3TC

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Process Description
Follow-up/ • After the initial visit, the patient should be given a two-
monitoring month follow-up appointment and thereafter quarterly ap-
clients on pointments
PrEP • Perform an HIV antibody test using the national HTS algo-
rithm and every three months.
• Note: Blood based HIVST is an alternative for PrEP refill in
case of absence of the national HTS standard recommended
in patients on PrEP.
• For women, perform a pregnancy test if there is history of
amenorrhea.
• Review the patient’s understanding of PrEP, any barriers to
adherence, tolerance to the medication as well as any side
effects.
• Review the patient’s risk exposure profile and perform
risk-reduction counseling.
Evaluate and support PrEP adherence at each clinic visit.
Evaluate the patient for any symptoms of STIs at every visit
and treat according to current STI treatment Guidelines.
Guidance • Acquisition of HIV infection
on discon- • Suspected signs and symptoms of acute HIV infection fol-
tinuing lowing a recent exposure within 4 weeks
PrEP • Changed life situations resulting in no longer being at sub-
stantial risk of HIV acquisitio
• Intolerable toxicities and side effects of ARVs
• Chronic non-adherence to the prescribed regimen despite
efforts to improve daily pill-taking.
• Personal choice
• HIV-negative in a sero-discordant relationship when the
positive partner on ART for >6 months and has achieved
sustained viral load suppression (condoms should still be
used consistently). The HIV negative partner can be allowed
to continue PrEP even if the positive partner is virally sup-
pressed if they choose to.
For detailed guidance on the provision of PrEP, please refer to the Tech-
nical Guidance on Pre-Exposure Prophylaxis for Persons at High Risk of
HIV in Uganda, 2022.

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3.6.2 Dapivirine Vaginal Ring (PrEP RING)

New Recommendation 2021: PrEP using the dapivirine

vaginal ring

The dapivirine vaginal ring may be offered as an additional prevention choice

for women at substantial risk of HIV infection as part of combination
prevention approaches.
Overview of the PrEP Ring

The PrEP ring is a long-acting HIV prevention method developed

specifically for clients who are unable or do not want to take oral PrEP or
when oral PrEP is not available. The ring has been studied for prevention
of HIV only among women during receptive vaginal sex and does not
prevent HIV acquisition through any other mode of transmission. The
ring is made of a flexible silicone material containing 25 mg of an ARV
drug called Dapivirine. It is inserted into the vagina and should remain in
place for one month. Dapivirine belongs to a class of ARVs called non-
nucleoside reverse transcriptase inhibitors (NNRTI) that reduce the ability
of HIV to replicate itself inside a healthy cell. The ring delivers the drug
directly to the site of potential infection over the course of one month, with
low absorption elsewhere in the body, lowering the likelihood of systemic
side effects. Clients can insert, remove, and replace the ring themselves each
month, or with the assistance of a health care provider if desired. The PrEP
ring does not prevent pregnancies. The number of pregnancies among active
ring users during the clinical trials was small; studies are ongoing to further
assess safety during pregnancy. An observational study suggests that small
amounts of Dapivirine are present in breastmilk for those who use the ring
while lactating. Results from a clinical trial of ring use while breastfeeding
are pending. For more information on ring use during pregnancy and
breastfeeding, see Management of Clients in Specific Situations below.
3.6.3 Formulation of the PrEP Ring

The PrEP ring is a flexible white silicone ring for vaginal insertion. The ring,
which is available in only one size, contains approximately 25 mg of the
NNRTI dapivirine.

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3.6.4 PrEP Ring Effectiveness

The ring was clinically shown to reduce the likelihood of HIV-1 acquisition
through vaginal sex in two randomized controlled trials: by 35% in IPM-
027/The Ring Study and 27% in MTN-020/ASPIRE. The subgroup analysis
by age of The Ring Study and ASPIRE data did not show efficacy among
women 18–21 years old, who were also shown to have low adherence to
the ring during the trials. These trials reported no notable differences in
reproductive health outcomes, including STIs and adverse events related to
pregnancy, fetal outcomes and/or infant outcomes, between the treatment
and placebo arms. Results from two subsequent open-label extension studies
— DREAM and HOPE — found increases in ring adherence and similar
safety profiles; modeling data suggest even greater risk reduction across
both studies. Results from one open-label extension study indicated a 62%
reduction in HIV transmission, comparing study results to a simulated
control. Further studies exploring the safety and acceptability of the ring
among adolescents and young people AFAB ages 15–21 have demonstrated
that the ring is acceptable to younger users, has a similar favorable safety
profile among younger and older users, and can be used effectively by
younger users with proper adherence support.
Possible Side Effects of the PrEP Ring

Possible side effects of the ring are typically mild and include urinary tract
infections (UTIs – experienced by about 15% of users), vaginal discharge
(experienced by about 7% of users), vulvar itching (experienced by about 6%
of users), and pelvic and lower abdominal pain (experienced by about 6%
of users). These side effects usually occur during the first month of use and
resolve without the need to remove the ring. Ring users should be counseled
on possible side effects and to contact their health care provider if they
experience any urinary or reproductive tract changes, because these could be
a sign of an STI or UTI needing treatment.
PrEP Ring and Other Drug Interactions

There are no known interactions between dapivirine and contraceptive

hormones, hormones used for gender-affirming hormone therapy, alcohol,
or recreational drugs. However, if a client or potential client thinks that
their use of alcohol or other substances is interfering or may interfere with
effective use of the ring, the provider should discuss and support behavior
change and offer additional prevention options, including use of condoms
and condom-compatible lubricant.

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Contraindications for PrEP Ring Use

The ring should not be provided to people with:

An HIV-positive test result according to the national HIV testing algorithm
Known exposure to HIV in the past 72 hours (because such clients may
derive more benefit from post-exposure prophylaxis (PEP) if the potential
for HIV exposure was high)
Signs of AHI (Box 3) AND potential exposure within the past 14 days
Inability to commit to effectively using the ring and attend scheduled follow-
up visits
Allergy or hypersensitivity to active substance or other substances listed in
the product information sheet
3.6.5 PrEP Ring Use

The ring may be offered as an option for people AFAB who wish to prevent
HIV acquisition through receptive vaginal sex and are unable or do not want
to take oral PrEP, or when oral PrEP is not available. The ring must be
inserted correctly into the vagina and worn for one month without removal.
The ring must be in place for at least 24 hours before it is maximally effective.
If a client wishes to discontinue use of the ring, they can remove it. It is not
known how long the ring must remain in place after a potential exposure
to be maximally effective. Ideally, clients who are discontinuing PrEP use
will alert their providers and receive support to use other HIV prevention
practices if they are still needed.
Inserting the PrEP Ring

Clients may need initial guidance and support to learn how to use the ring
and, once confident, can continue to use the ring on their own. Some clients
are comfortable using the ring on their own with minimal support from their
first use. However, for clients who prefer support, a health care provider can
help insert the ring or confirm placement. The ring is inserted by hand; there
is no need to use a speculum or other tools to insert the ring. Clear visual
instructions should be offered with the ring. Ring insertion steps for clients
are listed in Box 3.

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Box 3: Ring insertion steps for clients

1. Get into a position that is comfortable for inserting the ring, such as
squatting, one leg lifted, or lying down. If a health care provider is
assisting you, you should be in a reclining position.
2. With clean hands, squeeze the ring between the thumb and forefinger,
pressing both sides of the ring together so that the ring forms a
“figure 8” shape.
3. Use the other hand to open the folds of skin around the vagina.
4. Place the tip of the ring into the vaginal opening and use your fingers
to push the folded ring gently up into the vagina.
5. Push the ring as far toward the lower back as possible. If the ring feels
uncomfortable, it is probably not inserted far enough into the vagina.
Use a finger to push it as far up into the vagina as is comfortable.
*Ring insertion should be painless. If you have any bleeding or
discomfort upon insertion, contact your health care provider.

3.6.6 Removing the PrEP Ring

Clients can remove the ring without the help of a health care provider.
However, for clients who prefer support, a health care provider can help
remove the ring. The ring is removed by hand; there is no need to use a
speculum or other tools to remove the ring. If a client is being assisted by a
health care provider, they should be in a reclining position during removal.
Ring removal steps for clients are listed in Box 4.
Box 4: Ring removal steps for clients
1. Get into a position that is comfortable for removing the ring, such as
squatting, one leg lifted, or lying down.
2. With clean hands, insert one finger into the vagina and hook it around
the edge of the ring.
3. Gently pull the ring out of the vagina.
*Ring removal should be painless. If you have any bleeding or discomfort
upon removal, contact your health care provider.

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3.7 SWITCHING BETWEEN PREP METHODS

Clients may switch between the ring and oral PrEP. Possible patterns of using
different ARV-based prevention methods are many, and ideal use during a
transition between methods is not currently known or understood and will
require careful support and assessment.
Safety data on simultaneous use of oral PrEP and the ring are limited.
Although use of both methods is not likely to be less well-tolerated than use
of each individually, more data are needed to confirm the safety and efficacy
of simultaneous use of oral PrEP and the ring.
Some clients may decide to use both the ring and oral daily PrEP at the same
time. However, no evidence indicates that using them together will result in
any advantage. Whatever the choice, using ring or oral PrEP in a way that is
effectively prophylactic (as frequently as directed and for as long as is needed
to cover periods of potential exposure) is important to optimize effectiveness
of either method. Using either or both less frequently than directed or for
a duration that is not long enough to cover periods of potential exposure
would be ineffective for HIV prevention.

3.8 LONG-ACTING INJECTABLE CABOTEGRAVIR (CAB-LA)

3.8.1 New Recommendation 2021: Offering long acting
injectable cabotegravir for HIV prevention

Cabotegravir extended-release suspension is a long-acting integrase inhibitor

and is effective in preventing HIV. It is administered through an intramuscular
injection (in the buttocks) by a health care worker once every 4 weeks for 2
months, pand then once every 2 months. It can be offered to adults and
adolescents weighing at least 35 kilograms to reduce the risk of sexually
acquired HIV. It is indicated for all HIV negative persons at high risk of
HIV; however, it is contraindicated in people who are hypersensitive to any
active substances in CAB-LA. t
3.8.2 Long acting injectable cabotegravir (CAB-LA) Initiation

Before initiation, individuals must be screened for HIV using the national
HTS algorithm and rule out signs of Acute HIV infection as for oral PrEP.
• Administration: It’s administrated in the buttock once every 8 weeks
• Side effects: The injectable cabotegravir is safe and well-tolerated.
• Efficacy/Effectiveness: The injectable cabotegravir was found to be
over 95% effective
• Safety: No safety concerns have been associated

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• Acceptability and barriers: In a study setting it was highly acceptable

• Contraindications: Hypersensitivity to active substance
3.8.3 Stopping CAB-LA

Assess reasons why the client is stopping CAB-LA and the HIV risk profile.
If the client is no longer at risk of HIV, there is no need to tail off with oral
PrEP. Patient should be counseled on HIV risk reduction. If the client is at
risk of HIV, the patient should continue with oral PrEP as long as HIV risk
exists.
3.8.4 Service Delivery for CAB-LA

CAB-LA will be rolled out in a phased manner starting with high volume
PrEP implementing facilities with high catchment populations having high
HIV prevalence and incidence.
Both the facility and community-based models will be used to roll out CAB-
LA.
Note: For detailed guidance on the provision of CAB-LA, please refer to the
Technical Guidance on Pre-Exposure Prophylaxis for Persons at High Risk
of HIV in Uganda, 2022.

3.9 TRANSFUSION OF SAFE BLOOD

Provision of safe blood is a key component in Uganda’s minimum health care
package. It is also one of the biomedical interventions for HIV prevention.
1. Donor selection: Blood should only be accepted from voluntary, non-
remunerated, low risk, safe and healthy donors aged between 17 and
65 years. Efforts are directed towards maintaining adequate numbers
of repeat donors.
2. Pre-donation counselling should be given to provide accurate information
including modes of transmission of disease (HIV, Hepatitis B and C,
Syphilis), risk behavior, prevention interventions and to allow for self-
exclusion for patient safety.
3. Clinical assessment should be carried out to further screen for risk and
determine overall health status and suitability of the donor.
4. Blood testing: All donated blood should be routinely screened for
transfusion transmissible infections including HIV, Syphilis, Hepatitis
B and Hepatitis C.
5. Post-donation counselling should be provided to donors whose test
results are positive for HIV, Syphilis, Hepatitis B or C. Donors with
positive results should be referred for care and treatment services.

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6. Safe and appropriate use of blood and blood products: Hospitals should have
the capacity to carry out assessments and tests to ensure that those in
most need of a blood transfusion are identified and prioritized. They
should have the capacity to carry out blood group and compatibility
tests on recipients to ensure that donor and recipient blood are matched
and that a safe transfusion can be executed. Hospitals should also have
the capacity and SOPs in place to manage complications arising from
a blood transfusion.

3.10 KEY AND PRIORITY POPULATION PROGRAMMING

Worldwide, Key/priority populations are disproportionately burdened by
HIV and contribute significantly to new HIV infections. Globally, while
the key populations are defined as sex workers, men who have sex men,
trans-genders, injecting drug users and prisoners. This definition is informed
by the fact that they are more burdened by HIV, and are surrounded by
stigma, discrimination, legal and socio-cultural dimensions that make it
harder to access interventions. Priority populations are country context
specific and in Uganda these include fisher folk, truckers, uniformed forces,
immigrant workers among others. It should be noted that in Uganda, the
priority populations though may be at high risk of HIV, do not have legal,
socio-cultural issues that affect them because of who they are, and are not
stigmatized or discriminated although they may have access issues that could
arise from other environmental factors that surround them. Targeted services
for KP/PP increase access/uptake to services and reduce stigma. Innovative
approaches/models have improved reach of these populations within their
communities and increased access and uptake of health services.
The success of these models is based on having service providers trained
to provide friendly services to key, vulnerable and priority populations, in
addition to involving key population communities as peers-educators and
engaging duty bearers/stakeholders. Several strategies including APN, SNS,
and Differentiated Services Delivery approaches (see DSD tool kit for KP),
Drop-in Centers-DICs (detail in DIC guidelines) have also been adopted/
developed to increase access to services among Key populations.

3.11 STRUCTURAL INTERVENTIONS

Structural interventions are approaches that reduce HIV risk at the individual
or group level. These are elements outside individual knowledge or awareness
that have the potential to influence peoples’ vulnerability to HIV infection.

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The intervention focusses on addressing social (stigma, gender inequality),

cultural (religious beliefs), economic (lack of livelihood opportunities) and
legal- political (laws and regulation) factors. Structural interventions call for
a multi-sectoral approach. The health sector will focus on interventions to
address gender-based violence within health care settings.

3.12 PREVENTION AND MANAGEMENT OF GENDER-

BASED VIOLENCE
Gender-based violence (GBV) has the potential to increase the risk of
acquiring HIV. GBV can also negatively affect retention and ART adherence
of clients leading to poor treatment outcomes. Screening for preventing and
responding to GBV promptly will reduce the risk of HIV infection and may
improve treatment outcomes of those at risk for GBV. Some of the service
delivery points recommended for GBV screening include: OPD, ART clinic,
ANC/MCH and IPD. Every site providing GBV services and post-violence
care should have the following:
• A written algorithm with steps for active case identification and follow-up
• At least one staff member trained to provide post-violence care
• A focal point for GBV services at each facility
• Provision of PEP
• Referral pathway available at each facility
Screening for GBV

All PLHIV should be routinely screened for GBV. Clients should therefore
be assessed for GBV at least once every six months as part of the HIV
program. For individuals outside HIV care settings, GBV screening should
be provided at contact with the health care system. All individuals identified
with signs of GBV should be linked to the GBV focal person at the facility
for further assessment and help. However, health care workers should
screen clients with medical diagnosis suspected to be screened for
GBV:
• Injuries,
• Sexual Assault,
• UTIs,
• Recurrent STIs,
• Experiencing trauma,
• Children with malnutrition,
• Re-attendances with no clear diagnosis,
• Abortion,
• Unintended /teenage pregnancies,

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Within the ART department:

• Adherence challenges,
• Disclosure challenges,
• Missed appointment for ART refills,
• Non-suppressed viral load
• HIVST and APN.
A simplified screening tool adapted from the GBV assessment tool should
be used to screen for GBV as shown in Table 13.
Table 13: Gender-based violence (GBV) screening tool
Use this tool to identify GBV survivors for management and referrals
Names/ Date Telephone No.
Initials …/.../… ………………
OPD /ART Village
no.
Sex Subcounty
Age Highest Level of Education
Marital Screening Entry Points: Community
Status point at …………
Facility
Psychological Are you currently in a situation where Yes No
/emotional someone threatens, frightens or insults
Violence you?
Are you currently in a situation where you Yes No
are subjected to practices that may result
into trauma, anxiety, stress or shame?
Are you currently in a situation where you Yes No
are denied access to your children? Write
N/A (not applicable, if person does not
have children)
Physical Are you currently in a situation where Yes No
Violence someone physically hurts you? (Slapping,
Code No; hitting, kicking, choking, hurting you with
100 Injuries a weapon)
due to GBV

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Do you have a sexually transmitted Yes No

infection that you consider due to sexual
violence? Code No STI due to GBV
Sexual
Violence Have you ever experienced an abortion Yes No
due to physical, psychological and/or
sexual violence? Code No 113 Abortion
due to GBV
Are you currently in a situation where Yes No
someone forces you into sex without
your will or forces you to participate
in sexual activities that make you feel
uncomfortable?
Are you currently in an intimate Yes No
relationship in which you feel you were
made to become pregnant against your
will?
Have you currently in an intimate Yes No
relationship in which you feel you are
denied of your sexual rights?
Are you below 18 years and married/ Yes No
cohabiting experiencing physical,
psychological, economic and/or sexual
violence in a relationship?
If yes to any of the above qns;
State the Potential risk to the client e.g pregnancy, death ………………
Help given…………
Referred (where) …………………
Name of the provider …………………….. Cadre …………………
Services to provide: Medical examinations and treatment, counseling support,
STI/UTI screening for exposed clients, emergency contraception where
legal and appropriate, referrals for legal support, Shelter, Child Protection
Services, economic Empowerment
For sexual violence only: Rapid HIV testing and provision of PEP for
eligible clients

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Action: If the response is ‘Y’ to any of the questions above, provide

counseling and link to GBV services and document appropriately.
All individuals identified with signs of GBV should be linked to the GBV
focal person at the facility. The GBV focal person should provide first line
support using LIVES approach. LIVES job aide below
Figure 26: Four-question Screening Tool for GBV

FOUR QUESTION SCREENING TOOL FOR GBV

No. Question Y N
Has client felt psychologically or emotionally harmed
1.     
by anyone?
2.   Does client have any bruises, cuts, or physical injuries?    
3.   Has client been touched or fondled inappropriately?    
Has client been forced to have sexual contact or
4.      
intercourse?
When managing rape victims, the minimum package of services is indicated
in Table 14 below.
Table 14 : Minimum package for post-rape care services
Health facilities should provide the following clinical services as
part of post-rape care:
Initial assessment of the client
a. Rapid HIV testing and referral to care and treatment if HIV-positive
b. Post-exposure prophylaxis (PEP) for HIV if tested negative (see
Section 3.3.3)
c. STI screening/testing and treatment (see Section 6.14.1.2)
d. Forensic interviews and examinations
e. Emergency contraception, where legal and according to national
guidelines, if person reached within the first 72 hours
f. Counseling
The health facility should also identify, refer and link clients to non-
clinical services:

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Some of the services include the following:

1. Long-term psychosocial support
2. Legal counseling
3. Police (investigations, restraining orders)
4. Child protection services (e.g. emergency out-of-family care,
reintegration into family care when possible, permanent options
when reintegration into family impossible)
5. Economic empowerment
6. Emergency shelters
7. Long-term case management
Reporting:
Health facilities should use HMIS 105 to report GBV
Box 5: Key Highlights in HIV Prevention Services
• In order to address the multiple factors affecting the different sub-populations, a
combination HIV prevention approach using a mix of biomedical, behavioral and
structural interventions are recommended to reduce new HIV infections.
• HIV prevention biomedical interventions include STI screening and treatment,
eMTCT, safe male circumcision (SMC), ART for prevention, PEP, PrEP, condom
use and blood transfusion safety.
• Condoms should be used by sexually active persons at risk of HIV to prevent both
HIV and unintended pregnancies.
• PEP is given to uninfected persons that have exposed to HIV. It is a short-term use
of ARVs, and HIV status of the individual should be ascertained before initiation.
• SMC is done to reduce the risk of HIV acquisition by approximately 60%. It should
be coupled with other prevention interventions including condom use.
• PrEP is offered to HIV negative persons at substantial risk of acquiring HIV before
exposure to HIV. Populations such as discordant couples, sex workers, fisher folk,
long-distance truck drivers, men who have sex with men (MSM), uniformed forces,
and adolescents and young women including pregnant and lactating women at
substantial risk should always be assessed for eligibility for PrEP.
• Targeted services to key and priority populations increases access and decreases
stigma. Reaching KPs and PPs with HIV care and treatment interventions is critical
for epidemic control. However, there are still several factors that hinder access
to services including capacity of health service providers, stigma, socio-cultural
and legal environment which need to be addressed. Using innovative approaches
including DSDM, DIC, APN, Social Network strategies is critical to ensuring they
access and utilize services.

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4.0 ELIMINATION OF
VERTICAL TRANSMISSION
OF HIV AND IMPROVING
MATERNAL, NEWBORN, CHILD
AND ADOLESCENT HEALTH
(MNCAH)
4.1 INTRODUCTION
Vertical transmission of HIV accounts for up to 18% of all new infections in
Uganda and for up to 90% of infections among children. Current evidence
shows that with effective interventions, including use of antiretroviral
therapy, the rate of transmission could be reduced to less than 5% in a
breastfeeding setting like in Uganda. Over the past decade, tremendous
gains have been made in the prevention of mother-to-child transmission of
HIV, primarily as a result of bold policies, including universal antiretroviral
therapy (Option B+) for pregnant and breastfeeding women, which
catalyzed important programmatic leaps. In 2021 estimates indicate high
rates of infection in children, with over 5,955 children infected through
vertical transmission. Major sources of infections are mothers who drop off
ART either during pregnancy or breastfeeding and mothers who seroconvert
during breastfeeding. The transmission rate is 7% at the end of breastfeeding,
which implies that although the country is progressing towards elimination
of mother-to-child transmission of HIV, virtual elimination has not yet been
attained.
The World Health Assembly in 2016 endorsed three inter-linked global
health sector strategies on HIV, viral hepatitis and sexually transmitted
infections for the 2016 – 2021 period, which set ambitious targets for
elimination of mother-to-child transmission (EMTCT) of HIV, hepatitis
B and syphilis. This was based upon the pretext that mother-to-child
transmission of the three infections can be effectively prevented by simple
interventions including antenatal screening and treatment for women and
their partners, and vaccination for infants within the reproductive, maternal,
newborn and child health platform. The similarity in interventions to prevent
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

mother-to-child transmission of HIV, syphilis and hepatitis B, means that

an integrated approach to triple elimination is highly feasible. The move
towards triple elimination shall result in greater collaboration between the
related programmes and thus improve accessibility, effectiveness, efficiency
and sustainability of maternal, newborn and child health services to the
individual family and community at large.
4.1.1 Pregnant and breastfeeding adolescent girls and young
women

Although pregnant and breastfeeding adolescent girls and young women

(AGYW) share some characteristics with their adult counterparts, their
individual, physical, psychological, socio-economic and biological MCH/
PMTCT health care needs vary significantly. Therefore, there is growing
recognition that the approaches used to respond to the unique MCH/PMTCT
health care needs for pregnant and breastfeeding AGYWs significantly differ
from those of older mothers and this necessitates the need for adolescent
friendly interventions tailored to meet their special needs.
4.1.2 eMTCT Strategy

The eMTCT strategy comprises a package of interventions summarized

in four approaches (see Table 15). These interventions must be offered
simultaneously within the platform of MNCAH services throughout the
continuum of eMTCT services as will be described in Figure 27.

4.2 INTEGRATING eMTCT AND MATERNAL, NEWBORN,

CHILD AND ADOLESCENT HEALTH (MNCAH)
SERVICES
eMTCT interventions should be integrated into the MNCAH services which
include but not limited to the ANC, labour and delivery, postnatal care,
adolescent clinics, sick child clinic and YCC at health facilities and community
sites. The section defines which services in each eMTCT prong are offered
in each of the parts of the MNCAH services continuum: before pregnancy,
antenatal, labour and delivery, postnatal and community (see Figure 27).

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Figure 25: The eMTCT continuum of services

Figure 27: The eMTCT continuum of services

Community PMTCT

73

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Table 15: The PMTCT Strategy
Interven- Target Additional information
tion area group
Interven- Adoles- • This prong aims to prevent HIV in women and girls of reproductive age, and male partners.
tion area 1: cents, Interventions include:
Primary women, • HIV testing services for pregnant and non-pregnant women of reproductive age
prevention and men • Couples counseling and partner testing and retesting for the HIV-negative individuals
of HIV of repro- • Routine HIV testing services for pregnant and non-pregnant adolescents
infection ductive • Behavioral change communications and risk-reduction counseling to avoid high-risk sexual be-
age havior including:
• Safer sex practices, including dual protection (condom promotion) and delay of onset of sexual
activity
• Health information and education about risky behavior, life skills and benefits of HTS
• SMC; PrEP for discordant couples, pregnant and lactating mothers and adolescent girls at sub-
stantial risk of HIV acquisition; and GBV screening and management
• STI including syphilis and HBV screening and management
• Regular discussion of childbearing needs (current and future) and safer conception methods
(e.g., PrEP, timed unprotected intercourse) to reduce stigma and encourage testing, engagement
in care and PrEP uptake.
Interven- Adoles- • HIV testing and counseling in sexual and reproductive health (SRH) and FP settings
tion area cent girls • Regular discussions about childbearing needs (current and future) to reduce stigma and encour-
2: Pre- and wom- age engagement in care, partner testing and PrEP uptake by sero-discordant partner(s).
vention of en living • Education and provision of family planning (FP)/contraception counseling and/or safer con-
unintended with HIV ception counseling (SCC) consistent with PLHIV’s childbearing desires:
pregnan- and their • FP: Safer sex practices, including dual protection (condom use promotion)
cies among partners • SCC: Pre-conception counseling (whenever possible with both partners), safer conception
women methods (e.g., PrEP, timed unprotected intercourse), and referral for infertility investigation and
living with treatment
HIV
Interven- Target Additional information
tion area group

84
Interven- Preg- • This prong focuses on:
tion area 3: nant and • Quality antenatal, labour and delivery, and postnatal care
Prevention breast- • Access to HTS during ANC, labour and delivery, and postpartum period
of HIV feeding • Initiation of ARVs for prevention of HIV transmission and mother’s health
transmis- women • Adherence counseling and support
sion from living with • Retention monitoring
women HIV • Viral load testing and monitoring
living • ARV prophylaxis for HIV-exposed infants
with HIV • Safe delivery practices to decrease risk of infant exposure to HIV
to their • Infant and young child feeding counseling
infants • Community outreach and efforts to support partner involvement and testing
• TB screening, diagnosis and treatment
• INH prophylaxis
• STI and HBV screening and treatment
Interven- Target Additional information
tion area group
Interven- Women This prong addresses the treatment, care and support needs of HIV-infected women, their chil-
tion area living with dren and families (family-centered approach):
4: Provi- HIV and • Package of services for mothers • Package of services for HIV-ex- • Package of services for partner and the
sion of their fam- includes: posed and infected children: family:
• Lifelong ART • ARV prophylaxis for HEI • HIV testing of partners, children and other
treatment, ilies • Cotrimoxazole prophylaxis • ART for HIV-infected children family members and linkage to prevention
care, and • TB screening, diagnosis, and • OI prophylaxis and treatment (e.g., and care services
support to treatment
• INH prophylaxis CTX) • ART for HIV-infected family members
women in- • Prevention, diagnosis and treat- • INH prophylaxis for TB exposed • Cotrimoxazole prophylaxis for HIV-posi-
ment of malaria • Routine immunization and growth tive family members
fected with monitoring • TB screening, diagnosis, and treatment
• Continued infant feeding, assess-
HIV, their ment, counseling and support • HIV testing and advice on TB infection control in the
children • Nutrition assessment, counseling, • Infant and young child feeding family
and support (IYCF) assessment, counseling and • INH prophylaxis
and their • Sexual and reproductive health support • Prevention, diagnosis, and treatment of
families services including FP and con- • Nutrition assessment, counseling malaria
dom provision
• STI and HBV screening and and support • Nutrition assessment counseling and
treatment • Prevention, screening and manage- support
• Breast and cervical cancer screen- ment of infections • Sexual and reproductive health services
ing and referral • Psychosocial care and support including FP and condom provision
• Adherence, disclosure and psy- • Routine follow up and refills and • STIand HBV screening and treatment
chosocial support provision of age-appropriate sup- • Adherence, disclosure and psychosocial
• Risk-reduction counseling plements support
• Routine laboratory monitoring • Effective referrals and linkages to • Risk reduction counseling
(CD4 and viral load) other services (community and • Routine laboratory monitoring (CD4 and
• Routine follow-up, ARV refills
and other routine MCH sup- facility) viral load) for the HIV-positive
plements and drugs (Fe/Folic, • Routine follow-up, ARV refills and other
Mebendazole) routine supplements and drugs (Meben-
• Effective referrals and linkages to dazole)
other services (community and • Effective referrals and linkages to other

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facility) services (community and facility)
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• Symptom management and • Symptom management and palliative care

palliative care
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

4.3 SERVICES FOR NON-PREGNANT WOMEN

4.3.1 Primary Prevention of HIV Infection

Preventing HIV in women and girls of reproductive age reduces the risk of
HIV infection to infants. Some of the services to prevent HIV infection in
women and girls of reproductive age are presented in Table 16.
Table 16: Services for preventing HIV infection in women and
girls of reproductive age
Service Description
Routine HTS • Provide HTS to all women and girls of reproductive
and syphilis age and their partners. Also test for syphilis and link
testing in the to care as necessary.
MNCAH setting • Link all who test positive to HIV care and treatment
services and offer risk reduction counseling to all who
test HIV negative.
BCC • Safer sex practices, including dual protection (condom
promotion) and delay of onset of sexual activity
• Discuss childbearing needs (current and future) to
reduce stigma and encourage engagement in testing,
future care and PrEP uptake.
• Educate and provide FP/ contraception counseling
and/or safer conception options (e.g., PrEP, timed
unprotected intercourse) consistent with PLHIV’s
childbearing desires (current and future).
Other • Offer and refer SMC services to male partners of girls
prevention and women
services • Screen all adolescent girls and women of reproductive
age, for GBV and offer services within MCH including
PEP
• Offer PrEP to eligible adolescent girls and women
of reproductive age in line with the guidelines for
PrEP (see PrEP section); special consideration should
be given to women and adolescents in discordant
relations who desire to get pregnant (see Table 9 and
Table 14).
STI and HBV • Counsel and screen adolescent girls and women for
screening and STIs including syphilis and HBV and manage the STIs
treatment

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4.4 PREVENTION OF UNINTENDED PREGNANCIES,

CHILDBEARING NEEDS, AND SAFER
CONCEPTION
Routine discussions with adolescent girls and women about their childbearing
needs (current and future) can reduce stigma and encourage engagement
in testing, care and PrEP uptake among sero-discordant partners. Non-
judgmental education and provision of family planning (FP)/contraception
counseling and/or safer conception options (e.g., PrEP, timed unprotected
intercourse) consistent with PLHIV’s childbearing desires (current and
future) can reduce the number of unintended pregnancies, thereby reducing
the number of infants exposed to HIV and the overall risk of MTCT. FP/
contraception and safer conception methods also provides intrinsic benefits
by saving lives and enhancing the health status of women and their families.
However, FP and safer conception services should be provided based on
respect and fulfillment of PLHIV’s reproductive rights and choices as
well as informed consent. Women and girls should not be coerced into
contraception or childbearing; their sexual and reproductive choices should
be respected and safeguarded. Table 17 describes the process of offering
FP/contraception and safer conception counselling.
Table 17: Childbearing, family planning/contraception, and
safer conception services for HIV-infected women
of reproductive age.
Service Explanation
Routinely discuss • Encourage women and adolescent girls attending
childbearing needs ANC, PNC, YCC and ART services to discuss
their reproductive choices and support them as
appropriate.
• Facilitate routine discussions of childbearing
needs (current and future) to reduce stigma and
encourage engagement in care and PrEP uptake
among sero-discordant partner(s).
• Educate and provide FP/contraception counseling
and/or safer conception options (e.g., PrEP, timed
unprotected intercourse) consistent with patient’s
childbearing desires (current and future).

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Service Explanation
FP/contraception For HIV-positive women/couples who desire to
counseling NOT become pregnant.
• Provide routine FP/contraception information
and counseling to women and adolescent girls
attending ANC, PNC, YCC and ART services.
Family planning services can be included as part
of DSD service delivery for all DSD models
including community DSD models. Providers
should ensure that schedules for ART refills and
aligned with FP provision.
• Information provided during counseling should
cover:
• Family planning/contraceptive methods,
advantages and side effects
• Common misconceptions about family
planning/contraception
• Advantages of dual protection and also how to
negotiate condom use
• What to do when pregnancy occurs:
• Address misconceptions. Some are below:
• “Using hormonal contraception increases the risk
of HIV acquisition”
• Correct response: There is no increased risk of
HIV acquisition in women using oral hormonal
contraception. Since oral contraceptives are
not a mode of barrier protection it is still
important to use condoms to prevent all STIs
including HIV.
• “Hormonal contraception causes a decrease
in CD4 count, increased viral load and
progression to AIDS event or death.”
• Correct response: There is no evidence that
hormonal contraception causes a decrease
in CD4 count, an increase in viral load, or
progression to AIDS event or death.

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Service Explanation
Safer conception • For HIV-positive women/couples who desire TO
become pregnant.
counseling • Provide routine safer conception information
and counseling to women and adolescent girls
attending ANC, PNC, YCC and ART services.
Whenever possible, facilitate a visit with both
partners to discuss childbearing readiness, safer
conception methods, fertility tracking and linkages
to PMTCT.
Childbearing readiness:
• Determine couple’s disclosure status (offer APN as
needed), each partner’s health status, each partner’s
childbearing desire, number and health status of
current children, and strength of relationship to
support childbearing and raising child (see Figure
10 APN flow Chart).
• Safer conception methods (see Table 18):
Serodiscordant couples:
• Ensure HIV-positive partner is adherent to ARV
and viral load is suppressed. Recommend delay in
conception attempts until viral load suppression is
obtained. Offer PrEP to the HIV-negative partner
(See Table 10). Educate on Timed Unprotected
Intercourse to enhance chances of conception
and for couples who refuse PrEP (see Table 18).
Seroconcordant couples:
• Ensure partners are adherent to ARV and
viral loads are suppressed. Educate on Timed
Unprotected Intercourse to enhance chances
of conception and for couples with ARV non-
adherence, unsuppressed viral load, and/or recent
STI history (see Table 18).
• Ensure linkage to PMTCT and Early Infant
Diagnosis for couples who are successful in
conceiving.

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Service Explanation
After counseling, For HIV-positive women/couples who do not
offer FP on a one- desire to become pregnant:
on-one basis • Offer effective contraception
• Encourage dual contraception (use of both
hormonal contraception and condoms) to prevent
pregnancy, STIs, HIV transmission, and re-
infection
• The choice of contraceptive methods in HIV-
infected women is much the same as in HIV-
negative women
• Consider some drug interactions between HIV
medicines and contraceptives when offering FP
methods to women and adoelscent girls on ART
(see Table 18).
Ongoing support Counselling and adherence support for the chosen
for adolescent girls method:
and women when • Assess for possible side effects and manage
using FP accordingly
• Clients on injectable FP (Depo-Provera) and ART
should be counseled to return for injection on
appointment date or before if they cannot make it
on scheduled appointment date

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Table 18: Safer Conception
HIV Things to consider Clinical Safer conception Pros Cons
status of Evaluation Methods
couple
Sero- Disclosure HIV status, CD4 PrEP for HIV Risk of HIV Access to PrEP,
discordant Couples’ count, VL negative partner transmission is PrEP side
communication STI screening and greatly decreased effects
Risk of HIV/STI treatment Timed Private, Risk of
transmission to (males) Fertility Unprotected inexpensive, HIV/STI
partner and infant history, semen Intercourse (when transmission
enhanced
ART eligible analysis, genital HIV negative reduced but still
likelihood of
partner(s) stabilized exam refuses PrEP) present; requires
successful
on optimal therapy (females) Fertility accurate timing
conception
before conception history including of ovulation
Sero- attempts, has miscarriages, Timed Private, Some risk
concordant undetectable VL ectopic Unprotected inexpensive, of STI
(when testing is pregnancies, age, Intercourse enhanced transmission
available) pelvic exam, likelihood of
Identification and menstrual cycle successful
management of co- / ovulation, conception
morbidities hemoglobin
measurement
PrEP for HIV-
and viral load if
negative partner
HIV+
Baseline fertility

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

assessment
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

4.4.1 Recommendations for hormonal contraceptive use

among women at high risk of HIV infection- Medical
Eligibility Criteria (MEC) for FP/contraceptive methods

Women, adolescent girls and couples at high risk of HIV infection continue
to be eligible to use all forms of hormonal contraception. Informed decision-
making is a key organizing principle and standard in a human rights-based
approach to contraceptive information and services. A shared decision-
making approach to contraceptive use should be taken with all individuals,
but special attention should be paid to using this approach with vulnerable
populations, such as adolescent girls and women at high risk of acquiring
HIV. Adolescent girls and women at high risk can use the following hormonal
contraceptive methods without restriction (MEC category 1): combined
oral contraceptive pills (COCs), combined injectable contraceptives (CICs),
combined contraceptive patches and rings, progestogen-only pills (POPs),
and levonorgestrel (LNG) and etonogestrel (ETG) implants.
There continues to be evidence of a possible increased risk of acquiring HIV
among progestogen-only injectable users. Uncertainty exists about whether
this is due to methodological issues with the evidence or a real biological
effect. In many settings, unintended pregnancies and/or pregnancy-related
morbidity and mortality are common, and progestogen-only injectables
are among the few types of methods widely available. Adolescent girls and
women should not be denied the use of progestogen-only injectables because
of concerns about the possible increased risk. Adolescent girls and women
considering progestogen-only injectables should be advised about these
concerns, about the uncertainty over whether there is a causal relationship,
and about how to minimize their risk of acquiring HIV.
Contraceptive counselling is a core component for supporting informed
choice and decision-making by clients. Health care providers need support
to provide adolescent girls and women with comprehensive, evidence-based
information on the full range of available methods and the advantages and
disadvantages associated with their use.
4.4.2 Interactions between ART and Contraceptives

Interactions between ART and some contraceptives may sometimes interfere

with the effectiveness of contraceptives and women need to be counseled
about this and encouraged to use dual protection.

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Table 19: Interactions between ART and Contraceptives

ARV Drug
Type of NRTI(TDF/
contraception ABC/
DTG EFV LPV/r ATV/r NVP
AZT/3TC/
FTC)
Combined oral Nil Risk of contraceptive failure:
contraception must be used with a barrier
(Microgynon, method
Lofeminal)
Emergency Nil Levels of contraceptive reduced:
contraception Double dose of emergency
(Postinor 2) contraceptive to 4 tablets
Injectable Nil
(Depo-Provera)
Implants Nil Levels of contraceptive reduced:
(Implanon, additional barrier method
Jadelle) advised
IUD (TCu Nil
380A)
Condoms Nil

4.5 DURING PREGNANCY

This section outlines ANC services for all pregnant women including those
who are HIV-negative, with specific services for women living with HIV.
Table 20 describes services offered during pregnancy.

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Table 20: ANC and PMTCT Services for Pregnant Women
Service Description

94
Provide HTS, • Offer routine testing for HIV and syphilis at first ANC visit to all pregnant women and their partner(s), using a rights-based
syphilis testing, approach, with same-day results using the SD-Bioline duo HIV/syphilis test according to algorithm in Figure 14 (in chapter 2).
• If found positive for syphilis, rapidly treat to reduce syphilis (and HIV, if positive for HIV) transmission from mother to child using
and Hepatitis B the following:
testing in ANC • Pregnant women/girls with early syphilis (primary, secondary and early latent syphilis of not more than two years’ duration):
give Benzathine Penicillin G 2.4 million units intramuscularly once.
• In late syphilis or unknown stage of syphilis (infection of more than two years’ duration without evidence of treponemal
infection): give Benzathine Penicillin G 2.4 million units intramuscularly once weekly for three consecutive weeks.
• Note: Adequate maternal treatment for prevention of congenital syphilis is defined as at least one injection of 2.4 million units
of intramuscular Benzathine Penicillin at least 30 days prior to delivery.
• Alternative treatment with Procaine Penicillin or Erythromycin, Azithromycin and Ceftriaxone if allergic to penicillin.
Refer to Figure 28: Management of HIV and Syphilis in MCH.
• For women already on ART:
Offer syphilis screening using a syphilis rapid test.
Offer HTS (including PITC, VCT and couple testing) and support mutual disclosure.
• For Prevention:
• Link all HIV-positive seroconcordant couples as well as HIV-positive individuals in serodiscordant relationships to ART.
• Offer PrEP to all pregnant and breastfeeding mothers at substantial risk of HIV acquisition as well as negative partners in the
discordant couples.
• For HIV-negative pregnant women, re-test in the third trimester, during labor, or shortly after delivery, because of the high risk
of acquiring HIV infection during pregnancy
• Re-test HIV-negative pregnant women in a discordant relationship every three months.
• Re-test the following HIV negative pregnant women within four weeks of the first test:
• STI, HBV or TB-infected pregnant women.
• Those with a specific incidence of HIV-exposure within the past three months
• Provide risk reduction counseling to HIV-negative women.
• Test all pregnant women/girls and their partners for Hepatitis B during antenatal (See Figure 29)
• For patients who are HBsAg positive assess the HBeAg and HBV viral load. Patients who are HBeAG negative with a HBV
VL of <200,000 IU/ml should be monitored with CBC, LFTs and VL at 6 and 12 months (see Figure 30).
• For patients who are HBsAg positive assess the HBeAg and HBV viral load. Patients who are HBeAg positive with HBV
VL of >200,000 IU/ml should initiate prophylactic treatment at 24 weeks gestation or at the earliest contact. Discontinue
medication 3 months after delivery and reassess and monitor as per Hep B guidelines. After starting treatment, LFTs should
be monitored at 4, 8, 12 and 24 weeks and thereafter annually. Monitor HBV viral load at 6 and 12 months (see Figure 30).
Service Description
ANC package General care:
for all pregnant • All pregnant women/girls should have at least eight ANC visits; encourage and support mothers to
women start ANC in the first trimester
(regardless of • Routinely provide iron, folic acid, and multivitamin supplements
HIV status) • Deworm in the 2nd trimester using Mebendazole
• Provide nutrition assessment, counseling and support (see Chapter 8)
• Counsel and encourage women to deliver at the health facility
• Screen for TB and take appropriate action
• Take weight and BP at every visit
Laboratory services:
• Screen and treat for syphilis, HIV, hepatitis B, other STIs and anemia; use syndromic approach to
treating STIs
• Perform urinalysis to detect a urinary tract infection (UTI), protein in the urine (proteinuria), or
blood in the urine (hematuria) indicating kidney damage, or sugar in urine suggesting diabetes.
• Do a blood slide for malaria for all pregnant women.
• Perform a blood group test in anticipation of blood transfusion and check for hereditary conditions
if suspected (sickling test).
Laboratory • For HIV-positive women, perform a baseline CD4 count. The test result is not required for ART
investigations initiation.
specific to HIV- • For women and girls living with HIV who are already on ART, do VL test at first ANC visit, then
positive pregnant follow the VL testing algorithm for pregnant and breast feeding women
women • For newly diagnosed HIV-positive pregnant women/girls, do VL test 3 months after initiating ART
and then every 3 months until end of MTCT period

95
• For women on DTG do lab investigation for monitoring blood sugar as per NCD guidelines
Service Description
Comprehensive At each visit provide:
care for pregnant • Comprehensive clinical evaluation

96
women living • Provide cotrimoxazole preventive therapy (CPT)
with HIV • Pregnant women on CPT should not be given Sulphadoxine-Pyrimethamine (Fansidar) for intermittent
preventive treatment for malaria (IPTp)
• Screen for TB and take appropriate action
• INH for eligible women/girls (see Section 7.5.1)
• Screening and management of opportunistic infections (OIs)
• Screening and management for NCDs including mental health assessment
Assess risk of Conduct a risk assessment of the unborn baby at 1st ANC among all HIV positive pregnant women and at
unborn baby every visit and flag those at high-risk including:
among pregnant • Newly initiated on ART in the 3rd trimester or breastfeeding period
women living • Most recent VL is non-suppressed
• Mothers testing HIV positive later in pregnancy or during breastfeeding
with HIV at
Closely monitor all high-risk pregnancies.
ANC 1
ART for pregnant • All women/girls living with HIV identified during pregnancy, labour and delivery or while breastfeeding
or breastfeeding should be started on lifelong ART.
women and girls • ART should be initiated on the same day,
• All women should receive Pre-ART adherence counseling before initiating ART and ongoing adherence
support after that – intensively for first three months, than ongoing support (see Chapter 4)
• Initiate mother on once-daily FDC of TDF+3TC+DTG with pharmacovigilance (See Chapter 14)
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• Mothers with hypertension, DM and those intolerant to DTG should be initiated on TDF+3TC+TLE400
• For 2nd line see ART guidelines section
• Viral load is done 3 months after starting ART and every 3 months until end of breastfeeding.
• ART should be initiated and maintained in mother-baby care point in MCH.
What to do if mum refuses ART or if you know adherence is poor:
Maternal VL suppression is key for preventing breastfeeding transmission, so if VL suppression is not certain
infant prophylaxis may serve as a “back up” to prevent MTCT - similar to “Option A”. Clinical providers
should continue infant prophylaxis with NVP for these specific scenarios. Continuation of prophylaxis should
be seen as an interim measure while maternal adherence is improved.
Service Description
Risk reduction • Encourage consistent and correct condom use.
counseling and • Encourage women to deliver at the health facilities.
support • For negative pregnant women, offer other prevention services like SMC to partner and mitigate or
manage GBV.
Visit schedules HIV-positive pregnant woman/ HIV-positive pregnant woman/girl initiating ART in ANC (new
for HIV-infected girl already on ART and stable: clients)/unstable:
pregnant women • Viral suppression achieved • Recently initiated on ART (< 1 year on ART) or
• Adherence above 95% • Poor viral suppression, based on most recent VL as per VL
• On ART for more than one-year algorithm
• Stage T1 and no active OIs • Adherence less than 95%
• Not due for vital lab tests in the • Stage T3,4 and active OIs
next two months,e.g., viral load • Comorbidities/ co-infections
• Has disclosed to significant • CD4 <500
other/ household member/ • Due for vital lab tests in the next two months,e.g., viral load
family member • Has not disclosed to significant other/ household member/
family member
• 8 ANC visits • Follow-up visit 2 weeks after initiating ART, then monthly until
• Synchronize ART refills and delivery
adherence support with the • Follow routine MCH schedule after delivery, together with the
ANC visits exposed infant visit schedule (see Annex 2)
• Follow routine MCH schedule
after delivery, together with the
exposed infant visit schedule

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(see Annex 2)
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 28: Management of HIV and Syphilis in Maternal and Child Health
care settings

Figure 29: Algorithm for Hepatitis B screening and management in MCH

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4.6 SERVICES TO BE PROVIDED DURING LABOUR

AND DELIVERY
Labour and delivery are the periods of highest risk of transmission and
should be handled with extra care to avoid transmission from mother to the
child. This section outlines specific services to be offered during that period
(see Table 21).
Table 21: eMTCT services during labour and delivery
Service Description
Ascertain • Offer HTS, syphilis and Hepatitis B testing to all women
HIV status, who have never tested and manage appropriately
offer PITC • Link all HIV-negative mothers to prevention services
for the • Re-test HIV-negative women who did not re-test in 3rd
partner trimester
Safe obstet- • Safe obstetric practices help to reduce the risk of HIV trans-
ric practices mission during labor and delivery and reduce maternal and
infant death. The practices include:
• Use of a partogram to allow for early detection and
management of prolonged labor
• Avoid routine (artificial) rupture of membranes (ARM);
if prolonged labor is due to poor uterine contraction,
perform ARM at ≥6cm cervical dilation and augment
with oxytocin (Pitocin) or misoprostol
• Do not perform routine episiotomy except for specific
obstetric indications
• Avoid instrument delivery including vacuum extraction
• Avoid frequent vaginal examinations
• Do not ‘milk’ the umbilical cord before cutting
• Actively manage the third stage of labor: this reduces the
risk of postpartum hemorrhage, which increases the expo-
sure of the newborn to maternal blood. Active management
of the third stage of labor involves three important compo-
nents: (i) giving oxytocin within 1 minute following the birth
of the baby (ii) deliver the placenta using controlled cord
traction (iii) massage the uterus after delivery of the placenta

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Service Description
Maternal • Give ART to mother (for mothers on treatment, continue
ART and the same ART regimen)
manage- • Initiate ART for mothers not yet on treatment (see Section
ment for 13.8)
syphilis and • Manage mothers positive for Hepatitis B
Hepatitis B • Give treatment for syphilis if mother is positive
ARV pro- Initiate NVP prophylaxis for the infant at birth
phylaxis for • Low risk: Counsel mother and provide NVP syrup for
the HIV-ex- 6 weeks
posed • High risk: Counsel mother and provide NVP syrup for
infant up to 12 weeks
High-risk infants are breastfeeding infants whose mothers):
• Have received ART for four weeks or less before de-
livery.
• Have unsuppressed viral load within four weeks before
delivery, or were diagnosed with HIV during 3rd tri-
mester or the breastfeeding period (postnatal).
What to do if baby presents after 6 weeks:
• Do first PCR
• Give ART (1st line paed; give weight appropriate dose) for
6 weeks
• If PCR results are negative, give NVP for 6 weeks (after
completing the 6 weeks of ART)
• If PCR results are positive, continue ART
• Irrespective of timing, the mother should be started on
ART as soon as possible for her own health and to de-
crease risk of transmission to breastfeeding baby.
Establish- • Support the mother to initiate breastfeeding within 30
ing breast- minutes of delivery
feeding • Offer infant feeding counseling to the mother according
to the guidance and chosen method during pregnancy (see
Chapter 5)
At dis- • Counsel the mother and provide an appointment to return
charge for postnatal services and exposed infant testing and care
at 6 weeks
• If the mother is not going to receive services at this facility,
link the mother to HIV care services at the facility of their
choice using linkage guidelines in Section 2.2

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Figure 31: Assessment for High-Risk Mother-Infant Pairs

4.7 SERVICES TO BE PROVIDED DURING THE

POSTPARTUM PERIOD
Following delivery, address the treatment, care and support needs of HIV-
infected mothers, their children and families (Intervention area 4), provide
family planning/contraception services (Intervention area 2) and continue
to prevent HIV in mothers who were negative during pregnancy, labour, and

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delivery. The HIV-infected mother should continue to receive her care in the
mother-baby care point until the baby is 18 months of age. This section will
describe postnatal services for the mother (see Table 22). Services for infants
(including care for the HIV-exposed infant (HEI) and infant and young child
feeding counseling) are described in Chapter 5.0.
Table 22: eMTCT services during the postpartum period
Service Description
Postnatal • Follow-up for the mother is usually scheduled at six weeks fol-
services lowing delivery, which coincides with the baby’s immunization
for all schedule. At the postnatal visit:
mothers • Check for sepsis, anemia, high blood pressure,etc. and pro-
regardless vide vitamin A
of HIV • Offer FP/contraception counseling and services (see Table
status 14)
• Screen for TB and trat if infected
• Breast cancer screening
• Cervical cancer screening
• Screening for NCDs including mental health
HIV and • Provide HTS and syphilis testing for breastfeeding mothers who
syphilis have never tested, and for their partner
testing • Provide HIV retesting to mothers who were negative at ANC or
services labour and delivery
• Provide ART for all mothers newly diagnosed at PNC according
to the guidance in Section 13.8
• Continue to provide risk-reduction counseling and support to
HIV-negative mothers
• Do HIV retesting every three months during breastfeeding for
all HIV negative mothers
HIV care • ART
and man- • Cotrimoxazole prophylaxis
agement • Regular TB screening and provide INH prophylaxis if eligible
for the • Continued infant feeding counseling and support
HIV-in- • Nutritional assessment, counseling and support
fected • Sexual and reproductive health services including FP/contracep-
mother tion
and • Psychosocial support
family • Adherence counseling and support
• Monitor retention in care
• Assess all mothers who delivered outside the facility for OIs,pro-
vide appropriate care and initiate ART

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Psycho- • Link the mother to support services like FSG if they exist, in
social addition to other services
support
services

4.8 CARE OF THE HIV-EXPOSED INFANT/CHILD

HIV-exposed infants should receive care at the mother-baby care point,
together with their mothers, until they are 18 months of age. The goals of
HIV-exposed infant care services are:
To prevent the infant from being infected with HIV through vertical
transmission
To diagnose HIV infection early and treat
To offer child survival interventions to prevent early death from preventable
childhood illnesses
4.8.1 Visit schedule for HIV-Exposed Infants

Regular follow-up is the backbone of caring for HIV-exposed and infected

children. It ensures optimal healthcare and psychosocial support to the
family. The HEI and the mother should consistently visit the health facility
at least nine times during the breastfeeding period. The mother-baby pair
should be supported to adhere to the visit schedule, which is synchronized
with the child’s immunization schedule Annex 2.
4.8.2 Healthcare Services for the HIV Exposed-Infants

Table 23 below summarizes the services for HEI during the 18 months of
follow-up.

