Updating follow-up outcome

Clinical description

• Regularly review all patient cards and keep an appointment register to identify patients who are

overdue for their appointment as soon as possible.

• Try to contact the patient or the named guardian by phone or by home visit from 2 weeks after the

missed appointment. Confirm from ART Patient Card that consent was given for home visit.

o Patient is alive: counsel to return to the clinic as soon as possible and continue treatment.

o Patient has stopped, died or transferred out: update outcome and date of outcome on patient card and in register.

• Loss to follow-up (‘default’):

o Patient is overdue for the appointment and is not known to have stopped ART, died or transferred to another facility.

o Classify as ‘defaulted’ if the patient has run out of ARVs 2 or more months ago (based on the number of tins given at the last visit).

• Patients who are alive but known to have stopped ART (for any reason) should be classified as

‘stopped’ and not as ‘defaulted’.

• Ask guardians to notify the clinic if an ART patient has died. Bring back the patient health passport

and/or ART ID and any remaining ARVs.

98 Table 21: Symptom-based identification and management of side-effects Managing side effects Cause (in order of likelihood) Diagnosis Primary Management Secondary Management Body pains, weakness AZT, 3TC Severe anaemia: Hb <7 g/dl Stop AZT, consider transfusion Substitute AZT, continue ART without gap AZT Lactic acidosis (LA): shortness of breath, Any suspected LA: Stop all ART Don’t re-start ART before lactic acid nausea immediately <2mmol/l Serum lactate: suspect: 2-5 mmol/l, IV fluids, treat at hospital Can restart ART with AZT after suspected confirmed: ≥5 mmol/l LA Never give AZT after confirmed LA Can use ABC or TDF containing regimen Fever Onset independent of drugs: FBC, MPs, blood culture, urine dipstick, Bacteraemia, malaria, TB Xpert, chest x-ray, urine LAM Onset within 8 weeks of starting ABC, NVP or EFV hypersensitivity: Body Any suspected hypersensitivity: Stop all Do not re-start before symptoms have drugs: pains, vomiting, diarrhoea, abdominal ART and TPT immediately, treat at hospital resolved ABC, NVP, EFV, rifapentine pain, sore throat, cough, shortness of Don’t re-start 3HP (rifapentine) after Never use NVP or ABC again breath, rash, jaundice suspected hypersensitivity Replace NVP with EFV and ABC with TDF Rifapentine hypersensitivity: flu like Never restart TPT symptoms, fever, headache, sudden collapse (syncope)

Slimming: Cheeks, forearms, buttocks, legs (often prominent veins) Fattening: Back of neck (‘buffalo hump’), breast, stomach, and waist AZT, LPV/r, 3TC, TDF, HIV Lipodystrophy (from ART / HIV itself) Reassure patient EFV Substitute likely causative ARV DTG Metabolic syndrome (obesity) Reduce calorie intake, increase physical Substitute DTG to EFV or ATV/r if severe activity and no improvement Cause (in order of likelihood) Diagnosis Primary Management Secondary Management Breast swelling / enlargement: one- or both-sided, in males or children EFV, ketoconazole, cimetidine, Gynaecomastia: palpate enlarged breast Reassure patient Consider surgery for extreme omeprazole, spironolactone, gland Substitute EFV with DTG in ART regimen. gynaecomastia isoniazid, testicular tumours, Lipodystrophy: accumulation of fat (from physiological in adolescence and ART / HIV itself)

middle-aged/elderly testosterone deficiency (HIV), AZT, LPV/r Upper GI symptoms: Nausea, vomiting AZT, LPV/r, 3TC, DTG Lactic acidosis? (see ‘Body pains and Determine liver enzymes If no lactic acidosis: try to continue the Drug-induced hepatitis weakness’) Adults only: Promethazine 25 mg up to 12- same ART regimen Jaundice? (see ‘Yellow eyes’) hourly. Adults or children (lower dose): If persistent, substitute Chlorpheniramine (Piriton) 10 mg up to 8- hourly-oral rehydration solution (ORS)

Skin Rash Onset before starting drugs: HIV-related skin rash Adults only: Promethazine 25 mg 12- Consider scabies, etc.

