HIV TRANSMISSION, DIAGNOSIS & TREATMENT

SPECIFFIC OBJECTIVES
By the end of this topic the learner should be in position to;
● State how HIV is transmitted and How is not transmitted

● State the various modes of HIV transmission

● Discuss HIV disease progression and symptoms

● Explain HIV complications and opportunistic infections

● Discuss HIV diagnosis, treatment and management

TRANSMISSION OF HIV

HIV is present in semen, vaginal/ cervical secretions & body fluids


It may be present in tears, urine, breast milk & infected discharges,

saliva.
 HIV is spread when an infected individual come into contact with
infected body fluids or cells.
How HIV is NOT transmitted

 There is no evidence to show that HIV can be transmitted by: a)

casual social contact e.g. shaking hands, hugging
b) sneezing or coughing
c) shared facilities & equipment e.g. toilets, swimming pools
d) non wet kissing
e) sharing food & utensils
f) insect bites e.g. mosquitoes -HIV only lives for a short time and does not
reproduce in an insect
g) Injecting with sterile needles
h) Protected sex -If an unbroken latex condom is used, there is no risk of HIV
transmission.
There are myths saying that 'some very small viruses can pass through latex' -
this is not true.

MODES OF HIV TRANSMISSION

1. Sexual contact
  Any unprotected (no condom) penetrative sex whether vaginal,
anal or oral can transmit HIV from infected individual to
uninfected sexual partner.
 Heterosexual contact (man &woman) a/c 70%-80% of all HIV
transmission.
 Homosexual contact a/c 5-10%
 Oral sex is low risk but oral ulcers, bleeding gums, genital sores &
presence of STIs
(gonorrhea, syphilis & genital ulcers) do increase the risk of HIV
transmission
 Rape, & sodomy victims could get infected if the attacker is HIV+
 The victims should seek prompt medical attention because early
treatment with ARVs can greatly reduce chances of HIV infection.
 They will also require specialized counseling & psychological
/psychiatric care Factors that influence transmission through
sexual contact

 The risk of HIV transmission through sexual contact is influenced

by a number of factors: a) level of virus in the body
b) number of sexual partners
c) sex – male/female
d) age
e) STDs/STIs
f) Condom use

2. Intravenous Drug Use/ Contaminated Piercing Instruments

 I.V. drug use- is the administration of drugs of addiction e.g.
heroin into the blood stream by injecting into the veins
 Most drug users tend to shoot in groups & often share needles
 It there4 becomes very easy for transmission /infection to occur
from one infected group member to another
 It’s a significant modes in the developed countries a/c 5-10% of
HIV infections
 Procedures such as ear piercing & circumcisions when done with
poorly cleaned & unsterile instruments can lead to HIV
transmission.

3. Occupational exposure/ Infection in the health-care setting

 Occupational exposure is the accidental exposure of healthcare workers (e.g.

doctors & nurses) to body fluids from an infected patient in their care
 This is most frequently due to needle pricks or cuts with surgical instruments
  Infection can also occur due to contact with infected blood, lab samples
especially through broken skin.

4. Mother -to -child transmission/ MTCT

 Also called Vertical / perinatal transmission & a/c 13-40%
 It’s possible for HIV to be transmitted from HIV+ mothers to unborn
child.  This occurs in 3 ways: a) During pregnancy-
 The virus crosses from mother’s blood to child through the placenta.
 Although there’s no exchange of blood between mother & child,
researchers believe that the foetus can get HIV through diffusion
 A/c about 35%
b) During birth –
 Thro exposure to mother’s blood & other secretions. A/c 65%
c) After birth- through breast feeding.
 Breast milk contains minimal quantities of HIV
 A/c 15%

Factors that increase chances of MTCT/ Determinants

a) high level of HIV in mother’s blood & other body fluids (maternal viral load)
b) duration of exposure to maternal secretions during delivery
c) inadequate nutrition
d) pre-term delivery- premature babies are more prone to infection bcoz
immune mechanism is still very weak/ immature
e) Maternal immune response- maternal CD4 cell count
f) prolonged membrane rupture-increased risk if more than 4hours
g) obstetrical procedures- e.g. vacuum assisted delivery
h) unprotected sexual intercourse
i) presence & amount of virus in the genital tract
j) Placenta barrier- breaches in barrier leads to mixing of maternal and foetal
cells
k) Presence and amount of HIV in genital tracts

Prevention of MTCT (PMTCT)

 Prevent HIV infection in women

 Reduce the number of HIV exposed pregnancies
 ART- to infected pregnant women
 Preventing malaria in the pregnant woman
 Reducing trauma and shortening exposure of the baby to the virus during labour
and delivery
  Appropriate choice of feeding infants i.e. breastfeeding exclusively without any
supplements followed by abrupt but timely weaning or replacement feeding
from birth without any breast milk.
 Follow up and care (PMCT – Plus)

NB PMCT-Plus provides a package of services that include prophylaxis against

opportunistic infections, treatment of HIV complications, counseling of mothers and
ART for eligible mothers, children and family.