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Table 23: HIV-exposed infant care services
Service Description
Identifi- • Identify all HIV-exposed infants by determining their mother’s HIV status and document the mother’s status in the child

104
cation of card and mothers’ passport.
HIV-ex- • If infant’s HIV-exposure status is not documented or is unknown (i.e. the mother’s status is unknown and she is not
available for testing), then a rapid HIV testing can be offered.
posed • Rapid diagnostic tests for HIV serology can be used to assess HIV exposure among infants younger than four months
infants of age, or for infants 4–18 months of age whose mother’s status cannot be ascertained (e.g. mother does not attend clinic
with infant)
• The mother should be retested for HIV every 3 months until end of breastfeeding.
• The entry points for identification of HIV-exposed infants include YCC, OPD pediatric/Nutrition/TB wards and out-
reaches. Special attention should be paid during immunization both at static and outreach areas to ensure that all children
have their exposure status ascertained.
HIV • Follow the infant testing algorithm in Figure 15 to test and interpret the test results: Provide 1st PCR within
testing for • Provide 1st PCR within 4-6 weeks, or the earliest opportunity thereafter. 4-6 weeks or the earliest
infants • Provide 2nd PCR at 9 months, or earliest opportunity thereafter opportunity
• Provide 3rd PCR 6 weeks after cessation of breastfeeding
• Do DBS for confirmatory DNA PCR for all infants who test positive on the same day they Guidance for indetermi-
start ART nate test:
• Do a DNA PCR test for all HEI who develop signs/symptoms suggestive of HIV during Take off whole blood and
follow-up, irrespective of breastfeeding status. test at CPHL and trans-
• Conduct rapid HIV test at 18 months for all infants who test negative at 1st, 2nd and 3rd port within 2 days
PCR
Hold off ART until results
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

*** Where available point-of-care nucleic acid testing should be used to diagnose HIV
among infants and children younger than 18 months of age. of whole blood.
• ART for mothers and ePNP causes low viral particles which can be difficult to detect, some- Communicating results to
times below cycle threshold. An indeterminate range of viral copy equivalents should be caregiver
used to improve the accuracy of all nucleic acid–based early infant diagnosis assays
Testing intervals for
• Indeterminate range: a range of viral copy equivalents that would be too low to be
accurately diagnosed as HIV infected. The indeterminate range suggested is currently infants with repeated dis-
estimated to be approximately equivalent to a cycle threshold of 33 on the Roche CO- cordant results 4 weeks, 4
BAS® Ampliprep/COBAS® TaqMan® HIV-1 Qualitative Test v2.0 assay months, 8 months
Service Description
Routine • HIV-infected children are more susceptible to vaccine-preventable diseases than their HIV-uninfected
immuniza- counterparts.
tion • HIV-infected infants and children can safely receive most childhood vaccines if given at the right time.
All HIV-infected and exposed children should be immunized as per EPI immunization schedule.
• Health workers should review child immunization status at every visit.
• Some special considerations/modifications for HIV-exposed children include:
• BCG: When considering BCG vaccination at a later age (re-vaccination for no scar or missed earlier
vaccination), exclude symptomatic HIV infection. Children with symptomatic HIV infection should
not receive BCG.
• Measles: Although the measles vaccine is a live vaccine, it should be given even when the child has
symptoms of HIV. The measles illness from the vaccine is milder than that from the wild measles
virus, which is more severe and likely to cause death.
• Yellow Fever: Do not give yellow fever vaccine to symptomatic HIV-infected children; asymptomatic
children in endemic areas should receive the vaccine at nine months of age.
Growth • Growth and child nutrition should be monitored using weight, length/height, and MUAC at all encoun-
monitor- ters with a child, and recorded on the growth monitoring card (see Annex 11).
ing and • MUAC should only be measured starting at six months of age.
nutritional • Failure to gain weight or height, slow weight or height gain, and loss of weight may be an indication of
assessment HIV infection in an infant/young child. Failure to thrive affects as many as 50% of HIV-infected infants
and children. HIV-infected infants and children who are failing to thrive have a significantly increased
risk of mortality.
• Counsel the mother/caregiver on the child’s growth trend and take appropriate action where necessary.

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Service Description
Develop- • At each visit, assess the infant’s age-specific developmental milestones. The age-specific milestones are
ment mon- summarized in Annex 2.

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itoring • Infants are at high risk for HIV encephalopathy and severe neurologic disease
• Early identification of developmental delay can facilitate intervention and these children can improve
with treatment.
• Some forms of development delay are:
• The child may reach some developmental milestones but not others.
• The child may reach some milestones but lose them after some time.
• The child may fail to reach any developmental milestones at all.
• Test children with developmental delay for HIV and, if infected, initiate on ART.
• Measure the infant’s head circumference.
Early • The first two years of life are the most critical for brain development and influences during this period
Childhood significantly contribute to longer-term developmental outcomes.
Develop- • Years 0-8 are the most critical stage of life because the brain undergoes the most dramatic growth.
ment • ECD therefore comprises all the essential care and support a young child needs to survive and thrive in
life and spans from prenatal to eight years of age across multiple domains consisting of physical, cogni-
tive, language and communication, social and emotional and spiritual development.
• It is well established that infants and young children exposed or affected by HIV have poorer health
and developmental outcomes compared to their non-HIV affected peers. Prevention of mother-to-child
transmission (PMTCT) services, which focus on mothers and infants throughout the exposure period
provide an ideal platform during a period of life that affects both longer-term health and developmental
potential. The services along the PMTCT cascade are well aligned with intervention points for ECD.
• ECD services and messages will be well integrated into PMTCT/HEI services to improve outcomes of
HEI.
Service Description
ARV pro- • Provide NVP syrup to HEI from birth until six weeks of age.
phylaxis • For high-risk infants, give NVP syrup from birth until 12 weeks of age.
• If the baby presents after 6 weeks, conduct a 1st PCR test, provide 1st line ART (weight-based dose) for
6-weeks.
• If PCR results are negative, give NVP for 6 weeks to complete after the 6 weeks of ART
• If PCR results are positive, continue with 1st line ART
• Regardless of timing, the mother should be started on ART
Oppor- Cotrimoxazole prophylaxis:
tunistic • Cotrimoxazole (CTX) prophylaxis significantly reduces the incidence and severity of Pneumocystis Ji-
infection roveci pneumonia. It also offers protection against common bacterial infections, Toxoplasmosis and
prophy- Malaria.
laxis • Provide CTX prophylaxis to all HIV-exposed infants from six weeks of age until they are confirmed
uninfected (18 months or 6 weeks after cessation of breastfeeding).
• Infants who become HIV-infected should continue to receive CTX prophylaxis for life.
• If CTX is contraindicated, offer Dapsone at dose of 2mg/kg once daily (up to 100mg).
TB Preventive Treatment (TPT):
• Give INH for six months to HEI who are exposed to TB, after excluding TB disease.
• For newborn infants, if the mother has TB disease and has been on anti-TB drugs for at least two weeks
before delivery, INH prophylaxis should not be given.
Malaria prevention:
• All HEI and HIV-infected children should receive insecticide treated nets and CTX. Using both reduces
risk of malaria by 97%.
Actively • HEI are susceptible to common infections and OIs.
look for • Counsel caregivers to seek care to receive timely treatment.

107
and treat • At every visit, assess HEI for signs and symptoms of common childhood illnesses using the Integrated
infections Maternal, New-born and Childhood Illnesses Guidelines and provide treatment.
early
Service Description

108
Counseling • Provide infant feeding counseling and advice according to guidance in Chapter 5.
and feed-
ing advice
Educate • HEI depend on their caregivers to receive care.
the care- • Provide information to the caregivers and family about the care plan including what to expect and how
giver and to provide care for the infant.
• Caregivers should participate in making decisions and planning care for the child, including decisions
family about therapy and where the child should receive care.
• Empower caregivers to be partners with the health facility.
• Provide key aspects of home-based care for the child, including:
• Dispensing prophylaxis and treatment
• Maintaining adherence
• Complying with the follow-up schedule
• Ensuring good personal and food hygiene to prevent common infections
• Seeking prompt treatment for any infections or other health-related problem
• The most important thing for the child is to have a healthy mother. Ensure the mother/infected caregiver
is receiving their care. If the mother is sick, the infant will not receive care.
• When members of the same family as the mother-baby pair are in care, their appointments should be on
the same day.
Referrals • Link the caregiver and HEI to appropriate services like OVC care, psychosocial support including FSG
and Link- and other community support groups.
age
ART for • Initiate ART in infants who become infected according to guidance in Section 13.10
infected
infants
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

4.9 HEALTHCARE SERVICES FOR INFANTS

EXPOSED TO SYPHILIS AND MANAGEMENT OF
CONGENTIAL SYPHILIS
Mother-to-child transmission (MTCT) of HIV and/or syphilis remains a
significant cause of perinatal morbidity and mortality. Untreated maternal
syphilis results in significant adverse pregnancy outcomes, such as spontaneous
abortion, stillbirth, fetal death, preterm birth, low birth weight, neonatal
death and congenital syphilis. Additionally, maternal syphilis has been shown
to increase the risk of MTCT of HIV. Prenatal syphilis screening followed
by treatment early in pregnancy can effectively treat the pregnant woman and
prevent congenital syphilis.
Validation for the elimination of vertical transmission of syphilis calls for
achieving case rate of congenital syphilis of ≤50 per 100 000 live births.
Screening all pregnant women for HIV and syphilis at the first antenatal care
visit is recommended by WHO and in nearly all countries of the world. Early
diagnosis and treatment of both HIV and syphilis in pregnant women has
been proven as an effective strategy.
Infants with confirmed congenital syphilis or infants who are clinically
normal, but whose mothers either had untreated, inadequately treated
(including treatment within 30 days of delivery) or syphilis that was treated
with non penicillin regimens should be treated as per guidelines in Table 24
below. Infants whose mothers had syphilis that was adequately treated with
no signs of reinfection should be closely monitored, as recommended by the
WHO.
Table 24: Syphilis treatment for infants
Condition Recommended Alternative
Syphilis in infants (i.e., infants Aqueous benzyl Procaine penicillin
with confirmed congenital penicillin (Xpen) 50,000 U/kg/day
syphilis or infants who are 100,000-150,000 as a single dose
clinically healthy but whose U/kg/day is is administered
mothers had untreated syphilis, administered intramuscularly for
inadequately treated syphilis intravenously for 10-15 days.
(including treatment within 30 10-15 days.  
days of delivery), or syphilis  
treated with non-penicillin
regimen

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In infants who are clinically Close Benzathine

healthy and whose mothers monitoring of penicillin G
had syphilis that was adequately the infants. 50,000 U/kg/day
treated with no signs of as a single dose
reinfection. intramuscularly.

4.10 HEALTH CARE SERVICES FOR THE INFANTS

EXPOSED TO HEPATITIS B (PMTCT-HEPB)
In highly endemic areas, HBV is mostly spread from mother to child at
birth (perinatal transmission) or through horizontal transmission (exposure
to infected blood) from an infected close contact to an uninfected child
during the first five years of life. In Africa, mother to child transmission
is one of the most common routes through which new born babies are
infected with hepatitis B infection. Infection may occur during delivery or
after delivery, mainly in the first 6 weeks of life. About 90-95% of infants
exposed perinatally will not be able to clear the infection and will lead to
chronic infection. Exposure in early childhood will lead to chronic infection
among 30-50% of those exposed, whereas only 3-5% of those exposed at
age 5 or above will result in chronic infection. HBV infection often goes
undetected in childhood, as those infected are typically asymptomatic until
they present with liver complications later in life(>25-30years). Therefore,
pregnant women will need to be screened for HBV during ANC as part of
the triple elimination strategy for mother to child transmission.
Risk factors of mother to child transmission (MCT) of
HBV include:
• HBsAg positive mother or mother known to have chronic HBV infection
• A positive test for hepatitis B e antigen in the mother.
• Mother with high HBV titres ≥ 200,000 IU Unvaccinated babies born to
HBsAg positive mothers.
• Invasive procedures such as amniocentesis.
Care of neonate borne to a mother with chronic HBV
infection:
The goal is to prevent vertical transmission and is focused on the baby.
Active immunization for birth dose (the neonate should receive the
monovalent HBV vaccine preferably within the 24hours of life as it works
best during this period. However, if missed, it should be considered at the
first contact before 6 weeks).

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The usual childhood vaccine schedule (routine national Expanded Program

on Immunization, the pentavalent vaccine schedule at 6, 10, 14 weeks) should
be followed and completed after the birth dose.
Where available, passive vaccination with the hepatitis B immunoglobulin
should be also be offered within 24 hours of birth at a site different from
where the HBV monovalent vaccine was administered.
Note:
• All HIV-HBV co-infected mothers should have PMTCT care done as is
the case for HIV-mono-infected mothers.
• Neonates born to HIV-positive mothers should also be offered the HBV
monovalent vaccine and the HBIG (if available) maybe administered at
birth.
• Co-infected mothers should use combined ART regimen with at least 2
drugs active against both HBV and HIV. (Refer to the general guideline
for treatment of HBV/HIV coinfection)

4.11 EPI/PMTCT/EID INTEGRATION

DNA-PCR coverage remains a challenge, with only 64% of HIV exposed
infants (HEI) receiving a 1st DNA PCR test; less than 55% of HEI receiving
a virological test within 2 months of birth; and only 28% of these HEI
receiving their final rapid test at 18 months of age (MoH PMTCT annual
report 2014/15).
In contrast, the coverage of the Expanded Program on Immunizations (EPI)
is over 97% of the target population for DPT 1 (Annual Health sector report
2014/15). Therefore, although many women deliver outside health facilities,
most infants will routinely attend immunization or YCC clinics. According
to the 2016 Uganda Demographic health survey, childhood immunization
coverage was 94.9% at 6-weeks (DPT1-HepB-Hib); 89.9% at 10 weeks
(DPT2-HepB-Hib) and 78.6% at 14 weeks (DPT3-HepB-Hib). Integrating
EID with EPI services should be implemented to increase infant HIV
testing, increase the number of infants identified early, improve enrollment
in EID care and ultimately improve maternal retesting.

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Table 25: Integration of EID into EPI services

At each • Proactively determine the need for re-testing at every
immunization immunization encounter.
visit • Immunization card should have PMTCT section completed
at discharge from delivery.
• Screening for eligibility (for infant testing):
• Can take place at registration
• Standardize the screening process for infant’s HIV-exposed
status at 6-week immunizations visit
• If mother’s status is unknown (or >3 months have elapsed
since last test), re-test the mother (per algorithm for testing
breast feeding mothers)
• If mother is unavailable for testing, do a rapid test on the
infant < 4 months of age. If >4 months of age, DBS should
be sent for PCR testing.
• If DBS cannot be collected at the same time as outreach,
strong referral/linkage must be ensured with follow-up by the
peer/mentor mother or community-based volunteer.
• If an infant requires EID, or the mother needs re-testing, then
mentor mother should escort mother-baby pair to designated
testing area.
Schedule:
• Week 6 immunization (Polio, Penta, Pneumovax): First PCR
• Month 9 immunization (Measles): Second PCR
• Final outcome: 18 months if no longer breastfeeding, or 6
weeks after cession of breastfeeding
• If < 18 months, PCR
• If ≥ 18 months, RDT.
• Date of last HIV test should be clearly noted on the
immunization card.
• If mother is newly positive during breastfeeding, immediately
flag as high risk and link to treatment and facility or community
psychosocial supportive services.
• Data collection should include number of infants and mothers
screened and number of newly identified mothers and HEIs

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Box 6: Key highlights in Elimination of Mother-to-child

transmission of HIV (eMTCT) and improving Maternal,
Newborn, Child and Adolescent Health (MNCAH)
• The eMTCT strategy comprises a package of four approaches:
• Primary prevention of HIV among females of reproductive age and
their partners
• prevention of unintended pregnancies among HIV infected women
• prevention of HIV transmission from HIV infected women to their
infants
• provision of treatment, care, and support to women/ adolescent girls
infected with HIV, their children and their families.
• eMTCT interventions should be integrated and offered simultaneously
within the platform of MNCAH services.
• Provide Syphilis and Hepatitis B screening and treatment during ANC.
• Provide HIV prevention services to HIV-negative pregnant women in ANC
and re-test in the third trimester, during labor, or shortly after delivery due to
the high risk of acquiring HIV infection during pregnancy; and retest every 3
months during breastfeeding.
• Initiate HIV-positive pregnant or breastfeeding women in ANC/PNC onto
ART on the same day as diagnosis and give adherence counseling for at least
the first three months.
• The preferred 1st line ART regimen is TDF + 3TC + DTG or
TAF+FTC+DTG.
• Viral load will be done 3 months after initiation of ART and every 3
months until end of eMTCT period
• Pregnant and breastfeeding women who are on TLE or other regimens and
have suppressed VL at ANC 1, should remain on the same regimens until 6-9
months postpartum when they should be transitioned to TLD, if VL within
past 6 months is suppressed.
• HIV-pregnant and breastfeeding women already on ART should have a viral
load done at 1st ANC visit and every 3 months until end of eMTCT period
• The eMTCT strategy comprises a package of four approaches:
• Primary prevention of HIV among females of reproductive age and
their partners
• prevention of unintended pregnancies among HIV infected women
• prevention of HIV transmission from HIV infected women to their
infants
• provision of treatment, care, and support to women/ adolescent girls
infected with HIV, their children and their families.

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• eMTCT interventions should be integrated and offered simultaneously

within the platform of MNCAH services.
• Provide Syphilis and Hepatitis B screening and treatment during ANC.
• Provide HIV prevention services to HIV-negative pregnant women in ANC
and re-test in the third trimester, during labor, or shortly after delivery due to
the high risk of acquiring HIV infection during pregnancy; and retest every 3
months during breastfeeding.
• Initiate HIV-positive pregnant or breastfeeding women in ANC/PNC onto
ART on the same day as diagnosis and give adherence counseling for at least
the first three months.
• The preferred 1st line ART regimen is TDF + 3TC + DTG.
• Viral load will be done 3 months after initiation of ART and every 3
months until end of eMTCT period
• Pregnant and breastfeeding women who are on TLE or other regimens and
have suppressed VL at ANC 1, should remain on the same regimens until 6-9
months postpartum when they should be transitioned to TLD, if VL within
past 6 months is suppressed.
• HIV-pregnant and breastfeeding women already on ART should have a viral
load done at 1st ANC visit and every 3 months until end of eMTCT period

4.12 COMMUNITY PMTCT SERVICES

Community PMTCT services should be provided through existing
community structures and support networks for PLHIV. These structures
and networks should be supported to provide unique services that meet
the needs of pregnant and breastfeeding mothers and their infants. All
PMTCT implementing sites should establish a network of community-based
structures and systems within their catchment area to support the health
facility to deliver a minimum package of community-based MTCT services.
4.12.1 Minimum Package of Community PMTCT Services

The minimum package of community PMTCT services include:

• Community sensitization and mobilization for HIV prevention,
reproductive health and PMTCT services
• Identification, counseling, registration and referral of pregnant/lactating
mothers for comprehensive ANC services including screening for
TB symptoms, skilled delivery, PMTCT services for mother and baby
including EID, post-natal care, IYCF and FP.

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• Identification of partners and children of pregnant and breastfeeding

women in communities and ensuring that they know their HIV status,
either through outreaches/home-based HTS or through referral
• Address social and behavioral factors that affect uptake of PMTCT
services including stigma, disclosure, discrimination,GBV, etc.
• Adherence support.
• Follow-up, linkage, and tracking of mother-infant pairs through at least
18months postpartum and ensure infant’s final survival and HIV status
is known.
• Community ART and Cotrimoxazole refills.
• Provision of psychosocial support through Family Support Groups or
other community based PLHIV support groups, OVC programs, and
household economic strengthening/income generating activities.
• Assess infants with HIV positive mothers for eligibility for OVC programs.
• Promote family care, treatment, and support, including treatment support
for those who are not part of the family.
• Health education and advocacy for PMTCT services.
This package should be delivered using continuous quality improvement
approaches and monitored using a well-defined monitoring and evaluation
(M&E) structure.
4.12.2 Establishment of Community PMTCT Services
1. PMTCT sites should do the following in order to establish community
PMTCT services:
• Establish partnerships and networks with community-based organizations
(CBOs), NGOs and networks of PLHIV for community service delivery.
The networks and partnerships should be established by:
• Conducting or updating community mapping of resources, identifying
referral trigger factors, developing referral directories, and supporting
documentation of referral processes.
• Connecting with the community development officers, CBOs, FBOs,
NGOs and networks of PLHIV and other networks involved in
community-based PMTCT and meeting to agree on a common objective
and agenda.
• Establishing and strengthening comprehensive referral network systems
and coordination of two-way referrals between community and health
facilities and establishing mechanisms for assessing performance of these
systems.
• Promoting integration of PMTCT and HIV into reproductive health,
MCH, and other programs.

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• Identifying and collaborating with relevant sectors for community

empowerment and economic strengthening activities to reduce gender
inequalities and increase women’s access to assets.
• Promoting partner support by using different strategies to engage male
partners.
2. Identify, train, and facilitate community health workers.
• Identify, train, and facilitate community health workers, including peer
educators, in the catchment area to implement the community PMTCT
minimum package.
Establish coordination mechanism.

Each health facility should establish a mechanism for coordinating with

the community structures. Communication channels between the partners
should be clear and open.

4.13 ALDOSCENT GIRLS AND YOUNG WOMEN (AGYW)

Uganda has one of the youngest populations and adolescents and young
people are exposed to numerous challenges including HIV infection.
According to UPHIA 2020, the prevalence of HIV for AGYW was 2.9%
which is three times higher than their male counterparts (0.8%). More so,
the vulnerability and exposure to violence is very high according to UDHS
2016, the teenage pregnancy rate was 25%. In addition, the unmet need of
the family is high at 30% with low condom use at 46%.
Because of this, the Ministry of Health developed the National Health
Sector HIV Prevention Strategy for Adolescent Girls and Young Women,
2020-2025 to guide the implementation of AGYW focused interventions,
strengthen the HIV prevention response among AGYW, accelerate progress
towards 95:95:95 targets and end AIDS by 2030. Successful AGYW HIV
strategy implementation requires a collaborative effort. This section will
provide guidance on HIV prevention and sexual and reproductive health
services to AGYW.
4.13.1 The Harmonised AGYW Service Package

Context-specific HIV services will be delivered to AGYW, families and

communities to create a supportive and enabling environment and break the
barriers to access to integrated HIV services for AGYW. The service package
is guided by the National Heath Sector HIV Prevention AGYW Strategy
(2020-2025).

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The AGYW HIV Prevention Service Package is categorized along three

thematic age categories of AGYW as shown in the figure below:
Figure 32: Tailored age-appropriate AGYW service package for
impact
  10-14 15-19 20-24
• Screening for TB • Screening for TB • Screening for TB
• Screening for • Screening for HTS • Screening for
HTS eligibility (if eligibility HTS eligibility
out of school) • HIV & Violence • Community
• HIV & Violence Prevention and post Based HIV
prevention & violence care & Violence
post violence • Combination Socio- Prevention
care economic approaches • Combination
• Empowerment (ifout of school) socio-economic
with parenting • Empowerment with approaches (if
skills parenting skills out of school)
• Early warning • Early Warning systems • Information on
systems • Combined socio- menstrual hygiene
• Role modeling economic approaches (if management
• Age-appropriate out of school) • Social Behavior
life skills • Age-appropriate life skills change
and sexuality and sexuality education communication
education • Health Facility or on risk reduction
• Vocational Skills community SRHR • Vocational
& tooling (if out services skilling
of school) • Second Chance Education • Empowerment
• Second Chance • Vocational skilling (if out with parenting
Education of school) skills
• Information • Role Modeling • SRH services
Primary Interventions

and skills for • Information on menstrual

menstrual hygiene management
hygiene • Social Behavior change
management communication on risk
• Social Behavior reduction
Change • SRH services
Communication
on risk avoidance

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• Risk based HTS • Risk Based HTS • Risk based HTS

• Violence • Condoms (emancipated • Condoms
prevention, post- minors only) • Contraceptive
violence and • Contraceptive mix (for Mix
management care only emancipated minors) • Violence
• Education • Violence prevention, prevention, post-
subsidy post-violence care and violence care and
• ART (for HIV- management management
positive AGYW) • Parenting (for those 15- • PrEP
• 17yrs) • ART (for HIV-
• Education Subsidy positive AGYW)
• PrEP (for emancipated • Education
Secondary Interventions

minors at substantial risk) subsidies

• ART (for HIV-positive • Friendly PMTCT
AGYW) services for
• Group-ANC model or pregnant & breast
longitudinal follow-up feeding AGYW
through 2y post-partum in including Group
PMTCT mother-baby care ANC, follow up
point (for pregnant and in the MBCP
BF AGYW)
• Reducing risk in sexual partners (HTS, VMMC, ART)
• Community mobilization & Norms Change (SASA)
• Male engagement (Male Action Groups, GREAT & Partner
Tracking
• Primary prevention for KPs (Adolescent and young KPs)
CONTEXTUAL

• Condom promotion campaign/demand creation

• Vocational training and skilling
• Financial literacy and entrepreneurship; enterprise development
assistance and VSLA for AGYW living with HIV
• Socio economic approaches for caregivers (10-14)
• PEP 

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Table 26: HIV testing and prevention services for adolescent

girls and young women 10-24 years
Service Description
Routine • All AGYW attending facilities should be screened for HTS eligibility.
HTS • Provide HTS to all AGYW and their partners. Also test for syphilis and
link to care as necessary.
• Provide risk reduction counseling to all who test HIV negative.
• Link all who test HIV-positive to care and treatment services
• Services should be offered at the convenience of adolescents through
flexible opening hours, walk ins or same day appointments
• In facility setting, providers should physically escort adolescents to the
next point of care to ensure their successful linkage to appropriate HIV
prevention, treatment, and care and support services.
Self-testing • Utilize a peer led approach.
• Teach AGYW how to use a self-testing kit and provide the necessary
HIV pretest counselling.
• Follow up with the adolescents to ensure return of the self-testing results
• If the HIVST result is positive, link the AGYW to laboratory for the
confirmatory HIV test and ensure linkage to appropriate care and treat-
ment.
• For all HIV negative AGYW, provide the HIV prevention risk reduction
messages.
• Always screen AGYW for gender-based violence using standard tools
• Provide first line support to AGYW who experience GBV.
• Link to violence prevention and response services as necessary.
BCC • Safer sex practices, including dual protection (condom promotion) and
delay of onset of sexual activity (see Table 9.)
AGYW • Actively identify male partners of AGYW who are at risk of HIV infec-
Male Part- tion using a standard tool
ners • Screen for eligibility for HIV testing services. Also test for syphilis and
link to care as necessary.
• Avail HIVST kits to AGYW for their partners
• Provide risk reduction counseling to all who test HIV negative.
• If the HIVST result is positive, link to laboratory for the confirmatory
HIV test and ensure linkage to appropriate care and treatment
• Services should be offered at the convenience of AGYW’s male partners
through flexible opening hours, walk ins or same day appointments
• Offer SMC services to male partners of the girls and women using stan-
dard SMC guidelines

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PrEP • Screen all the AGYW for eligibility for PrEP using the standard
eligibility screen PrEP tool
• Identify designated entry points (i.e. IPD, OPD, ANC, and SRH)
and health workers or peers providing services for AGYW
• Offer PrEP to eligible adolescent girls and young women 15-24
years in line with the guidelines for PrEP (see PrEP section); (if
the Health facility is not providing PrEP, make appropriate referral
to a nearby PrEP site.)
• Use a peer led approach to PrEP service delivery.
• Conduct APN and partner tracking
• Monitor AGYW on PrEP at 1 month then every 3 months
• Note: refer to the PrEP guideline ( page XX) in this document
STI and Counsel and screen adolescent girls and women for STIs including
HBV syphilis and HBV and manage the STIs (see Section 9.1.1 ).
screening
and treat-
ment
HPV Vac- Screen and refer eligible AGYW for HPV vaccination.
cination The HPV vaccine protects against genital warts, one of the most
common types of sexually transmitted infection. In the long term,
the vaccine prevents development of cervical cancer in females and
anal cancer in both women and men.
Table 27: Prevention of gender-based violence and post violence care
Service Description
Violence • All AGYW attending the health facilities should be screened gen-
preven- der-based violence.
tion and If the AGYW has experience sexual gender-based violence:
post-vi- • Provide first line support using LIVES
olence • Provide psychosocial support and counselling to SGBV survivors.
• Screen all survivors for HIV, pregnancy, STI, trauma and manage ac-
care cordingly.
• Provider emergency contraceptives with in the 72 hours
• Screen and provide Post Exposure Prophylaxis (PEP) to all eligible sur-
vivors.
• If HIV positive link to appropriate HIV treatment and care services.
• If HIV negative provide HIV prevention information and services
• Link the survivor for legal services.
• Ensure continue follow up for six months.
• Services should be offered at the convenience of adolescents through
flexible opening hours, walk ins or same day appointments and ensure
confidentiality

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4.13.2 Prevention of Unintended Pregnancies among

Family planning (FP)/contraception for adolescent girls and women reduces

the number of unintended pregnancies, school dropout and improves their
overall wellbeing. FP/contraception also provides intrinsic benefits by
saving lives and enhancing the health status of girls and young women and
their families. However, FP services should be provided based on respect
and fulfillment of reproductive rights and choices. Adolescent girls and
young women should not be coerced into contraception, but provided
with information to make informed decisions and choices. Table 28 below
describes the process of offering FP/contraception.
Table 28: Family planning/contraception services for AGYW
and emancipated minors
Service Explanation
Counselling • Provide routine FP/contraception information and
counseling to AGYW attending OPD,ANC/G-ANC/
PNC, YCC and safe spaces
• Encourage AGYW to discuss their reproductive health
choices and support them as appropriate.
Information provided during counseling should cover:
• All FP/contraceptive methods, advantages and side
effects
• Common misconceptions about FP/contraception
• Advantages of dual protection and how to negotiate
condom use
• What to do if/when pregnancy occurs
Address misconceptions
After For AGYW who do not desire to become pregnant:
counseling, • Offer effective contraception
offer FP on • Encourage dual contraception (use of both hormonal
a one-on-one contraception and condoms) to prevent pregnancy, STIs,
basis HIV transmission, and re-infection.
Promote • AGYW who are sexually active should be counselled on
Condom safe sex practices, correct and consistent condom use.
Use among • Avail condom dispensers in appropriate spaces that are
Sexually youth friendly.
active
AGYW

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Service Explanation
Ongoing • Counselling and adherence suport for the chosen
support for method (provide a health workers contact in case of any
AGYW side effects)
• Assess for possible side effects and manage accordingly
• Clients on injectable FP (Depo-Provera) should be
counseled to return for injection on appointment date or
before if they cannot make it on scheduled appointment
date
Integration • All AGYW eligible for HIV related programs (GANC,
of AGYW YAPS, DREAMS, OVC, GBV among others) should be
services effectively linked
• Screen AGYW for TB using standard tools and reffer
those who need TB services using standard guidelines.
4.13.3 Multisectoral approach

Prevention of HIV among AGYW involves a range of services including

Health, Justice, Education, and Social services. Health care providers should
have a strong multi sectoral referral and linkage mechanism at all levels,
which promotes service equity and reduces the vulnerability of AGYW to
HIV infection.

4.14 MATERNAL, INFANT AND YOUNG CHILD

FEEDING GUIDELINES
4.14.1 Introduction

Infant feeding in the context of HIV has implications for child survival.
Balancing the risk of infants acquiring HIV through breast milk with the
higher risk of death from malnutrition, diarrhea, and pneumonia among non-
breastfed infants is a challenge. Protecting the infant from the risk of death
from these causes is as important as avoiding HIV transmission through
breastfeeding. Current evidence indicates that exclusive breastfeeding and
the use of antiretroviral drugs greatly reduce MTCT. The effectiveness of
ARV interventions with continued breastfeeding by HIV-infected mothers
until the infant is 12 months of age optimizes the maximum benefit of
breastfeeding to improve the infant’s chances of survival while reducing the
risk of HIV transmission.

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The objectives of maternal, infant and young child feed-

ing guidelines are to:
1. Promote optimal feeding for the HIV-exposed children to ensure HIV-
free survival
2. Minimize HIV transmission through breastfeeding; and
3. Ensure a healthy mother.
This section provides guidance for optimal maternal and infant feeding
counseling throughout the eMTCT service cascade.
4.14.2 Services Offered During Pregnancy

Nutrition counseling messages and services for HIV-infected pregnant

women are in Table 29.
Table 29: Nutrition Counseling Messages for Pregnant
Women
Nutrition Information
Diet • During pregnancy and breastfeeding: add extra
meals, drink adequate fluids, eat plenty of fruits and
vegetable,; eat foods rich in vitamin C to enhance
iron absorption, avoid tea or coffee within one hour
or with meals as this may interfere with absorption
of iron, and use iodized salt to prevent pregnancy
complications (abortions, miscarriages, stillbirths, fetal
growth retardation, and maternal goiter).
• Maintain high levels of personal and food hygiene and
food safety to prevent illness.
• Advise adolescent mothers to take extra care to get
adequate food and rest since they are still growing.
• Avoid alcohol, narcotics or tobacco products, and
medicines not prescribed by a trained health care
provider.

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Nutrition Information
Medications • Vitamins are important in pregnancy, including
during supplemental iron to prevent anemia and reduce the
pregnancy risk of low birth weight, folic acid to prevent fetal brain
and spinal cord congenital disabilities, de-worming
tablets to eliminate worms and prevent anemia.
• Provide 60mg of elemental iron (200mg of ferrous
sulphate) and 400ug folic acid OR combined iron
(150mg with 0.5mg folic acid) after three months
of gestation and continue to take them daily for six
months. Take supplements with food to overcome
side effects.
• Give iron 120mg + 4000ug folic acid daily for three
months to pregnant women with mild to moderate
anemia. After completing this treatment, continue
with routine supplementation for three months.
Initiatives to promote active Breastfeeding

The following activities should be done to promote breastfeeding:

• Counsel pregnant women on the benefits of breastfeeding, the importance
of adhering to ART regimen, and the risk of MTCT.
• Counsel on the benefits of exclusive breastfeeding for the first six months
regardless of the HIV serological status.
• Link mothers to support systems such as mother support groups on
discharge from the hospital or clinic.
• Demonstrate to mothers how to position infants when breastfeeding, and
how to maintain lactation should they be separated from their infants. Pay
attention to prevention of conditions such as cracked nipples or mastitis
that increase the risk of HIV transmission.
4.14.3 Services Offered During Labour and Delivery
1. Help mothers initiate breastfeeding within half an hour after delivery
including in cases of caesarean section.
2. Newborn infants should be fed only colostrum (the first milk) and
SHOULD NOT be given pre-lacteal feeds such as glucose, dill/gripe
water, mushroom soup, herbal extracts, etc.
3. Continue to counsel on demand feeding, exclusive breastfeeding, and
ways of holding and putting the baby to the breast (positioning and
attachment) to enhance breastfeeding.

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4. Mothers should continue supplementation with iron one tablet/day

and folic acid one tablet/day for three months after delivery in addition
to intake of iron rich foods.
4.14.4 Services Offered During the Postnatal Period

Feeding a child 0-6 months

HIV-Exposed Infants • HIV-infected mothers should exclusively
OR breastfeed (EBF) their Exposed infants or
HIV-infected infants for the first six months
Unknown HIV status
of life.
OR • Mothers should introduce nutritionally
HIV-infected infants adequate and safe foods (appropriate
complementary foods) at 6 months of life.
• The mother should be encouraged to
breastfeed as often as the infant wants (on
demand).
• Mothers should be supported to fully adhere
to ART
• Establish the HIV exposure status of those
infants with unknown status.

Heat-treated expressed breast milk

HIV positive mothers known to be living with HIV may consider expressing
and heat-treating breast milk as an interim feeding strategy in order to
maintain exclusive breastfeeding under special circumstances considered to
be high risk for HIV transmission:
• When maternal VL is not suppressed.
• The infant has low birth weight or is otherwise ill in the neonatal
period and unable to breastfeed.
• The mother is unwell and temporarily unable to breastfeed or has
a temporary breast health problem such as mastitis
If ARV drugs are temporarily not available.
For the procedures of heat treatment, refer to the IYCF Guidelines
Feeding a child 6–12 months – Complementary Feeding

After six months of age, appropriate complementary foods should be

introduced while continuing to breastfeed until 12 months.
Counseling messages on complementary feeding are summarized below:

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F = Frequency Feed the baby 3–5 times a day. Increase the frequency as
the baby grows.
A = Amount Start with 2–3 heaped tablespoons per feed. Gradually
increase the amount of food to at least one-third (1/3)
of a NICE cup. (A full NICE cup is 500 ml).
T = Thickness Mothers should mash and soften the food for easy
swallowing and digestion. Use animal milk or margarine/
(consistency)
ghee/oil (not water) to soften and enrich the food.
V = Variety Encourage mothers to include at least one type of
food from the three main food groups: Carbohydrates/
fats/oils (Energy-giving foods), plant/animal protein
(bodybuilding), and vegetables &fruits (protecting foods).
A = Active/ Mothers should be encouraged to feed their infants and
young children patiently and actively and to use a separate
responsive
plate for the infant to ensure adequate intake.
feeding
H = Hygiene Counsel mothers on hygienic food preparation and
handling to avoid food contamination leading to diarrhea
and illness. Encourage the use of clean, open cups.
Discourage use of feeding bottles, teats, or spouted cups
as they are very difficult to clean.
Feeding a child 12–24 months
HIV-exposed Encourage mothers to discontinue breastfeeding at 12
months for infants who are HIV-negative at 12 months.
At least 500 ml (1 NICE cup) a day of alternative forms
of milk (cow’s milk, goat’s milk, soya) should be given.
Encourage mothers to feed their children five times a
day: three main meals and two extra foods between meals
(snacks).
HIV-infected Encourage mothers to continue breastfeeding on demand,
day and night up to 24 months to maintain the baby’s
health and nutrition.
Give one extra snack to children who are well; one extra
meal (or 2 snacks) at onset of sickness; and three extra
meals (or 2 extra meals and one snack) when sick and
losing weight.

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Feeding a child 2-6 years

Encourage mothers to give a variety of foods prepared from the family meal
(each meal should consist of a carbohydrate, protein, vegetables & fruits) at
least three times a day.
Encourage caregivers to give nutritious snacks between meals e.g. fruit
(banana, pawpaw, orange, and mango), egg, bread, enriched thick porridge
or a glass of milk.
Sick and recuperating infants and children should be fed on small, frequent
meals which include porridge enriched with milk/groundnut paste/
margarine/honey/or oil; cooked, skinned, or mashed beans; thickened
soups; etc.
Additional Support Messages

HIV-positive mothers who decide to stop breastfeeding at any time should

stop gradually. This transition period should be between one to two weeks
which is not too long to increase exposure and not too short to cause physical
and psychological trauma to the mother and baby.
The mechanisms of transition include:
Expressing breast milk and feeding infant/child by cup; and
Substituting the expressed breast milk with suitable replacement feed
gradually.
Replacement feeding (using alternative milk other than breast milk in the first
six months of life) should be recommended only in extreme circumstances
(e.g. mother is absent, dead or mentally challenged) in accordance with the
regulations on the marketing of infant and young child foods.
Follow-up all HIV-exposed infants and continue to offer infant feeding
counseling and support to mothers/caregivers.
If an HIV-exposed child falls sick, counsel the mother/caregiver to feed
the child even more frequently than usual to meet that child’s nutritional
requirements.

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Box 7: Key highlights in Maternal, Infant and Young

Child Feeding guidelines
• Provide nutrition counseling and micronutrient supplementation for
optimal maternal nutrient intake during pregnancy.
• Breastfeeding should be initiated within half an hour after delivery
including in cases of caesarean section.
• Newborn infants should be fed only colostrum (the first milk) and
SHOULD NOT be given pre-lacteal feeds such as glucose, dill/gripe
water, mushroom soup, herbal extracts, etc.
• HEI should be exclusively breastfed for 6 months.
• After six months, appropriate complementary foods should be introduced
while continuing to breastfeed until:
• 12 months in HIV exposed infants.
• 24 months in HIV infected infants.
• Cessation of breastfeeding should be a gradual process over 1-2 weeks.

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5.0 CARE AND SUPPORT FOR

PEOPLE LIVING WITH HIV
The AIDS Control Program has developed a minimum healthcare services
package for PLHIV to standardize the programming, implementation and
delivery of integrated HIV services in Uganda. The details of this minimum
healthcare services package can be found in Integrated Health Care Services
Package for HIV Prevention, Treatment and Care Services for Uganda.

5.1 MINIMUM SERVICE PACKAGE FOR PEOPLE

LIVING WITH HIV AND WHO CLINICAL STAGING
The minimum care package should be offered to all people living with HIV
upon enrollment and during their entire time in HIV care. The package
should be tailored to their individual needs. The package is summarized in
Table 30.
Table 30: Summary of Minimum Care Package for PLHIV
Service Area Service Description
Clinical Provide clinical evaluation and monitoring to all
evaluation and PLHIV to ascertain the WHO clinical stage of
monitoring of disease and exclude comorbidities.
HIV disease
Antiretroviral Initiate at the earliest opportunity in all people with
therapy confirmed HIV infection; regardless of clinical stage
or CD4 cell count (see Chapter 13).
Nutrition Conduct nutrition assessment, counseling and
services support (NACS) (see Section 8.1).
Opportunistic • Provide Cotrimoxazole prophylaxis if eligible.
infection • Provide INH prophylaxis if eligible (see Section
screening, 7.5.3)
prevention, and • Screen and manage other OIs like TB and
management Cryptoccoccal infection (see Section 7.6)

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Service Area Service Description

Screening and Screen and manage NCDs including:
treatment of co- • Hypertension
morbidities • Diabetes
• Dyslipidemias
• Mental health (especially depression)
See Section 7 for detailed guidance on screening and
managing NCDs.
Sexual and • Screen and manage sexually transmitted infections
reproductive • Provide family planning/contraceptive and pre-
health services conception services (see Section 4.4. )
• Ensure resources for early identification of pregnant
mothers and linking them to ANC
• Promote facility delivery and postnatal care (see
Chapter 4)
Provide cervical and breast cancer screening (see
Section 9.2)
Adherence Do adherence preparation, monitoring and support
counseling (see Section 7.5)
Psychosocial • Assess family and community support to the client
support and • Assess for stigma and discrimination
palliative care • Link client to a psychosocial support group
• Assess for any social challenges the client might have
• Refer for palliative care when required.
Orphans and • Conduct basic assessment for vulnerability
vulnerable • Provide HIV testing for family members either at
children (OVC) facility or community level as appropriate
• Refer and link to a CBO/CDO
• Conduct nutrition assessment, counseling and
support
• Initiate ART for HIV-positive children and their
caretakers
• For details of OVC care, refer to the SPPI, Ministry
of Labor, Gender, and Social Development

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Service Area Service Description

Positive health, • Support client to disclose HIV status to family and
dignity and significant others
prevention • Provide active partner and family tracing for HIV
testing
• Educate, provide and promote correct and consistent
use of condoms
• Provide family planning counseling and services with
consent of the patient
• Provide STI screening, prevention and treatment
services
• Provide routine adherence counseling to patients on
ART
• Provide gender-based violence screening and support
Other prevention • Provide immunizations according to the national
services immunizations schedule
• Educate and promote use of long-lasting insecticide-
treated mosquito nets (LLINs)
• Educate and promote use of safe water, sanitation
and hygiene practices

WHO Clinical Staging

Clinical staging should be performed at HIV diagnosis, on entry into HIV

care, at ART initiation and at every visit thereafter to help guide patient care
and monitor disease progress. HIV‐related diseases are grouped into four
WHO clinical stages that correlate with disease progression and prognosis
of survival:
• Stage 1: asymptomatic
• Stage 2: mild
• Stage 3: advanced
• Stage 4: severe
See Annex 3 and Annex 4 for staging in adults and adolescents, and in
children respectively.

5.2 DELIVERING HIV SERVICES FOR ADOLESCENTS

An adolescent is a person aged 10–19 years. Adolescence is a period
characterized by rapid physical, emotional, cognitive, and social changes.
During this period, adolescents are at risk of poor health outcomes and

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acquisition of new HIV infections. Therefore, to improve access to HIV

prevention, care and treatment services and improve their health outcomes,
health care providers need to provide adolescent-friendly health services
(AFHS). The WHO minimum standards for adolescent health service
delivery and Uganda’s minimum health care package consider health services
adolescent friendly/responsive if they meet the minimum service standards i.e.
Provide aadolescent literacy (information and education); engage community
support (e.g., care giver involvement, linkages to community services);
offer an appropriate service package; ensure provider competencies; offer
favorable facility characteristics (space, flexible hours, separate clinics, privacy,
attractiveness, branding); ensure equity and non-discrimination; monitor and
ensure adolescent participation (peer-led). Adolescent responsive services
should also be accessible, acceptable, appropriate, equitable and effective.
Health facilities providing HIV/ART services should therefore ensure that
services are provided within this framework to target adolescents as indicated
in Table 70 below.
Table 70: Adolescent Friendly HIV Services
Guidance
1. Service delivery: The services offered should be adolescent-friendly
so that they can meet the needs of this age group.
Adolescent Literacy: Adolescents should be provided with accurate and
comprehensive information about HIV to help them protect themselves from
HIV infection. Such information should include the meaning of HIV and
AIDS, how HIV is transmitted and how HIV is prevented. Adolescents living
with HIV should be disclosed to about their HIV status and given information
about their treatment. Key information should include: the basic care package,
meaning of ART, TPT, benefits of ART, importance of ART, side-effects
of ARVs and basic clinic routines. Provide educational/information materials
in the form of posters and brochures in a language best understood by
the adolescents. Share available hotlines where the adolescents can access
information or counseling off-site.
Community Engagement: The support of caregivers is important for positive
outcomes for adolescents. Adolescents accessing HTS by themselves and
testing HIV positive should be encouraged and supported to disclose to
their parents or caregivers. Caregivers support adolescents to adhere to their
medication, remind them about clinic appointments, provide life necessities
and provide psychosocial support. In addition, vulnerable adolescents should
be linked to other non-health community services to ensure comprehensive
service provision and promote adherence as well as retention in care.

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Guidance
Adolescent service package in HIV settings: Health facilities should provide
a comprehensive service package for adolescents to minimize missed
opportunities. The recommended service package in HIV settings includes:
Information and counseling on health especially growth and development;
reproductive health issues; life skills education; GBV/VAC services; mental
health screening and management; counseling on alcohol and substance
abuse; pregnancy testing; nutrition services; HIV testing; ART/TB services;
referral and follow up; sexual reproductive health services e.g. antenatal care,
safe deliveries, post-natal care, STI prevention, screening and treatment;
modern contraceptive methods and recreation facilities. Delivery of these
services will follow a differentiated approach as described in Chapter 10.
Provider competencies:
a. Health workers providing adolescent services need to be trained in
adolescent health and HIV management using nationally approved
training curricula. These should constitute a multi-disciplinary team
including clinicians, counselors, nurses, and peer leaders.
b. A designated health worker should be assigned to serve as an adolescent
focal person.
c. Use of job aids developed for adolescent service delivery during service
provision.
Favorable facility characteristics:
• The facility should identify a convenient, comfortable, private, and
accessible place/area with a separate waiting area to offer adolescent
services.
• There should be branding right from the facility sign-post to show that the
facility offers AFHS. Signs indicating the location of the adolescent space
should be visible to guide the adolescents without the need for them to ask
for directions.
• Where space is a problem, conduct separate adolescent clinic days using
the available space.
• The dedicated adolescent space should be attractive to encourage them to
keep clinic appointments e.g. provide play materials, initiate activities that
keep them busy (drama, sporting, etc).
• Have flexible clinic hours that take care of both in-school and out-of-
school adolescents including running clinics until late (after 5 pm) and/ or
over weekends.
Equity and non-discrimination:
a. HIV services should be made available to all adolescents irrespective of
ethnicity, tribe, age, sex, or sexual orientation.

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Guidance
b. Offer free or affordable services to adolescents.
c. Offer services in line with the standard minimum care package for
adolescents.
d. Link adolescents to other services not provided by the facility to ensure
comprehensive service delivery
e. HIV services should be provided following a differentiated approach.
Adolescents are a heterogenous group and therefore services should be
tailored to the needs of various categories. For instance, health facilities
should implement adolescent responsive MCH services for pregnant
and breastfeeding adolescent girls e.g enrolment into Group ANC/
PNC.
Monitoring and Evaluation of Adolescent HIV services:
f. Adolescents’ treatment outcomes across the clinical cascade should
be monitored through routine data collection and reporting of the
HIV indicators. These should be part of the facility report submitted
routinely through the national reporting system.
g. Track and follow-up adolescents using the standard loss to follow-up
protocols and tools
Adolescent participation (Peer-led): Participation of adolescents in their
care is an effective approach in delivering adolescent health services.
Facilities should identify, train, and use peers to support the provision of
services across the clinical cascade using the standardized national peer
support guidelines. Activities implemented by adolescent peer supporters
should be monitoring to ascertain their contribution to the clinical
cascade.
h. Note: As much as possible, adolescent health/HIV services should
be integrated into the already existing health service delivery systems
making it ‘a one-stop shopping center’.
2. HIV testing services (HTS): Access and uptake of HTS among
adolescents is low partly due to their poor health seeking behavior
as well as the absence of an enabling environment. HTS is an entry
point to HIV prevention, care, and treatment services
HTS with linkage to prevention, treatment and care is recommended for
all adolescents with a focus on those from key populations.
Informed consent and HIV testing.
Adolescents aged 12 years and above can consent on their own for HTS
without the approval of their parent/guardian.

