HIV TESTING

1. Voluntary HIV Counseling and Testing

VCT is initiated by a client seeking to learn his/her HIV status Testing in the VCT is often thought of as "social" testing The test is requested by the individual, The test results are used by the individual for personal life decision making

2. Routine HIV Testing

Is provided as part of a standard screening package e.g. (PMCT) services. No medical decision regarding when to order a test is required The test is provided to all patients, except those who specifically decline the test

3. Provider Initiated HIV Testing/diagnostic testing and counseling

Is requested by the health worker Part of diagnostic work-up for patients who present with HIV related symptoms. When these signs or symptoms are present, diagnostic HIV testing should be performed routinely as a basic standard of care. Note: It is unacceptable for health care workers to test patients for HIV without their knowledge or without communicating test results to the patient.

4. Required HIV Testing

Is performed without specific consent in certain restricted settings, Testing may be ordered by a court of law. In all cases, those tested shall be informed of the test and have access to the results

5. Blood and Tissue Donations

Testing for HIV and other transfusion or tissue transmissible infections. Donors should be given general information about the testing and have access to their test results

6. HIV testing for Medical Research and Surveillance

Is performed under specific guidelines and regulations approved by appropriate scientific and ethical review boards for these activities

HIV TESTING STRATEGIES/MODALITIES A. OPT IN SYSTEM OF TESTING

Indivividual opt in/decides to undertake a HIV test.
Like in VCT

B. OPT-OUT SYSTEM OF TESTING

Individuals are tested for HIV routinely unless one categorically refuses the test. E.g in:
PMTCT- Prevention of Mother To Child Transmission DTC- Diagnostic Testing and Counseling PITC- Provider Initiated Testing and Counseling

HCT: Home Counseling and Testing

Indications for HIV testing

There should be no missed opportunities for HIV testing Some clinical indications:
Persistent diarhoea Severe and persistent respiratory infections or TB Oral and vaginal thrush General lymph node enlargement Herpes Zoster, current and recurrent Sexually tranmitted infetion Weight loss, more than 10% in one month

COMPREHENSIVE CARE CONCEPT

Components of comprehensive care

Physical care Psychological/emotional care Social care Spiritual care

Physical Care
Medical and nursing care:
Treatment and prophylaxis of illnesses and symptoms: opportunistic infections, STIs, TB etc Lab indicators of progression of disease ARVs prescription and dispensing Palliative and home based care

Physiotherapy strengthening muscles and bone after illness and weight loss Nutritional advice Occupational therapy to re-teach activities of daily living; teach new skills for income generation

Psychological/emotional care cont.

Spiritual Care
Care which relates to the spirit or soul of a person and facilitates its expression Spiritual means that within a person that relates to, or reaches out to, God, to the Creator, or to something or someone greater It also relates to values such as love, beauty, joy, honesty, integrity, absolute standards of right and wrong, forgiveness

Antiretroviral Therapy

Antiretroviral Drugs (ARVs)

Basic Descriptions ARVs act on the HIV by interfering with its viral life cycle:
1. Viral growth

2. Viral replication

Classes of Antiretrovirals
1.Reverse transcriptase (RT) inhibitors
Nucleoside RT inhibitors (NsRTIs) Non-nucleoside RT inhibitors (NNRTIs) Nucleotide RT inhibitors (NtRTIs)

2.Protease inhibitors (PIs) 3. Fusion inhibitors 4. Integrase inhibitors Not currently available in the market 5. CCR5 inhibitors

Reverse Transcriptase Inhibitors

Prevent copying of viral RNA to DNA Block all subsequent steps in viral replication Nucleoside/nucleotide analogs compete with natural substrate Non-nucleoside inhibitors bind at different site and change activity

Protease Inhibitors
Most HIV proteins made as polyproteins that must be cleaved to form mature product Inhibiting protease prevents maturation of virus/viral proteins Most protease inhibitors mimic peptide bonds and compete with natural substrate

Fusion Inhibitors
Prevent fusion of viral envelope with cell membrane Prevent entry of viral RNA and proteins into cell

