Hiv recent guidelines naco 2015

HIV Recent Guidelines
Dr. Mehakinder Singh
Post graduate student,
DEPTT. OF MEDICINE,
IGMC SHIMLA
HP-APICON 2015

Total: 35.0 million
[33.2 million – 37.2 million]
Middle East & North
Africa
230 000
Sub-Saharan Africa
24.7 million
Eastern Europe &
Central Asia
1.1 million
Asia and the Pacific
4.8 million
North America and Western and Central
Europe
2.3 million
Latin America
1.6 million
Caribbean
250 000
Adults and Children
Estimated to be living with HIV2013
Since the beginning of the pandemic an estimated
39 million people have died of AIDS related illnesses

Estimates for Adults and Children in India
Estimated
People living with HIV 2,100,000
Adults aged 15 to 49 prevalence rate 0.27%
Adults aged 15 and up living with HIV 1,900,000
Women aged 15 and up living with HIV 750,000
Deaths due to AIDS 140,000
Source: UNAIDS Global Report 2013; NACO HIV Estimations 2012

• On the basis of the HIV Technical report on HIV
estimates-2012 the epidemic of HIV /AIDS in
Himachal Pradesh is static and under control.
• Our state fall under the low prevalence category
where the infection rate among the adult HIV
prevalence is 0.17%.
• There are 8091 confirmed HIV positive persons in
the State till March 2015.
HIV/AIDS Situation in H.P.
4

National response to HIV/AIDS in India
1986: First case of HIV detected in Chennai
1990: HIV/AIDS Cell set up in MoHFW
1992: National AIDS Control Organisation (NACO)
established within MoHFW
1994-1999: NACP-I launched with a budget of Rs. 468.4
crores
1999-2006: NACP-II Budgetary Support: Rs. 2,690 crores
2007-2012: NACP-III Budgetary Support: Rs. 8,023 crores
2012-2017: NACP-IV Budgetary support: Rs.14,295 crores

57% Reduction in New Infections
(2001-12) with Scale-up of Prevention
Strategies
29% Reduction in AIDS-related Deaths
(2006-12) with Scale-up of Anti-Retroviral
Treatment
Source: UNAIDS Global Report 2013; NACO HIV Estimations 2012
Evidence of Programme Impact in India
AIDS related deathsNew Infections

HIV Care in General Health System
26
Link ART Centres and LAC Plus Centres
(987)
ART Centres
(448)
CoE
& ART
Plus
Centres(
54)
Three-Tier Model of HIV Treatment ServicePublic Health
Infrastructure
Selected Medical
Colleges
Medical colleges
and District Level
Hospitals
Sub-District level
Hospitals & CHC
Updated September 2014
CoE 10
PCoE 7
ART plus 37
Total CST Facilities: 1435

Diagnosis of HIV Infection
 National Guidelines on Testing Adults
• For symptomatic persons: the sample should be
reactive with two different kits
• For asymptomatic persons: the sample should be
reactive with three different kits

Pre – ART Care and Follow up
At the beginning of HIV care and prior to starting ART, a
clinical assessment should be performed to:
 Determine the clinical stage of HIV infection
 Identify history of past illnesses (especially those
related to HIV)
 Identify current HIV-related illnesses that require
treatment
 Determine the need for ART and OI prophylaxis
 Identify coexisting medical conditions and treatments
that may influence the choice of therapy
10

Primary OI Prophylaxis for adult
Opportunistic
Infection
Choice of
Antimicro
bial
Indication
Discontinue,
if CD4
counts stable
for > 6
months
PCP
CTX – DS,
1 tab OD
<250 cells/cmm
>250
cells/cmm
Toxoplasmosis
CTX – DS,
1 tab OD
<250 cells/cmm
>250
cells/cmm
Cryptococcal
Meningitis
- Not recommended -
Mycobacterium
TB
- Not recommended -
MAC - Not recommended -
Candidiasis - Not recommended -
CMV Retinitis - Not recommended -
Primary Prophylaxis

