Be proactive by taking your medication and trusing your healthcare provider, writes Dr Tendani Matoro.
AFTER the HIV test results, another long journey begins. The preparations for starting treatment are not as daunting as deciding to get tested. The process does however require commitment from the patient and ongoing support from family/friends. Luckily, healthcare providers will form part of this small circle of trust.
First Line Regimen
Supporting tests will depend on the choice of medication to be used for life-long treatment of HIV. For the first line regimen, kidney tests should be done to establish a baseline before starting treatment. One specific drug/medication (Tenofovir) is known to affect kidney functioning as a complication is some patients. If one has pre-existing kidney problems, an alternative drug can be given. Mental health review is mandatory before using Efavirenz as this drug can worsen specific untreated mental health problems.
Second Line Regimen
Second line medications are preceded by blood haemoglobin or cholesterol tests depending on which drug is being used. Haemoglobin can be affected by a drug called Zidovudine (AZT). Blood cholesterol or lipids can be increased with using Lopinavir and Ritonavir combination (Alluvia).
All patients, irrespective of treatment regimen, should be screened for TB. The complex dynamic interaction between HIV and TB can potentially complicate. Starting HIV medication without excluding underlying TB will “unmask” the full extent of the TB illness.
The process can also occur with other infections relying on HIV to weaken the immune system (opportunistic infections). The immune system is responsible for the apparent “unmasking” of undiagnosed TB or worsening of previously controlled TB infection.
A CD4 cells count measures specify cells of our immune system’s white blood cells that are both targeted by HIV infection and responsible for orchestrating the molecular fight against the virus. Every patient should have a CD4 count done as a baseline.
In the past, a CD4 count would determine one’s eligibility for ARVs (Anti-Retroviral Treatment). Thanks to the South African National Department of Health’s UTT (Universal Test and Treat) policy, all HIV positive patients, regardless of CD4 count, can be put on ARVs.
CD4 Count and Opportunistic Infections
The CD4 count currently assists with clinical management and identifying potential opportunistic infections at a specify CD4 count value. The lower one’s CD4, the more prone they are to uncommon bacterial, fungal, viral or parasitic infections. Specific cancer types also thrive with lower CD4 counts.
Acquired Immunodeficiency Syndrome (AIDS) typically occurs with a CD4 count below 200. One can have a CD4 less 200 without full blown AIDS symptoms.
AIDS is a both a clinical and laboratory diagnosis. Patients with AIDS will clinically show manifestations of severe wasting (extremely thin), several infections, brain’s higher functioning dysfunction in some patients and many other disseminated conditions. Before the era of ARVs, AIDS was an inevitable death sentence. Early ARV initiation at higher CD4 counts hopes to ultimately eliminate AIDS.
CD4 Count < 100
At a CD4 count less than 100, the Department of Health with the National Health Laboratory Services (NHLS) have allowed mass testing of patients’ blood for an opportunistic infection notorious for causing meningitis.
Cryptococcosis is caused by a fungus usually seen in people with a weakened immunes system. Dissemination of this fungus can lead to a cryptococcal meningitis which can present with headache and/or confusion amongst other symptoms.
In the National Department of Health HIV guidelines, there has been a slight change will collecting viral load at the time of one’s HIV diagnosis. This test indicating the HIV circulating in the blood, is now done at different times for adults, children and pregnant women. The idea however is that over 6 months, one’s viral load from drop significantly from the time treatment was started. Ideally, the viral load should be undetectable at 6 months. This test is currently used to test treatment efficacy and indirectly check adherence to treatment. Not taking one’s treatment well is the biggest reason for a persistently high viral load. Other factors are known to affect suppression of the virus in the blood. These include-
- Problems with absorption of ARVs
- Other opportunistic infections
- Not taking the correct dosage of ARVs
- Getting re-infected by another HIV positive person (not using condoms)
Taking other prescription, over the counter, herbal or traditional medicines that compete with ARVs in the liver for breakdown (metabolism).
On Every Visit
Ask about the common side effects that you might get from your ARVs. Knowing about these ensures that you are prepared should any problems arise. Report any new changes to your body and symptoms to the healthcare provider on every visit. Minor things like colour changes in your hands or eyes could mean something. If you had any problems prior to starting treatment, monitor such and ask your healthcare provider to assist with them. This is also a good opportunity to learn new things about your medication and illness. Do not hesitate to ask questions. This is also the best time to clear any myths or beliefs that were said by your friends or family at home about your illness or treatment. It is advisable to receive life-changing information and instructions from a trained professional than any other person.
Always inform your healthcare provider if you have any symptoms that might point towards TB. TB still remains common even in people who are taking treatment. HIV negative people also get TB. If any family member or house mate has TB, inform the healthcare provider. If TB is excluded, expect to receive a pill that prevents and reduces your chances of getting TB. This pill (Isoniazid/ INH) will be given for a period of time based on other medical factors.
If you are sexually active, you will be asked about condom usage and sexually transmitted infections. Your healthcare provider will also enquire about your partner and family. If you are still struggling with disclosure (about your illness and/or treatment) to your loved ones and would like to protect them as well, ask your healthcare provider for assistance.
Remember to inform your healthcare provider of any other illnesses that you are taking treatment for. This will help with treatment selection and future clinical monitoring. If you plan on using any other treatment for health benefits, ask your healthcare provider to check its compatibility with your ARVs. Disclose any allergies that you may have to medication or food as well.
Try and learn the names of your ARVs. This is a very helpful practice. Note any problems that you may have had with ARVs that your healthcare provider might have stopped you from taking. Some side effects may need you to avoid a specific pill. Your healthcare provider can give you more information on that.
There are still other investigations we have not discussed. There are also ARVs not mentioned in the article. Care for pregnant mothers and children is also not discussed above.
Visit a trained healthcare provider to discuss your HIV treatment plan and management.
Dr Tendani Matoro is a Medical Doctor (MBChB, UCT), General Practitioner (Polokwane), Clinical Advisor (Advanced Clinical Care HIV/AIDS and TB), Social Commentator (News24 and WordPress Blog) and Medical Columnist (Weekly Publications in African Times Newspaper)