HIV MANAGEMENT

JHM
 INTRODUCTION
 HIV/AIDS is not curable but its treatable
 The treatment is mainly through the use of Antiretrovirals drugs
 Other form of management includes proper/adequate diet and stress
reduction techniques.
 Italso involves prevention and management of opportunistic and
other infections.
ANTI RETRO VIRALS DRUGS

 ART are medications that treat HIV.

 The drugs do not kill or cure the virus. However,
when taken they can prevent the replication of
the virus.
 When the virus is slowed down, so is HIV disease.
 Antiretroviral drugs are referred to as ARVs
Classes of Antiretrovirals

 Reverse transcriptase (RT) inhibitors

–      Nucleoside RT inhibitors (NRTI)
–      Non-nucleoside RT inhibitors (NNRTI)
–      Nucleotide RT inhibitors
 Protease inhibitors (PI)
 Fusion inhibitors
 Integrase inhibitors
 CCR5 inhibitors
Five Goals of ART

 1. Reduce the amount of HIV viruses in the body

 2. Support- Restore the immune system
 3. Reduce HIV-related illness and deaths
 4. Improve the Quality of life
 5. Reduce general risk of transmission in the public
The objectives of anti HIV therapy

 Prolong life and improve quality of life for the long term.
 Suppress virus to below the limit of detection on the
currently available tests (below 50 copies of HIV RNA), or
as low as possible, for as long as possible.
 Optimise and extend the usefulness of the currently
available therapies.
 Minimise drug toxicity and manage side effects and drug
interactions
Initiation of ARV

 All individuals with confirmed HIV infection

irrespective of: CD4 count, WHO clinical staging,
Age, pregnancy or breastfeeding status, risk group
provided that the individual is willing and ready
to take the ART
 ART should be started as soon as
possible(preferably within 2weeks of infection)
Pre Exposure Prophylaxis (PrEP)

 Pre-exposure prophylaxis (or PrEP) is a way for preventing

HIV in people who do not have HIV but are at very high
risk of getting the infection; by taking a pill every day.
 The pill (brand name Truvada) contains two medicines
(tenofovir and emtricitabine) that are used in combination
with other medicines to treat HIV.
 When someone is exposed to HIV through sex or injection
drug use, these medicines can work to keep the virus from
establishing a permanent infection
 When taken daily, PrEP is highly effective for preventing
HIV.
 Studies have shown that:
• PrEP reduces the risk of getting HIV from sex by about
99% when taken daily.
• Among people who inject drugs, PrEP reduces the risk of
getting HIV by at least 74% when taken daily.
PrEP eligibility criteria
 HIV negative and above 18 years
 No suspicion of acute HIV infection
 Substantial risk for HIV infection
 Is in a relationship with a HIV positive person who is not virally
suppressed
 MSM engaging in unprotected sex
 Exchanges sex for money/goods and engages in unprotected sex
 Has unprotected sex with one or more partners of unknown HIV status
 No contraindications for the medicines
 Willingness to use PrEP as prescribed, including periodic HIV testing
and STI screening
Contraindications for PrEP

 HIV positive
 Renal impairment
 Signs and symptoms of acute HIV infection-probable
recent exposure
 Allergy or contraindication to the medicines in the
regimen
NOTE
When restarting PrEP ,maximum protection is reached after 7 doses of PrEP
 PrEP should only be offered after assessment to establish eligibility, readiness for
effective use.
 Follow up testing every 3 months
 PrEP is much less effective if it is not taken consistently.
 PrEP only protects against HIV, condoms are important for the protection against
other STDs.
 Condoms are also an important prevention strategy if PrEP is not taken consistently.
 When restarting PrEP ,maximum protection is reached after 7 doses of PrEP
 Remind PrEP users that it takes 7 doses of PrEP to achieve adequate levels of the ARVs in
tissues to be effective. During these days, safer sex practices should be encouraged (including
abstinence and condoms).
POST EXPOSURE PROPHYLAXIS

