- 6.2.
General care for people living with HIV
Children and adolescents
Children and adolescents should do at least an average of 60 minutes per day of moderate- to vigorous-intensity, mostly aerobic, physical activity, across the week (strong recommendation, moderate-certainty evidence).
Vigorous-intensity aerobic activities, as well as those that strengthen muscle and bone, should be incorporated at least three days a week (strong recommendation, moderate-certainty evidence).
Children and adolescents should limit the amount of time spent being sedentary, particularly the amount of recreational screen time (strong recommendation, low-certainty evidence).
Adults (18–64 years old) and older adults (65 years and older), including those with chronic conditions
All adults should undertake regular physical activity (strong recommendation, moderate-certainty evidence).
Adults should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week, for substantial health benefits (strong recommendation, moderate-certainty evidence).
Adults should also do muscle strengthening activities at moderate or greater intensity that involve all major muscle groups on two or more days a week, since these provide additional health benefits (strong recommendation, moderate-certainty evidence).
Adults may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits (conditional recommendation, moderate-certainty evidence).
Adults should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits (strong recommendation, moderate-certainty evidence).
To help reduce the detrimental effects of high levels of sedentary behaviour on health, adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity (strong recommendation, moderate-certainty evidence).
Additional recommendation for older adults (65 years and older)
As part of their weekly physical activity, older adults should do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity, on three or more days a week, to enhance functional capacity and to prevent falls (strong recommendation, moderate-certainty evidence).
- 6.3.
Co-trimoxazole prophylaxis
Co-trimoxazole prophylaxis is recommended for adults (including pregnant women) with severe or advanced HIV clinical disease (WHO stage 3 or 4) and/or with CD4 cell count ≤350 cells/mm3
(strong recommendation, moderate-certainty evidence).
In settings where malaria and/or severe bacterial infections are highly prevalent, co-trimoxazole prophylaxis should be initiated regardless of CD4 cell count or WHO stage (conditional recommendation, moderate-certainty evidence).
Co-trimoxazole prophylaxis may be discontinued for adults (including pregnant women) with HIV who are clinically stable on ART, with evidence of immune recovery and viral suppression (conditional recommendation, low-certainty evidence).
In settings where malaria and/or severe bacterial infections are highly prevalent, co-trimoxazole prophylaxis should be continued regardless of CD4 cell count or WHO clinical stage (conditional recommendation, moderate-certainty evidence).
Co-trimoxazole prophylaxis is recommended for infants, children and adolescents with HIV, regardless of clinical and immune conditions. Priority should be given to all children younger than five years old regardless of CD4 cell count or clinical stage and children with severe or advanced HIV clinical disease (WHO clinical stage 3 or 4) and/or those with CD4 cell count ≤350 cells/mm3(strong recommendation, high-certainty evidence).
In settings where malaria and/or severe bacterial infections are highly prevalent, co-trimoxazole prophylaxis should be continued until adulthood whether or not ART is being taken (conditional recommendation, moderate-certainty evidence).
In settings of low prevalence for both malaria and bacterial infections, co-trimoxazole prophylaxis may be discontinued for children five years of age and older who are clinically stable and/or virally suppressed on ART for at least six months and CD4 cell count >350 cells/mm3
(strong recommendation, very-low-certainty evidence).
Co-trimoxazole prophylaxis is recommended for HIV-exposed infants from four to six weeks of age and should be continued until HIV infection has been excluded by an age-appropriate HIV test to establish final diagnosis after complete cessation of breastfeeding (strong recommendation, very-low-certainty evidence).
Routine co-trimoxazole prophylaxis should be given to all people living with HIV with active TB disease regardless of CD4 cell count (strong recommendation, high-certainty evidence).
- 6.4.
Tuberculosis
- 6.4.1.
Screening and diagnosis
Systematic screening for TB among people living with HIV ★
People living with HIV should be systematically screened for TB disease at each visit to a health facility (strong recommendation, very-low-certainty evidence).
Tools for screening for TB among people living with HIV ★
Among adults and adolescents living with HIV, systematic screening for TB disease should be conducted using the WHO-recommended four-symptom screen, and those who report any one of the symptoms of current cough, fever, weight loss or night sweats may have TB and should be evaluated for TB and other diseases (strong recommendation, moderate-certainty evidence).