Upto October 2014: Cotrimoxazole Prophylaxis
When and How to initiate Cotrimoxazole Prophylaxis
Commencing
primary CPT
WHO clinical stage I and II: CD4 <250 cells/mm3 or
WHO clinical stage III and IV: Irrespective of CD4
count
Commencing
secondary CPT
For all patients who have completed successful
treatment for PCP until CD4 is >250 maintained over
a period of 6 months
Timing the initiation of
cotrimoxazole in relation
to initiating ART
Start cotrimoxazole prophylaxis first.
Start ART about two weeks later if the patient can
tolerate cotrimoxazole and has no symptoms of
allergy (rash, hepatotoxicity)
Meanwhile, make use of the time for adherence and
treatment preparation
Dosage of cotrimoxazole
in adults & adolescents
One double-strength tablet or two single-strength
tablets once daily – total daily dose of 960 mg
(800 mg SMZ + 160 mg TMP)

Revised guidelines on Timing of ART initiation
in relation cotrimoxazole prophylaxis
(November 2014 Guidelines)
 The existing guidelines stipulate that there shall be two
weeks of cotrimoxazole administration before initiating
first line ART. “Start ART about two weeks later if the
patient can tolerate cotrimoxazole and has no symptoms
of allergy (rash, hepatotoxicity)”
 However keeping in mind that many patients are lost in
this period if not initiated on ART and also keeping in
mind benefits of early ART initiation, especially in those
with low CD 4 count, it has been decided that ART
should be started 5-6 days after start of CPT
prophylaxis or as soon as CPT is tolerated and
patients has completed the “preparedness phase "of
counselling
17

 Do not start ART in the presence of an
active OI.
 In general, OIs should be treated or
stabilized before commencing ART.
18

Antiretroviral Therapy (ART)
ART is the combination of
different classes of ARV drugs
To achieve maximal and most
durable suppression of viral
replication
To prevent emergence of drug
resistant mutants
To improve survival and quality of
life
Before ART
One year after ART

Mechanism of Anti Retro Viral Drugs Action
4
Fusion
Inhibitor
Enfuviritide
CCR5
co receptor
Antagonist
Maraviroc
NRTIs NNRTIs
Integrase
Inhibitors
Protease
Inhibitors
NsRTI Nevirapine
(NVP)
Efavirenz (EFV)
Etravirine
Rilpivirine
Delavirdine,
DLV
Raltegravir RGV
Elvitegravir
ELV
Dolutegravir
DTG
Atazanavir (ATV)
Ritonavir (RTV)
Lopinavir (LPV)
Saquinavir (SQV)
Indinavir (IDV)
Nelfinavir (NFV)
Amprenavir (APV)
Fosamprenavir,
(FPV)
Tipranavir (TPV)
Darunavir (DRV)
Zidovudine (AZT)
Stavudine (d4T)
Lamivudine (3TC)
Abacavir (ABC)
Didanosine (ddI)
Emtricitabine (FTC)
NtRTI
Tenofovir (TDF)

Initiation of ART based on
CD4 count & WHO Clinical staging
WHO Clinical Staging Recommendations
HIV infected Adults & Adolescents
Clinical Stage I and II Start ART if CD4 <350 cells/mm3
Clinical Stage III and IV Start ART regardless of CD4 count
For HIV and Hepatitis B and C co-infected patients
HIV and HBV / HCV co-infection -
Without documented evidence of
severe chronic liver disease
Start ART if CD4 <350 cells/mm3
HIV and HBV / HCV co-infection -
With documented evidence of severe
chronic liver disease
Start ART regardless of CD4 count

Evolution of WHO ART Guidelines
TOPIC 2002 2003 2006 2010
When to
start ART
CD4 ≤200 CD4 ≤ 200
CD4 ≤ 200
- Consider 350
- CD4 ≤ 350 for TB
CD4 ≤ 350
-Irrespective CD4 for TB &
HBV
PMTCT
Since 2001
4 weeks AZT;
AZT+ 3TC, or
single dose NVP
2004
AZT from 28
weeks + single
dose NVP
AZT from 28 weeks
+ single dose NVP
+AZT/3TC 7days
Option A
(AZT +infant NVP)
Option B
(triple ARVs)
First line
ART
8 options
- AZT
preferred
4 options
- AZT preferred
8 options
- AZT or TDF
preferred
- d4T dose
reduction
6 options & FDCs
- AZT or TDF preferred
- d4T phase out
Second
line ART
Boosted PI Boosted PI
Boosted PI
ATV/r, DRV/r, FPV/r
LPV/r, SQV/r
Boosted PI
Heat stable FDC: LPV/r,
ATV/r
Viral load
Testing
No
No
(Desirable)
Yes
Tertiary centres
Yes
Phase in
Earlier initiation
Simpler treatment
Safer, more robust regimens
Better monitoring
Simplified treatment options for pregnant women
Vitoria M et al, Curr Opin HIV/AIDS 2013

