CARE AND MANAGEMENT

OF
HIV/AIDS (CHE 239)

PREPARED BY

UROM, ELISHA SAMUEL (B.Sc., M.Sc in view)

GENERAL OVERVIEW
The human immunodeficiency virus (HIV) has infected tens of millions of people around the
globe in the past three decades, with devastating results. In its advanced stage—acquired
immunodeficiency syndrome (AIDS)—the infected individual has no protection from
diseases that may not even threaten people who have healthy immune systems. While medical
treatment can delay the onset of AIDS, no cure is available for HIV or AIDS.

The human immunodeficiency virus (HIV) kills or impairs the cells of the immune system
and progressively destroys the body’s ability to protect itself. Over time, a person with a
deficient immune system (immunodeficiency) may become vulnerable to common and even
simple infections by disease-causing organisms such as bacteria or viruses. These infections
can become life-threatening.

The term AIDS comes from “Acquired Immunodeficiency Syndrome.” AIDS refers to the
most advanced stage of HIV infection. Medical treatment can delay the onset of AIDS, but
HIV infection eventually results in a syndrome of symptoms, diseases, and infections. The
diagnosis of AIDS requires evidence of HIV infection and the appearance of specific
conditions or diseases beyond just the HIV infection. Only a licensed medical provider can
make an AIDS diagnosis. A key concept is that all people diagnosed with AIDS have HIV, but
an individual may be infected with HIV and not yet have AIDS.

AIDS stands for Acquired Immune Deficiency Syndrome. AIDS is a serious condition that
weakens the body's immune system, leaving it unable to fight off illness.

AIDS is the last stage in a progression of diseases resulting from a viral infection known as
the Human Immunodeficiency Virus (HIV or AIDS virus). The diseases include a number of
unusual and severe infections, cancers and debilitating illnesses, resulting in severe weight
loss or wasting away, and diseases affecting the brain and central nervous system.

There is no cure for HIV infection or AIDS nor is there a vaccine to prevent HIV infection.
However, new medications not only can slow the progression of the infection, but can also
markedly suppress the virus, thereby restoring the body’s immune function and permitting
many HIV-infected individuals to lead a normal, disease-free life.

WHAT ARE THE SYMPTOMS OF HIV?

There are several symptoms of HIV. Not everyone will have the same symptoms. It depends
on the person and what stage of the disease they are in.

STAGES OF HIV AND SOME OF THE SYMPTOMS

Stage 1: Acute HIV Infection

Within 2 to 4 weeks after infection with HIV, about two-thirds of people will have a flu-like
illness. This is the body’s natural response to HIV infection.

Some Flu-like symptoms can include:

- Fever
- Chills
- Rash
- Night sweats
- Muscle aches
- Sore throat
- Fatigue
- Swollen lymph nodes
- Mouth ulcers
These symptoms can last anywhere from a few days to several weeks. But some people do not
have any symptoms at all during this early stage of HIV.

How Can You Tell If You Have HIV?

The only way to know for sure if you have HIV is to get tested. You can’t rely on symptoms
to tell whether you have HIV.

Knowing your HIV status gives you powerful information so you can take steps to keep
yourself and your partner(s) healthy.

If you test positive, you can take medicine to treat HIV. By taking HIV medicine daily as
prescribed, you can make the amount of HIV in your blood (your viral load) very low—so
low that a test can’t detect it (called an undetectable viral load). Getting and keeping an
undetectable viral load is the best thing you can do to stay healthy. If your viral load stays
undetectable, you have effectively no risk of transmitting HIV to an HIV-negative partner
through sex.
If you test negative, there are more HIV prevention tools available today than ever before.
If you are pregnant, you should be tested for HIV so that you can begin treatment if you're
HIV-positive. If an HIV-positive woman is treated for HIV early in her pregnancy, the risk of
transmitting HIV to her baby can be very low.
Use the HIV Services Locator to find an HIV testing site near you.

HIV self-testing is also an option. Self-testing allows people to take an HIV test and find out
their result in their own home or other private location. You can buy a self-test kit at a
pharmacy or online, or your health care provider may be able to order one for you. Some
health departments or community-based organizations also provide self-test kits for free.

These symptoms can last anywhere from a few days to several weeks. But some people do not
have any symptoms at all during this early stage of HIV.

Get tested as soon as possible! Find a HIV testing site near you: Locator.HIV.gov
Don’t assume you have HIV just because you have any of these symptoms —they can be
similar to those caused by other illnesses. But if you think you may have been exposed to
HIV, get an HIV test.

Find an HIV testing site near you—You can get an HIV test at your primary care provider’s
office, your local health department, a health clinic, or many other places. Use the HIV
Services Locator to find an HIV testing site near you.
Request an HIV test for recent infection—Most HIV tests detect antibodies (proteins your
body makes as a reaction to HIV), not HIV itself. But it can take a few weeks after you ’re
infected for your body to produce them. There are other types of tests that can detect HIV
infection sooner. Tell your doctor or clinic if you think you were recently exposed to HIV, and
ask if their tests can detect early infection.
Know your status—After you get tested, be sure to learn your test results. If you’re HIV-
positive, see a doctor as soon as possible so you can start treatment with HIV medicine. And
be aware: when you are in the early stage of infection, you are at very high risk of
transmitting HIV to others. It is important to take steps to reduce your risk of transmission. If
you are HIV-negative, there are prevention tools like pre-exposure prophylaxis (PrEP) that
can help you stay negative.

STAGE 2: CLINICAL LATENCY

In this stage, the virus still multiplies, but at very low levels. People in this stage may not feel
sick or have any symptoms. This stage is also called chronic HIV infection.

Without HIV treatment, people can stay in this stage for 10 or 15 years, but some move
through this stage faster.