Among children younger than 10 years who are living with HIV, systematic screening for TB disease should be conducted using a symptom screen including any one of the symptoms of current cough, fever, poor weight gain or close contact with a person with TB disease (strong recommendations, low-certainty evidence for test accuracy).
Among adults and adolescents living with HIV, C-reactive protein with a cut-off of >5 mg/L may be used to screen for TB disease (conditional recommendation, low-certainty evidence for test accuracy).
Among adults and adolescents living with HIV, chest X-ray may be used to screen for TB disease (conditional recommendation, moderate-certainty evidence for test accuracy).
Among individuals aged 15 years and older in populations in which TB screening is recommended, computer-aided detection software programmes may be used in place of human readers for interpreting digital chest X-rays for screening and triage for TB disease (conditional recommendation, low-certainty evidence).
Among adults and adolescents living with HIV, molecular WHO-recommended rapid diagnostic tests may be used to screen for TB disease (conditional recommendation, moderate-certainty evidence for test accuracy).
Adult and adolescent inpatients with HIV in medical wards where the TB prevalence is >10% should be tested systematically for TB disease with a molecular WHO-recommended rapid diagnostic test (strong recommendation, moderate-certainty evidence for test accuracy).
- 6.4.3.
Treatment
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 as possible (within the first eight weeks) following initiation of anti-TB treatment (strong recommendation, very-low-certainty evidence).
Identifying populations for latent TB infection testing and TB preventive treatment ★
Adults and adolescents
Adults and adolescents living with HIV who are unlikely to have active TB should receive TB preventive treatment as part of a comprehensive package of HIV care. Treatment should also be given to those receiving ART, to pregnant women and to those who have previously been treated for TB, irrespective of the degree of immunosuppression and even if latent TB infection testing is unavailable (strong recommendation, high-certainty evidence).
Infants aged <12 months
Infants aged <12 months 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 (strong recommendation, moderate-certainty evidence)
Children aged ≥12 months
Children aged ≥12 months living with HIV who are considered unlikely to have active TB on an appropriate clinical evaluation or according to national guidelines should be offered TB preventive treatment as part of a comprehensive package of HIV prevention and care if they live in a setting with high TB transmission, regardless of contact with a person with TB (strong recommendation, low-certainty evidence).
All children
All children living with HIV who have successfully completed treatment for TB disease may receive TB preventive treatment (conditional recommendation, low-certainty evidence).
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 (strong recommendation, moderate-certainty evidence).
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 (strong recommendation, moderate-certainty evidence).
Chest radiography may be offered to people living with HIV receiving ART and TB preventive treatment given to those with no abnormal radiographic findings (conditional recommendation, low-certainty evidence).
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 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 (strong recommendation, low-certainty evidence).
The absence of any symptoms of TB and the absence of abnormal chest radiographic findings may be used to rule out active TB disease among HIV-negative household contacts aged ≥5 years and other risk groups before TB preventive treatment (conditional recommendation, very-low-certainty evidence).
Testing for latent TB infection ★
Either a tuberculin skin test or interferon-gamma release assay can be used to test for latent TB infection (strong recommendation, very-low-certainty evidence).
TB preventive treatment options ★
The following options are recommended for the treatment of latent TB infection regardless of HIV status: six or nine months of daily isoniazid, or a three-month regimen of weekly rifapentine plus isoniazid, or a three-month regimen of daily isoniazid plus rifampicin (strong recommendation, moderate- to high-certainty evidence in the estimates of effect).
A one-month regimen of daily rifapentine plus isoniazid or four months of daily rifampicin alone may also be offered as alternatives (conditional recommendation, low- to moderate-certainty evidence).
In settings with high TB transmission, adults and adolescents living with HIV who have an unknown or a positive latent TB infection test and are unlikely to have active TB disease should receive at least 36 months of daily isoniazid preventive therapy. Daily isoniazid preventive therapy for 36 months should be given whether or not the person is receiving ART and irrespective of the degree of immunosuppression, history of previous TB treatment and pregnancy in settings considered to have high TB transmission as defined by national authorities (conditional recommendation, low-certainty evidence).
- 6.5.
Hepatitis B and C
- 6.5.2.
