6.7 HIV Prevention

This section describes the biomedical, structural interventions and Social Behavioural Change Communication (SBCC) that are related to prevention of HIV infection. Particular emphasis is given on the Positive Health, Dignity and Prevention (PHDP) package, also includes key HIV prevention services to Key and Vulnerable Populations (KVP).

Positive Health, Dignity and Prevention (PHDP)

PHDP focuses on improving and maintaining the health and well-being of PLHIV, which, in turn, contributes to the health and well-being of sexual partners, families and communities.

In order for PHDP programming to be successful, it must include a synergistic combination of interventions at three different levels.

Central Level Interventions

At Central level, interventions mainly focus on changes in the policy and legal framework to alter the environment in ways that promote and support implementation of PHDP activities and services.

Health Facility Interventions

HIV care and treatment clinics provide an important setting for HIV infection prevention and control. Components of a comprehensive package for HIV infection prevention and control in the clinical setting are:

• Condom promotion and distribution
• Messaging and counselling support for behavioural change including: sexual risk reduction; retention in care, adherence to medications, and partner HIV testing and counselling
• HIV testing and counselling
• ART as prevention
• Voluntary Medical Male Circumcision (VMMC)
• Screening and treatment of STIs and RTIs
• Prevention of Mother to Child Transmission (PMTCT)
• Safer pregnancy counselling and family planning services integration
• Identification of social needs, referral and linkage for community-based services
• Cervical cancer screening with visual check using acetic acid (VIA)

Community Level Interventions

Community level interventions are in line with the national guidelines on Community Based HIV Services (CBHS). The following are the components of the minimum package of the CBHS:

• Condom promotion and distribution
• Messaging and counselling support for health behaviours including: sexual risk reduction; retention in care, adherence to medications, and partner HIV testing and counselling
• HIV testing and counselling
• Screening of STI
• Safer pregnancy and family planning counselling
• Identification of needs for care, treatment, referral and linkage for health facility- based services

6.7.1 Post Exposure Prophylaxis (PEP)

Post Exposure Prophylaxis (PEP) is the immediate provision of preventive measures and medication following exposure to potentially infected blood or other bodily fluids in order to minimize the risk of acquiring infection. Several clinical studies have demonstrated that HIV transmission can be reduced by 81% following immediate administration of antiretroviral agents.

Effective post-exposure management entails the following elements:

• Management of exposure site
• Exposure reporting
• Assessment of infection risk
• Appropriate treatment
• Follow-up and counselling.

When an exposure occurs, the circumstances and post exposure management procedure applied should be recorded in the exposed person’s confidential form for easy follow up and care.

Evaluation of the Exposed Individuals

Individuals exposed to HIV should be evaluated within two hours and no later than 72 hours. A starter pack should be initiated within 2 hours after exposure and before testing the exposed person. Exposed healthcare workers should be counselled and tested for HIV at baseline in order to establish infection status at the time of exposure. PEP should be discontinued if an exposed healthcare worker refuses to test. Vaccination against Hepatitis B should be considered.

In addition, rape survivors should be:

• Offered counselling, crisis prevention and provision of an on-going psychosocial support so as to reduce/minimize immediate rape trauma disorder and longterm post-traumatic stress disorder should be offered.
• Referred to mental care, police and legal services, according to the law and regulations.

Evaluation of the Source Person

Evaluation of the source person should be performed when the exposed individual agrees to take PEP.

• If the HIV, HBV and HCV status of the source person is unknown perform these tests after obtaining consent. The exposed healthcare worker should not be involved in obtaining consent from the source person.
• If the source person is unknown, evaluation will depend on other risk criteria.
• Do not test discarded needles or syringes for viral contamination.

Treatment for HIV PEP

For Adults: TDF 300mg + 3TC 300mg + EFV 600mg once a day for 4 weeks

For children (based on body weight):

• Less than 3 years: AZT + 3TC + LPV/r twice daily for 4 weeks
• More than 3 years: AZT + 3TC twice daily + EFV once daily for 4 weeks

NOTE: If the source is using PI based regimen, then the PEP regimen should be PI based.(Similar to the source’s regimen)

Follow-up of HIV Exposed individuals

HIV antibody tests should be performed at least after 4–6 weeks post-exposure (i.e. at 6 & 12 weeks). HIV testing should also be performed for any exposed person who has an illness that is compatible with an acute retroviral syndrome, irrespective of the interval since exposure.

If PEP is administered, the exposed person should be monitored for drug toxicity at baseline and 2 weeks after starting PEP. Minimally, it should include a Full Blood Count (FBC), renal function test (RFT-Serum creatinine and urinalysis) and hepatic function tests (LFT- ALT).

Exposed persons should be re-evaluated within 72 hours, after additional information about the source of exposure including serologic status, viral load, current treatment, any resistance test results (if available) or information about factors that would modify recommendations, is obtained.