If you take HIV medicine every day, exactly as prescribed and get and keep an undetectable
viral load, you can protect your health and have effectively no risk of transmitting HIV to
your sexual partner(s).

But if your viral load is detectable, you can transmit HIV during this stage, even when you
have no symptoms. It’s important to see your health care provider regularly to get your viral
load checked.

STAGE 3: AIDS
If you have HIV and you are not on HIV treatment, eventually the virus will weaken your
body’s immune system and you will progress to AIDS (acquired immunodeficiency
syndrome). This is the late stage of HIV infection.

Symptoms of AIDS can include:

- Rapid weight loss
- Recurring fever or profuse night sweats
- Extreme and unexplained tiredness
 - Prolonged swelling of the lymph glands in the armpits, groin, or neck
- Diarrhea that lasts for more than a week
- Sores of the mouth, anus, or genitals
- Pneumonia
- Red, brown, pink, or purplish blotches on or under the skin or inside the mouth, nose,
or eyelids
- Memory loss, depression, and other neurologic disorder.

If you test positive, you can take medicine to treat HIV. By taking HIV medicine daily as
prescribed, you can make the amount of HIV in your blood (your viral load) very low—so
low that a test can’t detect it (called an undetectable viral load). Getting and keeping an
undetectable viral load is the best thing you can do to stay healthy. If your viral load stays
undetectable, you have effectively no risk of transmitting HIV to an HIV-negative partner
through sex.
If you test negative, there are more HIV prevention tools available today than ever before.
If you are pregnant, you should be tested for HIV so that you can begin treatment if you're
HIV-positive. If an HIV-positive woman is treated for HIV early in her pregnancy, the risk of
transmitting HIV to her baby can be very low.
Use the HIV Services Locator to find an HIV testing site near you.

HIV self-testing is also an option. Self-testing allows people to take an HIV test and find out
their result in their own home or other private location. You can buy a self-test kit at a
pharmacy or online, or your health care provider may be able to order one for you. Some
health departments or community-based organizations also provide self-test kits for free.

EPIDEMIOLOGY OF HIV & AIDS

Epidemiology is the study of how disease is distributed in populations and the factors that
influence the distribution. Epidemiologists try to discover why a disease develops in some
people and not in others. Clinically, AIDS was first recognized in the United States in 1981.
In 1983 HIV was discovered to be the cause of AIDS. Since then, the number of AIDS cases
has continued to increase both in the United States and in other countries.

HIV and AIDS cases are reportable; each state has its own laws and healthcare workers must
be familiar with those of the state in which they are licensed.

HIV/AIDS or Human Immunodeficiency Virus, is considered by some authors a global

pandemic. However, the WHO currently uses the term 'global epidemic' to describe HIV. As
of 2018, approximately 37.9 million people are infected with HIV globally. There were about
770,000 deaths from AIDS in 2018. The 2015 Global Burden of Disease Study, in a report
published in The Lancet, estimated that the global incidence of HIV infection peaked in 1997
at 3.3 million per year. Global incidence fell rapidly from 1997 to 2005, to about 2.6 million
per year, but remained stable from 2005 to 2015.
Sub-Saharan Africa is the region most affected. In 2018, an estimated 61% of new HIV
infections occurred in this region.
HIV & AIDS Statistics
About 24.5 million - 25.6 million people were accessing antiretroviral therapy in 2019.
About 31.6 million - 44.5 million people globally were living with HIV in 2019.
About 1.2 million - 2.2 million people became newly infected with HIV in 2019.
About 500 000 - 970 000 people died from AIDS-related illnesses in 2019.
About 55.9 million - 100 million people have become infected with HIV since the start of the
epidemic.
About 24.8 million - 42.2 million people have died from AIDS-related illnesses since the start
of the epidemic.

AIDS DEATH & MORTALITY

AIDS-related deaths have been reduced by 60% since the peak in 2004.
In 2019, around 690 000 people died from AIDS-related illnesses worldwide, compared to 1.7
million people in 2004 and 1.1 million 830 000 - 1.6 million people in 2010.
AIDS-related mortality has declined by 39% since 2010.

INVESTMENT
At the end of 2019, US$18.6 billion (constant 2016 dollars) was available for the AIDS
response in low and middle-income countries, almost US$1.3 billion less than in 2017
Around 57% of the total resources for HIV in low- and middle-income countries in 2019 were
from domestic sources.
UNAIDS estimates that US$26.2 billion (constant 2016 dollars) will be required for the AIDS
response in 2020.

MODE OF TRANSMISSION
HIV is a relatively fragile virus, which is not spread by casual contact. HIV is not easy to
“catch”, it must be acquired.

In order for HIV to be transmitted, three conditions must occur:

1. There must be a HIV source.
2. There must be a sufficient dose of virus.
3. There must be access to the bloodstream of another person.

HIV is transmitted through:

- Unprotected anal, vaginal, and oral intercourse
- Sharing needles or other injection equipment
- A mother passing the virus to her baby either before or during birth
- An infected woman breastfeeding her infant
- Accidental needlestick injuries, or infected body fluid coming into contact with the broken
skin or mucous membranes of another person (as with healthcare workers)
- A transfusion prior to 1986 of HIV-infected blood or blood products

PSYCHOLOGICAL EFFECT OF HIV & AIDS

 1. Feeling sad or anxious often or all the time
2. Not wanting to do activities that used to be fun
3. Feeling irritable‚ easily frustrated‚ or restless
4. Having trouble falling asleep or staying asleep
5. Waking up too early or sleeping too much
6. Eating more or less than usual or having no appetite
7. Experiencing aches, pains, headaches, or stomach problems that do not improve with
treatment
8. Having trouble concentrating, remembering details, or making decisions
9. Feeling tired‚ even after sleeping well
10. Feeling guilty, worthless, or helpless
11. Thinking about suicide or hurting yourself.

