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Updated 07 May 2013

How is HIV/Aids treated?

HIV/Aids is treated by anti-retroviral therapy and the management of opportunistic infections. It is also important to stay healthy to maintain a strong immune system.

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•    Discuss your HIV status with your partner(s). While this may be difficult to do, it is important that they be tested so that they can also be treated if necessary. In addition, they in turn may be unknowingly putting others at risk of HIV.
•    Protect your partner(s) from HIV by practising safer sex.
•    Stay healthy to maintain a strong immune system: eat a healthy, balanced diet, get enough rest and exercise, and avoid cigarettes and alcohol.

Medication

Management of opportunistic infections:

Once a person has tested positive for HIV, a thorough medical examination should be done to evaluate their present state of health. As other STIs and TB are often present in someone who is HIV positive, additional screening tests for these diseases should be done, so that they can be treated straight away.
Severe opportunistic infections need to be treated before anti-retroviral drugs can be started. If the patient's CD4 count is very low (less than 200 cells per microlitre of blood), the doctor will start prophylaxis for pneumocystis jerovecii. This organism can cause life threatening lung disease in late HIV infection.

Anti-retroviral therapy:

Anti-retroviral drugs slow down the rate at which the virus multiplies. Even though these drugs cannot completely eliminate the virus, by slowing down its multiplication they can prolong the symptom-free period of the disease and allow the immune system to recover. Once treatment is started, it must be continued for the rest of the infected person's life. Strict compliance is essential to prevent the development of drug resistance. Anti-retroviral medication should be started when the patient's immune system begins to fail. The presence of symptoms of HIV disease and the CD4 count are used to decide when to start anti-retroviral drugs. In South Africa anti-retroviral therapy is advised when the CD4+ count is less than or equal to 350 cells/ mm3 or in patients who have an Aids-defining illness (irrespective of the CD4+ count).

For more information on the South African guidelines, please refer to the Department of Health's ART Guideline.

These guidelines also give information on which drugs are suitable to start therapy with and how to monitor individuals on these drugs.

Anti-retroviral drugs block various stages in the viruses replication cycle. There are a growing number of different classes of drug, including:

•    Nucleoside and nucleotide reverse transcriptase inhibitors (NRTIs) such as zidovudine (AZT), lamivudine (3TC) and tenofovir (TDF).
•    Non-nucleoside reverse transcriptase inhibitors (NNRTIs) such as nevirapine, efavirenz, etravirone and delavirdine.
•    Protease inhibitors (PIs) such as indinavir, saquinavir, lopinavir and atazanavir.
•    Fusion/entry inhibitors such as maraviroc and enfuvirtide.
•    Integrase inhibitors such as raltegravir.
For details of the drugs used in the South African public sector refer to the Department of Health's ART Guideline.

The two groups of reverse transcriptase inhibitors handicap (inhibit) the viral enzyme that allows the virus to convert its RNA genome into DNA.

The protease inhibitors handicap the viral enzyme that allows young viruses to mature to the state in which they can infect new cells.

Entry inhibitors prevent the virus from gaining entry into the cell by blocking various target molecules.

Integrase inhibitors prevent the viral dsDNA from being incorporated into the cell’s DNA.

To treat HIV infection, a patient must receive a combination of three or more different antiviral drugs which target different steps in the viruses replication cycle. Using a cocktail of drugs reduces the chances that the virus will become resistant. Patients who are on antiretroviral drugs need to be monitored for evidence of drug side effects, evidence of clinical response to therapy (climbing CD4+ cell count indicates a recovering immune system) as well as for unexpected worsening of opportunistic infections. This can sometimes happen in the weeks following the start of antiretroviral treatment as the immune system recovers and turns to attack the invaders in the body. This condition is known as immune reconstitution inflammatory syndrome (IRIS). Severe inflammatory reactions occur in the tissues of the body infected by particular opportunistic organisms.

HIV drugs and mother to child transmission (MTCT)

Pregnant women who are HIV positive can reduce the risk of infecting their babies by using anti-retroviral drugs during pregnancy and labour. During pregnancy, at 14 weeks of gestation or as soon as possible, Zidovudine should be given for pregnant women who are not on ART and intrapartum every three hours until delivery. In addition, a single dose of Nevirapine during stage 1 of labour as well as a single dose of Tenofovir and Emtricitabine. The baby should be given Nevirapine at birth and then daily for 6 weeks. Thereafter, an HIV PCR test will be done to determine the ongoing management of the baby. A planned caesarean section will also reduce the risk of HIV being transmitted to the baby, as most infections occur during labour itself.

