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Details on the overview of HIV infection and AIDS can be accessed from the United States of America National Institutes of Health (NIH) https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/19/45/hiv-aids--the-basics and the World Health Organization (WHO) https://www.who.int/news-room/fact-sheets/detail/hiv-aids.
Details on the pathophysiology of HIV infection can be obtained from https://www.pagepress.org/journals/index.php/idr/article/view/idr.2013.s1.e6/pdf
Global and Kenyan epidemiological parameters on HIV infections can be accessed from UNAIDS (https://aidsinfo.unaids.org/), the WHO Country profiles interactive website (https://cfs.hivci.org/), the National AIDS and STI Control Programme (NASCOP) (https://www.nascop.or.ke/online-resources/), and the National AIDS Control Council (NACC) https://nacc.or.ke/2018-hiv-estimates/.
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History:The following questions provide a useful guide on what to ask a patient during the initial and subsequent clinic visits in case the HIV status is unknown to decide whether to test (Table 1).
Physical findings:
Any individual presenting to clinic should be subjected to a thorough physical examination by the clinician, taking into account various features within the body systems that will aid in guiding management of the HIV infection, as well as any co-infections and co-morbidities (Table 2).
This will depend on the organ involved during disease progression, particularly with onset of various OIs:
Dermatological system: Pruritic papular eruptions (PPE), seborrheic dermatitis, herpes simplex, and herpes zoster.
Respiratory system: Pneumocystis jirovecii pneumonia (PCP), pulmonary TB, bacterial pneumonia, and invasive aspergillosis.
Cardiovascular system: HIV-associated cardiomyopathy, tuberculous pericarditis, and coronary heart disease.
Lymphadenopathy: Persistent glandular lymphadenopathy (PGL), tuberculous lymphadenitis, and Hodgkin’s lymphoma.
Antibody testing is the most widely used screening test in many countries, particularly in low and middle-income countries (https://www.who.int/publications-detail/consolidated-guidelines-on-hiv-testing-services-for-a-changing-epidemic)1. However, in the majority of the high-income countries, initial testing is undertaken with a fourth generation antigen/antibody assay since they detect more acute HIV-1 infections whilst maintaining high degrees of diagnostic accuracy for established infections.
In addition, over the last decade, home HIV testing has been embraced, with the approval of the OraQuick In-Home HIV Test by the Food and Drug Administration (FDA) in 20122, and is currently available in Kenya. This strategy aimed to ensure more individuals who are unaware of their HIV status and would not otherwise receive HIV testing get access to testing services. However, individuals should be informed that a positive result requires immediate confirmation with a different test that is administered by a healthcare provider.
Use of antiretroviral therapy (ART) is currently the mainstay of management of PLHIV. This is achieved through a number of ART drug classes (Table 3) which are combined to form effective combination ART (cART) strategies (Table 4).
Various agencies have different treatment guidelines regarding the preferred and alterative regimens to be used by PLHIV in their jurisdictions (table 5)3, 4, 5, 6. However, the overarching theme across all guidelines is the preference for integrase strand inhibitor (INSTI)-based therapy as the preferred regimen.
Prevention:
Over the last two years, enormous interventions have been studied, a number of them proving to have overwhelming efficacy in the prevention of HIV transmission and acquisition:
The effectiveness of ART as a prevention tool is undisputed from both a public health and individual health perspective. This has been clearly demonstrated from findings generated in the HPTN 052 and PARTNER studies that have shown reduced infection transmissions from infected partners to their sexual partners7, 8. In addition, the “test and treat strategy” initiated by the WHO have contributed to a significant increase in the number of people on ART, hence further reducing the risk of HIV transmissions9.
Pre-exposure prophylaxis (PrEP) is an intervention where a daily course of antiretroviral mediccations aimed at protecting HIV-negative people from HIV before potential exposure is administered. Various studies have demonstrated its effectiveness in reducing HIV infection to near zero when adhered to exactly as prescribed
Studies have shown that, when PrEP is adhered to exactly as prescribed, it reduces the chances of HIV infection to near zero10. However, if not taken consistently, PrEP tends to be less effective thus increasing the risk of HIV infection substantially. In addition, PrEP does not offer protection against other sexually transmitted and blood-borne infections such as hepatitis C, syphilis, or gonorrhoea. The risk of acquisition of both HIV and other STIs can be minimized through proper application of barrier methods, the most common being condoms. For people who inject drugs (PWID), non-sharing of needles and using clean needles each episode will prevent infection from both HIV and other bloodborne illnesses, such as viral hepatitis.
Post-exposure prophylaxis (PEP) is short-term course of antiretroviral treatment taken after possible exposure to HIV.
It has been used by healthcare workers towards the end of the 20th century to date who may have been exposed to HIV-infected fluids11. Adhering to PEP for the prescribed amount of time is crucial for it to be effective (from within 72 hours of exposure and taken daily for 28 days), though this can be difficult as evidenced from a study among healthcare workers in Ghana which showed an adherence ratio of 77%. The main reason for non-adherence was side effects, thus underlining the importance of providing support to help people understand and manage side effects12.
Conclusion
HIV has over the decades being transformed from a death sentence to a life-long disease which is almost similar to the other chronic diseases. With significant investments and research in this field, there are long-acting injectable formulations and contraceptive-like depo formulations in development, hence the continued optimism of a low incidence and stabilized global prevalence as the years go by.