STIs, STDs, FGM and HIV/AIDS

 STDs are diseases that are transmittable from an infected person to another
through sexual intercourse
 STIs is a term applied to infections that are transmitted primarily through
sexual contact be it vaginal, oral, or anal intercourse
 They don’t necessarily involve sexual activity but
 The organisms that cause STIs enters mostly thro the soft & thin skin that cover
the inner surfaces i.e. mucus membrane of the vagina, urethra, anus & mouth.
 However in some instances exposure to sores or other types of skin to skin
contact may be insufficient to transmit the infection. Common examples of STIs/
STDs

 Syphilis.
 Gonorrhea.
 Candidacies.
 Hepatitis B & C.
 Chancroids ( genital sores)
 Genital herpes (Herpes Simplex V).  Genital warts( Human Papilloma V) 
Bacterial vaginosis.
 Trichomoniasis
Relationship between HIV & STDs/STIs

 STIs/STDs increase the risk of HIV infection by mobilizing a high population of

T cells to fight the STI/STD hence providing the breeding ground for HIV
 STDs/STIs also increase the risk of acquiring or transmitting the virus
 Both are transmitted through sexual contact & from infected mother to child
Dangers/ risks of STDs/STIs

 Increased risks of getting infected with HIV or the risk of infecting others
 High incidences of infertility e.g. pelvic inflammatory disease if untreated result
in infertility or tubal pregnancies.
 Future problems with pregnancies & child birth
 Mental disorders & deaths esp in syphilis
Treatment of STDs/STIs
  STDs/STIs require medical examination & medical treatment
 Any person who has contracted STD/STI & is receiving treatment should also:
a) Receive counseling from a qualified health worker on how to avoid future
infections
b) Take all medicines prescribed exactly according to all the instructions
c) Inform all sexual partners of the need to get examined & treated
d) Abstain from further risky sexual behaviors
e) Use condoms for protection

FGM (FEMALE GENITAL MUTILATION)

 It’s a destructive invasive procedure usually performed on girls before puberty.

 involves surgically removal of part or the whole clitoris using razor blades,
knives, and scissors
 Since the victims are young they are unable to give their informed consent.
 FGM is forced on approx 6000girls/day world wide
 Because of poverty & lack of medical facilities the procedure is frequently done
under less hygienic conditions & often without anaesthesia
 A person who is not medically trained usually circumcises about 20 girls of same
age group
Effects of FGM leads to conditions that favours HIV survival, they include;
a) An abnormal anatomy with anatomical distortion
b) Partial closure of the vagina
c) Incomplete healing brought about by infections i.e. acids & organisms from urine
d) Scar formation which may be excessive
e) Urinary tract infection
f) Inflammation of the genital area
g) Chronic urinary retention- urine is broken down to urea & uric acid accumulates
in joints & causes gout

DISEASE PROGRESSION AND SYMPTOMS.

 HIV infects cells of the immune system and the central nervous system mainly T
helper cell thus weakening the immune system.

Exposure vs. Infection

 When HIV+ individual encounters an uninfected person, this does not always
result in transmission of HIV to the uninfected person
 Only a fraction of the exposed people will be infected
 Different kinds of exposure between infected & uninfected individuals have
different probabilities of leading to infection
  Those who are exposed & become infected do not show sign of illnesses right
away.

Infection vs. Disease

 Among individuals who become infected with HIV, not everybody will develop
physical symptoms
 Most viral infections don’t show physical symptoms
 But most people infected with HIV ultimately develop some disease symptoms
caused by damage or destruction of cells & tissues in the infected person
 In some cases the damage may result from direct killing of cells by virus
 In the case of AIDS, most of physical symptoms are the indirect result of damage
to the I.S. by HIV
 Factors such as age, sex, genetic make-up, nutrition, environmental factors, &
encounters with other infectious agents can influence the exact nature of the
symptoms in a particular individual.

HIV infection can be broken down into 4 stages:

a) Primary HIV infection, window period & sero conversion

b) Clinically asymptomatic stage,

c) Symptomatic HIV infection,

d) Progression from HIV to AIDS.

i). Primary HIV infection

 This is the initial stage where one obtains the virus thro the various modes of
transmission.  It can be divided into:

a) Window period

 This stage of infection lasts for a few weeks to about 3 months and is often
accompanied by a short flu-like illness or no signs.
 HIV cannot be detected in blood screening although HIV is present in blood &
the blood is not 100% free of HIV
 The virus cannot be seen in the first 21 days.
 During this time a person can still transmit the virus to another person.
 It’s the most crucial stage
b) Sero conversion

 This is the development of the anti-bodies.