Testing for chronic HBV infection
General population testing
In settings with a ≥2% or ≥5%19 HBsAg seroprevalence in the general population, it is recommended that all adults and adolescents have routine access to and be offered HBsAg serological testing with linkage to prevention, care and treatment services. General population testing approaches should make use of existing community- or health facility–based testing opportunities or programmes such as at antenatal clinics, HIV or TB clinics (conditional recommendation, low-certainty evidence).
Routine testing in pregnant women
In settings with a ≥2% or ≥5%%19 HBsAg seroprevalence in the general population, it is recommended that HBsAg serological testing be routinely offered to all pregnant women in antenatal clinics,20 with linkage to prevention, care and treatment services. Couples and partners in antenatal care settings should be offered HBV testing services (strong recommendation, low-certainty evidence).
Focused testing in most affected populations
In all settings (and regardless of whether delivered through facility- or community-based testing), it is recommended that HBsAg serological testing and linkage to care and treatment services be offered to the following individuals:
adults and adolescents from populations most affected by HBV infection
21
(who either are part of a population with high HBV seroprevalence or have a history of exposure and/or high-risk behaviour for HBV infection);
adults, adolescents and children for whom chronic viral hepatitis
22 is clinically suspected (through symptoms, signs or laboratory markers);
sexual partners, children and other family members and close household contacts of those with HBV infection;
23
and
health-care workers: in all settings, it is recommended that HBsAg serological testing be offered and HBV vaccination given to all health-care workers who have not been vaccinated previously (adapted from existing guidance on HBV vaccination) (strong recommendation, low-certainty evidence).
Blood donors
In all settings, screening of blood donors should be mandatory with linkage to care, counselling and treatment for those who test positive.
- 6.5.2.
Testing for chronic HCV infection
Focused testing in most affected populations
In all settings (and regardless of whether delivered through facility- or community-based testing), it is recommended that serological testing for HCV antibody24
be offered with linkage to prevention, care and treatment services to the following individuals:
adults and adolescents from populations most affected by HCV infection
25
(who are either part of a population with high HCV seroprevalence or have a history of exposure to and/or high-risk behaviour for HCV infection); and
adults, adolescents and children for whom chronic viral hepatitis is clinically suspected
26
(through symptoms, signs or laboratory markers)
(strong recommendation, low-certainty evidence).
General population testing
In settings with a ≥2% or ≥5%27
HCV antibody seroprevalence in the general population, it is recommended that all adults have access to and be offered HCV serological testing with linkage to prevention, care and treatment services. General population testing approaches should make use of existing community- or facility-based testing opportunities or programmes such as HIV or TB clinics, drug treatment services and antenatal clinics28
(conditional recommendation, low-certainty evidence).
Birth cohort testing
This approach may be applied to specific identified birth cohorts of older people at higher risk of infection29 and morbidity within populations that have an overall lower general prevalence (conditional recommendation, low-certainty evidence).
- 6.5.5.
Preventing mother-to-child transmission of HBV infection
Routinely testing pregnant women for HIV, HBV and syphilis
All pregnant women should be tested for HIV, syphilis and HBsAg at least once and as early as possible in the pregnancy (HIV standing recommendation since 2007; syphilis: strong recommendation, moderate-certainty evidence; HBsAg: strong recommendation, low-certainty evidence).
Immunization
All infants should receive their first dose of HBV vaccine as soon as possible after birth, preferably within 24 hours. Delivery of HBV vaccine within 24 hours of birth should be a performance indicator for all immunization programmes, and reporting and monitoring systems should be strengthened to improve the quality of data on the birth dose. The birth dose should be followed by two or three doses to complete the primary series.
Tenofovir prophylaxis
Women coinfected with HIV and HBV should be receiving TDF-based ART, which will provide prophylaxis to prevent the mother-to-child transmission of HBV. This is in addition to three-dose HBV vaccination for all infants, including timely birth dose (conditional recommendation, moderate-certainty evidence).
- 6.6.
Malaria
Good practice statement ★
For people who have HIV and uncomplicated Plasmodium falciparum malaria, avoid artesunate + sulfadoxine-pyrimethamine if they are being treated with co-trimoxazole and avoid artesunate + amodiaquine if they are being treated with efavirenz or zidovudine.
- 6.8.
