The Human immunodeficiency virus (HIV) is an RNA retro virus existing in two forms: HIV - 1 which is the commonest cause of infections, while HIV - 2 is confined to certain parts of West Africa. HIV infection is transmitted through:
• Sexual contact
• Inoculation with infected blood/blood products
• Use of contaminated needles
• Vertical transmission from mother to child.
Infection with HIV - 1 results in a progressive destruction of the CD4 lymphocytes, and the rate of CD4 T - cell decline, determines the rate of immunodeficiency and subsequent development of HIV related opportunistic infections. The destruction of T - cell is due mainly to active viral replication.
Using the average time taken for development of acquired immunodeficiency syndrome (AIDS) following HIV infection, people can be broadly categorized as follows:
• "Average developer" who develop AIDS within approximately 10 years.
• The "rapid developers" (approximately 20% of all cases) who develop AIDS within 5 years following infection.
• The "slow developers" (approximately 5% of all cases) who remain asymptomatic for over 10 years without a significant decline in CD4 T cell count.
There is now sufficient evidence that triple combination antiretroviral therapy reduce viral load plasma level to undetectable levels. HIV related symptoms may disappear, the incidence of opportunistic infections is reduced and quality of life improves as illustrated in the following two graphs:
NATURAL HISTORY OF UNTREATED HIV- 1 INFECTION
Mortality in patients with CD4<100 and use of antiretroviral (ARV) therapy including a protease inhibitor among those patients, USA 1994-1997
Source: Palella et al., New England Journal of Medicene 1998 Mar 26; 338-60
The majority of people infected with HIV in the developing world have no access to the antiretroviral treatment. Access to antiretroviral treatment must be seen from a more comprehensive outlook of total continuation of care of HIV/AIDS patients. The Kenyan Health worker has an obligation to provide care, which should be continuous starting from hospital to the community. There should be active participation of doctors, volunteers, nurses, patients and their relatives. Educational programmes for physicians and general practitioners committed to HIV/AIDS care aim at avoiding unnecessary or inadequate therapeutic prescriptions.
The guidelines provide information on antiretroviral therapy including when to start treatment, what drugs to initiate, when to change therapy and therapeutic options to consider when changing therapy.
Laboratory monitoring including HIV, RNA, CID4T cell counts and clinical assessment on early diagnosis, choice of combination for antiretroviral management of acute HIV/AIDS, HIV/AIDS infected pregnant women and children, post exposure prophylaxis and structured interrupted treatments are indicated. It is meant to serve as a guide to antiretroviral treatment and we anticipate that these guidelines will trigger development of innovative approaches to better management of patients with HIV/ AIDS in Kenya.