WAYS OF PREVENTING DEPRESSION

1. Call your HIV health care provider.
2. Get help from another health care provider.
3. Reach out to a close friend or loved one.
4. Contact a minister, spiritual leader, or someone else in your faith community.

PATHOPHYSIOLOGY OF HIV & AIDS

The immune system protects the body by recognizing antigens on invading bacteria and
viruses and reacting to them.
An Antigen is any substance that induces a state of sensitivity and immune responsiveness.
Antigens interacts with antibodies and immune cells, initiating an immune response. This
process destroys the antigens allowing the body to be free of infections.

TYPES OF ANTIGEN
- Bacteria.
- Viruses.
- Fungi.
- Parasites.
The immune system consists of lymphoid organ and tissues, including bone marrow, thymus
glands, lymph nodes, spleen, tonsils, adenoids, appendix, blood and lymphatic vessels. All
components of the immune system are vital in the production and development of
lymphocytes or white blood cells. B-lymphocytes (B-cells) and T-lymphocytes (T-cells) are
produced but the T-lymphocytes travels to the thymus gland to complete their maturation.
There, the T-lymphocytes becomes immunocompetent, multiply, and become more
differentiated.
 B-LYMPHOCYTES
The main function of the B-lymphocytes is in humeral (anti-body) immunity. Each B cells
can recognize specific antigen targets and can secrete specific antibodies. Antibodies
functions by coating the antigens. The makes the antigens more vulnerable to
phagocytosis (engulfing and ingesting of invading organs by leukocytes or macrophages)
or by triggering the complement system, leading to an inflammatory response. Antibodies
are highly specialized serum protein molecules.
They are grouped into 5 classes:
- Immunoglobulins G (IgG)
- Immunoglobulins A (IgA)
- Immunoglobulins M (IgM)
- Immunoglobulins E (IgE)
- Immunoglobulins D (IgD)

T-LYMPHOCYTES
They function in the following ways:
1. Regulation of the immune system
2. Killing of cells that bear specific target antigens.
Each T-cells has a single marker such as CD4+, CD8+, and CD3+ that distinguish it from
other cells. CD4+ cells are helper cells that activate the B cells, killer cells and macrophages
when a specific target antigen is present.
They are two types of CD8+ cells:
- Cytotoxic CD8+ Cells: It kills cells infected by bacteria or virus as well as other
cancerous cells.
- T-Suppressors Cells: It inhibits or suppresses the immune responses. Normal CD8+
cells count is between 300 and 1000 cells in adults and children.
T cells secretes cytokines (chemicals that kills cells) such as INTERFERONS. Cytokines
can bind to target cells and activate the inflammatory process. They also promote cell
 growth, activate phagocytes, and destroys target cells. INTERLEUKINS are Cytokines
that serves as messengers between white blood cells. RECOMBINANT (laboratory
synthesized) interleukins are studied for clinical trials for patient with HIV infections.

PHAGOCYTES
Phagocytes includes Monocytes and Macrophages which are large white blood cells that
engulf and digest cells carrying antigenic particles. Found through out the body, phagocytes
rid the body of worn-out cells, initiate the immune response by presenting antigens to
leucocytes, are important in immune response regulation and inflammation, carry receptors
for cytokines. Dendritic cells are a type of phagocyte that have long thread-like extensions
that help trap lymphocytes and antigens, they are found in the spleen and lymph nodes.
Neutrophils are granulocytic phagocytes that are important in the inflammatory response.

COMPLEMENT SYSTEM
A Complement system consist of 25 proteins. Complement can induce an inflammatory
response when it functions with antibodies to facilitate phagocytosis or weaken the bacteria
cell membrane. The complement proteins interact with one another in a sequential activation
cascade, promoting the inflammatory process.

HIV STRUCTURE
The HIV consist of a cylindrical center surrounded by a sphere-shaped lipid bilayer envelope.
There are two major viral glycoproteins in this lipid bilayer which are:
- gp120
- gp140
The major function of those protein is to mediate recognition of the CD4+ cells and
Chemokine receptors, thereby enabling the virus to attach to and invade CD4+ cells. The
inner sphere contains two single-stranded copies of genomic materials, RNA as well as
multiple proteins and enzymes necessary for HIV replication and maturation: P24, P17,
reverse transcriptase, integrase, and protease.

The 3 principal genes are:

- gag
- pol
- evu
The gag gene encodes for core proteins, the pol gene encode for enzyme reverse
transcriptase, protease, and integrase. The enu gene encode the HIV structural components
called glycoproteins.
The remaining genes:
- rev
- nef
- vif
- vpv
- tat
These above genes are important for viral replication and enhancing HIV infectivity rate.

HIV LIFE CYCLE

Host cells infected with HIV have shortened life span as a result of the virus using them to
replicate itself (new copies of HIV) As much as 10 million to 10 billion virions (singular) are
produced per day. 24 hours after exposure, the HIV is captured by the dendritic cell in the
mucus membrane of the skin, within 5 days, these virus makes their way to the lymph nodes
and eventually to the peripheral blood. Where viral replication becomes rapid. CD4+
lymphocytes that are recruited to respond to viral antigens migrates to the lymph nodes. These
becomes activated and then proliferate via complex interactions of cytokines released in the
microenvironment of the lymph nodes. This sequence of events makes the CD4+ cells more
susceptible to HIV infections, and explains the series of acute retroviral syndrome seen in
adults and adolescents.

