2012 Botswana National HIV & AIDS Treatment Guidelines

Abstract

Underlying Principles and Rationale of the 2012 Botswana National HIV & AIDS Treatment Guidelines: 1 April 2012, Edition:


In accordance with the 2010 recommendations of the WHO, the Ministry of Health has improved access to ART by expanding eligibility criteria to all adults with CD4 counts ≤ 350 cells/μL. This change is also reflected in pediatric populations; all children ≤ 24 months of age as well as children from 2 – 5 years with CD4 counts ≤ 750 cells/μL or CD4 ≤ 25% will be eligible to begin ART. As a result of this eligibility change an estimated 7,400 deaths will be averted as well 12,700 HIV infections over the next five years.


In accordance with Vision 2016 in order to guarantee an AIDS Free Generation, Triple ART Prophylaxis (TAP) will be provided to all HIV-infected pregnant women. As a result, mother to child transmission rates are expected to fall below 1% annually.


Previously, in animal studies and retrospective human case reports, it was believed that efavirenz use in pregnant HIV-infected women (particularly during the first trimester) was linked to an increase in central nervous system birth defects. However, meta-analyses of available evidence to date have found no such increase risk when compared with exposure to other antiretrovirals. (Ford N, Calmy A, Mofenson, et al. Safety of efavirenz in the first-trimester of pregnancy: an updated systematic review and meta-analysis. AIDS 2011, 25(18): 2301-4.) Therefore, given the convenience of using a 1 dose daily fixed dose combination of TDF/FTC or 3TC/EFV (Atripla) and the low toxicity profile, all patients regardless of their reproductive status will be initiated on Atripla. While we expect no significant increase in central nervous system birth defects as a result of this policy, HIV clinicians, gynecologists and pediatricians should remain vigilant in reporting such cases directly to the DHAPC and the DRU. Plans to implement a national birth defect registry are underway to monitor any increases due to EFV use in pregnancy.


Likewise, previous concerns over the possible dangers of tenofovir use during pregnancy have changed. The 2010 WHO guidelines support TDF use during pregnancy. These 2012 revisions are now aligned and support the use of tenofovir, before, during and after pregnancy.


Until recently, Fixed Dose Combinations were only available for adult use. Now Pediatric FDCs have become widely available and should be used instead of individual dose regimens for children whenever possible. We expect that the added convenience of no longer using syrups or complicated regimen dosing will greatly improve pediatric adherence and long-term treatment outcomes.


Since 2008 the use of d4T in adults, unless under rare circumstances, is no longer recommended due to toxicities. This recommendation continues and now includes all pediatric patients. Any patient (adult, adolescent or pediatric) remaining on d4T should have clear clinical indications which require its use. Otherwise, all remaining adult patients on d4T will be switched to the most appropriate NRTI substitution and pediatric patients currentlyreceiving d4T/3TC containing regimens will be switched to ABC/3TC.


The inclusion of two new chapters: Pediatrics and Cancer/HIV, is provided to address the growing complexities of these special populations.


Customizing care to meet the particular challenges of children and adolescents infected with HIV will continue to be required now and in the years ahead. Furthermore, pediatric ART treatment failure rates are documented to be higher than those of adults. Optimizing treatment regimens to improve convenience and decrease long-term toxicities is therefore essential.


Adult and pediatric HIV patients suffering from cancer often face serious clinical challenges. Ensuring that they receive the best possible comprehensive HIV care, in addition to optimal chemotherapy and radiotherapy, requires that screening, prevention and appropriate treatment of cancer in the setting of HIV becomes a clinical priority.


Evidence based clinical trials have now clearly demonstrated the advantages of beginning ART in TB/HIV co-infected patients as soon as possible. New recommendations for the initiation of ART in TB patients, as well as guidance on ART regimen selection and administration, have therefore been updated and revised.

Published Date

Monday, 30 April 2012

Authors

Government of Botswana, Ministry of Health


Members of the Committee for the Clinical Care of TB and HIV/AIDS in Botswana as well as other physicians and healthcare professionals who contributed to the development of these guidelines include:


2010-2013 Committee for the Clinical Care of TB and HIV/AIDS in Botswana: Dr. Refeletswe Lebelonyane,Dr. Tendani Gaolathe, Dr. Ava Avalos, Dr. Haruna Jibril, Dr. Tebogo Madidimalo, Dr. Ronald Ncube, Dr. Marina Anderson, Ms. Koona Keapoletswe, Dr. Loeto Mazhani, Dr. Sandro Vento, Dr. Mike Tolle, Dr. Madisa Mine, Consultant Virologist, Dr. Doreen Ramagola-Masire, Dr. Michelle Haas, Dr. Chawangwa Modongo, Dr. Mary Kestler, Dr. Andrew Steenhoff, Dr. Hermann Bussmann, Dr. Mpho Letebele, Dr. Sinah Selelo, Dr. Diana Dickinson, Mr. Mark Ogbuabo, Dr. Sylvester Musa-Aisien.


Other Contributing Physicians & Healthcare Professionals: Dr. Mogomotsi Matshaba, Dr. Malebogo Pusoentsi, Dr. Miriam Haverkamp, Dr. Mosepele Mosepele, Dr. David Goldfarb, Dr. Tonya Arscott-Mills, Dr. Anu Agrawal, Dr. Memory Bvochora-Nsingo, Dr. Scott Dryden-Peterson, Ms. Panky Mogomotsi, Mrs. Elsie Hulela, Mrs. Nkotula Majingo, Mrs. Magadaline Mogoroshi, Mrs. Dinah Raamabya, Mr. Tim Chadborn, Mr. Stalin Makatye, Dr. Daniel Baxter.


 


 


 


 

Partners

ACHAP, Botswana-Harvard AIDS Institute Partnership, Botswana- U-Penn Partnership, Botswana-Baylor Clinical Center of Excellence, University of Botswana, CDC Botswana, PEPFAR, UNAIDS, World Health Organisation (WHO)

Document Type

Guideline

Download Document