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Guidance
Strategies for improving uptake of HTS among adolescents:
1. Use a peer-led approach where adolescent peers are trained to
provide pre and post-test counseling as well as performing HIV tests.
2. Offer services at the convenience of adolescents through flexible
working hours, walk-in services for those without an appointment,
weekend or same-day appointments.
3. Offer services in a place that ensures privacy and confidentiality.
4. Provide age-appropriate information such as benefits of knowing
one’s HIV status.
Generating demand for HTS
Consider where the adolescents live (rural or urban).
A wide range of approaches can be used including:
1. Peer-to-peer engagement.
2. Multimedia campaigns including TV, radio, billboards and brochures.
3. Social media: Facebook, Twitter, WhatsApp, Instagram, etc.
4. Phone technology: SMS messages with a platform that allows self-
assessment for risk and determining whether to test.
5. Performing artists and celebrities.
6. Sports gala.
7. Music and drama festivals.
8. School extracurricular activities/clubs.
9. Community events such as promotions, meetings, bazaars.
10. Health education.
Providing opportunities for HIV testing.
HTS services should be offered using facility or community service
delivery approach as integrated or stand-alone services.
For the facility approach, create HIV testing opportunities within existing
service points where adolescents routinely receive care including:
1. OPD/YCC, ANC, maternity, family planning and sexual and
reproductive health service delivery points.
2. Youth/adolescent information centers/corners.
3. Community-based/mobile outreach testing sites targeting key
populations
4. examples include moonlight testing for out of school adolescents,
bars, and brothels).
Prevention services for adolescents: Provide adolescent friendly risk-
reduction interventions to prevent HIV, teenage pregnancy, and other
STIs.

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Guidance
• Assess the sexual behavior of the adolescent.
• Provide HTS to sexually active adolescents (test every three months for
on-going risk, and once a year if exposed after last HTS). Messages should
focus on avoiding cross generation sex, multiple partners, transactional
sex and promote abstinence and delayed sexual activity.
• Encourage condom use for those sexually active.
• Screen for STIs and treat as appropriate.
• Identify and link adolescents to other available services at the facility as
appropriate (VMMC, ART).
• Offer voluntary contraception options.
• Assess for gender-based violence (GBV) and refer as appropriate.
• Identify, refer and link adolescents to other available community
programs.
Linkage to care and treatment.
A peer-led approach should be used to link adolescents living with HIV
(ALHIV) into care and treatment services preferably on the same day.
• Use community-based structures such as village health teams, and
community health extension workers to complement peer leaders
• Ensure complete linkage through establishing a feedback mechanism.
HIV care and treatment for adolescents
ART delivery for adolescents will mainly be facility-based using any of
the three delivery approaches recommended for the facility-based model:
• Fast-track drug pickup approach for stable clients picking their drugs
quarterly.
• Comprehensive clinical evaluation for all.
• Facility-based treatment clubs/healthcare managed groups for drug
refills within their groups/clubs, adherence support, peer support and
psychosocial support.
Psychosocial support for adolescents.

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Guidance
All HIV positive adolescents should receive psychosocial assessment and
support as part of their routine care. The assessment should be done
using the Home, Education/ Eating/ Employment, Activity, Drugs,
Sex, and Sexuality, Suicidal ideation/mental health (HEADSS) tool at
each clinical visit ( Annex 10). In addition, they should be assessed for
adherence, mental health problems; social vulnerabilities and violence
using standard national tools.
Adolescents should be supported to deal with common psychosocial
problems including disclosure of HIV status; stigma and discrimination;
adherence, loss and bereavement as well as socio-economic challenges. All
these singly or in combination affect the quality of treatment outcomes.
Benefits of psychosocial wellbeing include:
1. Improved adherence to medicines and access to essential services.
2. Reduced psychological distress.
3. Increased likelihood of appropriate disclosure to others.
4. Better engagement in HIV-related care.
5. A better understanding of HIV and related conditions.
6. Improved uptake of Positive Health Dignity and Prevention (PHDP)
services.
Retention: Adolescents living with HIV may need additional support to
remain engaged in care. Retention in ART care is critical for continued
adherence to ART, monitoring for drug toxicity/resistance and successful
viral suppression.
• Offer adolescent-friendly services.
• Form and use peer support groups.
• Conduct special programs for adolescents including life skills training.
• Regularly update contact information especially physical address and
telephone contacts, use appointment calendars and send messages (SMS
reminders for appointments).
• Conduct activities such as games and sports, music, drama, etc.
• Identify, refer and link adolescents to other available community
programs.
• Consider providing ART within community settings.
Transition: Purposeful and planned transition to adult-oriented services is
an important factor in the long-term well-being of an adolescent.

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Guidance
The transition should depend on the service delivery approach at each
health facility. Transitioning should consider the neurocognitive condition
of the adolescent.
In settings where there is an integrated clinic providing services for
children, adolescents, and adults at the same facility the process should
follow the steps below:
• Identify and develop a transition team at the adolescent clinic. The team
should include: a clinician, counselor, peer supporter, caregiver and
adolescent.
• Develop a transition plan when the adolescent turns 18 years or at the
first encounter if older than that.
• Update the transition plan and assess the adolescent’s readiness at each
clinical encounter over at least a two-year period.
• Once the young adult is 20 years and older and is ready to transition, give
them an appointment for the adult clinic.
• On the same day that they express readiness to transition introduce the
adolescent to the adult care team (who may be the same staff).
However, for health facilities with a separate adolescent clinic from the
adult one they should also:
Invite the adult transition team to meet at the adolescent clinic, the young
person who is ready to transition and agree on an appointment date (if
feasible).
Introduce the adult treatment team to the adolescent at the agreed
appointment and hand them over.

5.2.1 Supporting Continuity in Care and Treatment

All PLHIV should be supported to remain in care. For the test and treat
guideline implementation to contribute to the achievement of the 95-95-95
targets, patients must be retained in HIV care and efforts should be made to
avoid interruption in treatment (IIT).
5.2.2 Prevention of Interruption in Treatment

To mitigate such losses of patients from care during the test and start
implementations the country will implement the strategies outlined in Table
71 below.

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Table 71: Strategies for Preventing interruption in Treatment

Strategy Rationale
Decentralization of ART care and Decentralization improves
laboratory services retention by:
• MOH and district health teams will • Taking services closer to the
work to decentralize ART services to all target population, lowering
HCIIIs and eligible HCIIs. transport costs for patients, and
• Laboratory services will be thereby increasing the likelihood
decentralized to the appropriate health that they stay in care.
services. • Improving access to all HIV
• Where specific labs services are services.
not available, health facilities will • Reducing patient burden at
be supported to access the services higher level facilities and may
through the current transport hub and reduce waiting time at those
sample referral system. facilities.
Implementing differentiated service • DSD will reduce frequency
delivery models of clinic visits by dispensing
• Health care workers will be trained and medication for longer periods
supported to implement DSD models • Community models will take
starting at high volume sites. services closer to the clients
• For more details of the models refer to and reduce transport costs for
the DSD implementation manual. patients
• Health worker time will be
freed, and they can give
sufficient time to the patients
who require more care and time
Institute/strengthen comprehensive • Patients who miss appointments
patient appointment and tracking systems. will be identified easily and will
Will include: be followed-up and brought
back into care if found.
• Use of appointment books
• SMS reminders and phone calls
• Home visits
• Partnerships with community-based
service providers to support community
follow-up, and patient tracking
• Early retention and birth cohort control
monitoring
• All these strategies should be
implemented through CQI initiatives

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Strategy Rationale
• Strengthening client counseling and • When patients are educated
education services at the health facilities and counseled well, they are
• Health workers, counselors, VHTs, empowered to support their
CHEWs, expert clients, peer mothers care and are more likely to stay
and lay testers will be trained to provide in care.
standardized patient counseling services
including adherence and psychosocial
support.
• Patients will be initiated on treatment
when they have been prepared and are
ready to start ART.
Implement evidenced based • Improving patient education
communication strategy and addressing barriers
The country will use a communication will improve health seeking
strategy that will address individual, behaviours.
interpersonal, organization, community
and society barriers to retention in care.

5.2.3 Tracing and re-engagement in care

HIV programs should implement interventions to trace people who have

disengaged from care and provide support for re-engagement. Tracing and
re-engagement action is more successful when people are traced soon after a
missed visit compared with a longer period of disengagement. Approaches
to tracing included remote communication (phone, text messages, mail and
email), in-person tracing and a combination of both approaches.
5.2.4 Implementation considerations

Support for re-engagement in care can include interventions directed towards

people living with HIV, such as peer or health-care provider outreach and
navigation back to care. It can also be directed towards health-care providers
and health facilities through systems to alert healthcare providers that people
have disengaged and prompt action.
Interventions can include reminders (such as phone calls or text messages),
economic interventions (such as financial incentives or conditional cash
transfers), case management or policy interventions, with steps taken to
ensure confidentiality.

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Programme- or facility-level confidential contact details should be kept up to

date to ensure successful tracing if and when required.
When considering tracing people who are not engaged in care, adequate
assessment of the risks to vulnerable and key populations is critical. For
example, women are subject to increased levels of both intimate partner
and gender-based violence in the context of HIV, and appropriately training
health care providers is essential.
The criteria for tracing and recall should consider those who are seven or
more calendar days late for a scheduled appointment. Although efforts
should be made to trace everyone who has missed appointments and/or has
abnormal results, the following groups should be given priority:
• People initiating treatment in the past six months with advanced HIV
disease
• People with abnormal results
• People not initiating treatment
• People overdue for clinical consultations or laboratory tests.
A non-judgmental approach is essential to supporting people in returning
to care; this requires reducing system barriers and improving interpersonal
communication by developing the capacity of health-care providers.
All patients interrupting their treatment more than 28 days are referred to as
lost to follow up and should be traced and supported to re-engage in care.
The following interventions will be implemented:
• Support patient tracking and follow up
• Line list all missed appointments
• Conduct phone call follow up
• Link to community follow up structures (Peer networks, OVCs, CBOs,
PLHIV networks, KP CSOs etc.)
• Conduct home visits
• Document all patient tracking and follow-up outcomes in the HIV care
card and electronic records
• Conduct appropriate investigations
5.2.5 People interrupting treatment (less than 90 days)

Conduct a comprehensive clinical evaluation to identify signs and symptoms

of AHD and co-morbidities; conduct a PSS assessment to identify barriers
to continuity.

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Table 72: Re-engaging Adolescents after <90 days

Absence of signs and Presence of signs and symptoms
symptoms
provide adherence Screen, identify and manage and refer
counselling and PSS appropriately
TB, CCM, HTN, DM, Mental health etc
restart most recent ART Conduct a CD4 count test, if <200cc/ul,
regimen follow AHD protocol,
viral load test as per original Provide adherence counselling and PSS
schedule of their follow-up
Restart ART
5.2.6 People interrupting treatment (more than 90 days)

Conduct a comprehensive clinical evaluation to identify signs and symptoms

of AHD and co-morbidities; conduct PSS assessment to identify barriers to
continuity;
conduct a CD4 cell count.
Table 73: Re-engaging Adolescents after >90 days
CD4 count >200 cells/ul CD4 count < 200 cells/ul
Provide intensive adherence Conduct AHD screen as per AHD
counselling and PSS for protocol
continuity in care.
Restart most recent ART regimen Restart most recent ART regimen
Repeat viral load test at 3 months Repeat viral load test at 3 months
after restarting ART. after restarting ART.
Manage comorbidities and OIs Manage comorbidities and other OIs
Provide intensive adherence
counselling and PSS for continuity in
care

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Box 9: Key highlights in Psychosocial Care and Adher-

ence Support for PLHIV
Psychosocial care and support are an essential component of HIV
prevention, care and treatment as it addresses fear, stigma and impacts on
behavior change, access to services, adherence to medication and retention
in care.
Poor adherence is the major cause of ART treatment failure. Adherence
to ART is therefore critical to viral load suppression, reduced risk of drug
resistance development and improved treatment outcomes. Adherence
should be routinely assessed and continuously reinforced. Intensive
Adherence Counseling and support (IAC) is a targeted and structured
counseling and support intervention and should be offered to patients
on ART with a non-suppressed viral load (patients with viral load >200
copies/ml or 400 for plasma and DBS respectivly).
It is important to establish referral and linkage systems within facilities and
in the communities for increased access and retention along the continuum
of care.
Establishing adolescent friendly service delivery in order to create demand
and increase access to services among this population. Implementation
of innovative approaches including peer-led approaches, social media,
mobile phones technology, flexible clinic hours, dedicated spaces and
community/school activities in prevention, care and treatment services are
recommended.

5.3 PREVENTION, SCREENING AND MANAGEMENT

OF CO-INFECTIONS AND NON-COMMUNICABLE
DISEASES
This section will provide guidance on how to prevent, screen and manage co-
infections and non-communicable diseases (NCDs). In particular, this section
will provide guidance on Tuberculosis (TB), Cryptoccoccal Meningitis,
Histoplasmosis, Pneumocystis Jiroveci Pneumonia (PJP), Hepatitis B and C
virus infections, and STIs as well as cervical cancer, diabetes, hypertension,
depression, anxiety and alcohol and substance abuse. Management of
other co-infections including oral Candidiasis, esophageal Candidiasis,
Toxoplasmosis and chronic diarrhea can be found in “The Uganda Clinical
Guidelines 2016.”

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5.3.1 Management of Advanced HIV Disease

5.3.1.1 Definition of Advanced HIV Disease

For adults, adolescents, and children five years or older, Advanced HIV
Disease (AHD) is defined as CD4 cell count <200cells/mm3 or with a
current WHO stage 3 or 4 event. Children younger than five years of age
with HIV regardless of CD4 cell count are considered as having advanced
HIV disease due to high viremia and rapid disease progression with high
mortality. However, children younger than 5 years who have been on ART
for more than one year, are virally suppressed and are clinically stable, are not
considered to have AHD.
5.3.1.2 Background

Approximately, 30% and 15% of newly identified PLHIV present to care

with CD4 cell counts less than 200cells/mm3 and 100cells/mm3 respectively.
Furthermore, a proportion of PLHIV in care experience treatment failure
to ART regimens and approximately 25% of PLHIV are returning to care
with advanced HIV disease after treatment interruption. PLHIV with
advanced disease are particularly at high risk of death, even after initiating
ART, with this risk increasing with decreasing CD4 cell count. The most
common causes of death among adults with advanced disease include TB,
Cryptococcal Meningitis (CM), Histoplasmosis, aspergillosis and severe
bacterial infections. Similarly, the major causes of morbidity and mortality
among children living with HIV are pneumonia (including pneumocystis
pneumonia), TB, severe bacterial infections, diarrheal diseases and severe
acute malnutrition. All efforts should be made to identify these conditions
early to avert mortality. Despite the shift to ‘test and treat’ for ART, CD4
cell count remains an important parameter and should be done in all ART-
naïve individuals, non-suppressed and those returning to care after treatment
interruption for more than 90 days to guide identification of Advanced HIV
Disease.
5.3.1.3 Identifying individuals with Advanced HIV Disease
• Identifying people with advanced HIV disease who are eligible for
elements of the package of care requires performing a CD4 cell count for
newly initiating patients, patients re-engaging in care after more than 90
days, patients who are not virologically suppressed and patients presenting
with symptoms suggesting WHO Stage 3 or 4 disease.

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• CD4 cell count testing can be performed using point of care technologies
such as laboratory based CD4 analyzers and device -free semi-quantitative
rapid tests.
• If a CD4 cell count is not readily available onsite, use a symptom screen
that assesses for symptoms associated with opportunistic disease (refer to
Figure 33 below), and send the CD4 sample to the hub for testing.
• Note that relying on WHO clinical staging alone risks missing substantial
numbers of people living with HIV with severe immune suppression.
5.3.1.4 Components of the package of care for PLHIV with
advanced disease

Table 31 below summarizes the recommended package of interventions

for managing PLHIV with advanced disease. It includes interventions for
screening, prophylaxis and treatment for opportunistic conditions, rapid
ART initiation and enhanced adherence support. The package below should
be offered to people with advanced HIV disease who are new, re-engaging
with care after 90 days of ART interruption, or to those with viral non-
suppression. People living with HIV should be systematically screened for
TB disease at each visit to a health facility (refer to section 7.4 for details on
TB screening and management).
5.3.1.5 Package Of Care For Children With AHD

Screen, Treat, Optimize and Prevent AIDS (STOP AIDS)

Package

The STOP AIDS package of care is the WHO recommended set of

interventions for children presenting with advanced HIV disease. The Table
31 below summarizes the recommended interventions for screening, treating,
optimizing ART and preventing advanced HIV in children living with HIV

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Table 31: Screening, diagnosis, treating and prevention

components of the package of care for children and
adolescents with advanced HIV disease
Intervention Component <5 5–9 10–19
years years years
Screening and • Screen for TB using the TB ICF Yes Yes Yes
diagnosis guide or CXR. Use Point of care
CRP for adolescents in addition
to the ICF guide
• Use the recommended clinical
algorithm for diagnosis of TB
(Figure 35)
• Use the following diagnostic
tests to confirm TB
**Rapid molecular diagnostic
tests e.g., GeneXpert, TRUENAT
or TBLAMP assays as the
preferred test using (expectorated
or induced) sputum, gastric
aspirate, stool or nasopharyngeal
aspirate or other extrapulmonary
specimens
**Lateral flow urine
lipoarabinomannan (LF-LAM)
assay
Use CXR to aid TB diagnosis if Yes Yes Yes
available.
Cryptococcal antigen screening No No Yes
among adolescents
(Specimen: Serum, plasma, or
whole blood)
If blood cryptococcal antigen
positive or symptomatic, do a
lumbar puncture
Malnutrition; Assess weight for Yes Yes Yes
Height, Height for Age and Mid
Upper Arm Circumference

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Treat If/When diagnosed, treat for Yes Yes Yes

TB, severe pneumonia, severe
bacterial infections, cryptococcal
meningitis and severe acute
malnutrition according to national
guidelines
Optimize Rapidly initiate Yes Yes Yes
ART optimal antiretroviral regimen
i.e. within seven days and
antiretroviral therapy counselling
Prevention Co-trimoxazole to prevent Yes Yes Yes
through severe bacterial infections and
prophylaxis, pneumocystis pneumonia
pre-emptive TB preventive treatment Yes Yes Yes
treatment and Fluconazole pre-emptive therapy Not Not Yes
vaccination for those with cryptococcal appli- appli-
cable cable
antigen–positive test without
evidence of meningitis
HPV vaccine No No Yes
BCG vaccination at birth Yes No No
Pneumococcal conjugate vaccine Yes No No
(catch-up)

Treating TB in Children

Treat drug-sensitive TB among children with a four-drug regimen that

includes rifampicin (R), isoniazid (H), pyrazinamide (Z) and ethambutol
(E). Drug–drug interactions between rifampicin and Lopinavir/ritonavir
(LPV/r) need to be taken into account and antiretroviral therapy
adjusted accordingly, using a super-boosting strategy or double-dose
LPV/r depending on age and ability to swallow medication. Drug–
drug interactions between rifampicin and dolutegravir (DTG) can also
be adjusted for by double-dosing DTG (children >25 kg). Shorter TB
treatment duration for children will be available in the future and updates
will be communicated.

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Treating severe pneumonia in children living with HIV

The most common cause of severe pneumonia in children living with

HIV include Streptococcus pneumoniae and Staphylococcus aureus, therefore
antibiotics that are effective against these organisms can be used. Treat
all infants living with HIV with severe pneumonia empirically with co-
trimoxazole and the antibiotics recommended in national guidelines
because of the high prevalence of Pneumocystis pneumonia in this age
group.
For children between one and five years old, the recommendation is to use
antibiotics recommended in national guidelines and not cotrimoxazole due
to the lower prevalence of PCP in this age group
Treating severe bacterial infections

The commonest causes of severe bacterial infections in children living with

HIV in the community are Streptococcus or Staphylococcus whereas gram
negative bacteria are the commonest cause for health facility associated
bacterial infections. Salmonella is also a common cause of bacteraemia
among children living with HIV. Treatment should be provided according
to current national guidelines and tailored according to age, suspicion of
meningitis and blood and cerebrospinal fluid culture if available
Treating Cryptococcal Meningitis in adolescents

Routine cryptococcal antigen screening and pre-emptive therapy are not

recommended for children younger than 10 years because of the low
prevalence of cryptococcal meningitis in this age group. However, if a child
younger than 10 years presents with signs and symptoms of meningitis,
cryptococcal meningitis should still be considered and the appropriate
investigations and treatment for this should be implemented. A short-
course (one- week) induction regimen with amphotericin B deoxycholate
(1.0 mg/kg per day) and flucytosine (100 mg/kg per day, divided into
four doses per day) is the preferred option for children living with HIV
Treating malnutrition in Children with HIV

Severe acute malnutrition is common at HIV diagnosis and carries a high

risk of mortality. The availability of ready- to-use therapeutic food where
appropriate, are considered essential components of HIV treatment for
children

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5.3.1.6 Package of Care for Adults with AHD

The package of care for adults with AHD has similar interventions with that
of the children. However, there are some differences in the components of
care provided to adults. Table 32 shows the recommended package of care
for adults.
Table 32: Package of care for adults with advanced HIV
disease
Intervention Component Eligibility criteria

Urine TB LAM CD4 ≤200 cells/mm3 or

Danger signs or
WHO Stage 3 or 4
Sputum Xpert All presumptive TB cases regardless of
MTB/ RIF CD4 count
Cryptococcal CD4 ≤200 cells/mm3 or
antigen screening Danger signs or
(CrAg) WHO Stage 3 or 4
Diagnosis

Nutritional All regardless of CD4 count

assessment and
Support
Cotrimoxazole Newly initiating PLHIV
prophylaxis WHO stage 3 or 4 event or other
Prophylaxis and Pre-emptive

symptoms of AHD
Pregnant and breast-feeding women
Children (aged ≤15)
Patients suspected to have treatment
failure
TB preventive Negative TB Symptom Screen
Therapy Any CD4 count
treatment

Fluconazole PLHIV with a Positive serum CrAg

Pre-emptive test who have a negative CSF CrAg (on
treatment Lumbar Puncture)
Rapid ART Any CD4 and Negative TB and CM
Rapid ART

initiation Symptom Screen

initiation

Defer ART Positive TB and CM Symptom Screen

initiation or
in presence of: TB diagnosis or Positive CrAg

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Tailored Any person with advanced HIV

Adherence support
counselling to disease
ensure optimal
adherence to
the advanced
disease package,
including phone
calls and
home visits

Using TBLAM for TB diagnosis in advanced HIV disease

The lateral flow urine lipoarabinomannan assay (Urine TB LAM) should

be used as the preferred initial test for TB diagnosis, followed by mWRD
such as GeneXpert, TRUNAT or TBLAMP, or microscopy in the following
categories of patients:
• People living with HIV:
• With advanced HIV disease or
• Who are seriously ill irrespective of signs and symptoms of TB and
CD4 cell count or
• With unsuppressed viral load (i.e. VL > 1000 copies/ml of blood)
Note:
1. TB LAM MUST NOT be used for HIV NEGATIVE patients
2. The above national recommendations apply to both in-patient and out-
patient settings
3. Whereas children less than 5 years who are new and have been on ART
for less than one year are all considered to have AHD, they will only be
eligible for a TBLAM test if they have AHD symptoms and signs (refer
to the symptom and advanced disease management pathway)
Regardless of TB LAM results, a sputum sample should be collected and sent
for mWRD (such as Gene Xpert, TRUENAT, TB-LAMP) for simultaneous
detection of M. tuberculosis and Rif-Resistance. All PLHIVs with a positive
TB LAM should be classified as “Bacteriologically confirmed pulmonary
TB patients-(P-BC)” and promptly started on TB treatment. Treatment
monitoring for all TB LAM positive PLHIVs should be done by microscopy
using a sputum sample. Follow up sputum smears should be done at the end
of month 2 and beginning of 5 and 6 months of TB treatment.

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5.3.1.7 Rapid ART Initiation

All patients should undergo the symptom screen for the Advanced Disease
Pathway (see Figure 33 below). Patients presenting for the first time or those
returning to care and not on ART should undergo the symptom screen for
the Advanced Disease Pathway before rapid ART initiation is offered. Rapid
ART initiation should be deferred when symptom screen is positive or when
there is a TB diagnosis, or the patient is CrAg positive. Note that CD4 testing
is not a pre-condition for ART initiation.
5.3.1.8 People interrupting treatment (more than 90 days)

Those who interrupted treatment for more than 90 days and have a negative
symptom screen and CD4 >200cells/ml should be restarted on their
old regimen, receive three intensive adherence counselling sessions with
documented good adherence (one month apart) and a viral load test after
3 months of restarting therapy. Those with a CD4 <200cells/ml should be
investigated for advanced HIV disease and a viral load test done immediately
upon re-engaging in care.
5.3.1.9 People interrupting treatment (less than 90 days)

Those who interrupted treatment for less than 90 days and have a negative
symptom screen should be restarted on their old regimen, receive adherence
counselling and a viral load test as per original schedule of their follow-up.
5.3.1.10 Adherence support

People with advanced HIV disease require closer follow-up during the first 3
months to ensure adherence to treatment since they are likely to be ill, have a
higher pill burden due to treatment of comorbidities and easily drop out of
care. Follow up can be through clinic or home visits, telephone consultation,
and text messaging.
Figure 33: Symptom Screen and Advanced Disease Management
Pathway

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5.4 CO-INFECTION SCREENING, TREATMENT, AND

PREVENTION
5.4.1 HIV and Tuberculosis

HIV is the strongest risk factor for developing TB disease. PLHIV are 20–37
times more likely to develop TB than HIV-uninfected individuals. TB is also
the leading cause of HIV-related hospitalization and mortality. TB accounts
for 27% and 30% of deaths among hospitalized HIV-infected adults and
children, respectively. Also, patients with TB and HIV have poorer treatment
outcomes (such as death) compared to patients with TB alone. In Uganda,
about 40% of all TB cases in clinical settings are co-infected with HIV.
Therefore, all patients with presumptive or diagnosed TB should be routinely
screened for HIV and all PLHIV should be routinely screened for TB. The
Ministry of Health further recommends that TB/HIV services should be
provided at the same location and preferably by the same health worker (see
Figure 34).

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Figure 34: Algorithm for screening, diagnosis, and

management of TB among PLHIV

1. Positive ICF screen is presence of current cough, fever >2-week,

noticeable weight loss, excessive night sweats, if child-poor weight
gain and history of contact with a PTB patient
2. Danger signs for adults refer to signs of a seriously sick
person and they include respiratory rate > 30/min, temperature
>39 °C, heart rate 120/min and unable to walk unaided.
Danger signs for children include lethargy, convulsions, inability
to feed, repeated vomiting, temperature above 390c and tachycardia/
tachypnoea
3. Appropriate sample types include; sputum, CSF, Gastric aspirate,
urine, stool

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4. Do a Molecular WHO Recommended Diagnostic (mWRD) test e.g.,

Genexpert, TRUENAT and TB-LAMP, if you are able to obtain a
specimen, so as to rule out rifampicin resistance. Note TB LAMP
does not detect rifampicin resistance.
5. For any TB LAM positive other co-morbidities such as cryptococcus,
bacterial infections should be ruled out.
6. Children less than 5 years who are new and have been on ART for
less than one year are eligible for a TB LAM test if they have AHD
symptoms and signs (refer to the symptom screen and advanced
disease management pathway).
Figure 35: Algorithm for the Diagnosis of TB in Children

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Figure 36: One stop shop model for TBHIV service delivery

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TB SCREENING IN INFANTS, CHILDREN, ADOLESCENTS

AND ADULTS
TB Screening

TB screening should be conducted at each clinic visit using the intensified

case finding (ICF) guide (see Annex 5). All HIV-positive infants and children
who have any of the symptoms of TB, including cough of any duration,
persistent fevers, poor weight gain and history of TB contact should be
assessed for TB. All HIV-positive adolescents and adults who have any of the
symptoms of TB including cough of any duration, persistent fevers, weight
loss, or excessive night sweats should be assessed for TB. Where possible,
chest X-ray can be used for screening.
Tools for systematic TB screening and diagnosis among
people living with HIV

All PLHIV should be screened for TB at each care visit using the ICF guide.
If available, POC-CRP should be used for TB screening in addition to the
symptom screen for adolescents and adults. If available, CXR should also be
used for TB screening.
Note: Computer-aided detection (CAD) software programs are
recommended for individuals aged 15 years and older
If the symptom screen is positive and/or CRP cutoff is more than 5mg/L,
or CXR is abnormal, the client has presumptive TB and should be tested
using a molecular WHO recommended rapid diagnostic test (mWRD) e.g.,
nucleic acid amplification test (NAAT) such as GeneXpert, TRUENAT and
TB LAMP. If mWRD is not available on site, do smear microscopy and
refer a sample for mWRD test. If the mWRD is negative, do further clinical
evaluation and a chest X- ray to aid in clinical diagnosis of TB. (See section
on diagnosis).
Note: CRP point of care test is not recommended for children younger
than 10 years of age. For TB screening where CRP is not available, use
a chest X-ray
TB diagnosis in HIV-infected infants, children, adolescents
and adults

The molecular WHO recommended rapid diagnostic (mWRD) test is the

recommended TB diagnostic test for all PLHIV (Annex 6 and Annex 7) with

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presumptive TB. Examples include; GeneXpert, TRUENAT, TB LAMP.

For PLHIV with CD4<200 cells/ µL and seriously ill PLHIV (have danger
signs), do a lateral flow urine lipoarabinomannan assay (Urine TB LAM) test
because it has a shorter turnaround time followed by mWRD which is more
sensitive and can detect rifampicin resistance (note that among mWRDs, the
Xpert MTB/RIF detects rifampicin resistance in a single step whereas the TRUNAT
detects rifampicin resistance in two steps). If either test is positive, classify patient as
PBC (Pulmonary Bacteriologically Confirmed) and start anti-TB treatment.
In health facilities without on-site access to mWRD, smear microscopy
(Ziehl- Nielsen/Fluorescent microscopy) TB test should be performed and
a second sample referred for mWRD testing using the hub transport system.
If the mWRD is positive and indicates rifampicin resistance, refer the patient
to an MDR-TB treatment site.
In addition to the mWRD test, chest radiography is another useful investigation
for aiding diagnosis of TB especially among infants and children.
Note: The mWRD used should have the capacity to detect rifampicin
resistance.
TB Treatment

The recommended TB treatment regimens for TB-HIV co-infected patients

are similar to those used for HIV-negative individuals with TB (Table 35).
Table 35: Anti-TB treatment regimens for infants, children,
adolescents, and adults
Popula- Regimen
tion group Site of TB disease Intensive Continuation
phase phase
Adults and All forms of TB
Adolescents (Excluding TB Meningitis and 2RHZE 4RH
bone TB)
TB Meningitis
2RHZE 10RH
Bone (osteoarticular) TB
Children All forms of TB
(Excluding TB Meningitis and 2RHZ+E* 4RH
bone TB)
TB Meningitis
2RHZ+E* 10RH
Bone (osteoarticular) TB

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For all PLHIV patients:

1. Xpert MTB +ve/Rif sensitive: Treat as a new patient.
2. Xpert MTB +ve/Rif resistant: Refer to MDR-TB treatment site for further
management.
3. Xpert MTB +ve/Rif indeterminate: Start First line TB treatment and send
sample for culture and drug susceptibility testing.
4. Xpert MTB Trace/Rif indeterminate: Start First line TB treatment and send
sample for culture and drug susceptibility testing.
*In children, Ethambutol should be given as separate tablet using the
recommended dosages

Table 36: Dosage of Anti TB medicines by weight band for

children
Weight Bands Intensive Phase Continuation Phase
RHZ (75/50/150) E (100) RH (75/50)
4-7kg* 1 1 1
8-11kg 2 2 2
12-15kg 3 3 3
16-24 kg 4 4 4
25 - 32 kg 4 4 4
* If a child is < 4kgs, determine the appropriate dose based on patient’s weight using
table 28 below
Table 37: Dosage of Anti TB medicines by weight band for
adults
Weight bands Intensive Phase Continuation Phase
RHZE (150+75+400+275) mg RH (150+75) mg
33 – 39 kg 2 tablets 2 tablets
40 – 54 kg 3 tablets 3 tablets
55 – 70 kg 4 tablets 4 tablets
>70 kg 5 tablets 5 tablets
If an adult is < 33kgs, determine the appropriate dose based on patient’s weight using
table 29 below

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Table 38: Dosage of Anti TB medicines by weight for

children and adults
TB drug Children Adults
Rifampicin 15 (10 – 20) mg/kg body wt. 10mg/kg body wt.
(max. 600mg) (max.600mg)
Isoniazid 10 (7 – 15) mg/kg body wt. 10 mg/kg body wt.
(max. 300mg) (max.300mg)
Pyrazinamide 35 (30 – 40) mg/kg body wt. 30 – 40 mg/kg body wt.
(max dose 2500 mg)
Ethambutol 20 (15 – 25) mg/kg body wt. 15mg/kg body wt.

ART for TB/HIV co-infected patients

ART should be initiated in all TB/HIV co-infected people irrespective of

their clinical stage or CD4 count. However, the timing of initiating treatment
may differ based on whether the patient is diagnosed with TB before or after
initiating ART.
Timing of ART for adults, adolescents and children being treated for
HIV-associated TB
ART should be started as soon as possible within two weeks of initiating
TB treatment, regardless of CD4 cell count, among people living with HIV
(Except when signs and symptoms of meningitis are present)
• If the patient is already on ART, start TB treatment immediately and
adjust the ART regimen as recommended (Table 36 and Table 37).
• If the patient is not on ART, initiate anti-TB treatment immediately and
start ART two weeks after initiation of TB treatment.
• If the patient is not on ART and is diagnosed with MDR-TB, ART should
be initiated 4-6 weeks after second-line TB treatment initiation. However,
if the patient is already on ART, continue ART and adjust ART regimen
as per the MDR TB guidelines.
First-line ART regimen for TB/HIV co-infected patients
who are not on ART
There are situations when a new patient is diagnosed with both HIV and TB.
The recommended first line regimen for a TB patient initiating ART are as
indicated in Table 39.

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Table 39: ART regimens for TB/HIV co-infected patients

initiating First- and Second -line ART
Patient cate- Recommended Alternative ART regimens
gory ART regimens
Firstline
Adults and TD- If TDF or TAF is contraindicated, use
adolescents F+3TC+DTG or ABC:
≥30Kg, includ- TAF+FTC+DTG ABC or TAF+FTC+DTG
ing pregnant Increase dose of Increase dose of DTG to twice a day
and breastfeed- DTG to
If DTG is contraindicated, use EFV:
ing women twice a day
TDF or ABC→ +3TC+ EFV400 or
TAF+FTC+EFV400
No dose adjustments
If DTG and EFV are contraindicated,
use ATV/r:
TDF or ABC → +3TC+ATV/r or
TAF+FTC+ATV
Substitute Rifampicin with Rifabutin
Children ≥ ABC +3TC+ If ABC is contraindicated, use AZT or
20Kg - <30Kg DTG or TAF:
TAF+FTC+DTG ABC +3TC+ DTG or
Increase dose of TAF+FTC+DTG
DTG to Increase dose of DTG to twice a day
twice a day If DTG is contraindicated, use LPV/r
or EFV:
ABC or AZT +3TC+LPV/r or
TAF+FTC+LPV/r
Double both the morning and evening
doses
of LPV/r. After TB treatment return to
normal dose of LPV/r.
OR
Substitute Rifampicin with Rifabutin
ABC or AZT+3TC+EFV or
TAF+FTC+EFV
In children >3 years - Substitute EFV
with DTG
or LPV/r after TB treatment

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Children< ABC+3TC+ DTG If ABC is contraindicated, use AZT:

20Kg Increase dose of AZT+3TC+DTG
DTG to Increase dose of DTG to twice a day
twice a day If DTG is contraindicated use LPV/r
or EFV or RAL or Triple NRTI:
ABC or AZT→ +3TC+LPV/r
Super-boosting LPV/r morning and
evening doses with additional ritonavir
(RTV) (to make LPV/r ratio of 1:1
instead of 4:1, i.e. equal doses of LPV
and RTV). After TB treatment return to
normal dose of LPV/r.
OR
Substitute Rifampicin with Rifabutin
ABC or AZT→+3TC+EFV
In children >3 years or weighing
>10Kg- Substitute EFV with DTG or
LPV/r after TB treatment
ABC or AZT → +3TC + RAL
Double the dose of RAL -substitute
RAL with DTG or LPV/r after TB
Treatment
ABC+3TC+AZT
In children <3 years or weighing
<10Kg- Substitute AZT with DTG or
LPV/r after TB treatment

Patient cate- Recommended Alternative ART regimens

gory ART regimen
Second Line
Adults and AZT or TD- AZT or TDF +3TC+LPV/r or
adolescents F+3TC+ DTG or TAF+FTC+LPV/r
≥30Kg, includ- TAF+FTC +DTG Double both the morning and evening
ing pregnant Increase dose of doses of LPV/r. After TB treatment
and breastfeed- DTG to twice a day return to normal dose of LPV/r.
ing women OR
AZT or TDF
Substitute Rifampicin with Rifabutin
+3TC+ATV/r
TAF+FTC+ATV/r
Substitute Rifampi-
cin with Rifabutin

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Children ≥ TAF + FTC + TAF +FTC + LPV/r or AZT or

20Kg – <30Kg DTG or AZT ABC→ +3TC+LPV/r
or ABC→ Double both the morning and evening
+3TC+DTG doses of LPV/r. After TB treatment
Increase dose of return to normal dose of LPV/r.
DTG to twice a day Substitute Rifampicin with Rifabutin
TAF+FTC +DTG TAF + FTC + DRV/r or AZT or
or AZT or ABC→ ABC→ +3TC+DRV/r
+3TC+LPV/r Substitute Rifampicin with Rifabutin
Substitute Rifampi-
cin with Rifabutin
OR
Double the am and
pm dose of LPV/r
Children AZT or ABC→ AZT or ABC → +3TC+LPV/r
<20Kg +3TC+DTG Super-boosting LPV/r morning and
Increase dose of evening doses with additional ritonavir
DTG to twice a day (RTV) (to make LPV/r ratio of 1:1
instead of 4:1, i.e. equal doses of LPV
and RTV). After TB treatment return to
normal dose of LPV/r.
OR
Substitute Rifampicin with Rifabutin
TAF or AZT or ABC → +3TC + RAL
Double the dose of RAL (substitute
RAL with DTG or LPV/r after TB
Treatment)
AZT or ABC → AZT or ABC → +3TC+DRV/r
+3TC+LPV/r Substitute Rifampicin with Rifabutin
Substitute Rifampi-
cin with Rifabutin
OR
Double the am and
pm dose of LPV/r

Note: for patients on rifapentine based regimen, look out for potential
drug-drug interactions

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ART and TB treatment Drug interaction

Patients should be initiated on ART following the ART guidelines for

initiating 1st and 2nd line ART (See Table 39), however, considerations must
be taken to avoid drug-drug interactions that interfere with the effectiveness
of ART (see Table 40 and Table 82).
Notes:
1. The use of Rifampicin with PIs is contraindicated. These guidelines
recommend substitution of Rifampicin with Rifabutin when using PIs.
However, in the absence of Rifabutin:
2. LPV/r can be given at double the usual dose (give double the dose in
the morning and double the dose in the evening). In children <20kg
who are on LPV/r regimens, super boost the morning and evening
doses with ritonavir with additional ritonavir (RTV) (to make LPV/r
ratio of 1:1 instead of 4:1, i.e. equal doses of LPV and RTV). After TB
treatment return to normal dose of LPV/r.
3. Doubling the dose of ATV/r or DRV/r is NOT recommended.
ATV/r and DRV/r should only be used with a TB regimen containing
Rifabutin. In the scenario where Rifabutin is unavailable, an alternative
ARV should be selected.
4. For patients initiating 2nd line ART, it is important to take into
consideration the previous failing regimen to ensure selection of an
effective regimen for use in 2nd line ART-TB co-treatment.
5. Raltegravir (given as a double dose) is recommended in TB-HIV co-
treatment for children who cannot tolerate double dosing of LPV/r or
for whom Rifabutin is unavailable for treatment with DRV/r.
6. Children <20Kg on TB treatment should only be initiated on a triple
NRTI regimen (ABC+3TC+AZT) if all the other options provided in
the table above are not feasible, as this is an inferior regimen.
After completion of TB treatment, all ART regimens that are not
optimal, should be optimized (in line with the ART guidelines).
5.4.1.1 ART regimen substitutions for patients diagnosed
with TB while on ART

Anti-TB treatment should be initiated immediately upon diagnosis while

continuing ART. However, the ARV regimen should be reviewed and may
need substitutions to ensure optimal treatment of both TB and HIV and to
decrease the potential for toxicities and drug–drug interactions (Table 40).

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Table 40: ARV regimen substitutions for patients initiating

TB treatment while already on ART
Regimen
Age when
Recommended action/substitution
Group diagnosed
with TB
Adults and If on EFV- Continue with the same regimen and dose. After TB
adolescents based regimen* treatment optimize the regimen if virally suppressed
≥30Kg (substitute EFV with DTG). If not virally suppressed
including switch to 2nd line ART.
pregnant If on DTG- Continue the same regimen but increase the dose of
and breast- based regimen DTG (give DTG 50mg twice daily instead of once
feeding daily). After TB treatment return to DTG once a day.
women
If on NVP- Substitute NVP with EFV. After TB treatment optimize
based regimen* ART regimen if virally suppressed (substitute EFV with
DTG). If not virally suppressed switch to 2nd line ART.
If on ATV/r- • Continue the same regimen but substitute Rifampicin
based regimen* with Rifabutin
OR
• If on 2nd line, substitute ATV/r with LPV/r and
double both the morning and evening doses of
LPV/r. If virally suppressed after TB treatment, return
to ATV/r (if there is previous exposure to DTG) or
optimize to DTG-based regimen if no previous DTG
exposure.
OR
• If on 1st line and EFV is not contraindicated, substitute
ATV/r with EFV for the duration of TB treatment.
After TB treatment optimize the regimen if virally
suppressed.
• If not virally suppressed after TB treatment, switch to
2nd line or 3rd line (with HIVDR).
If on LPV/r Double both the morning and evening doses of LPV/r.
-based If virally suppressed after TB treatment, return to
regimen* normal dose of LPV/r (if on 2nd line with previous
DTG-based regimen) or optimize to DTG-based
regimen if no previous DTG exposure. After TB
treatment return to normal dose of LPV/r.
• OR
• Substitute Rifampicin with Rifabutin
• If not virally suppressed after TB treatment, switch to
2nd line or 3rd line (with HIVDR).

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Regimen
Age when
Recommended action/substitution
Group diagnosed
with TB
Children If on DTG- Continue the same regimen but increase the dose of
≥ 20Kg- based regimen DTG to twice daily. After TB treatment, return to
<30Kg DTG once a day.
If on EFV- Continue the same regimen. After TB treatment
based regimen* optimize the regimen if virally suppressed (substitute
EFV with DTG). If not virally suppressed switch to 2nd
line ART
If on NVP • Substitute NVP with EFV (if >3 years and >10Kg)
-based OR
regimen* • If EFV is contraindicated, give a triple NRTI regimen
(ABC+3TC+AZT).
After TB treatment optimize treatment with a DTG-
based regimen if virally suppressed. If not virally
suppressed switch to 2nd line ART
If on LPV/r- Double both the morning and evening doses of LPV/r.
based regimen After TB treatment return to normal dose of LPV/r.
OR
Substitute Rifampicin with Rifabutin.
If the child cannot tolerate double dose of LPV/r
a. Substitute LPV/r with Raltegravir. Double
the dose of Raltegravir. Return to LPV/r after
completion of TB treatment.
If on DRV//r- Substitute Rifampicin with Rifabutin
based regimen
Children If on DTG- Continue the same regimen but increase the dose of
<20Kg based regimen DTG to twice daily. After TB treatment, return to
DTG once a day.
If on LPV/r- Continue the same regimen but either
based regimen Super-boosting LPV/r morning and evening doses with
additional ritonavir (RTV) (to make LPV/r ratio of 1:1
instead of 4:1, i.e. equal doses of LPV and RTV) After
TB treatment return to normal dose of LPV/r.
OR
Substitute Rifampicin with Rifabutin.
If the child cannot tolerate double dose of LPV/r
a. Substitute LPV/r with Raltegravir. Double the dose
of Raltegravir. Return to LPV/r after completion
of TB treatment.

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Regimen
Age when
Recommended action/substitution
Group diagnosed
with TB
If on NVP- • If >3 years and >10Kg substitute NVP with EFV.
based regimen* • If EFV is contraindicated, give a triple NRTI regimen
(ABC+3TC+AZT).
• If <3 years and <10Kg give triple NRTI regimen
(ABC+3TC+AZT).
After TB treatment optimize treatment with a DTG
or LPV/r -based regimen if virally suppressed. If not
virally suppressed switch to 2nd line ART.
If on DRV/r- Substitute Rifampicin with Rifabutin
based regimen

Note:
1. In case ARVs are to be substituted in patients initiating TB treatment
while on ART, careful consideration of previous ART regimens should
be taken in order not to give an ARV to which the client may already
have resistance.
2. Raltegravir (given as a double dose) is recommended in TB-HIV co-
treatment for children who cannot tolerate double dosing of LPV/r or
for whom Rifabutin is unavailable for treatment with DRV/r.
3. Children on NVP-based regimens should be switched to a triple NRTI
regimen (ABC+3TC+AZT) only if EFV is contraindicated, as this is
an inferior regimen.
4. *After completion of TB treatment, ensure that the ART regimen is
optimized:
5. If virally suppressed, optimize the regimen.
6. For adults, when optimizing 2nd line PI-based regimens, ensure that the
client was not previously exposed to DTG in the 1st line ART regimen.
If the client was on a DTG-based 1st line ART Regimen and is currently
on a PI-based 2nd line regimen and virally suppressed, maintain the PI-
based regimen after TB treatment.
7. If viral load is not suppressed switch the client to 2nd or 3rd line
following the recommendations in Chapter 13 (see recommended first
and second line in Table 81).
Treatment of people with drug-resistant TB

WHO recommends ART for all people with HIV and drug-resistant TB,
requiring second-line anti-TB drugs irrespective of CD4 cell count, as early

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as possible (within the first eight weeks) following initiation of anti-TB

treatment
Note: Multidrug-resistant TB is TB that is resistant to at least isoniazid
and rifampicin. People with both HIV and multidrug-resistant TB face
complicated clinical management, fewer treatment options and poorer
treatment outcomes
TB PREVENTION

TB prevention should be based on the following principles:

• Vaccination with BCG to prevent severe forms of TB in children.
• Early identification and prompt treatment of TB patients.
• Providing TB Preventive Treatment (TPT).
• Implementation of infection control practices within the health facility
and household settings.
TB Preventive Treatment (TPT)

TPT prevents the progression of TB infection to active TB disease. All

PLHIV with a negative TB symptom screen should be evaluated for TPT
eligibility and offered TPT if eligible (see section 6.7.4.1.1). TPT is currently
NOT recommended for contacts of patients with MDR-TB.
Algorithms to rule out active TB disease

Adults and adolescents living with HIV should be screened for TB according
to a clinical algorithm. Those who do not report any of the symptoms of
current cough, fever, weight loss or night sweats are unlikely to have active
TB and should be offered preventive treatment, regardless of their ART
status.
Adults and adolescents living with HIV who are screened for TB according
to a clinical algorithm and who report any of the symptoms of current
cough, fever, weight loss or night sweats may have active TB and should
be evaluated for TB and other diseases and offered preventive treatment if
active TB is excluded.
Chest radiography may be offered to people living with HIV receiving ART
and TB preventive treatment given to those with no abnormal radiographic
findings
Infants and children living with HIV who have poor weight gain, fever or
current cough or who have a history of contact with a person with TB

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should be evaluated for TB and other diseases that cause such symptoms. If
TB disease is excluded after an appropriate clinical evaluation or according to
national guidelines, these children should be offered TB preventive treatment,
regardless of their age.
The following regimens could be used for TPT as guided in Table 41 and
Table 42 below:
• 6H: Daily Isoniazid for 6 months.
• Note: Isoniazid may be available in combination with co-trimoxazole and
pyridoxine as a fixed dose combination referred to as Q-TIB: In this case,
Q-TIB is also administered daily for 6 months.
• 3HP: Weekly Isoniazid and Rifapentine for 3 months (Recommended for
patients aged more than 2 years).
• 3RH: Daily Rifampicin and Isoniazid for 3 months (Recommended for
children less than 15 years).
NOTE: Isoniazid containing TPT should be coupled with pyridoxine
to prevent peripheral neuropathy
Eligibility for TPT
• Infants aged <one year living with HIV who are in contact with a person
with TB and who are unlikely to have active TB on an appropriate clinical
evaluation or according to national guidelines should receive TB preventive
treatment
• HIV-positive children (≥one year of age), adolescents and adults with no
signs and symptoms of TB irrespective of ART status
• HIV-positive infants and children <5 years with a history of TB contact
who have no signs and symptoms of active TB disease, irrespective of
previous TPT.
• HIV-positive pregnant mothers with a history of contact with a TB patient
a after ruling out active TB.
• HIV-positive pregnant mothers with a WHO Stage 3 or 4 event and/or
CD4<200 without active TB.
• TPT should also be given to those who have previously been treated for
TB immediately after completing TB treatment.
• Note:
• TPT should be offered to eligible patients irrespective of the degree
of immunosuppression and even when latent TB infection testing is
unavailable.
• For HIV-positive pregnant mothers without a history of TB
exposure, TPT will be deferred until 3 months after delivery.

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• For HIV positive women and adolescent girls on TPT who get pregnant,
continue and complete the TPT while closely monitoring for side effects.
See TB Preventive Treatment in Uganda 2020 for more information on
determining eligibility for TPT.
Table 41: TPT regimen for adolescents ≥ 15 years and adults
on ART
ARV Drug TPT regimen Rationale for TPT regimen
Regimen Options
TDF or AZT or Isoniazid (6H) No dose adjustment of DTG with
ABC + 3TC + or Isoniazid-Rifapentin-based regimen
DTG or TAF Isoniazid-
+FTC + DTG Rifapentine-
based regimens
TDF or AZT or Isoniazid (6H) Co-administration of rifamycins
ABC + 3TC+ (such as rifampicin) with protease
ATV/r TDF or inhibitors has been associated
AZT or ABC + with reduction in plasma levels of
3TC + LPV/r or protease inhibitors.
or TAF +FTC +
LPV/r
TDF or AZT Isoniazid (6H) A higher dose of EFV, i.e. 600mg
or ABC + or is recommended if Isoniazid/
3TC+EFV or Isoniazid/ Rifapentin-based regimen is used
TAF +FTC + Rifapentine-
EFV based regimens

Table 42: TPT regimen for children < 15 years on ART

ARV Regimen TPT regimen options Rationale for TPT regimen
ABC or AZT Isoniazid (6H) Co-administration of
+3TC+LPV/r rifamycins (such as
ABC or AZT+3TC rifampicin) with protease
+ATV/r inhibitors has been
associated with reduction
in plasma levels of protease
inhibitors.