 The term post-exposure prophylaxis is generally

understood to mean the medical response given to
prevent the transmission of blood-borne pathogens
following a potential exposure to HIV.
 Drugs for PEP are usually administered as a result of
accidental exposure to HIV as early as 2 hours and within
24 hours of the accidental exposure and not later than 72
hours.
Eligibility for PEP
Individuals are eligible for HIV PEP if:
 Exposure occurred within the past 72 hours
 The potentially exposed individual is not infected or not
known to be infected with HIV
 Mucous membrane or non-intact skin was significantly
exposed to a potentially infectious body fluid
PMTCT

 Offeredas part of the comprehensive package of

Antenatal care
 LifelongART should be initiated in all pregnant
and breastfeeding living with HIV
 Infant to receive ARV prophylaxis
 All infants to be exclusively breastfed
Adherence to ARVs
 Adherence is central to the success of ART. Almost perfect adherence (rates exceeding 95%) is desirable in
order to maximize the benefits of ART.
 This means taking the correct dose of drugs at the correct times while observing any dietary or fluid
restrictions.
 ARVs are unforgiving to poor adherence. In ‘Adherence’ there is involvement of the patient in the process. If
patient cannot adhere, HIV may become resistant to ARVs, and he/she can infect others with the resistant
virus.
 Adherence involves Storing the medication correctly,Taking medication on time,regularly attending clinic
visit and complying to all instructions given by the clinician.
Reasons for non-adherence
o Forgetting
o Regimen complexity
o Side effects
o Substance abuse
o Fear of medications
o Denial of need for treatment
 HIV/AIDS PREVENTION AND CONTROL

HIV/AIDS prevention and control focuses on the three

main ways of transmission
 Sexual transmission
 Parentral(blood) transmission
 Vertical (mother to child)transmission
PREVENTION OF SEXUAL TRANSMISSION OF HIV

 The most frequent mode of HIV infection, sexual transmission, is normally a result of unprotected vaginal or
anal intercourse.
 Worldwide, heterosexual transmission is responsible for the majority of new HIV infections.
 An important subset of sexually transmitted cases of HIV involves sexual activity that occurs when one or both
participants are under the influence of various substances, such as drugs or alcohol.
 Intoxicants may increase risk for transmission by clouding individual judgment and reducing inhibitions
regarding behaviors that facilitate HIV transmission.
Effective interventions to prevent sexual transmission include:
 Behavior change programs
 Prevention and treatment of sexually transmitted diseases (STDs)
 Voluntary counselling and testing (VCT)
 Voluntary medical male circumcision (VMMC))
Behavior Change Programs

 Programs to encourage safer sexual behaviors are anchored in a wide range of recognized behavioral
theories.
 Theory-based prevention programs include those that attempt to directly alter personal beliefs, attitudes
and behaviors, as well as interventions that indirectly seek to influence personal behavior by affecting social
networks and community norms.
 These approaches seek to increase condom use among people, who are sexually active, persuade individuals
to reduce their number of sexual partners, and encourage young people to remain abstinent or delay
initiation of sexual activity.
Sexual Abstinence - Sexual abstinence means to abstain from different levels of sexual activity.This includes:
 Avoiding vaginal and anal intercourse
 Avoiding oral-genital contact
 Avoiding genital contact
Safe sex
Safe sexes mainly refer to practising sex in a way that will not put any of the partners at risk.
It involves being faithful to one partner.
It is safe to have sex with one partner on the condition that;
 Both of you are uninfected (HIV negative)
 Both of you have sex strictly only with their partner.
 On condition that neither of you gets exposed to HIV through drug use, blood transfusion or other unsafe
activities.
USE OF CONDOMS
 The use of condom can be traced back several thousand years.
 It is known that around 1000BC the ancient Egyptians used a linen sheath for protection against disease.
 For sexually active people, studies have shown that if a latex condom is used correctly every time you
have sex, it is effective in providing protection against HIV
Correct and Consistent Use of Condoms

