Communicable Diseases Module: 29. Positive Living and Prevention of HIV Transmission for PLHIV

29.2  PLHIV and prevention of HIV transmission

In Study Session 25, you learnt about preventative measures that individuals — whether they know their HIV status or not — may take into consideration in order to reduce risks of HIV infection via the sexual route, and by direct contact with objects contaminated with infected blood. In this section, we are going to discuss specific issues that relate to sexual transmission of HIV, and to a lesser extent transmission by contact with infected blood, in the context of HIV treatment, care and support provided to PLHIV.

Patients who are on antiretroviral therapy (ART) should be informed that HIV transmission to other people is still possible, even if treatment has been effective and they are informed by health workers that they have undetectable levels of HIV in their blood. Very low levels of HIV can still be present in the blood and/or sexual fluids of PLHIV undergoing ART, and these may be sufficient for the virus to infect another person.

29.2.1  Re-infection with HIV

Another subject that PLHIV should consider is re-infection, which refers to the situation in which a person already living with HIV is infected with a new strain of HIV from another PLHIV. Re-infection can accelerate progression to AIDS in two ways. First, re-infection can increase the viral load (i.e. the levels of HIV in the blood) of a person living with HIV, as it may take some time for either the patient’s immune system (whose function is already impaired), or antiretroviral (ARV) drugs to be effective against the new type of virus. This will result in further damage to the immune system, making the person with a re-infection more vulnerable to opportunistic infections.

Secondly, a PLHIV may be re-infected with another type of HIV that is already resistant to the ARV drugs they are taking, which may ultimately lead to treatment failure. The consequence of ART failure of first-line drugs is replacement with second-line ARV drugs, which may be less effective in controlling HIV infection (Study Session 23). Thus, it is always advisable for PLHIV not only to minimise risks of HIV transmission to other people, but also to avoid re-infection by HIV from another person.

29.2.2  Strategies to minimise HIV transmission

Having established that PLHIV can still transmit the virus to uninfected individuals or to other PLHIV, we shall now discuss ways that PLHIV can minimise the risks of HIV transmission via the sexual route.

Engaging the sexual partners of PLHIV

When providing information to PLHIV about general and specific issues on prevention of HIV transmission via the sexual route, it is also important to engage their partner(s) in the discussion, whether they know their HIV status or not. This is important so that all partners involved play an active role in the prevention of HIV transmission (or re-infection). However, you should discuss with PLHIV the benefits (e.g. good adherence to ART) and/or problems of disclosing their status to their partners before they decide to do so.

• Biruk and Hiwot are a young married couple in your community. Biruk is HIV-positive, so for the duration of their marriage they have engaged in safer sex practises to reduce the risk of HIV transmission to Hiwot (who has remained HIV-negative). They now want to have a baby. What issues would you discuss with them?

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• You should make sure that they understand that unprotected penetrative sex will greatly increase the risk of HIV infection for Hiwot. This may have consequences for the health of Hiwot and for the health of the child, should she become pregnant. If they are still intent on having a baby, refer them to the nearest health centre for further care and support.

Finally, you should also advise PLHIV (and their partner(s) and close family) on issues related to HIV transmission via contact with blood-contaminated objects. PLHIV and their close family should be particularly attentive to sharing common objects that may have been contaminated with blood. These include utensils such as needles, razor blades and toothbrushes (Figure 29.1).

It is also important to emphasise that PLHIV should never give blood for transfusion, as this could result in HIV transmission to other patients that receive their blood or blood-related products.

Figure 29.1 Each member of a household with a person living with HIV should have their own easily-identifiable toothbrush to avoid exposure to contaminated blood. (Photo: Basiro Davey)

29.3  PLHIV should be informed about their health

Figure 29.2  Clear information about HIV/AIDS and positive living is vital for PLHIV.

Informing the PLHIV in your care about their health status builds up their confidence, thereby encouraging their active involvement in improving their own health. At each visit, you should inform patients about how they are progressing health-wise, and provide them with health information materials that are available from your health post to build their ability to manage their own health issues. When working with patients, you should ask them if they have any questions about HIV/AIDS and/or their specific health issues in a relaxed and non-confrontational manner. It is advisable to encourage PLHIV to attend their visits accompanied by members of their family or treatment supporters, especially if this helps them express any concerns they may have about their health status (Figure 29.2).

You should encourage your patients to learn, to the best of their abilities, about HIV infection, AIDS and related health problems. Understanding more about HIV may lessen a patient’s fear of HIV, and help them identify and maintain strategies to stay healthy. Knowing more about HIV may also help your patients remember to take their medications correctly and at the prescribed times, hence promoting good adherence to ART.

29.4  PLHIV should take medication as prescribed

In Study Session 23, you learnt about the importance of adherence to ART for PLHIV. Remember that 100% adherence is the goal for patients who are on ART so that HIV replication is suppressed (Figure 29.3).