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ARV Regimen TPT regimen options Rationale for TPT regimen

ABC or AZT+ Isoniazid (6H) Lack of data to support the
3TC+DTG or use of Rifapentine among
Isoniazid/Rifapentine- children aged < 2 years.
based regimens (for Double the dose of DTG if
children aged > 2 3RH is used
years)
or
Rifampicin/ Isoniazid
(3RH)
ABC or AZT Isoniazid (6H)
+3TC+ EFV or
Isoniazid/Rifapentine-
Lack of data to support the
based regimens (for
use of Rifapentine among
children aged > 2
children aged < 2 years.
years)
or
Rifampicin/ Isoniazid
(3RH)
ABC or AZT + Isoniazid (6H) Lack of data to support the
3TC+RAL or use of Rifapentine among
Isoniazid/Rifapentine- children aged < 2 years.
based regimens (for Double the dose of RAL if
children aged > 2 3RH is used
years)
or
Rifampicin/ Isoniazid
(3RH)
Timing of TPT in children
• Contacts of known TB patients: Initiate TPT immediately (or within 2
weeks of ART initiation if newly identified HIV positive)
• Virally suppressed children currently on NNRTI: Initiate TPT as
soon as possible and complete course before ART optimization.
• Virally suppressed children currently on PI or DTG: Initiate TPT if
the child has been on ART for at least 3 months.
• Newly initiating ART: Initiate TPT prophylaxis after 3 months on ART.
Co-administration of DTG and TPT

Although studies have found that the co-administration of DTG and

INH is well tolerated, liver injury is a recognized adverse effect of each of

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these drugs. Since there is potential for hepatotoxicity, the following are
recommendations for co-administration.
a. New Patient: For newly identified patients, start on TLD with active
symptomatic monitoring for adverse events (Chapter 14). Initiate TPT
after 3 months to allow time for potential unmasking of TB and to
monitor any toxicities that may arise from DTG, prior to initiation of
TPT.
b. For stable patients already transitioned to DTG: If patient has been on
TLD for 3 months or more, initiate TPT immediately.
c. If client is already on TPT and a non-DTG based regimen: Optimization
to DTG will be deferred until completion of TPT.
d. Stable patients for DTG transition and have not received TPT before:
a. In case TLE stock is available: First complete TPT and then
transition to DTG.
b. In case TLE stock is not available: Transition to DTG and initiate
TPT after 3 months.
Note: All patients receiving INH prophylaxis and DTG+INH should be
closely monitored for signs and symptoms of liver toxicity as specified in the
pharmacovigilance guidelines.
Table 43: TPT dosing table

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BCG vaccination

BCG is protective against severe forms of TB such as miliary TB and TB

Meningitis and is administered at birth in Uganda. However, if an infant did
not receive BCG at birth and is confirmed to be HIV-positive, s/he should
not be given BCG unless they are stable on ART. The follow up of a neonate
born to an HIV-positive mother with active TB is summarized in Figure 38.
Figure 37: Follow up of a Neonate born to an HIV-positive Mother with
Active TB.

COTRIMOXAZOLE PREVENTIVE THERAPY

Cotrimoxazole preventive therapy (CPT) can reduce the risk of malaria,

diarrhoea and pneumonia caused by bacterial infections; hospitalization; and
mortality. However, the benefits of CPT reduce markedly in clients who are
stable on ART. For this reason, only certain categories of PLHIV listed
below should be maintained on CPT.
The following groups have been prioritized for cotri-
moxazole preventive therapy:
• All PLHIV newly initiating on ART.
• Those having a current WHO stage 3 or 4 event or other symptoms of
advanced disease.
• Pregnant and breast-feeding women.
Note: Additional intermittent preventive treatment for malaria using
Sulfadoxine-Pyrimethamine (SP) is not required for pregnant women
on CPT.

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• Children and adolescents aged 0-15 years.

• Patients with treatment failure or having AHD.
Table 33: Cotrimoxazole dosing
Weight <5kg 5-14.9kg 15-29.9kg ≥30kg
Dose (once daily) 120mg 240mg 480mg 960mg

Co-trimoxazole toxicity

Adverse effects of Co-trimoxazole are rare but include skin rash, Stevens-
Johnson syndrome, anaemia, neutropenia, jaundice and renal failure. In the
event of skin reaction to Cotrimoxazole, see guidance on management in
Table 34.
Table 34: Management of Cotrimoxazole hypersensitivity
Severity Description Management
Mild Dry skin, erythema +/- Continue CTX, monitor closely,
fine papules or itching consider symptomatic treatment
affecting <50% of body with antihistamines +/- topical
surface area steroids (NOT oral steroids)
Moderate Dry skin, erythema +/- Stop CTX, consider symptomatic
fine papules, or itching treatment with antihistamines
affecting >50% of body +/-topical steroids (NOT
surface area oral steroids), consider trial of
desensitization after symptoms
completely resolved
Severe Mucosal involvement Stop CTX, admit to hospital
or blistering with for supportive management (IV
associated fever fluids, wound care, pain control,
infection control, monitoring for
affecting any % of body superinfection), patient should
surface area (Steven- NEVER be re-challenged with
Johnsons syndrome) CTX or other sulfa-containing
drugs
Guidance for when to stop CPT in stable PLHIV

To ensure that CPT is stopped without adversely affecting the health of PLHIV,
health workers should carefully select PLHIV for CPT discontinuation. The
five (5) conditions below should be fulfilled prior to CPT discontinuation:
• Patient should be older than 15 years of age.
• Patient should not be pregnant.

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• Patient should have been on ART for at least one year.

• Patient should not have a current WHO stage 3 or 4 event or other
symptoms of advanced HIV disease at the time of stopping CPT.
Restarting CPT in PLHIV
CPT can be restarted in the following scenarios:
• New pregnancy
In case CPT was stopped earlier (in stable women), re-start CPT and
maintain it throughout pregnancy and in the immediate postpartum
period (up to 6 weeks after delivery).
• Suspected treatment failure
If VL becomes unsuppressed in a patient whose CPT was previously
discontinued, re-start CPT and continue until the VL is again
suppressed.
• New Treatment WHO stage 3 or 4 condition
In case CPT was discontinued earlier, it should be restarted when a
patient develops an active WHO stage 3 or 4 infection and continued
until the condition has been treated and resolved.
Contraindications to CPT
CPT should not be given to people with known allergy to sulphur-containing
drugs or trimethoprim, severe anaemia,and/or severe neutropenia (<5000
cells/mm3).
Alternate Drugs for Hypersensitivity or Contraindication to
Cotrimoxazole
In patients with Cotrimoxazole hypersensitivity, Dapsone should be used.
Dapsone provides protection against PJP. It does not have the other
preventive benefits CPT provides. Therefore, pregnant women receiving
Dapsone should also receive intermittent preventive therapy for Malaria with
Sulphadoxine-pyrimethamine (Fansidar). In the rare event that a patient who
has hypersensitivity to Cotrimoxazole also reacts to Dapsone, Atovaquone
can be given as an alternative.
Dapsone dosing
• Weight of ≥25Kg: 100mg once a day or 1.4mg/kg in children
5.4.2 HIV and Cryptoccoccal Infection

In Uganda, Cryptococcal Meningitis (CM) is associated with mortality of

up to 39%. Patients with a CD4 cell count of <200 cells/mm3 are at the

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highest risk of CM. This section describes screening and management of

early Cryptococcal disease.
Screening and management of early Cryptococcal disease

The following categories of patients should be screened for Cryptococcal

disease:
• All HIV-infected ART-naïve with CD4 <200 cells/mm3
• ART experienced PLHIV returning to care after 90 days of treatment
interruption with CD4 <200 cells/mm3.
• All HIV-infected virologically unsuppressed patients with CD4 <200
cells/mm3.
• All patients with WHO Stage 3 or 4 event.
• All PLHIV who have a positive symptom screen on the Advanced Disease
Pathway.
How to screen for Cryptococcal disease
1. To screen for Cryptococcal disease, health workers should do
Cryptococcal antigen (CrAg) test using the lateral flow assay (LFA) on
plasma, serum, or finger-prick blood. The LFA for Cryptococcal antigen
has the advantage that does not require laboratory infrastructure. It can
be done at the bedside using finger prick whole blood.
2. The process of screening patients for Cryptoccoccal Meningitis is
guided by the algorithm in Figure 17.
For serum CrAg positive patients at facilities where lumbar
puncture can be performed
• Patients with a positive serum CrAg should be assessed for early and
late signs and symptoms of CM including decreased hearing, dizziness
or light-headedness, cognitive delay (acting unusual to friends, family or
provider), difficulty walking, double or blurry vision, weak arms or legs,
headache, presence of seizures, altered consciousness, photophobia, neck
stiffness, or a positive Kernig’s or Brudzinski sign.
• Patients with a positive serum CrAg are at high risk of having CM even in
the absence of symptoms. Therefore, a lumbar puncture is recommended
for all patients with a positive serum CrAg test to exclude CM. The CrAg
test should be conducted on CSF.
• If the CSF CrAg test is negative with or without signs of CNS disease:
the patient has Cryptoccoccal disease but without CNS involvement
and the patient should be started on pre-emptive therapy.
• If the CSF CrAg test is positive, the patient has CM and should be
treated for Cryptococcal Meningitis (see Table 44).

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Table 44: Treatment regimen for non-meningeal Cryptococcal

disease
Induction Phase Consolidation phase Maintenance phase
Fluconazole 800 mg Fluconazole 400 mg Fluconazole 200 mg for
for 2 weeks or 12 mg/ (or 6 mg/kg/day 14 weeks to complete 6
kg/day for children up to 400mg) for 8 months of treatment
and adolescents weeks
Note: For patients on
rifampicin, increase
Fluconazole dose by
50% across all phases

Figure 38: Algorithm for screening and managing

Cryptococcal disease

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For serum CrAg-positive patients at facilities where lumbar

puncture cannot be performed
Health workers at some health facilities may not be trained to do LPs. Patients
at such sites should also be assessed for signs of CM. Patients with early or
late Cryptococcal disease findings should be started on daily Fluconazole
1200mg, counseled and referred to a site where LP can be done.
For serum CrAg-negative patients

Assess the patient for signs and symptoms of Cryptococcal Meningitis

including decreased hearing, dizziness or light-headedness, cognitive delay
(acting unusual to friends, family or provider), difficulty walking, double
or blurry vision, weak arms or legs, headache, presence of seizures, altered
consciousness, photophobia, neck stiffness, and a positive Kernig’s or
Brudzinski’s sign.
If there are no signs of Meningitis, start ART in the patient immediately.
If there are signs of Meningitis, do a lumbar puncture and CSF gram stain,
including CSF CrAg and GeneXpert and manage accordingly.
Diagnosis of Cryptococcal Meningitis

The diagnosis of Cryptococcal Meningitis can only be made by demonstrating

the presence of Cryptococcal antigen in cerebrospinal fluid or a positive
culture showing Cryptococcal yeasts. A lumbar puncture and CrAg test on
CSF (CSF CrAg) is the recommended diagnostic approach for Cryptococcal
Meningitis. However, if a patient has signs and symptoms of Cryptoccoccal
Meningitis and a lumbar puncture cannot be performed for any reason, it is
recommended to perform a rapid serum CrAg using the LFA and treat as
possible Cryptoccoccal Meningitis.
Treatment of Cryptococcal Meningitis

There are three phases in the treatment of Cryptococcal Meningitis: the

induction phase, consolidation phase, and maintenance phase. The drugs
for the different phases, duration of treatment, when to initiate ART, when
to stop antifungals, how to prevent drug toxicity, how to manage increased
intracranial pressure, and relapse disease are summarized in Table 36.
Considerations for drug interactions during treatment of
Cryptococcal disease
• Antifungals and aminoglycosides (e.g. Gentamicin): Increased risk of
nephrotoxicity. Avoid combining the drug classes.

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• Antifungals and cardiac glycosides (e.g. Digoxin): Increased risk of cardiac

toxicity, especially in clients with hypokalemia. Monitor potassium very
closely.
• Antifungals and antiepileptic medicines: Antifungals may increase serum
concentration of carbamazepine, alprazolam, and other benzodiazepines.
May need to reduce antiepileptic by 50% if concurrently using or monitor
very closely.
• Amphotericin B and non-potassium sparing diuretics: Increased risk of
hypokalemia. Ensure adequate potassium supplementation.
• Amphotericin B and Flucytosine: Amphotericin B can decrease renal
clearance of 5-FC, and increase cellular uptake, which may increase the
risk of 5-FC toxicity. May require close monitoring of liver function.
• Nevirapine use and Fluconazole: Fluconazole increases plasma
concentration of Nevirapine and some protease inhibitors. Monitor
closely for toxicity.
• TB medicines and Fluconazole: Rifampicin increases the metabolism of
Fluconazole, thus increase the dose of Fluconazole by 50%.
• Pregnant and breastfeeding women: Whereas there is no data against the
use of Amphotericin B in pregnancy, it is not encouraged. There have been
numerous reports of multiple congenital abnormalities associated with
long-term use of high dose Fluconazole in the first trimester of pregnant
women. The recommendation is to treat Cryptoccoccal Meningitis in
pregnancy with Amphotericin B. Avoid Fluconazole during the first
trimester and preferably start Fluconazole after delivery. Flucytosine is
teratogenic in animals and should only be used when no alternative is
available. In liver disease, use with caution.
Figure 39: ART timing with CCM

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Table 45: Management of Cryptococcal Meningitis

Phase Drug Comments
Newly
Diagnosed
Patient
Induction Recommended: Preventing Amphotericin toxicity:
Phase Amphotericin B lipo- To prevent nephrotoxicity and
(2 weeks) somal single high dose hypokalemia, for patients on
(10mg/kg) + Flucytosine amphotericin deoxycholate do the
(100mg/kg/day in four following:
divided doses) + Fluco-
• Pre-hydration with 1L normal sa-
nazole 1200mg/day for
line before starting the daily Am-
14 days
photericin B dose.
Or
• Monitor serum potassium and
Amphotericin B deoxy-
creatinine levels at initiation and
cholate (1mg/kg/day) +
at least twice weekly to detect
Flucytosine
changes in renal function.
(100mg/kg/day in four
• Routine administration of 40
divided doses) for 1 week,
mEq/day (mixed in 500ml NS
followed by 1 week of
over 4 hours) of potassium chlo-
fluconazole (1200 mg/day
ride or 1 tablet of 600mg twice
for adults, 12 mg/kg/day
daily while on amphotericin B
for children and adoles-
can decrease the incidence of
cents).
Amphotericin B-related hypoka-
Or
lemia.
Fluconazole (1200 mg
• For electrolyte supplementation,
daily for adults, 12 mg/
two tablets daily of Magnesium
kg/day for children and
Chloride 310 mg or slow Magne-
adolescents) + Flucytosine
sium Chloride 535mg or Magne-
(100 mg/kg/day, divided
sium trisilicate 250mg while on
into four doses per day.
amphotericin B
Or
• Consider alternate day Ampho-
Amphotericin B deoxy-
tericin B if creatinine is >3mg/
cholate (1mg/kg/day) +
dl.
high-dose Fluconazole
• To monitor for flucytosine (5FC)
1200mg/day.
toxicity, CBC with differential
Or
counts at least twice weekly is
Alternative: recommended
Fluconazole 1200mg/
day (or 6-12mg/kg/day in
children)

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Consolida- Fluconazole 800mg/day Initiate ART 4–6 weeks after

tion phase (or 6-12mg/kg/day in starting CM treatment and there
(8 weeks) children and adolescents) is clinical response to antifungal
therapy.
Mainte- Fluconazole 200mg/day Criteria to stop after a minimum
nance (or 6 mg/kg/day up to of 18 months of maintenance
Phase (18 200mg in children and phase:
months) adolescents) Adults: VL<1,000 copies/mm3 &
CD4 ≥ 200 or CD4 ≥200 (if viral
load not available) after 12 and 18
months
Children: If CD4>25% or viral
suppressed
Relapse disease
Presents with a recurrence of symptoms of Meningitis and have a positive
cerebrospinal fluid culture following a prior confirmed diagnosis of Crypto-
coccal Meningitis.
Evaluate for drug resistance: Send CSF to Central Public Health Laboratory
(CPHL) for culture and sensitivity testing, if there are no drug resistance
results, re-initiate the induction therapy for two weeks and complete other
phases of treatment.
Adequate control of elevated CSF pressure
Control of increased intracranial pressure improves survival by 25% in per-
sons with Cryptococcal Meningitis.
All patients with a CSF Pressure >250mm H2O will need a therapeutic LP
the following day to reduce the CSF pressure to <200 mm.
In the absence of a manometer, one may use an IV giving set to create an
improvised manometer measuring the height with a meter stick.
Removing 20-30mL of CSF (even in the absence of a manometer) may be
adequate to decrease CSF pressure. Most patients will need 2-3LPs during the
induction phase.

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Table 46: Liposomal Amphotericin B dosing weight bands

Table 47: Flucytosine (5FC) dosing weight bands

5.4.3 Pneumocystis Jiroveci Pneumonia

Pneumocystis Jiroveci Pneumonia (PJP), formerly known as Pneumocystis carinii

pneumonia (PCP), is the most common opportunistic infection in persons
with advanced HIV disease. However, the frequency is decreasing with the
use of Cotrimoxazole prophylaxis and ART. Table 49 below describes the
signs, symptoms and management of PJP.
Table 49: Signs/symptoms, management and prevention of
Pneumocystis Jiroveci Pneumonia
Signs and Symptoms: Progressive exertional dyspnea (95%), fever
symptoms and chills (>80%), non-productive cough (95%), chest
discomfort, difficult breathing, fast breathing and weight
loss.
Signs: Pulmonary symptoms: tachypnea, pulmonary
examination may reveal mild crackles and rhonchi
but may yield normal findings in up to half of the
patients.  Children may have cyanosis, nasal flaring, and
intercostal retractions.

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Diagnosis Chest X-Ray is the main diagnostic tool

• Diffuse interstitial infiltrates extending from the peri-
hilar region
• Pneumatoceles and pneumothorax are possible but not
common.
• Pleural effusions and intrathoracic adenopathy are rare.
However, the chest X-Ray may also be normal
Management Admit
and treatment Give oxygen
Preferred therapy: Cotrimoxazole (10-20mg/kg/day
IV) for 21 days
Adjunctive therapy: Use corticosteroids only in
patients with severe PJP
Prevention Initiate all HIV-infected people on Cotrimoxazole
preventive therapy
5.4.4 HIV and Hepatitis B
Acute Phase: Non specific signs and symptoms :
Signs and abdominal pain, fever, nausea, vomiting, +/-jaundice.
symptoms Chronic Phase: Chronic fatigue, ascites, bleeding
under the skin, jaundice, and mental derangement.
All PLHIV initiating or failing on ART should be
Screening for
routinely screened for HBV infection using Hep B
HBV
surface Antigen (HBsAg).
These tests should be done at baseline and at six
months
Tests in persons • A complete blood count.
diagnosed with • Liver function tests (ALT,AST, albumin and bilirubin
HBV infection levels, and PTT).
• Abdominal ultrasound scan
• AFP and HBeAg if available.
Initiate ART with TDF or TAF -containing regimen.
If ART cannot be given or if the patient refuses ART use:
Treatment of Peg-IFN-alfa 2a 180 mcg subcutaneously once weekly for
HBV/HIV co- 48 weeks
infected person or
Peg-IFN-alfa 2b 1.5 mcg/kg subcutaneously once weekly
for 48 weeks.

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Evaluate the patient for HBV treatment failure:

• If jaundice, malaise and abdominal right upper
quadrant pain are present or if LFTs are abnormal
Follow-up after
do a viral load test.
six months
• If HB VL unavailable or HB VL >2000IU/ml at
24 weeks of Rx: refer for further evaluation and
management while continuing ART.
• Risk reduction: Safe sex practices, avoid needle
sharing and minimize risk from household contacts.
• Screen all household members and sexual partners/
HBV prevention
contacts
• HBV vaccination to all people regardless of HIV
status in endemic areas.

5.4.5 HIV and Histoplasmosis

Histoplasmosis is a disease caused by the fungus Histoplasma Capsulatum.

Histoplasmosis is one of the most frequent opportunistic infections caused
by fungal pathogens among people living with HIV. The symptoms of
disseminated histoplasmosis are non-specific and may be indistinguishable
from those of other infectious diseases, especially disseminated tuberculosis
(TB), thus complicating diagnosis and treatment.
Table 48: Classification andTreatment regimen for
disseminated Histoplasmosis disease
Classification Induction Phase Maintenance phase
Treating severe Preferred regimen liposomal Itraconazole 200 mg
or moderately amphotericin B, 3.0 mg/kg, twice daily for 12
severe for two weeks for children months
histoplasmosis and adolescents
among PLHIV Alternate regimen
deoxycholate amphotericin B,
0.7– 1.0 mg/kg for two weeks
Mild to Itraconazole 200 mg three Itraconazole 200 mg
moderate times daily for three days and twice daily for 12
histoplasmosis then 200 mg twice daily for months
among PLHIV: two weeks

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Antiretroviral therapy should be initiated as soon as possible among

people with disseminated histoplasmosis for whom central nervous system
involvement is not suspected or proven
5.4.6 HIV and Aspergillosis

Aspergillus species continue to be an important cause of life-threatening

infection in immunocompromised patients. Recent evidence suggests that
chronic pulmonary aspergillosis and aspergillus sensitisation might be
responsible for significant mortality in patients treated for tuberculosis in
Uganda. Aspergillus infection may complicate active pulmonary TB and
efforts need to be made to rule out aspergillosis in PLHIV presenting with
advanced HIV disease.
There are 3 major forms of aspergillosis: invasive aspergillosis (IA); chronic
(and saprophytic) forms of aspergillosis; and allergic forms of aspergillosis.
Given the clinical importance of IA, emphasis is placed upon the diagnosis,
treatment, and prevention of the different forms of IA, including invasive
pulmonary aspergillosis (IPA), Aspergillus sinusitis, disseminated aspergillosis,
and several types of single-organ IA
Signs and Signs and symptoms depend on which organs are
symptoms affected, but in general, invasive aspergillosis can cause:
Fever and chills.
A cough that brings up blood (hemoptysis)
Shortness of breath.
Chest or joint pain.
Headaches or eye symptoms.
Skin lesions
Risk factors Weakened immunity
Low white blood cell count
Lung cavities
Asthma or cystic fibrosis
Long term corticosteroid therapy

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Diagnosis Imaging tests. A chest X-ray or computerized

tomography (CT) scan — a type of X-ray that produces
more-detailed images than conventional X-rays do —
can usually reveal a fungal mass (aspergilloma), as well as
characteristic signs of invasive aspergillosis and allergic
bronchopulmonary aspergillosis
Sputum for staining; In this test, a sample of your
sputum is stained with a dye and checked for the
presence of aspergillus filaments. The specimen is then
placed in a culture that encourages the mold to grow to
help confirm the diagnosis.
Tissue and blood test; Skin testing, as well as sputum
and blood tests, may be helpful in confirming allergic
bronchopulmonary aspergillosis. For the skin test, a small
amount of aspergillus antigen is injected into the skin of
your forearm. If your blood has antibodies to the mold,
you’ll develop a hard, red bump at the injection site.
Blood tests look for high levels of certain antibodies,
indicating an allergic response.
Biopsy. In some cases, examining a sample of tissue
from your lungs or sinuses under a microscope may be
necessary to confirm a diagnosis of invasive aspergillosis.
Management Voriconazole (preferred) or Amphotericin B (alternate)
and for 6-12 weeks
treatment Prophylaxis with itraconazole for 6 months
Prevention Avoid places where you’re likely to encounter mold, such
as damp places, construction sites, compost piles and
buildings that store grain
5.4.7 HIV and NON-COMMUNICABLE DISEASE

Uganda suffers a dual burden of NCDs and HIV/AIDS with an overall

prevalence of pre-hypertension of 38.8% among its 42 million population.
HIV-infected adults experience more chronic metabolic complications
because of both the HIV infection itself and ART. They are more likely
to develop Diabetes Mellitus (DM), hypertension and mental illness as
compared to HIV-negative individuals. Studies report that up to 10% of
HIV-positive patients on ART develop DM within four years and 24.3%
of 15,000 persons living with HIV (PLHIV) screened at an urban clinic in
Uganda were found to be hypertensive. Currently health care services for

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these conditions are organised in separate(vertical) clinics making it difficult

for a patient with multiple conditions to access care. Evidence from studies
have shown that Integrating care for HIV and NCDs is feasible, acceptable,
less costly and a possible solution to improving access to care among patients
with multiple conditions.
At each clinic visit, the patient should be screened for the common NCDs
particularly diabetes mellitus, hypertension and mental health (anxiety,
depression, substance and alcohol use disorders).
5.4.7.1 Diabetes Mellitus (DM)

Risk factors for development of diabetes mellitus in HIV-

positive patients
• In addition to the usual risk factors for development of DM, there are
several HIV-related risk factors:
• Fluctuating viral load and CD4 cell count which cause a chronic
inflammatory state which may induce insulin resistance.
• Rapid weight gain, co-infection with Hepatitis C, dyslipidemia, and
lipodystrophy.
• Anti-retroviral drugs are a major cause of the development of DM in
PLHIV. Protease inhibitors such as Lopinavir, and Ritonavir cause insulin
resistance by causing lipodystrophy, impaired glucose transporter type 4
translocation, reduced adipocyte differentiation, reduced insulin secretion,
and dyslipidemia with lipotoxicity. Hyperglycemia has been reported
among HIV patients on DTG. Although causality has not yet been
determined, systems for pharmacovigilance are recommended to assess
the relationship and guide mitigation measures.
Screening and diagnosis for DM

Patients should be assessed for risk factors for DM before initiation of ART,
while on ART, and when clinically indicated using the DM screening tool. All
PLHIV should thereafter be re-screened every six months (see Figure 43).
Treatment For DM

HIV-positive patients with DM should be treated as per the treatment

protocol (see Figure 44) adopted from the Uganda Clinical Guidelines.
However, the following should be observed:
• Reinforce lifestyle interventions at every clinic visit (refer to section 1.1.4)
• Healthy heart diet
• Adequate exercise (at least 30 minutes per day or 150 minutes per week)

186
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• Weight loss/management
• Cessation of smoking
• Elimination/reduction of alcohol consumption
• Advise on foot care for all diabetics to prevent wounds/ulcers from
developing.
• Metabolically neutral ARVs should be prescribed for patients at risk of
developing DM. These include ABC, TDF and 3TC.
• Exclude HIV-associated nephropathy and liver toxicity before initiating
metformin because it may lead to Metformin Associated Lactic Acidosis
(MALA).
• HIV patients on metformin should be educated about the symptoms
of lactic acidosis, including fatigue, weight loss, nausea, abdominal
pain, dyspnea, and arrhythmia. Liver-related symptoms such as tender
hepatomegaly, edema, ascites, and encephalopathy may occur, but jaundice
is uncommon.
• The gastrointestinal side effects of metformin are increased in patients
with HIV enteropathy. Metformin should, therefore, be started at a low
dose and increased gradually.
•
•
Lopinavir/r, ATV/r, and DRV/r can be used with close monitoring.
Lopinavir/r, ATV/r, and DRV/r can be used with close monitoring.
•• DTG
DTG should
should not
not be be used.
used.
Figure 42: Algorithm for Screening, Diagnosis and
Management
Figure 40: Algorithm for Screening, of Diabetes
Diagnosis Mellitusof Diabetes Mellitus
and Management

Figure 41: Treatment protocol for diabetes mellitus

187
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 43: Treatment protocol for diabetes mellitus

Step1: Lifestyle Modification and re-assess in 3 months

If glycaemic target not achieved go to step 2

Table 55: Sulfonylurea oral glucose lowering agents with

starting
Table 54: Sulfonylurea and escalating
oral glucose doses
lowering agents with starting and escalating doses
Next Next Next Next
dose if
Next
dose
Next
if dose if dose if Range
Start- glucose
dose if glucose glucose
dose if Next dose Nextglucose
dose of daily
ing target
glucos target target if glucose
glucos if glucose target Rangedosage
of
Medication doseStarting
notemet
target not
e target
met target
notnot
met target
notnot
met daily dosage
(mg)
Medication dose not met not met met met (mg)
Glimepiride
Glimepiride 2mg 2mg 4mg 4mg 6mg
6mg 1-61-6
Gliclazide controlled
Gliclazide
release 30 mg 60 mg 80 mg 160 320 30-320
controlled
Glipizide 2.5-20
release
Glibenclamide 30 mg 2.5 mg 605mg
mg 80 mg 12.5160
10 mg mg 320
15 mg 30-320
2.5-151
Glipizide 2.5-20
Figure 40: Contraindications for Metformin and Glibenclaminde
Gliben-
clamide 2.5 mg 5 mg 10 mg 12.5 mg 15 mg 2.5-151
165

188
Metformin is contraindicated in: Glibenclamide is not recommended
•people with chronic kidney disease in:
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022
(estimated glomerular filtration rate •people aged 50 years or older
(eGFR) <30 mL/minute/1.73m2) •people with severe liver disease
Figure 40: Contraindications for Metformin and
•people with severe reduced
Glibenclaminde liver •in patients for whom hypoglycemia is a
function concern (people who are at risk of falls,
•people with acute
Metformin cardiac
is contraindicated in: who have impaired
Glibenclamide is notawareness
recommended of
insufficiency
•people with chronic kidney disease hypoglycemia, who live alone)
in:
(estimated glomerular filtration rate •people aged 50 years or older
•people
(eGFR) with
<30respiratory
mL/minute/1.73m2) •peoplewith
•people whosevere
driveliver
or operate
disease machinery as
insufficiency
•people with severe reduced liver part
•in of their
patients forjob.
whom hypoglycemia is a
function
•people who abuse alcohol concern (people who are at risk of falls,
•people with acute cardiac who have impaired awareness of
•people with history
insufficiency of lactic hypoglycemia, who live alone)
acidosis
•people with respiratory •people who drive or operate machinery as
insufficiency part of their job.
INTERACTIONS OF METFORMIN MEDICINE WITH DTG
•people who abuse alcohol
Metformin andhistory
•people with DTG**:of alactic
lower dose of metformin may be needed with closer monitoring
acidosis
of blood glucose
INTERACTIONS OF METFORMIN MEDICINE WITH DTG
Metformin and DTG**: a lower dose of metformin may be needed with closer monitoring
Figure 42: DM Screening
of blood glucose Algorithm for PLHIV Transitioning to DTG

Figure 42: DM Screening Algorithm for PLHIV Transitioning to DTG

Figure 44: DM Screening Algorithm for PLHIV Transitioning to DTG

10.1.4 Screening and management of complications of Diabetes Mellitus

Good control of diabetes results in the reduction of occurrence of complications such as
retinopathy (visual problems), nephropathy (kidney problems), Neuropathy (problems of the
Screening
nerves and
of extremities), management
cardiovascular of complications
disease including hypertension. It isof Diabetes
therefore important
Mellitus
10.1.4 Screening and management of complications of Diabetes Mellitus 166

Good control of diabetes results in the reduction of occurrence of complications such as of

Good control of diabetes results in the reduction of occurrence
complications
retinopathy such nephropathy
(visual problems), as retinopathy (visual problems),
(kidney problems), nephropathy
Neuropathy (problems of the
(kidney problems), Neuropathy (problems of the nerves of extremities),
nerves of extremities), cardiovascular disease including hypertension. It is therefore important

166
189
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

cardiovascular disease including hypertension. It is therefore important for

a healthworker to encourage the patient to adhere to treatment for glycemic
controlfor aand be screen as often as possible for early identification and
healthworker to encourage the patient to adhere to treatment for glycemic control and be
management
screen as often as possible for early identification and management

Figure 45: Screening for Complications with DM

Figure 43: Screening for Complications with DM

SCREENING FOR CHRONIC MANAGEMENT OF ACUTE

COMPLICATIONS COMPLICATIONS

• Always measure blood pressure SEVERE HYPOGLYCAEMIA/ SIGNS

at every scheduled visit for a AND SYMPTOMS
diabetic patient review medication
as per hypertension protocol Plasma glucose < 50 mg/dl or 2.8
mmol/L)
• REFER for eye exam upon
diagnosis and every 2 years • If conscious, give a sugar-
thereafter, or as per sweetened drink
ophthalmologist recommendation
• If unconscious, give 20–50 ml
• Examine feet for ulcers at every of 50% glucose (dextrose) IV
visit over 1–3 minutes

• REFER to higher level of care if SEVERE HYPERGLYCAEMIA/

ulcer present SIGNS AND SYMPTOMS

• Assess risk of lower limb Plasma glucose > 18 mmol/L (325

amputation annually(foot pulses, mg/dl) and urine ketone 2+)
sensory neuropathy by • Set up intravenous drip 0.9%
monofilament, presence of NaCl 1 litre in 2 hours;
healed or open ulcers, calluses) • continue at 1 litre every 4 hours
and REFER to higher level of • REFER to hospital
care if ulcer present or pulse
absent
• Test for proteinuria annually –
REFER to higher level of care if
positive

Screening, Diagnosis and Management of Obesity

10.2 SCREENING, DIAGNOSIS AND MANAGEMENT OF OBESITY
According 2021 global nutrition, 10.4% of the adult women (>18 years) and 2.3% of the adult
males are obese in Uganda and yet the country has shown little progress towards achieving
According 2021
diet related NCDglobal nutrition,
targets. Obesity 10.4%
is a preventable of disorder
medical the adult women
involving excessive(>18
body years)
and 2.3% of the adult males are obese in Uganda and yet the country has
fat and often increases the risk of health problems/diseases such as heart disease and diabetes

shown little progress towards achieving diet related NCD targets. Obesity is a
preventable medical disorder involving excessive body fat and often 167 increases
the risk of health problems/diseases such as heart disease and diabetes
Risk factors for obesity

Although there are genetic, behavioural, metabolic and hormonal influences

on body weight, obesity occurs when you take in more calories than you
burn through normal daily activities and exercise. The risk factors that can
be modified include; an unhealthy diet i.e high in calories, lacking in fruits
and vegetables, b. inactivity: Sedentary lifestyle, c. Stress, d. some medical
conditions can lead to weight gain

190
calories, lacking in fruits and vegetables, b. inactivity: Sedentary lifes
medical conditions can lead
Consolidated Guidelines for the to weight
Prevention gainof HIV and Aids in Uganda - 2022
and Treatment

Figure 46: WHO classification of weight status and

Figure 44: calculation
WHO classification
of BMI of weight status and calculation of B

BMI is calculated to classify a person’s weight and diagnose obesity. For

BMI is calculated
example, to classify
for a person with a person’s
weight 70Kg weight
and Height and diagnose obesity. F
170cm:
with=weight
BMI 70Kg
70/ (1.7)2 and
= 24.2 Height
(Normal 170cm:
BMI)
Prevention and2 Management: Lifestyle modification
BMI = 70/ (1.7) = 24.2 (Normal BMI)
Advise patients to do the following:
• Eat a healthy balanced diet: rich in fresh fruits and vegetables, avoid
10.2.2 Prevention
carbonated and
beverages, Management:
reduce Lifestyle
alcohol intake or modification
quit alcohol
• Increase physical activity to equivalent of 30 minutes of aerobic exercise a
Advise patients
day, at least 5 daysto do week
every the following:
- Eat aand
• Consistency healthy
disciplinebalanced
are Key diet: rich in fresh fruits and vege
5.4.7.2 Screening, Diagnosis and Management of
beverages, reduce alcohol intake or quit alcohol
Hypertension
- Increase
All PLHIV should physical
be screened activity
for risktofactors
equivalent of 30 minutes
of hypertension such as of aerob
tobacco smoking,
days everybeingweek
overweight or obese, physical inactivity, dyslipidemia,
history of adverse cardiovascular event like stroke and heart attack and
- Consistency
unhealthy diet at every and
visit. discipline
They shouldare alsoKey
have their blood pressure
(BP) measurement at every clinic visit. Note that protease inhibitors can also
contribute to increased cardiovascular disease risk. Persistently high resting
10.3defined
BP SCREENING, DIAGNOSIS
as >140/90mmHg on at least AND MANAGEMENT
two measurements OF HYPE
five minutes
apart with the patient seated should be managed as guided by the algorithm
All PLHIV
(Figure should
47). People be screened
with any for riskshould
risk factor identified factors of hypertension
be advised to modify such
overweight or obese, physical inactivity, dyslipidemia, history of ad
lifestyle as described below.

like stroke and heart attack and unhealthy diet at every visit. Th
blood pressure (BP) measurement at every clinic visit. 191
Note that p
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 47: Algorithm for diagnosis and management of

hypertension

Table 56: Hypertension Treatment Protocol

  Least
Preferred
Alternative 1 Alternative 2 Level of
drugs
care
Step 1: If BP is HC2
≥ 140-159/90-
99 mmHg with
< 3 risk factors, Offer Lifestyle modification
no target organ
damage.
Follow-up in
3months

192
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Step 2: If BP is Bendroflu- HC3

≥ 140/90mmHg, Amlodipine Amlodipine methiazide
Follow-up in 4 5mg 5mg 2.5mg once
weeks daily

Step 3: If BP is Amlodipine Amlodipine Bendroflu- HC3

≥ 140/90mmHg, 5mg + 5mg + methiazide
Follow-up in 4 Valsartan Losartan 5mg once
weeks
80mg 25mg daily

Step 4: If BP is Bendroflu- HC3

Amlodipine Amlodipine
≥ 140/90mmHg, methiazide
10mg + 10mg +
Follow-up in 4 5mg +
Valsartan Losartan
weeks Nifedipine
80mg 25mg
20mg bd

Step 5: If BP is Bendrofl- HC3

Amlodipine Amlodipine
≥ 140/90mmHg, umethiazide
10mg + 10mg +
Follow-up in 4 5mg +
Valsartan Losartan
weeks Nifedipine
160mg 50mg
40mg bd

Step 6: If BP is Amlodipine Amlodipine Bendrofl- HC4

≥ 140/90mmHg, 10mg + 10mg + umethiazide
Follow-up in 4 Valsartan Losartan 5mg +
weeks 160mg + 50mg + Nifedipine
Hydrochl- Hydrochl- 40mg bd +
orothiazide orothiazide Captopril
12.5mg 12.5mg 50mg tds
Step 7: If BP is ≥ 140/90mmHg: Refer to a hospital for further
management
Note: Maintain lifestyle modification with treatment; assess and offer
adherence support

193
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure
Note: Maintain
support
48:lifestyleLifestyle Modification
modification with treatment; Counselling for
assess and offer adherence

Hypertension
Figure 46: Lifestyle Modification Counselling for Hypertension
Lifestyle Counselling
• Tobacco smoking cessation: Ceasing to smoke reduces the risk of, uncontrolled hypertension,
diabetes, heart disease, stroke and chronic lung diseases.
• Regular physical activity: Persons should be advised to have aerobic exercises for at least 30
minutes a day, 5 days a week. Health care workers should help patients find activities that they
enjoy because this increases adherence.
• Healthy diet: Eat a diet high in fruits and vegetables and low in fat
o Limit processed and fast foods.
o Reduce refined sugar intake.
• Salt reduction: Reduce sodium intake to <1.5 g/day (less than one teaspoon)
• Weight control: Maintain a normal body weight of a body mass index of 18 – 25kg/m2 and or a
waist circumference of < 82cm for females and < 102cm for males.
• Avoid harmful use of alcohol.
Adherence counselling for integrated HIV
Hypertension and diabetes Care
• The goal of treatment is blood pressure
<140/90mmHg, Diabetes is FBG < 7mmol/l and LIFESTYLE MODIFICATION
viral load< 200copies/ml
• Patients with uncontrolled hypertension and
blood sugar may suffer complication such as
heart attack, stroke, chronic kidney disease,
blindness, numbness of limbs and heart failure,
• Hypertension, diabetes and HIV/ART treatment is
lifelong.
• Hypertension often has no symptoms, HIV
patients with unsuppressed viral loads may
initially show no symptoms but they will appear
in the worst form and those with high blood
sugar will show symptoms immediately
• ART, diabetes and hypertension medicines can
be taken at the same time.
• Maintain lifestyle modification and risk reduction
with treatment.
• Adherence to ARTminimizes complications of HIV
infection on the blood vessels.
• Explain potential side effects of hypertension
medicines. 171

10.3.1 Monitoring treatment for Hypertension and diabetes among PLHIV

194
• Measure blood pressure on every clinic visit.

Figure 47: Laboratory Monitoring for PLHIV on Hypertension Medications

Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Monitoring treatment for Hypertension and diabetes among

PLHIV
10.3.1 Monitoring treatment for Hypertension and diabetes among PLHIV
• Measure blood pressure on every clinic visit.
• Measure blood pressure on every clinic visit.
Figure 49: Laboratory Monitoring for PLHIV on Hypertension
Figure 47: Laboratory Monitoring for PLHIV on Hypertension Medications
Medications
LABORATORY MONITORING FOR PLHIV ON HYPERTENSION MEDICINES
6 months 12 months 2 years

• Fasting blood sugar • ECG

• Lipid profile • Fundoscopy
• Urine protein
• Potassium and Sodium (if on diuretic or ACEI/ARB)
• Creatinine (if on ACEI/ARB)

ACEI – Angiotensin converting enzyme inhibitors; ARB - Angiotensin receptor blockers

Drug-Drug interactions and common side effects of some of

the NCD drugs
172
PLHIV with
10.3.2 co-morbidities
Drug-Drug often
interactions and takeside
common multiple
effects ofdrugs
some ofsome
the NCD ofdrugs
which interact
and may
PLHIVincrease or decrease
with co-morbidities ofteneach other’sdrugs
take multiple levelsome
affecting
of which the outcome.
interact and It is
may increase
important that aorhealth
decrease each other’s
worker payslevel affecting the
attention outcome.
to the It is important
different types that
of drugs
a health worker pays attention to the different types of drugs a patient is receiving.
a patient is receiving. This way there will be minimal effect on the outcome
This way there will be minimal effect on the outcome and less side effects (see tables
and less side
57 and 58).effects (see tables 57 and 58).

TableTable Interactions
57:56: Interactions of hypertension
of hypertension medicine medicine
INTERACTIONS OF HYPERTENSION MEDICINE WITH ARVs
Hypertension Drug Interaction with ART Action required
Efavirenz and Niverapine could No dose adjustments are
Dihydropyridines (amlodipine and potentially decrease drug levels required
Nifedipine) LPV/r, ATV/r and DRV/r increase drug
Use Nifedipine with caution
levels
Efavirenz may reduce formation of active No dose adjustments are
form of losartan required
Losartan Use with caution, in
Protease inhibitors reduce elimination of
patients with hepatic
losartan
impairment
Valsartan (and other ARBs except No clinically significant drug-drug
None
losartan and Ibesartan) interactions
All ACE inhibitors (including No clinically significant drug-drug
None
captopril) interactions
All diuretics (including
No clinically significant drug-drug
Hydrochlorothiazide and None
interactions
Bendroflumethiazide)
LPV/r - Lopinavir/ritonavir, ATV/r – Atazanavir/ritonavir, DRV/r – Darunavir/ritonavir, PIs – Protease Inhibitors

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Table 57: Potential side effects of hypertension medicine

Table 58: Potential side effects of hypertension medicine
POTENTIAL SIDE EFFECTS OF HYPERTENSION MEDICINES
Drug Common Side Effects Management

Amlodipine/ • Lower limb edema (1-10%) Observe on treatment. Consider alternative

Nifedipine medicine if excessive or persistent after using a
diuretic.
• Headache (7%), Usually self-limiting, observe on treatment.
• Palpitations (1-3%)
• Male sexual disorder (1-2%) Explore for other causes and reassure.

• Muscle cramps Usually self-limiting, observe on treatment.

Valsartan/ • Hypotension with dizziness Monitor blood pressure and consider dose reduction
Losartan (10%) if systolic BP is < 100mmHg or person is frail.
• Hyperkalemia (4-10%) Monitor potassium and creatinine. Stop drug when
potassium is > 5.5mmol/L and or eGFR <30ml/min.
• Angioedema (rare) Stop immediately and provide alternative medicine.

Captopril • Hyperkalemia (1-11%) Monitor potassium and creatinine. Stop drug when
potassium is > 5.5mmol/L and or eGFR <30ml/min.
• Pruritus (2%) Usually self-limiting, observe on treatment.

• Cough (1-2%) Monitor on treatment and consider alternative

medicine if persistent
Hydrochlorothiazide • Hyperuricemia
• Hyperlipidemia
Monitor while on treatment.
• Hypercalcemia
• Photosensitization
• Exacerbation of gout Consider alternative medicine if persistent after diet
modification.

Management of Clinic Reviews for Stable HIV Patients with NCDs

HIV patients with diabetes and hypertension often have to attend separate
HIV and NCD clinics on different days of the month. This comes at a cost
to the patient; time off work, transport costs to the health facility and often
affects their adherence to either ARVs or NCD drugs. Therefore:
a. Stable HIV patients with NCDs and without any complications should
be given same clinic appointment and seen by the same clinician (where
possible).
b. Provide comprehensive health education sessions that is inclusive of
both HIV and NCD information during the clinic. 174
c. Manage the patients’ records/charts in the same location for easier
access and retrieval when needed.
d. Patients who develop NCD-related complications should be referred
to higher level/specialists for further management.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

5.4.7.3 Assessment and Management of Common Mental

Disorders Amongst PLHIV

Assessment and management of depression

PLHIV are at risk of mental and neurological disorders. About 10–20% of

PLHIV have major depression. PLHIV with mental health disorder are less
likely to achieve optimal ART adherence and could have poor treatment
outcomes.   Assessing and managing the most common mental illnesses
among people living with HIV is important and should be an integral part
of HIV care programs.
Screening for depression, anxiety, substance and alcohol use
disorder

Clinicians should screen for depression and anxiety as part of the routine
mental health assessment and when symptoms suggest its presence. It
is particularly important to screen for depression and anxiety during the
following crisis points:
• When newly diagnosed with HIV or at disclosure of HIV status to family
and friends.
• Occurrence of any physical illness, recognition of new symptoms/
progression of disease or hospitalization or diagnosis of AIDS.
• Initiation of medication.
• Death of a significant other.
• Necessity of making end of life and permanency planning decisions.
• Major life changes,e.g., childbirth, pregnancy, loss of a job, end of a
relationship.
Procedure for Mental Health assessment at TRIAGE
Procedure for mental Health assessment of Triage
• General health education on common Mental Health disorders to all
attending patients.
• Educate about the signs & symptoms of common mental health disorders.
• Identify and sort out patients that report any of the signs & symptoms.
• Set up a private corner at triage point.
• Use the screening tools provided to assess the patients individually.
• Ensure the triage nurse/ peer is well trained to screen for Mental health.
• Use language which is most comfortable and understandable for the
patient.
• Document in the patient file

197
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• Escort patients with positive screen to clinician for farther assessment &
management.
Tools for screening for depression, anxiety, Substance and Alcohol Use
disorder
a. Self-Reporting Questionnaire 20(SRQ-20)
b. SAD PERSONS Scale
c. AUDIT – C +1 question on other substance abuse
Figure 50: Self-Reporting Questionnaire Screening Tool

If the person scores 6 or more on the SRQ- 20, then they are further assessed
for suicide using a SAD PERSONS scale (see below).
SAD PERSONS scale
• S – Sex: 1 if male; 0 if female; (more females attempt, more males succeed)
• A – Age: 1 if < 20 or > 44
• D – Depression: 1 if depression is present
• P – Previous attempt: 1 if present
• E – Ethanol abuse: 1 if present
• R – Rational thinking loss: 1 if present
• S – Social Supports Lacking: 1 if present
• O – Organized Plan: 1 if plan is made and lethal
• N – No Spouse: 1 if divorced, widowed, separated, or single
• S – Sickness: 1 if chronic, debilitating, and severe

198
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 51: Degree of Risk after Assessment using the SAD

PERSON’s Scale
Total points  Risk
0–4 Low suicide risk
5–7 Moderate suicide risk
8 – 10 High suicide risk
Figure 52: AUDIT-C tool for substance and alcohol use
disorder
0 1 2 3 4 Score
1. How often have Never Monthly 2-4 2-3 4 or
you taken a drink times/ times/ more
containing alcohol month week times a
to cope with stress? week
2. How many drinks 1 or 2 3 or 4 5 or 6 7 to 9 10 or
containing alcohol more
do you have on a
typical day when
you are drinking?
3. How often do Never Less monthly weekly Daily
you have six or than a or
more drinks on one monthly almost
occasion? daily
Do you currently Never
use any substance?
Scoring and interpreting AUDIT-C

Add the scores (shown in the top line) for each of the three questions for
a total score out of 12. The following total scores provide an indication of
whether to advise no alcohol use and/or refer the woman to a specialist
addiction treatment service. They are a guide only.
• 0-3 Low-risk drinking (advise no use)
• 4-5 Moderate-risk drinking (advise no use and use professional judgement
to consider referral to a specialist addiction service)
• ≥5 High-risk drinking (definite referral to a specialist addiction

199
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Management of Depression and Anxiety

First line treatment includes psychotherapy or counseling through which the

affected person is provided with knowledge and a variety of skills to help
them overcome depression. If there is no improvement, psychotherapy is
combined with medications, as shown on Table 59. The psychotherapy can
be group (GSP) or individual psychotherapy.
Table 59: Psychotherapy and Medications for Anxiety and Depression
Psychotherapy (Mild- Medications (Severe depression)
Moderate depression)
• Teach skills to; • The drugs for treatment of depression are called
• Acknowledge antidepressants.
stressful situations • The common antidepressants are; Fluoxetine,
• Cope with stressful amitriptyline and imipramine.
situations.
• Replace unhelpful Dosage
ways of thinking • Fluoxetine 20mg once daily in the morning is
with helpful ways preferred
of thinking. • Start with 10mg in the elderly
• Practice new skills • If not better after 4-6 weeks, increase to 40mg
• Connect with other • Amitriptyline or Imipramine 50mg at bed time is
people the alternative
• Positive creative
visualization, • Increase by 25mg every week aiming at 100-150mg
• Express gratitude. in divided doses or single bedtime dose by 4-6
• Practice positive weeks of treatment.
self-talk NB:
• Practice spirituality • Continue for at least 9-12 months if patient is
• Engage in helping responding to medication.
acts.
• Maintain good • Consider stopping if patient has been without
nutrition, and depressive symptoms and able to carry out normal
general physical activities for at least 8 months.
health. • Counsel the patient about withdrawal symptoms
(dizziness, tingling, anxiety, irritability, nausea,
headache, sleep problems)
• Counsel the patient about possibility of relapse and
when to come back

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Referral

Please refer the patient to a mental health worker (Psychiatric Nurse,

Psychiatric Clinical Officer, Psychologist, Psychiatrist) at closest health
center if the following happens:
• Acute aggressive behavior
• Alcohol withdrawal symptoms
• High suicide risk (SAD PERSONS score >7)
• Hearing voices of people they cannot see (auditory hallucinations)
• Seeing things that others do not see (visual hallucinations)
• Persisting suicidal ideation after 4 sessions of psychotherapy
Management of Alcohol and Substance Use Disorder

Motivational interviewing (brief intervention) for alcohol and substance use:

• Provide personalized feedback to the person about the risks associated
with their pattern of substance use
• Encourage the person to take responsibility for their substance use choices,
and the choice of whether to seek assistance for their substance use.
• Ask the person the reasons for their substance use
• Ask about their perception of both the positive and negative consequences
of their substance use
• Ask about the person’s personal goals, and whether their substance use is
helping them or preventing them from reaching these goals.
• Have a discussion with the person based on the statements about their
substance use, its causes, consequences, and their personal goals, allowing
exploration of apparent inconsistencies between the consequences of
substance use and the person’s stated goals.
• Discuss options for change based on the choice of realistic goals and try
to find a mutually agreed course of action.
• Support the person to enact these changes by communicating your
confidence in them to make positive changes in their life
Management of Mental Health Disorders using Group Support
Psychotherapy (GSP)

What is group support psychotherapy?

