HIV/AIDS

 

HIV/AIDS

Human immunodeficiency virus (HIV) is a blood-borne, sexually transmissible virus and its transmission is facilitated by the presence of other STIs. HIV is caused by infection with HIV-1 or HIV-2, both of which cause very similar conditions. HIV -1 is more virulent than HIV-2. HIV-2 carries a slight lower risk of transmission, tends to progress more slowly to Acquired Immune Deficiency Syndrome (AIDS). This may be due to a less-aggressive infection rather than a specific property of the virus itself. Persons infected with HIV-2 tend to have a lower viral load than people with HIV-1, and a greater viral load is associated with more rapid progression to AIDS in HIV-1 infections.  An important strategy in the control of HIV infection is the rapid and effective treatment of treatable STIs (Bennett, 2011).

 

Mode of transmission

1.     Unprotected sexual intercourse

2.     Sharing intravenous drug among drug users

3.     Mother-to-child transmission (MTCT), which can occur during the birth process or during breastfeeding

4.     Receipt of contaminated blood products with HIV (blood transfusion and organ transplants) (Bennett, 2011).

 

WHO STAGING  IN ADULTS AND ADOLESCENTS CLINICAL STAGE 1 Ø  Asymptomatic Ø  Persistent generalized lymphadenopathy

CLINICAL STAGE 2 Ø  Moderate unexplained weight loss (<10% of presumed or measured body weight) Ø  Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis) Ø  Herpes zoster Ø  Angular cheilitis Ø  Recurrent oral ulceration Ø  Papular pruritic eruptions Ø  Seborrhoeic dermatitis Ø  Fungal nail infections CLINICAL STAGE 3 Ø  Unexplained severe weight loss (>10% of presumed or measured body weight)1 Ø  Unexplained chronic candidiasis for > 1 month Ø  Unexplained persistent fever (intermittent or constant for > 1 month) Ø  Persistent oral candidiasis Ø  Oral hairy leukoplakia Ø  Pulmonary tuberculosis Ø  Severe bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteraemia) Ø  Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis Ø  Unexplained anaemia (<8 g/dl ), neutropenia (<0.5 x 109/l) and/or chronic thrombocytopenia (<50 x 109 /l)  CLINICAL STAGE 4 Ø  HIV wasting syndrome Ø  Pneumocystis pneumonia Ø  Recurrent severe bacterial pneumonia Ø  Chronic herpes simplex infection (orolabial, genital or anorectal of >1 month's duration or visceral at any site) Ø  Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs) Ø  Extrapulmonary tuberculosis Ø  Kaposis sarcoma Ø  Cytomegalovirus infection (retinitis or infection of other organs) Ø  Central nervous system toxoplasmosis Ø  HIV encephalopathy Ø  Extrapulmonary cryptococcosis including meningitis Ø  Disseminated non-tuberculous mycobacterial infection Ø  Progressive multifocal leukoencephalopathy Ø  Chronic cryptosporidiosis Ø  Chronic isosporiasis Ø  Disseminated mycosis (extrapulmonary histoplasmosis, coccidiomycosis) Ø  Recurrent septicaemia (including non-typhoidal Salmonella) Ø  Lymphoma (cerebral or B cell non-Hodgkin) Ø  Invasive cervical carcinoma Ø  Atypical disseminated leishmaniasis Ø  Symptomatic HIV-associated nephropathy or HIV-associated cardiomyopathy  (Gallant e al, 2008). Eligibility to start ART This is dependent on WHO staging and CD4 count/ Total lymphocyte count. WHO stage I Ø  CD4 available: use CD4-guided criteria ( See CD4 Criteria for Initiation of Art) Ø  CD4 not available: do not treat WHO stage II Ø  CD4 available: use CD4-guided criteria Ø   CD4 not available: treat if total lymphocyte count <1200 (CD4 count strongly recommended) WHO Stage III: Ø  CD4 available: treat if CD4 <350. If CD4 >350, treat if more than 3  problems in stage 3 Ø  CD4 not available: treat WHO Stage IV: treat regardless of CD4 CD4 CRITERIA FOR INITIATION OF ART Ø  CD4 <200: Treat regardless of clinical stage Ø  CD4 200-350: Treat if WHO stage III or pregnancy Ø  CD4 >350: Treat if >1 stage III sign or repeated stage III conditions. For others, monitor and consider ART based on clinical or immunologic deterioration. Always start before CD4 decreases to <200. Ø  Measure CD4 after stabilization of any intercurrent illness  (Gallant et al, 2008). Baseline laboratory  investigations before initiation of ARVS According to Gallant et al, (2008) the following laboratory investigations must be carried out before initiation of ARVs: 1.     Creatinine if to start TDF 2.     ALT and AST if to start NVP 3.     Haemoglobin and WBC if to start AZT 4.     RPR to rule out STIs 5.     PAP smear to rule cervical cancer 6.     Pregnancy test in women of reproductive age