Figure 29.3  Strict adherence to drug regimens is essential for PLHIV. (Photo: Basiro Davey)

Therefore, educating patients about essential points of good adherence to treatment at regular visits is essential to promote health for PLHIV, and to strengthen positive living. For example, you should make sure that HIV-positive patients understand that HIV has no cure, that HIV infection is at present a lifelong condition, but also that medications can help a patient live a healthier and longer life.

Adherence is not restricted to ARV drugs, and should include medication (such as cotrimoxazole) for prevention of opportunistic infections. The message given to patients should be concise and clear. Here is an example:

In addition, medications may be available to help manage some side-effects of ART, such as pain, vomiting and diarrhoea. Although strict adherence to these treatments is not as critical for the long-term health of PLHIV as it is for adherence to ART and opportunistic infection prophylaxis, all medications should be taken in the proper doses and on time for them to be effective in improving a patient’s health.

Lifestyle and unprescribed medications may influence the outcome of ART. Many herbal/traditional medications can interact with ARV or prophylactic drugs and render them less effective. Thus, patients should not take any medication without first consulting their respective health worker. Alcohol, cigarettes, and chewing ‘khat’ may also interfere with ART or prophylactic medication, and these should be avoided. In addition, these lifestyle choices will have a negative effect on the overall health (in particular, the function of the immune system) of the patient, who will then become more susceptible to opportunistic infections.

29.5  PLHIV should work as their energy allows, and avoid stress

Being able to work, either full- or part-time, and/or being involved in daily routines are important assets for maintaining a positive attitude and a healthy lifestyle. When discussing positive living practises with PLHIV, you should emphasise that work provides income, stability, satisfaction, friendships and fulfilment to many people, and may therefore promote their psychological and physical wellbeing. You should encourage your patients to continue working for as long as they are able to reasonably manage their workloads. In the event of episodes of ill health, it may be quite difficult to continue regular work, and PLHIV should determine whether they are fit enough for work. However, they should keep in mind that returning to work after illness may help improve their quality of life.

Avoiding stress and dealing with worries in a positive manner is also important for PLHIV to maintain their health. Specific strategies on how to deal with stress, anxiety and depression are discussed in detail in the Module on Non-Communicable Diseases, Emergency Care and Mental Health. For example, they may need to find positive ways to deal with stress such as talking with friends or family members, and avoid negative ways of dealing with stress such as abusing alcohol, chewing khat or taking other recreational drugs. It is important to emphasise that alcohol or chewing khat may make them forget their problems for a short while, but may lead them to be involved in risky behaviours such as unsafe sex.

29.6  PLHIV should maintain good nutrition

Maintaining a good nutritional status is essential for improving the quality of health of people presenting with any disease, including HIV and AIDS, as sick people have more nutritional needs than healthy ones. HIV infection by itself, in particular at the late stages of the disease, and/or the presence of opportunistic infections, have been associated with poor nutritional status and extreme weight loss. Poor nutrition in PLHIV may lead to further impairment in the function of an already damaged immune system and favour an increased incidence of opportunistic infections.

Other contributing factors to weight loss are the presence of diarrhoea and vomiting (common in patients with AIDS), which impair nutrient absorption through the gut, and loss of appetite, sometimes related to difficulties in eating. In addition, nausea and vomiting are common side-effects of ARV drugs, and may also play a role in the poor nutritional status observed in many PLHIV. You should advise PLHIV in your community to adhere to the following recommendations if they feel nauseated or they lose their appetite — eat small frequent meals, eat bland foods (e.g. porridge), do not eat oily or spicy foods, and take ARV drugs with or soon after meals.

Also remember that the nutritional requirement of people who are sick is greater than that of healthy people. This is because additional energy is needed to compensate for the increased energy needs of the body due to illness. PLHIV who are also coping with opportunistic or other infections will need to eat more nutritious food in order to help their immune system fight the infectious agents.

PLHIV, in particular those diagnosed with AIDS, should eat a well-balanced diet consisting of regular meals (even when they do not feel hungry). Meals should include protein, fat, carbohydrates and vitamins in the recommended proportions, as described in the Nutrition Module, and illustrated in Figure 29.4. In addition, a well-balanced diet involves drinking plenty of clean water, up to two litres per day. You should discuss with patients about how to incorporate a well-balanced diet into their life routines, and about factors such as lifestyle and economic status that may negatively affect it. If needed, suggest they ask for help when preparing meals and cooking. You may also need to refer patients to food support services at your nearest health centre.

Figure 29.4  A well-balanced diet should include a variety of foods. This is particularly important for vegetarian diets such as the one shown. (Photo: Tom Heller)

29.7  PLHIV should avoid getting infections

As you already know, since HIV affects the function of the immune system, a person with HIV is more susceptible to opportunistic infections. People with HIV should take effective actions to prevent communicable diseases which may have important consequences for their health. Here, we will briefly discuss some preventative measures to reduce the risks of some common infections, but you should refer to the more detailed discussion of prevention in other study sessions in this Communicable Diseases Module when giving advice to PLHIV.