National ART Regimens
Summary of Changes in WHO Recommendations
When to Start in Adults
Target population
(ARV-Naive)
2010 ART
Guidelines
2013 ART guidelines
Strength of
Recommendation
& Quality of
Evidence
HIV+
Asymptomatic
CD4 ≤350 cells/mm3
(CD4 ≤350 cells/mm3
as a priority)
Strong,
recommendation
moderate-quality
evidence
HIV+
Symptomatic
WHO clinical stage 3 or
4 regardless of CD4 cell
count
No change
Strong, moderate-
quality evidence
Pregnant and
breastfeeding
women with HIV
or
WHO clinical stage 3 or
4
Regardless of CD4 cell
count or WHO clinical
stage
Strong, moderate-
quality evidence
HIV-TB
co-infection
Presence of active TB
disease, regardless of
CD4 cell count
No change
Strong, low-quality
evidence
HIV-HBV
CO-INFECTION
Evidence of chronic
active HCV disease,
regardless of CD4 cell
count
Evidence of severe
chronic HBV liver
disease, regardless of
CD4 cell count
Strong, low-quality
evidence
HIV+ Partners in
Sero discordant
Couple
No recommendation
established
Regardless of CD4 cell
count or WHO clinical
stage
Strong, high-quality
evidence

Summary of Changes in Recommendations:
on What to Start in Adults
First-line ARV regimens
Target
population
2012 ART Guidelines
2014 ART
Guidelines
HIV+ adults
AZT or TDF + 3TC + EFV or
NVP
TDF + 3TC +
EFV
(as fixed dose
combination)
HIV+ pregnant
women
AZT + 3TC + NVP or EFV
HIV-TB
Co-infection
AZT or TDF + 3TC + EFV
HIV-HBV / HBC
Co-infection
TDF + 3TC + EFV
TARIKA 300mg
LOVABLE 300mg
EXPERIENCE 600mg

 In India, the agreed practical definition of IRIS
would be the “occurrence or manifestations of new
OIs or existing OIs within six weeks to six
months after initiating ART; with an increase in
CD4 count”.
IRIS (NACO May 2013)

 Most commonly present with fever and worsening of
pre-existing lymphadenopathy or respiratory
disease.
 There are no standard guidelines for the treatment of
IRIS. Most cases resolve without any additional
treatment. Milder forms of IRIS resolve with
continuing anti-infective therapy and HAART.
 In the majority of cases, HAART can be safely
continued and need not be interrupted.
IRIS

 However, the discontinuation of ART should be
considered if the inflammatory responses are considered
life-threatening (e.g. intracranial IRIS leading to
encephalitis, cerebritis, perilesional cerebral oedema and
pulmonary IRIS with ARDS/acute respiratory distress
syndrome), or are unresponsive to steroids.
 Non-steroidal anti-inflammatory drugs (NSAIDs) are
helpful in controlling inflammation and fever associated
with IRIS.
 However, in severe IRIS, a short course of oral
prednisolone is required to alleviate the symptoms.
IRIS

First line ART: Drug Toxicities
Drugs
Short term
toxicities
Medium term
toxicities
Long term
toxicities
Zidovudine
Headache, nausea,
vomiting, malaise,
Diarrhoea
Bone Marrow
suppression
Anaemia (Macrocytic)
Bone Marrow
suppression
Anaemia (Macrocytic)
Hyper pigmentation
Lactic Acidosis
Proximal myopathy
Stavudine
Lactic Acidosis
Pancreatitis
Peripheral Neuritis
Lipodystrophy
Dyslipidemia
Tenofovir
Nephrotoxicity (low incidence), Fanconi syndrome and rarely
Acute Renal Failure
Nevirapine
Skin Rashes
Hepato toxicity
Efavirenz
Drowsiness, dizziness,
Confusion, Vivid
dreams
Skin Rashes
Hepato toxicity (very
rare)