Thus; HIV infected monocytes allows viral replication but resist killing. The monocytes act
as storage for the HIV and as effector of tissue damage such as Brain.
The HIV life cycle includes the following:
- Binding and entry
- Reverse transcription
- Integration
- Replication
- Budding
- Maturation
BINDING AND ENTRY
The envelop protein gp120 and gp41 binds to CD4+ cells receptors and coreceptors on the
outside of CD4+ cells and macrophages.
The joining of the protein and the receptors and coreceptors fuses the HIV membrane and the
CD4+ cells membrane, and the virus enters the CD4+ cell and the macrophages. The HIV
membrane and envelope proteins remain outside, whereas, the core of the virus enters the
CD4+ cells. The CD4+ cells enzymes interact with the viral core and stimulate the release of
the viral RNA and the viral enzymes reverse transcriptase, integrase, and protease.

REVERSE TRANSCRIPTION
This occurs in a sequence where the HIV RNA is converted to DNA before being
incorporated into the DNA of the CD4+ cells. This incorporation must happen for the virus to
multiply. The conversion of RNA to DNA is termed reverse transcription and is mediated by
the HIV enzyme reverse transcriptase. This results in the production of single strand of DNA,
which then undergoes replication into the double stranded HIV DNA.

INTEGRATION
The viral enzyme integrase transcriptase then inserts the viral DNA into the CD4+ cell DNA.
This process is called INTEGRATION. The CD4+ cells have been changed into a factory
used to produce more HIV virus.

REPLICATION
The new DNA found causes the production of messenger DNA that initiates the synthesis of
HIV proteins.

BUDDING
The new virus pushes through the different parts of the cell wall by budding. These new virus
leaves the CD4+ cells and contain all the components necessary to infect other CD4+ cells.

MATURATION
The new virus matures before it can infect other CD4+ cells. During this process, the HIV
protease enzymes cuts HIV proteins of the virus into smaller functional units that then
reassemble to form a mature virus. The virus is now ready to infect other CD4+ cells.

TYPES OF HIV
1. HIV type 1 virus (HIV-1)
2. HIV type 2 virus (HIV-2)

CLINICAL CATEGORIES OF HIV INFECTION

1. Primary infection or Acute retroviral syndrome
2. Clinical Latency/Asymptomatic Disease (Clinical stage 1)
 3. Mild sign and symptoms of HIV (Clinical stage 2)
4. Advance science and symptoms of HIV (Clinical stage 3)
5. Clinical stage 4

TEST FOR HIV and AIDS

The primary tests for diagnosing HIV and AIDs include:
ELISA Test ELISA: which stands for Enzyme-Linked Immunosorbent Assay, is used to
detect HIV infection. If an ELISA test is positive, the Western blot test is usually administered
to confirm the diagnosis. If an ELISA test is negative, but you think you may have HIV, you
should be tested again in one to three months. ELISA is quite sensitive in chronic HIV
infection, but because antibodies aren't produced immediately upon infection, you may test
negative during a window of a few weeks to a few months after being infected. Even though
your test result may be negative during this window, you may have a high level of the virus
and be at risk of transmitting infection.

Home Tests: The only home test approved by the U.S. Food and Drug Administration is
called the Home Access Express Test, which is sold in pharmacies.

Saliva Tests: A cotton pad is used to obtain saliva from the inside of your cheek. The pad is
placed in a vial and submitted to a laboratory for testing. Results are available in three days.
Positive results should be confirmed with a blood test.

Viral Load Test: This test measures the amount of HIV in your blood. Generally, it's used to
monitor treatment progress or detect early HIV infection. Three technologies measure HIV

viral load in the blood: reverse transcription polymerase chain reaction (RT-PCR), branched
DNA (bDNA) and nucleic acid sequence-based amplification assay (NASBA). The basic
principles of these tests are similar. HIV is detected using DNA sequences that bind
specifically to those in the virus. It is important to note that results may vary between tests.
Western Blot This is a very sensitive blood test used to confirm a positive ELISA test result.

HCT (HIV Counseling and Testing)

HIV Counseling and Testing is the service rendered to an individual in order for him/her to
know his HIV status, which could be either positive or negative and is usually confidential.

HCT is done in three distinct components, pre- test counseling before the blood is taken and
this is meant to prepare the individual for the test and assess the risk level to HIV virus the
person possessed. Also, it helps one to anticipate the result, whether it turns out HIV positive
or negative. The second component is the taking of blood sample and test by using rapid test
kits and lastly is disclosure of result, counseling and referrals, depending on the outcome of
the result.

HCT is an integral part of HIV/AIDS. Without HCT, diagnosing HIV may not be possible
except when an individual comes down seriously with some of the known symptoms of the
disease. The National Agency for the Control of AIDS is using all strategy available to
increase HCT uptake in the country. Provider Initiative HCT strategy is being introduced to
most government funded hospitals to ensure that all patients that come in to health facility
have access to HCT services at no cost.

The importance Of HIV Counseling and Testing includes:

1 HCT helped millions of people to know their status either they are positive or negative.

2 HCT helps in preventing the spread of HIV.

3 HCT allows the public to have access to medical care when tested positive.

4 HCT educates people who tested negative on the ways to stay negative and for a
positive test result, how to live positively without infecting others.

5 HCT provides critical information about HIV and the testing process.

6 HCT gives information about how HIV is transmitted and how the public can protect
themselves from infection.

7 It also educates the public to know that HIV testing should be done regularly.

Finally, testing for HIV is the gateway to prevention, care and treatment. HIV testing and
counseling should be routine test for every Nigerians, as this is the surest way to guarantee an
HIV free generation.

GUIDELINES/PRINCIPLES IN HIV TESTING AND COUNSELLING

1. People receiving HIV testing and counselling must give informed consent (verbal consent
is sufficient and written consent is not required) to be tested and counselled. They should be
informed of the process for HIV testing and counselling and their right to decline testing.