Leishmaniasis
People coinfected with visceral leishmaniasis and HIV in eastern Africa ★
Liposomal amphotericin B + miltefosine regimen
Liposomal amphotericin B (up to a total of 30 mg/kg at 5 mg/kg on days 1, 3, 5, 7, 9 and 11) + miltefosine (100 mg/day for 28 days) (conditional recommendation, very-low-certainty evidence)
People coinfected with visceral leishmaniasis and HIV in South-East Asia ★
Liposomal amphotericin B + miltefosine regimen
Liposomal amphotericin B (up to a total of 30 mg/kg at 5 mg/kg on days 1, 3, 5, 7, 9 and 11) + miltefosine (100 mg/day for 14 days) (conditional recommendation, very-low-certainty evidence).
Provide secondary prophylaxis after the first episode of visceral leishmaniasis for all people coinfected with visceral leishmaniasis and HIV (conditional recommendation, very-low-certainty evidence). ★
- 6.9.
Cervical cancer
Screening and treatment recommendations to prevent cervical cancer for women living with HIV ★
WHO recommends using HPV DNA detection as the primary screening test rather than visual inspection of the cervix with acetic acid (VIA) or cytology in screening and treatment approaches among women living with HIV (strong recommendation, moderate-certainty evidence).
Remarks: Existing programmes with quality-assured cytology as the primary screening test should be continued until HPV DNA testing is operational; existing programmes using VIA as the primary screening test should transition rapidly because of the inherent challenges with quality assurance.
WHO suggests using an HPV DNA primary screening test with triage rather than without triage to prevent cervical cancer among women living with HIV (conditional recommendation, moderate-certainty evidence).
In a screen, triage and treat approach using HPV DNA detection as the primary screening test, WHO suggests using partial genotyping, colposcopy, VIA or cytology to triage women living with HIV after a positive HPV DNA test (conditional recommendation, moderate-certainty evidence).
Remarks: The benefits, harm and programmatic costs of the triage options are similar; therefore, the choice of triage method will depend on feasibility, training, programme quality assurance and resources in countries. HPV16/18 genotyping could be integrated into the HPV DNA test.
When HPV DNA testing is provided, WHO suggests using either samples taken by a health-care provider or self-collected samples (conditional recommendation, low-certainty evidence).
WHO suggests starting regular cervical cancer screening at the age of 25 years among women living with HIV (conditional recommendation, low-certainty evidence).
Remarks: Moderate-certainty evidence found that few women living with HIV younger than 25 years are likely to have cervical cancer. This recommendation applies to women living with HIV regardless of when they first tested positive for HIV.
After the age of 50 years, WHO suggests that screening be stopped after two consecutive negative screening results, consistent with the recommended regular screening intervals among women living with HIV (conditional recommendation, very-low-certainty evidence).
Remarks: VIA and ablation treatment are not suitable for screening women for whom the transformation zone is not visible. Inadequate visualization is typical after menopause.
Good-practice statement
Priority should be given to screening women living with HIV 25–49 years old. When tools are available to manage postmenopausal women, women living with HIV 50–65 years old who have never been screened should also be given priority.
WHO suggests a regular screening interval of every 3–5 years when using HPV DNA detection as the primary screening test among women living with HIV (conditional recommendation, low-certainty evidence).
Where HPV DNA testing is not yet operational, WHO suggests a regular screening interval of every three years when using VIA or cytology as the primary screening test among women living with HIV (conditional recommendation, low-certainty evidence).
Good-practice statement
While transitioning to a programme with a recommended regular screening interval, screening even just twice in a lifetime is beneficial.
WHO suggests that women living with HIV who have screened positive on an HPV DNA primary screening test and then negative on a triage test be retested with HPV DNA testing in 12 months and, if negative, move to the recommended screening interval (conditional recommendation, low-certainty evidence).
WHO suggests that women living with HIV who have screened positive on a cytology primary screening test and then have normal results on colposcopy be retested with HPV DNA testing in 12 months and, if negative, move to the recommended regular screening interval (conditional recommendation, low-certainty evidence).
WHO suggests that women living with HIV who have been treated for histologically confirmed CIN2/3 or adenocarcinoma in situ or treated as a result of a positive screening test be retested in 12 months with HPV DNA testing when available rather than with cytology or VIA or co-testing, and, if negative, be retested again at 12 months and, if negative again, move to the recommended screening interval (conditional recommendation, low-certainty evidence).
