Management of HIV and AIDS

Which could be client or health care worker initiated. This is an essential component of HIV/AIDS care that helps to reduce risky behaviors and aids early detection and management of new infections.

Individuals are counseled before and after the test. The courage of our clients is routinely commended for presenting for the test and their degree of vulnerability is explored to know areas of their social life to emphasize on during post-test counseling.

Thereafter they are educated on measures of HIV prevention. Condoms are provided free. Its use is demonstrated, and they are encouraged to use it during social sex.

Clients are allowed to ask questions and encouraged to join our support groups if tested positive.

The level of public awareness of HIV/AIDS in the state is quite impressive, as many people (94%) know the routes of transmission of the virus, namely; unprotected sex, transfusion of an infected blood, and accidental pricks from contaminated needles and sharp objects and from an infected mother to child.

They equally know that the virus is not contracted from touching, hugging, or sharing household utensils or using public toilets³⁸.

Despite this high level of AIDS-related awareness, the majority of the populace have a very poor personal risk perception of acquiring the infection. Only 3.9% consider themselves at risk of contracting HIV and 60% are not ready to have HCT.

Status disclosure is a strong prerequisite for a successful HIV/AIDS control program. Clients are encouraged to disclose their status to a spouse or a trusted family member. This may encourage them to seek testing or change from risky behavior. In addition, disclosure encourages adherence to medications.

Identified reasons for low disclosure rate were fear of discrimination, stigmatization, and shame of being labeled sexually loose, fear of possible violence, outright rejection or divorce, especially among the females in polygamous marriages, and future difficulties of getting suitors for the singles amongst them.

The problem of disclosure could be resolved by requesting each client to have a treatment support partner who would be in the know of their status and give necessary supports and the employment of treatment support specialists (TSS) by the UITH’s management who were role-playing positive living with HIV/AIDS at every clinic session. With these measures in place along with sustained community awareness campaign against discrimination, a far higher disclosure rate of 70% was recorded six years later.

Psychological supports and reassurances are provided to our patients to cope with the news of being newly diagnosed HIV positive. They are taught how to positively live with the virus, especially prompt report and treatment of HIV-related illnesses and healthy lifestyle. To these, water guard, insecticide-treated mosquito nets, buckets, and water jars are provided to the newly diagnosed patients, and to those on follow-up care; water guard and an unlimited supply of condoms are provided at each clinic visit.

PLHIV are encouraged to join and regularly attend one of our six support groups’ meetings (Morning Stars, Save Lives, Anuoluwa, Golden Women, Love and Care, and Kiddies Club). They are encouraged to speak out on issues bothering them so that solutions could be proffered.

For easy understanding; PLHIV could be grouped into three: asymptomatic group; (WHO stage 1), symptomatic group with early features of HIV infection; (WHO stages 2 & 3); and those with established AIDS defining illnesses; (WHO stage 4). What is common to all these groups is a persistent viral replication with varying degree of CD4 cells depletion. The aim of management in all the groups therefore is to reduce viral replication to as low a level as possible and maintain it there.

Treatment of Asymptomatic Group

Consists of advice on good nutrition, prevention of HIV transmission to others, and follow-up counseling. PLHIV are enjoined to take locally available, cheap nutritious foods such as grains, legumes, lots of fruits and vegetables, and poultry in adequate quantity. Courtesy of IHVN, patients are routinely given action meal supplements. This is a blend-in high energy meal from maize, soya beans, and groundnut that is fortified with minerals and essential vitamins.

Further transmission of the virus to others is discouraged by advising PLHIV to voluntarily abstain from sex or be faithful to their spouses or regularly use condoms if the earlier two options are difficult to adopt. To this end, free condoms are available at every clinic visit to all our clients and to people on courtesy and social visits to our clinic.

To prevent mothers-to-be from infecting their unborn babies, they are encouraged to get pregnant only when their CD4 cells count is well above 500 cells/mm3, register early for antenatal care with our PMTCT team, and report early to the hospital once they fall into labor. By these measures, the mother is assured of a continuum of a comprehensive package of care from preconception stage with the adult ART team to having her pregnancy, labor, and delivery supervised by the PMTCT team who will also offer her reproductive healthcare advice post-delivery.

Her baby would also benefit from care and advice from the Paediatrics ART team on safer infant-feeding practices.