2. HIV testing and counselling services are confidential, meaning that what the HIV testing
and counselling provider and the person discuss will not be disclosed to anyone else without
the expressed consent of the person being tested. Although confidentiality should be
respected, it should not be allowed to reinforce secrecy, stigma or shame. Counsellors should
raise, among other issues, whom else the person may wish to inform and how they would like
this to be done. Shared confidentiality with a partner or family members and trusted others
and with health care providers is often highly beneficial.

3. HIV testing and counselling services must be accompanied by appropriate and high-quality
pre-test information (which can be provided as group pre-test information in some settings)
and post-test counselling. Quality assurance mechanisms and supportive supervision and
mentoring systems should be in place to ensure the provision of high-quality counselling.
4. HIV testing and counselling providers should strive to provide high-quality testing
services, and quality assurance mechanisms should be in place to ensure the provision of
correct test results. Quality assurance may include both internal and external measures and
should include support from the national reference laboratory as needed.

5. Connections to prevention, care and treatment services should include the provision of
effective referral to appropriate follow-up services as indicated, including long term
prevention and treatment support.

THE FIVE C's ESSENTIAL FOR HIV TESTING

1.consent
2. confidentiality
3. counselling
4. correct test results
5. connection to HIV prevention, treatment and care.

ANTIRETROVIRAL DRUGS
Antiretroviral therapy reduces the amount of HIV in the body. When a person takes them
consistently, antiretroviral drugs are very effective at limiting the impact of the virus . This
therapy helps keep the body healthy and prevent infections. Specifically, successful
antiretroviral therapy prevents people from developing advanced HIV and makes it
impossible to transmit the virus to others.

MODES OF ACTION
HIV is a retrovirus that targets the immune system, which is the system that fights off
infection and disease. The virus damages or destroys white blood cells called CD4 cells. This
makes it difficult for the body to fight off illness.
Antiretroviral therapy prevents the virus from multiplying, which reduces the amount of HIV
in the body. This gives the immune system a chance to produce more CD4 cells.
Although antiretroviral therapy cannot completely remove HIV from the body, it keeps the
immune system strong enough to combat infections and some HIV-related cancers.
Antiretroviral therapy reduces the amount of HIV in the body. When a person takes them
consistently, antiretroviral drugs are very effective at limiting the impact of the virus.

Although inequities exist by region and population, advances in antiretroviral therapy have
made it possible for many people with HIV to live a comparable life span to those without
HIV.

This therapy helps keep the body healthy and prevent infections. Specifically, successful
antiretroviral therapy prevents people from developing advanced HIV and makes it
impossible to transmit the virus to others.
The Centers for Disease Control and Protection (CDC) recommend that all people with HIV
take antiretroviral therapy, regardless of how long they have had the virus or their current
state of health.

Antiretroviral therapy has become more potent, less toxic, and easier to use than in the past. It
produces fewer and less severe side effects than before.

This article describes various antiretroviral drugs, how they work, and their possible side
effects. It also provides information about beginning treatment.

HIV is a retrovirus that targets the immune system, which is the system that fights off
infection and disease. The virus damages or destroys white blood cells called CD4 cells. This
makes it difficult for the body to fight off illness.

Antiretroviral therapy prevents the virus from multiplying, which reduces the amount of HIV
in the body. This gives the immune system a chance to produce more CD4 cells.

Although antiretroviral therapy cannot completely remove HIV from the body, it keeps the
immune system strong enough to combat infections and some HIV-related cancers.

The aim of antiretroviral therapy is to reduce the amount of HIV in the blood to very low
levels. Viral suppression occurs when the count reaches fewer than 200 copies of the virus per
milliliter of blood.

When the viral load is so low that it is undetectable, it no longer damages the immune system,
and there is no risk of transmitting the virus to others. This is known as “undetectable =
untransmutable.”

In most people using antiretroviral drugs, the virus is under control within 6 months.

TYPES OF ANTI-RETROVIRAL DRUGS

Antiretroviral therapy involves taking a combination of drugs each day. An HIV treatment
regimen usually involves at least three different drugs from at least two different drug classes.

The following are the different categories of antiretroviral drug:

- Nucleoside reverse transcriptase inhibitors (NRTIs)
NRTIs block the action of an enzyme called viral reverse transcriptase, which is necessary for
HIV to replicate.

Some examples of NRTIs include:

- abacavir (Ziagen)
- emtricitabine (Emtriva)
 - lamivudine (Epivir)
- stavudine (Stavudine)
- tenofovir disoproxil fumarate (Viread)
- zidovudine (Retrovir)
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
NNRTIs work similarly to NRTIs. The only difference is that they act on different sites of the
enzyme.

Some examples of these antiretroviral medications include:

- doravirine (Pifeltro)
- efavirenz (Sustiva)
- etravirine (Intelence)
- nevirapine (Viramune)
- rilpivirine (Edurant)
- Protease inhibitors (PIs)
PIs impede another viral enzyme, called HIV protease. HIV requires protease to replicate.

Some types of PI include:

- atazanavir (Reyataz)
- darunavir (Prezista)
- fosamprenavir (Lexiva, Telzir)
- indinavir (Crixivan)
- lopinavir/ritonavir (Kaletra)
- ritonavir (Norvir)
- saquinavir (Invirase)
- tipranavir (Aptivus)

Entry inhibitors
As the name suggests, these drugs prevent the virus from entering the targeted cells.

To penetrate immune cells, HIV must fuse to the cells’ receptors, and these drugs work to stop
this from happening.

People often take entry inhibitors when other treatments have not worked.

Some examples currently in use include:

- enfuvirtide (Fuzeon)
- maraviroc (Selzentry).