  Immune system begins to respond to HIV by producing HIV antibodies and
cytotoxic lymphocytes.
 If an HIV antibody test is done before seroconversion is complete then it may
not be positive.
 In this stage a person may have flu like illnesses, fever, fatigue, sore throat, joint
pains & lymphadenopathy
 Some will not experience any illnesses at this stage. ii). Clinical asymptomatic
HIV infection/ Latent phase

 The presence of HIV without major symptoms  Although there may be swollen
glands.
 The level of HIV in the peripheral blood drops to very low levels but people
remain infectious and
 HIV antibodies are detectable in the blood, so antibody tests will show a positive
result.
 HIV is not dormant during this stage, but is very active in the lymph nodes.
 Large amounts of T helper cells are infected and die and a large amount of virus
is produced.  This period can last for many years (5 – 15 years)
Initial Infection Symptoms

 Mononucleosis-like illness (sore throat, swollen glands, fever) & skin rash
 Encephalopathy i.e. Brain infections - brain swelling & inflammation of the brain
lining or meninges
 This causes headache, fever, brain functions impairment, difficulty in conc.,
remembering or solving problems
 Personality changes may also occur
NB: Asymptomatic period – some type of balance exist between HIV infection & the
I.S. in the infected person

iii). Symptomatic HIV infection/AIDS Related Complex (ARC) phase

 Over time the immune system loses the struggle to contain HIV due to the
following main reasons:
a) The lymph nodes and tissues become damaged or 'burnt out' because of the years
of activity;

b) HIV mutates and becomes more pathogenic, i.e. stronger and more varied,
leading to more T helper cell destruction;

c) The body fails to keep up with replacing the T helper cells that are lost.

 As the immune system fails, so symptoms develop.

 Initially many of the symptoms are mild, but as the immune system deteriorates
the symptoms worsen.
 When the viral load reaches a critical amounts, the I.S. is suppressed to such a
degree that other infections which under normal circumstances will not be
difficult to resist gain entrance i.e. opportunistic infections
 Opportunistic infections – they take advantage of the impairment of the I.S. &
sometimes are caused by organisms that don’t cause infections/ diseases in man.
Symptoms of HIV infection in this stage

 Two or more of the following signs / symptoms may occur

-Chronic fever -Lethargy (fatigue/ tiredness)

-Continuous diarrhea - Eczema (allergy of the face)

-More than 10% wt loss - Psoriasis (itchy pimples)

-Lymphadenopathy - Dermatitis (itchy skin)

-Night sweats - Oral candidiasis (sores in mouth)

-Dementia (short term memory loss)

 Incubation period- is the length in time between initial infection & becoming
symptomatic.
 It varies between people & depends on a length of factors iv). Progression of
HIV to AIDS

 As the immune system becomes more and more damaged the illnesses that
present become more and more severe leading eventually to an AIDS diagnosis.
 It’s the most advanced stage of HIV infection
 At this time when CD4 cell count has gone down below 200 CD4 cells/ml, HIV
develops to one or more severe opportunistic infections or cancer
 The infection / cancer may be life threatening due to the weakened I.S.
Common symptoms in this stage/ Initial Disease Symptoms

 An infected individual may have symptoms from more than one of these classes;

a) HIV wasting syndrome: -

• Sudden unexplained loss in body weight ( >10% of total body weight),
• Unexplained chronic diarrhea (>1 month)
• Chronic weakness
• Unexplained prolonged fever usually at night that causes night sweats (>1
month).  Brain damage due to high temp that causes fevers
 b) Lymphadenopathy syndrome (LAS)/ persistent generalized
lymphadenopathy (PGL):  Lymph glands enlargement is persistent
• They swell in groin, armpits, head & neck but are not painful
• Some infected people may experience both LAS & Wasting Syndrome

c) Neurologic disease-
• direct damage of the brain by HIV or by other agent
• Damage of parts of the nervous system can also cause different neurologic
symptoms. For e.g. i) Dementias
• Impaired mental functions, forgetfulness, loss of mental functions
• Difficulty reasoning & performing mental tasks
• Depression, social withdrawals & personality changes
• Unable to care for themselves eventually
• Coma & death may follow ii) Spinal cord damage/ swelling
(myelopathy)
• Spinal cord transmits nerve impulses to the muscles of the body
• Bcoz of this, damage may result in weaknesses or paralysis of voluntary
muscles/ limbs
iii) Peripheral nerve swelling/ damage (neuropathy)
• these nerves sense pain
• when damaged can cause burning or stinging sensations in the hands or
feet or occurrence of numbness
NB: individual patients may experience a mixture of any of these illnesses

