SIDA & VIH
Introduction to HIV & AIDS treatment and care
People living with HIV have differing needs depending their personal circumstances and stage of infection. Forms of HIV treatment and care can be grouped into three broad categories according to when they are usually first needed. A comprehensive package of care covers the entire journey from diagnosis to death, which with antiretroviral treatment may span several decades.
| Early stage | Later stages | End of life stage |
|---|---|---|
 |
||
| HIV testing | Prevention and treatment of OIs | End of life care |
| Counselling & psychosocial support | Managing nutritional effects | Preparing for death |
| Prevention of onward transmission | Palliative care | Support for surviving family and orphans |
| Protection from stigma and discrimination | Antiretroviral therapy | |
| Complementary and alternative medicine | ||
Early stage
Most people remain without major symptoms for several years after becoming infected with HIV.
HIV testing
A sex worker taking an HIV test
HIV testing provides the gateway to accessing other services; a person living with HIV cannot receive any care until they have been diagnosed. The conventional model is VCT (voluntary counselling and testing), requiring people to come forward to be tested. Recent years have seen increasing promotion of routine testing as well. Under this system, everyone attending certain healthcare facilities – for example antenatal clinics, sexual health clinics or doctors’ surgeries – is routinely tested for HIV unless they refuse.
Early diagnosis enables more effective treatment and care. If HIV is first detected in the late stages of infection then more complex care may be needed, and there is less chance that treatment will work. Early diagnosis also reduces the risk of onward transmission; once someone knows they have HIV they are more likely to take precautions to avoid infecting others.
Counselling and psychosocial support
Receiving an HIV positive test result can be traumatic. Psychosocial support aims to help HIV positive people and their caregivers cope with psychological distress, adjust to change and resume a normal life. Patients who receive good quality counselling are less likely to develop serious mental health problems. Health workers should be able to provide psychosocial support, and additional care can come from trained volunteers or AIDS service organisations.
Support is also crucial to the success of any medical treatment. People should understand why and how HIV-related illnesses should be treated, and should be informed of what forms of treatment and care are available locally and how to access them.
Malnourishment hastens the progression from HIV infection to AIDS and death. Nutritional counselling can enable people to stay healthy for longer, delaying the point at which they need to begin antiretroviral therapy.
Prevention of onward transmission
HIV positive people should receive counselling to help prevent them transmitting HIV to other adults. This means promoting safer sexual behaviour through condom use, fidelity and voluntary abstinence. Counsellors should ask about partners who might be at risk of HIV infection, and discuss how these partners may be notified.
Some sexually transmitted infections – most notably genital herpes – can increase the risk of HIV transmission. It is therefore particularly important that people diagnosed with HIV receive treatment for any other sexually transmitted infections they might have.
Mother-to-child transmission of HIV can occur during pregnancy, at the time of delivery, and after birth through breastfeeding. Antiretroviral drugs and safer infant feeding can greatly reduce the risk of a baby becoming infected. Pregnant women with HIV must be diagnosed early to receive the maximum benefit, including education and counselling on prevention methods.
Protection from stigma and discrimination
Stigma and discrimination are triggered by many factors, including lack of understanding of the disease, myths about how HIV is transmitted, prejudice, lack of treatment and social fears. These negative attitudes can deter HIV infected people from getting tested, contribute to them infecting others, and prevent them receiving adequate care and treatment.
The involvement of people living with HIV/AIDS in activities for reducing stigma and discrimination is essential. Having people speak openly about their HIV status is one of the first steps to be taken in tackling stigma and discrimination. This can make people realise that HIV is part of their community and not just “someone else's problem”. In addition, the role of people who are HIV negative should not be underestimated. HIV negative people who speak out about HIV/AIDS can help to promote wider support for those who are infected.
Later stages
The progression from HIV infection to AIDS is gradual; symptoms tend to worsen over time but the pattern varies from person to person.
Prevention and treatment for opportunistic infections
Opportunistic infections occur when HIV has weakened the body’s defences against disease. Common examples are tuberculosis, pneumonia and candidiasis. Providing prevention and treatment for these infections not only helps the sufferer, but also prevents the further spread of disease.
Even in the best-resourced areas, treatment for opportunistic infections remains essential, especially for those who have yet to start, or have only recently started, antiretroviral therapy. For young children and people with weak immune systems, drugs such as cotrimoxazole may be recommended to prevent opportunistic infections occurring.
Managing nutritional effects
As the immune system weakens, people living with HIV become more vulnerable to weight loss and malnutrition. There are likely to be three overlapping causes:
- Reductions in food intake, perhaps due to painful sores in the mouth, fatigue, psychological factors or loss of income.
- Nutrient malabsorption due to HIV itself, gut infections or diarrhoea.
- Metabolic alterations caused by HIV or other infections, leading to increased energy expenditure.
As already mentioned, weight loss and malnutrition can worsen disease progression. In addition, people are less likely to benefit from antiretroviral treatment if they are malnourished. It is therefore important that people receive the help they require to maintain a healthy diet. Emergency food provision may be appropriate for those in direst need.
Palliative care
Home-based care in rural Eastern Cape
Palliative care can be defined to encompass everything that improves the quality of life of patients and their families. This definition includes many of the interventions described separately in this page, as well as various other forms of symptom control and supportive care.