To date, over 300 women who are positively living with HIV in our center have been successfully delivered of HIV-free babies.

Treatment of Symptomatic PLHIV

Consists of prevention and treatment of OIs, provision of ARV drugs, and palliative care. OIs are common amongst PLHIV and they increase their morbidity and mortality. They are, therefore, better prevented or aggressively treated when diagnosed. The level of CD4 counts is an important guide for determining the time of initiation and discontinuation of prophylaxis against OIs⁴¹, table 2. We have observed a strong correlation between CD4 cells count and the level of immunologic competence of PLHIV as well as the OIs they are susceptible to⁴². Patients with CD4 count less than 350 cells/mm³ are routinely commenced on co-trimoxazole prophylaxis.

Knowledge of the life cycle of HIV has led to the development of drugs (ARVs) that target different stages of the viral reproductive process, Figure 4. ARV drugs cannot cure HIV/AIDS, but can halt disease progression and allow the immune system to recover.

Sites of action of different ARV drugs

×

Sites of action of different ARV drugs

ARV drugs are taken daily for life. Their remedial effects are observed qualitatively as clinical improvement and could be measured quantitatively by estimates of both viral load and CD4 cell count.

Indications to start ARV drugs

National ART Guideline44 recommends that therapy should be initiated in the following category of patients:

1. PLHIV with CD4 cell count less than 200 cells/mm³ with or without symptoms,
2. Symptomatic PLHIV with CD4 count less than 350 cells/mm³,
3. Patients with an AIDS-defining illness.

Such a patient will have clinical (OIs, psychiatric illness, pregnancy, alcohol) and laboratory (complete blood count, liver and renal function tests, serum glucose, lipid profiles, and viral load) assessments to determine the appropriate ART that would best suit him/her. Two Nucleoside reverse transcriptase inhibitors (NRTIs) are usually combined with a Non-nucleoside reverse transcriptase inhibitor (NNRTI) or a Protease inhibitor (PI), or an integrase inhibitor (II) to make up a triple drug regimen popularly called HAART- Highly Active Antiretroviral therapy.

Single Tablet Regimens

• Efavirenz (EFV) + Tenofovir Disoproxil Fumarate (TDF) + Emtricitabine/Lamivudine (FTC/3TC)
• Rilpivirine (RPV) + Tenofovir Disoproxil Fumarate (TDF) + Emtricitabine (FTC)
• Elvitegravir (EVG) + Tenofovir Alafenamide (TAF) + Emtricitabine (FTC) + Cobicistat (COBI)
• Dolutegravir (DTG) + Abacavir (ABC) + Lamivudine (3TC)
• Doravirine (DOR) + Tenofovir Disoproxil Fumarate (TDF) + Lamivudine (3TC)
• Dolutegravir (DTG) + Rilpivirine (RPV)

Adherence is to behave as agreed with the health care provider, i.e., come to 100% of appointments and take 100% of ARV medications (in the correct dose, at the correct frequency, and at the correct time). This exercise involves active participation of the patient, their health care providers, and treatment support partners (family, friend, or HIV+ peers). Adherence is the key determinant of ART success. It leads to a long-term decrease in viral load with a reciprocal improvement in the body's immune system and a lower risk of OIs.

However, to achieve these goals, a minimum of 95% or greater adherence is needed from PLHIV. Patients can only miss 1½ days of ARV drugs, which is a maximum of 3 doses in a month.

Adherence rates among our adult patients are quite good; over 70% of 253 PLHIV evaluated in 2010 had excellent adherence. Less than 10% (24 patients) of the studied population had poor adherence.

Adherence is, however, difficult to achieve in geriatric HIV-infected patients because of the peculiarity of this age group. A few elderly patients, 73 years and above, who were treated in our facility in 2013 had initial perfect adherence until, after some time, they started to deny their status and stopped taking ARV drugs.

To achieve near 100% adherence, we anchor ARV drug intake to our patients' daily routines, such as morning and evening prayer time or breakfast and dinner time. We also encourage adherence by asking them to find a treatment partner who will monitor their drug intake. Pill boxes and calendars, when available, are provided to check off dosing and avoid dose confusion.