Drug Substitution
Drug Toxicity Drug Substitution
Zidovudine
Persistent GI
intolerance or severe
haematological
toxicity
Substitute with Tenofovir
Tenofovir
Nephrotoxicity
Fanconi syndrome
Acute Renal Failure
Substitute with
Zidovudine, if Hb is >9
gm/dl
Substitute with
Stavudine, if anaemic
(Hb is <9 gm/dl)
Both
Zidovudine
and
Tenofovir
As above Substitute with Stavudine

Drug Substitution
Drug Toxicity Drug Substitution
Nevirapine
Hepatotoxicity, Skin rash
but not life threatening
(Except Grade 4)
Substitute with
Efavirenz
Severe rash;
life threatening (Grade 4):
Stevens-Johnson
syndrome to Nevirapine
Substitute with
Atazanavir/ritonavir
Efavirenz Persistent CNS toxicity
Substitute with
Nevirapine
Both
Nevirapine
and
Efavirenz
As above
Substitute with

Efavirenz: CNS Effects
• CNS toxicity: Vivid dreams, nightmare, insomnia,
dizziness, headache, impaired concentration and
attention span, depression, hallucination, exacerbation
of psychiatric disorders, psychosis and suicidal ideation
• CNS effects (at least some) are observed during first few
doses of Efavirenz in >50% of patients
– Typically starts after 1st and / or 2nd dose of Efavirenz
– Usually subsides by 2 to 6 weeks
35

Refer to SACEP
Suspect treatment failure during the medical consultation
• Clinical: Advancing T-stage of disease – WHO stage 3/4 conditions
• Fall of CD4 count to pre-therapy baseline
• 50% fall from the on-treatment peak value
• Persistent CD4 levels below 100 cells
Signs or symptoms of OI
Manage IRIS or OI, especially TB
Repeat CD4 immediately
Perform clinical staging
Give prophylaxis and/or treatment for OI
Continue 1st line ART and support adherence
Work with patient / caregiver to resolve issues causing
non-adherence
Continue First line ART, give OI prophylaxis if necessary
Follow-up monthly; Reassess clinically
Repeat CD4 after two weeks (to confirm validity and exclude lab
and physiological variability)
If CD4 not declining, continue adherence support and repeat
CD4 in 3 months. Reassess and determine if treatment failure
NOPatient has been on
ART for at least
6 months
Is adherence to
first-line ART optimal?
YES
YES
Most recent CD4
within 1 month of
current medical
consultation
CD4 indicating
treatment failure?
YES
YES
NO
NO
NO
State AIDS Clinical Expert Panel
37

Current Recommendation for Second line ART is based
on:
A new class of ARV, a Ritonavir boosted PI
(Atazanavir/ritonavir or Lopinavir/ritonavir)
Supported by at least one new and unused NRTI
(Zidovudine or Tenofovir or Stavudine)
Continued Lamivudine administration ensures
reduced viral fitness
Formulation of Second line ART

For PLHIV failed to Tenofovir based First line ART Regimens
Regimen ART Regimen Preference
Regimen
III
Zidovudine +
Lamivudine +
Second line regimen for those who
were on Tenofovir containing first
line regimen, if Hb >9gm/dl
Regimen
III(a)
Zidovudine +
Lamivudine +
Lopinavir/ritonavir
For patients of Regimen III, who
developed severe Atazanavir toxicity
Regimen V
Stavudine +
Lamivudine +
Second line regimen for those who
were on Tenofovir containing first
line regimen, if Hb <9gm/dl
Regimen
V(a)
Stavudine +
Lamivudine +
Lopinavir/ritonavir
For patients of Regimen V, who
developed severe Atazanavir toxicity

ART Regimen Indications
Tenofovir 300mg +
Lamivudine 300 mg +
Lopinavir/ritonavir
(800/200)
First line regimen for patients
with confirmed HIV-2 infection
alone or combined HIV-1 and HIV-2
infection, regardless of Hb level
HIV-2 Infection: NACO ART Regimen
41

Paediatric HIV can be prevented by effective PPTCT
42

NACO Guidelines (December 2013)
What ART to Start
in Pregnant & Breast-feeding Women
Life long therapy
Tenofovir + Lamivudine + Efavirenz
for all HIV Positive
Pregnant and breast feeding women
regardless of clinical stage
or CD4 count or duration of pregnancy
<Rolled out across the country from January 2014>

HIV-positive partners in
HIV sero-discordant couples
 The results of the HPTN052 study strongly support
the use of ART to prevent HIV transmission among
HIV-sero-discordant couples (96% reduction)
 The Guidelines, therefore, endorse that the sexual
partner with HIV in a sero-discordant couple
should be offered ART regardless of CD4 count

Considerations for Co-infection of
Tuberculosis and HIV
 HIV-TB co-infection is one of the most
challenging issues in the effort to scale up ART
since more than 60% of PLHIV develop TB.
 Active TB is the commonest OI among HIV-
infected individuals and is also the leading cause
of death in PLHIV.