Babies can be infected through breastfeeding, so most specialists strongly recommend that mothers who are HIV positive should only bottle feed their babies. If pure bottle feeding is not an option, then pure breastfeeding is recommended, and mixed feeding (breast and bottle) should be avoided. It is believed that mixed feeding may actually increase the chance of HIV transmission through the mother's milk. Most antenatal clinics in the country have a "training" programme to show mothers how to use formula milk properly. So although the benefits of breast milk are unfortunately lost in these infants, receiving formula or bottle milk at least ensures they are not exposed to HIV. Some mothers may choose to express their breast milk which can then be pasteurised (at home). This process kills viable HIV, but preserves the unique nutrient content of the milk. All infants who are HIV-exposed should have an HIV PCR test done at six weeks to determine whether they have contracted HIV. For infants who are breast fed, a PCR test should be done on the baby six weeks after cessation of breast feeding. All infants with a positive PCR test should start anti-retroviral therapy immediately, irrespective of their CD4+ count.

Prevention of MTCT is a very complex problem. If you are HIV positive and pregnant you would need to discuss the issues at length with a health care professional knowledgeable in the area.

Post exposure prophylaxis:

Health care workers who are accidentally exposed to HIV through, for example, a needleprick accident should start taking anti-retroviral drugs (usually AZT and 3TC) as soon as possible after the incident and preferably within 24 hours. The drugs are usually taken for one month. From analysing thousands of such accidental exposures to health care workers, it has been calculated that even though the risk of getting HIV infection from such an accident is quite low (0.3% of cases), taking anti-retroviral drugs reduces the risk of infection by about 80%.

Women who have been raped should also start anti-retroviral drugs as soon as possible. Although there is no proof as yet in humans, most specialists believe that this is highly likely to reduce the risk of HIV infection, just as the drugs reduce infections after needleprick accidents and reduces transmission of HIV from a mother to her newborn baby. Recently some experimental work in monkeys and data from rape clinics have confirmed this theory, and showed that the drugs must be taken early (definitely before 72 hours, and preferably within 36 hours) to be effective.

The South African government now funds anti-retroviral drugs in the context of rape. However, this treatment may be difficult to obtain outside of large hospitals. There are special rape centres where treatment is available, and the police in your area should be able to help.

Follow-up

Follow-up treatment and examinations will include regular visits to a doctor to monitor the progress of HIV disease, to diagnose and treat other infections and to keep up to date with new treatments.

Regular dental examinations are necessary, because people with HIV have a higher rate of mouth problems, including gum disease.
How can HIV infection be prevented?

How to protect yourself from getting HIV:

•    Reduce the number of sexual partners.
•    Always practice safer sex:
o    Use condoms from start to finish during anal or vaginal sex. Male latex condoms as well as female condoms provide protection against infection.
o    Always use male condoms when performing oral sex on a man.
o    For oral sex on a woman, cover the vaginal area with plastic wrap (cling wrap), a condom cut open or dental dams.
o    Never use oil-based lubricants with male condoms.
o    Engage in non-penetrative sex practices such as kissing, massaging, hugging, touching, body rubbing and masturbation.
o    Avoid alcohol and drugs, which can impair judgement and motivation to practice safer sex.
o    Do not share needles/syringes when using intravenous drugs - preferably don't use recreational or illegal drugs at all!
o    Make sure all medical and surgical instruments, including those used for tattooing, body piercing or circumcision, are completely sterilised before re-use or are safely discarded.

Be tested regularly and get treatment for other STIs (women and men with open sores from herpes, syphilis or chancroid are more susceptible to HIV than other people).

Preventative treatment for opportunistic infections

Preventative treatment for opportunistic infections covers primary prevention (preventing illness before it occurs) and secondary prevention (preventing a disease that a person has already had from coming back).

Children should receive their routine vaccinations, but if they already have Aids, they should not get the vaccine against TB. Extra vaccinations may be recommended in both adults and children. All children, as well as adults who have started to show the signs of HIV disease (or have CD4+ count less than 200 cells pe mm3), should take an antibiotic called co-trimoxazole continuously. This antibiotic prevents Pneumocystis jerovici pneumonia. Adults or children who have had TB or who have contact with people with TB (especially at home) should take anti-TB drugs as well.

Other

HIV-positive people often have to deal with being treated differently by others (discrimination) or even shunned because they carry an infectious disease that is transferred by sex. There is also the anxiety about the threat of illness and death. It may therefore be important to get emotional support from a psychologist or a support group.

It may happen that, when it is known that people have HIV, their colleagues do not want to work with them or their employer will want to fire them. Information on legal and human rights for people living with HIV/Aids may be obtained from an Aids service organisation.

(Reviewed by Dr Diana Hardie, clinical virologist, National Health Laboratory Service and University of Cape Town, July 2010, Additional review by Dr Avron Urison, Medical Director of AllLife, 2013)


 
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