 Condoms are the most reliable method available for situations where people want to protect themselves or
their partner from any risk of STI.
 Used correctly, they form a barrier that keeps out even the smallest bacteria and viruses.
 Most STIs can be prevented by condom use, however Genital ulcers or warts can be transmitted through
contact with parts of the body not covered by the condom.
 More commonly, though, people get an STI because they misuse condoms, or use them inconsistently.
 When handled or stored incorrectly—in wallets or in a hot place, for example—or if used with oil-based
lubricants, condoms may fail.
 Condom breakage is usually due to incorrect use, not to defects in the device.
 Most importantly, condoms can only protect against STI when they are used consistently and correctly.
 When used correctly during every act of intercourse, condoms can greatly reduce the risks of both pregnancy
and STI (dual protection), including HIV infection.
Instructions for use of a male condom

1. Choose a brand that fits comfortably. Remove the condom from the package carefully, to avoid tearing. Do
not use teeth to open packet. Be careful not to tear condom with nails. Check ‘use by’ date (expiry date).
2. Holding the tip, unroll the condom on to erect penis. Pull back on foreskin before applying condom (if
uncircumcised). Squeeze the air out of the tip of the condom.
3. Unroll the condom onto the erect penis. Always use water-based lubricant. Do not use oil or Vaseline,
petroleum jelly. During sex, check condom is still in place.
4. After ejaculation, withdraw the penis from the vagina while the penis is still erect. Hold on to the rim of the
condom while withdrawing to prevent it from slipping off and the semen spilling into the vagina. Use condom
only once.
5. Remove condom from penis, and tie a knot in it to prevent spills or leaks. Dispose of condom safely (where it
cannot cause any hazard).
 The use of water-based lubricant is essential because it reduces trauma during sex and is compatible with
latex condoms.
 Oil-based lubricant like massage oil, skin moisturizer, cooking oil, butter or sun lotion must be avoided as
they damage latex condoms, making them more likely to break during sex. Hereby, possibly exposing each
partner to the risk of sexually transmitted infections including HIV.
 What do you do if a condom breaks?
 If a condom breaks during sexual intercourse, then pull out quickly and replace the condom.
 Whilst you are having sex, check the condom from time to time, to make sure it has not split or slipped off.
The ABCs of combination prevention

The ABC combination prevention strategy is used by informed individuals who are in a position to make a
decision.
These individuals can choose at different times in their lives to reduce their risk of exposing themselves or
others to HIV.
 A – Means Abstinence
This means not engaging in sexual intercourse or delayed sexual initiation.
 B – means being Faithful/Being safer
By being faithful to ones uninfected partner or reducing the number of sexual partners. The lifetime number of
sexual partners is a very important predictor of HIV infection.
 C – Means Correct and Consistent Condom use
Condoms reduce the risk of HIV transmission for sexually active young people, couples in which one person is HIV
– positive, sex workers and their clients, and anyone engaging in sexual activity with partners who may have
been at risk of HIV exposure.
STIs Control
 Sexually transmitted diseases increase HIV risk by at least two to five times.
 Untreated STDs enhance the infectivity of HIV-positive individuals and render uninfected people more
susceptible to transmission of the virus.
 Experts agree that an integral component of a comprehensive HIV prevention effort is the early detection
and treatment of STDs.
Voluntary Counseling and Testing
 The vast majority of people living with HIV/AIDS in low-income countries are unaware they are infected, a
factor that substantially weakens efforts to respond effectively to HIV/AIDS in resource-limited settings.
 Voluntary counseling and testing (VCT) is not only a gateway to care for people living with HIV but also a
critical component of a comprehensive strategy to prevent HIV transmission.
 VCT serves as an entry point for the continuum of care for those who test positive. It has three principles:
 Its Voluntary – no coercion, the is client educated on the importance of having the test and if ready one
consents to get tested
 Confidentiality – clients are tested anonymously and no report is written only test results are discussed with
the client
 Education & Counselling – education clarifies points around the HIV and helps equip the client with the
necessary knowledge to reduce risks of HIV infection or re-infection
Barriers to Access & Use of VCT