Initiation of First line ART
in PLHIV with TB Co-infection
Type of
Tuberculosis
Eligible
Clinical Staging
and CD4 Counts
Timing of ART
in relation to start of
TB treatment
ART Regimen
Pulmonary TB
(Stage III)
Start ART
irrespective of
any clinical
stage
and
irrespective of
any CD4 count
Start ATT first
(Category I or II)
Start ART as soon as
TB treatment is
tolerated
(after 2 weeks &
before 2 months)
TDF+3TC+EFV
(Single pill at
bed time)Extra
pulmonary TB
(Stage IV)

Second Line ART for HIV-TB in India
Tenofovir / Zidovudine / Stavudine
+
Lamivudine
+
47

Management Plan for TB in patients on
Second line ART & Alternate First line ART
(Receiving Atazanavir/ritonavir or Lopinavir/ritonavir)
Rifampicin suppresses the action of boosted PI
(Atazanavir/ritonavir or Lopinavir/ritonavir)
However, Rifabutin does not suppress the action
of Atazanavir/ritonavir or Lopinavir/ritonavir
Ritonavir boosts Rifabutin availability
Rifabutin 300 mg thrice weekly has to be substituted
for Rifampicin in category I or II treatment protocol
48

HIV negative
HIV Source code
No PEP
required
Status/Source
unknown
HIV SC unknown
HIV positive
Low titer exposure
Asymptomatic,
high CD4
High titer exposure
Advanced disease,
low CD4
HIV SC1 HIV SC2
HIV status of exposure source

No
Is the Source material is blood, bloody fluid or Other Potentially Infected
Material (OPIM) or an instrument contaminated with one of these substances?
Mucous Membrane or
Skin integrity
compromised
Volume
Small volume-
few drops /
short duration
Large volume-
major splash /
long duration
Less severe-
solid needle,
Superficial scratch
No PEP
required
Intact Skin only
No PEP
required
Severity
EC 2 EC 3EC1 EC 2
What Type of exposure has occurred?
More severe-
hollow bore,
deep injury
Percutaneous
exposure
Yes
HIV Exposure code
51

Revised PEP Recommendations
{December, 2014}
Occupational Exposure
Exposure
Code
HIV Source
Code
PEP Recommendations Duration
1 1 Not warranted
28 days
1 2
Recommended
2 1
2 2
3 1 or 2
2/3 Unknown
Consider PEP, if HIV
prevalence is high in the
given population & risk
categorisation

PEP Regimens
Revised Guidelines - December, 2014
a. Wherever PEP is indicated and source is ART naive or
unknown: recommended regimen is Tenofovir 300 mg +
Lamivudine 300 mg + Efavirenz 600 mg once daily for 28
days.
• Wherever available, single pill containing these
formulations should be used.
• Dual drug regimen should not be used any longer in any
situation for PEP
b. The first dose of PEP regular should be administered as soon
as possible, preferably within 2 hours of exposure and the
subsequently dose should be given at bed time with clear
instruction to take it 2-3 hours after dinner & to avoid fatty
food in dinner

In case of Sexual Assault:
 PEP should be provided to exposed person in case of
sexual assault as a part of overall package of post
sexual assault care
Revised PEP Recommendations
{December, 2014}

Pre- vs Postexposure Prophylaxis
 After exposure to HIV,
infection may become
established
 Postexposure prophylaxis
(initiated soon after
exposure) reduces the
chance of infection
 Pre-exposure prophylaxis
begins treatment earlier
(before exposure), which
might increase the
prophylactic effect
HIV
infection
0 hr 36 hrs 72 hrs
HIV
exposure
1 mos 3 mos 5 mos
Postexposure
prophylaxis
Pre-exposure
prophylaxis
55