Others include:

 Coughs & gasping of breath

 Seizure- lack of coordination
 Difficulty or pain during swallowing
 Psychotic symptoms- mental confusion & forgetfulness
 Loss of vision
 Severe head ache
 Nausea
 Abdominal crump & vomiting
 Extreme fatigue
 Cancers-m of blood, BM etc
 Coma
 Death
HIV+ patient can die any moment at this stage
Common infant symptoms of HIV/AIDS

 Growth failure
 Persistent diarrhea
 Chronic cough
 Chronic fever
 Pulmonary/ chest infections
 Lymphadenopathy

OTHER COMPLICATIONS IN HIV PATIENTS- manifest when I.S is weak

a) Common brain infections

 Tumors, Swelling of the brain, Nerve damage

- They can cause

 Headache & confusion, Poor coordination of feet, Blindness

 Enlarged lymph nodes
 Fever, sore throat, weaknesses
b) Common skin infections

 When I.S. is damaged in HIV patients the skin conditions tend to persist more
& they become difficult to treat
 In most cases these conditions are caused by bacteria, viruses or fungi E.g. of
Bacterial infections
 frequent boils that reoccur
 cellute- stays in one place in lower part of the leg or under the feet/ finger
nails. E.g. of fungal infections
 ring worms & fungal infections of hair &nails
 Tinea pedes(nails), Tinea capolis (hair), Tinea capidis(ringworms) E.g. of viral
infections
 HSV 1&2 (burnt face or genitals)
 Herpes zoster (rushes around waistline –shingles)
 skin cancers
 genital warts (rough sores in skin that affects a small area initially but rapidly
spread

Factors that lead to faster development of HIV infection to full-

blown AIDs 1. Age

  Persons who get infected after the age of 35years move faster from HIV
infection to full blown AIDS than those who get infected in their mid 20s.

Children who get infected at birth die faster simply because their immune
system is not well developed at their tender age.
2. Type of HIV contracted

 There are two well known types: HIV1 and HIV2.

 HIV1 is harsher on people hence kills faster than HIV2.
3. Mode of transmission

 HIV got through blood transfusion kills faster than one got through sexual
contact.
 This is because the amount of virus channeled into the bloodstream is in large
quantity.
4. Ill- health & other types of infections

 People who are already sick & then get infected move faster than those
infected when healthy
 Tropical diseases such as malaria, typhoid & intestinal worms makes patients
to develop AIDS faster
5. Nutritional status

 Those infected & are not eating enough of wll balanced foods are more likely
to develop AIDS faster
6. Lifestyle

 People who expose themselves to re-infection with other strains of HIV or

STIs/STDs and other illnesses move faster from HIV to AIDS
7. Opportunistic infections

 If they are not competently treated , then the HIV+ person develops AIDS
faster.

OPPORTUNISTIC INFECTIONS

E.g. of fungal infections

a) PCP

 Inflammation of the lungs caused by infection with fungus called Pneumocystis

carinii.
 Inflamed areas of lungs appear as white spots in x-rays
 It’s the leading cause of death in AIDS patients i.e. about 50% of AIDS patients will
eventually develop PCP
b) Candida
 Fungus similar to baker’s yeast
 Found on skin & mucosal surfaces (mouth, vagina)
 In mouth they appear like white plaques that feel furry
 Antifungal e.g. mycostatin can be used
 They are difficult to completely eliminate
 They can spread to oesophagus & cause painful burning sensation when eating i.e.
oesophagitis.  50% of AIDS patients will experience candidacies. c) Systemic
mycosis
 Soil fungus that can cause generalized infections in AIDS patients
 Exist in either mold like or yeast like form & are called dimorphic
 Are of 3 types- Histoplasmosis, Coccidiomycosis, & Cryptococcus
 They cause lung infections in healthy patients
 But in AIDS patients, the brain, skin, bone, liver & lymphatic tissue may also be
highly infected.