Group support psychotherapy (GSP) is a culturally sensitive counseling
intervention that aims to treat depression by enhancing social support,
teaching positive coping skills, and income-generating skills.

201
▪ Group support psychotherapy (GSP) is a culturally sensitive counseling
intervention that aims to treat depression by enhancing social support,
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022
teaching positive coping skills, and income-generating skills.

Figure
Figure 51:53: Structure
Structure of GSP of GSP

10.5.11 Interactions between ARVs and antidepressants

Interactions
Interactions between
between ARVs
ARVs and and antidepressants
antidepressants are summarized in Table 61.

Interactions
Table betweenbetween
59: Interactions ARVs and antidepressants
ARVs are summarized
and common antidepressants, andin Table 61.
recommended management
Table 60: Interactions between ARVs and common
ARV antidepressants,
Antidepressant and recommended
Interaction Management management
Ritonavir Amitriptyline Increased Monitor and adjust amitriptyline dose as
Antidepres-amitriptyline
ARV Interaction indicated Management
sant levels/effect
Fluoxetine Increased ritonavir No dose adjustment required
Ritonavir Amitriptyline Increased ami- Monitor and adjust amitripty-
effects
Efavirenz Bupropion triptyline levels/
Decreased Monitorline
fordose
signs as
andindicated
symptoms of
bupropion effects depression and titrate bupropion dose to
effect effect
Lopinavir/ Bupropion Decreased
ritonavir
Fluoxetine bupropion
Increased
effects
ri- MonitorNofordose
signs and symptoms of
adjustment required
depression and titrate bupropion dose to
tonavir effectseffect
Trazodone Increased Use with caution; if benefits outweigh risk,
Efavirenz Bupropion trazodone
Decreased bu-start withMonitor forofsigns
low dose and symp-
trazodone
levels/effects
Darunavir Paroxetine
propion effects
Decreased
toms of depression and titrate
Titrate paroxetine dose to effect; monitor
paroxetine levels bupropion dose to effect
for response
Sertraline Decreased Titrate paroxetine dose to effect; monitor
Lopinavir/ Bupropion sertraline
Decreased
effects bu-for response
Monitor for signs and symp-
ritonavir Trazodone propion effects
Increased toms
Use with of depression
caution; and titrate
if benefits outweigh risk,
bupropion dose to effect180
Trazodone Increased tra- Use with caution; if benefits
zodone levels/ outweigh risk, start with low
effects dose of trazodone

202
PLHIV in malaria endemic regions are at high risk of complications of malaria. I
children under five years of age, and pregnant women are at risk of severe and comp
malaria. Key Consolidated
malaria control interventions
Guidelines for the Prevention and include
Treatment ofearly diagnosis,
HIV and Aids in Uganda - prompt
2022 and e
treatment with artemisinin-based combination therapies (ACT), use of long-lasting inse
treated mosquito nets (LLINs), indoor residual spraying (IRS) to control the vector mosq
Antidepres-
ARV
and intermittent Interaction Management
sant preventive treatment during pregnancy (IPT). PLHIV (as for the
population) should routinely use LLINs or have access to IRS to reduce their risk of ex
Darunavir Paroxetine Decreased par- Titrate paroxetine dose to
to malaria.
oxetine levels effect; monitor for response
PLHIV who develop malaria Decreased
Sertraline should receive
ser- prompt and
Titrate effective anti-malaria
paroxetine dose to treatmen
ACTs. PLHIV receiving AZT or EFV should,
traline effects if possible, avoid Amodiaquine-con
effect; monitor for response
artemisinin-based combination regimens because of the increased risk of neutropenia
used with AZTTrazodone Increased
and hepatotoxicity when trazo- Use EFV.
used with with IPT
caution;
with if benefits
Sulfadoxine-Pyrimet
done
should not be given to pregnant effectswith HIV
women outweigh risk,
receiving start with lowprophylaxis
Cotrimoxazole
dose of trazodone
8.0 NUTRITION
5.5
CARE AND SUPPORT FOR PLHIV
NUTRITION CARE AND SUPPORT FOR PLHIV
There is a synergistic and cyclical relationship between HIV and under nutrition. HIV
There is a by
nutrition synergistic andnutrient
increasing cyclical requirements,
relationship between HIVfood
decreasing and consumption,
under im
nutrition. HIV affects nutrition by increasing nutrient requirements, decreasing
nutrient absorption, and causing metabolic changes that lead to weight loss and vitam
food consumption,
mineral deficiencies.impairing nutrientstatus
Poor nutritional absorption, and causing
is associated metabolic
with faster HIV disease prog
changes that lead to weight loss and vitamin and mineral deficiencies. Poor
and death.
nutritional status is associated with faster HIV disease progression and death.
Figure 38:
Figure 40:The
Cycle of Under
The Cycle nutrition
of Under andand
nutrition HIV/AIDS
HIV/AIDS

Adapted from Tomkins, Andrew and Fiona Watson. 1989. ‘Malnutrition

and Infection–A review’, Nutrition Policy Discussion Paper No. 5. Geneva:
United Nations Administrative Committee on Coordination Subcommittee
on Nutrition.
Nutrition Assessment Counseling and Support (NACS) is an important
component of comprehensive care for PLHIV. NACS therefore, should be

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

conducted in PLHIV from enrolment and extended throughout the care

continuum.
5.5.1 Steps In Implementing NACS

NACS should be implemented in HIV care settings using the “The Seven
Steps” approach in Table 51.
Table 51: Seven steps approach for implementing NACS
Step Activities
Step 1: Create awareness on benefits of proper nutrition
Nutrition Sensitize clients on how to ensure proper nutrition and mon-
and itoring of nutritional status
health edu-
cation
Step 2: Anthropometry: Take and record the anthropometric mea-
Nutrition surements (weight, length/height, or MUAC) of PLHIV at
assessment each visit.
Routinely monitor and promote growth for children <5 years
Biochemical analysis: Monitor micronutrient deficiencies
such as haemoglobin level. Conduct Lipid profiling for ART
clients annually.
Clinical assessment: Check for signs of under nutrition
including bilateral pitting oedema, wasting, hair changes,
anemia (pale conjunctiva, gums, nails, skin), breathlessness,
and rapid pulse. Assess for symptoms that affect food intake
(diarrhea, nausea, vomiting, anorexia, mouth/throat sores
and oral thrush).
Dietary assessment: Collect information about the types
and amounts of food consumed, appetite, and eating be-
haviours
Living environment: Assess for the cleanliness and sani-
tation of the client’s environment, access to and use of safe
water, food hygiene especially for immune-compromised
HIV patients.
Lifestyle practices: Smoking, alcohol and drug abuse can
affect food intake and decrease effectiveness of some medi-
cations.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Step Activities
Step 3: Classify nutritional status and decide on care plan, see Figure
Nutrition 40.
classifica-
tion
Step 4: Encourage clients to consume a variety of locally available,
Nutrition high-energy and nutrient dense foods; increased feeding
counselling frequency and intake per meal; high-protein intake (especially
animal); frequent hydration; intake of fats and sugar in mod-
eration; exercise, hygiene, and sanitation.
Step 5: Severe acute malnutrition (SAM) with complications
Nutrition Manage in inpatient therapeutic care (ITC) using F75, F100
therapy Severe acute malnutrition (SAM) without complications
Counsel and manage in outpatient therapeutic care (OTC)
using ready to use therapeutic food (RUTF) for children 6-59
months or nutrient rich/enhanced food for older children,
adolescents and adults.
Moderate acute malnutrition (MAM)
Counsel and refer to supplementary feeding program or
livelihood programs
Micronutrient deficiencies
Provide appropriate micronutrient (iron, folate, vitamin A,
zinc) supplements, see The Micronutrient Guidelines for
Uganda, Ministry of Health 2013
Food and drug interactions
Manage complications that affect food intake/utilization,
drug adherence, and efficacy, Integrated Nutrition Assess-
ment, Counselling and Support into Health Service Delivery,
Reference Manual, 2016
Step 6: Follow-up all clients with acute malnutrition
Follow-up Routine and scheduled follow-up for clients on nutrition
for nutrition treatment: where appropriate, synchronize with other ser-
care and vices
support

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Step Activities
Step 7: Link malnourished patients to livelihood and/or supplemen-
Community tary feeding programs where possible
linkage

5.5.2 Dietary Recommendation For PLHIV

HIV increases patient’s energy needs. Encourage patients and devise

strategies for patients to increase energy intake by eating smaller meals (and
snacks) more frequently throughout the day, particularly if appetite is poor.
Adults living with HIV in early/asymptomatic stage need 10% more energy
or about 210 additional kilocalories, equivalent to one additional snack per
day e.g. one mug of porridge.
Adults living with HIV in advanced/symptomatic stages need 20% - 30%
additional energy, which is 420 to 630 kilocalories depending on severity of
symptoms. This is equivalent to 2-3 additional snacks e.g. 2 to 3 mugs of
porridge taken during the day.
Children living with HIV need 10% more energy to maintain growth if the
child is asymptomatic. For children who are symptomatic, the energy needs
increase by about 20-30% more per day. Children who are symptomatic
and experiencing weight loss need between 50% - 100% more energy per
day.
Encourage adequate protein intake from both animal and plant sources. Adequate
protein intake ensures that the body uses protein to build and maintain
muscle mass and support the immune system. Recommended protein intake
for PLHIV is 12%-15% of total energy intake. Protein from animal sources
is of higher quality than from plant sources and tends to have vitamins and
minerals that are more easily absorbed.
PLHIV without fat malabsorption of diarrhea can be encouraged to consume fat in
moderation to help meet their increased energy needs. Recommended fat intake
for PLHIV is 20%-35% of total calories.
5.5.2.1 Nutrition Support for PLHIV

Under nourished PLHIV should be supported with therapeutic/

supplementary foods for the purpose of improving their nutritional status
and treatment outcomes.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Management of Severely malnourished PLHIV

Severely malnourished PLHIV can be managed in Outpatient Therapeutic

Care (OTC) or Inpatient Therapeutic Care (ITC). Patients who require
inpatient care generally have a poor appetite and usually have medical
complications. Thus, the patients will often require treatment for both the
complication and the malnutrition. For children 6-59 months admitted
in ITC, manage them with therapeutic commercial formulas; F75 and
F100. Ready to-Use-Therapeutic food (RUTF) is used in OTC. For older
children, adolescents, and adults, locally made F75 and F100 should be used
and patients are transitioned to nutrient-rich/enhanced family foods after
stabilization phase.
Justification: Adolescents and adults rarely associate wasting or oedema with
their diet except in famine conditions resulting in disbelief that altering their
diet will help them. Even in famine conditions, they are often very reluctant to
eat anything except traditional foods, which they view as perfectly satisfactory.
They are often reluctant to take formula feeds and/or RUTF unless they can
be persuaded that such feeds are a form of medicine. This problem is one of
the most difficult aspects of treating adolescents and adults.
Clients with no appetite should be encouraged to consume smaller amounts
of family food more frequently or sip feeding.
• Explain to the client how to prepare and use nutrient-rich family foods
and locally available fortified blended flour enriched with oil, vitamins and
minerals.
• Counsel on how to modify family foods to improve appetite.
• Counsel on 1) weight monitoring at least once a month, 2) increasing
energy density of home foods, 3) managing HIV/Tuberculosis related
symptoms through diet, 4) managing medicine-food interactions, 5)
sanitation and hygiene, especially safe drinking water.
• Make an appointment for review after 2 weeks of discharge.
Newly identified PLHIV who are severely malnourished should receive
nutrition rehabilitation first before initiation of ART- start treatment
as soon as possible after acute phase – stabilization of metabolic
complications and sepsis or start 14 days after admission in patients
failing to respond.
For undernourished PLHIV who are not able to take food orally, health
workers should administer nasal gastric tube and/or parenteral therapeutic
nutrition.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

HIV infected children with severe acute malnutrition generally respond

slower to nutritional rehabilitation and therefore need close monitoring
when they are started on antiretroviral treatment, they should be monitored
closely in the first 6–8 weeks following initiation of ART to identify early
metabolic complications and opportunistic infections.
Note: Avoid Amphotericin B in SAM patients with HIV because of its
high toxicity.
PLHIV with severe acute malnutrition in whom persistent diarrhoea does
not resolve with standard management should be investigated to exclude
carbohydrate intolerance and infective causes, which may require different
management, such as modification of fluid and feed intake, or antibiotics.
Successful management of the severely malnourished PLHIV requires that
both medical and social problems be recognized and corrected. If the illness
is viewed as being only a medical disorder, the patient is likely to relapse
when they return home.
Refer to Integrated Management of Acute Malnutrition (IMAM)
Guidelines, 2020 for more detailed information on management of
malnutrition
Management of PLHIV with over nutrition (overweight/obese)

PLHIV with BMI greater than 30 should be counselled on how to reduce

weight without compromising their nutritional status by:
1. Controlling energy intake by increasing intake of low- energy foods
such as vegetables and high fiber diets; whole grains are excellent
sources of fiber and nutrients essential for weight control.
• Restricting intake of sugar, fats and oils, and salt.
• Excess intake of fats/oils and sugar increases the risk of overweight/
obesity.
• Excess intake of salt increases the risk of high blood pressure
• Reduce intake of processed drinks like sodas and sugar added drinks
• Read food labels to be able to make healthy food choices
2. Increasing daily water intake.
3. Ensuring regular exercise/physical activity.
• Adults should engage in 30mins of moderate intense physical activity
per day.
• Children and adolescent should engage in 60mins of moderate intense
physical activity per day

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• Examples of moderate intense physical activities include walking,

climbing stairs, domestic work, gardening, jogging, aerobics, cycling
and sports.
4. Ensure regular medical check- up.
Regular medical check-up is crucial for the benefit of general wellbeing and
overall health as it helps to detect any upcoming health issues that can be
diagnosed and treated properly. It is therefore important to go for regular
medical check-up every 6 months for:
• Body Mass Index
• Blood pressure
• Blood sugar levels
• Cholesterol levels
• Cancers like, breast, prostate, cervical
Figure 39: Algorithm for nutrition assessment, classification, and care plan of acute
Figure
malnutrition41: Algorithm for nutrition assessment, classification,
and care plan of acute malnutrition
Classification
Assessment Classification
and Action
Plan
Nutrition Assessment Severe acute malnutrition (SAM) SAM with medical
2 Check for bilateral Bilateral pitting oedema (any grade) complication
pitting oedema OR OR bilateral oedema
3 Measure MUAC WFL/H/BMI for age <-3 z-scores +++
Follow up
4 Measure weight and Adults: BMI<16 OR infant less than 6
every 1-2
length/height and for OR months (manage in
weeks
children interpret the MUAC ITC)
growth curve 6 to 59 months <11.5 cm
5 Determine the WFH 5 to <10 years <13.5cm SAM with no
for children less than 5 10 to <15 years <16.0cm medical complication
years 15 to <18 years<18.5cm Passes appetite test
6 Determine the BMI for Adults 18 years and above: <19.0 cm on RUTF, (manage in
age for children 5 to 19 Pregnant/lactating women: <19.0 cm OTC)
years Elderly 60 years and above: <16.0 cm
7 Determine the BMI for
adults Moderate acute malnutrition
8 Assess for medical (MAM)
complications No bilateral pitting oedema
WFL/H/BMI for age ≥ -3 and < -2 z-
score
Adults BMI ≥ 16 and <17OR MUAC
6 to 59 months: ≥11.5 to<12.5 cm For all MAM manage
5 to <10 years: ≥13.5 to<14.5 cm Follow up
in SFP
10 to <15 years: ≥16.0 to<18.5cm every 1-2
15 to <18 years: ≥18.5 to < 21.0 cm weeks
Adults 18 years and above: ≥ 19 to
and <22.0 cm
Pregnant/lactating women: ≥19 to
<23.0 cm
Elderly 60 years and above: ≥16.0to
≤18.5cm

No acute malnutrition
Weight gain parallel to or greater Encourage and
than the median growth curve counsel on good
WFL/H ≥ -2 z-scores nutrition
OR MUAC
6 to 59 months: ≥12.5cm
5 to <10 years: ≥ 14.5cm
10 to <15 years: ≥ 18.5cm
15 to <18 years: ≥21.0 cm
Adults 18 years and above: >22.0 cm
Pregnant/lactating women: ≥23.0 cm
159

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

5.6 SEXUAL AND REPRODUCTIVE HEALTH

SERVICES
5.6.1 Screening and Management of Sexually Transmitted
Infections (STIS)

STIs often coexist with HIV and are known to increase the risk of HIV
transmission. On the other hand, HIV may alter the natural history of STIs
by increasing recurrences and severity of STIs. The prevalence of STIs
among HIV positive patients on ART and those not on ART is similar. It is,
therefore, important to screen and appropriately manage STIs irrespective
of whether the patient is on ART or not. All pregnant women living with
HIV should have a syphilis test (RPR and/or TPHA) at the first antenatal
visit.
STI Screening Tool

All HIV-infected sexually active adults and adolescents should be screened

for STIs at every clinic visit. The client should be asked about the following
syndromes and if the answer is yes, explore related symptoms and treat
according to Uganda syndromic management chart (Table 52).
Table 52: STI screening tool
Syndrome Key Symptoms
URETHRAL • Discharge from the urethral opening or vagina
DISCHARGE • In men, blood in the semen or urine
• Difficulty starting urination
GENITAL For men: a genital sore is any sore or lesion that appears
ULCER DIS- on the
EASE • Penis
• Scrotum
• Urethra
• Perineum
• Anal and perianal region
For women: a genital sore is any sore or lesion that
appears on the
• Skin surrounding the vulva,
• Labia
• Vagina
• Perineum
• Anal and perianal region

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

ABNORMAL Fungal cause:

VAGINAL • Vaginal discharge that is thick, white, cheesy
DISCHARGE Bacterial cause:
• Vaginal discharge that is white, gray, or yellow and may
have a fishy or foul odor
LOWER AB- • Dull pain in the stomach or lower abdomen
DOMINAL • Pain during sex
PAIN (PID)

STI Management

Uganda adopted the syndromic approach to the management of STIs,

National STI Treatment Guidelines, 2009/2010 (see Annex 8).
Cervical Cancer Screening

Over 90% of the incident cervical cancer cases occur in the less-
developed regions of the world, where access to prevention,
screening, and treatment services are severely limited. In Uganda,
cervical cancer contributes 6,959 (20%) of the new  global  cancer
cases annually  and  4,607  (20%)  of   all  global  cancer  deaths  annually. 
It is the leading cause of  cancer related deaths in Uganda for all sexes
combined.  HPV is the recognized necessary cause of 99.7% of all
cervical cancers and is sexually transmitted.  Women living with HIV
have a higher risk for cervical cancer  compared to their counter parts
that are HIV negative. Cervical cancer screening using HPV testing is the
primary cervical cancer screening method in Uganda .. Additionally visual
inspection with acetic acid (VIA)where HPV testing is not available or Pap
smear for especially post-menopausal women is also recommended .The
cervical screening should be repeated every three years. Patients with pre-
cancerous cervical lesions should be managed using Ablative (destroying
abnormal tissue by heating it with thermal coagulation or freezing it with
cryotherapy) or Excisional (surgically removing abnormal tissue with LEEP
(Loop Electrosurgical Excision Procedure) or cold knife conization (CKC)

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Table 53: Eligibility criteria for cryotherapy/

thermocoagulation
Eligibility • Positive screening test for cervical pre-cancer
criteria •  Lesion small enough to be covered by the cryoprobe, with
no more than 2mm beyond its edges
• The lesion and all edges are fully visible, with no extension
into the endocervix or to the vaginal walls
• If the woman has recently delivered, she is at least six
months postpartum
Exclusion • Evidence or suspicion of invasive disease or glandular
criteria dysplasia*
• The lesion extends more than 2mm beyond the cryoprobe
edges
• The lesion extends into the endocervix*
•  Pregnancy*
• Pelvic inflammatory disease (until treated)
•  Active menstruation

If lesion is more than 2mm beyond its edges use LEEP

* Refer for further management
Prevention of cervical cancer

Cervical cancer is caused by the Human Papiloma Virus (HPV). The HPV
vaccine is more effective for young girls and young women before  the
onset of sexual activity. In Uganda, girls aged 9-15 years are eligible for
vaccination. Currently, HPV vaccination is not recommended for adolescent
boys because it is not cost effective. Table 42: HPV vaccine and dosing
schedule describes the available HPV vaccine.
Table 54 HPV vaccine and dosing schedule
    Quadrivalent vaccine
Manufacturer: Trade name  Merck: Gardasil®
 Virus-like particles of genotypes: 6, 11, 16, 18
 Dosing schedule: 0, 2, and 6 months
 Recommended age at first dose:  Females: 9–15 years

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

5.8 VACCINES FOR PEOPLE LIVING WITH HIV

All HIV-exposed/ infected infants and children will receive the routine
vaccinations as recommended by UNEPI.
BCG VACCINE
All HIV-infected and exposed children should be immunized as per EPI
immunization schedule. However, when considering BCG vaccination at a
later age (re-vaccination for no scar or missed earlier vaccination), exclude
symptomatic HIV infection. Children with symptomatic HIV infection
should not receive BCG.See Section 4.8.2.
HBV VACCINE
Offer HBV vaccine to all people regardless of HIV status in endemic areas.
See Section 6.10.
HPV VACCINE
Adolescents aged 9 to 15 years will receive the HPV according to the national
recommendation (See section Section6.14.2).
YELLOW FEVER
Yellow fever is endemic in most of sub-Saharan Africa. Yellow fever vaccine
is a live attenuated vaccine. It can be given to HIV-positive patients with CD4
count >200 cells/mm3.Itis recommended during yellow fever outbreaks and
for those intending to travel to high-risk areas for yellow fever. The single
vaccine gives lifetime coverage.
Box 8: Key highlights in Care and Support for people
living with HIV.

• PLHIV should be educated, encouraged and supported to improve

their nutrition, regularly assessed and screened for malnutrition and
linked to appropriate management. PLHIV should be encouraged to
practice proper personal and food hygiene and ensure water safety.
• PLHIV with Advanced HIV disease (CD4<200cells/mm3, WHO stage
3 and 4) should be screened for OIs ( especially TB and Cryptococcal
Meningitis) and appropriately receive prophylaxis or treatment before
initiation of ART. Initiate treatment for diagnosed OIs and defer ART
initiation for at least 2 weeks to decrease risk of IRIS.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• TB/HIV co-infection: If patient is already on ART, start TB treatment

and modify the ART regimen appropriately. If Patient is ART naïve,
start TB treatment and initiate ART 2 weeks after (earlier than 2 weeks
in adult patients with CD4 <50 cells/mm3).
• ARV and/or TB regimen adjustments may be made in the treatment
of TB-HIV co-infection to address drug interactions and ensure
optimization of both the ART and TB medication.
• TB Preventive Therapy (TPT): All PLHIV with a negative TB screen,
and children and pregnant women/adolescent girls with history
of TB contact should be given TPT. Do not initiate TPT and ART
concurrently.
• In children and pregnant women/adolescent girls with exposure
to person with active TB: Initiate TPT immediately and delay ART
initiation or ART optimization.
• In pregnant women/adolescent girls without TB exposure, defer TPT
until 3 months postpartum.
• In PLHIV initiating ART or optimizing ART regimens: defer TPT until
3 months after ART initiation or ART optimization.

5.9 PSYCHOSOCIAL CARE AND ADHERENCE SUPPORT

FOR PLHIV
With implementation of “test and treat”, the need for psychosocial care and
support is more critical to enhance adherence, retention and viral suppression.
This section of the guidelines highlights the key interventions to guide
adherence support and provision of psychosocial care. Psychosocial care and
support, including support for behavior change and treatment adherence, is
an essential component of HIV prevention, care and treatment. Those who
are infected often must deal with anger, fear and self-stigmatization because
HIV is a highly stigmatized and life-long, chronic disease. Their partners,
children, and family frequently face grief, bewilderment and high levels of
stress. Psychological and social needs vary, depending on sero-status, stage
of disease, prognosis and other factors. Providing psychosocial support can
bring about behavioral changes in support of prevention, care, and treatment
among people living with HIV, their partners and families.

214
PSS should be provided at both facility and community levels. The med
worker/ counsellor/nurse-counsellor shall
Consolidated Guidelines for the Prevention and beofthe
Treatment PSS
HIV and Aids infocal
Uganda -person
2022 and s
lead in coordinating PSS services both at facility and community level. Th
5.9.1 Who Should Provide Psychosocial Support (PSS) to
person shall be responsible for:
PLHIV?
1. Ensuring PSS services are well coordinated within the fa
PSS should be provided at both facility and community levels. The medical
community.
social worker/ counsellor/nurse-counsellor shall be the PSS focal person and
should2. take
A lead
strong and effective
in coordinating referral
PSS services both and linkage
at facility system is establ
and community
level. Themaintained
PSS focal person shall be responsible for:
1. Ensuring PSS services are well coordinated within the facility and
3. Documentation of PSS services is accurately done.
community.
2. 4. A strong and effective
Ensuring referral andfor
routine reporting linkage system is established and
PSS services.
maintained
5. PSS services should be provided by a multi-disciplinary team tha
3. Documentation of PSS services is accurately done.
with the
4. Ensuring client
routine throughout
reporting for PSSthe process of care as shown in Figure 55
services.
5. PSS services should be provided by a multi-disciplinary team that
interacts with the client throughout the process of care as shown in
Figure 52: Who to provide Psychosocial Support Services to PLHIV
Figure 55 below.
Figure 54: Who to provide Psychosocial Support Services to PLHIV

For the facility to offer comprehensive PSS services, the health facility should
ensure effective bi-directional linkages between the facility to the community
and vice versa.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

5.9.2 Psychosocial Care and Support Service Package

The following package of services is recommended to ensure provision of

comprehensive psychosocial care for PLHIV:
• Psychosocial screening and assessment.
• Health education.
• Adherence preparation, monitoring and support.
• Counseling and psychotherapy.
• Mental health screening and support.
• Positive Health Dignity and Prevention (PHDP).
• Family /Social support.
• Care and support for GBV Survivors.
• Nutritional care and support.
• Referral and Linkage:
• Other specialized health care
• Socio-economic support
• Legal support and the fight against discrimination
• Spiritual support
• OVC services
This package should be offered in the context of clients’ differences related
to culture, gender, age, and the vulnerabilities of people with HIV-particularly
among children, adolescents, and women.
Table 61: Minimum Standards for Providing Psychosocial
Support Services
Standard What should be done
S1: All health • Create space within the health facility to provide
facilities should room for screening and provision of individual and
provide a group psychosocial support.
conducive • Ensure privacy.
environment • Arrange the PSS service space to suit different
both physical population categories (adolescents, men, children,
and social women).
for providing • Organize the HIV/ART care points client flow to
psychosocial include psychosocial support.
support • Ensure a safe and confidential filing, record keeping
and storage system.
• Provide relevant supplies and logistics for providing
PSS (play materials, job aids, edutainment etc).

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Standard What should be done

S2: All PSS • The health facility management should ensure that:
service providers • All PSS service providers are trained in PSS
should have the according to national standards.
competences to • Health workers are mentored and supervised
deliver quality regularly to keep their skills updated.
PSS services • Health workers have the required job-aids and
tools to enable them provide PSS to all categories
of populations including children, adolescents,
pregnant women, and key populations.
• PSS should be provided following MOH approved
standard approaches for different sub-populations
• Determine the relevant approaches for providing
PSS (Individual, couple or group approach).
• Create or make referrals to peer support groups/
clubs for provision of PSS.
• Integrate PSS services in all health-related plans
and routine health care services.
• Offer PSS services in community settings
following a targeted approach especially for
priority populations.
• Identify and support a focal person to oversee PSS
service provision.
S3: All health The health workers should assess clients PSS needs
care providers using standard screening and assessment tools. These
should routinely include:
assess clients • PHQ-2 Depression screening tool
for PSS needs • GBV screening tool
and provide • HEADSS tool
appropriate care • OVC Screening tool
and support
to PLHIV as
an integral
component of
comprehensive
HIV prevention,
care, treatment
and support

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Standard What should be done

S5: All Health • Document and report PSS services using MOH
Facilities approved tools. Key tools include HIV Care/ART
shall use data Card, ART Register, Linkage and Referral Register,
collected to Referral and Linkage form, Peer Psychosocial
improve the support Tracking Log and HMIS 106a.
quality of PSS • Develop SOPs to guide documentation and
services of HIV reporting of PSS services.
care services • Conduct periodic internal data reviews to ensure
data quality.
• Utilize PSS data for continuous quality improvement.
S4: All health • Establish intra and inter facility referral and linkage
facilities should systems for psychosocial issues which the provider
establish and may not have capacity to address.
maintain an • Establish referral network from the facility to other
effective referral community services.
and linkage • Ensure availability of a service directory for different
system for PSS services within the health facility catchment
provision of area. The directory should specify name of provider,
a minimum services offered, contact person, address of provider,
package of PSS costs (if involved) and service time.
services for • The PSS focal person remains the designated focal
PLHIV person for referrals and linkages.
• Avail and mentor PSS providers on the use of
approved documentation tools (Community-facility
referral and linkage register and the Comprehensive
HIV Referral Form).
• Routinely document all facility-community and
community-facility referrals and feedback in
approved tools.
• Establish and strengthen feedback mechanisms
(phone calls, physical follow up, etc).
5.9.3 Adherence Preparation, Monitoring and Support

Good adherence to ART is key for sustained HIV viral suppression, reduced
risk of drug resistance, improved overall health, quality of life, and survival,
as well as decreased risk of HIV transmission. Conversely, poor adherence
is the major cause of ART treatment failure. Adherence should be routinely

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assessed and reinforced by everyone in the clinical team (physicians,

counselors, nurses, pharmacists, peer educators,etc.) at each of the patient’s
visits to the clinic. This section will cover how to prepare patients for ART,
and monitor and support them to adhere to ART.
ADHERENCE PREPARATION
Preparing people to start antiretroviral therapy (ART) is an important step
to achieving ART success. Healthcare providers should initiate a detailed
discussion about the willingness and readiness of patients to initiate ART.
However, the choice to accept or decline ART ultimately lies with the person
or his or her caregiver. If they choose to defer initiation, ART can be offered
again at subsequent visits.
Health workers should provide information on circumstances where delays
in starting ART can have negative consequences, particularly for people with
tuberculosis (TB), advanced immune suppression, and/or who are at high
risk of death. The healthcare team should use the 5As principles for chronic
care as a guide to offer pre-ART adherence counseling and psychosocial
support. These are Assess, Advise, Assist, Agree and Arrange Table 62.
Table 62: 5As for adherence preparation support
Guide Components
Assess Goal: To assess patients’ knowledge of HIV,ARVs and
potential barriers to adherence
1. Knowledge about HIV and ARVs
2. Myths and misconceptions about HIV and ARVs
3. Potential barriers to adherence
4. Patient psychosocial concerns and needs that may
hinder adherence to ART
5. Patient willingness and commitment to take medicines
correctly
6. Patient readiness to honor subsequent appointment for
treatment support
7. Patient’s support systems at family and community level
8. Disclosure status and implications

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Guide Components
Advise Goal: To provide the patient with knowledge about HIV/
(information ARVs to enable themdecide to initiate treatment
giving) • Give information about HIV and ARVs
• Provide information on adherence to ART. Include
information on the 5 Rs (taking the right medicine, at
the right time, right dose, right way, and right frequency)
• Demonstrate how the ARVs are taken
• Provide information about side effects of ARVs,
improved quality of life while on ART, changes that may
occur in a person’s life once on treatment
• Explain the benefits of disclosure and support systems
to adherence
• Explain to the patient how often they will be monitored
once on treatment; other ways of assessing adherence
and response to treatment including pill counts
• Emphasize the importance of attending all the clinic
appointments for review and support
• Discuss the Positive Health, Dignity, and Prevention
package
• Explain the implication of not adhering to ARV treatment
• Explain what VL test is and the meaning of suppressed
and unsuppressed viral load
Assist Goal: To support client identify possible barriers and
consider different options of dealing with the barriers.
The client:
• Evaluates the possible barriers to adherence and how to
overcome them
• Identifies the support systems that will enable the client
to take his drugs and to regularly come to the facility such
as treatment supporter, social support groups
• Consider disclosing to a trusted person of their choice
such as a treatment supporter, social support group, etc.

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Guide Components
Agree on Goal: To guide the client to develop a realistic individual
adherence plan. The client considers and where possible
documents:
An adherence plan (Table 47)
Family and community support systems (expert client in
the community)
Possibility of home visit and consent
Possibility of testing other family members including
sexual partner and children
Assess client’s readiness to start ART (see Table 48: ART
readiness assessment form)
Arrange for • The patient to see a clinician for ARV prescription if
they are ready to start ART
• Follow-up adherence counseling and psychosocial
support sessions
• At one month for patients who have initiated ART
• At agreed time but probably a week for those who
were not ready for ART at theinitial visit
1. The patient to join psychosocial support groups and
use support systems
2. Follow-up appointments (home visiting where
appropriate, phone call reminders and text messages
where appropriate)
3. Monthly counseling sessions for drug adherence.
4. Reviewing the action plans at every encounter
5. When to bring other family members for testing
6. Supported disclosure where it has not happened

Table 63: Checklist for developing an adherence plan

Question
• How many pills of the medicine will you take/give per day?
• (client demonstrates as you observe)
• What time will you take/give the medicine?
• How will you remember to take/give the medicine?
• Where will you keep the medicine?

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Question
• What will motivate you to take/give the medicine?
• Whom have you disclosed to/plan to disclose to?
• Who is your or your child’s treatment buddy?
• Who will pick your/your child’s medicine if you cannot come to the
clinic?
• How will you ensure you keep your appointments as scheduled?
• What challenges/factors may affect your adherence? (Explore for non-
disclosure, alcohol and substance abuse, sexual partner(s), and stigma)

Table 64: ART readiness assessment checklist

A. Psychosocial/knowledge criteria (applies to
Yes No
patients and caregivers)
1. Understands how HIV affects the body and benefits
of ART?
2. Has screened negative for alcohol or other drug use
disorder?
3. Is willing to disclose/has disclosed HIV status to a
sexual partner and significant other?
4. Has received demonstration of how to take/administer
ART and other prescribed medication?
5. Has received information on predictable side effects
of ART and understands what steps to take in case of
these side effects?
6. For patients dependent on a caregiver: caregiver is
committed to long-term support of the patient, daily
administration of ART, and meets the criteria above?
7. Other likely barriers to adherence have been identified,
and there is a plan in place to address them (e.g.
frequent travel for work, plan to deal with unexpected
travel, distance from clinic, etc.)?
8. Patient/caregiver has provided address and contact
details?
9. Patient/caregiver feels ready to start ART today?

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10. Has identified convenient time/s of the day for taking

ART?
11. Has treatment supporter been identified and engaged
in HIV education, or will attend next counseling
session?
12. Is aware of the support group meeting time/s?
13. Has enrolled into SMS reminder system? (If facility
has reminder system)
14. Are other support systems in place or planned (e.g.
setting phone alarm, pill box)?
15. Patient newly diagnosed with TB:
Start TB treatment
Defer ART until 2 weeks after starting TB treatment
16. Patient diagnosed with cryptococcal meningitis
or has symptoms consistent with cryptococcal
meningitis (headache, the presence of seizures, altered
consciousness, photophobia, neck stiffness, and a
positive Kernig’s sign):
Treat cryptococcal meningitis
Defer ART until 4-6 weeks after initiating treatment for
cryptococcal meningitis

5.9.4 Monitoring Adherence to ART

Adherence to ART requires life-long assessment and monitoring and should

be part of each clinic visit, as factors that influence adherence are dynamic
and require different approaches to address them as they change over time.
A combination of methods to assess adherence is recommended as below.
Viral Load Monitoring

Viral load monitoring is considered the gold standard for monitoring

adherence and confirming treatment response. All HIV-infected patients
should receive a viral load test 6 months after initiating treatment and annually
thereafter. Following an initial high viral load (>200 copies/ml and >400
copies/ml) for plasma and DBS samples respectively), enhanced/intensive
adherence counseling should be carried out before conducting a repeat viral
load test.

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• Three consecutive IAC sessions with scores >95% is recommended

before a repeat VL test is done.
• However, if scores persistently remain <95%, then initiate a Directly
Observed Therapy or treatment supporter at the 4th, 5th, and 6th IAC
session and conduct a repeat VL thereafter.
• Irrespective of the adherence scores at the 6th IAC session, conduct
a repeat VL where two samples are withdrawn with an anticipation of
conducting HIV DR in case the repeat VL result is unsuppressed.
Self-Reporting

Self-reporting is rapid, inexpensive, easily carried out in clinical settings and

is frequently used in routine care. It involves asking questions regarding
missed doses to establish adherence. It is essential that these questions be
posed in as non-threatening and sensitive a way as possible. All patients,
especially adolescents should be encouraged to speak openly, and they should
be reassured that many people find it difficult to take all their medications.
When using self-report, use the four guide questions to determine adherence
and reasons for not adhering to ART (Table 65).
Table 65: Question guide for reviewing an adherence plan
Question
1. How many times do you take drugs in a day?
2. What time do you take it?
3. How many doses have you missed in the past month?
4. What are the reasons for missing your drugs?
Use the number of missed ARV doses in the past month to determine
adherence level and appropriate action (Table 66).
Pill Counting

This approach compares the actual to the expected consumption of ART

since last dispensed by the pharmacy. The effectiveness of pill counting is
limited by the fact that patients may discard tablets not taken before their
routine clinic visit leading to overestimated adherence. Pill count performs
better when combined with self-reported adherence.
Using pill counts to determine adherence levels
Count the number of pills the patient has in the medicines bottle.

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Determine the number of pills the patient should have taken since the last
clinic visit.
Compute the percent adherence using the formula below:
% adherence=
After computing % adherence, use Table 66 to determine the adherence level
and support the client accordingly.
Table 66: Determining adherence levels from self-report and
pill count and recommended action
Missed doses per
months
Once Twice Percent Adherence Recommended
daily daily adherence ranking Action
dosing dosing
Review adherence
plan
<2 doses ≤ 2 doses ≥95% Good
Support to continue
adhering well.
2-4 doses 4-8 doses 85–94% Average • Address the causes
≥5 doses ≥9 doses <85% Poor of average/poor
adherence
• Review adherence
plan
Note: Adherence >105% could imply potential drug sharing or other
inconsistencies in dosing and should be investigated.
What should be done in case a PLHIV forgets taking his or her dose; -The
principle of drug half-life should apply.
For drugs taken twice a day, take the forgotten dose within 6 hrs of
remembering. For drugs, taken once a day, the forgotten dose can be taken
within 12 hrs of remembering. Beyond 6 and 12 hrs respectively for defer the
forgotten dose and continue with the next dose.
Pharmacy Refill/Clinic Records

Adherence can also be assessed by viewing the patient’s clinic and pharmacy
records. Such records document if and when a patient or caregiver
collected their ARVs; irregular collection may indicate adherence challenges.

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Additionally, computerized pharmacy records assist health managers to

assess the overall adherence. Pharmacy records are more reliable than self-
reporting if documentation is accurate.
5.9.5 Adherence Support

Adherence support interventions should be provided to people on ART. The

following interventions have demonstrated benefit in improving adherence
and viral suppression:
• Adherence counseling: This is a one-on-one interaction between the client and
health care provider aimed at helping the client identify barriers related to
their adherence and develop strategies to overcome the identified barriers.
• Peer support system: This enables clients to learn from each other’s
experiences and to cope better with the disease. A peer is a person who
shares similar characteristics with a particular group of people. In HIV
care, peers include mentor mothers in the eMTCT
• program, adolescent peer supporters (YAPS), expert clients and other
peers as patients and caregivers usually relate better to peers. Peer support
can be provided either in form of peer counseling or peer support groups.
• Mobile phone calls and text messages: These should be used with the patient’s
or caregiver’s consent. The patient or caregiver should provide the
appropriate phone numbers to avoid accidental disclosure when messages
are sent to a wrong person.
• Reminder devices like calendars, pill boxes, cell phone alarmsand diaries
can be used by clients.
• Behavioral skills training and medication adherence training: These
include module-based interventions and those designed to improve life
skills, attitudes, behavior and knowledge.
• Fixed-dose combinations and once-daily regimens: When available,
health-care workers should prescribe fixed dose combinations because
they reduce the pill burden. If once daily regimens are available and
recommended, they should be used.
• Use of treatment buddies(supporters): This is an individual identified by the
client to take on the role of a treatment supporter. This person reminds/
gives the client their medication whenever it is time and reminds them of
their refill dates.
• Directly observed therapy (DOT):, the recipient of care takes/ swallows drugs
under the observation of a second person who is chosen in consultation
with the client. This can be a health care worker, peer supporter etc.
• Peer-led dialogues: These include group discussions among clients. They
could discuss the challenges they face and come up with possible solutions.

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5.9.6 Intensive Adherence Counseling and Support for

Patients with Detectable Viral Load

Intensive Adherence Counseling (IAC) and support refers to a targeted

and structured counseling and support intervention offered to patients on
ART with a non-suppressed viral load (patients with viral load >200 and
>400 copies/ml respectively for plasma and DBS samples). IAC is offered
systematically and routinely as per scheduled appointments; one month
apart. IAC helps a client develop a comprehensive plan for adhering to ARVs
by identifying their barriers to adherence, gaining insight of the barriers,
exploring possible ways to overcome barriers and planning to adhere to
medicine. Provision of IAC requires a multidisciplinary team including
clinicians, nurses, counselors, family members, peers, etc. It may also require
consultations from experts or referrals to address the issues related to stigma,
disclosure, mental health and nutrition.
How to offer IAC

The 5As counseling framework applies to provision of intensive adherence

counseling and psychosocial support. Key messages at every step are
summarized below in Table 67 below.
Table 67: 5As for adherence support for people with non-
suppressed viral load
Guide Components
IAC Session 1
Assess Explain purpose of session
Disclose VL test results to client and explain the meaning of
suppressed and non-suppressed VL
Explain reasons for non-suppressed VL results (non-
adherence to drugs or drugs may not be working well)
Discuss implications of non-suppressed results to the client
Determine adherence levels
Calculate the adherence score using the adherence
percentage formula
Assess client’s barriers to adherence
Use the adherence assessment checklist to ascertain client’s
adherence practices.
Identify barriers to client’s adherence (arising from the
assessment)

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Guide Components
Advise Identify information gaps from assessment
Educate client in relation to specific barriers identified
Review benefits of good adherence
Assess client’s knowledge of benefits
Provide correct and complete information on
Discuss consequences of non-adherence
Assess client’s knowledge on the dangers of non-adherence
Educate client on the consequences of non-adherence
Assist Evaluate the underlying causes of the identified barriers
Prioritize the barriers
Identify possible root causes of each barrier (where
applicable)
Identify client specific strategies to overcome identified
barriers
Discuss possible options to address key barriers
Provide information about available support systems e.g.
CBOs, peer support groups etc
Discuss the pros and cons of each strategy/option
Agree on Agree on client’s action points to address the key barriers
Identify appropriate strategies
Provide relevant and necessary information
Evaluate each action point using the 5 Ws and 1H
What, where, when, who, which, how?
Document agreed upon action points on the IAC session
form
Develop and document a new adherence plan on the IAC
session form

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Guide Components
Arrange Summarize the session
Review the action points
Review the new adherence plan
Arrange for ART refill
Explain the schedule for IAC intervention
Explain the number of sessions
Emphasize appointment keeping
Schedule the 2nd IAC session
Document the next appointment date on the IAC session
form
Remind client to bring remaining pills at next visit
Refer and link to other services as appropriate
IAC Session 2
Assess 1. Assess adherence levels
a. Document the adherence score
b. Compare current score with the previous
3. Assess progress in dealing with barriers
Identify what worked
a. Identify what did not work
b. Discuss new strategies
3. Assess compliance to adherence plan
a. Identify what worked
b. Identify what did not work
c. Discuss new strategies
4. Assess for possible new barriers to adherence
Use adherence assessment checklist
Advise Do as in IAC Session 1
Assist Do as in IAC Session 1
Agree on Do as in IAC Session 1
Arrange Do as in IAC Session 1
IAC Session 3
Assess Do as in IAC Session 2
Advise Do as in IAC Session 1
Assist Do as in IAC Session 1
Agree on Do as in IAC Session 1

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Guide Components
Arrange Review adherence scores for 1st,, 2nd and current IAC visits
• If adherence score is consistently good (>95%) for three
consecutive IAC visits, give 1month appointment for 2nd
VL bleeding
• If adherence score is not consistently good for three
consecutive IAC sessions, give appointment for 4th IAC
session
Guide Components
Give appointment for 2nd bleeding for VL test (After 1
Arrange
month)
Review adherence scores for 1 , 2 and current IAC visits
st, nd

• If adherence score is consistently good (>95%) for three consecutive IAC

• Remind and appointment
visits, give 1month emphasize for 2 to client to keep the next
VL bleeding
nd

• appointment.
If adherence score is not consistently good for three consecutive IAC
sessions, give appointment for 4 IAC session
th

• Flag
Give the client’s
appointment file asfor due
for 2 bleeding
nd
VL testfor repeat
(After 1 month)VL testing (indicate
• Remind and emphasize to client to keep the next appointment.
due date on the red sticker)
• Flag the client’s file as due for repeat VL testing (indicate due date on the
Discuss reminder plans with clients who are due for bleeding
red sticker)
Discuss reminder plans with clients who are due for bleeding
• • Provide ARV drugs for 1 month (strictly)
Provide ARV drugs for 1 month (strictly)
• • Call client
Call client 1 toweek
1 week the dueto
datethe duethem
to remind date to remind them of
of appointment
appointment
Figure 53: Flow-chart for offering IAC to non-suppressed Adult PLHIV
Figure 55: Flow-chart for offering IAC to non-suppressed
Adult PLHIV

11.6.2 Providing Intensive Adherence Counseling and Support to non-suppressed

children and adolescents
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Providing Intensive Adherence Counseling and Support to

non-suppressed children and adolescents

Due to the high levels of pre-treatment NNRTI resistance in Uganda (see

Section 13.14.3), these guidelines recommend optimization of ART for
children. Children and adolescents whose viral load are not suppressed
should receive IAC following the recommendations below:
• All children and adolescents on NNRTI-based regimens with a non-
suppressed viral load:
• Switch immediately to second line ART without waiting for a repeat
viral load result.
• IAC should be initiated immediately and provided monthly.
• IAC should be continued until child/adolescents stabilizes on their
new regimen for a maximum of 6 months.
• Resume routine adherence support aligned to clinic appointments.
• Children and adolescents on DTG or PI-based regimens: DTG and
PIs have a high barrier to resistance, so poor adherence is a more likely
cause for an unsuppressed VL than resistance. Therefore, for children
and adolescents on DTG or LPV/r-based first line regimens with non-
suppressed VL:
• Conduct IAC and repeat VL after 3 months.
• If repeat VL is still not suppressed after 3C good IAC interventions with
scores>95%, conduct HIV DR to guide the next course of action.
• Adherence scores persistently <95%, initiate a Directly Observed Therapy
or treatment supporter at the 4th, 5th, and 6th IAC session and conduct
a repeat VL thereafter.
• Irrespective of the adherence scores at the 6th IAC session, conduct
a repeat VL where two samples are withdrawn with an anticipation of
conducting HIV DR in case the repeat VL result is unsuppressed.
5.9.7 Positive Health, Dignity and Prevention (PHDP)

Positive health, dignity, and prevention (PHDP); also referred to as self-

care, is a set of interventions PLHIV can undertake to keep physically,
mentally and psychologically healthy and as well as prevent transmission of
HIV. PHDP empowers PLHIV to take charge of their prevention, care and
treatment responsibilities.

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Table 68: Positive health, dignity, and prevention intervention

Intervention Description
Preventing HIV PLHIV should be encouraged to adopt safer
transmission sexual practices including abstinence, correct and
consistent condom use. Condom use prevents
HIV transmission, reduces risk of other STIs, and
prevents unintended pregnancies.
Disclosure and PLHIV should actively explore ways of disclosing
partner testing their HIV status to sexual partners, family members
and significant others. Offer provider- and/or
counselor-mediated or supported disclosure as
options for those who do not feel comfortable
disclosing on their own.
Family planning Encourage PLHIV to discuss their reproductive
choices and support them to adopt those which
do not compromise their health. For women who
choose to conceive, link them to eMTCT services.
Alcohol and other Educate on risks of alcohol abuse leading to poor
risk reduction treatment adherence resulting in disease progression,
and the likelihood of engaging in risky sexual
behaviours, placing themselves at increased risk for
acquiring STIs and placing their negative partners at
risk for infection.

5.10 OVC CARE AND SUPPORT

Programming for children orphaned and made vulnerable by HIV/AIDS
contributes to the achievement of an AIDS-free generation by responding to
the social, economic and emotional consequences of the disease on children,
their families, and communities that support them. Health workers therefore
should screen all children and adolescents for vulnerability and appropriately
link them to OVC services within the facility’s catchment area.
A standardized screening tool for vulnerability within health facilities is
provided in Table 69 below.

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Table 69: OVC Vulnerability screening tool

No Question Y N
1 Is child/adolescent enrolled in an OVC Program?
2 Has child/ adolescent had less than two meals on any
day in the last seven days?
3 If school-going, has child/adolescent missed school
in the last 7 days?
4 Does child/adolescent have a non-suppressing Viral
load?
5 Has child/adolescent missed appointment in the last
3 months?
6 Does child/adolescent have signs of abuse,
exploitation and neglect?
Action: If the response is ‘Y’ to any of the questions, link to OVC
Program for an assessment using a Triplicate referral form and document
appropriately

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6. ANTIRETROVIRAL
THERAPY FOR PEOPLE
LIVING WITH HIV
6.1 THE GOAL OF ART
The aim of antiretroviral therapy is to suppress viral load levels amongst
PLHIV to undetectable levels, reduce the risk of morbidity and mortality
associated with HIV, and reduce transmission of HIV.

6.2 COMPOSITION OF ART

Standard ART consists of a combination of at least 3 antiretroviral (ARV)
drugs to maximally suppress the HIV and stop the spread of HIV/AIDS
disease. ART regimens usually comprise a “Backbone” of 2 Nucleoside
Reverse Transcriptase Inhibitors (NRTIs) and a 3rd “Anchor” ARV from
another class (including Integrase Strand Transfer Inhibitors, Protease
Inhibitors, Non-Nucleoside Reverse Transcriptase Inhibitors).

6.3 WHEN TO START ART

ART should be initiated at the earliest opportunity in all people with
confirmed HIV infection, regardless of clinical stage or CD4 cell count.

Rationale for treating all people living with HIV

Since 2013, evidence and programmatic experience have continued to favour

early initiation of ART because it results in reduced mortality, morbidity, and
HIV transmission outcomes.