Classification of ARVS
A. Reverse transcriptase inhibitors
(i) Nucleoside reverse transcriptase inhibitors (NsRTIs)
Abacavir (ABC) Didanosine (ddI) Emtricitabine (FTC) (3TC) Stavudine (d4T) Zidovudine (AZT, ZDV) Nucleotide reverse transcriptase inhibitors (NtRTIs) Tenofovir (TFV)

(ii) Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

Efavirenz (EFV) Nevirapine (NVP)

Classification of ARVS cont

B. Protease inhibitors (PIs)
Amprenavir (APV) Atazanavir (ATZ) Fosamprenavir (fos-APV) Indinavir (IDV) Lopinavir with ritonavir (LPV/r) Nelfinavir (NFV) Ritonavir (RTV, r) Saquinavir (SQV)

Classification of ARVS cont

C. Fusion inhibitors
Enfuvirtide (T-20)

D: Integrase inhibitors
Raltegravir

E: CCR5 inhibitors
Maraviroc

HAART
Highly Active Anti-Retroviral Therapy (HAART) A combination of three very potent agents: Two nucleoside analogs and one non-nucleoside Two nucleoside analogs and one protease inhibitor One nucleoside, one non-nucleoside, and one protease inhibitor Three nucleosides (including Abacavir) inferior to o ther combinations

Goals of ART
1. Reduce the amount of HIV viruses in the body 2. Support- Restore the immune system 3. Reduce HIV-related illness and deaths 4. Improve the Quality of life 5. Reduce general risk of transmission in the public

Suppression of viral replication

For Maximal and durable suppression of viral replication ARVs must be taken in combination of at least 3 drugs (HAART) Strict adherence to treatment is of the utmost importance <95% adherence allows the rapid development of viral resistance Poor adherers do badly - fail treatment much

Restoration and/or preservation of immune function

CD4 cell count can recover Improved function of CD4 cells There is improved overall function of the immune system since CD4 cells are central to the immune system It takes from 6 to 8 weeks for this to become evident clinically

Reduced HIV related morbidity and mortality

ART prevents CD4 destruction by HIV Decreased hospitalizations Decreased risk of illnesses Increased general well-being Reversal of weight loss Ability to return to work This result in Improved quality of life for the client

When to Start ART in Adults and Adolescents

WHO stage IV disease, irrespective of the CD4 cell count WHO stage III disease if CD4 <350/ mm3 Patients with WHO stage II with Total Lymphocyte Count (TLC) < 1200/mm3 WHO stage I or II HIV disease if CD4 count <200/ mm3 All patients with WHO stages III and IV disease if CD4 count is not available

Pregnancy and ART

ART greatly decreases vertical transmission of HIV from the mother to the child In general, it is best to defer initiation of ART to after the first trimester-after organs have developed in the fetus ART also allows mother to remain well to care for her child

Adherence to ART
Cornerstone of therapy ARVs are unforgiving to poor adherence We say Adherence instead of Compliance, since we involve the patient in the process If patient cannot adhere, HIV may become resistant to ARVs, and he/she can infect others with the resistant virus

How to Promote Adherence

CounsellingVery vital Participation of the patient in a plan of care. Dont rush to ARV, patient must be ready! Information/Education/Communication on ARV drugs:
Provide simple written information Educate and motivate: basic drug info, importance of adherence, timing of medications, drug interactions, etc Warn patients about common side effects

NUTRITION AND HIV/AIDS

Malnutrition and HIV: A vicious cycle Malnutrition and HIV negatively affect each other. HIV infection may result in poor nutrition as a result of insufficient dietary intake, malabsorption, and altered metabolism. This cycle has the following results: Weight loss, the most common and often disturbing symptom of HIV, reported in 95 percent to 100 percent of all patients with advanced disease Loss of muscle tissue and body fat Vitamin and mineral deficiencies Reduced immune function and competence Increased susceptibility to secondary infections Increased nutritional needs because of reduced food intake and increased loss of nutrients leading to rapid HIV disease progression