CDC Guideline:
Recommended PrEP Regimen
 Fixed-dose TDF/FTC is the recommended PrEP regimen
for MSM, heterosexually active men and women, and IDU
who meet PrEP prescribing criteria
 Dosed as a single pill (300/200 mg) once daily
 This regimen is approved by the FDA for PrEP use
 Provide a prescription or refill for no more than 90 days
 TDF alone may be considered as an alternative for IDU and
heterosexually active men and women (but not MSM)
 Based on efficacy data from clinical trials
 This regimen is NOT approved by the FDA for PrEP use

Palliative Care in HIV
The Government of India has adopted WHO’s definition of
palliative care, which is the active total care of patients whose
disease is not responsive to curative treatment
(Manual on Palliative Care, MOHFW, November 2005).

End-of-life Care
“ How people die lives on the memory of those left
behind”
 The terminal phase is defined as the period when day-to-
day deterioration, particularly of strength, appetite and
awareness are occurring. The aim of care at this stage
should be to ensure the patient’s comfort holistically, and
a peaceful and dignified death.
 Provide psychosocial and spiritual support to the patient.
 Help the family come to terms with the fact that the
patient is leaving them soon: let family members be
around to see and talk to the patient
58

ART PLUS CENTRE Shimla
<September 2015>
 Total PLHIV registered- 2392
 Started on ART- 1553 (alive 482, dead 310, LFU 56,
optout 15, transfer out 689, stopped 1)
 PLHIV on 2nd line ART – 7
 Pre ART – 839 (alive 77, dead 154, LFU 278, opt out
18, transfer out 312)

G U R U N A N A K
“In the places where the lowly and
discarded are cared for, there resides
the blessings of Your Grace”
Thank you

Cotrimoxazole Prophylaxis
When to stop Cotrimoxazole Prophylaxis
When to stop
prophylaxis
(cotrimoxazole or
dapsone) in
patients on ART
If CD4 count >250 for at least 6 months
and If patient is on ART for at least 6 months,
is asymptomatic and well
Cotrimoxazole for pregnant women- Women who fulfill the criteria for
CPT should be started on and continued on it throughout pregnancy.
Breastfeeding women should continue CPT where indicated
Patients allergic to sulpha-based medications should be given Dapsone
100 mg per day, if available

 Do not start ART in the presence of an active OI.
 In general, OIs should be treated or stabilized
before commencing ART.
 Mycobacterium Avium Complex (MAC) and
progressive multifocal leukoencephalopathy (PML)
are exceptions, in which commencing ART may be
the preferred treatment, especially when specific
MAC therapy is not available.
23

HIV status of source of exposure
Source of
HIV
Definition of Risk in Source
HIV Negative
Source is not HIV infected; but consider HBV &
HCV
Low Risk HIV Positive and clinically Asymptomatic
High Risk HIV Positive and clinically Symptomatic
Unknown
• Status of the patient unknown
• Neither patient nor his / her blood available for
testing
• The risk assessment will be based only upon
the exposure (HIV Prevalence in the
geographical area should be considered)

8
National ART Regimens
NACO ART Regimen Revised 2012
Regimen National ART Regimen Indications & Comments
Regimen I
Zidovudine +
Lamivudine + Nevirapine
First line regimen for patients with
Hb >9 gm/dl
Regimen I (a)
Tenofovir +
Hb <9 gm/dl
Regimen II
Zidovudine +
Lamivudine + Efavirenz
Hb >9 gm/dl and on concomitant
Rifampicin containing ATT
Regimen II (a)
Tenofovir +
• First line regimen for patients
with Hb <9 gm/dl and on
concomitant Rifampicin
containing ATT
• First line regimen for all patients
with Hepatitis B & Hepatitis C
co- infection
• First line regimen for pregnant
women, with no exposure to sd-
NVP / NNRTI in the past

ART Regimen for those already “on ART”
Regimen
Already on
ART Regimen
ART Continuation
Drug Dispensing
Regimen I
Zidovudine +
Continue Zidovudine +
Regimen I (a)
Tenofovir +
(Single Pill)
Regimen II
Zidovudine +
Continue Zidovudine +
Lamivudine + Efavirenz (ZLE) even
after ATT is completed , if on ATT
Regimen II (a)
Tenofovir +
(Single Pill)

Hiv recent guidelines naco 2015

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