6.4 THE PROCESS OF STARTING ART

Although the program recommends starting all PLHIV on ART, health
workers should do the following:
• Assess all clients with the Symptom Screen for Advanced Disease Pathway
(Figure 33) any evidence of opportunistic infections (OIs) especially
TB and cryptococcal meningitis. If the patient has TB or cryptococcal
meningitis, ART should be deferred and initiated after starting treatment

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for these OIs as outlined in Chapter 7. Treatment for other OIs and ART
can be initiated concurrently.
• For patients without TB or cryptococcal meningitis, offer ART on the
same day through an opt-out approach. In this approach, patients should
be prepared for ART on the same day according to the guidelines in
Section 7.5.2 and assessed for readiness to start ART using the readiness
checklist (Table 64).
• If a client is ready, ART should be initiated on the same day. If a client
is not ready or opts out of same-day initiation, a timely ART preparation
plan should be agreed upon with the aim of initiating ART within seven
days for children and pregnant women, and within one month for adults.
See Figure 56 for the process of evaluating patients for ART.
• For institutions starting patients on ARTS for research purposes, there
should be a clear post ART access plane for approved drugs but not yet
accessible in the public facilities
• Post-Trial Access: Research institutions should collaboratively work with
its partners to ensure post trial/Research access to efficacious/safe study
HIV treatment regimens for HIV positive clients enrolled for study
purposes until the drugs become available through the national supply
chain. If the
• If a client patients
is ready, canbeafford
ART should prescribed
initiated on the same day.ART regimens
If a client is not but are not
available
ready oron optsthe
outessential
of same-daydrugs list aand
initiation, notART
timely accessible
preparation through
plan the national
should be agreed upon with the aim of initiating ART within seven days for
supply chain system, facilitate access to options of these new generation
children and pregnant women, and within one month for adults. See Figure
drugs
56 for the process of evaluating patients for ART.
Figure 56:toHow
Figure 54: How evaluateto evaluate
patients patients for ART initiation
for ART initiation

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

6.5 FIRST-LINE ART REGIMENS FOR PATIENTS

INITIATING ART
Principles for selecting the ARV regimens (treatment optimization):
The first-line ART regimens for treating HIV infection in Uganda were
selected based on the universal principles:
• Toxicity: regimens with less toxicity are preferred.
• Palatability and pill burden; better palatability and lower pill burden
preferred.
• Increased durability and efficacy.
• Sequencing: spares other available formulations for use in the 2nd line
regimen.
• Harmonization of regimen across age and population.
• Lower cost.
DOLUTEGRAVIR (DTG) is an integrase inhibitor and is recommended
for use as the anchor ARV in the preferred first, second- and third-line
treatment regimens for all recipients of care such as children, adolescents,
men, women including pregnant women, breastfeeding women, adolescent
girls and women of childbearing potential).
RATIONALE FOR USING DOLUTEGRAVIR (DTG)
a. High Circulating levels of resistance to NNRTI-containing First-line
Therapy
NNRTI-containing combinations have been used as first-line regimens
for adults in Uganda since the start of ART services in 2005. However,
there are growing concerns of increasing levels of transmitted drug
resistance, mostly to NNRTIs, in Uganda and elsewhere. A study by
the Uganda Virus Research Institute (UVRI) conducted in Uganda
in 2016/2017 revealed high levels of pre-treatment drug resistance
(PDR) estimated at 15.9% to NNRTIs, exceeding the threshold of
10.0% set by WHO for first line ARVs.
b. Superior Efficacy over Current Standard of Care Regimens
DTG is superior to alternative ARV options and patients can experience
rapid viral suppression, thereby reducing risk of transmitting HIV
while prolonging time on first-line treatment. It has been shown that
patients who receive DTG achieve viral suppression faster as compared
to those who receive EFV.

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c. Better Tolerability
DTG shows improved tolerability versus current preferred regimens
with substantial reductions in treatment-limiting adverse drug reactions.
Specifically, patients can avoid some of the psychiatric adverse events
of EFV (ie depression and suicidal tendencies). Overall, in country
and WHO evidence supports DTG as a highly tolerated medicine that
is less likely to result in treatment discontinuation.
d. Higher genetic barrier to resistance
The higher genetic barrier of DTG means patients are less likely to
develop resistance and therefore postponing the need for superior line
treatment

6.6 SCREENING FOR RISK FACTORS PRIOR TO

INITIATING DGT
DTG is a very well-tolerated drug, with lower overall adverse effects when
compared to other drugs like EFV. Hyperglycemia among previously non-
diabetic adults and worsening of hyperglycemia among diabetics has been
reported among clients on DTG. Although the hyperglycemia associated
with DTG has been reported among clients newly initiated on ART as well
as among those already on ART and transitioned to DTG-based regimens,
the hyperglycemia appears to occur more commonly among the latter group.
Adults being initiated on DTG should be screened for risk factors for
hyperglycemia:
• Age ≥ 40 years
• BMI≥ 24 kg/m2
• History of hypertension
• Known diabetics should not be initiated or transitioned to DTG. Give an
EFV400 or an ATV/r-based regimen.
• Clients with 2 or more risk factors for hyperglycemia and a high baseline
RBS or FBS should not be initiated/transitioned to DTG. Give an EFV400
or ATZ/r -based regimen.
• Clients with 2 or more risk factors for hyperglycemia with normal baseline
RBS or FBS: Initiate or transition to DTG and monitor RBS or FBS every
3 months for 6 months.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Figure 57: Screening Algorithm for PLHIV initiating or

transitioning to DTG

6.6.1 Rationale for Using EFV400

Studies have shown that efavirenz at a dose of 400 mg is not only virologically
non-inferior to Efavirenz 600mg but also has fewer adverse events which
is the major limiting factor of efavirenz use. Fewer adverse events lower
the risk of treatment discontinuation. EFV 400 mg can be co-administered
with Rifampicin-containing anti-TB treatment, with co-administration well
tolerated and plasma concentrations maintained above the levels considered
to be effective. EFV400 is recommended for use as an alternative first line
anchor ARV when DTG is contraindicated.
RECOMMENDED FIRSTLINE REGIMEN FOR INITIATING
ART IN ADULTS AND ADOLESCENTS WEIGHING ≥30kg

All eligible HIV-infected adults and adolescents weighing ≥ 30kg should

be initiated on Tenofovir or tenofovir alefenamide, Lamivudine and
Dolutegravir (TDF + 3TC +DTG or TAF+FTC+DTG) (Table 74).

6.7 WHEN TO USE ALTERNATIVE FIRST LINE

REGIMENS
When to use TDF+ 3TC+EFV400 or TAF+FTC+EFV400

Adults and adolescents should only be initiated on TDF+3TC+EFV400 if

they are ineligible for DTG i.e. Table 74.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• If weight does not allow for use of the currently available DTG
formulations (containing 50mg).
• Diabetic patients.
• An EFV based regimen may also be considered if the client needs
concurrent TB treatment and doubling the dose of DTG is not an option
(See Chapter 6, Table 39 and Table 40).
When to use TDF+3TC + ATV/r or TAF+FTC+ATV/r

Adults and adolescents should only be initiated on TDF+3TC+ATV/r if

they are ineligible for DTG and EFV (Table 74).
When to use ABC+3TC + DTG or TAF +FTC+DTG

Adults and adolescents eligible for DTG should only be initiated on

ABC+3TC+DTG if TDF is contraindicated (Table 74), including the
following conditions:
• Kidney disease and estimated glomerular filtration rate (GFR) below 60
ml/min.
• Adolescents below 30kg of weight.
When to use ABC+ 3TC +EFV400 or TAF +3TC+EFV400

Adults and adolescents should only be initiated on ABC+3TC+EFV400:

• If TDF is contraindicated and they are ineligible for DTG (Table 78).
• If the client requires concurrent TB treatment and doubling the dose of
DTG is not an option (Tables 30 and 31).

6.8 PREGNANT AND BREATSFEEDING WOMEN

NEWLY INITIATING ON ART
Newly diagnosed HIV-infected pregnant and breastfeeding women will be
initiated on Tenofovir tenofovir alefenamide, Lamivudine and Dolutegravir
(TDF+ 3TC + DTG or TAF + FTC + DTG).
6.8.1 When to use Alternative Firstline Regimens

When to use TDF +3TC + EFV400 or TAF +FTC+EFV400

Pregnant and breastfeeding women will only be initiated if DTG is
contraindicated (Table 74).
When to use ABC+3TC +EFV400 or TAF +FTC+EFV400

Pregnant or breastfeeding women should only be initiated on ABC+3TC+EFV

if TDF and DTG are contraindicated (Table 74).

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

When to use TDF + 3TC + ATV/r or TAF +FTC+ATV/r

Pregnant or breastfeeding women should only be initiated on

TDF+3TC+ATV/r if EFV and DTG are contraindicated (Table 74).
PREGNANT AND BREATSFEEDING WOMEN ALREADY ON
FIRST LINE ART

Do viral load test at the 1st ANC/PNC visit:

1. If already on TDF or TAF +3TC+EFV and stable with suppressed
VL, maintain on TDF or TAF +3TC+EFV400 until 6-9 months
postpartum and then transition to TDF or TAF +3TC+DTG if VL
within past 6 months is suppressed.
2. If already on TDF or TAF +3TC+DTG and stable with suppressed
VL, maintain this regimen.
3. If on a first line regimen containing NVP, ABC or AZT and VL at
ANC 1 is suppressed, maintain same regimen and switch to TDF or
TAF +3TC+DTG at 6-9 months postpartum if VL within past 6
months is suppressed.
4. Note: In the case of a pregnant or breastfeeding woman on Abacavir
consider the possibility that she was given the Abacavir because of a
contraindication to Tenofovir. Screen the women carefully for eligibility
for TDF before initiating TLD.
RECOMMENDED FIRSTLINE REGIMEN FOR INITIAT-
ING ART IN CHILDREN WEIGHING BETWEEN 20Kg TO
LESS THAN 30KG (≥20Kg to <30Kg)
RECOMMENDED FIRSTLINE REGIMEN: ABC or TAF
+3TC+DTG
All HIV-infected children weighing between 20kg to less than 30kg should be
initiated on Abacavir or Tenofovir alefenamide + Lamivudine+ Dolutegravir
(ABC or TAF +3TC+DTG) (Table 74)
Rationale for using ABC based regimen as recommended 1st line regimen
Using ABC in first-line regimens spares AZT for use in 2nd line. Also, ABC
or TAF +3TC+DTG can be given as once a day dose which may improve
adherence.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

6.9 WHEN TO USE ALTERNATIVE FIRSTLINE

REGIMENS
When to use ABC+3TC+LPV/r
Children who weigh between 20kg to <30kg should only be initiated on
ABC+3TC+LPV/r if DTG is contraindicated or not tolerated (Table 78).
When to use TAF/3TC/DTG
Patients will be given TAF/3TC/DTG if ABC and AZT are contraindicated.
TAF (when available) should be given to children who are older than 6 years
and weigh ≥ 25kg.

6.10 RECOMMENDED FIRSTLINE REGIMEN FOR

INITIATING ART IN CHILDREN LESS THAN 20KG
RECOMMENDED FIRSTLINE REGIMEN: ABC+3TC+DTG
All HIV-infected children weighing less than 20kg should be initiated on
Abacavir + Lamivudine + Dolutegravir (ABC + 3TC + DTG)
(Table 74)
If DTG is contra-indicated, initiate on Abacavir + Lamivudine+ Ritonavir-
boosted Lopinavir (ABC+3TC+LPV/r).
LPV/r syrup, pellets or tablets should be prescribed/dispensed on
the basis of the individual child’s ABILITY to CORRECTLY take the
specific formulation. As soon as the child is able to take pellets, these
will be prescribed instead of syrup. Likewise, as soon as a child is able to
swallow tablets without breaking, crushing or chewing them, these will be
prescribed instead of pellets.

6.11 WHEN TO USE ALTERNATIVE FIRSTLINE

REGIMENS
All PLHIV on raltegravir should be immediately transitioned to DTG
irrespective of the VL status.
13.11.2 When to use AZT+3TC+DTG or LPV/r
AZT+3TC+ DTG or LPV/r should only be used in children who experience
a hypersensitivity reaction to Abacavir (ABC).

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Table 74: Recommended first-line ARV regimens in Children,

adolescents, adults and pregnant or breastfeeding
women
Patient Cate- Preferred Alternative regimens
gory regimens
ADULTS AND ADOLESCENTS
Adults and TAF + FTC Pregnant and breastfeeding women:
adolescents ≥ + DTG or TDF + 3TC + EFV400 or TAF + FTC
30Kg TDF + 3TC +EFV400
+ DTG
If DTG is contraindicated1:
Pregnant and TAF +FTC TDF + 3TC + EFV400 or TAF + FTC
breastfeeding + DTG +EFV400
women or TDF
+3TC+ If TDFor TAF is contraindicated 2: ABC +
DTG 3TC +DTG
If both TDF or TAF and DTG are contraindi-
cated:
ABC +3TC +EFV400
If EFV and DTG are contraindicated:
TDF +3TC + ATV/r or TAF + FTC +ATV/r
or ABC + 3TC + ATV/r
CHILDREN
Children ABC + 3TC If DTG is contraindicated:
≥20Kg- + DTG ABC + 3TC + LPV/r (tablets)
<30Kg
If ABC is contraindicated:
AZT + 3TC + DTG or
TAF + 3TC + DTG (TAF in children> 6 years
and ≥25Kg)
Chil- ABC + 3TC If intolerant or appropriate DTG formulations
dren<20Kg + DTG3 are not available:
ABC +3TC + LPV/r Granles.
If intolerant to LPV/r:
ABC + 3TC + EFV (in children > 3 years and
>10Kg)
If ABC is contraindicated:
AZT + 3TC + DTG or LPV/r

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

1. Contraindications for DTG (use DTG screening tool prior to 4. Chil-

DTG initiation) including: known diabetics, patients on anticon- dren will
vulsants (carbamazepine, phenytoin, phenobarbital) be assessed
2. Contraindications for TDF: Renal disease and/or GFR individually
<60ml/min, weight <30Kg for ability to
correctly take
3. TAF is preferred to TDF
the different
formulations
of LPV/r

*Refer to Table 78 for complete list of ARV adverse effects/toxicities and

recommended drug substitutions.

6.12 MONITORING RESPONSE TO ART

This chapter provides guidance on how to and when to use clinical assessment
and laboratory monitoring tests to monitor response to ART, ART side
effects and toxicity, and how to diagnose ART treatment failure. The purpose
of monitoring patients on ART is to assess:
• Response to ART and diagnose treatment failure
• Safety of the medicines- side effects and toxicity.
• Adherence to ART
Monitoring adherence to ART is covered in Chapter 11. The visit schedule
and the recommended clinical and laboratory monitoring are in Table 77.
What should be done in case a PLHIV forgets taking his or her dose; -The
principle of drug half-life should apply.
For drugs taken twice a day, take the forgotten dose within 6 hrs of
remembering. For drugs, taken once a day, the forgotten dose can be taken
within 12 hrs of remembering. Beyond 6 and 12 hrs respectively, defer the
forgotten dose and continue with the next dose.
6.12.1 Clinical Monitoring

Clinical monitoring involves taking a medical history and doing a physical

exam. In this section, we shall describe a comprehensive clinical assessment
for patients who are well and are in the fast-track model of differentiated
service delivery.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Table 75: Components of a comprehensive clinical

assessment of PLHIV
Components
1. Demographics (age, sex etc.)
2. Symptom Screen and Advanced Disease Pathway-ask all patients all
questions
3. Screen for signs and symptoms of Hepatitis B and C infections,
malaria, and other infections
4. Screen for pregnancy (women of reproductive age)
5. Screen for co-morbidities especially Hypertension, Diabetes, CA
cervix
6. Screen for STIs
7. Screen for symptoms of depression, anxiety and substance abuse
8. Obtain previous history of ART
9. Obtain previous history of chronic illnesses (hypertension, DM,
COPD, kidney disease)
10. Obtain a list of current medication(s)
11. Screen for side/adverse effects of medications.
12. Establish family planning methods currently in use
13. Assess development, sexual awareness, and behavioral issues in
adolescents
14. Assess school attendance (children of school-going age)
15. Determine progress with disclosure if not done already
16. Perform nutritional assessment: weight and height in all patients,
plus mid-upper arm circumference (MUAC) in children 6-59 months
17. Assess growth and development in children under 5 years; monitor
for changes
18. Ensure examination of vital signs, skin, eyes, oropharynx (presence
of thrush), lymph nodes, lungs, heart, abdomen, genital tract (for
STIs), extremities, nervous system
19. Determine WHO clinical staging
6.12.2 Laboratory Monitoring

Viral load monitoring

Uganda adopted viral load monitoring as the preferred approach for

monitoring response to antiretroviral therapy (ART) and to diagnose/
confirm ART treatment failure, defined as two consecutive viral load results
of >1,000 copies/mL. Compared to clinical or immunological monitoring,

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

virological monitoring provides an early and more accurate indication of

treatment failure and indicates the need to switch from first line to second-
line drugs, and from second- line to third-line drugs, toward reducing
accumulation of drug-resistance mutations and improved clinical outcomes.
Dolutegravir (DTG)-based regimens (e.g., tenofovir/lamivudine/dolutegravir
[TLD]) have increased viral load suppression (VLS) rates to unprecedented
levels, hence a need to actively monitor patients for low-level viremia to keep
DTG a durable treatment option for as long as possible.
Furthermore, low-level viraemia monitoring can enhances monitoring
of achieving and sustaining HIV epidemic control, as viral load of >200
copies/mL is associated with potential risk of sexual transmission as well as
subsequent virologic non-suppression and treatment failure.
Given the above background and taking into consider the 2021 World Health
Organization guidance to monitor low-level viremia, the guidelines have
been designed to carter for health facilities with capacity to utilize plasma and
dried blood spot (DBS) samples at suppression cut off points of 200 copies/
mL and 400 copies/mL respectively, as shown in Figure 58.
A patient who has been on ART for more than 6 months and is responding
to ART is considered virally suppressed at VL <200 copies/mL and <400
copies/mL for plasma and DBS samples, respectively. Facilities should
constitute a multidisciplinary VL review committees to review, track, and
make decisions to optimize ART regimen by switching to second-line, third-
line, or a more potent regimen. At the minimum, the committee should
consist of a healthcare worker and a lay provider (e.g. expert client, counselor,
peer education, VHT) who knows the client.
6.12.3 Frequency of viral load monitoring
1. Children and adolescents under 19 years of age: the first VL test should
be done at 6 and 12 months after initiating ART, if it is suppressed,
every 6 months thereafter. If not suppressed, follow the algorithm in
Figure 58.
2. Adults: the first VL test should be done 6 months after initiation of
ART. The second VL following the first suppressed viral load should
be done at 12 months after initiation of ART and thereafter every 12
months if it is suppressed. If not suppressed, follow the algorithm in
Figure 58.
3. HIV positive pregnant and breastfeeding women: If newly initiated on
ART at ANC, conduct a VL test at 3 months on ART. If VL supressed

245
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

repeat VL every 3 months throughout pregnancy and until cessation

of breastfeeding. If not suppressed, follow the algorithm in Figure 58.
4. HIV-positive pregnant and breastfeeding women already on ART at
ANC1 or MBCP: If HIV+ woman is already on ART at ANC1 or
enrolled at MBCP, conduct a VL test at first ANC or MBCP visit. If
VL is supressed repeat VL every 3 months throughout pregnancy until
cessation of breastfeeding. If not suppressed, follow the algorithm in
Figure 58.
5. After every switch in treatment (after failure): The VL test should be
done at 6 months after a switch to second- and third-line ART.
6. Third line ART patients: The VL test should be done every 6 months.
If VL is un-suppressed, then genotype testing is recommended.
Figure 58: VL testing algorithm for children, adolescents and adults for
Chapterhealth
7 facilities using plasma and DBS samples

For PLHIV with non-suppressed viral load, the following 10- point package
should be applied in all health facilities:
1. Engage multidisciplinary switch team at health facilities to discuss
failing patients.
2. Sort viral load results from the laboratory as suppressed vs non-
suppressed (NS) for rapid action by the ART clinic.

246
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

3. Apply the red stickers for non-suppressed clients to flag non-suppressed

client files.
4. Conduct a first intensive adherence counselling within 7-30 days of
result return.
5. Record IAC sessions on HIV care card to support completion of 3
consecutive IAC sessions.
6. Form viral load focal teams with clinical–lab interface for routine
review of non-suppressed files.
7. Utilization of non-suppressed registers.
8. Integrate viral load monitoring talks into routine health education
sessions.
9. Linkage with community structures for peer support and client tracking.
10. VL CQI site-level initiatives for managing non-suppressed patients.
Genotype testing

HIV genotypic resistance test is a qualitative test that detects mutations

associated with ARV drug resistance. The test evaluates if the HIV strain
infecting the individual has developed resistance to one or more ARV drugs.
This is useful in identifying a combination of ARVs to which the HIV strain is
susceptible. There is documented high level of pre-treatment drug resistance
to Nevirapine and Efavirenz in Uganda (15.4% in the general population and
35.7% among infants of HIV infected mothers).
As a priority, eligible PLHIV on non-DTG based regimens should be
transitioned to DTG and monitored appropriately. In the era of DTG as an
anchor drug with high resistance barrier, genotype testing is the recommended
approach for PLHIV switching from one regimen to a superior regimen after
3-consecutive IAC with scores ≥95% and a non-suppressed repeat VL.
CD4 monitoring

CD4 cell count testing can be performed using point of care technologies
such as laboratory based CD4 analyzers and device -free semi-quantitative
rapid tests. If a CD4 cell count is not readily available onsite, draw a sample
and send to the nearby hub laboratory for testing.
CD4 cell count is recommended in the following scenarios:
• At baseline when initiating ART; Baseline CD4 helps to screen for risk for
opportunistic infections, e.g. cryptococcal infection in patients with CD4
less than 200 cells/mm3.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• ART patients with non supressed VL and/or WHO clinical Stage 3 or 4

disease.
• PLHIV re-engaging in care after interrupting treatment for 3 or more
months.
• PLHIV who are on treatment or prophylaxis for cryptococcal infection to
inform decision on when to stop fluconazole.
Other laboratory tests

Other laboratory tests should be done when clinically indicated (Table 76).
Table 76: Follow-up lab tests and their clinical indication
Test Indication
CrAg (CD4<200cells/mm3)
Urine TB LAM (CD4<200cells/mm3)
Complete blood Patients at risk of anaemic conditions, e.g. patients on
count (CBC) AZT, anti-cancer drugs, chronic renal disease, etc.
Lipid profile If PLHIV has comorbidities (diabetes mellitus,
and blood hypertension) or lifestyle risk factors or on ART for
glucose more than five years or is ≥ 45 years
TB tests If TB is suspected
RFTs: Serum
If PLHIV has comorbidities (DM, hypertension)
creatinine
LFTs: ALT, Compromised liver function, e.g. Hepatitis B or C
AST infection, ART hepatotoxicity

248
Table 77: Follow-up schedule for PLHIV and monitoring components
Before During ART
Time ART
DSD from 6 months After 12 months on ART
Baseline 1 month 2 months 3 months 6 months 9 months 12 3 monthly 6 monthly 12 monthly
months
Clinical assessment
Comprehensive clinical X X X x X X x X X x
assessment (Table57)
Prepare for ART (refer X
to Section 7.5)
Assess readiness for ART X
(refer to Section 6.5)
Provide CTX X X X x X X x x** x** x**
Provide FP if required X
Assess for drug X X x X X x X X x
intolerance, side effects/
toxicities
Assess for Immune X X x X
reconstitution
inflammatory syndrome
(IRIS)
Adherence assessment, X X x X X x X X x
monitoring, and support
ART and CTX refill X X x X X x X X x

249
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

(in children adjust dose

based on weight)
FP refill X X x X X x X X x

250
TB Screening X X X x
Follow up review: If the patient is clinically well:
Give ONE month refill X X x
and appointment
Give THREEmonths X X x X
refill and appointment
Laboratory tests
Viral Load x* x* x** x
CD 4 X
HBsAg, X
CrAg if CD4 <200, X
TB LAM if CD4 <200, X
FBS/RBS (especially X x X X X X
adults at risk on DTG)
LFTs X
Do other lab tests if X X X x X X X X X x
clinically indicated (Table
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

58)
Cervical cancer screening x
x* If VL is not suppressed, call the patient back for intensive adherence counseling
x** This is to be done in children, adolescents, pregnant and breastfeeding women
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022
Figure 57: Monitoring patients initiated or transitioned to DTG
Figure 59: Monitoring patients initiated or transitioned to
DTG

6.13 PHARMACOVIGILANCE
13.15 WHAT TO EXPECT IN THE FIRST MONTHS OF ART
Pharmacovigilance (PV)commitment,
Although ART is a lifelong is defined by
thethe
firstWorld
monthsHealth Organization
of therapy are especially(WHO,
2006) as the science and activities relating to the detection, assessment,
important.
understanding,
• Clinical andand prevention
immunological of adverse
improvement effects
and of medicines
viral suppression or any other
are expected
when individuals adhere to ART.
medicine related problem.
This• section recommends
Opportunistic infections heightened
(OIs) and immunepharmacovigilance, re-emphasizes
reconstitution inflammatory
the systems in place for reporting and monitoring drug safety.
syndrome (IRIS) may develop, as well as early adverse drug reactions, such as
drug hypersensitivity, especially in the first three months of treatment.

IMPORTANT OF PV
• ART significantly decreases mortality overall, but death rates are also highest
in the first three months of ART. These complications are most common when
Approval of new
the people medicines
starting for use
ART already is advanced
have based onHIV thedisease
information
with severefrom the
pre-approval studies. However,
immunodeficiency and existingthese studiesand/or
coinfections cannot identify allseverely
comorbidities, the possible
adverselowoutcomes
hemoglobin, lowa body
that drugmass
mayindex,
cause,and
andvery low CD4
several cell counts orside
unexpected are effects
severely malnourished.
manifest during clinical use which must be monitored, and managed. Health
workers
• More must therefore
frequent make
visits and effortcan
monitoring tohelp
monitor/detect, understand causes,
reduce this mortality.
report,
• Poormanage and mitigate
adherence theseisreactions
in this period (pharmacovigilance).
also associated with the risk of early
treatment failure and rapid development of drug resistance.
Toxicities may occur at any time during treatment. Toxicities or adverse drug
reactions refer to unintended harmful events due to exposure to medicines.
They may be mild to severe and should be anticipated and monitored in a
timely manner to avoid severe morbidity and mortality outcomes. Adverse
drug reactions may negatively affect treatment uptake, adherence and
retention in care.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

MAJOR AIMS OF PV
a. Early detection of previously unknown adverse reactions and
interactions.
b. Detection of increase in known adverse drug reactions.
c. Identification of predisposing risk factors and possible mechanisms
underlying adverse reaction.
d. Estimation of quantitative aspects of risk/ benefits analysis and
dissemination of needed information to improve drug prescribing, use
and regulation.
METHODS OF PV

There are different methods of PV which include Spontaneous reporting

and Active pharmacovigilance however, the method approved for HIV and
TB implementing site is active pharmacovigilance.
Figure 63: Steps and key players in Pharmacovigilance

PHARMACOVIGILANCE
14.5 PHARMACOVIGILANCE STRATEGY FOR
STRATEGY FOR THETHE
ART ART PROGRAM
PROGRAM IN
UGANDAIN UGANDA
The program adopted active PV as part of the routine standard of care in all HIV and
The program
TB facilities. The adopted
strategy foractive
activePV as part of theshall
PV implementation routine
applystandard
in all HIVof
andcare
TB in all
clinics,and
HIV and TB
will facilities.
include: The strategy for active PV implementation shall apply
• Screening for any suspected ADRs as per screening tool at triage area
in all HIV and TB clinics, and will include:
• Clinical evaluation of the reported signs and symptoms
• Screening
• Baseline for any suspected
Laboratory screening ADRs asthe
to detect perpresence
screening tool atoftriage
or absence area
adverse
• Clinical evaluation of the reported signs and symptoms
drug reactions
• Baseline
• RoutineLaboratory screening
Laboratory screening to detect
for adverse the presence
drug reactions to monitororARV
absence
and of
TB drug
adverse toxicities
drug to better understand the risks of taking the drug regimen
reactions
under conditions of programmatic use
• Management of severity of adverse drug events in a timely manner
• Systematic and standardized recording and reporting of AEs
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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• Routine Laboratory screening for adverse drug reactions to monitor ARV

and TB drug toxicities to better understand the risks of taking the drug
regimen under conditions of programmatic use
• Management of severity of adverse drug events in a timely manner
• Systematic and standardized recording and reporting of AEs
ACTIVE PHARMACOVIGILANCE

Active PV, in contrast to spontaneous PV, seeks to ascertain completely

the extent of adverse events through a continuous systematic process. To
complement spontaneous reporting, active PV enables enhanced monitoring
& data capture of ADRs including management of adverse events for
improved treatment outcomes.
The processes of Active PV implementation will be as follows:
a. All RRHs, some District Hospitals and centres of excellency that act
as HUBs for delivery of active PV services shall be sentinel sites for
active PV services delivery.
b. Sentinel sites shall pro-actively follow-up patients to detect drug
reactions and, conduct the following laboratory screening for all
Recipients of Care (RoC):
i) Baseline laboratory investigations for suspected adverse drug event
in addition to clinical screening as per the guidelines
ii) Routine laboratory investigations for suspected or confirmed adverse
drug event in addition to clinical screening as per the guidelines
iii) Both laboratory and clinical screenings shall be conducted for
patients during treatment to detect ADRs and AEs even when the
patient has no signs and symptoms
c. Non- sentinel sites (Spokes) shall conduct risk-based screening to
determine what laboratory tests are to be done. For patients who
screen positive to a minimum of two questions on the screening tool
shall be eligible for relevant laboratory tests.
i) Samples for relevant laboratory tests to investigate for suspected
adverse drug events shall be transported to the nearby Hub using
laboratory Hub transport system
d. For each encounter, the health worker should screen for any suspected
ADRs as per screening tool above at triage.
e. Clinicians should further evaluate reported signs and symptoms.
f. Where applicable the clinician should request for additional tests
(including laboratory and radiological) for patients with signs or
symptoms suggesting ADRs.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

g. Routine Screening for active PV: Clinicians/ Health workers shall

request for tests at baseline and periodically thereafter as described in
Table 64 below.
h. All AEs detected should be managed according to severity in accordance
to the guidelines
i. All suspected ADRs should be recorded on the relevant tools: Patient
care cards, Registers, entered in eMRS, and aDSM report form. All
suspected ADRs/AEs data should be reviewed at the site by the facility
pharmacovigilance team. The aDSM report form should be relayed to
the NDA either online or as a hard copy (Annex 15).
j. Data on ADRs and AEs from ART and TB medicines should regularly
be analyzed by the NDA to inform regulatory decision and stakeholders
feedback in quarterly aDSM technical working group meetings.
14.5.2 Procedure of reporting an adverse drug reaction
Procedure of reporting an adverse drug reaction
Figure 62:
Figure 64:Showing reporting
Showing processprocess
reporting of adverse drug reaction
of adverse drug reaction

AsAssoon as an
soon as anADR
ADRis is suspected/detected,
suspected/detected, healthhealth
workerworker
should:should:
• • Immediately
Immediately and and adequately
adequatelyassess
assess
the the patient
patient for adverse
for adverse drug events/
drug events/reactions
• reactions
Record the diagnosis in the client care card, OPD/IPD register and eMRS.
Fill thethe
• • Record aDSM report form,
diagnosis in thecollect
clientall thecard,
care filledOPD/IPD
forms, tally, register
and enter theeMRS.
and record
• Fill the aDSM report form, collect all the filled forms, tally, and HMIS
into relevant registers, and reported into HMIS database that include; enter
Form 105 for ADR from PrEP and PMTCT and HMIS Form 106a for all other
the record into relevant registers, and reported into HMIS database that
ADRs
include; HMIS Form 105 for ADR from PrEP and PMTCT and HMIS
• The suspected ADR should concurrently be recorded on the Active Drug Safety
Form 106a for all other ADRs
Monitoring (aDSM) form in Annex 15. The aDSM form should be filled in
• The suspected
duplicates; ADRcopy
- Original should concurrently
submitted be recorded
to the National on the Active
Pharmacovigilance Centre
Drug
at theSafety Monitoring
NDA secretariat, (aDSM) (blue
the duplicate formcopy)in Annex
stays at 15. The aDSM
the Health form
Unit/Facility.
should be filled
A validly filledaDSM
in duplicates; - Original
report should have thecopy submitted
following minimumto information
the National a)
Pharmacovigilance
Source of information, Centre at details,
b) Patient the NDA secretariat,
c) Drug the duplicate
details d) Reaction details. (blue
• Ensure relevant tests are conducted
• The report is then submitted to the pharmacovigilance focal person within the
facility, or if no such person exists, to the regional referral within your catchment
254area or to the nearest NDA office, or directly to the national Pharmacovigilance
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

copy) stays at the Health Unit/Facility. A validly filled aDSM report should
have the following minimum information a) Source of information, b)
Patient details, c) Drug details d) Reaction details.
• Ensure relevant tests are conducted
• The report is then submitted to the pharmacovigilance focal person within
the facility, or if no such person exists, to the regional referral within your
catchment area or to the nearest NDA office, or directly to the national
Pharmacovigilance Centre at the NDA head office
• For reports on serious adverse events, within 24 to 48 hours of detection/
diagnosis.
• For non-serious adverse events report as soon as possible but, in any case,
not later than 15 days.
• Follow up of the ADR should be done appropriately and any emerging
supplementary/additional information should be forwarded immediately.
The tally data for the previous month (collected from HMIS 105 and
HMIS 108) should be entered into the HMIS database. NB: – Use a
separate form for each event.
Alternative methods of reporting may include:
1. Telephone/WhatsApp line; a reporter can call the National Drug
Authority or Regional Pharmacovigilance Centre or send a WhatsApp
message. The essential information is captured or transcribed on to the
suspected ADR reporting form for follow-up.
2. Toll free line: 0800101999
3. WhatsApp: on 0740002070
4. Email: [email protected]
Screening tool for Active Pharmacovigilance

This tool (see below) is to be placed in the recipient of care’s file and should
be used as a checklist to screen for side effects of ART or TB medicines at
the triage point.

255
Figure 65: Screening tool for Active Pharmacovigilance

256
Screening tool for Active Pharmacovigilance in ART/TB clinics
To be used at the triage point for screening all patient at every visit
Name: …………………………Clinic……………Patient Clinic No…………… Facility Name:
……………………… District: …………… Sex …………… Age………………… Initial assessment
Date ………………………………… Regimen: ……………………………………..
Since you began taking your medicines, have you noticed any changes in the following (Ensure to ask about all the
adverse events) Actions to take:
Tick  if any symptom/complaint is present, or ☒ if absent
Record Adverse Event in patient’s card and refer to clinician
Clinician/Nurse will take all necessary actions to address the Adverse Event and fill the aDSM form which should
be submitted to NDA
Does the patient have any of the Month of Visit
following symptoms or complaints? Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 Neuropsychiatric symptoms (bad

Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

dreams, convulsions, suicidal

thoughts, insomnia, headaches,
anxiety, nervousness, memory
or mood changes) (e.g. CS, EFV,
DTG)
Younger children: Ask for
irritability (in addition to the above
symptoms)
2 Peripheral neuropathy (numbness,
tingling, feeling of pins and
needles, burning sensation in hands
and/or feet)
Younger children: Ask for pain in
hands and feet, regression in motor
milestones - refusal to crawl, walk
or run, reduced playfulness (in
addition to the above symptoms)
(e.g. H, DTG, LZD)
3 Abdominal symptoms (nausea &
vomiting, diarrhea, abdominal pain)
(e.g. ETO)
4 Hepatotoxicity (nausea, vomiting,
right upper quadrant abdominal
pain, yellow urine or eyes) (e.g
H, PZA, ETO, BDQ, CFZ,
Rifabutine, FLQ, Z, DTG)
5 Musculoskeletal symptoms (muscle
cramps, joint pains, tiredness,
weakness, inability to move limb/s)
(e.g LZD, Z, LFX, ETO, TDF)
6 Eye symptoms (blurred vision,
double vision, redness, tearing)
(LZD, E)
7 Kidney symptoms (lower limb

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swelling, facial puffiness, reduced

urine output) (e.g. AMK,TDF)
8 Blood disorders (Aneamia,

258
leucopenia, Thrombocytopeania)
Bruising or bleeding (subcutaneous,
mucosal petechia, nose or gum
bleeding) (e.g. LZD, AZT, 3TC)

9 Cardiac symptoms (palpitations,

fainting, easy fatigability) (e.g.
BDQ, AZT)
10 Skin changes (new skin rashes or
skin discoloration, dermatitis) (e.g.
CFZ, H)
11 Breast enlargement (painful
bilateral male breast enlargement)
(e.g. ETO, EFV)
12 Thyroid symptoms (weight gain,
constipation, dry skin, fatigue, neck
swelling, cold intorelence, hoarse
voices) (e.g. ETO)
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

13 Hearing disturbance and vestibular

toxicity (hearing loss, tinnitus,
dizziness, nausea and vomiting, loss
of balance) (e.g. Kanamycin)
14 Hyperglycemia or diabetes.
(Increased appetite, increased
thirst, and excessive urination). (e.g.
DTG). Younger children: Ask for
irritability (in addition to the above
symptoms)
15 Fever (e.g. LZD)
16 Abnormal weight gain (e.g. DTG)

17 Sexual dysfunction (increased or

low libido) indicate type in remarks
(e.g. ETO, DTG)
18 Congenital Anomaly/Birth Defect
19 Other SEs.
Specify; ____________________
___________________________
______________________
Sign (initials)

Key to the abbreviation:

AMK: Amikacin CF: Clofazimine ETO: Ethionamide
BDQ: Bedaquiline CS : Cycloserine FLQ: Fluoroquinolones
CM: Capreomycin DTG: Dolutegravir H: Isoniazid

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CFZ: Clofazimine DLM: Delamanid LZD:Linezolid

LFX: Levofloxacin MFX: Moxifloxacin RFB: Rifabutine
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Table 83: Laboratory monitoring for Active

Pharmacovigilance in non-sentinel sites
Category Drugs Screening procedures
of Patient
ART At the time of starting/switching to DTG or starting
naïve or INH
experienced
DTG 1. Review eligibility for DTG (Figure25)
patient being
initiated or 2. Perform Baseline Random or Fasting
switched Blood Glucose for those eligible
to DTG according to the DTG eligibility
or starting screening tool (Figure 22).
Isoniazid Isoniazid 1. Review eligibility for INH/3HP
preventive /3HP 2. Perform risk-based baseline Liver
therapy Function Tests checked against any
previous values (Minimum AST and
ALT)
3. Hepatitis B test
After initiating/switching to DTG or starting INH/3HP
DTG 1. Screen using screening tool to identify
any developing signs and symptoms.
3. Perform RBS every 3 months for those
at high risk for hyperglycaemia in the
first 12 months, then thereafter use
clinical indication to determine need
for tests.
Isoniazid/ 1. Screen using screening tool to identify
3HP any developing signs and symptoms.
Prophylaxis 2. Do Liver Function Tests based on
clinical indication.
TDF 1. Do Serum creatinine & eGFR for naïve
patient initiating ART with TDF back
borne at base
2. Do Serum creatinine & eGFR for
experienced patient on TDF every 12
months

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Patients 1. Screen using screening tool to identify

on other any developing signs and symptoms.
regimens Any ART 2. Perform laboratory and radiological
and not on investigations based on clinical
this table indication.
Table 84: Laboratory monitoring for Active
Pharmacovigilance in sentinel sites
Category of Drugs Screening procedures
Patient
ART At the time of starting/switching to DTG or starting
naïve or INH
experienced
DTG 1. Review eligibility for DTG (Figure 57)
patient
being 2. Perform Baseline Random or Fasting
initiated Blood Glucose checked against any
switched previous values
to DTG Isoniazid 1. Review eligibility for INH/3HP
or starting /3HP 2. Baseline Liver Function Tests checked
Isoniazid against any previous values (Minimum
preventive AST and ALT)
therapy
3. Hepatitis B test
After initiating/switching to DTG or starting INH
DTG 1. Screen using screening tool to identify
any developing signs and symptoms.
3. Routine RBS every 3 months in the first
12 months, then thereafter use clinical
indication to determine need for tests.
Isoniazid/ 1. Screen using screening tool to identify
3HP any developing signs and symptoms.
Prophylaxis 2. Routine Liver Function Tests at 3
months after initiating INH/3HP

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Category of Drugs Screening procedures

Patient
TDF 1. Do Serum creatinine & eGFR for naïve
patient initiating ART with TDF back
borne at base
2. Do Serum creatinine & eGFR for
experienced patient on TDF every 12
months
Patients on 1. Screen using screening tool to identify any
any other developing signs and symptoms.
regimens Any ART
and not on 2. Perform laboratory and radiological
this table investigations based on clinical indication

*Unavailability of laboratory tests should not prevent transition. Use clinical

screening to assess for adverse effects.

6.14 COMMON DRUG TOXICITIES IN HIV CARE

Antiretroviral drugs and other drugs used in HIV care can cause a wide range
of toxicities, from low-grade intolerance that may be self-limiting to life-
threatening side effects. Differentiating between ART toxicity (also known as
adverse reactions) and complications of HIV disease is sometimes difficult.
An observed toxicity could be due to a concurrent infectious process or due
to a reaction to medications other than ARVs such as Isoniazid–induced
hepatitis in a child on treatment for TB or a rash induced by Cotrimoxazole.
Drug-related side effects while on ART can occur immediately (soon after
a drug has been administered), early (within the first days or weeks of
treatment) or late (after months or years of treatment). Adverse reactions
may be specific to a particular drug, or they may be generic to the class of
drugs in use. Toxicity is a concern because it can be life-threatening, can
cause non-adherence to ARVs, and may be disfiguring like lipodystrophy. See
Table 78 for common ARV side effects and toxicities.
Managing ARV and TB Drug Toxicity

Healthcare workers should assess patients on ART and TB medicines for

side effects and toxicities at every clinic visit. If the patient has side effects
or toxicity do the following:

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• Determine the seriousness of the toxicity.

• Evaluate concurrent medications and establish whether the toxicity may
be attributable to an ARV or TB medicine, or to any other medication
taken at the same time.
• Consider other disease processes. Not all problems that arise during
treatment are caused bymedicines.
• Manage the side effects and toxicities according to severity (Table 85).
• Report the event using the Adverse Drug Reaction form.
Table 85: Management of ARV side effects/toxicities
Category Action
Severe, Immediately discontinue all ARV drugs, manage the
medical event and substitute the offending drug when the
life-
patient is stable.
threatening
reactions
Severe Substitute the offending drug without stopping the ART.
reactions
Moderate Substitute with a drug in the same ARV class but with a
reactions different toxicity profile, or with a drug in a different class.
Do not discontinue ART. Continue ART as long as
feasible. If the patient does not improve on symptomatic
therapy, consider single –drug substitution.
Mild Do not discontinue or substitute ART.
reactions
Reassure the patient or caregiver that while the reaction
may be bothersome, it does not require a change in
therapy; provide support to mitigate the adverse reactions
as well as counseling about the events.

263
Table 86: Symptomatic and Laboratory Severity Grading for common ADRs
Parameter Grade 1: Mild Grade 2: Moderate Grade 3: Severe Grade 4: Potentially
life threatening

264
Note: For all symptoms reported as potential ADRs, grade them according to the criteria above.

Symptomatic Mild symptoms Moderate symptoms Severe symptoms Potentially life-

grading causing no or causing greater than causing inability to threatening symptoms
minimal interference minimal interference perform usual social causing inability to
with usual social & with usual social & & functional activities perform basic self-
functional activities functional activities with intervention care functions with
with intervention not with intervention or hospitalization intervention indicated
indicated indicated indicated to prevent permanent
impairment, persistent
disability, or death
Note: Use the reference ranges below to grade the severity of events where laboratory investigations are available.
For laboratory investigations not included, refer to DAIDS Grading tables for grading: https://rsc.niaid.nih.gov/
clinical-research-sites/daids-adverse-event-grading-tables
Random Blood 116 to 160 mg/dL > 160 to 250 mg/dL > 250 to 500 mg/dL ≥ 500 mg/dL
Sugar 6.44 to < 8.89 8.89 to < 13.89 13.89 to < 27.75 ≥ 27.75 mmol/L
mmol/L mmol/L mmol/L
Fasting Blood 110 to 125 mg/dL > 125 to 250 mg/dL > 250 to 500 mg/dL ≥ 500 mg/dL
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Sugar 6.11 to < 6.95 6.95 to < 13.89 13.89 to < 27.75 ≥ 27.75 mmol/L
mmol/L mmol/L mmol/L
Glycosuria Trace to 1+ or 2+ or ˃ 250 to > 2+ or > 500 mg N/A
(random ≤ 250 mg ≤ 500 mg
collection tested
by dipstick)
Parameter Grade 1: Mild Grade 2: Moderate Grade 3: Severe Grade 4: Potentially
life threatening
LFTs 1.25 to < 2.5 x ULN 2.5 to < 5.0 x ULN to < 10.0 x ULN ≥ 10.0 x ULN
(Transaminases) (For any) (For any) (For any) (For any)
ALT or SGPT *ULN=Upper limit
and of Normal
AST or SGOT
RFTs N/A < 90 to 60 ml/min or< 60 to 30 ml/min or < 30 ml/min or ml/
(Creatinine) ml/min/1.73 m2 OR ml/min/1.73 m2 OR min/1.73 m2 OR ≥
10 to < 30% decrease30 to < 50% decrease 50% decrease from
from participant’s from participant’s participant’s baseline or
baseline baseline dialysis needed
Cholesterol, 200 to < 240 mg/dL; 240 to < 300 mg/dL; ≥ 300 mg/dL; N/A
Fasting, High 5.18 to < 6.19 6.19 to < 7.77 ≥ 7.77 mmol/L
≥ 18 years of mmol/L mmol/L
age
LDL, Fasting, 130 to < 160 mg/dL; 160 to < 190 mg/dL; ≥ 190 mg/dL; NA
High 3.37 to < 4.12 4.12 to < 4.90 ≥ 4.90 mmol/L
≥ 18 years of mmol/L mmol/L
age
Triglycerides, 150 to 300 mg/dL; >300 to 500 mg/dL; >500 to < 1,000 mg/ > 1,000 mg/dL;
Fasting, High 1.71 to 3.42 mmol/L >3.42 to 5.7 mmol/L dL; > 11.4 mmol/L
>5.7 to 11.4 mmol/L

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Drug substitutions for ARV drug toxicity

Substitution is the process of replacing one ARV drug with another. The
duration on ART is important when doing ARV substitution. If substitutions
are being done within six months of starting ART, it is not necessary to
perform a viral load test.
However, after six months on ART, a viral load test may be required to
rule out treatment failure before a drug is substituted in a failing patient. If
the viral load is not suppressed, it is possible the patient may be failing on
treatment. Follow the viral load algorithm to rule out treatment failure. In a
failing patient, the ART regimen should be switched to 2nd line. See Table 78
for side effects of commonly used ARVs and recommended substitutions.
HEPATOTOXICITY FOLLOWING CO-ADMINISTRATION OF
ART AND TPT /TB MEDICINES

Co-administration of ART and TPT/TB medicines increases the likelihood

of toxicities especially hepatotoxicity. Health workers should therefore take
care to adequately screen patients for TPT eligibility prior to initiation of
TPT. Once toxicity occurs, it should be managed appropriately according to
the grading (refer to Table 86 for grading).
Contraindication for TPT:
• Presence of acute liver disease
• History of alcohol abuse
• Known hypersentivity to INH
• Presence of mental illness
• Presence of seizures
• Presence of severe neuropathy
• Newly initiated on DTG (within the last 3 months)
Co-administration with Nevirapine. Note, for patients transitioning from
NVP, ensure to wait for at least 2 weeks before starting TPT.

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Box 11: Key highlights in Pharmacovigilance

• These guidelines emphasize the importance of pharmacovigilance for the
early identification and management of adverse effects of medications
especially HIV and TB medicines.
• Method of pharmacovigilance adopted for all HIV and TB facilities shall
be Active pharmacovigilance.
• All facilities, as part of routine care should routinely screen, investigate,
manage and report adverse drug reactions as they present at the facility.
Healthcare workers should assess patients on HIV and TB medicines for
side effects and toxicities at every clinic visit.
• Active pharmacovigilance involves pro-active investigation of patients
during treatment and follows them up to detect adverse drug reactions
and adverse events even when the patient has no signs or symptoms.
• All suspected ADRs (whether mild or severe) should be recorded into
the various HMIS tools; ART Cards, Registers, eMRS, reviewed and
reported.
• Reports from active PV should be submitted to the National Drug
Authority through the Regional Referral Hospital and NDA Regional
Offices.
• Side effects and toxicities of ARVs and TB medicines should be managed
according to severity. For moderate and severe reactions, the responsible
ARV or TB medicine should be substituted following the specific
substitution guidance. For life-threatening reactions, ART and/or TB
medication should be discontinued, and the event managed. ART and
TB medication should be resumed with substitution of the responsible
ARV or TB medication when the patient is stable.

WHAT TO EXPECT IN THE FIRST MONTHS OF ART

Although ART is a lifelong commitment, the first months of therapy are

especially important.
• Clinical and immunological improvement and viral suppression are
expected when individuals adhere to ART.
• Opportunistic infections (OIs) and immune reconstitution inflammatory
syndrome (IRIS) may develop, as well as early adverse drug reactions, such
as drug hypersensitivity, especially in the first three months of treatment.
• ART significantly decreases mortality overall, but death rates are also
highest in the first three months of ART. These complications are most
common when the people starting ART already have advanced HIV

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disease with severe immunodeficiency and existing coinfections and/or

comorbidities, severely low hemoglobin, low body mass index, and very
low CD4 cell counts or are severely malnourished.
• More frequent visits and monitoring can help reduce this mortality.
• Poor adherence in this period is also associated with the risk of early
treatment failure and rapid development of drug resistance.
IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME
(IRIS)

IRIS is a spectrum of clinical signs and symptoms thought to be associated

with immune recovery brought about by a response to ART. It is a widely
recognized phenomenon that occurs among 10–30% of the people initiating
ART, usually within the first 4–8 weeks after initiating therapy. IRIS should
be considered only when the presentation cannot be explained by a new
infection, the expected course of a known infection, or drug toxicity. The
most serious and life-threatening forms of IRIS occur in patients co-infected
with TB, Cryptococcus, Kaposi’s sarcoma and herpes zoster. BCG vaccine–
associated IRIS (localized and systemic) may occur in infants infected with
HIV in settings where BCG immunization is routine.
Risk factors for IRIS include a low CD4+ cell count (<50 cells/mm3) at
ART initiation, disseminated opportunistic infections or tumors and/or a
shorter duration of therapy for opportunistic infections before ART starts.
Managing IRIS

IRIS is generally self-limiting, and interruption of ART is rarely indicated.

Treat any co-infections to reduce morbidity and symptoms. If the symptoms
are protracted, reassure the patient to prevent discontinuation of, or poor
adherence to ART.
Steps to reduce development of IRIS
1. Diagnose HIV early and initiate ART before CD4 declines to below
200 cells/mm3.
2. Screen and optimally manage opportunistic infections before initiating
ART, especially TB and Cryptococcus.
3. The timing of ART in people with opportunistic infections requires
balancing a greater risk of IRIS after early initiation against continuing
high mortality if ART is delayed.

