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When you have completed this unit you should be able to:
It is important that attention is paid to the following:
In summary, develop a healthy, positive lifestyle. This is a very important part of managing a person with HIV infection. Each person with HIV infection needs a wellness programme.
A healthy lifestyle is very important for people who are HIV positive.
This is an active programme to encourage HIV-infected people to remain physically and emotionally well for as long as possible. A wellness programme promotes a healthy lifestyle. Both regular follow-up by an HIV clinic and support from the community are important. The media (radio, TV, newspapers, magazines, books) also have a role to play in promoting wellness.
The most important step in helping people with HIV infection is to enable them to learn about and understand their disease. They need to feel that they are still in control of their own lives and can play an active role in managing their illness. They must be empowered to make the best decisions for themselves. A good understanding of HIV infection and AIDS helps to reduce their anxiety and develop confidence and hope.
Knowledge and understanding is power.
It is essential that HIV-positive people practise safer sex.
The only way of totally preventing the sexual transmission of HIV is to avoid sex. However, the risk of HIV infection can be greatly reduced by changing sexual practices (safer sex). Condoms must be used every time the person has sex. Avoid multiple partners. Anal sex is particularly dangerous. Although oral sex is safer, it is still a recognised way of transmitting HIV.
The ‘ABC’ of safer sex is Abstinence (no sex), Be faithful (one partner only) and Condoms (always use a condom).
Condoms are only partially effective as contraception. Therefore some other form of contraception must be used as well. Progesterone injections (e.g. Petogen three-monthly or Nur-Isterate two-monthly) are best as some medication taken by HIV-infected people may interfere with oral contraceptives (the pill).
Any HIV-infected woman planning to fall pregnant should get advice from an HIV clinic.
Having a good diet, adequate rest and keeping fit with moderate exercise help to maintain the normal function of the immune system. It is important that people in the latent phase look after their health and wellbeing. This will prolong the period of asymptomatic HIV infection.
Because marked weight loss and poor nutrition are associated with a rapid progress to AIDS. Malnutrition weakens the immune system.
Weight loss in HIV-infected people may be due to:
Unintentional weight loss is often an early sign of symptomatic HIV infection. It is important to maintain normal body weight for as long as possible.
A balanced diet is important to provide sufficient amounts of carbohydrates, fats and protein. A diet containing an adequate supply of vitamins and trace elements may be supplemented with a daily multivitamin pill. A good calorie and protein intake helps to prevent weight loss.
First the person’s present diet and pattern of eating should be reviewed. Then the person can be advised on local, affordable foods which would improve the diet. Small frequent meals are best. Alcohol intake should be reduced or stopped and smoking discouraged. The nutritional value of meals can be improved by:
A good diet need not be expensive and helps to improve and maintain the immune system.
It is very important for all HIV-infected people to understand that every effort must be made to prolong the latent phase and delay the onset of symptomatic HIV infection. Antiretroviral treatment is only recommended when HIV becomes symptomatic or when the patients CD4 is less than 500 cells/mm³.
Many of the symptoms of AIDS can be relieved and HIV-associated infections can be treated. However, antiretroviral treatment is the only effective management of AIDS and offers the only hope of prolonging a good quality of life.
Many plants have an effect on the immune system. Some are believed to be helpful while others have been shown to depress the immune system. However, only very limited clinical trials have been conducted, with mixed results. It is hoped to identify herbal compounds which may strengthen the immune system and delay the onset of AIDS. Plant and other non-medical (alternative) substances can have serious side effects. They may also interfere with antiretroviral treatment.
Most of the morbidity and mortality in HIV-infected patients are due to HIV-associated infections. Primary prophylaxis is the use of specific antibiotics to prevent some of these infections. Therefore primary prophylaxis is an important part of healthcare during the asymptomatic phase of HIV infection.
Co-trimoxazole and INH are the most important drugs used for primary prophylaxis.
Most adults will have received the routine schedule of childhood immunisations. Some additional immunisations may be helpful in well people with HIV infection:
The influenza immunisation is not effective in people with a CD4 below 200. Unfortunately these immunisations are expensive and are not always available from state clinics.
The risk of severe malaria is increased in people infected with HIV. Therefore malaria is a major cause of death in HIV-infected people in some countries. If possible, they should avoid entering known malaria areas. Avoid mosquito bites by using insecticide-impregnated bed nets and insect repellents. Stay indoors from late afternoon to midmorning and wear long sleeves and trousers as well as shoes.
Prophylactic drugs are recommended. Co-trimoxazole helps reduce the risk of malaria. Treat immediately if symptoms of malaria develop within a few weeks of entering a malaria area.
