The continuous ingestion of drugs through a life time is challenging. They may simply deny their status if in stable state, or may be depressed, simply forget or traveled out. The patients need to be counseled before initiation of therapy; these should be followed by assessment of adherence and more counseling. They may need supporters to serve as reminders and to encourage them. Taking the drugs without failing ensures that the virus population is kept in check, the issue of the drug not working again (resistance) is eliminated. The virus population becomes so few that transmission to the child and spouse hardly occur.
The children are mostly infected from mother to child transmission and unsafe blood transfusion. In Africa, blood is considered as life; however in rural areas some facilities do not screen blood before transfusion. They offer blood as wonder cure for fevers and to raise their fees. An infected mother should be placed on drugs to reduce viral load and prevent transmission to the child and spouse. Thereafter the child is placed on antiretroviral to prevent transmission during breastfeeding. The mother continues to support the child with preventive drugs while breastfeeding. Immunizations as prescribed by the national immunization program should be done to the latter. There are no contraindications to an HIV child to receive immunization because they are safe for an infected child.
The transition to teenage is a trying time for the child. Adolescent are trying to assert themselves and take an identity. One client said “my parents did not tell what was wrong with me to justify my taking drugs every day. They said I will fall sick if I didn’t take the medicine. But frequently I was sick. When I am strong even I go to collect the drugs myself I will hide them and not take them. I had never seen any of my friends taking these drugs.”At what point exactly should the disclosure be made? The clinics need to be youth friendly and peer support groups created to support each other. In my facility we have educative films, sports such as badminton, scrabble etc. coupled with meetings to help each other and share experiences.
The effects of HIV infection goes beyond the physical aspects. Psychologically they can have anxiety, Depression is a state of persistent low mood characterized by feelings of sadness, sleeplessness, and lack of interest in activities and disheveled look. In Psychosis, they are disorientated in time, place and person, being confused on these parameters. There could be family discord, physical, mental and verbal abuse. The couple may separate and even divorce. A discordant couple said”. I was afraid to tell my husband because I don’t know his reaction. I told my mother and we went together. I couldn’t have done anything. We are married and Christians and no divorce is tolerated. It’s God protecting me and forever…” The functioning becomes affected with advanced disease. The clients lose man hours on the job and farm. Repeated illness and admissions take a financial toll on the client and family. In some places it is a taboo to marry from a family with recorded history of HIV infection or death. When I served in a general hospital, ward one was a no go area! When seen there you are stigmatized even by relations and friends as ogbeiku and nobody dares to marry from the family of victims while the body is buried in the evil forest.
In Nigeria, despite the Abuja declaration there seems as yet no political will to tackle HIV headlong. The budget for health is a token less than 10% of the total, the enabling laws to support the primary healthcare funding are obeyed in the breach, and the gap in healthcare worker deficiency has also taken a toll further exacerbated by the so called brain drain. I heard a few months ago of about 500 doctors attempting to migrate to the UK under this pandemic at a time flights had been suspended. They were turned back! But I bet they must all be in the UK by now with temporal but special permits. Trust Nigerians, where there is a will there will be a way. These factors could be responsible for the gaps in drug administration since most people do not know their status, they have not tested or are simply unaware. The WHO has set an ambitious goal to enable 90% of the population to know their status, 90% of those positive should be on antiretroviral while 90% on antiretroviral should be suppressed after one year of therapy.
With the newer drugs especially Dolutegravir-based combination drugs, the patients are better, suffering less illnesses and recording improved physical functioning. Many have returned to their work and farms. The Viral loads are suppressed to undetectable levels. These clients cannot transmit to their children and spouse and mates. Zero Viruses means Zero transmission of the infections (0=0). After a long period of despondency, there is now a real chance that we might just get the pandemic under control and it will be like other diseases such as hypertension and diabetes. This is exciting news!
But despite the upbeat mood we must be reminded that in solidarity we stand, everybody taking responsibility for himself and others seriously.
We must ensure individual and communal testing, linkage to care for those who are positive and making sure these measures start from individuals, family and the community at large so that no one is left behind in terms of health promotion, prevention of infection, treatment of the disease and rehabilitation of the moribund. For now going forward this is the way to go. The scale up of political commitment by governments with a view to increasing funding for health systems improvement; health care workers have to be trained to increase their numbers and their numbers scaled up to improve health outcomes; the equipment such as CD4 and viral load machines will have to be provided to ensure adequate follow up of clients; drugs and other commodities should be provided in adequate quantities and of good quality to reach those not accessing care and most importantly good leadership must be provided. The leaders should inspire the workers, be transparent and accountable in all functions; all finances should be used judiciously to justify their provision. I remember there was an outcry of unjustified expenditure by the global fund on HIV funding in Nigeria, this leaves a lot to be desired.
Concluded.
Dr John Kpamor FWACP(FM), Consultant Family Physician and Health Manager, can be reached on 08092163911(SMS only).
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