In many cases palliative care can be provided at home or in the community, rather than in a health facility. For example, family members or community caregivers may help a person to cope with common symptoms such as pain, diarrhoea, nausea and fatigue. Examples of supportive care include counselling, spiritual support, legal assistance, and addressing the essential needs of family members, such as school fees.
Antiretroviral therapy
Antiretroviral therapy is the only effective way to control HIV infection. This treatment reduces the amount of virus in the body to very low levels, allowing the immune system to recover its strength. Current guidelines recommend starting antiretroviral therapy at a relatively advanced stage of disease, usually several years after becoming infected.
HIV is highly adept at developing resistance to medications. To prevent this happening, it is essential that the drugs be taken every day in the correct way, and that patients undergo regular monitoring. If resistance does emerge then the drug combination must usually be changed.
Most people who take antiretroviral treatment experience side effects. In some cases these can be severe, and in rare instances they can be life threatening. Doctors must watch for symptoms of side effects and provide help where needed. Many side effects are treatable or can be stopped by switching drugs.
Antiretroviral therapy has transformed HIV infection in rich countries from a death sentence to a chronic illness that people may live with for decades. But in many parts of the world access to antiretroviral treatment remains scarce, mainly because of inadequate resources. Almost all developing countries have only a small range of available drugs, so there are few options for those who must change treatment because of resistance or side effects. Even in rich countries, some people eventually run out of new drugs to switch to, so there is a continuing need for research and development, as well as for expanding access to existing medications.
Complementary, alternative and traditional medicine
Complementary and alternative medicine consists of all medical and health care systems, practices, and products that are not presently considered to be part of conventional Western medicine. Complementary and alternative medicine – including treatments such as herbal supplements, acupuncture and homeopathy – is highly popular among people living with HIV. In rich countries the level of use has changed little since the introduction of antiretroviral therapy, but there has been a shift away from trying to combat HIV or other infections, and towards targeting drug side effects.
Yet although some complementary treatments may be helpful for treating minor ailments, others are likely to do more harm than good. Adverse effects may be due to toxicity, injury or interactions with other medications. Doctors need to be aware of all forms of treatment their patients are receiving.
For people in resource poor countries, traditional treatments for HIV/AIDS can be attractive as they are easily accessible and culturally acceptable. Close collaboration between traditional healers and Western doctors can improve safety and encourage referral to clinics when necessary.
End of life stage
End of life care becomes necessary when antiretroviral treatment is unavailable, is refused, or is no longer working because of drug resistance.
End of life care
End of life care aims to provide comfort and support for people who are terminally ill and, ultimately, to allow them to die with dignity. This can involve controlling pain, treating symptoms such as diarrhoea and vomiting, relieving psychological or spiritual anguish, and supporting families and caregivers.
It is estimated that at least half of all people with HIV will suffer from severe pain in the course of their disease, and so might require strong painkillers such as morphine. It is recommended that health workers should not withhold pain relief because they worry that a patient will become addicted to the drugs. Pain medication should be reviewed frequently and increased when necessary, and pain should be controlled in a way that keeps the patient as alert and active as possible.
In many resource-poor countries, the health infrastructure is inadequate to provide hospital care for everyone approaching the end of life. Even when hospital care is available this may not be what is wanted. Training can enable family and community caregivers to provide medications and other forms of home-based care, with health workers making occasional home visits as required.
Preparing for death
It is often believed that it is inappropriate to talk about the fact that somebody is going to die, and that mentioning death will in some way hasten it. However, for those who wish to discuss death, open discussion, ideally from early diagnosis, can help dying people to feel that their concerns are heard, that their wishes are followed, and that they are not alone.
Most people want to know that they will be remembered. Encouraging friends and family to share stories or memories of the person's life makes the person feel loved and cared for. People who are nearing death are frequently afraid of dying in great pain. Health workers or caregivers should be able to reassure patients that pain relief will be administered up to the point of death.
Another great worry is what will happen to a patient's dependants after they die. Where possible, plans should be made for dependants and partners. Although it can be distressing to discuss these issues, making plans can reduce anxiety. Making a will can also prevent family conflict and ensure that partners and children are not left destitute. This is particularly important in cultures where “property grabbing” is common.
Support for surviving family and orphans
For family members, partners and friends, looking after someone with HIV can be very daunting. And the need to offer counselling to partners and families following the death of a family member or friend is often overlooked, particularly in resource poor countries.
Counselling can help a person to discuss their loss and to mourn appropriately. The family members may have unresolved fears about HIV infection for themselves, and can be helped to come to decisions about HIV testing. The process of grieving may last many months, and possibly even years. However, for some people a single counselling session may be sufficient to clarify their thoughts and feelings, and to reassure them that they are coping as best as they can under the circumstances. Other people may need several sessions, and some people never completely come to terms with a loss, particularly that of a child.
The impact of loss of life differs across families and communities, but one thing is clear: a child's life often falls apart when she or he loses a parent. More than 15 million children under 18 have lost one or both parents to AIDS. Helping these children requires action at all levels. In the countries hardest hit by HIV/AIDS, care for orphans often lies with their extended families or communities, who without support may struggle to cope.