TREATMENT OF HIV

HIV is not curable but the progression to AIDS can be controlled or halted by use of antiretroviral therapy (ART). For clients to start taking ART they need to be committed and this can be assessed during adherence counseling. ARVs are to be taken for life and have side effects that can make them difficult for some clients to take. Thus, the decision as when to start therapy is an important one. 

 

General principles of ART

According to Gallant et al, (2008) the following are the general principles of ART:

1.     Use of combinations of at least 3 ARV drugs

2.     Maximize adherence to ARV regimen

3.     Rational sequencing of ARV drugs

4.     Avoid resistance

 

CLASSES OF ANTIRETROVIRAL DRUGS

Nucleoside analogue Reverse Transcriptase Inhibitors

·       Zidovudine (AZT)

·       Lamivudine (3TC)

·       Tenofovir disoproxil fumerate (TDF)

·       Emitricitabine (FTC)

·       Didanosine (ddl)

·       Stavudine (d4T)

·       Abacavir (ABC)

·       Zalcitabine (ddC)

 

Non- Nucleoside  Reverse Transcriptase Inhibitors

·       Nevirapine (NVP)

·       Efavirenz (EFV)

·       Delavirdine (DLV)

 

Protease Inhibitors

·       Lopinavir/Ritonavir (LPV/RTV)- Kaletra

·       Ritonavir (RTV)

·       Indinavir (INV)

·       Nelfinavir NFV)

·       Saquinavir (SGV)

·       Amprenavir (APV)

·       Anazanavir (ATV)

(MOH, 2008)

 

RECOMMENDED REGIMENS FOR HAART WITH CD4 COUNT < 350

1^st line treatment

Regimen of 2NRTI plus 1 NNRTI

Ø  Tenofovir / Emtricitabine (Truvada) + Efavirenz / Nevirapine (Avoid Efavirenz in first trimester of pregnancy, it is associated with serious birth defects )

2^nd line treatment

Regimen of 2NRTI plus 1 Protease Inhibitors

Ø  Zidovudine + Lamivudine +  Lopinavir/ Ritonavir (Kaletra) (preferred treatment)

Ø  Stavudine / Lamivudine + Lopinavir/ Ritonavir (Kaletra)

     (MOH, 2009)

 

RECOMMENDED REGIMEN FOR PMTCT (CD4 COUNT > 350)

In pregnancy

Ø  Zidovudine 300mg twice daily from 14 weeks till labour starts

 

In labour & delivery

Ø  Nevirapine 200mg stat at onset of  labour

Ø  Combivir (Zidovudine 300mg + Lamivudine 150mg) at onset of labour and thereafter repeat every 12 hours until delivery

 

 

 

Patient education on prevention of HIV 

1.     Counseling on safer sex practices

2.     Treatment of concurrent STIs

3.     Disclosure

4.     Counseling of intravenous drug users on the risk of sharing needles and syringes

5.     Use of Antiretroviral  drugs (ARVs)

 (Gallant et al, 2008)

 

CONCLUSION

HIV/AIDS has got devastating effects on individuals and societies.  Health personnel could play a pivotal role in managing this condition as it affects the immune system. The health personnel need to understand how HIV is transmitted, prevented and treatment which should be given (ARVs) to control disease progression. The battle to fight AIDS cannot be won single handedly but need collaborative efforts from all stake holders.