Good-practice statement
As programmes introduce HPV DNA testing, use this test when rescreening women living with HIV regardless of the test that was used at the previous screening. In existing programmes with cytology or VIA as the primary screening test, rescreening with the same test should be continued until HPV DNA testing is operational.
General population and women living with HIV ★
Good practice statement
Once a decision to treat a woman is made, treating as soon as possible within six months is good practice to reduce losses to treatment. However, for women who are pregnant, good practice includes deferral until after pregnancy.
In circumstances when treatment is not provided within this time frame, evaluating the woman before treatment is good practice.
WHO suggests large loop excision of the transformation zone or cold-knife conization for women who have histologically confirmed adenocarcinoma in situ (conditional recommendation, low-certainty evidence for effects).
Remarks: Loop excision may be preferred for women of reproductive age, in settings with greater availability of large loop excision of the transformation zone and by providers with greater expertise performing large loop excision of the transformation zone. Cold-knife conization may be preferred when interpretation of the margins of the histological specimen is imperative.
- 6.10.
Noncommunicable diseases
Assessment and management of cardiovascular risk should be provided for all individuals living with HIV according to standard protocols recommended for general population (conditional recommendation, very-low-certainty evidence).30
Good practice statement
Strategies for the prevention and risk reduction of cardiovascular diseases by addressing modifiable factors such as blood pressure, smoking, obesity status, unhealthy diet and lack of physical activity should be applied to all people living with HIV.
- 6.11.
Mental health among people living with HIV
Assessment and management of depression should be included in the package of HIV care services for all individuals living with HIV (conditional recommendation, very-low-certainty evidence).
- 6.13.
Sexually transmitted infections
For men who have sex with men and transgender people
Men who have sex with men and transgender people with symptomatic sexually transmitted infections should seek and be offered syndromic management and treatment.
Offering periodic testing for asymptomatic urethral and rectal N. gonorrhoeae and C. trachomatis infections using NAAT is suggested over not offering such testing for men who have sex with men and transgender people (conditional recommendation, low-certainty evidence).
Not offering periodic testing for asymptomatic urethral and rectal N. gonorrhoeae infections using culture is suggested over offering such testing for men who have sex with men and transgender people (conditional recommendation, low-certainty evidence).
Offering periodic serological testing for asymptomatic syphilis infection to men who have sex with men and transgender people is strongly recommended over not offering such screening (strong recommendation, moderate-certainty evidence).
For sex workers and their clients in low- and middle-income countries
WHO suggests offering periodic screening for asymptomatic sexually transmitted infections to female sex workers (conditional recommendation, low-certainty evidence).
WHO suggests offering female sex workers, in settings with high prevalence and limited clinical services, periodic presumptive treatment for asymptomatic sexually transmitted infections (conditional recommendation, moderate- to high-certainty evidence).
For sex workers and their clients in low- and middle-income countries
The WHO sexually transmitted infection guideline recommends screening all pregnant women for syphilis during the first antenatal care visit (strong recommendation, moderate-certainty evidence).
This recommendation applies to all settings, including settings with high or low prevalence of syphilis.
Management of urethral discharge ★
For people who present with urethral discharge from the penis, management is recommended to be based on the results of quality-assured molecular assays. However, in settings with limited or no molecular tests or laboratory capacity, WHO recommends syndromic treatment to ensure treatment on the same day of the visit (strong recommendation, moderate-certainty evidence).
Management of vaginal discharge ★
For people who present with vaginal discharge, WHO recommends treatment for N. gonorrhoeae and/or C. trachomatis and/or T. vaginalis on the same visit. WHO suggests treatment based on the results of quality-assured molecular assays for N. gonorrhoeae and/or C. trachomatis and/or T. vaginalis. In settings in which treatment based on the results of molecular assay in the same visit is not feasible or that have limited or no molecular testing, WHO suggests treatment based on testing with quality-assured rapid point-of-care tests or on syndromic treatment (strong recommendation, moderate-certainty evidence).
WHO suggests treating for bacterial vaginosis if vaginal discharge is present (for example, tenacious or thin) or based on the results of microscopy, if available (conditional recommendation low-certainty evidence).
WHO suggests treating for candidiasis, where indicated by type of discharge (such as curd-like with vaginal itching) or by the results of microscopy, if available (conditional recommendation low-certainty evidence).