Three samples of pill boxes

×

Three samples of pill boxes

This is care given to PLHIV in their homes. It involves comfort measures, such as proper positioning, aiding mobility, bathing, skin care, guidance and support for adequate nutrition. Other aspects of home-based care include relieving pain and itching, treating diarrhea and vomiting. In serious cases, patients are referred to the hospital for appropriate treatment. Additionally, family caregivers are educated on how to protect themselves from contact with patients' blood and body fluids by wearing gloves, using disinfectants and detergents to clean up the patient and the linen, and regularly washing their hands with soap and water.

This is an essential component of care for PLHIV that aims to improve the quality of life of the patient and reduce the stress of care on both the healthcare worker and patient family caregiver. It is provided as symptomatic care to relieve a variety of discomforts PLHIV may experience during the course of their illness - such as pain, itching, diarrhea, cough, nausea, and seizures, etc.

Medications that used to be available for Palliative care are as shown in the table below

Pain is a common problem amongst PLHIV, it was present in 27.8% of our clients, and its intensity was of moderate to severe in 1 out of every 4 cases. Commonly affected parts of the body were the lower limbs (44.4%), head and neck, and the abdomen (32% each). Its causes are diverse but respond satisfactorily to palliative measures.

This is one of our success stories that is carried out in our support group meetings. We encourage marriages between seropositive men and women and for this, we often break the ice and facilitate interactions amongst our patients who are singles, widowers or widows, and divorcees. We encourage commitment from both sides and once they understand each other's language, we step aside.

By discouraging marriages between serodiscordant men and women, we are reducing viral transmission, reducing the number of infected babies, and reducing the number of orphans.

Stigma is a set of attributes or characteristics used to qualify HIV-infected persons in a way that devalues them. Stigmatization of PLHIV is commonplace in Nigeria. Majority see immoral behavior as the cause of HIV infection, and this affects societal attitudes towards PLHIV. They are denied social interactions, some are denied employment or lose their jobs, and are sometimes barrier nursed in the hospitals.

Stigma and discrimination are triggered by poor knowledge of how HIV infection is acquired and transmitted. This often leads to speculation and the buildup of myths about the disease. The danger is that stigmatization of PLHIV will deter people from going for HIV counseling and testing (HCT), and seropositive people will be infecting others ignorantly. It also delays PLHIV from having early diagnosis and initiation of treatment.

This was my experience with a professional colleague who had HIV/Syphilis co-infection in 2007. Because of the fear of stigma in his place of work, diagnosis was delayed, and he developed neurological extension of syphilis - neurosyphilis. When diagnosis was finally made and treatment instituted, he got better and became stable, but because of fear of negative reactions from his colleagues, he abandoned hospital care for a prayer house therapy, which unfortunately cost him his life.

Tuberculosis (TB) is a chronic bacterial infection caused by Mycobacterium tuberculosis (MTB) complex, a strict aerobic bacillus. In most infected individuals, the bacillus remains dormant for years because the host’s cell-mediated immunity will prevent it from developing into active TB. HIV, however, targets and depletes cells responsible for this protective immunity. In Nigeria now, HIV infection is the most potent risk factor for reactivation of latent TB focus and progression of new infection to active TB.

About 27% of all TB cases in Nigeria are HIV co-infected, and it is the leading cause of death amongst them. Early in the course of HIV, TB manifests as a localized pulmonary disease (PTB). However, as immunity declines, clinical presentation becomes atypical, and TB now presents as extrapulmonary (EPTB), miliary, or disseminated disease.

Our local data here in Ilorin suggest a rising prevalence of TB in this environment. This is a reflection of TB prevalence in the country at large. Salami et al. recorded a prevalence rate of 9.2% in 2002, which represented a 700% increase over a rate of 1.6% recorded 5 years earlier in a sentinel survey for HIV/TB co-infection in Kwara State.

The rate of HIV/TB co-infection has also been rising over the years largely because of the HIV-induced immune dysregulation that enhances rapid progression of both diseases in co-infected patients. In 2001, the prevalence rate of HIV/TB co-infection was 12.6%. Sixty percent of the affected adults were below 50 years of age (15-44 years), the same age group that is most vulnerable to HIV infection.