E.g. of Bacterial infections

 Components of I.S. responsible for controlling the common bacteria are less affected
by HIV infection, thus adult AIDS patients do not generally suffer infections with
common bacteria a) Mycobacterium
 Infection with Mycobacterium avium intracellular is most common in AIDS patients
 It does not cause disease in healthy people but it causes TB-like disease in the lungs
of AIDS patients
 Also causes infection of BM & presence of bacteria in blood at high levels
 Patients will have fevers & low no. of WBCs
 Mycobacterium tuberculosis that causes TB is also common in AIDS patients

E.g. of Viral infections

a) Cytomegalovirus (CMV)
 Common virus that infect people inn childhood with no symptoms but may cause
mononucleosislike illness (sore throat, swollen glands, fevers) in adults
 Congenital infections(fetus) can also lead to permanent brain damage
 In AIDS patients CMV infect retinas of the eyes causing blindness & also adrenal
glands leading to hormonal imbalance
 CMV can cause pneumonia, fevers, rash & gastroenteritis in AIDS patients  CMV
pneumonia in patients with PCP is fatal b) Varicella (shingles)
 Painful rash condition that occurs on human trunk
 Latent varicella zoster (that causes chicken pox in childhood) is reactivated when the
I.S. is compromised
 Antiviral drugs e.g. acyclovir is sometimes used to control shingles
E.g. of Protozoan infections
a) Cryptosporidium gastroenteritis
 Caused by protozoan called cryptosporidium
 It infect lining of the intestinal tract & causes diarrhea (gastroenteritis)
 In normal/ healthy people diarrhea lasts a few days but in AIDS patients it is
prolonged & severe  That is about 20-50 watery stools per day accompanied by
abdominal cramps & weight loss b) Toxoplasmosis
 Caused by Toxoplasma gondii that causes asymptomatic infections in healthy adults
 In AIDS patients it causes brain infections with symptoms similar to brain tumors
(e.g.
convulsions, dementias).

E.g. of Cancers
a) Kaposi’s sarcoma
(KS)  Are tumors
of blood vessels
 In non- AIDS patients KS is seen in older men of Jewish ancestry
 Initially few tumors appear as pink, purple or brown skin lesions located on arms or
legs
 Eventually they spread & bcom widely distributed in most linings of the body
 They are difficult to control if they spread to the lungs  Chemotherapy can
eradicate them
b) Lymphomas
 Cancers derived from B cells of I.S. are the common type of lymphomas in AIDS
patients
 Epstein-Barr virus causes mononucleosis but it can also transform normal B cell into
cancer cell  Unusual lymphoma that spread to the brain also occur in AIDS
patients

c) Cervical cancers
 Its common in female AIDS patients
 Infections with certain strains of Human Papilloma Virus (HPV) that cause warts in
the genital tract is an underlying cause of cervical cancer
 Cancer caused or induced by HPV develops faster when I.S. is compromised in
AIDS patients.
Hairy leukoplakia
 Abnormal condition of the mouth in which white plaques appear on the surface of
the tongue
 This is due to abnormal growth of papillae cells of the tongue
 They can’t be scrapped off
 They resemble cancer cells
DIAGNOSIS AND TREATMENT OF HIV/AIDS

DIAGNOSIS OF HIV

 An HIV test is done to detect presence of HIV in a sample ( usually blood) drawn
from an individual
 It’s also possible to determine the actual amount /level/ quantity of HIV in the
blood i.e. Viral load test
 The term viral load is used to describe the level of virus in the blood

Requirements
 Individual should give consent before testing is done
 The individual should be well counseled before & after the test
 Test results should not be revealed to others unless consent is sought & given
 Adequate care by health care workers should be taken to protect individual’s rights
to privacy.

Laboratory methods to test for HIV

 Several methods are used to either detect or quantify HIV

1). HIV Antibody Test

 Tests for antibodies produced against HIV
 When HIV enters our bodies we respond by producing antibodies ‘specific’ to HIV
 These antibodies for HIV can be detected using certain lab techniques
 Presence of HIV antibodies indicate that one has been infected with HIV bcoz that’s
the only way the body can produce HIV antibodies
 But, HIV antibody test could be inappropriate in infants born to HIV+ mothers
 This is becoz for nearly 18 months the infants may have antibodies against HIV from
mother that may lead to erroneous results
 As the child grows older, maternal HIV antibodies are cleared from the body as
their immune system continues to develop

E.g. of HIV antibody tests

 Currently there are 3 antibody based HIV tests in routine use

a) ELISA (Enzyme Linked Immuno Sorbent Assay).