For management of women with lower abdominal pain ★
For sexually active women who present with lower abdominal pain, WHO suggests assessing for pelvic inflammatory disease and treating syndromically.
WHO suggests the following.
Treat for pelvic inflammatory disease on the same visit.
Test for infection with N. gonorrhoeae and C. trachomatis and, if available, Mycoplasma genitalium, to support partner management when tests are available (conditional recommendation, low-certainty evidence).
Management of genital ulcer disease, including anorectal ulcers ★
For people who present with genital ulcers (including anorectal ulcers), WHO recommends treatment based on quality-assured molecular assays of the ulcer. However, in settings with limited or no molecular tests or laboratory capacity, WHO recommends syndromic treatment to ensure treatment on the same day of the visit (strong recommendation, moderate-certainty evidence).
Management of anorectal discharge ★
For people who present with anorectal discharge and report receptive anal sex, WHO recommends management based on the results of quality-assured molecular assays. However, in settings with limited or no molecular tests or laboratory capacity, WHO recommends syndromic treatment to ensure treatment on the same day of the visit (strong recommendation, moderate-certainty evidence).
Good practice for men includes:
taking a medical and sexual history and assessing risk for sexually transmitted infections;
performing a physical examination of the genital and anal areas;
offering HIV and syphilis testing and other preventive services as recommended in other guidelines;
if symptoms persist at review, good practice includes checking partner notification and treatment history; and
for people with recurrent or persistent urethral discharge, referring people to a centre with laboratory capacity to diagnose infection with N. gonorrhoeae, C. trachomatis, M. genitalium and T. vaginalis and to test for antimicrobial-resistant N. gonorrhoeae and M. genitalium.
Good practice for women includes:
taking a medical and sexual history and assessing risk for sexually transmitted infections;
performing a physical examination, including abdominal and pelvic examination to assess for pelvic inflammatory disease, surgical conditions or pregnancy and external vulvo-vaginal examination to visualize any lesions, overt genital discharge or vulval erythema and excoriations;
bimanual digital examination of the vagina to (1) assess for cervical motion tenderness or pain with palpation of the pelvic area to exclude pelvic inflammatory disease; and (2) assess for the presence of vaginal discharge and the colour and consistency of the discharge on the glove;
offering HIV and syphilis testing and other preventive services as recommended in other guidelines; and
for people with recurrent or persistent vaginal discharge, referring to a centre with laboratory capacity to diagnose infection with N. gonorrhoeae, C. trachomatis, M. genitalium, T. vaginalis and bacterial vaginosis and to test for antimicrobial-resistant N. gonorrhoeae and M. genitalium (if there is a test) or for a specialist’s assessment (sexually transmitted infection expert and physician or a gynaecologist), when no such testing is available in primary health care centres.
- 6.16.1.
Infant feeding in the context of HIV
Mothers living with HIV should breastfeed for at least 12 months and may continue breastfeeding for up to 24 months or longer (similar to the general population) while being fully supported for ART adherence (see Chapter 7 for interventions to optimize adherence) (strong recommendation, low-certainty evidence for 12 months; very-low-certainty evidence for 24 months).31
Remarks
The Guideline Development Group agreed that this recommendation should be framed as follows. In settings in which health services provide and support lifelong ART, including adherence counselling, and promote and support breastfeeding among women living with HIV, the duration of breastfeeding should not be restricted. Further, mothers living with HIV (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first six months of life, introducing appropriate complementary foods thereafter and continue breastfeeding. Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast-milk can be provided.
This recommendation updates the component of the 2010 recommendation on which breastfeeding practices and for how long related to the duration of breastfeeding. The components of the 2010 recommendation on breastfeeding practices and stopping breastfeeding remain unchanged and valid.
When mothers living with HIV do not exclusively breastfeed
Good practice statement
Mothers living with HIV and health-care workers can be reassured that ART reduces the risk of postnatal HIV transmission in the context of mixed feeding. Although exclusive breastfeeding is recommended, practising mixed feeding is not a reason to stop breastfeeding in the presence of ARV drugs.
When mothers living with HIV do not plan to breastfeed for 12 months
Good practice statement
Mothers living with HIV and health-care workers can be reassured that shorter durations of breastfeeding of less than 12 months are better than never initiating breastfeeding at all.