Integrase inhibitors
HIV uses a protein called integrase to send its genetic material into the cells that its targets.
Integrase inhibitors block this action.
ADVERSE REACTION TO ANTIRETROVIRAL DRUGS
Antiretroviral drugs can have adverse effects. Most are manageable, but some can be serious.
Newer drugs tend to cause fewer and less severe side effects.

The benefits of taking HIV medications typically outweigh the side effects. These treatments
can help people live long, healthy lives with reduced risks of HIV-related complications and
transmission.

The potential side effects vary depending on the types of medication a person uses. Also, the
same medication can have different side effects in different people.

Some side effects from antiretroviral therapy, such as nausea or fatigue, may last only a few
days or weeks. Other side effects, such as high cholesterol, may not appear for a few months
or years.

Some other possible side effects of antiretroviral therapy include:

- Headache
- nausea and vomiting
- diarrhea
- fatigue
- difficulty sleeping
- dry mouth
- rashes
- dizziness
- pain

Some long-term side effects may include:

- depression
- diabetes
- heart disease
- insomnia
- kidney damage
- liver damage
- nerve damage
- weak bones, or osteoporosis
- higher levels of fat in the blood

COMMON OPPROTUNISTIC INFECTION ASSOCIATED WITH HIV/AIDS

- cryptococcal meningitis
- toxoplasmosis
- PCP (a type of pneumonia)
- oesophageal candidiasis
- certain cancers, including Kaposi’s sarcoma.
WAYS OF PREVENTING OPPORTUNISTIC INFECTION
- Practice safe sex. Several OIs are transmitted sexually.
- Practice safe food preparation.
- Take care around animals.
- Take care around people.
- Get vaccinated.
- Take preventive medicines if needed.
- Take antiretroviral medicines for your HIV.
- Keep a health journal and write down any new symptoms.

PROPHYLAXIS FOR OPPORTUNISTIC INFECTIONS

Prophylaxis is a treatment given or action taken to prevent disease.

UNIVERSAL PRECAUTIONS OF HIV&AIDS IN HEALTH CARE SETTINGS

1. Take care to prevent injuries when using needles, scalpels, and other sharp instruments or
devices; when handling sharp instruments after procedures; when cleaning used instruments;
and when disposing of used needles. Do not recap used needles by hand; do not remove used
needles from disposable syringes by hand; and do not bend, break, or otherwise manipulate
used needles by hand. Place used disposable syringes and needles, scalpel blades, and other
sharp items in puncture-resistant containers for disposal. Locate the puncture-resistant
containers as close to the use area as is practical.
2. Use protective barriers to prevent exposure to blood, body fluids containing visible blood,
and other fluids to which universal precautions apply. The type of protective barrier(s) should
be appropriate for the procedure being performed and the type of exposure anticipated.
3. Immediately and thoroughly wash hands and other skin surfaces that are contaminated with
blood, body fluids containing visible blood, or other body fluids to which universal
precautions apply.

CARE AND SUPPORT FOR PEOPLE LIVING WITH HIV/AIDS

Care can be showed to people living with HIV/AIDS in the following ways:
1. showing love, respect and support
2. knowing the facts about HIV/AIDS and talking openly about the disease
3. helping to reduce stress and stressful situations
4. helping to provide balanced and nutritious meals
5. encouraging them to get treatment if they are sick because most infections are easily treated
and cured, even if the person is HIV positive.

Support can be showed to people living with HIV/AIDS in the following ways:

1. Talk: Be available to have open, honest conversations about HIV. Follow the lead of the
person who is diagnosed with HIV. They may not always want to talk about it, or may not be
ready. They may want to connect with you in the same ways they did before being diagnosed.
Do things you did together before their diagnosis; talk about things you talked about before
their diagnosis. Show them that you see them as the same person and that they are more than
their diagnosis.
2. Listen: Being diagnosed with HIV is life-changing news. Listen to your loved one and offer
your support. Reassure them that HIV is a manageable health condition. There are medicines
that can treat HIV and help them stay healthy.
3. Learn: Educate yourself about HIV: what it is, how it is transmitted, how it is treated, and
how people can stay healthy while living with HIV. Having a solid understanding of HIV is a
big step forward in supporting your loved one. This website is a good place to begin to
familiarize yourself with HIV. Have these resources available for your newly diagnosed friend
if they want them. Knowledge is empowering, but keep in mind that your friend may not want
the information right away.
4. Encourage treatment: Some people who are recently diagnosed may find it hard to take that
first step to HIV treatment. Your support and assistance may be helpful. By getting linked to
HIV medical care early, starting treatment with HIV medication (called antiretroviral therapy
or ART), adhering to medication, and staying in care, people with HIV can keep the virus
under control, and prevent their HIV infection from progressing to AIDS. HIV treatment is
recommended for all people with HIV and should be started as soon as possible after
diagnosis. Encourage your friend or loved one to see a doctor and start HIV treatment as soon
as possible. If they do not have an HIV care provider, you can help them find one. There are
programs that can provide HIV medical care or help with paying for HIV medications. Use
HIV.gov’s HIV Testing Sites & Care Services Locator to find a provider.
5. Support medication adherence: It is important for people living with HIV to take their HIV
medication every day, exactly as prescribed. Ask your loved one what you can do to support
them in establishing a medication routine and sticking to it. Also ask what other needs they
might have and how you can help them stay healthy. Learn more about treatment adherence.
6. Get support: Take care of yourself and get support if you need it. Turn to others for any
questions, concerns, or anxieties you may have, so that the person who is diagnosed can focus
on taking care of their own health.

