Care and support for people living with HIV/AIDS

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Care and support for people living with HIV/AIDSBetter prospects for preventing infections in those with HIVGiven the limited diagnostic facilities available in developing countries and the highcosts of many drugs for treating opportunistic infections, let alone antiretrovirals, theoption of prevention is receiving renewed attention. The bulk of evidence now suggeststhat a few relatively inexpensive drugs could help ward off severe illness andadd months, if not years, to the lives of HIV-positive people in even the poorestdeveloping countries. Indeed, preventive drugs had begun to prolong survival in thehigh-income countries even before antiretroviral therapy was available.One drug is isoniazid, which has been shown to be effective in warding off 60% ofactive tuberculosis episodes in people with HIV. In at least one study, isoniazid preventionprolonged life significantly for those who were infected with both HIV and thebacillus that causes tuberculosis. A simple regimen costs on average just a fewcents a day for both the medicine and the health services involved.Tuberculosis prophylaxis is especially important because in half the cases HIVinfectedindividuals develop a form of TB which cannot be easily diagnosed andwhich thus goes untreated. Diagnosing disseminated tuberculosis requires sophisticatedlaboratory equipment that is largely unavailable in many of the poorer developingcountries. This is why UNAIDS and WHO have recommended since 1998 thata simple and inexpensive regimen for preventing tuberculosis should be part of theessential care package for people with HIV (see Table 1, page 98).New developments point the way to preventing other severe infections.Cotrimoxazole – a pill combining an antibiotic and a sulfa drug which has helpedprevent Pneumocystis carinii pneumonia, the biggest AIDS-related killer in highincomecountries – was tested for its preventive impact in Côte d’Ivoire. In one studyin Abidjan, where the drug costs of a 12-month regimen were just US$ 17.50, cotrimoxazoleprophylaxis resulted in significantly fewer severe infections (as measuredby hospital admissions). In another study, cotrimoxazole warded off infections sosuccessfully that it extended life by half a year. The drug combination appeared tobe effective in preventing some bacterial pneumonias, diarrhoeal diseases andinfections of the blood, and possibly toxoplasmosis (a parasitic brain disease) andisosporiasis (a parasitic infection of the intestines).In the light of these hopeful findings it is urgent to implement cotrimoxazole regimensin sub-Saharan Africa as part of the essential care package for adults and childrenliving with HIV (see Box 20). At the same time, scientists will need to keep carefulwatch so that the value of this drug combination is not undermined by the developmentof resistance to it.105
Report on the global HIV/AIDS epidemic – June 2000Box 20. Use of cotrimoxazole prophylaxis in people with HIV/AIDS inAfricaIn March 2000, UNAIDS and WHO brought together clinicians, public health specialists,national AIDS programme managers, people living with HIV/AIDS, donorsand AIDS activists to discuss the use of cotrimoxazole as preventive therapy for HIVpositiveindividuals in Africa. The outcome of this consultative workshop in Harare,Zimbabwe, was that cotrimoxazole prophylaxis for people who have already developedsymptoms of HIV infection should be part of the essential care and supportpackage. The participants recommended dosages, defined criteria for patient eligibility,and issued recommendations for training, education and capacity developmentin countries.The UNAIDS Secretariat is working with WHO to ensure rapid implementation ofthese recommendations through resource mobilization efforts. By July 2000, throughconsultative meetings with national governments, 14 African countries participatingin the US Government’s LIFE Initiative will have considered making cotrimoxazoleprophylaxis part of their care package.A new incentive for testing?Experience from around the world shows that seeking counselling and HIV testing isnot an easy step to take. In the high-income countries, the hope of benefiting fromearly treatment created a major incentive for people to find out whether they wereinfected. As therapies improved – even before the advent of antiretrovirals – peoplewho suspected they might have HIV saw that they stood to gain months or years oflife by getting tested.Isoniazid and cotrimoxazole prophylaxis – which can only be offered to people withproven HIV infection, in contrast to some other forms of health care described in thischapter – may similarly increase people’s interest and willingness to be tested forHIV. If these preventive regimens are made more widely available along with HIVcounselling and testing services, the survival benefits for individuals and their familiesare likely to be compounded by the benefits of large-scale testing, includingreduced HIV transmission to partners and to infants, and greater visibility of theinsidious HIV epidemic.106
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