fqs

What is HIV?

HIV stands for Human Immunodeficiency Virus. Human infection with HIV results in a complex clinical disease known as Acquired Immune Deficiency Syndrome (AIDS), which may take ten years or more to develop.

What is the difference between HIV infection and AIDS?

When one contracts or is infected with the HIV, the well-being of the individual remains normal for a long time. There is no indication that one has the virus circulating in his/her body except from laboratory tests. However, if the person is found to be HIV positive, he/she may not display any signs of the disease. HIV is slowly and unnoticeably breaking down the infected person’s immune system.

There comes a point where the immune system is no longer able to protect the body from infections. At this point the person is said to have AIDS.

How can HIV infection be managed?

  • Immune support

  • Prophylaxis of opportunistic infections

  • Treatment of opportunistic infections

  • Anti-retrovirals

What are some of the ways through which HIV is transmitted from one person to another?

  • Unsafe heterosexual contact

  • Perinatal transmission

  • Blood transfusion

  • Exposure to the virus through needle-stick injuries (prick by a contaminated instrument) or sexual assault.

What are Lymphocytes, T-cells and CD4+ cells?

  • Lymphocytes are part of the WBC (White Blood Cells), which are responsible for disposing off disease-causing organisms (germs) from the body. These include viruses, bacteria and cancer cells. The term, lymphocytes, covers 3 types of cells, T-cells, B-cells and the rare NK (“Natural Killer”) cells

  • B-cells make antibodies, which are proteins that help to destroy germs whereas NK cells target virus-infested and cancerous cells

  • T-cells are given this name as they are programmed in the thymus in the neck, which are used by the immune system to discriminate between the body’s own cells and germs. The 2 types of T-cells are CD8+ (fight infections inside body cells) and CD4+ (Instruct all other immune cells).

Mainly CD4+ cells are targeted by HIV. Some of these cells are used to determine the capacity of a HIV-positive person’s immune system to fight disease, including HIV itself. For uninfected people, the average ranges between 500 and 1100 CD4 cells in a milliliter of blood. When a person’s CD4+ cell count falls below 200/mm³ of blood, he/she is considered to have AIDS. As the strength of the immune system weakens and becomes vulnerable to infections like TB, pneumonia, fungal infections etc. It is thereby advisable for people with HIV/AIDS, to have their CD4 cell levels checked at most twice a year so that the situation can be corrected.

What is ART and how does it work?

Anti-retroviral therapy (ART) is a treatment that may be considered to be taken if your immune system is very weak.

Antiretroviral drugs (ARVs) act on HIV by interfering with its reproductive cycle. The main stages of the cycle where these drugs act to inhibit replication of the virus are:

  • Inhibit reverse transcriptase enzyme to interrupt the production of proviral DNA. ARVs prevent formation of proviral DNA. The NRTIs and NNRTIs act here.

  • Inhibit maturation of virion by interrupting the protein processing and virus assembly. During this stage protease enzymes are required and protease inhibitors act here.

ART slows down the HIV from multiplying thereby reducing the attack to the immune system by viruses. It helps the immune system get strong so it can keep out opportunistic infections and get sick less often so as to feel better for longer periods of time.

Why is ARV treatment important?

  • Essential for the 40 million already infected

  • Necessary to optimize prevention efforts - people will not be tested if there are no treatment options

  • Necessary to prevent infection in children

  • Necessary for continued economic development

What are the benefits of ART?

  • Voluntary testing/counseling

  • Awareness of HIV

  • Motivation of health care workers

  • Expenses for palliative and OI care

  • Number of orphans

  • Keeps households and businesses intact

  • Access to health facilities

  • Potential to enhance prevention:

  • Behavioral: access to prevention education during care encounters

  • Biological: decreased transmission due to lowered viral load

What is HAART?

The term HAART (Highly Active Anti-retroviral Therapy) is used to describe the multi-drug regimens used today to treat HIV infection. Multiple drugs, usually from 2 or more classes as prescribed below:

  • 2 x NRTIs + PI

  • 2 x NRTIs + NNRTI

  • 3xNRTIs

  • 2xPIs

Neucleotide RTI

NAME STRENGTH ADULT DOSING
Tenofovir Tablets, 300mg 300mg OD

Non - Nucleoside analogue Reverse Transcriptase Inhibitors (NNRTIs)

NAME STRENGTH ADULT DOSING

Efavirenz (EFZ)
Nevirapine (NVP)
Delavirdine (DLV)

Capsules, 200mg
Tablets, 300mg
Capsules, 100mg

600mg OD
200mg BD
600mg BD

Protease Inhibitors (PI)

NAME STRENGTH ADULT DOSING

Saquinavir hard- gel (SQV)
Saquinavir soft gel (SQV)
Ritonavir** (RTV)
Indinavir (IDV)
Nelfinavir** (NFV)

Amprenavir ^ (AMV)
Lopinavir + Ritonavir

Capsules, 200mg
Capsules, 200mg
Capsules, 100mg
Capsules, 200mg
Tablets, 250mg

Tablets, 300mg
Capsules (I 3.3mg
Lopinavir + 33.3mg
Ritonavir).