 Detects the presence of HIV antibodies in serum, fluid or whole blood
 The presence of HIV antibody is shown by a colour change(red) & the test is said to
be positive i.e. HIV+
 If the test solution remains clear, this indicates that there are no detectable HIV
antibodies & the test is said to be negative i.e. HIV-  Thus the terms HIV+ & HIV-
 Modern ELISA tests are quite accurate (98-99%)
 They are associated with false+ (1%)
 They are very sensitive and requires laboratory testing by a qualified personnel

b) Rapid HIV tests -Unigolds and

determines  Produces very quick results
in about 10-20 minutes  These are rapid
tests recommended for VCT’s in Kenya 
They are simple, free and require no
laboratory c) Western blot
 This reacts to the presence of specific elements of HIV.
 It relies on detection of antibodies to multiple different parts of HIV to confirm a
HIV+ result
 It requires an HIV antibody test which is + to different but specific parts of gp of
HIV in order to confirm an HIV+ status
 Its there4 the standard for determining the + HIV antibody test which is a
confirmatory test
 Its more reliable & less prone to giving false results i.e. accurate
 It takes about 7 days & is very expensive.( at least Ksh.5000 per test) 2). HIV
Antigen tests
 This tests directly for HIV itself and not for HIV antibodies
 Are extremely sensitive & can detect even small fragments of HIV
 Can detect HIV within days or weeks of infection, unlike HIV antibody test which
can take up to 6 wks
 Are especially used in babies

E.g. of HIV antigen test

a) Polymerase chain reaction (PCR) assay
 It detect presence of HIV genetic material & can be used to detect both HIV-1
& HIV2

b) Branch chain DNA (bDNA) assay

 Also detect both HIV-1 & HIV-2

 It’s not widely used bcoz it has not been approved by Food & Drug Administration
(FDA) in America.
NB. -HIV antigen tests are expensive.

-They can be used to detect & quantify HIV

3). Viral cultures

 It’s based on growing HIV in the lab

 A specimen is taken from a sample (e.g. blood) & cultured in lab grown cells
(culture/media)
 If HIV grows then that is proof that one has been infected with HIV
 This is because the cell media is HIV specific making it incapable of supporting
growth of other viruses
 It’s expensive & tedious
 It’s used only for research purposes.

OTHER TESTS – to quantify HIV

I. CD4 cell count

 The test is able to determine & count the amount of CD4 cells remaining in the blood
as an indicator of the strength of the immune system.
 After testing & finding the HIV status to be +ve, its important to know how much
the immune system has deteriorated
 If conc. of CD4 cell is high, then that of HIV will be low & vice versa
 This is because HIV destroy CD4 cells
 Normal CD4 cell count is 1000-1500 CD4 cells / ml
 If its below 200 CD4 cells / ml, then one becomes highly accessible to OIs
 If CD4 cell is 1000 & viral load is low then such a person need not to go on
treatment
 This is because the body is capable of adequately protecting itself
 Those who fall in this category are called long term survivors
 If CD4 cell count is below 1000 & viral load is high then treatment should be
administered

II. Viral load test

 This also tests for the virus itself.

 It’s a test to quantify the level of HIV in the body i.e. to determine the amount of
HIV in the body
 High viral load is an indicator of an advanced HIV infection
 CDC has set guidelines that treatment for HIV+ people should start when viral load
shows values of above 10000 viral copies / ml of blood

NB:

 Many labs in Kenya offer ELISA & western blot

 Facilities are also available for PCR & bDNA assays
 HIV testing methods which use saliva or urine other than blood have also been
developed & are easier to undertake bcoz no drawing of blood is involved /
required
 However, they are not reliable & are not used routinely
 Handling of blood & blood products remains the work of a qualified medical or lab
staff as it carries a great risk of HIV transmission if adequate precautions are not
undertaken

HIV/AIDS TREATMENT (ART)

HAART

 Highly Active Antiretroviral Therapy

 In the early days of HIV management single drugs (monotherapy) was used to
manage the disease.
 It had very poor outcome as the HIV quickly developed resistance to the drug.
 It was then found that an increase in the number of drugs increased the potency/
effectiveness of the drug and also reduced the emmergence of the resistant strains.
 This combination is known as HAART.

Anti-Retroviral drugs (ARVs)

 Are drugs that stop HIV from multiplying inside the human cell.
 They are not the cure.
 These drugs have led to:
a) Reduction of the virus circulating in the blood
b) Significant reduction of death due to HIV.
c) Have improved the quality of life for those infected with HIV
d) Have improved immunological responses of those infected
e) Have led to a reversal of symptoms of the opportunistic infections/ diseases.