HIV-positive patients should bring their sexual partners, husband or wife, and children to the clinic for HIV counselling and testing (HCT). Screening all high-risk groups of people for HIV infection is important in limiting the spread of infection. Ideally everyone should be screened.
If the HIV epidemic is to be controlled and patients with HIV infection adequately managed, the community will have to become actively involved in all aspects of prevention, support and care. This is difficult where poverty, gender inequality, stigma and discrimination are common and HIV-infected people see themselves as helpless victims.
Local communities must take ownership of their joint problem and not simply rely on government providing the services. Fear, denial, stigma and discrimination will have to be overcome before a communal sense of responsibility can be developed and people believe they can contribute positively to solving the problem and make a difference.
Communities must become actively involved in addressing the enormous problem of HIV infection and AIDS.
Prevention and management of HIV infection must be seen as parts of the same integrated community programme. One will not be effective without the other.
The community has a very important part to play in the prevention and management of HIV infection.
Everyone in the community has a part to play. Without a community partnership, health services will have only a limited impact in preventing HIV infection and managing people with HIV infection.
One of the best ways of supporting someone with HIV infection is for them to join a group of people who also have HIV. Here they can share experiences in a safe, non-judgemental environment. Group meetings can be used to provide education, understanding and hope and result in an improved quality of life.
These are members of the community who want to help people who are living with HIV. Home nursing is the greatest need. Patients need to be fed, cleaned, comforted and cared for. Help with simple chores such as cooking, cleaning, shopping and collecting water and firewood make a big difference.
Provision of knowledge, skills and support for lay health volunteers is essential. Volunteer health workers are the most realistic way of providing home-based care. They also play an important role in reducing stigma and discrimination in the community.
Stigma is the negative thoughts and feelings that people have. It is a form of discrimination and has an important negative effect on people with HIV infection and their families. Unfortunately stigma is common and causes great personal suffering. It remains one of the most difficult obstacles in tackling the HIV epidemic.
Stigma is a negative, damaging attitude towards people who are HIV positive.
People with HIV who are stigmatised feel lonely, helpless and afraid. They are made to feel bad, despised, embarrassed and shameful and may hate themselves. They often feel that they are no longer respected and have brought disgrace on themselves, their family and their community because they are HIV positive. Due to stigma and discrimination, people with HIV are often avoided, feel socially isolated, and stop seeing friends and family. They may be thrown out of their homes, sacked from their jobs, abandoned by friends and even assaulted or killed.
Owing to the effects of stigma and fear of discrimination, many people refuse to be tested for HIV or deny their HIV status. This often leads to a fear of disclosure, delay in treatment and failure of preventing the spread of HIV. Some people choose to die of AIDS rather than disclose their HIV status and seek treatment. In many societies the words ‘HIV’ and ‘AIDS’ are not even used. People deny there is anyone with AIDS in their community despite the fact that everyone knows that many people are dying of HIV.
Stigma results in fear, denial and failure to prevent the spread of HIV.
Owing to the fear of stigma, the HIV status of pregnant women is sometimes not recorded on the antenatal cards, while that of their infants is not recorded on their Road-to-Health cards. This can prevent essential communication between healthcare workers.
Usually ignorance and fear. The stigma towards HIV infection is usually due to the stigma surrounding sex and sexual activity. Stigma to sex is the real problem. In many societies, sex is seen as shameful and not spoken about or even acknowledged. Sex and the use of condoms are ‘taboo’ subjects. Negative attitudes towards sex are often promoted by the male head of the family, traditional leaders and the church. Many believe that the immorality of young women is the cause of the HIV epidemic. It may even be viewed as a punishment to society for the sin of promiscuity.
Education, understanding, and critical and open discussion are the most effective ways of preventing and overcoming stigma. People need to learn appropriate emotional responses to sex and HIV infection. Support groups, where sexuality and HIV infection can be debated, are of great help and support.
Groups such as the Treatment Action Campaign and LoveLife have tried to make people aware of the damage that is being done by stigma to HIV. Life skills training at schools could reduce stigma to HIV by teaching healthy, open attitudes towards sexuality and the risk of sexually transmitted diseases. Government, church and community leaders, sports people and entertainers who are HIV positive need to disclose their status.
It is essential to create a social climate where people are not afraid of admitting they have HIV. Then they can openly practise safer sex and seek healthcare.