600mg TID
1200mg TID
600mg BD
800mg TID
1250mg BD
or 750mg TDS
1200mg BD
400mg
Lopinavir +
100mg
Ritovavir BD

Drugs marked ^ are not currently available in Kenya and drugs marked ** are available in pediatrics formulations.

 

What are the drug combinations to start with?

Initiation of Therapy:

Leading Regimens to consider

NNRTI sparing

  • 2 Nucleoside RTIs + Protease Inhibitor

PI sparing

  • 2 Nucleoside RTIs + Non-Nucleoside RTI

PI and NNRTI sparing

  • 3 Nucleoside RTIs (including Abacavir)

In view of the proposition to scale ARV therapy countrywide, the need of a simple guide on ARV regime has been realized. The regimen will assist in standardizing care while making it possible for 1st line health workers such as clinical officers and nurses to participate in active management of patients.

The regimens proposed herein have been deliberated on in several meetings by members of the ARV taskforce which draws representation from a number of multi-sectoral partners.

First Line

  • Zidovudine (AZT)/Stavudine (D4T) + Lamivudine (3TC) + Efavirenz (EFV)

  • AZT/D4T + 3TC + Nevirapine (NVP) in pregnant women

This combination is associated with better tolerability, is cost effective and efficacious. D4T was selected because of being cost effective and is not associated with bone marrow suppression as is AZT. Secondly anemia is a common presentation in our population, whether it is due to nutritional deficiencies, disease or as a result of HIV/AIDS.

EFV and Nevirapine (NVP) compare favorably cost-wise. EFV has been shown to be efficacious, is better tolerated and pill burden is absent as compared to NVP. Thirdly, NVP is associated with liver damage unlike EFV.

However, in pregnant women or women likely to become pregnant, NVP was preferred to EFV because the latter has been shown to be teratogenic in animal studies.

ARV THERAPY IN PATIENTS WITH TB

  • AZT/D4T + 3TC + EFV

It is recommended that ARV therapy should be withheld during the intensive phase of TB therapy to allow close monitoring of patient response to anti-TB drugs. Secondly, the patients will be excused from a heavy pill burden. It is emphasized that protease inhibitors should not be combined with Rifampicin due to drug interaction.

ADULTS AND ADOLESCENTS

1ST LINE

  • AZT/D4T + 3TC + EFV

  • AZTD4T + 3TC + NVP in pregnant women or women likely to become pregnant.
     

2nd LINE

  • AZT + DDI + Lopinavir/Ritonavir (or NLF)

  • TDF + AB +  Lopinavir/Ritonavir(or NLF)

CHILDREN UNDER 13 YEARS

1ST LINE

  • D4T + 3TC + NVP

PREVENTION OF MOTHER TO CHILD TRANSMISSION

1ST LINE
Nevirapine if mother is asymptomatic
D4T + 3TC + NVP in symptomatic disease

PATIENTS WITH TUBERCULOSIS

  • Avoid ARVs during intensive phase

  • D4T + 3TC + EFV

POST EXPOSURE PROPHYLAXIS

  • Low risk exposure- AZT + 3TC

  • High risk exposure- AZT + 3TC + Indinavir

The Goals of HAART?

  • Prolong and improve the quality of life of people living with HIV and AIDS

  • Reduce the viral load as much as possible for as long as possible in order to halt disease progression and prevent/reduce resistant variants

  • Achieve immune reconstitution that is quantitative (CD4 count in normal range) and qualitative (pathogen-specific immune response)

  • Reduce mother-to-child transmission.

What progress has been made so far? (Stated by World Health Organization –WHO)

A number of international developments enhance the possibility of treating more people living with AIDS in the developing world:

  • There is awareness that prevention and treatment are both necessary for controlling the spread of HIV/AIDS and that these two approaches are mutually reinforcing elements of a comprehensive response to HIV/AIDS

  • There has been a significant reduction – more than 90 per cent in some cases – in the price of ARV drugs offered to all sub-Saharan African countries reducing costs from about US$10,000 per year to as low as US$240 for some combinations

  • Many developing countries, including several in Africa, have made a promising start by showing that ARV treatment is not only implementable, but also affordable and sustainable

  • The World Trade Organization decision in late August 2003 allowing poorer nations to import generic versions of patented anti-retroviral drugs under certain circumstances, can facilitate the provision of low cost drugs for people living with HIV/AIDS in developing countries

  • There are growing numbers of partners engaged in the response to the epidemic, and continuing forceful activism and advocacy by people living with HIV/AIDS and civil society

  •  The increased availability of international financial resources, including the creation of the Global Fund to fight AIDS, Tuberculosis and Malaria, signals a renewed commitment from the international community with the global fight against AIDS

What action has the Organization of African Unity (OAU) committed to support Africa against AIDS?

  • Giving fullest political commitment to mobilizing society as a whole for the fight against AIDS

  • Stepping up action to prevent the sexual transmission of HIV

  • Planning for care of people with HIV infection and AIDS and the support their families and survivors

  • Supporting appropriate and relevant AIDS research

  • Using our leadership position to ensure that all sectors of society work together to tackle AIDS epidemic

  • Making AIDS a top priority for external resource allocation so that our continent benefits from maximum international cooperation and solidarity in overcoming the epidemic and its impact.


 
webmail
downloadtab