RELATIONSHIP BETWEEN HIV/AIDS AND NUTRITION

For an individual being HIV-positive, good nutrition can have several benefits, such as:
1. Improve your overall quality of life by providing nutrients your body needs.
2. Keep your immune system stronger so you can better fight disease.
3. Help manage HIV symptoms and complications.
4. Process medications and help manage their side effects.
NEW GUIDANCE ON PREVENTION OF MOTHER TO CHILD TRANSMISSION
OF HIV AND INFANTS FEEDING

1. Earlier antiretroviral therapy (ART) for a larger group of HIV-positive pregnant women to
benefit both the health of the mother and prevent HIV transmission to her child during
pregnancy and breastfeeding.
2. Longer provision of antiretroviral (ARV) prophylaxis for HIV-positive pregnant women
with relatively strong immune systems who do not need ART for their own health. This would
reduce the risk of HIV transmission from mother to child.
3. Provision of ARV prophylaxis to the mother or child to reduce the risk of HIV transmission
during the breastfeeding period. For the first time, there is enough evidence for WHO to
recommend ARVs while breastfeeding.
4. Lifelong ART for HIV-infected women in need of treatment for their own health, which is
also safe and effective in reducing mother to child transmission of HIV (MTCT).
5. Short-term ARV prophylaxis to prevent MTCT during pregnancy, delivery and
breastfeeding for HIV-infected women not in need of treatment.

ARV PROPHYLAXIS
The 2006 guidelines proposed starting ARV prophylaxis in the third trimester (28 weeks) of
pregnancy. They recommended a regimen of twice daily zidovudine (AZT), single-dose
nevirapine at onset of labor, a combination of AZT+3TC during delivery and one week
postpartum, as well as infant prophylaxis for one week after birth.

The 2010 guidelines include two options, both of which should start earlier in pregnancy, at
14 weeks or as soon as possible thereafter. The two options provide significant reduction in
MTCT with equal efficacy in this group of women who are not eligible for ART:

Option A. Twice daily AZT for the mother and infant prophylaxis with either AZT or NVP for
six weeks after birth if the infant is not breastfeeding. If the infant is breastfeeding, daily NVP
infant prophylaxis should be continued for one week after the end of the breastfeeding period.
A three-drug prophylactic regimen for the mother taken during pregnancy and throughout the
breastfeeding period, as well as infant prophylaxis for six weeks after birth, whether or not the
infant is breastfeeding.

STRATEGIES FOR EMTCT (Elimination of Mother to Child Transmission)

1. Advocate for Intensified Political and Financial Commitment for PMTCT (Prevention of
Mother to Child Transmission)
2. Continue Focused Innovation to Target High-Risk Populations.
3. Refine Novel Service Delivery Modalities for the PMTCT Context.
4. Recognize the Importance of Viral Load Monitoring During Pregnancy and Postpartum.
5. Harness Technology to Advance PMTCT's Impact.

FACTORS FACILITATING PMTCT

1. Awareness on HIV risk
2. Barriers to PMTCT service utilization
3. Community factors
4. Stigma
5. Discrimination
6. Individual and family related factors
7. Fear of divorce
8. Lack of family and partner support
9. Health care service factor
10. Facilitators for PMTCT service utilization
11. Community factors
12. Individual and family related factors.
13. Health care service factors.

VULNERABLE CHILDREN
Highly Vulnerable children (HVC) generally refers to individuals under age 18 whose safety,
well-being, and/or development is at significant risk due to inadequate care, protection or
access to essential services.

MEASURES OF PREVENTING TRANSMISSION OF HIV TO VULNERABLE

CHILDREN
1. Barrier methods, such as the use of condoms or dental dams during sexual activity
2. Antiretroviral medicines or antiretroviral therapy (ART)
3. Pre-exposure prophylaxis
4. Postexposure prophylaxis
5. Voluntary Male Circumcision
6. Microbicides for sexually transmitted diseases
7. Low dead space syringes

ETHICAL PRINCIPLES FOR HIV/AIDS

The ethical issues mainly revolve around the standard of care, informed consent across
cultures, privacy and confidentiality, stigma and discrimination, protection of vulnerable
groups, community consultation, ethical review mechanisms, international collaboration,
epidemiological studies, clinical trials and also socio-behavioral studies on HIV/AIDS.

HEALTH CARE EXECUTIVE APPROACH TO ETHICAL ISSUES' DECISION

MAKING IN HEALTH CARE

1. Create a culture that fosters ethical clinical and administrative practices and ethical
decision making.
2.Communicate the organization's commitment to ethical decision making through its mission
or value statements and its organizational code of ethics.
3. Demonstrate through their professional behavior the importance of ethics to the
organization.
4. Offer educational programs to boards, staff, physicians and others on their organization's
ethical standards of practice and on the more global issues of ethical decision making in
today's healthcare environment. Further, healthcare executives should promote learning
opportunities, such as those provided through professional societies or academic
organizations, that will facilitate open discussion of ethical issues.
5. Ensure that the organizational resources addressing ethics issues are readily available and
include individuals who are competent to address ethical concerns and reflect diverse
perspectives. An organization's ethics committee, for example, might include representatives
from groups such as physicians, nurses, managers, board members, social workers, attorneys,
patients and/or the community and clergy. All these groups are likely to bring unique and
valuable perspectives to bear on discussions of ethical issues.
6. Ensure that ethics resources are competent to address a broad range of ethical concerns,
e.g., clinical, organizational, business and management.
7. Seek assistance from ethics resources when there is ethical uncertainty. Furthermore,
encourage others to use organizational resources to address challenging ethical issues.
8. Evaluate and continually refine organizational processes for addressing ethical issues.
9. Promote decision making that results in the appropriate use of power while balancing
individual, organizational and societal issues.