 Synergistic effects of malnutrition and HIV

Malnutrition and HIV affect the body in similar ways. Both conditions affect the capacity of the immune system to fight infection and keep the body healthy. Before AIDS, the impairment of immune function caused by malnutrition was called nutritionally acquired immune deficiency syndrome, or NAIDS. the following changes in the immune function resulting from malnutrition are similar to those caused by HIV and AIDS: CD4 T-lymphocyte number CD8 T-lymphocyte number Delayed cutaneous hypersensitivity CD4/CD8 ratio Serologic response after immunizations Bacteria killing

 Effects of HIV/AIDS on nutrition HIV affects nutrition in three sometimes overlapping ways: It is associated with symptoms that cause a reduction in the amount of food consumed It interferes with the digestion and absorption of nutrients consumed It changes metabolism, or the way the body transports, uses, stores, and excretes many of the nutrients

 Decreased food consumption HIV/AIDS is associated with conditions that result in reduced food intake. Decreased food consumption may result from the following factors: Inability to eat or swallow because of painful sores in the mouth and throat Loss of appetite as a result of fatigue, depression, and other changes in the mental state Side effects of medications, including nausea, loss of appetite, a metallic taste in the mouth, diarrhea, vomiting, and abdominal cramps Reduced quantity and quality of food in the household as a result of the inability to work or reduced income because of HIV-related illness

 Nutrient and food absorption

HIV infection also interferes with the bodys ability to absorb nutrients, an effect that occurs with many infections. Poor absorption of fats and carbohydrates can occur at any stage of HIV infection in both adults and children and results in excess nutrient loss. Poor absorption is caused by the following: HIV infection of the intestinal cells, which may damage the gut, even in people with no other symptoms of infection

Increased incidence of opportunistic infections such as diarrhea, which is a common cause of weight loss in people living with HIV Poor absorption of fat reduces the absorption and use of fat-soluble vitamins such as vitamins A and E. This can further compromise nutrition and immune status.

 Changes in metabolism Changes in metabolism in HIV-infected people occur as a result of the immune systems response to HIV infection. When the body mounts its acute phase response to infection, it releases pro-oxidant cytokines and other oxygen-reactive species. These cytokines produce several results, including anorexia (causing lower intake of food) and fever (increasing energy requirements).

 If the infection is prolonged, muscle wasting occurs because muscle tissue is broken down to provide the amino acids with the immune protein and enzymes they need. These processes increase energy requirements of people living with HIV/AIDS during the asymptomatic phase by 10 percent over the level of energy intake recommendedfor healthy, non-HIV-infected people of the same age, sex, and physical activity level. They increase energy requirements during the symptomatic phase by 20 percent-30 percent over the level of energy intake recommended for healthy, non-HIV-infected people of the same age, sex, and physical activity level (Seumo-Fosso and Cogill 2003).

 The body also responds to this release of prooxidant cytokines by increasing the demand for antioxidant vitamins and minerals, such as vitamins E and C, betacarotene,zinc, and selenium. These vitamins and minerals are used to form antioxidant enzymes.

Role of nutrition in HIV disease progression

HIV affects nutrition by decreasing food consumption, impairing nutrient absorption, and causing changes in metabolism, HIV associated wasting. Nutritional status also affects HIV disease progression and mortality.

Improving and maintaining good nutrition may prolong health and delay HIV disease progression. The impact begins early in the course of HIV infection,even before other symptoms are observed. Counseling and other interventions to prevent or reverse weight loss are likely to have the greatest impact early in the course of HIV infection.
Nutritional supplements, particularly antioxidant vitamins and minerals, may improve immune function and other HIV-related outcomes, especially in nutritionally vulnerable populations.

HOME BASED CARE

CONCEPTS AND PRINCIPLES OF HOME BASED CARE

OBJECTIVES: - Concept of HBC - Components of HBC - Rationale for HBC - Objectives and principles of HBC - Objectives of a HBC programme - Advantages of HBC - Key players of HBC

CONCEPT OF HBC
Home based care is care provided in the home with the support of the client, family, community and community volunteers, with support supervision and monitoring provided by trained health workers who work within government and non - government care facilities.(Mild May international;WHO 1994;NASCOP 2002)

Cont.
In HBC, the care is extended from the hospital or health facility where the patient is initially seen to their homes. This therefore implies that these patients require certain services which form the components of HBC.

