In previous study sessions, you have learnt about the basic biology of HIV and opportunistic infections associated with AIDS. You have also learnt about the treatment used by people living with HIV (PLHIV) to prevent and/or slow down progression to AIDS. Remember that patients infected with HIV need to follow their treatment correctly and strictly in order to maintain a healthy life. In this study session we will be discussing positive living, which means a lifestyle for PLHIV that is aimed at maintaining their quality of life for as long as possible. To encourage a positive living lifestyle, PLHIV should actively sustain the following practises: be informed about health issues; take medications as prescribed; work as their energy allows; avoid stress; maintain good nutrition; prevent infections; practise regular exercise; and seek regular medical care. Most importantly, positive living for PLHIV also involves playing an active role in preventing the spread of HIV, and you should stress the importance of safer sex practises in this context.
After studying this session, you will be able to advise PLHIV in your community to adopt a ‘positive living’ lifestyle and to make them aware of the fact that, even if they are on antiretroviral therapy (ART), they can still transmit the virus. In this way, you will also be able to provide information to patients who have misconceptions about HIV, its transmission and treatment. In addition, you may consider referring patients to the nearest health centre if you determine that they should receive additional clinical services and psychosocial support. In brief, by helping PLHIV to adopt positive living practises, you will be able to encourage them to live a healthy and good quality life.
When you have studied this session, you should be able to:
29.1 Define and use correctly all of the key words printed in bold. (SAQ 29.1)
29.2 Explain that people taking antiretroviral therapy can still transmit HIV, and can still be re-infected with another strain of HIV. (SAQs 29.1 and 29.2)
29.3 Explain how you would advise PLHIV on positive living and good nutrition. (SAQ 29.1)
29.4 Explain how you would advise PLHIV about the importance of seeking regular medical care at the health centre or hospital. (SAQ 29.3)
Positive living is a lifestyle adopted by an HIV-infected person in order to live life as fully as possible while slowing progression to AIDS. Adopting positive living practises improves the quality of life of PLHIV remarkably. Important aspects of positive living for PLHIV include making positive choices to care for one’s mental and physical health, having a positive outlook on life, and avoiding risky behaviours.
In this context, risky behaviours refer to situations in which there is an increased risk of transmission of HIV and/or other infections such as STIs for the patient or for their partners (e.g. unsafe penetrative sex).
Your role as a Health Extension Practitioner consists in promoting positive living practises for PLHIV in the community. In doing so, you will maintain the continuity of care patients receive from the health centres and hospitals at the level of their own community. Your role in supporting PLHIV to practise positive living includes the following key tasks:
The points listed in Box 29.1 should form the basis of your discussions with PLHIV to promote the adoption of positive living practises. In the following sections we will be discussing these specific issues in more detail.
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.
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.
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.
What are the most widely known strategies for prevention of HIV transmission through the sexual route?
These are known as the ‘ABC Rules’. ‘A’ stands for ‘Abstinence’, which means refraining from premarital sexual intercourse; ‘B’ stands for ‘Be faithful’, which means maintaining faithful relationships with a long-term partner; and ‘C’ stands for ‘proper use of Condoms’, which means correct and consistent use of condoms in sexual relations (Study Session 25).
Abstinence is certainly a choice for PLHIV with the aim to eliminate the risks of transmitting HIV to uninfected people or other PLHIV. However, it is still possible for PLHIV to engage in a rich and satisfying, active sex life, and we will discuss this topic in the context of the ‘B’ (maintaining faithful relationships) and ‘C’ (safer sex practises) rules.
In general, maintaining faithful relationships is an effective measure for individuals to reduce the risk of HIV infection. Remember the linear relationship between HIV transmission and the number of sexual partners that is; the higher the number of partners, the higher the risk of HIV transmission (Study Session 25). This particularly applies to PLHIV — the more partners they have, the more likely it is that they transmit the virus to other people and/or that they become re-infected.