ROLE/RESPONSIBILITIES OF COMMUNITY HEALTH WORKERS TO HIV/AIDS

PATIENTS
1. Cultural mediation between individual communities and health and social system.
2. Providing culturally appropriate health education and information.
3. Care coordination, Case Management and system navigation.
4. Providing coaching and social support
5. Advocating for individuals and communities.
6. Building individuals and community capacity.
7. Providing direct service.
8. Implementing individuals and community assessment.
9. Conducting outreaches.
10. Participating in evaluation and research.

REFERRAL
In medicine, referral is the transfer of care for a patient from one clinician or clinic to another
by request.
A referral can be defined as a process in which a health worker at a one level of the health
system, having insufficient resources (drugs, equipment, skills) to manage a clinical
condition, seeks the assistance of a better or differently resourced facility at the same or
higher level to assist in, or take over the management of, the client’s case. Key reasons for
deciding to refer either an emergency or routine case include:

TYPES OF REFERRAL
1. Experienced based referral
2. Reputation based referral
3. Specialization based referral

COMPONENTS OF A REFERAL SYSTEM

- health system issues
- performance expectations and involvement of organisations
- initiating facility
- referral practicalities
- receiving facility
- supervision and capacity building
- continuous quality improvement.

TIPS FOR A SUCCESSFUL REFERRAL

1. Make it a priority: For many businesses, referrals are an added bonus. Start by
documenting your current sales process. Make referrals part of training or mentoring
for any new employees you bring on board.
2. Create a compelling story: To earn a referral, a customer needs to feel compelled to
give it. Clients are looking for salespeople who proactively monitor their needs,
provide monthly communications and keep them up to date. Build your expertise so
your clients view you as a trusted advisor that they’ll want to recommend to others.
3. Make referrals fun internally: Get people on board with referrals by holding a
contest where the person with the most referrals wins a gift card or tickets to an event
in the community.
4. Evaluate your current contacts: Examine your current contacts to identify potential
referrals. Remember that referrals can come from a variety of sources, so evaluate
anyone you have a connection with. A good place to start is to review your client lists
to determine potential referral leads. In addition, look up companies on LinkedIn that
you’d like to connect with and see what shared connections you have who may be
willing to make an introduction. Once you have reviewed these contacts, make a list
of referral sources to reach out to.
5. Create a list of “inner circle” contacts: Once you’ve created your list, narrow it
down even further by making a list of inner circle contacts. These will be individuals
that your employees have strong relationships with and that you know value your
business and would refer you to others without any incentive.
6. Incentivize referrals: There are two types of referral programs: an incentive program
and non-incentive program. An incentive program offers participants a reward for
referring your business to someone they know. Not all incentives have to be cash—in
fact, non-cash incentives can be powerful motivators as well. For instance, writing a
handwritten note thanking a connection for a referral can go a long way in showing
your gratitude.
7. Track what you do for your clients: Oftentimes, a client has no idea of the work
you do behind the scenes. Providing your clients with an annual stewardship report
that highlights all that you do can translate into an easy way to ask for referrals.
8. Create metrics: Many referral programs fail to reach their potential due to a lack of
accountability. Hold your team responsible for referrals by creating metrics that
monitor their successes. Some potential metrics include: revenue generated from
referrals, number of new referred customers and number of referral meetings each
week or month. By tracking these metrics and communicating expectations and
progress with employees on a regular basis, you can create a culture that is focused
on referrals and win new business.
STEPS IN IMPLEMENTING AND STRENGTHENING A REFERRAL NETWORK

1. Keep it Personal: It’s important to keep in mind that each practice, hospital, and
company is made up of individuals. Although home health agencies receive referrals
from the same source more than once, oftentimes they don’t have a personal
relationship with the caseworkers, social workers, or doctors who are making the
referral. It is invaluable to know exactly who is referring to your company —not just
the name of the hospital, doctor’s office, organization, or agency. Creating a personal
relationship will lead to more referrals in the future.

2. Regularly Communicate with Referral Partners: Consistent communication is

vital, but don’t fall into the habit of always seeking a referral when speaking to a
referral source. Think of subjects to talk about beyond what your business does. Find
some resources that can specifically help them or their patients. Offer advice,
advocacy, and education pro-bono, without seeking anything in return, and your
referral partner will begin to see your company as something their patients can rely
on. Becoming a resource establishes your credibility, which is important for long-
term relationships.
3. Stay Relevant by keeping up with Technology: It used to be that digitizing patient
records was all it took to stay current, but simply sending and receiving information
digitally is no longer enough. There are many software companies bridging the gap
across multiple health systems, enabling companies and their referral sources to stay
as current as possible. With reimbursement becoming more focused on patient
outcomes and penalties for hospital readmissions increasing, companies want to keep
track of their patients more than ever before. Become familiar with and begin
implementing technologies that allow all providers to access important patient data.
Increased speed and fluidity of care transitions will show your referral source that you
can keep up with today’s ever-shifting home health landscape.

4. Measure and Track Referral Sources: In order to increase referral volume, you
need to have a sketch of your current referral trends. Find out who in your network is
referring and whether the referrals are remaining constant, increasing, or decreasing.
Without measuring your progress, it becomes nearly impossible to know if your
outreach efforts are successful. It does’t make sense to exert time and effort on a
strategy if it proves ineffective.

5. Remember, it’s a Two-Way Street: In order to get referrals, you also have to
sometimes return the favor and give referrals, a point many people forget. Strengthen
your relationships and encourage people to refer to you again by keeping things even.
Most companies don’t have the scope of services to use every referral they get, so
why not pass it on to someone who has helped you in the past? Turning yourself into
an asset is a great way to encourage people to refer to you again and again.
THE CONCEPT OF MONITORING AND EVALUATION (M&E)
Monitoring and evaluation (often called M&E) is a combination of data collection and
analysis (monitoring) and assessing to what extent a program or intervention has, or has not,
met its objectives (evaluation).