Five years later, in a study that reviewed the pattern and trend of HIV-associated TB in Ilorin, the rate of HIV/TB co-infection had increased to 40% amongst 744 TB cases seen over that period. Seventy-nine percent of these were HIV/PTB, and 21% were HIV/EPTB. The annual case detection rate had more than doubled to an average of 47 new cases diagnosed per year, as opposed to 21 new cases per year in the previous nine years (1991 to 1999). This observation is a wake-up call if the epidemic of HIV/TB co-infection is to be prevented in the country, in tandem with the prevailing wave of the HIV epidemic.

We usually make a presumptive diagnosis of TB from microscopic observation of acid-fast bacilli (AFB) in the smear of specimens from infected tissue/fluid using Ziehl-Neelson (ZN) technique. Low sensitivity, however, is the major drawback of this method. In a study to determine the incidence and distribution of smear-positive TB in UITH in 2006, 17,535 pooled specimens of sputum (97%), urine (1.56%), and pleural aspirates (1.0%) were reviewed. Only 10.6% of these were smear-positive for AFB.

However, our newly acquired fluorescent microscope (FM) - courtesy of IHVN that uses auramine-rhodamine stain - is a much more sensitive alternative. It picks up AFB where the ZN stain returns a smear-negative result. Of the 110 ZN-stained smear-negative reports in 2012, 67% became positive with FM (Salami, et al unpublished).

It is important to acknowledge the role of X-ray imaging in the diagnosis of paucibacillary HIV/PTB co-infection and difficult-to-diagnose extrapulmonary TB, since high-tech diagnostic tools such as polymerase chain reaction and nucleic acid line probes are not yet available in our clinic.

Bilateral soft nodular opacities worse in both lower lobes

×

Bilateral soft nodular opacities worse in both lower lobes

Right sided pleural effusion with nodular opacities

×

Right sided pleural effusion with nodular opacities

Smear Isolation of Tubercle Bacilli

Smear isolation of tubercle bacilli is essential for epidemiological monitoring of TB. The proportion of sputum smear-positive cases is calculated out of all new pulmonary cases and has an expected value of 55%-70%. It is a measure of a country’s national TB case detection rate (CDR). The lower it is, the higher the prevalence of TB in that region. Nigerian national CDR is low, 13%-16%, perhaps because of the inadequacy (45%) of the country DOTS coverage.

A slightly better local annual CDR of 33.2% has, however, been established for UITH with a bimodal monthly distribution of cases. The first peak was at the beginning of the year (January to March), due to increased bacilli transmission during the cold, dusty weather of harmattan that commonly forces people indoors and in close contact for most of the time. The second peak was due to the annual end of the year (November to December) influx of people from different parts of the country for Christmas and New Year celebration as well as other festivities.

It is implemented with a six-month regimen of four drugs comprising isoniazid, rifampicin, pyrazinamide, and ethambutol, all in mg/kg body weight of the patient. Anti-TB and ARV drugs are free and both are dispensed to co-infected patients during a single clinic visit. Anti-TB chemotherapy is very effective amongst HIV-negative TB patients. Sputum conversion is rapid, and the cure rate is good when the diagnosis is made early, and DOTS initiated on time at the appropriate dosage and for the correct length of time.

Monthly distribution of smear positive TB

×

Monthly distribution of smear positive TB

However, treatment outcomes were not always good amongst HIV/TB co-infected patients because of the increased pill burden and the overlapping toxicities of anti-TB and ARV drugs on the patients. In a review of management outcomes of 1,741 TB cases in 2003, only a 43.7% cure rate was achieved, 44.2% of the cases defaulted treatment, and 11.6% died. This cure rate was quite low when compared to the WHO's expected target of 85% from a good and effective TB control program. The national cure rate was only fair, ranging from 66% in 2003 to 72% in 2010.

In managing dual HIV/TB co-infection, the rifampicin component of the anti-TB regimen significantly reduces the bioavailability of some ARV drugs (PIs and NNRTI) so much that these ARV drugs would be ineffective in suppressing HIV replication.

However, to limit mortality amongst HIV/TB co-infected patients, Anti-TB and ARV drugs have to be co-administered in the best acceptable combinations with the aim of managing any resultant adverse effects. This is mild in most cases, but could be severe in a few others. In our experience, hepatotoxicity, central nervous system toxicities such as paraesthesia, drug-induced psychosis and seizures, and cutaneous hypersensitivities such as urticaria, Steven Johnson syndrome, toxic epidermal necrolysis, and exfoliative dermatitis were common adverse drug reactions among TB/HIV co-infected patients.