 Concern about confidentiality of the information

 Stigma associated with HIV/AIDS and the fact that those infected are considered as immoral
 Fear in case one tests positive
 Some people do not perceive themselves to be at risk and others do not realize the benefits of knowing
their status
 Lack of information on where to find VCTs
 Some people belief knowing their status will increase anxiety and depression
VOLUNTARY MEDICAL MALE CIRCUMCISION

 Research has demonstrated that medical male circumcision reduces the incidence of infection with HIV-1n
heterosexual men by at least one half.
 As a result, the World Health Organization and the Joint United Nations Programme on HIV/AIDS recommends
voluntary medical male circumcision (VMMC) as one component of a comprehensive preventive strategy in
regions with low male circumcision rates and a high prevalence of HIV-1 infection and where heterosexual sex
is the main mode of transmission.
 The Government of Kenya launched the national VMMC programme in Nyanza province in 2008 which has
higher prevalence of HIV compared to the rest of the country.
 Kenya is now the leading country in the uptake of voluntary male medical circumcision in Africa. With 40%
circumcisions done in Kenya over the last three years, Kenya is ahead of other 14 African countries that are
implementing voluntary male medical circumcision as a method of preventing HIV infections
PREVENTION OF PARENTERAL TRANSMISSION OF HIV

 Direct exposure to the virus through the bloodstream is the most efficient route of HIV transmission.
 Most cases of parenteral transmission occur as a result of the sharing of needles during injection drug use,
but a notable percentage also stem from improper blood collection and transfusion practices.
 Injection drug use accounts for an estimated 10 percent of the world’s HIV infections, although it is the
cause of a majority of infections in certain Asian and European countries.
 The transfusion of HIV-infected blood or blood products is believed to be responsible for 5 to 10 percent of
cumulative infections worldwide
 Substandard hygienic practices in health care settings including improper sterilization and the reuse of
medical equipment also pose a risk of HIV transmission, although the precise contribution of such practices
to the spread of HIV/AIDS is unclear.
Prevention of Parenteral Transmission

 HIV Prevention among Injection Drug Users - needle exchange

projects have been shown to reduce the risk of transmission without
contributing to an increase in drug use 
 Drug Treatment - substance abuse treatment are effective in
preventing HIV transmission. Not only does drug treatment reduce
drug use and therefore help prevent practices that can lead to HIV
transmission, but initiation of drug treatment often produces
significant reductions in HIV-related sexual risk behaviors.
 Improving the Safety of the Blood Supply
Blood donations are screened for HIV and other blood borne viruses,
including Hepatitis B (HBV), Hepatitis C (HCV) and Syphilis.
PREVENTION OF MOTHER TO CHILD TRANSMISSION (PMTCT) OF HIV

 HIV may be transmitted to the infant during pregnancy, at the time of delivery, and through breast
feeding; most transmission is thought to take place during delivery.
 Mother to Child is responsible for most HIV infections in children.
 The best preventive measure is to prevent the mother from getting infected.
 For the infected mother, efforts are geared towards improving their health and reducing chances of the
mother infecting the child
Strategies for prevention:
 Increase the level of general knowledge on transmission
 Need to attend anti-natal clinic
 Use of anti-retroviral drugs given during pregnancy, labor or both
 Avoiding prolonged labor
 caesarean section
 Factors that may increase the risk of vertical
transmission:
 High maternal viral load: at time of seroconversion and during late HIV disease, CD4 cell counts
 Recurrent STDs
 Malaria interferes with placental functions and eases viral transmission across the placenta
 Vitamin A deficiency
 Preterm delivery
 Vaginal delivery
Summary
 In this lecture we have focused on HIV management,prevention and control putting emphasis on:
 ART
 Behaviour change programs
 Prevention and treatment of sexually transmitted diseases (STDs)
 Voluntary counselling and testing (VCT)
 Voluntary male medical circumcision(VMMC)
 Prevention of blood to blood transmission
 Prevention of Mother To Child Transmission (PMTCT)