Counselling is a process of education, communication and support by which a counsellor helps people to cope with difficult situations in their lives so that they are able to make important decisions and find realistic ways to solve their problems. Counselling, therefore, helps people make their own choices and supports these decisions, rather than simply giving them advice and information or telling them what to do. Counselling is far more than simply educating and is best provided by a trained counsellor.
Counselling is about empowering people to make important decisions and to solve their own problems.
A counsellor is someone who is trained to educate, assist and give psychosocial support to people with problems. A good counsellor helps people to understand and accept their HIV status and to take the best course of action to lead a positive life.
Either a professional healthcare worker (nurse, social worker, doctor) or a lay person can be trained as a counsellor. Training large numbers of good lay counsellors is one of the major challenges facing those who care for people with HIV infection.
Both professional and lay people can be trained to be good counsellors.
Patients with HIV infection have many concerns about their future. Once they understand the nature of HIV infection and know that their immune system will become progressively damaged, they need to be able to speak about their worries and fears and obtain good information. They need good counselling.
Counselling is needed:
Two essential skills are needed for HIV counselling:
Communication in counselling is a two-way process in which information, knowledge, thoughts and ideas are passed between the person being counselled and the counsellor. The spoken word is the most important means of communication but the counsellor must be aware that people may also pass important messages by showing their emotions and in their body language (how they act). The counsellor must learn to pick up these signs as it helps in gathering information and giving appropriate understanding (empathy) and emotional support. Effective communication requires the skill of active listening.
Effective communication is a combination of active listening and using words with care and consideration.
Active listening is the process of hearing not only the words people say, but also noting their body language and emotional reactions, and trying to understand the meaning behind their words and actions. In order to understand what a person is saying and to respond appropriately, the counsellor must become skilled in actively listening to people.
Active listening is the key to effective counselling.
A good counsellor should:
‘If you do not listen to the person being counselled, do not expect them to listen to you.’
Good communication is blocked when the counsellor is judgemental, critical, threatening, manipulative, uninterested, or tries to control the discussion.
The CD4 count. CD4 cells are lymphocytes that play a very important role in the normal functioning of the immune system. HIV attaches to CD4 cells and kills them. As a result the number of CD4 cells gradually falls as the HIV infection progresses and more and more CD4 cells are killed. Therefore the CD4 count is the best measure of the degree that HIV has damaged the immune system.
The CD4 count measures the degree of damage done by HIV to the immune system.
The normal CD4 count in HIV-negative, healthy adults is 500 to 1500 cells/µl. As the CD4 count falls below 500 cells/µl the function of the immune system steadily becomes worse and the patient is at increased risk of many infections.
The normal CD4 count is above 500 cells/µl.
The lower the CD4 count, the greater the risk of symptomatic HIV infection and AIDS. Therefore, the CD4 count is the best predictor of the risk that an HIV-positive person will develop severe HIV-associated infections (i.e. AIDS).
The 2014 South African guidelines recommend that antiretroviral treatment should be offered when the CD4 count falls below 500 cells/µl. However, antiretroviral treatment should also be offered to all people with Stage 3 or 4 HIV diseases and all pregnant women, women who are breastfeeding and people with Hepatitis B or TB irrespective of their CD4 count.
The CD4 count also indicates how quickly a person will progress to symptomatic HIV disease.
In most HIV-infected people who are not on antiretroviral treatment, the CD4 count falls each year by approximately 25 to 50 cells/µl. This will result in the CD4 count falling from 600 to 200 in four to eight years. Most HIV-positive people will have symptoms and signs of HIV infection by the time the CD4 count has reached 200 cells/µl.
In some people the CD4 count falls particularly fast (rapid progressors) while in others it falls slower than usual (slow progressors).
The CD4 count is generally an accurate measurement. However, the CD4 count may vary, therefore the test should be repeated if the result is unexpected. Temporary falls may be due to an acute illness or recent vaccination.
In HIV-positive people who are well, the CD4 count should be measured every 6 months to assess the condition of the immune system. Antiretroviral treatment should be started when the CD4 count falls below 500 cells/µl. Regular monitoring of the CD4 count is an important part of the management of people with HIV infection.
The CD4 count is the best way of monitoring the progress of HIV infection.
There is no need to routinely measure the viral load in patients with HIV infection who are not yet on antiretroviral treatment. Regular measurements of viral load are used to monitor the response to antiretroviral treatment.
There is no need to routinely measure viral load in patients who are not on antiretroviral treatment.
Palliative care is the care of patients who have an incurable disease (such as HIV infection). It aims at reducing suffering and improving the quality of life in these patients. Palliative care starts at the time of the diagnosis and addresses all the patient’s physical, emotional, social and spiritual needs. Although HIV infection cannot be cured, most of the HIV-associated conditions can be prevented or adequately treated and controlled.