However, for the ‘B’ rule to be effective, both partners need to be confirmed as HIV negative. It is not sufficient to maintain a faithful relationship in order to prevent HIV transmission where PLHIV are concerned, whether their partner(s) are HIV negative (as it would lead to HIV infection of a previously uninfected person) or HIV positive (as it would lead to re-infection of a person living with HIV).
In this context, it is critical that you stress the importance of consistent and correct safer sex practises to PLHIV (whether they have opted for faithful relationships or for multiple sex partners).
What are the safer sex alternatives to unprotected penetrative sex?
Non-penetrative sex practices, or penetrative sex with a condom (Study Session 25).
Thus, to reduce the risk of HIV transmission or re-infection, sexually active PLHIV should be advised to ALWAYS engage with a partner using either non-penetrative sex practises, or penetrative sex practices with a correctly used condom. If condoms are correctly used they can prevent the transmission of HIV by more than 98% (the remaining 2% reflects incorrect use of condoms). Refer to Study Session 25 for information on the correct use of condoms. In this context, safer sexual practises are also beneficial in the prevention of other sexually transmitted infections (STIs), a topic that will be further discussed in Study Session 31.
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?
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.
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.
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).
What are the consequences of poor adherence for the health of a person living with HIV?
Poor adherence may lead to drug resistance, increased viral load, decreased levels of CD4 lymphocytes, higher incidence of opportunistic infections and faster progression to AIDS, and increased possibility of sickness and death.
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:
‘You may feel well now but, if you want to stay healthy, you should take all your medications regularly and consistently.’
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.
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.
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.
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.
Can you give any examples of common infectious diseases that PLHIV may contract due to improper handling of food and unclean water?
You may have thought of giardiasis, amoebiasis and diarrhoeal diseases caused by bacteria or viruses.
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.
You will learn about specific faeco-oral diseases in Study Sessions 32 to 34 of this Module.
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.
What are the main preventative measures to reduce the risk of STIs and HIV re-infection?
Abstaining from sex, being faithful to a long-term partner, and adopting safer sex practices, such as the use of condoms.
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.
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.
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.
In Study Session 29, you have learned that:
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.
Which of the following statements in relation to positive living and PLHIV are false? In each case explain what is incorrect.
A A Person living with HIV who is on ART cannot transmit HIV to other people.
B The correct use of condoms prevents the transmission of HIV by about 50%.
C The nutritional needs of PLHIV who have an opportunistic infection are higher than that of uninfected people.
D Hand washing with soap and water is important to prevent faeco-oral diseases.
A is false: Even if patients are taking ART they can transmit HIV to other people if they engage in unprotected penetrative sex. This is because ARV drugs do not eliminate HIV from the body; they suppress viral replication.
B is false: If condoms are correctly used, they can prevent the transmission of HIV by more than 98%. The remaining 2% transmission usually results from incorrect use of condoms by the user.
C is true: The nutritional requirement of sick people is higher than that of healthy people. This is because additional energy is needed to compensate for the increased metabolic needs due to illness.
D is true: Handwashing with soap and water is very important in preventing faeco-oral diseases.
In your community a couple who are both HIV-positive come to your health post asking for advice on their sexual life. Both consider they should not be using condoms as they are already HIV-positive. What will your advice to them be?
Even when both partners are HIV-positive, they have to practise safer sex alternatives such as the consistent and correct use of condoms. If they are involved in unsafe sex, re-infection may occur and different strains of HIV will be passed from one person to the other. This will result in the replication of new viruses that may have different sensitivity to the drugs currently taken by the patient.
A 30-year old man comes to the health post. He tells you he was diagnosed HIV-positive six months earlier. He says he is not feeling well these days. He barely sleeps at night and sometimes thinks he will be dying very soon. He feels so anxious that he has stopped working. What will you advise him?
In the early periods after being diagnosed as HIV-positive, patients may have different psychological reactions. In this case, the patient might be suffering from mental illness associated with the life-changing news of being HIV-positive. You should encourage him to take a more positive mental attitude, and reassure him about the effectiveness of ART. Refer him to the health centre for further psychological and/or psychiatric evaluation and management. You also need to encourage him to come to your health post or to the health centre for any issues related to his health and/or psychological and physical wellbeing.