Classes of ARVS

 There are three classes of ARVs which have been found effective in inhibiting &
suppressing multiplication of HIV

a) Non-Nucleoside Analogue Reverse Transcriptase Inhibitors (NNRTI)

 Binds RT & prevents the conversion of viral RNA to

viral DNA  Side effects- Nausea, vomiting, skin rash

b) Nucleoside Analogue Reverse Transcriptase Inhibitors (NRTI)

 Incorporate into the viral DNA thus stopping the building process  The resulting
DNA is incomplete Side effects

 Anaemia, Nausea, vomiting, skin rash,

 Peripheral neuropathy- xtised by sensations similar to needle pricks on fingertips &
other extreme parts of the body

c) Protease Inhibitor

 Prevent the virus from being successfully assembled & released out of the human
cell Side effects

 Dietary restrictions (lots of water -1.5L/day), High fat diets

 Unpleasant tastes ( 16 pills / day)
 Interfere with elimination of other drugs from the body e.g. antifungal, anti TB
drugs
 Interfere with body sugar levels & as a result may cause or complicate diabetes
 Alter fat distribution ( women appear pregnant bcoz fat is deposited in abdomen
& men at the shoulders creating hump) Advantages of ARVs

 Restores immune functions and slows down the decline of the immune function
 Prolong life and improves the quality of life
 decreases risk of illnesses and hospitalization
 Improves symptoms of the HIV opportunistic infections.
 Improves health and strength. Disadvantages of ARVs

 ARVs are not the cure and may raise false hope.
 They may have to be taken for the remainder of the patient’s life.
 At least three drugs have to be taken have to be taken together to be effective.
 Most of the regimens have a complicated schedule.
 Most of the drugs have side effects which might make the patient discontinue
taking the drugs.
 If resistance develops the drug no longer works effectively.
 Most of the drugs are expensive.

Factors to consider when initiating HAART

a) Clinical symptoms

 HAART should be given to all individuals exhibiting clinical AIDS symptoms. b)

CD4 cell count

 When CD4 cells have shown to drop significantly, HAART should be administered.
 CDC has set guidelines below 500CD4 cells/mm3 should be given.
 Bcoz of regional & individual variations in CD4 cell count, there is no consensus on
CD4 cell count at which treatment should begin
c) Viral count

 High viral load is an indicator of advanced HIV infection.

 CDC has set value of above 10,000 viral copies per mm3 of blood.
 There is no consensus on viral load level at which treatment should begin

Limitations of HAART

 When HAART was 1st dvpd, researchers believed that they had the ability to
completely eradicate HIV within a few years
 However more studies & further experiences with HAART dampened their
expectations Factors that limits effectiveness of HAART

a) High cost limit long term use

b) Toxicity could limit long term use
c) Complexity of drug instructions & high amt of pills may result in patient not
adhering to treatment
d) Dvpt of resistance to one /more drug combination- doctors may identify the
drug in the combination & replace it with a new drug.
 -New drug combination is called salvage therapy

e) Sanctuary sites- drugs are not able to penetrate into certain sites in sufficient
levels e.g. testis, brain, macrophages
f) Latent viruses – ARVs work on a replicating virus & not on non-dividing viruses
 -If HAART is withdrawn, HIV in sanctuary sites are released into blood &
latent viruses may start multiplying
AREAS OF RESEARCH

 More potent drugs -that will try to eliminate HIV

 Drugs with lower pill burden instead of many pills- one drug is now
available in some countries
 Structured treatment interruptions (STIs)- to allow patients to go on drug
holidays i.e. to go off medication for some periods
 Fusion/ entry inhibitors- to prevent HIV from attaching (fusion) &
entering (entry) the cell
 Integrase inhibitors – to interfere with incorporation of viral DNA into
human DNA
 Introducing artificial CD4 cells for HIV to attach to
 Immune modulators- strengthen I.S. e.g growth hormones & interleukins2
  Microbicides- anti HIV creams to be applied by women  Vaccines-
preventive & therapeutic vaccines

MANAGEMENT OF HIV/AIDS
 The approaches to managing HIV/AIDS include:
a) Destigmatization
b) Behavior change
c) Proper nutrition
d) Living positively
e) Voluntary Counseling and Testing(VCT)
f) Anti-Retroviral Therapy(ART)
g) Home Based Care(HBC)