COMPONENTS OF HBC
Clinical care Nursing care Counseling and psycho spiritual care Social support

KEY PLAYERS AND COMPONENTS OF HBC

NGO

Hospital/RHC

Volunteers

Other Govt. sectors: Agriculture Social services Education Etc

Patient support centre Hospice

Church

Trained CBO/CHW Family carer

Support groups

1) Clinical care
Comprises early diagnosis, rational and targeted treatment and planning for the care of persons suffering from chronic or terminal debilitating illnesses.

Objectives of clinical care include:

Ensuring early detection, treatment of opportunistic infections and other complications that occur as a result of HIV/AIDS and cancer Reducing the suffering from conditions associated with the HIV/AIDS infection, cancer, diabetes, hypertension and other chronic illness

Cont.
Protecting the client against further infections especially during a long hospital stay Preventing transmission of HIV or other opportunistic infections from PLWHAs to health workers, relatives and friends Ensuring that drugs prescribed to client by clinician are administered at home according to the regimen of intake

2) Nursing care
Clients for HBC need nursing care to promote and maintain good health, hygiene and nutrition. Nursing is the art of assisting individuals to do those things that they would do on their own if they had the strength, knowledge or will, or to a peaceful death.

Nursing care comprises

Care for the clients environment Activities to ensure good personal hygiene Preventing the transmission of microbes Physical therapy Pain management Administering drugs as per prescription to ensure adherence

Cont.
Maintaining the nutritional status of the client Taking the PLWHA/client to the health facility when need arises Observing clients to detect problems like dehydration, dyspnoea, dysphagia, oedema or fever Reassuring the client at all times

3) Counseling and psycho spiritual care

Counseling and psycho spiritual care reduces stress and anxiety for both the clients and their families. It also helps the client to make informed decisions on say HIV testing, plan for the future, make behavioural changes, and involve sexual partner(s) in such decisions

Types of counseling in the concept of HBC:

Pre and post test HIV counseling (VCT/DTC/DCT) Behaviour change counseling Group counseling/therapy Family counseling Supportive counseling Crisis counseling Spiritual/pastoral counseling Death and bereavement counseling

4) Social support
Palliative care clients on discharge require to be linked to a network of social and support services that they can benefit from. These include: - Support groups like youth groups, church organization - Welfare services (social workers, childrens department)

Cont.
- Legal advice - Material assistance These services compliment the care given in health facilities. When clients are provided with services that meet their needs, this helps them to: Meet material/psychological needs Provide a sense of belonging

Cont.
Reduce anxiety Improve on relationships Ensure a high quality of care

RATIONALE FOR HBC

The concept of HBC has been adopted because: Health institutions have many limitations such as shortage of health workers, few hospital beds and a shortage of other resources People with chronic illnesses need continuity of care to prolong their lives and reduce their suffering

Cont.
People with debilitating illnesses are discharged from health institutions where there trained professionals and sent to home to be care for by untrained relatives with no professional backup or support The care givers at home are often women with no training in nursing or how to protect themselves from risks related to infections and injuries as a result of the care they give

ADVANTAGES OF HBC
Advantages to patient/client: Patient is cared for in familiar environment hence suffers less stress/anxiety and illness is more tolerable When people are cared for in their homes, they continue to participate in family matters

Cont.
When patient is at their home, they experience greater sense of belonging When one is in close contact with familiar people they are likely to accept their condition thus quicker recovery

Advantages to the family:

Care given at home less expensive than in hospital Care at home prevents separation and holds family members together Education of families on disease conditions helps them understand these disease better and accept the patients

Advantages to the community:

Costs of visiting a sick person in hospital are reduced Community cohesiveness is maintained, thus ensuring community is able to respond to other members needs Training on HBC helps community to be aware of various illnesses affecting their own and are hence able to counteract harmful myths and beliefs and therefore actively participate in prevention efforts