PEP should be administered for 4 weeks if tolerated. If not tolerated manage symptoms accordingly and if intolerance persists change to more tolerable PI based regimen. If the patient seroconvert and the exposed person becomes HIV infected, he/she should be referred to a CTC for proper care and treatment service.

6.7.2 Voluntary Medical Male Circumcision (VMMC)

Voluntary Medical Male Circumcision (VMMC) has been implemented in different subSaharan countries in an effort to reduce the incidence of HIV infection amongst heterosexual men. Surgical removal of the foreskin reduces male’s vulnerability to HIV in penile-vaginal intercourse. Therefore, VMMC is an important component of comprehensive HIV prevention in areas with a high prevalence of heterosexuallytransmitted HIV infection. Early Infant Male Circumcision (EIMC) is another component in Tanzania’s National HIV prevention strategy.

Minimum Package of VMMC Services

All HCW offering VMMC services should:

• Educate clients on the link between VMMC and HIV prevention.
• Offer HIV testing and counselling so that clients know their HIV status and refer client who test positive to a care and treatment clinic.
• Refer clients who test positive to care and treatment for clients who test HIV positive.
• Screen for STIs and RTIs (and treatment, when indicated) since STIs increase a person’s risk of acquiring or transmitting HIV.
• Counsel on risk reduction,
• Promote and distribute A: male and female condoms together with the promotion of their correct and consistent use.
• Provide surgical care that is safe and of high quality, in settings that are adequately equipped and environmentally suitable for minor surgical procedures.
• Provide appropriate postoperative care and care of any associated adverse events.

Minimum Package of Early Infant Male Circumcision (EIMC) Services All HCW at facilities offering EIMC services for HIV prevention must:

• Provide information to parents or guardians on advantages and risks of EIMC.
• Offer of HIV testing and counselling to parents or guardians to ensure identification of HIV-exposed infants.
• Link HIV-positive parents to HIV care and treatment services.
• Counsel on the post-operative care of circumcised infants and identification of related complications, danger signs and where to go for follow-up care, if required.
• Provide surgical care that is safe and of high quality, in settings that are adequately equipped and environmentally suitable for minor surgical procedures.
• Provide appropriate postoperative care and care of any associated adverse events.
• Refer clients to appropriate services such as immunization, well baby care, and HIV care and treatment for HIV-exposed infants and/or those infants found to be HIV-positive through Early Infant Diagnosis (EID).

6.7.3 Blood Safety

Unsafe blood transfusion is a well-documented mode of transmission of HIV and other infections. Many recipients of blood and blood products are at risk of transfusiontransmissible infections, including HIV, as a result of poor blood donor recruitment and selection practices and the use of unscreened blood.

6.7.4 HIV Prevention Services to Key and Vulnerable Populations (KVP)

Key Populations (KPs): KPs are defined as groups who, due to specific higher-risk behaviours, are at increased risk of HIV irrespective of the epidemic type or local context. Also, they often have legal and social issues related to their behaviours that increase their vulnerability to HIV.

Vulnerable populations (VPs): are groups of people who are particularly vulnerable to HIV infection in certain situations or contexts, such as adolescents (particularly girls in sub-Saharan Africa), orphans, street children, people with disabilities and migrant and mobile workers.

Key and vulnerable populations (KVP) are therefore, important to the dynamics of HIV transmission and in an effective response to the epidemic. The groups include:

• Sex workers–SW and their clients
• people who inject or use drugs–PWID/PWUD
• people in prisons and other closed settings
• Adolescent girls and young women (AGYW)
• mobile populations (long distance truck drivers, fisher folks and fishing communities, miners and mining communities, construction and plantation workers)
• disabled persons in all forms
• Street living, working children and displaced people.

Health service providers need to provide non-judgmental, non-discriminatory services to be able to identify and address the special needs of key and vulnerable populations within and beyond the health care setting. The following list summarizes the key services to be offered to KVP:

• Promote and provide A: male and female condoms
• Provide VMMC service
• Provide HTS
• Provide ART to HIV infected individuals
• Screen and manage STIs, RTIs and cervical cancer
• Counsel and offer Reproductive Health Services (RHS) inclusive of family planning services and dual protection as well as counselling and PMTCT
• Link to facility providing medication-assisted treatment (MAT) and other drug dependence treatments (i.e. harm reduction)
• Provide behaviour change and communication service
• Screen for Hepatitis B and C and provide vaccination for Hepatitis B as appropriate
• Screen for Tuberculosis and manage accordingly
• Screen for sexual violence and provide PEP along with other interventions for gender-based violence (GBV)
• Link with psychosocial support services
• Proper Linkage and referral mechanisms to community support programmes (e.g. psychosocial support, income generating groups, spiritual support and legal support etc.).