A) DESTIGMATIZATION
• Stigmatization- is an act of identifying, labeling undesirable qualities targeted
towards those perceived as being shamefully different from social ideal
• It’s an attribute that discredits affected and infected people from the normalized
social ideal
• To destigmatize- is to remove stigma such that the infected are not neglected
and seen as bad people, but as responsible people i.e. freely talk about HIV to
create awareness.
B) BEHAVIOR CHANGE
• Avoiding high risk behavior and situations that can increase the spread of HIV
• E.g. of high risk behaviors
- Drug use and abuse - Rape
- Pre and extra marital sex - Prostitution
- Early and forced marriages - Incest
- Early sexual encounters - Group sex
- Homosexuality and lesbianism - Peer pressure
- Emulating negative role models - Sugar daddies /mummies
• E.g. of risk free behaviors
- Chastity
- Proper use of leisure time
- Proper courtship and marriage
- Setting and emulating positive role model
- Encouraging peer counseling and education
C) PROPER NUTRITION FOR PLWHAS
• Nutrition is the science of food value i.e. it’s the use of a balanced diet
 • Eating well is an important part of keeping well balanced diet that can help if
you are HIV positive.
• There is no better intervention to infection than good nutrition.
• Good nutrition is the key to good health and it is more important than medicine.
• Everyone needs to eat food from the three basic food groups everyday i.e.
proteins, vitamins & carbohydrates. This is called a balanced diet. Other food
groups include fats, minerals and water.
• A balanced diet is a part of the food that the body uses:
a) To build and repair worn out body cells/ tissues i.e. proteins
b) To provide energy to the body i.e. carbohydrates
c) To protect the body against infections i.e. vitamins
d) To store energy to be used sparingly when there is danger i.e. fats
e) To stimulate the appetite e.g. water
f) Improve well being of the body and the spirit
• PLWHAs need to be careful about their nutrition.
• As the disease progresses it may cause them to loose appetite so that they eat
less and no longer get the nutrients they need.
• HIV may also affect the way the body uses the nutrients it gets
• BUT the body has greater need for good nutrition as a result of HIV and
opportunistic infections.
•Eating a well balanced diet will help the PLWHAs to stay healthy longer by
providing the nutrients the body needs to maintain strength and fight
diseases.
Advantages of proper nutrition
• Provides the body with all the essential nutrients required for good health
• Helps to prevent illnesses esp. vitamins
• Enables the immune system to work at its best capacity
• Maintains weight esp. proteins
• Improves health and energy esp. carbohydrates
• Prevents dehydration
• Proper nutrition can be enjoyable
Key indicators of health problems
• Lack of appetite
• Low or high body temperature
• Lack of sleep (insomnia)
• Poor digestion
• Toxic colon i.e. unhealthy stool Signs of healthy and unhealthy stool
healthy unhealthy

size Large in diameter (1-2 inches) Narrow( ¼- ½ inch), indicating an inflamed

 colon
colour Medium brown Green, dark brown indicating high fat in stool

Form Soft but firm, floats in toilet Mud-like, very hard or very soft, smells
bowel ammonia
Ways of increasing appetite
• Chilies
• Digestive herbs e.g. ginger, garlic
• Drinking purified water
• Body exercise
Treating of insomnia
• Chilies
• Herbal tea
• Sun bathing
• Body exercise
• Drink lemon olive oil
Hints of a health life
• Eat more fresh foods, fruits and vegetables
• Eat less cooking fats and less fried foods
• If your eyes are yellow it’s better to eat boiled foods
• Avoid alcohol and street drugs
• Flush your system by drinking 8 glasses of water per day
• Drink lemon olive oil

D) LIVING POSITIVELY
• It involves accepting one’s HIV status and possible ways of delaying the onset of
AIDS Ways of living positively
• Accepting one’s HIV status- it can’t be changed
• Refusing to be a victim- focusing on what one can do best but not on dying of
AIDS  Seeking support and not pity- living one day at a time
• Exercising more regularly- it’s good for the body and reduces stress  Seeking
prompt treatment for any illness.
• Seeking advice when planning to have a baby.
• Paying attention to nutritional needs- eating locally available food stuffs(veges
& fruits), and consulting a doctor on the best diet
• Managing stress effectively through continued support counseling and freely
socializing with colleagues at work, friends and family members
• Keeping busy- no self pity, but concentrating on development
• Taking enough rest to regain energy- do not overstrain
• Thinking and acting positively- seeking out for people who are honest,
trustworthy and supportive and avoiding people who judge you
 • Embracing your own spirituality- joining Faith Based Organization
• Accepting responsibility- using condoms to prevent infection and re-infection-
do not deliberately infect others.

What to avoid when living with HIV/AIDS

• Avoid lifestyle that can expose one to further infections with HIV and other
illnesses
• Avoid unsafe sex- exposure to other infections
• Avoid the use of unprescribed drugs for effective control of diseases
• Avoid living in isolation- participate in social activities
• Avoid pregnancy
• Avoid consumption of alcohol and cigarettes due to opportunistic infections

How to help PLWHAs to live positively

• Prevent disruption of normal life and promote solution for domestic violence
• Keep confidentiality between care giver and patient
• The patient is to feel loved – e.g. by feeding, bathing- it gives hope to the patient
• Material support- donation of clothes, drugs- makes them feel supported
• Expression of views-give them time to express views- it makes it easier to advice
them
• Enlightening on nutritional foodstuff- encourage a balanced diet  Delivering of
health services