Palliative care addresses the physical, emotional, social and spiritual needs of people with an incurable disease.
In contrast, terminal care is the active care of patients whose disease no longer responds to treatment, e.g. antiretroviral drugs. Terminal care is not the same as no care or poor care. Patients who are dying of AIDS need terminal care. Care should never be withdrawn because there is no longer any hope for a cure.
Despite antiretroviral treatment some patients with advanced HIV will require terminal care. Terminal care is most needed in patients who are likely to die within months or weeks.
Home care is the basis of terminal care. If at all possible these patients should be cared for in their own home where they are comfortable in their own surrounding and with their family and friends. Only if this is impossible should they be given care in an institution, preferably in a hospice.
Terminal care should be provided at home if possible.
This is a place where terminally ill patients can be cared for. Management is aimed at compassionate care and support rather than cure. Members of a hospice team also help to care for patients who are at home.
As there are so many aspects to terminal care, it is best provided by a team of people who are trained in this special type of care. A multidisciplinary approach is needed to meet the many different physical, psychosocial and spiritual needs of terminally ill patients. Patients, family and friends also have a role in terminal care.
To improve the quality of care of patients, and their families, who are facing death. Terminal care offers prevention and relief of suffering. The goal of terminal care is not necessarily to prolong life, but to reduce suffering.
The goal of terminal care is to prevent and relieve suffering.
These patients are often wasted and very underweight. They may also have a poor appetite, nausea and difficulty swallowing. It may be difficult for them to obtain and prepare food.
High-calorie and protein foods are important. It is important that patients are able to choose foods which they prefer. If possible, intravenous fluids or nasogastric feeds should be avoided.
Yes, severe pain is very common in patients who are dying of AIDS. It is likely to be under-diagnosed and under-treated. Pain significantly reduces the quality of life and results in fear and despair. Pain also causes distress to the family.
Severe pain is a major problem in patients who are dying of AIDS.
The aim of pain management is to control pain by giving analgesia regularly so that pain can be prevented.
The aim of pain management is to prevent pain.
The choice of analgesics for an individual depends on their degree of pain. As pain increases one moves up the ‘treatment ladder’ from step 1 (non-opioids such as paracetamol and ibuprofen) to step 2 (weak opioids such as tramadol or codeine phosphate) to step 3 (strong opioids such as morphine).
If possible, it should be given orally. A dose must be given every four hours as the action of morphine is short. Give an extra dose equivalent to the four-hourly dose if the pain is not controlled. Giving extra doses for ‘breakthrough’ pain is very important. The starting dose of 5 to 10 mg should be increased by 50% every second day until the pain is controlled (the total dose over 24 hours should be divided by two to give the amount that the daily dose should be increased). There is no maximum dose. The correct dose is the dose which is effective. Therefore the dose of morphine should be titrated against the degree of pain.
Morphine can also be given by continuous subcutaneous infusion with a syringe driver, intramuscularly or intravenously.
Frequent doses of oral morphine are the most effective form of pain relief.
Addiction is not of concern when morphine is used to control pain in terminally ill patients. Do not stop morphine suddenly as this may result in withdrawal symptoms. Respiratory depression is uncommon when morphine is used to control pain.
A syndromic approach is used in terminal care when the symptoms are managed even if the underlying cause cannot be treated. Help from hospice staff is very useful in preventing and managing most of these problems.
Nausea is a common problem, especially when treatment with morphine is started. Metoclopramide (Maxolon) 10 mg orally eight-hourly is helpful.
Treating the symptoms caused by HIV-associated infections can greatly improve the quality of the last weeks of life. For example, treating painful mouth ulcers, or relieving painful swallowing by managing fungal oesophagitis, or preventing blindness due to CMV retinitis.
Relief of symptoms is often best achieved by treating HIV-associated infections.
Yes. Patients should never be allowed to feel abandoned by their health carers. Pain, discomfort and distress must always be aggressively managed. However, sometimes it may not be realistic to treat terminally ill patients if the treatment will only prolong their suffering.
The question that must always be asked is ‘will this make a difference to the quality of the person’s life?’
Anxiety, fear and depression are common in terminally ill patients and are often not recognised. It is important to manage anxiety and depression as they both aggravate pain.
Anxiety, fear and depression make pain worse.
Withdrawal, sadness, sleep disturbances, poor appetite, depressed mood, lack of energy and interest in the world around them, and suicidal thoughts. Depression is common and unfortunately often missed. Management consists of emotional support and antidepressants. Response to medication may take a few weeks.