To prevent the occurrence of faeco-oral diseases, caused by transmission of infectious agents from the faeces to the mouth (usually on the hands or in food and water), your advice should include instructions on clean preparation of food and water before consumption. For example, vegetables and fruits should be washed with clean water. Drinking water should be cleaned by boiling it vigorously for a few seconds, then cooling it. Advise your patients to eat only well-cooked food. For example, cooked meat should be brown and have no traces of blood in it, and soups should always be boiled before being eaten.

Another very important hygienic measure used to prevent faeco-oral diseases includes frequently washing hands with soap, in particular after using the toilet and before preparing food or eating.

Prevention of sexual transmission of HIV (Section 29.2) and sexually transmitted infections (STIs) (Study Session 31) should be actively encouraged. Remember that PLHIV can still transmit HIV if they are involved in unsafe sexual practises, even if they are on ART.

If your community is in a malaria-endemic area, you should educate PLHIV to use bed nets regularly at night, to prevent being bitten by mosquitoes (Study Session 9). This is because PLHIV are particularly susceptible to malaria.

Finally, common hygienic measures to reduce the risk of infections from minor injuries or wounds include thorough cleaning and wound care. You should actively encourage PLHIV to attend the nearest health post or health centre as soon as possible in the event of a minor injury or wound.

29.8  PLHIV should get regular exercise and rest

Exercise is a good and low-cost way of maintaining the health of your clients. You should encourage PLHIV to practice regular exercise and to find time for adequate rest to improve and maintain their health. Regular exercise includes any sort of activities that fits into the daily routine life of your clients. These activities may range from moderate exercise (being more active around the house), to active team sports or jogging. There are many ways in which PLHIV may improve their regular exercise routine, such as walking to and from work; walking to the church or the mosque; and indoor regular exercise routines (for example, work-outs early in the morning before bathing). The benefits of regular exercise include increased energy levels, increased appetite and decreased nausea, which will also help your patients to maintain a good nutritional status. Exercise also helps to maintain muscle tone, which may be beneficial to prevent weight loss.

In the same way you advised your patients to continue working as long as they are able to reasonably manage it, PLHIV should not exert themselves by regular exercise to the extent that it becomes detrimental to their health. You should advise your patients to take sufficient rest and sleep between exercise routines. In the event of episodes of ill health, PLHIV should determine whether they feel fit enough to continue regular exercise. However, they should keep in mind that returning to regular exercise routines after illness may help improve their quality of life.

29.9  PLHIV should seek regular medical care

PLHIV should be given information about when and how to seek medical care. These situations may include their regular scheduled visits at the health centre or hospital, or new appointments at your health post or at the clinic when they feel ill.

Attending regular scheduled visits at the health centre or hospital helps PLHIV to monitor their health status. For example, all patients on ART will be assigned a clinic appointment schedule. This schedule will include regular follow-ups and medication refills at the health centre and hospital, regardless of whether the patient feels healthy or not. Patients should be encouraged to strictly adhere to all appointments at the health centre and hospital. A way you can help them is by reminding them when their next appointment is scheduled.

Patients should attend a clinic promptly and regularly during episodes of ill health. Early treatment of infections can prevent further illnesses and slow down progression to AIDS. During your regular visits or appointments, you should ask PLHIV to describe any new symptoms they may have experienced since your last visit, and encourage them to get prompt treatment for any health problems that cannot be managed at home or at your health post. If this is the case, refer them to the health centre without delay.

Summary of Study Session 29

In Study Session 29, you have learned that:

1. Positive living is a lifestyle choice for PLHIV that includes preventing the spread of HIV, being informed about their health, taking medication as prescribed, working as their energy allows, avoiding stress, maintaining good nutrition, preventing infections, getting regular exercise, and seeking regular medical care.
2. It is essential that PLHIV put measures into place to reduce the risks of sexual HIV transmission, even if they are on ART. These may include abstinence, maintaining faithful relationships, and/or safer sex practises.
3. Complete adherence to all HIV treatment, care and support is critical to maintaining the health of PLHIV.
4. Giving clear information about HIV/AIDS and positive living to PLHIV helps their active participation in managing their own health, and seeking advice in episodes of ill health.
5. PLHIV need to eat more food than normal to help their immune system to fight infections.
6. Personal hygiene is particularly important for PLHIV to avoid infections, and they should keep minor wounds clean.
7. Regular exercise is recommended for PLHIV, as long as their energy allows. They also need plenty of rest.

Self-Assessment Questions (SAQs) for Study Session 29

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the notes on the Self-Assessment Questions at the end of this Module.

SAQ 29.3 (tests Learning Outcome 29.4)