Seborrhoeic dermatitis (“bumpy hourly itch”) Adults or children (lower dose):

Pruritic papular eruption Chlorpheniramine (Piriton) 10 mg 8-hourly Calamine lotion Onset within 8 weeks of starting Mild hypersensitivity Continue EFV, reassure: initial rash mostly Switch to DTG based regimen drugs: Macular/papular rash not involving resolves.

Managing side effects 99 NVP, ABC, Cotrimoxazole, EFV mouth, eyes, and genitalia Adults only: Promethazine 25mg 12-hourly No fever, body pain, weakness, etc. Adults or children (lower dose):

Chlorpheniramine (Piriton) 10 mg 8-hourly 100 Managing side effects Cause (in order of likelihood) Diagnosis Primary Management Secondary Management Lower GI symptoms: Diarrhoea, lower abdominal pain Onset before ART initiation: Stepwise empirical treatment Stepwise empirical treatment of chronic HIV-induced HIV diarrhoea (see page 27)

Onset within 6 weeks of starting Drug toxicity For adults only: Loperamide 2 mg 8-hourly Try to continue same ART regimen drug: (mainly for LPV/r induced diarrhoea) If persistent substitute LPV/r, AZT, 3TC, DTG Severe upper abdominal pain, nausea and vomiting 3TC Pancreatitis Stop all ART immediately Restart ART after complete remission Serum amylase >1.5 times above upper Treat at hospital Call DHA for guidance normal limit EFV, alcohol, viral hepatitis Acute fulminant liver failure Discontinue ART immediately Never re-start ARV drug that was the Liver function tests Treat at hospital suspected cause Identify cause and manage accordingly Reinitiate ART one month after jaundice is resolved, and LFT <2.5 of upper normal limit Yellow eyes Viral hepatitis, alcohol, ATV/r, LFT and ultrasound scan to differentiate: Discontinue ART and TPT immediately if Never re-start the ARV or TPT that was NVP, INH, Rifapentine, EFV, ABC, Viral hepatitis, cirrhosis, drug hepatitis, jaundice develops after start. See notes the suspected cause.

severe malaria, primary liver cancer, metastases below Table 16 on page 68 for patients on Re-initiate ART 1 month after jaundice Cancer ATV/r. has resolved and LFT <2.5 times upper Rifapentine can stain eyes/body Identify cause and manage accordingly normal limit fluids orange (LFT, ultrasound, hepatitis serology).

Reassure patients for orange discolouration of eyes and body fluids Cause (in order of likelihood) Diagnosis Primary Management Secondary Management Swollen face and eyelids, particularly in the morning/tiredness, too much or too little urine Onset before starting drugs Confirm nephropathy with serum Identify cause and manage accordingly. Adjust ART dosage according to creatinine HIV, diabetes, hypertension creatinine, serum albumin and protein in Stop all nephrotoxic drugs. Consult clearance urine specialist physician Onset within 1 year of starting Confirm nephropathy with serum Admit to hospital Adjust ART dosage according to creatinine drugs: creatinine, serum albumin and protein in Substitute TDF to ABC without gap clearance TDF urine Drowsiness, confusion, nightmares, insomnia, psychosis EFV, DTG Neuropsychiatric EFV or DTG toxicity Drowsiness/ bad dreams usually disappear If intolerable beyond 2 weeks:

after a few weeks without the need to replace EFV with DTG discontinue ART. replace DTG with PI Take EFV before bed. Take DTG in the morning.

Confusion / psychosis: replace EFV or DTG with PI immediately Leg pain, numbness or burning, inability to walk Onset before starting drugs: Mild peripheral neuropathy (PN): no Amitriptyline 25 mg nightly for 4 weeks If no improvement after 4 weeks: stop HIV neuropathy sleep disturbance Pain control using WHO analgesic ladder amitriptyline, continue analgesics Onset or worsening after starting drugs INH, vincristine, paclitaxel Moderate PN: sleep disturbance Managing side effects 101 Onset independent of drugs Stop responsible drug Alcohol, diabetes WHO analgesic ladder Severe PN: severe pain, muscular weakness