268
Table 78: Toxicities/side effects of commonly used ARVs and
recommended substitutions
MAJOR ADVERSE/ PRESENTING SIGNS/ SUGGESTED MANAGEMENT
TOXICITY EVENTS SYMPTOMS
REGIMENS FOR ADULTS AND ADOLESCENTS
DTG • Hyperglycaemia • Excessive drinking/eating, Do RBS to confirm hyperglycaemia
• Insomnia excessive urination then substitute with EFV
• Hepatotoxicity • Difficulty falling asleep Insomnia: Ensure patient is taking
• Hypersensitivity reactions • Nausea, vomiting, right upper DTG during the day if it persists then
quadrant abdominal pain, yellow substitute with EFV
urine or eyes
If EFV is contraindicated: Substitute
• Skin itching (localized or diffuse),
with ATV/r
dizziness, faintness, difficulty
breathing, nausea, vomiting,
diarrhoea, and abdominal cramping
EFV • Persistent central nervous • Dizziness, insomnia, abnormal In case on EFV 600mg
system toxicity dreams, or mental symptoms • Lower the dose of EFV to 400mg.
• Convulsions (anxiety, depression, mental In case on EFV 400mg
• Hepatotoxicity confusion, suicidality)
• Reassure,
• Severe skin and • New-onset seizures
• If symptoms persist
hypersensitivity reactions • Nausea, vomiting, right upper
Substitute EFV with DTG
• Gynecomastia quadrant abdominal pain, yellow
urine or eyes If DTG is contraindicated: substitute
• New-onset skin rash with ATV/r
• Breast enlargement in men

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MAJOR ADVERSE/ PRESENTING SIGNS/ SUGGESTED MANAGEMENT
TOXICITY EVENTS SYMPTOMS

270
TDF • Chronic kidney disease, • Lower back pain, change in urine Do LFTs and RFTs. If deranged
acute kidney injury and volume (elevated liver enzymes and/or GFR
Fanconi syndrome • Bone aches, spontaneous is < 60mls/min) then substitute with
• Decreased bone mineral fractures ABC
density • Exhaustion or extreme fatigue,
• Lactic acidosis or severe muscle cramps or pain, headache.
If ABC is contraindicated: substitute
• Hepatomegaly with • Abdominal pain or discomfort,
with AZT
steatosis decrease in appetite.
ABC • Hypersensitivity reaction • Skin itching (localized or diffuse) Substitute with TDF
dizziness, faintness, difficulty If TDF is contraindicated: substitute
breathing, nausea, vomiting, with AZT
diarrhoea, and abdominal
cramping
AZT • Severe anaemia, • Easy fatigability, breathlessness, Do Hb (if < 8mg/dl): Substitute with
neutropenia recurrent infections TDF
• Lactic acidosis or severe • Exhaustion or extreme fatigue,
hepatomegaly with steatosis muscle cramps or pain, headache.
If TDF is contraindicated: substitute
• Lipoatrophy, lipodystrophy, • Abdominal pain or discomfort
with ABC
myopathy decrease in appetite.
• Severe vomiting • Persistent vomiting resulting in
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

severe dehydration
NVP • Acute symptomatic • Nausea, vomiting, right upper Substitute or switch to appropriate
hepatitis quadrant abdominal pain, yellow regimen
• Hypersensitivity reaction, urine or eyes NOTE: NVP is not recommended
Stevens-Johnson Syndrome • Severe or life-threatening rash in ART regimens. NVP should be
(severe or life-threatening with mucosal involvement (ulcers substituted even in absence of ARs/
rash, mucosal involvement) in the mouth or eyes) toxicity OR regimen switched if client
is failing
MAJOR ADVERSE/ PRESENTING SIGNS/ SUGGESTED MANAGEMENT
TOXICITY EVENTS SYMPTOMS
ATV/r • Electrocardiographic • Dizziness or fainting Do ECG; Use with caution in people
abnormalities (PR and QRS • Refer to Blood Lipid levels in Table with pre-existing conduction disease or
interval prolongation) 68 who are on concomitant drugs that may
• • Yellowing of eyes, dark yellow prolong the PR or QRS intervals, pre-
• Elevated Lipid urine, yellow stools existing coronary disease or previous
• Indirect hyperbilirubinemia • Severe lower back pain that comes stroke.
(clinical jaundice) in waves and fluctuates in intensity, Jaundice is clinically benign but
• History of nephrolithiasis pain on urination, cloudy or foul- potentially stigmatizing.
smelling urine. Do LFTs and Lipid profile. If deranged:
Substitute with DTG or LPV/r
DRV/r • Hepatotoxicity • Nausea, vomiting, right upper Do LFTs if deranged
• Severe skin and quadrant abdominal pain, yellow Substitute with ATV/r or LPV/r.
hypersensitivity reactions urine or eyes
When it is used in third-line ART,
• Skin itching (localized or diffuse)
limited options are available.
dizziness, faintness, difficulty
breathing. For hypersensitivity reactions, substitute
with another therapeutic class.
ETV • Severe skin and • Skin itching (localized or diffuse) Substitute with another therapeutic class
hypersensitivity reactions dizziness, faintness, difficulty (integrase inhibitors or boosted PIs).
breathing.
LPV/r • Electrocardiographic • Dizziness, fainting Do ECG; Use with caution in people
abnormalities (PR and • Nausea, vomiting, right upper with pre-existing conduction disease or
QRS interval prolongation, quadrant abdominal pain, yellow who are on concomitant drugs that may
torsades de pointes) urine or eyes prolong the PR or QRS intervals, pre-
• Hepatotoxicity • Upper abdominal pain that feels existing coronary disease or previous
• Pancreatitis worse after eating, fever, rapid stroke.
• Dyslipidemia pulse, nausea and vomiting. Do LFTs, Serum Amylase and Lipid

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• Diarrhoea • Refer to Blood Lipid levels in Table profile: if deranged: Substitute with
• Unable to tolerate taste 86. DTG or ATV/r
• ≥3 watery stool motions/ day.
MAJOR ADVERSE/ PRESENTING SIGNS/ SUGGESTED MANAGEMENT

272
TOXICITY EVENTS SYMPTOMS
REGIMENS FOR CHILDREN 0-10 YEARS
ABC Hypersensitivity reaction Skin itching (localized or diffuse) Substitute with AZT.
dizziness, faintness, difficulty
breathing.
EFV • Persistent central nervous • Dizziness, insomnia, abnormal Reassure,
system toxicity (such dreams, or mental symptoms If symptoms persist, substitute EFV
as dizziness, insomnia, (anxiety, depression, mental with DTG or LPV/r (if appropriate
abnormal dreams) or confusion, suicidality) DTG formulation is not available)
mental symptoms (anxiety, • New-onset seizures
depression, mental • Nausea, vomiting, right upper
confusion) quadrant abdominal pain, yellow
• Convulsions urine or eyes
• Hepatotoxicity • New-onset skin rash
• Severe skin and • Breast enlargement
hypersensitivity reactions
• Gynecomastia
NVP • Acute symptomatic hepatitis • Nausea, vomiting, right upper Substitute with DTG or LPV/r
• Hypersensitivity reaction, quadrant abdominal pain, yellow NVP is not recommended in ART
Stevens-Johnson Syndrome urine or eyes regimens. NVP should be substituted
• Severe or life-threatening rash with even in absence of ARs/toxicity OR
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

mucosal involvement (ulcers in the regimen switched if treatment failure

mouth or eyes) confirmed
NOTE: NVP will continue to be used
for prophylaxis in EMTCT
MAJOR ADVERSE/ PRESENTING SIGNS/ SUGGESTED MANAGEMENT
TOXICITY EVENTS SYMPTOMS
LPV/r • Electrocardiographic • Dizziness, fainting Do ECG; Use with caution in people
abnormalities (PR and • Nausea, vomiting, right upper with pre-existing conduction disease or
QRS interval prolongation, quadrant abdominal pain, yellow who are on concomitant drugs that may
torsadesde pointes) urine or eyes prolong the PR or QRS intervals, pre-
• Hepatotoxicity • Upper abdominal pain that feels existing coronary disease or previous
• Pancreatitis worse after eating, fever, rapid stroke.
• Dyslipidemia pulse, nausea and vomiting. Do LFTs, Serum amylase and Lipid
• Diarrhoea • Refer to Blood Lipid levels in Table profile. If deranged: Substitute with
• Unable to tolerate taste 66. DTG
• ≥3 watery stool motions/ day
If DTG contraindicated: (formulation
• Changes in taste of food, low
not available): Substitute with RAL
appetite
If RAL contraindicated and child is >3
years:
Substitute with DRV/r
AZT • Severe anemia, neutropenia • Refer to Blood Counts. Do Hb (if < 8mg/dl)
• Lactic acidosis or severe • Exhaustion or extreme fatigue, Substitute with ABC
hepatomegaly with steatosis muscle cramps or pain, headache.
• Lipoatrophy, lipodystrophy, • Abdominal pain, discomfort or
myopathy decrease in appetite.
• Severe vomiting • Persistent vomiting resulting in
severe dehydration
RAL • Rhabdomyolysis, myopathy, • Severe muscle pain, muscle wasting Do LFTs if deranged and
myalgia • Nausea, vomiting, right upper child is > 3 years:
• Hepatitis and hepatic failure quadrant abdominal pain, yellow
Substitute with DRV/r
• Severe skin rash and urine or eyes
hypersensitivity reaction • Skin itching (localized or diffuse) If child is <3 years: Substitute with

273
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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Table 79: Criteria for switching ART due to treatment failure

Failure Definition Comments
• Each criterion below can be used independently to determine treatment
failure. You do not need to have both to diagnose treatment failure.
• It’s important to note that the major criteria for switching ART in Uganda
is Virologic failure with switch guided by HIV DR testing
Virologic Two consecutive viral loads above 1000 The patient should
failure copies/ml, done at least 3-6months apart, have been on ART
with adherence support following the 1st for at least six
VL test. months
Clinical Adults, adolescents and children: The condition must
failure New or recurrent WHO clinical stage 3 or be differentiated
  stage 4 event (except TB) in a patient from IRIS
who has been on effective ART regimen occurring
for at least six months. after initiating ART

6.15 CHILDREN WITH A NON-SUPPRESSED VIRAL

LOAD
If the child is on an NNRTI regimen and VL is not suppressed, switch to
2nd line immediately and do IAC simultaneously. Do not postpone switch.
If the child is on a DTG or LPV/r-based first line ART regimen, conduct
IAC and repeat VL after 3 months. DTG and PI have high resistance barrier
so poor adherence is a m vore likely cause for an unsuppressed VL than
resistance. If VL is still not suppressed after IAC interventions, conduct HIV
drug resistance to guide the next cause of action.

6.16 WHAT REGIMEN TO SWITCH TO (SECOND LINE

AND THIRD LINE ART)
Second line for adults, adolescents and children will be guided by HIV
genotyping.
Table 80: Recommended NRTI sequence from first-line to
second-line
First line NRTIs Second line NRTIs
Adults and adolescents ≥30Kg
TDF+3TC or TAF+FTC AZT+3TC
ABC+3TC or TAF +FTC TDF +3TC
AZT+3TC TDF + 3TC or TAF +FTC

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Children <30Kg
ABC+3TC AZT+3TC
AZT+3TC TAF*+FTC
AZT+3TC ABC+3TC
*TAF is recommended for children >6 years and >25Kg.
6.16.1 Second Line ARVs In Adults And Adolescents ≥30Kg,
Including Pregnant and Breastfeeding Women

RECOMMENDED 2ndline REGIMEN:

2NRTIs + DTG
(if client failed on a PI- or NNRTI-based 1st line ART regimen)
or 2 NRTIs + ATV/r
(if client failed on a DTG-based or NNRTI-based 1st-line ART regimen)
The choice of NRTI should be determined based on the NRTI the patient
was previously on (For NRTI sequencing see Table 62 and for 2nd line
regimens see Table 63
Rationale for using ATV/r
Atazanavir is preferred over LPV/r because it offers an option of once daily
dosing with lower pill burden and better GI tolerability as compared to LPV/r
which is taken twice daily and has higher pill burden. Furthermore, ATV/r
is more affordable than LPV/r ($2 less per patient per month). Therefore,
ATV/r is the preferred PI when DTG was used in the first-line regimen.
WHEN TO USE ALTERNATIVE 2NDLINE REGIMEN: 2NRTIs
+LPV/r

LPV/r should only be used for second line in adults and adolescents if
ATV/r or DTG are contraindicated.
6.16.2 Second Line ARVs In Children ≥20Kg – 30Kg

RECOMMENDED 2ndline REGIMEN: 2NRTIs + DTG*

(If child failed on a PI- or NNRTI-based 1st line ART regimen)
Or 2NRTIs + LPV/r
(If child failed on a DTG- or NNRTI-based 1st line ART regimen)
The choice of NRTI should be determined based on the regimen the
patient was previously on (for NRTI sequencing see Table 80 and for 2nd
line regimens see Table 81).

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*DTG is the preferred anchor ARV for 2nd line ART for children
switching from an NNRTI-based regimen. However, if DTG
formulations are not available, opt for an LPV/r-based regimen.
WHEN TO USE ALTERNATIVE 2ND LINE REGIMEN: TAF+FTC+
DTG or LPV/r

For children who have failed on AZT+3TCNRTI backbone, give TAF+FTC

NRTI backbone as part of second line ART regimen.
WHEN TO USE ALTERNATIVE 2ND LINE REGIMEN: 2NRTIs +
DRV/r

DRV/r -based regimens will be used for children who failed on a DTG- or
LPV/r- based first line regimen and in whom the preferred 2nd line regimen
anchor ARV (LPV/r or DTG) is contraindicated or unavailable.
6.16.3 Second Line ARVs In Children <20Kg

RECOMMENDED 2nd line REGIMEN: 2NRTIs + DTG*

(If child failed on a PI- or NNRTI-based 1st line ART regimen)
or 2NRTIs + DRV/r
(If child failed on a DTG-based or NNRTI 1st line ART Regimen)
The choice of NRTI should be determined based on the regimen the
patient was previously on (For NRTI sequencing see Table 80 and for 2nd
line regimens see Table 81).
*DTG in the preferred anchor ARV for 2nd line ART for children
switching from an NNRTI-based regimen. However, if DTG
formulations are not available or contraindicated, opt for an DRV/r-
based regimen.
WHEN TO USE ALTERNATIVE 2ND LINE REGIMEN: 2NRTIs +
LPV/r

LPV/r is recommended in children who have used NNRTI in their first line
regimen and for whom DTG formulation is unavailable.
WHEN TO USE ALTERNATIVE 2ND LINE REGIMEN: 2NRTIs +
LPV/r

LPV/r -based regimens will be used for children in whom the preferred 2nd
line regimen anchor ARV (DRV/r or DTG) is contraindicated or unavailable.

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Table 81: First-Second- and third-line ART regimens for

patients failing on treatment:
Population Failing first line Recommended Alternative
regimens second line reg- second line Third line
imen; guided by regimen regimens1,2
HIV DR
TAF + FTC + EFV or All third line
TDF + 3TC+EFV or AZT+3TC+ regimens to
AZT+3TC+DTG
DRV/r or ATV/r be guided
TDF+3TC+NVP
by HIV DR
TAF + FTC + DTG or AZT+3TC+AT-
Adults and AZT+3TC+DRV/r resistance
TDF+3TC+DTG V/r
adolescents testing.
AZT+3TC+NVP
≥ 30Kg, In case of
TAF + FTC + TAF + FTG +
including AZT+3TC+EFV
DTG or TD- ATV/r or TD- suscepti-
pregnant and ABC/3TC/NVP bility to all
F+3TC+DTG F+3TC+ATV/r
breastfeeding ABC+ 3TC+ EFV drugs, use
women the table to
TAF+ FTC + TAF+ FTC guide the
AZT+3TC+DTG
DRV/r or TD- +ATV/r or TD- preferred or
ABC+3TC+DTG alternative
F+3TC+ DRV/r F+3TC+ATV/r
choices.
ABC+3TC+EFV AZ-
AZT+3TC+DTG
ABC+3TC+NVP T+3TC+LPV/r
AZ-
ABC+3TC+LPV/r AZT+3TC+DTG
T+3TC+DRV/r
AZ- NOTE: For
ABC+3TC+DTG AZT+3TC+DRV/r
Children T+3TC+LPV/r details on the
TAF + FTC + TAF+ FTC third-line ART,
≥ 20Kg - AZT+3TC+EFV
DTG or AB- +LPV/r or AB- please see the
<30Kg AZT+3TC+NVP
C+3TC+DTG C+3TC+LPVr third-line ART
TAF + FTC TAF+ FTC + implementation
AZT+3TC+LPV/r +DTG or AB- DRV/r or ABC+ guides.
C+3TC+DTG 3TC+DRV/r
TAF+FTC + TAF + FTC
AZT+3TC+DTG DRV/r or AB- +LPV/r or AB-
C+3TC+ DRV/r C+3TC+ LPV/r

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

ABC+3TC+EFV AZ-
AZT+3TC+DTG
ABC+3TC+NVP T+3TC+LPV/r
AZ-
ABC+3TC+LPV/r AZT+3TC+DTG
T+3TC+DRV/r
AZT+3TC+ AZT+3TC+
ABC+3TC+DTG
Children DRV/r LPV/r
<20Kg AZT+3TC+EFV AB-
ABC+3TC+DTG
AZT+3TC+NVP C+3TC+LPV/r
AB-
AZT+3TC+LPV/r ABC+3TC+DTG
C+3TC+DRV/r
ABC+3TC+ ABC+3TC+
AZT+3TC+DTG
DRV/r LPV/r

All PLHIV should receive resistance testing to inform the prescription of 2nd
and 3rd-line medicines
• In case of susceptibility to all drugs, use the table to guide the preferred
or alternative choices.
• Since all 3rd-line PLHIV will have prior PI Exposure, DRV/r will be
taken twice a day.
• For recipients of care on NNRTI-based First Line regimen whose VL
is not suppressed, switch without a second VL but conduct IAC to
improve adherence to new regimen.
• All PLHIV on raltegravir should be immediately transitioned to DTG
if there are no contra indications irrespective of the VL status.
6.16.4 Programmatic Drug Substitution on 2nd Line
Regimens

Adults on ATV/r or LPV/r-based 2nd line regimens who are virally

suppressed (basing on VL result within the past 6 months) and who did
not receive DTG in their 1st line regimens should have ATV/r or LPV/r
substituted with DTG.
Pregnant and breastfeeding women on ATV/r or LPV/r-based 2nd line
regimens who are virally suppressed and who did not receive DTG in
their1stlineregimens should be maintained on the same regimens. At 6-9
months postpartum, if their VL is suppressed (basing on VL result within
past 6 months), ATV/r or LPV/r should be substituted with DTG.
Although simplification of regimens including once-a-day dosing is a
main goal of ART optimization, children and adolescents who are virally

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

suppressed and stable on 2nd line regimens containing twice-daily LPV/r

will be maintained on their regimens so as to preserve their options for 3rd
line regimens. Drug substitutions may be considered on a case by case basis
especially in children and adolescents in whom twice-daily dosing may hinder
adherence.

6.17 THIRD-LINE ART REGIMENS

6.17.1 Eligibility for Third-Line ART

Patients on second-line ART who meet the following criteria are eligible for
third line ARVs:
• If they have a detectable viral load test result >1000 copies/ml at the
repeat viral load test following intensified adherence counseling.
• The patient should have had three intensified adherence counseling
sessions one month apart after the initial detectable viral load.
• The patient has three consecutive scores of adherence >95% as determined
by adherence support team. In case the 3 scores are less than 95%, then do
DOTs for three months and repeat VL irrespective of adherence scores.
6.17.2 When a patient on second line has suspected
resistance to secondline ART

When a patient on second-line ART is suspected to be failing on second-line

ART following the first unsuppressed viral load, and the adherence scores
are > 95% for three consecutive IAC sessions, the following should be done:
• Two samples of venous blood should be taken off and sent to CPHL
(Central Public Health Laboratories).
• The samples should be accompanied by the combined viral load and
HIV drug resistance form. The first sample will be used by CPHL to
conduct the repeat viral load test. Once the result is > 200 or 400 copies/
Ml for plasma and DBS respectively, CPHL will proceed to facilitate the
geno typing process either by CPHL, JCRC or UVRI as may be deemed
necessary
• The resistance test results will be dispatched by CPHL to respective
regions for action. The regional teams will review the results alongside
the patient details and make the decision to switch or not to switch the
patient to third-line ART. Please refer to Figure 63 for the third-line ART
flow chart.
• The case discussion and decision reached will always be instituted in the
HIV DR data base for monitoring by the National team.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

• The health facility team will follow up the patient to initiate them on third-
line ART.
6.17.3 Recommended third-line regimens for adults,
• The health facility team will follow up the patient to initiate them on third-line
adolescents and children
ART.
The recommended anchor drug for third-line regimens for adults, adolescents
13.22.2 Recommended third-line regimens for adults, adolescents and children
and children will be ritonavir-booster Darunavir (DRV/r). DTG will be
The recommended anchor drug for third-line regimens for adults, adolescents and
considered
children will for children <20Kg
be ritonavir-booster who (DRV/r).
Darunavir utilized DTG
DRV/r forconsidered
will be their second-line
for
regimen. However,
children <20Kg selection
who utilized DRV/r of for
third-line ART regimens
their second-line will be guided
regimen. However,
selection
by of third-line
resistance ART regimens
profiling will be guided by
of the antiretroviral resistance
drugs. profiling
In the of the
initial phase of
antiretroviral drugs. In the initial phase of implementation of the third-line ART
implementation of the third-line ART program within the national
program within the national system, the drugs will be kept at the regional referral
system,
the drugsto will
hospitals whichbethekept
healthatfacilities
the regional
will makereferral hospitals
their orders. to on
For details which the health
guidance
facilities
on how towill
ordermake their
for and reportorders. For details
on third-line ontoguidance
ART, refer Chapter 13.on how to order for
and report on third-line ART, refer to Chapter 13.
Figure 60: Third-Line ART Flow Chart
Figure 62: Third-Line ART Flow Chart

Table 81: Drug interactions

Drug Family ARV Drug Interaction Action

Anti-TB medicines NVP Rifampicin decreases Do not co-administer NVP and
NVP concentrations in rifampicin
blood. See Table 39 and Table 40 for
Could cause liver toxicity TB/ARV co-management
DTG Rifampicin lowers DTG Adjust DTG dose to twice daily

235

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Table 82: Drug interactions

Drug Family ARV Interaction Action
Drug
Anti-TB med- NVP Rifampicin Do not co-administer
icines decreases NVP NVP and rifampicin
concentrations See Table 39 and Table
in blood. 40 for TB/ARV co-man-
Could cause agement
liver toxicity
DTG Rifampicin Adjust DTG dose to
lowers DTG twice daily
levels
ATV/r, Rifampicin If given together with
LPV/r, boosts metabo- LPV/r increase the dose
DRV and lism of PIs of RTV to achieve 1:1
RTV ratio
Combined oral EFV or Risk of Use additional barrier
contraceptive ATV/r, contraceptive method
pills, hormon- LPV/r, failure due or
al implants DRV and to increased
Use Depo-Provera or
(etonogestrel) RTV metabolism of
IUDs
contraceptives
Anxiolytics, ATV/r, Risk of respira- Reduce dose of midazol-
e.g. midazolam, LPV/r, tory depression am or diazepam
diazepam DRV and (midazolam)
RTV Increased seda-
tion (diazepam)
Antifungals, NVP Risk of hepato- Use fluconazole
e.g. keto- toxicity
conazole
Simvastatin, ATV/r, Inhibition Use atorvastatin with
rosuvastatin, LPV/r, of CYP450 lowered dose and mon-
atorvastatin DRV and 3A4 (reduced itor for side effects like
RTV metabolism of muscle pains
statins)

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Drug Family ARV Interaction Action

Drug
Anti-epileptics, EFV, Carbamazepine Use valproic acid
e.g. carbamaz- DTG, decreases DTG
epine, pheno- Etravirine, levels by 30-
barbital, and 70%
phenytoin
Drugs for ATV/r Reduced con- Use alternatives like ranit-
acid reflux centrations of idine, cimetidine, etc.
or ulcers, e.g. Atazanavir
omeprazole,
esomeprazole,
lansoprazole,
pantoprazole
Polyvalent cat- DTG Reduce DTG Use DTG 2 hours before
ion products levels or 6 hours after the prod-
containing Mg, uct to avoid interaction
Al, Fe, Ca, Zn
(e.g. vitamin
supplements
and antacids)
Antimalarial ATV Both could When given with arte-
drugs: prolong QT mether/lumefantrine
artemether/ interval monitor closely for unde-
lumefantrine, sired effects
halofantrine Halofantrine: do not give
together (contraindicated)
Metformin DTG DTG increas- Close follow-up (rou-
es metformin tine electrolytes, BUN
levels. May and Creatinine, Random
increase risk of Blood Sugar tests) recom-
hypoglycemia mended
and metabolic
acidosis

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Box 10: Key highlights in Antiretroviral Therapy for people living

with HIV

• Optimization of ART regimens with more efficacious and durable

drugs and simplified dosing is recommended for improved long-
term viral suppression.
• The preferred first-line ART for all adults, adolescents and children
is Dolutegravir-based.
• PLHIV on NNRTI-based first-line regimens should have their viral
loads assessed. If virally suppressed, their ART should be transitioned
to optimal preferred first-line regimens. If not suppressed, the
patients should be switched to second-line ART with IAC.
• PLHIV initiated on DTG should be longitudinally monitored
for adverse effects following recommended pharmacovigilance
protocols.
• Newly diagnosed pregnant and breastfeeding women shall be
initiated on TDF+3TC+DTG or TAF+FTC+DTG.
• Pregnant and breastfeeding women already on TLE should be
maintained on this regimen until 6-9 months postpartum when they
should be transitioned to TLD if the VL within the past 6 months
is suppressed.
• Women becoming pregnant while on DTG-based regimens shall be
maintained on the regimen.
• Treatment should be monitored by measuring viral load 6 months
after initiation of ART and every 6-12 months or when clinically
indicated.
• A repeat viral load of >1000cells/mm3 suggests treatment failure
and is indication for HIV DR and appropriate switch after ruling out
adherence challenges.
• The preferred second-line ART for adults, adolescents and children
are either DTG-based or PI-based, depending on the failing first-
line regimens.
• Second and third line regimens shall be guided by genotype
(resistance) testing.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

7 SERVICE DELIVERY
APPROACHES
This chapter will discuss differentiated service delivery for PLHIV including
children, adolescents and Adults, the comprehensive community service
delivery approach and continuous quality improvement in DSD.

7.1 DIFFERENTIATED SERVICE DELIVERY (DSD)

Differentiated service delivery refers to various ways of providing HIV
prevention, care and treatment services that are tailored to the needs and
preferences of PLHIV with the aim of maintaining good clinical outcomes
and improving efficiency in service delivery.
Differentiated service delivery will improve the efficiency of existing
approaches. It addresses individuals’ needs, informs targeted interventions
with better outcomes among clients; improve access, coverage and quality of
services and lead to efficient utilization of resources.
This section presents the recommended differentiated service models for
HTS, care and treatment for PLHIV and TB for adoption by the facilities and
communities managing PHLIV. The details on how the differentiated care
models will be implemented in Uganda are described in the Implementation
guide for Differentiated Service Delivery Models (DSDM) for HIV and TB
services in Uganda (version November 2022).
7.1.1 Core principles of differentiated service delivery

The core principles of differentiated care are client-centered and improved

health system efficiency.
a) Client-centered care
The core principle for differentiating care is to provide ART delivery in a
way that acknowledges specific barriers identified by clients and empowers
them to manage their disease with the support of the health system. WHO
highlights the need for client-centered care to improve the quality of HIV
care services.

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

b) Health system efficiency

With the population of PLHIV having increasingly diverse needs, it is
acknowledged that health systems will have to adapt away from a “one-
size-fits-all” approach. DSD supports shifting resources to clients who are
the most in need by supporting stable clients to have fewer and less intense
interactions with the health system.

7.1.2 Why differentiated service delivery is needed

Differentiated service delivery can improve the efficiency of existing

approaches. It shall address individuals’ needs, inform targeted interventions
with better outcomes among clients, improve coverage and quality of
services, and lead to efficient utilization of resources. It will allow health
providers to better identify and categorize PLHIV early on, streamline care
and treatment services for stable clients, and focus more time and attention
on the clients requiring more attention. The recommended differentiated
service delivery models in most cases will not require significant policy
changes or additional resources since they are mainly streamlining what is
already being implemented.
7.1.3 The Target Groups For Differentiated Service Delivery

The DSD will meet the different care and treatment needs of different
groups of clients including clients newly initiating ART, children, adolescents,
pregnant and lactating women, adult men and women, key populations and
patients with advanced disease. All these groups will be served either at
facility or in the community depending on their preferred model.
7.1.4 Building Blocks for Differentiated Delivery

There are four building blocks or delivery components that facilities need to
address when considering the different models to adopt for specific client
groups or populations. Figure 66 below summarizes these building blocks
which include:
1. The type of services delivered – WHAT
2. The location of service delivery - WHERE
3. The provider of the services – WHO
4. The frequency of the services – WHEN

285
3 The location of service delivery - WHERE
4 The provider of the services – WHO
5Consolidated
The frequency
Guidelines forof
thethe services
Prevention – WHEN
and Treatment of HIV and Aids in Uganda - 2022

Figure
Figure 64:66:
The The building
building blocks
blocks for for differentiated
differentiated service
service delivery
delivery

InInall
allmodels
modelsofofservice
servicedelivery,
delivery,thetheclient
clientis isatatthe
thecenter.
center.The
Thestakeholders must
stakeholders
balance
must balance the goal of improving client outcomes with their ability tothe
the goal of improving client outcomes with their ability to utilize
available health
utilize the system
available resources.
health system resources.
7.1.5 The 5 A’s criteria to choosing a preferred DSD approach
15.1.5 The 5 A’s criteria to choosing a preferred DSD approach
In DSD it is important for the health care worker (HCW) to guide the client
IntoDSD
makeit an
is important
informedfor the health
decision andcare worker
choose (HCW)
a DSD to guide
model that the client to make
is appropriate
an
forinformed decision
their needs. HCWs andshould
chooseuse
a DSD
theirmodel
knowledgethat isofappropriate
the client’sforneeds
their and
needs.
HCWs should
limitations anduse theirthem
guide knowledge of the
using the 5 A’sclient’s needs and limitations and guide
criteria.
1. using
them Assess the 5 A’s criteria.
a.
1) Assess Explain the purpose of the session
b. Assess the client’s barriers to adherence to DSD approaches
2. a. Explain the purpose of the session
Assist
b.
a. Assess the client’s
Evaluate barriers to
the underlying adherence
causes of thetoidentified
DSD approaches
barriers
b.
2) Assist Identify client-specific strategies to overcome identified barriers
c. Discuss the pros and cons of each strategy/option(s)
a. Evaluate the underlying causes of the identified barriers
3. Advise
b. Identify client-specific strategies to overcome identified barriers
253

286
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

a. Give necessary information about the different approaches

b. Review benefits of good adherence in relation to DSD
c. Discuss consequences of non-adherence
4. Agree on
a. Agree on the client’s action points to address the key barriers
b. Evaluate each action point
c. The document agreed upon action points
5. Arrange
a. Summarize the session
b. Arrange for ART refill in the agreed upon approach
c. Schedule and Document the next appointment date on the visit
session form
d. Refer and link to other services as appropriate
7.1.6 Recommended differentiated services

The two services for adopting differentiated models are:

• Differentiated HIV testing services.
• Differentiated HIV care and treatment services.
DIFFERENTIATED HIV TESTING SERVICES

This section discusses the differentiated HTS approaches with the aim of
helping health facility managers, facility in-charges, health care workers
(HCWs), community- based health service providers and other stakeholders
to adopt efficient HTS approaches for reaching the undiagnosed PLHIV.
Definition

Differentiated HIV Testing Services are service-delivery models that are

adapted to address the specific barriers or bottlenecks requirements of a
subgroup of individual clients to enable them to know their HIV status.
The recommended models and approaches

The recommended ways of differentiating HIV testing and screening include

1) facility-based models and 2) community-based models, summarized under
Chapter 4 as well as in Figure 67 below.
HTS services will be offered in the facility (facility-based HTS model) or
in the community (community-based HTS model). Facility-based HTS
includes provider-initiated HTS (i.e. Routine HTS, OPD testing, Diagnostic
HTS and Index client HTS) and client-initiated counseling and testing (i.e.at

287
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

OPD and other testing points or Health Facility based Drop in Centers).
Health Facility based Drop in Centers). Community-based HTS includes provider-
Community-based HTS includes provider-initiated HTS (i.e. Home based
initiated HTS (i.e. Home based HTS, Snowballing and HTS in Education
HTS, Snowballing
Establishments and active
for sexually HTS youth)
in Education Establishments
and Client-initiated for sexually
counseling active
and testing
(i.e.youth) and Client-initiated
outreach/mobile HTS and HTScounseling and testing
at Community Drop in(i.e. outreach/mobile HTS
Centers).
and HTS at Community Drop in Centers).
Figure 65: Recommended differentiated HTS delivery models
Figure 67: Recommended differentiated HTS delivery models

15.3 DIFFERENTIATED CARE AND TREATMENT SERVICES

7.1.7 Differentiated Care and Treatment Services
Differentiated HIV treatment and care refers to a strategic mix of approaches to
address the specific requirements of a subgroup of clients living with HIV. It
Differentiated HIV treatment and care refers to a strategic mix of approaches
includes approaches aimed at modifications of client flow, schedules and location of
HIVtotreatment
address the
andspecific requirements
care services of aaccess,
for improved subgroup of clients
coverage, livingofwith
and quality care.HIV.
It includes approaches aimed at modifications of client flow, schedules and
15.3.1 The recommended models and approaches
location of HIV treatment and care services for improved access, coverage,
The recommended ways of differentiating HIV treatment and care include 1) facility-
andmodels
based qualityand
of 2)care.
community-based models, summarized in the Figure 67.
The recommended models and approaches

The recommended ways of differentiating HIV treatment and care include

1) facility-based models and 2) community-based models, summarized in the
Figure 67.

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Figure 68: Recommended differentiated care and treatment

service delivery models and their respective target
Figure 66: Recommended differentiated care and treatment service delivery
models and populations
their respective target populations

Category of Recipient of Care

• PLHIV newly identified and or re-engaging in care when clinically well

• PLHIV newly identified and or re-engaging in care with advanced HIV disease
• PLHIV established on ART and or with controlled chronic illnesses / NCDs.
• PLHIV with uncontrolled chronic illness / NCDs, and any Drug limiting toxicities
• PLHIV with treatment failure
Treatment at Facility or in Community

Group Model Individual Model

Managed by HCW Managed by client Based at facilities Based in community

Examples Examples Examples Examples
FBG (e.g., FSG, CCLAD FTDR CRPDDP
Viraemia clinics, G- CLDDP FBIM (e.g. Adolescent Drop in centers
ANC) centers) Peer led models (e.g.
CDDP YAPS, Home ART
delivery)

15.4 CATEGORIZATION OF CLIENT CHARACTERISTICS FOR DSD

CATEGORIZATION OF CLIENT
In order to provide client-centered care, thereCHARACTERISTICS FOR DSD
is a need to consider the following:
1) PLHIV newly identified and or re-engaging in care when clinically well
In order tonewly
2) PLHIV provide client-centered
identified and or re-engagingcare, there
in care is a need
with advanced HIV to consider the
disease
following:
3) PLHIV established on ART and or controlled chronic illness / NCDs
1. 4) PLHIV newly
PLHIV with identified
uncontrolled chronicand or /re-engaging
illness NCDs and any in care
Drug when
limiting clinically well
toxicities
2. 5) PLHIV newly identified and or re-engaging in care with advanced HIV
PLHIV with treatment failure
disease
3. PLHIV established on ART and or controlled chronic illness / NCDs
4. PLHIV with uncontrolled chronic illness / NCDs and any Drug
limiting toxicities
5. PLHIV with treatment failure
Table 88: Definition of the DSD Categories
PLHIV newly PLHIV PLHIV Estab- PLHIV with PLHIV with
256
identified and newly iden- lished on ART and uncontrolled Treatment
or re-engaging tified and or or with Controlled chronic illness / Failure
in care when re-engaging chronic illnesses / NCDs and any
clinically well in care with NCDs Drug limiting
advanced toxicities
HIV disease

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• CD4≥ 200 • CD4 • Receiving ART • FBG ≥ 7mmol • 2 consec-

Cells/mm3 <200 for at least 6 • RBG ≥ utive Non
• WHO stage cells/ months 11mmol suppressed
1 and 2 mm3 • No current • HTN ≥ VL ≥ 1000
• WHO illness 140/90mmhg copies
stage 3 or • Controlled • SRQ≥ 6 • Has current
4 at pre- chronic health • Audit-C > 3 or history
sentation conditions • HPV/VIA of WHO
for care • Good under- positive clients stages 3 or 4
• Children standing of life- event within
< 5 years long adherence the past one
• Evidence of year.
treatment
success (at least
one suppressed
VL in the last 6
months)
• No ART limiting
drug toxicity
DSD MODELS

DSD will continue to be implemented both at the facility and in the

community. There will be broadly two models namely; group model and
Individual model. Each of these, will be further divided into two i.e. Group
model managed by health care worker or client and individual model based
at facility or community, with the different approaches listed in the schemer
above.
Table 89: Client categories for HIV Care and Treatment
services under the various differentiated categories
ROC Categories Group Model Individual Model
Managed Managed Based Based
by HCW by client at the in the
facility community
PLHIV newly
identified and or re-
engaging in care when
clinically well
PLHIV newly
identified and or re-
engaging in care with
advanced HIV disease

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PLHIV established
on ART and or with
Controlled chronic
illness / NCDs
PLHIV with
uncontrolled chronic
illness / NCDs, and
any Drug limiting
toxicities
PLHIV with treatment
failure

Note: Eligibility criteria for RoC to be enrolled into any of the DSD
approaches of their choice have been removed.
Unsuppressed clients can now also receive care from a community based
approach like CDDPs
For the less intensive approaches, a RoC can change from one approach to
another if they have a suppressed viral load in the last 12 months.
DSD APPROACHES

The approaches will be implemented at the facility and the community as

shown in Figure 67.
Facility approaches

These include:
1. Facility-Based Individual Management (FBIM), where RoC gets
a comprehensive assessment on every visit at the facility (Clinical
assessment, review of results and other services like PSS)
2. Facility-Based Groups (FBGs), usually for clients that require peer
support or special attention like PBFW, children, unsuppressed clients.
These are usually for 15-40 clients meeting monthly or quarterly.
Examples include FSG, Viraemia clinics, G-ANC.
3. Fast track drug refill (FTDR), where clients are fast tracked to get their
drug refills after being triaged for adherence, TB, Nutrition etc.

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Community Approaches

These include:
1. Community Client Led ART Delivery (CCLAD), that comprises of 3-6
people who will provide peer support to each other and alternate drug
refill pickups at the facility. These clients stay in the same community
for easy access to each other.
2. Community Drug Distribution Points (CDDPs), where ART is delivered
to the community by both health workers and peers through outreach
sites to reach hard to reach populations or poor accessibility to health
facilities. For CDDPs managed by health workers, these guidelines
allow even the non- suppressed clients, children and adolescents to
be part of the CDDPs with agreed upon visit times to the CDDP. A
comprehensive care package should be given while at the CDDP site.
CDDP can be subdivided into the following:
• Drop-in Centers. This is the movement of services to a site nearer to the
population to be served.
• Community Retail Pharmacy Drug Distribution Point. Where a private
retail pharmacy, is attached to a parent health facility to service eligible
clients for this approach to improve convenience as these work past ART
clinic hours and even on weekends.
• Eligibility criteria for CRPDDP
• Not pregnant
• Not breastfeeding
• On ART for 1+ years
• Age 20+
• Client Led Drug Distribution Points. Where the clients demand for facility
services from a nearby health facility. These communities will use some of
their savings to facilitate transport and facilitation of the health workers
and the services will be integrated to include FP,SRH, Lab.
• Home delivery. This will be done by a peer support or where possible a
health care worker in the community.
• Peer led Models like YAPS.

7.2 MULTI- MONTH PRESCRIPTIONS

Multi-month prescriptions apply to clients in the different approaches.
This is defined as prescriptions for 3- or 6-months. Previous guidelines
recommended 3 months prescriptions for clients on stable approaches
like i.e., FTDR, CDDP and CCLAD. These guidelines recommend the

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introduction of 6 months prescription to all eligible clients for MMDs in

their respective approaches.
7.2.1 Frequency of clinical visits and ART pick up

PLHIV established on ART should be offered clinical visits and or ART

refills every 3–6 months, preferably every six months if feasible, which have
been associated with improved outcomes compared with monthly schedules.
7.2.2 DSD for children and adolescents

With the new categorization, children and adolescents can now be served
through both group and individual models together with their parents /
guardians. Previous guidelines restricted differentiation of HIV/TB services
for children to FBIM or FBG while the adolescents were restricted to
FBIM, FBG or FTDR. These guidelines recommend the expansion of DSD
approaches for children and adolescents to be with their caregivers and are
eligible to community-based approaches.
7.2.3 DSD implementation in the context of ART
optimization

All stable PLHIV transitioning to other regimens due to policy changes

(e.g. ART optimization) shall be retained in their current DSD approaches
if all other factors stay constant. Efforts should be made to strengthen
pharmacovigilance in all DSD models and approaches.
• Providing patient education about side effects and when to return to
facility
• Scheduling a clinical review one-month post regimen change with a one
month refill of the new regimen
• If no major concerns are identified during the clinical review one-month
post regimen change, RoC can resume multi-month refills (MMRs) and
reassessed for DSD approach
Clients enrolled into Community Drug Distribution Point (CDDP) approach
shall have their regimen optimization done as follows:
Regimen change done by clinician at the CDDP
Patient education about side effects and when to return to facility provided
at the CDDP
3 or 6 -months refill provided
Clinical review scheduled at 1 month later at the facility. If no major concerns
identified the client is referred back to the CDDP for the next scheduled visit

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Clients enrolled into the Community Retail Pharmacy Drug Distribution

Point (CRPDDP) approach shall have their regimen optimization done as
follows:
• Facility will inform the pharmacy about eligible clients for ART
optimization and send them back to the facility.
• Facility will also inform the eligible clients to come to the facility on their
next visit.
• Regimen change done by clinician at the facility.
• Patient education about side effects and when to return to facility provided
at the facility and CRPDDP
• 3 or 6 -months refill provided
• Clinical review scheduled at 1 month later at the facility or CRPDDP.
7.2.4 Provision of TPT Within DSD Models And Approaches

TB Preventive Therapy (TPT) is recommended for specific sub-populations

who are at an increased risk of getting TB disease as per details in Chapter
6. The following should be followed while providing TPT in the context of
DSD:
7.2.5 TPT initiation

TPT should be initiated by a clinician regardless of which DSD approach

the client is on. Efforts should be undertaken to have baseline tests done (i.e.
LFTs) prior to initiation of TPT.
TPT should be initiated at the health facility and community for all clients
receiving ART services through FBIM, FBG, FTDR, CRPDDP and CCLAD.
For clients enrolled onto CDDPs, TPT should be initiated from the CDDP
during the clinicians visit. Efforts should be undertaken to have baseline tests
done (i.e. LFTs) at the time of initiation of TPT.
Patient education about side effects and when to return to the facility should
be provided at the time of TPT initiation regardless of DSD approach.
TPT and ART refills should be aligned
7.2.6 Monitoring clients on TPT

Clinical monitoring of clients on TPT should be done at every clinical

encounter regardless of DSD approach the client is on:
Monitoring can be done through history taking and physical examination for
signs suggestive of hepatic injury (i.e. Yellowing of eyes, body itching, body
rash)

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Monitoring can also be done through follow up phone calls to the clients.
During the phones calls health workers should explore for signs of liver
injury, adherence to treatment and provide client education.
LFTs should be done at baseline and at 3 months
7.2.7 How to Introduce DSD Models

Health care workers and other service providers in direct contact with
clients need to be familiar with DSDM and therefore need to be trained to
implement the selected approaches, and to enter data and maintain records
that will help in future analysis of results.
During and immediately following the training of health care workers on
DSD, MoH recommends the stepwise approach detailed in Table 90 to be
followed in your facility to introduce differentiated models of service delivery.
This approach will facilitate effective implementation and coordination of
DSDM.
Table 90: Stepwise approach to introduce differentiated
models of service delivery
Step 1: Establish a committee to coordinate DSDM activities
Strengthen an existing committee to undertake DSDM activities. At a
minimum they should include:
• ART In Charge
• HTS Focal Person
• HMIS/Data Clerk
• Logistics Focal Person
• QI Focal Person
• PMTCT/EID Focal Person
• Community Representative (Health Assistant, CDO, VHTs, CHEWs)
• TB Focal Person
• Laboratory Focal Person
NOTE:
i) This team should be supervised by the Health Facility In-charge
To ensure buy-in and facilitate quick and easy DSDM implementation
in the facility, the established committee will be in charge of
coordinating the development and implementation of the work
plan

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Step 2: Conduct assessments to:

• Determine the current practices i.e. what models and approaches are
being implemented in the facility and community based on the building
blocks and the elements.
• Define the priority sub populations receiving services in your facility and
communities. These will be the populations for whom both HTS and
Care and Treatment services will be differentiated.
• Determine the characteristics of each of the identified sub populations
above.
• Engage with community members and volunteers.
• Determine the challenges by service providers in delivering different
services to specific groups.
Step 3: Review results from the various assessments to determine the
appropriate model(s) and approach(es) for your facility both HTS and
Care and Treatment
Step 4: Assess resource needs
The approaches do not require additional resources in the run phase.
However, they will require upfront investments. The facility needs to have
a clear understanding of resource requirements before starting. Resources
may include human resources, extra materials/equipment, and financial
support.
Step 5A: Devise a clear work plan and implement selected model(s), with
key milestones. Designate responsible persons
Step 5B: Implement and Monitor the model(s)
• Refer to details for each model and approach on how to implement
(Differentiated HTS and differentiated HIV Care and Treatment sections)
• Utilize relevant SOPs, job aides, tools and registers for each model
• Monitor set indicators for each model and approach (Refer to M&E
section)
• Review progress through CMEs, review meetings, etc.
• Identify areas for improvement and use QI approach to address them
(Refer to QI section)
• Assess impact of the QI interventions and make necessary adaptations
• Report (Refer to M&E section)
NOTE:
At the end of each month report how many new approaches (by model)
have been formed

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Step 6: Document best practices

• Documentation for best practices should be detailed enough, addressing
aspects such as:
• Processes that were undertaken
• Structures/systems that were developed and/or strengthened
• Positions that were designated for key DSD activities
• Resources used, including how they were mobilized - from who or which
organization and whether they fostered TB/HIV collaboration efforts
• Networks that were developed – within the community, across facilities etc.
and how this was done
• Successes attained
• Challenges encountered and how they were addressed or attempted to be
address (if the challenges still exist); etc.
Refer to the Implementation guide for Differentiated Service Delivery
for HIV and TB Services in Uganda for details.
Box 12: Key highlights in Service Delivery Approaches
The core principle for differentiating care is to make it client-centered
by providing ART service delivery in a way that acknowledges specific
barriers identified by clients and empowers them to manage their disease
with the support of the health system.
Determining the type of DSD bases on the category of patients (adults,
adolescents, children, pregnant and breastfeeding women, key and
priority populations), clinical status of patients (stable or unstable) and
the context (rural or urban).
DSD may be provided in the facility and in the community. Unstable
patients will receive facility-based DSD interventions while stable
patients may receive community-based DSD interventions.
Multi-month prescriptions for ART and other medications for up to 6
months are recommended for eligible stable clients in whom frequent
drug pickups may compromise their adherence to ART including key
populations, migratory and those in hard to reach settings.
Community structures and systems play a key role in completing the
continuum of care by increasing demand, uptake and continuous
utilization of HIV prevention, HTS, care and treatment services both in
facilities and community. A coordinated system of referral and linkage
between community structures and health facilities should be established
to ensure access to services and optimal outcomes.

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7.3 COMMUNITY SYSTEMS AND STRUCTURES IN

OPTIMIZING DELIVERY OF HIV/TB SERVICES
Community engagement aims at ensuring inclusiveness and involvement of
all stakeholders such as the community based, community led organizations
and other stakeholders in the delivery of services to ensure that services
respond to the needs of clients, gender responsive and informed by and
respond to an analysis of equity.
The National Community Health Strategy provides guidance to all
stakeholders on the strategic direction and implementation of community
interventions and the community engagement framework is hinged on the
above strategy intended to define the implementation of community services
in HIV/TB geared at achieving epidemic control.
Figure 73: Community Engagement Conceptual Frame-
work

Guided by the above conceptual framework, the framework is intended to

define the standard package of community based services relevant to all
People Living with HIV and communities based on principles of personal
centeredness, community leadership, and enabling linkages with existing
services. The framework stipulates four pillars that should be implemented by
the health facility to achieve maximum support towards achieving epidemic
control as explained below.

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7.3.1 Coordination and Collaboration of all Community

Stakeholders in Delivery of Services to Communities

At all levels of support, structures should be established with a mechanism

for coordinating the different stakeholders to ensure clients receive a
continuum of services.
A comprehensive service mapping should be conducted to operationalize
the coordination at all level. This exercise is geared to establish, build and
strengthen functional beneficiary referral networks at all levels.  The exercise
will enable all districts to establish the existing community resources and
service delivery structures to generate data that facilitates the building of
strong and formal partner service linkages and networks. The establishment
of strong formal linkages and referral networks will scale up accessibility and
utilization of core services, and expand the case management approach to
build long term sustainability. Through enhanced coordination, user-friendly
directories, effective follow-up mechanisms and improved service provider
capacities, People Living with HIV who access one key core service will
be linked to multiple core services that pave the way to sustained health
outcomes and graduation from social assistance.
These structures should be operationalized at national, regional and
community level as explained below.
Figure 74: Functionalizing a Coordination Structure

At national level

The Ministry of Health will provide overall strategic policy direction

and guidance together with key line Ministries and other national level

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stakeholders through the National Community Technical Working Group.

Additionally, the Ministry of Health will provide technical assistance through
the regional referral hospital community health department to operationalize
coordination for all the partners in the regions.
Regional level

The Regional Referral Hospitals’ through the Community Health Department

shall work with the regional partners to functionalize a regional coordination
structure.
District Level

The District Community Development Office together with the District

Health Office will spear head planning, coordination, monitoring and
supervision of the implementation of the community interventions
beginning with mapping of all stakeholders with in their catchment area.
The District will monitor and supervise activities that provide an enabling
environment for smooth implementation of the community interventions.
The District will also ensure the functionality of multi sectoral coordination
committees at both sub-county, parish and community levels.
Health facility level

Facilities will establish a functional community referral focal desk operated

by the community resource persons to ensure documentation, completion
and timely feedback. The referral focal desk through the referral focal person
will be the site of engagement between health workers and lay counselors,
addressing challenges, defining priorities and responding to challenging
cases requiring coordinated interventions. The health facility should train
community resource persons (Para Social Workers, Village Health Teams,
Expert Clients, Health Assistants, peer educators, mentor mothers, and male
champions) as well as compiling and reporting on the community-based care
activities and indicators.
The health facility should map children on ART and in organized settings such
as (education institutions, institutional homes and foster homes) to ensure
they receive a continuum of services they require to adhere to treatment.
Staff working in these institutions should be trained using the MOH
community HIV training curriculum and equip them with the treatment
literacy handbooks to support the CALHIV in schools as well as linking
them to nearby health facilities for additional support. The operational step
by step SOP can be found in the treatment literacy handbook

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Community Level

Community based organizations and other organized groups including

People Living with HIV networks, peer support groups, Expert Clients, male
action groups, youth and adolescent groups provide services to the target
populations as guided by the core package of community-based services and
established Memorandum of Understanding with implementing partners
and facilities as appropriate. The organizations will periodically compile and
report on the community- based care activities to the district.
7.3.2 Client-Centered Service Delivery

Integrated client centered service delivery aims at promoting a Family-

centered approach which is community led, promotes participation of people
living with HIV and empowers patients to take responsibility and ownership
of their health for HIV epidemic control.
Figure 75: Integrated Community Service Delivery Model

How does the approach work?