Advantages to the health care system:

Services that could otherwise be inaccessible to communities in remote hardship areas can be realized through HBC training HBC reduces pressure on hospital services and hence the health care system

KEY PLAYERS IN HBC

The patient/client Family members and care givers Home care team Health workers Community government

KEY PLAYERS AND COMPONENTS OF HBC

NGO

Hospital/RHC

Volunteers

Other Govt. sectors: Agriculture Social services Education Etc

Patient support centre Hospice

Church

Trained CBO/CHW Family carer

Support groups

REFERRAL AND NETWORKING FOR HOME BASED CARE

In a community set up, it is not possible to do it all alone. Hence the need for referral and networking to ensure continuity of quality care for the client at all times.

A home based care referral network

Health facility

Legal services and aid Home care team

Spiritual/counseling support

Communication with family Patient/client

Care for orphans/ widows/widowers

Referral is an effective and efficient two way process of linking a client from one caring service to another. A network is a group of individuals or organizations that work together, undertake joint activities, or exchange information in order to strengthen and extend their individual capacities.

NETWORKING AND REFERRALS

Hosp.

Church

VCT/DCT

NGO

H/centre clinic

CBO

Advantages of Networking:
Reduces duplication of work Promotes unity, harmony and understanding among the groups or individuals Provides a learning experience: people and groups can learn from each other Reduces the isolation of individuals or groups working alone and provides a forum for consultation Promotes peer support Can assist individuals an groups to address complex problems by involving others

In HBC, several networks exist. There are networks for individuals working with PLWHAs, cancer patients, and so on.

Why refer patients/clients?

For better, more competent management in the next stage of referral When services or resources within reach are not able to meet the clients immediate needs In cases where the acute phase of the disease has been dealt with and it is considered safe to transfer care to other caring services/organizations within the community

 When the care giver experiences burnout and has no access to counseling services for personal growth
When the caregiver has limitations in meeting certain needs of the client e.g based on religious beliefs

 For continuity of care from the health facility downwards or from family level back to the health facility
For specialized care in hospital setting, especially if the clients condition is deteriorating

LIMITATIONS IN REFERRAL AND NETWORKING

lack of referral and networking guidelines as well as standardized referral procedures Competition among various organizations, hence they do not disclose what they are doing and which services they offer. They prefer working in isolation Lack of resources needed for clients to travel from one point to another

 Lack of evenly distributed community HBC programmes, with the result that some areas lack services and some are overcrowded Ignorance among family members about HBC due to lack of awareness and proper guidance Fear of breach of confidentiality Poor mobilisation and sensitization of partners

 Stigma and discrimination associated with HIV/AIDS, which makes PLWHAs reluctant to accept referral to certain facilities Culture, social, religious and economic factors Lack of confidence in the institution/service where referral is made Lack of updated and proper directory of referral and networking Lack of knowledge by people referring on how and when to refer or network

What steps can a health worker take to address above limitations?

Holding collaborative meetings among various referral and networking partners Giving correct/proper information on referral to the PLWHA and a proper client history to the referral point Ensuring confidentiality Lobbying and advocating for the rights of the client

HIV Preventive strategies

 Primary HIV preventive strategies = efforts towards ensuring no new infections of HIV(infection not yet occurred)
Secondary = efforts towards managing HIV positive persons starting to deveop HIV/AIDS(infection has occurred)

Primary prevention Activities [strategies]

Behaviour change communication. Advocacy and lobbying for societal change and reduction of denial Condom promotion and Availability. Sexually Transmitted Infection management. Voluntary Counselling and Testing. Prevention of mother to Child Transmission. Blood Safety. Stigma Reduction. Harm Reduction for Injecting drug users.

Secondary Prevention
This includes the management of the HIV positive person starting to develop HIV/AIDS. This is a holistic approach that involves physical, social, psychological and spiritual interventions. The provision of sexually transmitted diseases care. The provision of Anti-Retro viral medications. Reducing fertility. This alludes to encouraging women who have the infection not to have children. Health promotion strategies must be pursued aggressively