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Referral and warning signs
When to refer
Refer to comprehensive HIV care/ART clinic for initiation/ongoing management. Refer for complex ART issues, side effects, treatment failure, OIs.
Red flags
- Signs of severe opportunistic infection
- Severe ART side effects
- High maternal VL near delivery
- Infant testing positive for HIV
Signs and symptoms
- Often asymptomatic.
- May present with symptoms of HIV/AIDS opportunistic infections or related conditions.
- Focus is on screening, diagnosis, and management within pregnancy context.
Risk factors
- Engaging in behaviours that risk HIV acquisition.
- Lack of access/uptake of HIV prevention/testing services.
Diagnosis
Clinical assessment
Routine HIV counselling and testing (Opt-out approach) offered at first ANC visit (and partner). Repeat testing in 3rd trimester/labour for initially negative.
Investigations
- HIV rapid antibody testing (Serial algorithm per national guidelines).
- Viral Load (VL) monitoring (baseline, periodically).
- CD4 count (baseline useful for OI risk/prophylaxis).
Diagnostic criteria
Positive HIV antibody test confirmed by national algorithm.
Management
Non-pharmacological management
- Comprehensive counseling (status, lifelong ART, adherence, disclosure, partner testing, safer sex, infant feeding, FP).
- Psychosocial support (peer groups).
- Nutritional counseling.
- Safe obstetric practices.
- Linkage to ongoing care.
Pharmacological treatment
- Maternal ART (Lifelong - Option B+): Initiate preferred first-line ART (typically TDF+3TC+DTG FDC) IMMEDIATELY upon diagnosis, regardless of CD4/gestation. Continue existing effective regimen.
- Infant ARV Prophylaxis: Daily Nevirapine (NVP) syrup from birth for 6 weeks (standard risk). Extended prophylaxis (12w NVP or NVP+AZT) if high risk (e.g., preterm, mother untreated/high VL). Follow current PMTCT guidelines.
- Infant Cotrimoxazole Prophylaxis: Start at 6 weeks for ALL HIV-exposed infants, continue until HIV excluded post-breastfeeding.
Monitoring
Maternal: Adherence, VL (e.g., 6m post-start, then annually if suppressed), CD4, OI screening. Infant: Prophylaxis adherence, Growth, Development, HIV testing (6wks PCR, post-BF antibody test).
Complications
- Mother-to-child transmission (MTCT) of HIV.
- Increased maternal/infant morbidity/mortality if untreated.
- Opportunistic infections.
- ART side effects.
- Stigma.
Prevention
- Primary HIV prevention.
- Effective PMTCT interventions (universal testing, immediate ART, infant prophylaxis, safer feeding).
Patient education
- Understanding HIV/ART.
- Lifelong ART.
- Adherence importance.
- Infant prophylaxis (ARV, Cotrimoxazole).
- Infant feeding counseling (exclusive choice BF/replacement).
- Safer sex.
- Partner testing/disclosure.
- Infant HIV testing schedule.
- Follow-up importance.
Uganda-specific notes
Option B+ is national policy. TDF/3TC/DTG preferred 1st line. PMTCT integrated into MCH. Exclusive breastfeeding for 6m, continued to 1yr recommended for mothers on ART. VL monitoring improving.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 16, Section 16.2.2
- Uganda Clinical Guidelines (UCG) 2023
Chapter 3 (HIV Management)
- Consolidated Guidelines for Prevention and Treatment of HIV in Uganda, MOH
(Current National PMTCT/ART protocols)