This family centered approach to care is applicable for all Recipient of Care
and their family members or caregivers at household and community (village)
level. People living with HIV are grouped according to their villages into cells
for provision of the minimum package of services. The approach offers a
platform for clinical support and linkage to other support services using the
4 building blocks to ultimately improve the quality of clinical care and social
wellbeing.

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How to operationalize the model

At the Facility
• Update the EMR and other primary data sources
• Conduct a mapping exercise of non-suppressed clients;
• Line list all people living with HIV in the facility by District, Sub county,
Parish and villages where they live.
• Zone the people living with HIV according to the villages of residence.
Follow up the line listed people living with HIV by their villages
passively for those returning within one month and actively for those
with an appointment longer than a month to return to the health
facility on a scheduled date for the inception meeting.
• Map the community Health Workers from the same villages where the
non-suppressed are coming from.
• Attach community health workers (peer mother, client linkage
facilitators, caregiver mentor, para- workers, safe space leader)
depending on village/safe space of abode.
• Conduct HIV training for Community health workers using the Ministry
of Health training curriculum for community actors.
• Conduct meeting between community health workers and the non-
suppressed to be supported at health facility.
• Give information on the model, obtain a written consent
• Zone household of the non-suppressed per villages/cells into groups
of 5-10 families and agree on the day and central meeting place in the
community
• Introduce package to be offered
• Provide 3 months refill to non-suppressed and 6 months refill to
suppressed clients and family members in the community.
• Synchronize clinical appointments for care and drug refills for the clients
and the community health worker (Safe space leader) at health facility.
In the community

Pre safe space meeting preparations

• The health worker uses service gap identifier tool to offer services to
eligible for all people living with HIV and their family members.
• Safe space lead conducts pre appointment reminders to patients on the
agreed location and date
• The safe space lead prepares and delivers play materials

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At the quarterly safe space meeting

• Safe space lead mobilizes clients for services
• Health worker or safe space lead gives health information
• The health worker updates service gap identifier tool to offer services to
eligible people living with HIV and their family members.
At the monthly safe space meeting
• Safe space lead gives health information
• Skills building and economic strengthening
• Saving and Loans schemes activities
• Provide play materials for children at the spaces in the community
• Schedule appointments
Daily safe space visits (at the agreed meeting point)

The second 2 weeks after household Directly Observed Treatment and

support the treatment supporter will move with the non-suppressing people
living with HIV to the agreed meeting point. This is intended to ensure that
the people living with HIV is taking the medicine the right way as guided by
the safe space lead.
The safe space lead will;
• Give health information
• Conduct Directly Observed Treatment and support
• Do Pill count
• Provide Intensive Adherence Counselling support
• Link clients to social services
Daily household visits

The safe space leader will conduct daily Directly Observed Treatment and
support at household level for the first 2 weeks (14 days) during the intensive
phase of the Directly Observed Treatment and support to improve adherence
on treatment for the non-suppressed people living with HIV.
• Health workers will conduct an initial joint home visit with the Community
Health Worker (Safe space lead) and Orphans and Vulnerable Children
team to each of the household of a non-suppressed. They will conduct a
root cause analysis (RCA) and develop a joint care plan including.
• 2 weeks of daily contact
• Cell lead gives health information (treatment literacy)
• Directly Observed Treatment
• Pill count
• Intensive Adherence Counselling and support

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• Linkage to other social services

7.3.3 Treatment Literacy

Treatment literacy is one of the challenges causing the slow progress to the
achievement of the global 95-95-95 targets. This has been observed in how
care givers administer treatment to children. There is limited knowledge on
the importance of timely viral load bleeding and there remains significant
stigma and discrimination in the community and households.
As guided by the community framework, the Ministry of Health developed a
treatment literacy pillar to address the gaps in knowledge and understanding
of HIV among the different sub populations.
Treatment literacy translates medical information on Antiretroviral Treatment
(ART) into languages and formats that are understandable by all. It is defined
as understanding the major issues related to an illness or disease – such as the
science, treatment, side-effects, and guidelines – so that the patient can be more
responsible for their own care and will demand their rights when proper care is
not available to them.
Treatment literacy encompasses a matrix of approaches and stakeholders
at national, regional, district and community level. These approaches link
to each other and engage a wide number of stakeholders as shared in the
Community Engagement Framework.

7.4 INTEGRATING CONTINUOUS QUALITY

IMPROVEMENT INTO HIV CARE
The Ministry of Health recommends the use of continuous quality
improvement (CQI) as means to ensure the provision of high-quality health
services and attainment of the 90-90-90 HIV targets. CQI is an approach
to improvement of service systems and processes through the routine use
of health and program data to meet patient, and program needs. The basis
of CQI is a continuous measurement of the actual performance against the
desired performance as per set national standards. The Ministry of Health
recommends a combination of work environment organization using 5Ss
(Sort, Set, Shine, Standardize, Sustain) and CQI methodologies to achieve
Total Quality Management (TQM).
The health sector quality improvement framework clearly spells out quality
improvement roles and responsibilities at the different levels of the health
system from national level through regional, district, health sub-district,

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health facility to work improvement team levels.The functionality of these

structures is crucial to the integration of CQI in health care services. This
chapter will describe the process of using CQI to improve HIV service
delivery through addressing the service delivery gaps.
7.4.1 Steps to use CQI To Address HIV Services Delivery
GAPS

CQI embraces five principles of client focus, teamwork, review of processes

and systems, use of data to make decisions, and effective communication.
Table 93 below describes the steps involved in using CQI to address HIV
service delivery gaps. Steps 1 and 2 describe the process of forming teams
while steps 4 and 5 describe how the teams implement CQI. Steps 3–5
should be followed for each performance gap and regularly repeated (at least
monthly) until the performance gap has been closed.
Table 93: Steps to use CQI to improvement HIV service
delivery gaps
Step Description
Establish the Team should have leader.
health facility QI They will supervise the HIV work improvement teams
team (WIT) for different care processes.
Set up • WIT should be set up for the different care processes
HIV work along the HIV continuum of care.
improvement • They will dedicate time to understanding their current
teams (WIT) process for providing HIV care services, identify gaps
and bottlenecks.
• They will use the CQI approach through applying the
principles of an iterative cycle of improvement (Plan,
Do, Study, Act [PDSA] Cycle).
Identify gaps • WIT should regularly review performance and HIV
QI indicators.
• WIT should analyze the data and identify performance
gaps by comparing current performance to set targets.
Gap analysis to • Use QI tools such as brainstorming, flow charting,
get root causes five whys, cause and effect analysis to identify the root
causes of the performance gaps.
Develop • Use QI tools like the driver diagram to develop
possible possible solutions to address the performance gaps
solutions

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Step Description
Prioritizing • Use a prioritization matrix to prioritize the solutions
solutions to be implemented.
to address • Look for solutions that give maximum benefit at
performance relatively low cost.
gaps
Developing WIT will:
improvement • Develop improvement aims from the prioritized gaps.
projects • List all the activities in a particular process targeted
using the for improvement.
documentation • Use the activities to develop a flow chart for the
journal process.
• Use the flow chart to identify the individuals who will
perform the different activities and include them in
the WIT for the process.
• Develop an improvement objective from the
prioritized performance gap with the aid of the HIV
QI indicator manual.
• Document the data in the graph template of the
documentation journal.
• Develop an action plan indicating the changes that
the team agreed to test or redesigning the service
delivery model.
7.4.2 Monitoring of CQI Implementation
• Work improvement teams working on a particular improvement project
should regularly review performance data (in the documentation journals)
resulting from the implementation of changes targeting the improvement.
• Health facility QI teams and QI focal person should jointly review the
teams’ documentation journals and provide guidance as necessary regularly
(at least monthly).
• District QI committees should supervise and guide QI implementation at
health facilities.
• Regional QI Committees should mentor and supervise district and selected
facility QI implementation.
7.4.3 The following documents provide more guidance on
implementing CQI:
a. Health Sector Development Plan (HSDP) 2015/16-2019/20 (Ministry
of Health)
b. Health Sector Quality Improvement Framework and Strategic Plan
(QIF & SP) 2015/16 - 2019/20 (Ministry of Health).

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c. CQI training curriculum for health workers 2020

d. The clinical Audit tool
Box 13: Key highlights in Service Delivery Approaches
• The core principle for differentiating care is to make it client-centered by
providing ART service delivery in a way that acknowledges specific barriers
identified by clients and empowers them to manage their disease with the
support of the health system.
• Determining the type of DSD bases on the category of patients (adults,
adolescents, children, pregnant and breastfeeding women, key and priority
populations), clinical status of patients (stable or unstable) and the context
(rural or urban).
• DSD may be provided in the facility and in the community. Unstable patients
will receive facility-based DSD interventions while stable patients may receive
community-based DSD interventions.
• Multi-month prescriptions for ART and other medications for up to 6
months are recommended for eligible stable clients in whom frequent drug
pickups may compromise their adherence to ART including key populations,
migratory and those in hard-to-reach settings.
• Community structures and systems play a key role in completing the
continuum of care by increasing demand, uptake and continuous utilization
of HIV prevention, HTS, care and treatment services both in facilities
and community. A coordinated system of referral and linkage between
community structures and health facilities should be established to ensure
access to services and optimal outcomes.

7.4.4 Monitoring and Evaluation of the Strategy

All programs will be required to monitor and track progress towards achieving
the four major pillars of the framework. Data should also be used to build a
knowledge base on effective two-way referrals, linkages and quality service
delivery between facilities and communities, including implementation
of differentiated service delivery. This will help identify strengths and key
areas for improvement, and to define and implement quality improvement
activities.
Community Led Monitoring will be used as a client feedback mechanism to
generate information for improvement of quality of HIV services.

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Community Led Monitoring is a social accountability and advocacy strategy

with the primary objective of contributing to improvement of quality of HIV
and TB services by holding duty bearers and healthcare service providers
accountable for the quality of HIV and TB services offered.
The primary purpose of Community Led Monitoring is to engage community
stakeholders affected by HIV and TB to use data to improve the quality of
client-centered care.
Community Led Monitoring is led by civil society organizations representing
communities living with, affected by and at high risk of HIV and TB to
independently conduct systematic and routine monitoring of facility and
community service delivery sites and to use their findings to advocate for
improvements in the quality and accessibility of HIV and TB services

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8 HEALTH PRODUCTS
MANAGEMENT
8.1 INTRODUCTION
This section describes the health products management to support the scale-
up of HIV prevention, care and treatment services for Uganda to attain the
95-95-95 targets. This includes product selection in line with the updated
guidelines and patient regimens, aspects of quantification, ordering and
reporting as well as commodity management by health facilities.

8.2 PRODUCT SELECTION, QUANTIFICATION AT THE

CENTRAL LEVEL
At the National level, products are selected according to the consolidated
guidelines for HIV prevention, care, and treatment. New commodities,
formulations, strengths, and pack sizes are adopted as recommended in
the guidelines while obsolete ones are equivocally dropped. The Essential
Medicines and Health Supplies List of Uganda (EMHSLU) is reviewed
periodically, and such changes considered.
The Department of Pharmaceuticals and Natural Medicines through the
Quantification and Procurement Planning Unit (QPPU) in consultation with
the ACP is responsible for the national level quantification, supply planning
and ensuring reliable and uninterrupted supply of HIV commodities at
National Medical Stores and Joint Medical Store.
Table 94: New Formulations being introduced.
# Item Description Dosage form
1 Tenofovir alafenamide /Emtricitabine/Dolutegravir Tablet
25/200/50mg - TAF/FTC/DTG 25/200/50mg)
2 Darunavir/Ritonavir 400/50mg (DRV/r 400/50mg) Tablet
3 Lopinavir/Ritovir 40/10 mg - LPV/r 40/10 Granules Granules
4 Dapivirine 25mg vaginal ring Ring
5 Cabotegravir 600mg/3ml – Long Acting (CAB-LA) Injection
The timing for the introduction of each of the formulations will be
communicated by MoH.

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8.3 FLOW FOR COMMODITIES USED IN THE

PREVENTION, CARE AND TREATMENT FOR HIV.
Figure 76: Flow for Commodities used in the Prevention,
Care and Treatment for HIV.

Except for antiretroviral medicines meant for clients on third line and a
few special distribution commodities, Supply of Commodities Used in
the Prevention, Care and Treatment for HIV follows the one warehouse
one health facility policy and the 2012 ART rationalization guidelines
where every health facility is allocated one central warehouse for supply and
resupply of Essential Medicines and Health supplies as illustrated above and
emphasized below.
• National Medical Stores is responsible for supplying commodities to all
ART accredited health facilities within the public sector while.
• Joint Medical Store supplies the ART accredited health facilities within the
Private Not for Profit (PNFP) sector.
• Newly accredited facilities should refer to the accreditation letter for
information on warehouse allocation.
Flow for Antiretroviral medicines meant for Third line
Clients.

• Flow of third line commodities follows the current recommended support

structure for third line programing which is provided through the regional
referral hospitals (RRHs).

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• Currently, National Medical Stores is the only warehouse that supplies

commodities meant for third line. These are supplied to RRHs which later
supply to the health facilities and or Centers of Excellence (CoEs) under
their support.
• PNFP health facilities in Kampala and Wakiso access third line ARVs from
the CoE that directly supports them.
Special Distribution Commodities.

• The include commodities meant for Pre-exposure Prophylaxis (PrEP),

Voluntary Medical Male Circumcision (VMMC), Medication Assisted
Therapy (MAT) and STI medications funded specifically for HIV
programing usually donor specific.
Figure 77: Commodity Flow, Ordering and Reporting
Timelines for PrEP, STI and VMMC commodities

Note

• Given the restrictions associated with handling the MAT commodities,

they are delivered straight to the sites offering MAT services that have
strong rooms and adequate training to avoid misuse.
• Plans to integrate above commodities into the National supply chain are
underway, MoH will provide further guidance.

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8.4 SELECTION OF HEALTH PRODUCTS AT FACILTY

LEVEL
In general, all health facilities should select antiretroviral drugs and related
commodities for both existing and new patients in line with the current
Consolidated Guidelines for the Prevention, Care and Treatment for HIV
and AIDS in Uganda (see Chapter 3).
• It is recommended that the overall number of ARV- formulations and
related commodities be minimized to optimize treatment.
• A health facility should select and order for formulations which have
clients benefiting from them.
• Guidance for introduction for new formulations will always be given by
MoH.
• Health facility teams should constantly monitor and review formulations
with clients and those which no longer have clients taking them should be
deleted from the facility list to avoid ordering and accumulation of either
obsolete or unnecessary items.
• For third line ART program, only health facilities designated to order for
third line ARVs (RRHs) should select and order for third line ARVs.
8.5 ORDERING AND REPORTING BY THE HEALTH
FACILITIES
All facilities are required to quantify their need for HIV commodities (ARVs,
OI medicines, PrEP, HIV test kits, laboratory monitoring reagents. etc.)
required for all existing and new patients to ensure uninterrupted availability.
The number of patients on treatment, rate of consumption of the various
commodities should inform the quantities of commodities to be ordered,
putting into consideration the recommended minimum and maximum stock
levels.
General Guidance
• Ordering and reporting of medicines and HIV test kits and related
laboratory reagents at health facilities is a multi-disciplinary task that
should involve the pharmacist, dispenser, clinician, the laboratory officer,
the M&E officer, and inventory officers where applicable.
• Ordering processes should be coordinated and led by a pharmacist or a
dispenser or a person designated to manage medicines and health supplies
in the facility.
• Facilities should order medicines and HIV test kits on a bi-monthly basis
following schedules provided by their respective central warehouses.
Complete, correct, and timely orders should always be submitted.

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• Health facilities should order for ARVs, Fluconazole, Cotrimoxazole,

Dapsone, L-Amphotericin B and Flucytosine using the ARV Medicine
order and Patient report form (HMIS PHAR - 017)
• Isoniazid and Rifapentine should be ordered using the Health Facility
Order Form for First Line TB Drugs (HMIS PHAR-026).
• HIV test kits should be ordered using the bimonthly report and order
calculation form for HIV test kits (HMIS PHAR-021)
• Other laboratory commodities should be ordered using the general
laboratory order form (HMIS PHAR-023)
• All paper orders should be fed into the electronic ordering platform (NMS
CSSP for public sector facilities and electronic Logistics Management
Information Systems (eLMIS) App in DHIS 2 for PNFP health facilities).
• The Ministry of Health revised all logistics management information
system (LMIS) tools to accommodate changes in the 2022 treatment
guidelines. Health facilities should obtain copies of updated LMIS from
the warehouses.
Preparing Bi-Monthly Orders and Reports

When making bi-monthly orders and reports, health facilities should prepare
and use the following information:
• Consumption data obtained from dispensing logs or electronic logistics
management information systems if available and consistently used.
• Stock on hand of commodities obtained from the stock cards after
conducting a physical count. Stock on hand should include balance of
commodities in the dispensary and any other units where medicines are
stored or dispensed.
Facility patient data including:

• The number of existing patients on treatment aggregated by age and

treatment regimens at the beginning of the reporting period obtained from
the ART registered or the Electronic Medical Records (EMR).
• The number of new patients enrolled in the reporting period including
those patients switching to other lines of treatment regimens obtained
from the ART registered or the Electronic Medical Records (EMR).
Other considerations when ordering include:
• The minimum and maximum stock levels
• The required delivery date for new orders
• Any anticipated risk of expiry

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• Transition of patients should be planned to take into consideration the

available stock and lead time for the next cycle delivery to avoid stock out
and wastage of existing formulations.
Submitting the bi-monthly order
• Health facilities should submit timely orders and reports to the appropriate
warehouse in line with their ordering and delivery schedules.
• Health facilities should first compile the bi-monthly order using the hard
copy of the appropriate HMIS PHAR tool, have it reviewed by the teams
for any errors, make all necessary correction to have a final order that is
representative of the facility need.
• The final orders should be submitted electronically through the
recommended electronic systems (NMS CSSP for public sector facilities
and electronic Logistics Management Information Systems (eLMIS) App
in DHIS 2 for PNFP health facilities).
• A hard copy of the final order should be always filed for quick reference
and validation.
NEW FORMULATIONS INTRODUCED
Dolutegravir/Emtricitabine/Tenofovir
Darunavir/Ritonavir 400/50mg (DRV/r
alafenamide 50/200/25mg
400/50mg)
(TAF/FTC/DTG 25/200/50mg)
Pack size

30 tablets Pack size: 60 tablets

90 tablets

Lopinavir/Ritovir 40/10MG Granules-Pack of 120

8.6 GUIDANCE ON ORDERING AND REPORTING FOR

THIRD-LINE ART MEDICINES
Ordering and reporting for third line ARVs is currently restricted to regional
referral hospitals. This means only regional referral hospitals will be ordering
and reporting on the consumption and usage of third line ARVs. The RRHs
shall aggregate the medicines need for all patients in the region and submit
a consolidated third line ARV order for the entire region. Once medicines

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are received at the RRHs, they should be distributed through the same
mechanism.
The referral hospitals shall use the standard ARV ordering and reporting
forms to order and report on third line ARV following the bi monthly
ordering and reporting cycle. This should be done alongside other ARVs.
Orders should be submitted through the NMS CSSP before the order
deadline.
Table95: How To Access Third Line ARV Medicines.
Facility Source Of Third Line Medicine
All public health facilities Regional referral hospital for the
respective region
Centers of Excellence Regional referral hospital for the
respective region
PNFP health facilities outside Regional referral hospital for the
Kampala and Wakiso. respective region
PNFP health facilities within Centers of Excellence that directly
Kampala and Wakiso. support them.

8.7 ISSUING THIRD LINE ARVS TO FOLLOW-UP

FACILITY
At the regional referral hospital
• The regional referral hospital is responsible for issuing third line ARVs
to all lower-level health facilities within the region even when their other
ARVs are provided through a different mechanism.
• The implementing partner in coordination with the district should facilitate
the movement of the ARVs from the RRH to the lower facility.
• The RRH should consider ARVs issued to the lower-level facility as
consumed and therefore should proceed and update the stock card.
• This information should be used to prepare the next ARV order and report.
At the facility
• Once the third line ARVs have reached the lower facility, the medicine
should be entered into a stock card.
• The facility should then follow the issuing procedures prescribed in the
Uganda Essential Medicines and Health Supplies Management Manual.
• Once the medicine is dispensed to the patient, the dispensing log should
be updated immediately.

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8.8 GUIDANCE FOR STOCK MANAGEMENT AT HEALTH

FACILITY
• Medicines and medical supplies should be received at the facility store
according to the recommended receipt procedure.
• The facility should then follow the issuing procedures prescribed in the
Uganda Essential Medicines and Health Supplies Management Manual.
• The person receiving the supplies should enter them into the facility stock
cards and store them under recommended storage conditions.
• Stock cards should be updated whenever stock is issued from the health
facility main store.
• Monthly physical counts should be done and reasons for any discrepancy
noted.
• All documents related to medicines transactions should be filed and kept
for future reference.

8.9 DISPENSING MEDICINES

Health care workers should do the following while dispensing ARV medicines:
• Ensure availability of dispensing tools at all dispensing points.
• Ensure medicine shelf life is long enough to cover the treatment duration.
• Dispensing to all patients should preferably be done using the primary
packaging.
• Record all transactions in the medicine dispensing log.
• Provide all the necessary information that the client needs to appropriately
take the medicines. Double check to assess understanding.
Stock Redistribution
• Redistribution should be triggered if the facility is overstocked with more
than four months of stock, there is risk of expiries or when is the either an
eminent or actual medicine stock out.
• The stock should be redistributed in line with the Uganda National
Redistribution Guidelines for Prevention of Expiry and Handling Expired
Medicines and Health Supplies, 2019.
• It is important to note that redistribution does not lead to financial loss
to the affected health facility since HIV commodities are non-credit line
items.
• It instead mitigates financial loss due to expiries and additional cost of
treatment incurred due to stock outs.
• Stock monitoring and reporting in real time is recommended to inform
redistribution.

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8.10 RATIONAL MEDICINES USE

Rational medicines use ensures patients receive medications appropriate to
their clinical needs, in doses that meet their individual requirements for an
adequate period, and at the lowest cost to them and their community.
The principles of rational medicines use are as follows:
a. Rational prescribing
Healthcare workers should prescribe medicines according to the following
principles:
• Prescribe medicines according to the treatment guidelines.
• Prescribe doses that are age and weight appropriate.
• Use the correct combination of drugs.
• Prescribe medicines for the correct treatment duration.
• Counsel patients on how to take the medicines.
• Counsel patients on substituting or switching treatment regimens.
Chapter
• Counsel 7 on safety and use of medicines
patients

Special Considerations for LPV/r 40/10mg Granules

• LPV/r 40/10 granules is one of the new ARV formulations introduced in
the new guidelines. The LPV/r 40/10 mg granules are recommended over
pellets because.
• They can be used right from 2 weeks of age as opposed to the pellets
which are recommended to start at 3 months,
• and they are easier to administer compared to the pellets.

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Table 96: Dosing for LPV/r 40/10mg Granules

Weight (kg) Number of sachets
Morning Evening
3.0 - 5.9 2 2
6.0 - 9.9 3 3
10.0 - 13.9 4 4
14.0 - 19.9 5 5
The LPV/r 40/10mg Granules are prescribed according to
body weight. The Number of sachets to be dispensed are as
highlighted in the table above.
Figure 78: Administration of LPV/r 40/10mg Granules.
LPV/r 40/10mg granules
are only one of the ARVs
that your child might
need. The mother/ care
giver still needs to give
the other ARVs at the
same time as prescribed
and advised by the health
care worker.

b. Rational dispensing
Healthcare workers should dispense medicines according to the following
principles:
• Dispense the correct quantity, dose, and dosage formulation to the correct
patient. Fixed-dose combinations are preferred.
• Provide explanation on how patients should take their medicines and
always double check to assess understanding.
• Appropriately label the medicine packs to include medicine name and
strength, patient’s name, and dose and dosage.
• Package and label medicines for individual patients that are for distribution
under the community drug delivery points.
• Offer further explanation/counseling to patients on multiple medicines
because of other co-morbidities. Communicate possible drug interactions
and adverse effects.
• Effectively introduce new formulations to patients while taking into
consideration medication branding.
• Counsel patient on adherence

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Dispensing of medicines to patients under facility-based DSD

models.

These are the clients who are receiving ARVs and other form of care directly
from the health facility. Health care workers should do the following while
dispensing ARV and other medicines;

• Ensure adequate medicines are requisitioned from facility store for

dispensing.
• Medicines shelf life should be long enough to cover duration of use by
the client.
• Preferably issue 3 months of stock for Multi-Month Dispensing using
multi-month packs where applicable
• In some stable patients who fit eligibility criteria (see section 10.1.11), 6
months of stock of drugs may be prescribed and dispensed.
• Supply medicine to newly initiating patients for a duration determined by
the clinician.
• Appropriately record all medicines issued in appropriate logistics HMIS
tools.
Dispensing of medicines to Community-based clients

These are clients receiving ARVs and other form of care from the
communities where they live. Health care workers should:

• Take into consideration recommendations for dispensing medicines to

facility-based clients above.
• Dispense medicines to the CCLAD representative using the patient held
card for each CCLAD member.
• Use the ART medicines return forms and the CCLAD monitoring forms
to ensure traceability.
• For the CDDP, ensure that medicines for CDDP are prepacked, labeled
according to the expected client refill list for each of the CDDP. These
medicines should be given to the health worker or the peer leader for that
CDDP. Once medicines are issued to the client, the patient file should be
updated accordingly.
• This information should be transferred to the appropriate dispensing log
on return to the facility.

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8.11 CRPDDP APPROACH

The Ministry of Health adopted the extended Differentiated Service
Delivery (DSD) as a model to optimize service delivery to community. Under
this DSD model, Implementing Partner (IP) organizations, district local
governments, health facilities, and Community pharmacies implement the
Alternative Drug Distribution Point (ADDP) approach; Community Retail
Pharmacy Drug Distribution Point (CRPDDP).

Figure 79: Flow for Commodities Under the CRPDDP

Approach.

Key Supply Chain considerations under CRPDDP:

• The Community Retail Pharmacy is an extension of the health facility

(i.e., extra dispensing point), therefore the overall responsibility for the
commodities that move to the CRP remains with the supporting health
facility.
• The CRP should have all the necessary hard copy tools as back bout for
system malfunctioning. The tools include, the requisition and issue voucher,
stock card, and ART dispensing log.
• Use of the electronic platform (ART Access) should take prioritized in
undertaking supply chain activities including ordering, receiving, and
dispensing of commodities, hard copies should only be used in case of the
system malfunction.

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• The CRP team should ensure that adequate medicines are requisitioned
from the facility for the clients on appointment.
• Medicines shelf life should be long enough to cover duration of use by
the client.
• A maximum of 6 months of stock of drugs may be prescribed and
dispensed to clients depending on stock availability.
• Documentation should be on a transactional basis for any activity
undertaken.
• Recommended minimum and maximum stock levels are 2 and 4 weeks of
stock respectively.

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9 MONITORING AND
EVALUATION
9.1 INTRODUCTION
A comprehensive and well-functioning monitoring and evaluation (M&E)
framework is essential to ensure that Uganda’s program to prevent and treat
HIV using ART is effective and efficient. This module provides a highlight
of the HIV/AIDS programme monitoring and plan for monitoring the roll
out of the revised guidelines.
The module is aligned to the guidance contained in the National HIV and
AIDS Strategic Plan 2015/2016–2019/2020, Health Sector HIV and AIDS
Strategic Plan (HSHASP)2018/19 -2022/23 and Health Sector HIV and
AIDS Monitoring and Evaluation Plan 2018/19 – 2022/2023.

9.2 OVERVIEW OF HIV/AIDS PROGRAMME

MONITORING
9.2.1 Pateint Data Recording

The current patient monitoring system uses paper-based tools and electronic
medical records system. However, the primary data collection method at
facilities is paper-based, and includes pre-primary, primary and secondary
tools as detailed in the Ministry of Health HMIS Manual, 2020. Paper-based
records are used to update electronic medical record systems where they
exist.
9.2.2 Patient Data Reporting

Health facilities should submit timely reports of aggregated patient data on

a weekly, monthly and quarterly basis. The monthly and quarterly reports
shall be consolidated and entered into DHIS-2. Table 94 below shows the
different reports and frequency of submission. An online dashboard to track
the implementation of the consolidated guidelines will be developed.
NB: non -ART REFILL/ absence from the health facility visits for 28 Days
or more is considered a lost followup

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Table 97: Routine reports and their frequency

Report Description Source docu- Frequency
ments
Registers: Linkag-
Reports the quarterly
HMIS 106A: es and Pre-ART,
attendance figures for
Health Unit ART, PEP, EID,
HIV care/ART, ART Quarterly
Quarterly TB, DSD, SMC,
outcomes, nutrition, and
Report PrEP, CrAg, Viral
TB services
Load .
Reports the monthly
attendance figures for HCT Register,
HMIS 105:
OPD, OPD diagnoses, EID Register,
Health Unit
MCH, HIV/AIDS ser- Safe Male Circum-
Outpatient Monthly
vice data, EID, laboratory cision Register,
Monthly
data, stock-out of essen- Laboratory Tests
Report
tial drugs and supplies Daily Summary
and financial data
HMIS 033B:
Health Unit Reports cases of noti- HIV Laboratory
Weekly Epi- fiable diseases after the Tests Log and
Weekly
demiological first few cases have been eMTCT Drug
Surveillance notified. Dispensing Log
Report
Note: Indicators for routine monitoring have been updated and can be
found in the Monitoring plan for the HSHASP 2018-2023. Facility ARV
stock and orders shall be monitored via the Web-Based ARV Ordering
System (WAOS).
9.2.3 Other programme data sources

The following sources complement the data generated from routine HIV/
AIDS programme data
• Surveys (population based, ANC surveillance, case-based surveillance,
other special surveys including size estimations, modes of transmission,
etc.)
• Programme Evaluations (PMTCT Impact evaluation, eMTCT validation,
etc.)

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Operational research

Special studies and assessments (Cohort studies, HIV drug resistance, etc.)
9.2.4 Programme Data Quality and Use

The programme has institutionalised interventions that geared to ensure that

programme data is of high quality to inform planning and decision making.
These include but not limited to; standardised HMIS manual with indicator
descriptions and definitions, annual data quality assessments, integrated and
technical supervisions.
At national, sub national (region and district) and health facility levels, use of
programme data generated from HMIS is emphasised. This is done through;
• Dashboards – tools that summarize and display aggregated data (VL, EID,
B+, HIV stituation room, WHO DHIS2 App, etc.)
• Routine data/performance reviews
• Continous Quality Improvement projects

9.3 MONITORING ROLL OUT OF REVISED GUIDELINES

9.3.1 Tracking progress of roll out

Rolling out of the revised guidelines at health facilities and training of Health
workers to ensure effective utilization of the guidelines will be tracked using
the training reports, that will be entered into the online training database.
Data will be summarized as follows; weekly for the first three months and
bimonthly thereafter. Summaries generated will be disseminated to key
stakeholder to provide an update on the roll out of the guidelines.
9.3.2 Supervision on implementation of revised guidelines

This will be conducted at the following planned intervals;

• 3 months from onset of roll out amongst the health facilities that would
have rolled out;
• One month after completion of national roll out of the revised guidelines
at health facilities
This supervision exercises are aimed at assessing whether the HIV/AIDS
services are provided based on the revised guidelines as well as identifying
challenges encountered during in the utilization of the revised guidelines.

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9.3.3 Review of the guidelines

The process of reviewing these guidelines will be informed by new emerging

facts mainly from recommendations from WHO, results of operational
research, programme evaluations and revised national strategic plans.
9.3.4 Indicator matrix

The Health Sector HIV and AIDS M&E plan 2018/19 – 2022/23 provides a
comprehensive plan that tracks programme implementation and sustainable
HIV control at national and sub national levels. Whereas several indicators
pertaining to the revised guidelines are already covered in the sector HIV
AIDS M&E plan, there are some process indicators, key to monitoring
this roll out that are not catered for by the broader M&E plan. A list of
indicators has been developed to track efficient implementation of the
revised guidelines.

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Annex 1: HIV-exposed infants visit schedule and

care package

Visit schedule Birth 6wks 10wks 14wks 5mo 6mo 9mo 12mo 15mo 18mo 24mo

Immunization X X X X -­‐ X -­‐ -­‐

Clinical
assessment X X X X X X X X X X X

Growth and
development X X X X X X X X X X X

Stable motherc- Give baby Nevirapine prophylaxis for 6weeks

CTX and ARV Unstable motherd – Give baby Nevirapine prophylaxis for 12 weeks
prophylaxis Cotrimoxazole should be started at six weeks of age or thereafter and continued
until infant is determined to be HIV-negative
Do 1stPCR at 6 weeks of age or as soon as infant is
Infant identified
Do antibody
diagnosis Do 2ndPCR at 9 months
test at 18
testinge None
Do 3rdPCR 6 weeks after cessation of breastfeeding months

Counseling
and feeding X X X X X X X X X X X
advice
Mother’s care
and treatment X X X X X X X X X X X

a - At every visit, the EID card, EID register, mother’s HIV care/ART card
and ART register should be updated as well the Open MRS/EID database
where it exists
b – The standard is starting Nevirapine at birth and cotrimoxazole at 6
weeks of age
c – Stable mother
d – Unstable mother
e - Infants should come every month until test results are given to the
caretaker

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Annex 2: WHO staging for HIV infection and

disease in adults and adolescents
Clinical Stage I:
• Asymptomatic
• Persistent generalized lymphadenopathy
• Performance Scale 1: Asymptomatic, normal activity
Clinical Stage II:
• Moderate weight loss (less than 10% of presumed or measured body
weight)
• Minor mucocutaneous manifestations (seborrhoeic dermatitis, prurigo,
fungal nail infections, recurrent oral ulcerations, angular stomatitis)
• Herpes zoster within the last five years
• Recurrent upper respiratory tract infections, e.g., bacterial sinusitis,
tonsillitis, otitis media and pharyngitis
• And/or Performance Scale 2: Symptomatic but normal activity
Clinical Stage III:
• Severe weight loss (more than 10% of presumed or measured body
weight)
• Unexplained chronic diarrhea for more than one month
• Unexplained prolonged fever, intermittent or constant, for more than
one month
• Oral candidiasis
• Oral hairy leukoplakia
• Pulmonary tuberculosis (current)
• Severe bacterial infections such as pneumonia, pyomyositis, empyema,
bacteremia or meningitis
• Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
• Unexplained anemia (<8gm/dl), neutropenia (<0.5× 109 per liter), or
chronic thrombocytopenia (<50× 109 per liter)
And/or Performance Scale 3: Bed-ridden for less than 50% of the day during
the last month

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Clinical Stage IV:

• HIV wasting syndrome – weight loss of more than 10%, and either
unexplained chronic diarrhea for more than onemonth or chronic
weakness or unexplained prolonged fever for more than one month
• Pneumocystis pneumonia (PCP)
• Recurrent severe bacterial pneumonia
• Toxoplasmosis of the brain
• Cryptosporidiosis with diarrhea for more than one month
• Chronic Isosporiasis
• Extrapulmonary Cryptococcosis including meningitis
• Cytomegalovirus infection (retinitis or infection of other organs)
• Herpes simplex virus (HSV) infection, mucocutaneous for more than
one month, or visceral at any site
• Progressive multifocal leukoencephalopathy (PML)
• Any disseminated endemic mycosis such as histoplasmosis,
coccidioidomycosis
• Candidiasis of the oesophagus, trachea, bronchi or lungs
• Atypical mycobacteriosis, disseminated
• Recurrent non-typhoid salmonella septicemia
• Extrapulmonary tuberculosis
• Lymphoma
• Invasive cancer of the cervix
• Kaposi’s sarcoma
• HIV encephalopathy – disabling cognitive and/or motor dysfunction
interfering with activities of daily living, progressing slowly over weeks
or months, in the absence of concurrent illness or condition other than
HIV infection that could account for the findings
• Atypical disseminated leishmaniasis
• Symptomatic HIV-associated nephropathy or symptomatic HIV-
associated cardiomyopathy
And/or Performance Scale 4: Bed-ridden for more than 50% of the day
during the last month

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Annex 3: WHO staging for HIV infection and

disease in infants and children
Clinical Stage I:
1. Asymptomatic
2. Persistent generalized lymphadenopathy
Clinical Stage II:
• Unexplained persistent hepatosplenomegaly
• Papular pruritic eruptions
• Extensive wart virus infection
• Extensive molluscum contagiosum
• Recurrent oral ulcerations
• Unexplained persistent parotid enlargement
• Linear gingival erythema
• Herpes zoster
• Recurrent or chronic upper respiratory tract infections (otitis media,
otorrhoea, sinusitis, tonsillitis)
• Fungal nail infections
Clinical Stage III:
1. Unexplained moderate malnutrition not adequately responding to
standard therapy
2. Unexplained persistent diarrhea (14 days or more)
3. Unexplained persistent fever (above 37.5 ºC, intermittent or constant,
for longer than one month)
4. Persistent oral candidiasis (after first six weeks of life)
5. Oral hairy leukoplakia
6. Acute necrotizing ulcerative gingivitis/periodontitis
7. Lymph node TB
8. Pulmonary TB
9. Severe recurrent bacterial pneumonia
10. Symptomatic lymphoid interstitial pneumonitis
11. Chronic HIV-associated lung disease including bronchiectasis
12. Unexplained anaemia (<8.0 g/dl), neutropenia (<0.5 x 109/L3) or
chronic thrombocytopenia (<50 x 109/ L3)

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Clinical Stage IV:

• Unexplained severe wasting, stunting or severe malnutrition not
responding to standard therapy
• Pneumocystis pneumonia (PCP)
• Severe recurrent bacterial infections (e.g. empyema, pyomyositis, bone
or joint infection, meningitis, but excluding pneumonia)
• Chronic herpes simplex infection; (oral, labial or cutaneous of more
than one month’s duration, or visceral at any site)
• Extrapulmonary TB
• Kaposi’s sarcoma
• Oesophageal candidiasis (or Candida of trachea, bronchi or lungs)
• Toxoplasmosis of the brain (after the neonatal period)
• HIV encephalopathy
• Cytomegalovirus (CMV) infection (retinitis or infection of other
organs) with onset at age over one month
• Extrapulmonary cryptococcosis (including meningitis)
• Disseminated endemic mycosis (extrapulmonary histoplasmosis,
coccidiomycosis)
• Chronic cryptosporidiosis (with diarrhea )
• Chronic isosporiasis
• Disseminated non-tuberculous mycobacteria infection
• Cerebral or B-cell non-Hodgkin lymphoma
• Progressive multifocal leukoencephalopathy
• HIV-associated cardiomyopathy or nephropathy

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Annex 4: Intensified TB case finding guide

Annex 5: Intensified TB case finding guide

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Annex 6: Algorithm for TB diagnosis in children
Annex 5: Algorithm for TB diagnosis in children

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Annex 6: Algorithm for TB diagnosis in HIV

positive adults and adolescents
Annex 7: Algorithm for TB diagnosis in HIV positive adults and adolescents

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Annex 7: Treatment algorithms for sexually

transmitted diseases in Uganda
Annex 8: Treatment algorithms for sexually transmitted diseases in Uganda

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Annex 8: Human resources for differentiated

service delivery and their roles

Mentor Mothers), CBOs and

CSOs working with PLHIV
Trained Nursing Assistants

Technicians/ Dispensers/

Laboratory Technicians/

Clients, VHTs, CHEWS,

Doctor/ Clinical Officer

Assistants/ Data Clerk

Lay providers (Expert
Laboratory Assistants
Nurses/ storekeepers
Pharmacists/ Pharm

Health Information
Nurse/ Midwives

VHT
Comprehensive
clinical services
including, NACS,
X X
symptom screening
for NCDs, TB,
STIs and hepatitis
Prescription of
ART, initiation
and follow up for X X
adults, adolescents
and children
Switching and
substituting ART
regimens by a X
multidisciplinary
‘switch team’
Management
of complicated
cases(e.g.
cryptococcal
X
meningitis (CCM);
second line
treatment failure
etc.)

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Mentor Mothers), CBOs and

CSOs working with PLHIV
Trained Nursing Assistants

Technicians/ Dispensers/

Laboratory Technicians/

Clients, VHTs, CHEWS,

Doctor/ Clinical Officer

Assistants/ Data Clerk

Lay providers (Expert
Laboratory Assistants
Nurses/ storekeepers
Pharmacists/ Pharm

Health Information
Nurse/ Midwives

VHT
TB initiation of
smear or gene
X-pert positive
X X
cases for adults,
adolescents and
children
TB initiation
for adults and
adolescents
requiring chest
x-ray (CXR) X
interpretation,
and for children
where no sputum
is available
HIV testing
X X X X X X X
services
Health Education X X X X
Registration
and filling of
X X X X
appointment
diaries
Performing vital
X X X
signs (triage)
Dried blood spot
(DBS), VL sample
X X X X X
collection, testing
and results delivery

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Mentor Mothers), CBOs and

CSOs working with PLHIV
Trained Nursing Assistants

Technicians/ Dispensers/

Laboratory Technicians/

Clients, VHTs, CHEWS,

Doctor/ Clinical Officer

Assistants/ Data Clerk

Lay providers (Expert
Laboratory Assistants
Nurses/ storekeepers
Pharmacists/ Pharm

Health Information
Nurse/ Midwives

VHT
Coordinating and
supervising the X X X
community groups
Linkage facilitation X X X X
Pre-packing
medicines, picking
drug refills,
distribution of
refills, Forecasting
and ordering of
X X X* X
commodities from
the warehouses,
Dispensing,
Filling/updating
the dispensing log
and tracking tools
ART preparation
and adherence
counselling for
adults, adolescents,
X X X X X X
children and
pregnant women
including
treatment failure
Defaulter tracing X X X X X

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Mentor Mothers), CBOs and

CSOs working with PLHIV
Trained Nursing Assistants

Technicians/ Dispensers/

Laboratory Technicians/

Clients, VHTs, CHEWS,

Doctor/ Clinical Officer

Assistants/ Data Clerk

Lay providers (Expert
Laboratory Assistants
Nurses/ storekeepers
Pharmacists/ Pharm

Health Information
Nurse/ Midwives

VHT
Client records
management/data
entry & updating X X X X X
registers (for area
of service)
Phlebotomy X X X
Reporting on
community
activities/client
groups, support; X
coordinate and
supervise their
peers
Community –
facility referrals X
and vice versa

*These service providers will be supervised while undertaking these tasks

**Lay clients include; expert clients, VHTs, CHEWS, andmentor mothers

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Annex 9: Home education/eating/exercise

activities drugs/depression sexuality
suicidality/safety assessment tool in
adolescents
HEADSS ASSESSMENT TOOL
Component Area of assessment Assessment
results
Home, • Who lives with the young person? Where?
situation, • Do they have their room?
family • What are relationships like at home?
• What do parent and relatives do for a living?
Ever institutionalized? Incarcerated?
Recent moves? Running away?
• New people in ahome environment?
• Have they disclosed their HIV status?
If yes, with whom? If not, what are the
reason?
Education • School/grade performance--any recent
and changes? Any past dramatic changes?
employment • Favourite subjects--worst subjects?
(include grades)
• Any years repeated/classes failed?
• Suspension, termination, dropping out?
• Future education/employment plans?
• Any current or past employment?
• Relations with teachers, employers--
school, work attendance?

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HEADSS ASSESSMENT TOOL

Component Area of assessment Assessment
results
Activities • On own, with peers (what do you do for
fun? where? when?)
• With family?
• Sports--regular exercise?
• Religious attendance, clubs, projects?
• Hobbies--other activities?
• Reading for fun--what?
• TV--how much weekly--favourite shows?
• Favourite music?
• Doestheyoung person have acar, use seat
belts?
• History of arrests--acting out--crime?
Drugs / • Use by peers? Use by a young person?
tobacco/ (include tobacco, alcohol)
alcohol • Use by family members? (include tobacco,
alcohol)
• Amounts, frequency, patterns of use/
abuse, and car use while intoxicated?
• Source—how theypaid for them?
Sexuality • Orientation?
• Degree and types of sexual experience and
acts?
• The number of partners?
• Masturbation? (normalize)
• History of pregnancy/abortion?
• Sexually transmitted diseases--knowledge
and prevention?
• Contraception? The frequency of use?
Comfort with sexual activity, enjoyment/
pleasure obtained? History of sexual/
physical abuse?

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HEADSS ASSESSMENT TOOL

Component Area of assessment Assessment
results
Suicide / • Sleep disorders (usually induction
Depression problems, also early/frequent waking or
greatly increased sleep and complaints of
increasing fatigue)
• Appetite/eating behavior changes
• Feelings of ‘boredom’
• Emotional outbursts and highly impulsive
behaviour
• History of withdrawal/isolation
• Hopeless/helpless feelings
• History of past suicide attempts,
depression, psychological
• History of suicide attempts in family or
peers
• History of recurrent serious ‘accidents’
• Psychosomatic symptomology
• Suicidal ideation (including significant
current and past losses)
• Decreased affect at theinterview, avoidance
of eye contact--depression posturing
Preoccupation with death (clothing, media,
music, art)

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Annex 10: Child health card

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Annex 11: Patient Health Questionnaire-9 (PHQ-9)

PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9)
Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke
and colleagues, with an educational grant from Pfizer Inc. No permission
required to reproduce, translate, display or distribute.
Over the last two weeks, how often have you been bothered by any of the
following problems? (Use “✓” to indicate your answer)
Question Not Several More Nearly
at all days than half every
the days day
1. Little interest or pleasure in doing things 0 1 2 3
2. Feeling down, depressed, or hopeless 0 1 2 3
3. Trouble falling or staying asleep, or 0 1 2 3
sleeping too much
4. Feeling tired or having little energy 0 1 2 3
5. Poor appetite or overeating 0 1 2 3
6. Feeling bad about yourself — or that 0 1 2 3
you are a failure or have let yourself or
yourfamilydown
7. Trouble concentrating on things, such 0 1 2 3
as reading the newspaper or watching
television
• Moving or speaking so slowly that other 0 1 2 3
people could have noticed? Or the
opposite — being so fidgety or restless
that you have been moving around a
lot more than usual
• Thoughts that you would be better off 0 1 2 3
dead or of hurting yourself in some way
Column total ___ +______ +___
Add totals together = _______________
If you checked off any problems, how difficult have these problems made it
for you to do your work, take care of things at home, or get along with other
people?
Not difficult at all Somewhat difficult Very difficult
Extremely difficult

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Annex 12: ARV Dosing Tables

344
Adolescents
10.0– 14.0– 20.0–
Formulations and 3.0–5.9kg 6.0–9.9kg 25.0–34.9kg and adults
13.9kg 19.9kg 24.9kg
strengths >35kg
AM PM AM PM AM PM AM PM AM PM AM PM AM PM
ABC/3TC 120/60mg − 1 − 1.5 − 2 − 2.5 − 3 - - - -
ABC/3TC 600/300mg - - - - - - - - - - − 1 − 1
AZT/3TC 60/30mg 1 1 1.5 1.5 2 2 2.5 2.5 3 3 - - - -
AZT/3TC 300/150mg - - - - - - - - - - 1 1 1 1
TDF/3TC 300/300mg - - - - - - - - - - - - − 1
TDF/3TC/EFV
- - - - - - - - - - - - - 1
300/300/400mg
TDF/3TC/DTG
¬- - - - - - - - - - - - 1 -
300/300/50mg
TAF/FTC/DTG
- - - - - - - - - - 1 - 1 -
25/200/50mg
ABC/3TC/DTG
- - - - - - - - - - 1 - 1 -
600/300/50mg
ABC/3TC/DTG

Fixed Dose Combination Tablets/Granules

2 - 3 - 4 - 5 - 6 - - - - --
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

60/30/5mg
ABC/3TC/LPV/r
2 2 3 3 4 4 5 5 6 6 - - - -
30/15/40/10mg
Adolescents
10.0– 14.0– 20.0– 25.0–
Formulations and 3.0–5.9kg 6.0–9.9kg and adults
13.9kg 19.9kg 24.9kg 34.9kg
strengths >35kg
AM PM AM PM AM PM AM PM AM PM AM PM AM PM
DTG 50mg - - - - - - - - 1 - 1 - 1 1
DTG 10mg 1 - 1.5 - 2 - 2.5 - 3 - - - - -
EFV 200mg - - - - − 1 − 1.5 − 1.5 − 2 - -
LPV/r pellets 2 2 3 3 4 4 5 5 6 6 − − - -
40/10mg1
LPV/r 100/25mg2 - - - - 2 1 2 2 2 2 - - - -
LPV/r 200/50mg - - - - - - - - - - 2 1 2 2
DRV/r 400/50mg - - - - - - - - - - - - 2 -
ATV/r 300/100mg - - - - - - - - - - - - − 1
Raltegravir 25mg - - - - 3 3 - - - - - - - -
Chewable Tablet
Raltegravir 100mg - - - - - - 1 1 1.5 1.5 - - - -
Chewable Tablet
Raltegravir 400mg - - - - - - - - - - 1 1 1 1
- - - - 3 3 5 - - - -
5 +RTV 5 +RTV 5 +RTV
DRV 75mg Tablets3 +RTV +RTV +RTV
50mg 50mg 50mg
0.5ml 0.5ml 50mg

4 +RTV 4 +RTV 4 +RTV 4 +RTV

DRV 150mg - - - - - - - - - -
100mg 100mg 100mg 100mg

Fixed Dose Combination Tablets/Pellets/Syrups

1 +RTV 1 +RTV 1 +RTV 1 +RTV
DRV 600mg4 - - - - - - - - - -
100mg 100mg 100mg 100mg
RTV 25mg - - - - - - 2 2 2 2 - - - -

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Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

RTV 100mg - - - - - - - - - - 1 1 1 1
ETV 200mg - - - - - - - - - - - - 1 1
1. For children≥10kg that are able to swallow tablets, give LPV/r 100/25mg tablet.

346
2. tablets of LPV/r 100/25mg can be substituted with 1 tablet of LPV/r 200/50mg in order to reduce the pill burden.
These tablets should be administered fully intact/whole i.e. not cut or crushed.
3. DRV must be administered with 0.5mL of RTV 80mg/mL oral suspension in children <15kg, with 2 tab of RTV 25mg
in children 15 to 25kg and 3 tab of RTV 25mg in children above 25kg. DRV is always taken with food.
4. DRV 600mg must be co-administered with RTV 100mg.
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022
Consolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda - 2022

Annex 13: Dosing of RUTF

Sachets/ Sachets/ Sachet/two Sachets/
Weight (kg)
day week weeks month

3.0 - 3.4 1.25 9 18 35

3.5 - 3.9 1.5 11 22 44

4.0 - 5.4 2 14 28 56

5.5 - 6.9 2.5 18 35 70

7.0 - 8.4 3 21 42 84

8.5 - 9.4 3.5 25 49 98

9.5 - 10.4 4 28 56 112

10.5 - 11.9 4.5 32 63 126

≥ 12.0 5 35 70 140

14 years and
6 42 84 168
above

Source: Integrated Management of Acute Malnutrition Guidelines

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Annex 14: Suspected Adverse Drug Reaction

Reporting form

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350