This is a simple box that parents can store mementos in for their children. Photographs, letters and cards are kept in the box which is given to the children when they are older to help them remember a parent who has died of AIDS. A memory box is one of the many ways that a parent can prepare themselves before death separates them from their children.
Most people as they near the end of their lives need to speak to someone about their approaching death. The spiritual needs of members of a religious group usually are well attended to. However, many people who have not regarded themselves as religious also need spiritual counselling. It is important for the members of the health team to find someone suitable to meet this need.
Yes. This is often forgotten or not realised. Care of the carers is a very important part of terminal care. It is physically and emotionally exhausting to care for terminally ill patients. Practical help with lifting, turning, washing and feeding is needed, as well as emotional support.
A young woman with asymptomatic HIV infection is referred to a primary-care clinic where the staff have a special interest in managing HIV-positive people who are still well. She wants to learn how to live with her condition.
To help these people to remain well for as long as possible and teach them how to live a healthy lifestyle. They also need to prevent spreading HIV infection to others.
Take a balanced diet, get adequate rest and regular exercise. Avoid excessive alcohol, do not smoke or abuse drugs and develop a positive outlook on life.
She can join a wellness programme.
This is a group of people with HIV infection who can support each other and share experiences in a safe, non-judgemental environment. They can learn from one another how to live a healthy life.
Abstinence is the only way to be completely safe. However, being faithful to a single partner and using a condom are ways to greatly reduce the risk of getting or passing on an HIV infection.
Much can be done to remain well for many years after HIV infection. Minor problems can also be successfully managed. However, antiretroviral treatment is the only effective management when a patient develops AIDS.
A healthy man with asymptomatic HIV infection has been followed up at a local clinic for a number of years. At his last visit his CD4 count is 650 cells/µl.
Yes, as the normal range is 500 to 1500 cells/µl.
A patient with asymptomatic HIV infection should have a routine CD4 count measured every 6 months.
The rate of fall varies from one person to another. However, the CD4 count in most HIV-infected people falls by 25 to 50 cells/µl each year.
The viral load is not routinely measured unless the person is being managed on antiretroviral treatment.
Unexpected weight loss may be an early sign of symptomatic HIV infection or tuberculosis. Maintaining a normal body weight by taking a good, balanced diet helps to prolong the latent phase.
Multivitamin supplementation is good but there is little evidence that specific nutritional supplements help if the person is on a good diet, while herbal remedies can have serious side effects and drug interactions with the antiretroviral medication.
A depressed patient with AIDS is referred to a HIV counsellor. She has a good knowledge of HIV infections and is aware of the importance of her symptoms. She is on antiretroviral treatment but has been diagnosed with lymphoma and is not responding well to chemotherapy.
Counselling is a method which uses education, communication and support to help a person manage their lives better, make decisions and find realistic ways to handle their problems. Counselling is more than just education.
Yes. Many people from the community can be trained to become good counsellors.
They need to have a good knowledge of HIV infection and also be able to communicate well with people.
Active listening notices body language and emotional reactions as well as words to understand what a person is trying to say. Active listening is the key to effective counselling.
A depressed mood, sadness, lack of interest in the world around them, sleep disturbances and suicidal thoughts. Depressed patients should be referred for assessment and possible treatment with antidepressants.
Most definitely. Many of the symptoms of AIDS can be relieved and the quality of their lives improved during the last weeks and months. Patients should never be allowed to feel that they have been abandoned by the health carers.
A terminally ill man with AIDS is being cared for at home by his family. He has constant severe pain and the family is exhausted and can no longer manage.
It would be best if he could remain at home, but the family will need help. Failing this, it may be possible to move him to a hospice. Only as a last resort should he be admitted to hospital. Volunteer health workers could help with the many tasks needed in the home, such as cleaning and cooking. They can also help with washing and cleaning the patient.
Yes. Staff from the local hospice do home visits and are very experienced in the care of terminally ill patients.
Usually analgesics for mild pain (e.g. paracetamol) and moderate pain (e.g. tramadol or codeine) are tried first. However, this patient probably needs morphine for severe pain.
By mouth every four hours. The dose of morphine is increased until the pain is controlled. The aim is to prevent pain and not to give morphine only when the pain is severe.
Constipation. This can be controlled by adding fruit, bran and extra liquid to the diet. A laxative should also be given. Nausea and drowsiness may occur but they usually improve with time.
It is a box in which dying patients can put mementos, such as photographs, letters and cards, that can be given to their children when they are older. It enables terminally ill patients to leave something behind which will help their children remember them.