Management of HIV Positives & AIDS Patients
UN Secretary General (Former) Kafi Annan termed. HIV / AIDS I as more than a national problem because it is more than a health problem. His statement denotes the all important role of care and support HIV positives and AIDS patients (PHAs) need. Mr. Anan called for an approach transcending conventional health vision to draw our attention to modern concept of health. WHO defined that `health is a state of physical, mental and social well being not merely the absence of disease or infirmity'. In our present state of knowledge to combat AIDS with medicine, enlighten understanding and application of this concept perhaps contains the best hope for the PHAs. Nevertheless, optimum benefit must be materialized from judicious application of existing antiretroviral medication. It is therefore relevant to briefly touch upon the antiretroviral drugs before elaborating the often overlooked significance and role of conservative therapy in managing PHAs.
AIDS Related Antiretroviral Fall among Three Groups:
Protease inhibitor (PI), Nucleoside Reverse Transcriptase Inhibitors (NsRTI) and Non Nucleoside Reverse Transcriptase Inhibitors (NNRT1). The triple drug therapy, a combined use of medicine from all three groups, is the most effective available medication to combat AIDS. It is applied to inhibit replication of the virus and then to bring down viral load to undetectable levels, usually below 50 copies/ml. [at full blown level?]. Another use of is the treatment and prophylaxis (preventive measures) of opportunistic infections. The ultimate goal of antiretroviral medication is to prolong the survival.
The antiretroviral generally target key enzymes required by the virus to replicate. In the process the drugs preserve the immune function, prevent disease progression and reduce incidence of opportunistic infection. Results differ depending on baseline viral load. However, in most patients, it cuts down viral load by about 90 per cent in 2-8 weeks. Data suggests that the initial decline of viral load is indicative of sustained viral load suppression. As a result viral load should continue to decline and by 16-20 weeks in most individuals become undetectable (< 50 RNA copies/ml). Specifically, benefits accruing to the users of antiretroviral are ; Increasing CD4 (protective / immune cells) cell count Decreasing viral load Decreasing the incidence of opportunistic infections. Prevention of disease progression.
Prolonging survival Ability to lead productive life Improved quality of life. Reduction of the risk of transmission. Full blown AIDS patients are keen to take antiretroviral. Antiretroviral should be prescribed by trained or expert practitioners so that the terminal stage patients may not suffer from serious side effects like alopecia (disproportionate body structure) or severe skin rash as experienced in Uganda and Nepal. Because of the deadly consequence the virus brings and transmission channels it takes, AIDS became collective social issue surpassing individual personal health concerns. Broadly, AIDS is encountered in three frontiers: by PHAs, by health professionals and by society.
It is crucial for the wellbeing of PHAs and the society to recognize that the anti retroviral can produce the best results only if preceded and complemented by conventional therapy. Following sections elaborate the indispensability of non-clinical (non-medical) considerations among the defenders at all frontiers of AIDS in human-quality management of PHAs.
AIDS epidemic devastated large part of Africa even before the disease could be definitely identified. Already suffered devastation before detection of cause probably played the greatest role in traumatizing our society at large and stigmatized sections of society (including medical health professionals) in various degrees. However, few simple facts will help all of us respond to PHAs in sensible human ways.
First, in relation to AIDS. a population can be divided in to three 2 categories; a. HIV negative, b. HIV positive (carrier) and c. AIDS affected. There is absolutely no difference. whatsoever, between the people of categories a and b, except that the HIV positive is more vulnerable to acquire the immune deficiencies (just like people with Hepatitis B, C positive). Until and unless the related complexities have developed HIV positive can and should live like anybody else (again, like people with Hepatitis B, C positive). Second, we have neither reason to be scared of AIDS patients around nor have the need to despise him/her. This is proved beyond doubt that AIDS is not the most dangerous of known disease. It is neither the top killer nor the fastest spreading disease. [Diseases that kill more, spread faster] It can transmit only through contamination of body fluid by infected fluid (blood, seamen, vaginal fluid, 99 per cent cases ??) and through sexual intercourse (1 per cent cases ??, 2-9 per cent more for female, where as STDs).
Yet, the greatest obstacle for PHAs in Bangladesh is the paranoia of the society. Partial information, misinformation, improper presentation and too much attention are probably reasons behind such situation. Nevertheless, the preceding section, though briefly but logically establishes that PHAs are no different than people with other disease. They are not going to die any moment so they can not be abandoned (example). Nor they are spreading out the disease with even breath (which people with influenza, tuberculosis ...do). So, no need to run away fromythem.
They are same as people with other prolonged ailment such as cancer...... Therefore, the PHAs have the right and necessity to be treated (by medical professionals and by the society) without discrimination or despise. In fact they don't need anything except what they have been robbed of - their rights.
It has been Mentioned Earlier that There are Three Frontiers:
PHAs, health professionals and the society. Naturally all three frontiers must respond to the disease in enlightened, informed and educated manner. We, belonging to one or more of the frontier force have both rights to protect and responsibilities to discharge. Irresponsible behavior of others tantamount infringement of our rights and without exception, our refusal to discharge responsibility infringes upon others right.
It would be an illusionary fancy to forget that each of us play 'we' in one situation and 'others' in another situation. So, it is only wasteful to point fingers to some one else for any wrong doing that afflicts common people. Let us then concentrate on what best we can do in each of the fronts against AIDS. After all, the disease is the enemy not the patient and the disease do not die with the patients. We may try to avoid the PHAs but the `Immune Deficiency' virus wouldn't avoid us. The only way to put up effective defense against it is to do the best we can do on all three frontiers.
PHAs Like any other diseased person, PHAs must act in a responsible manner for individual and collective wellbeing and healthy life. They are prone to infections and due to lack of immunity the infection may turn deadly. So, PHAs must maintain personal hygiene and take special care against infection from injuries and contagious diseases. If infected they must take prompt treatment. Once detected positive / affected PHAs withdraw from medical supervision and counseling, instead converge with society without precautionary measures. Such actions do not help the PHAs in any way.
Rather they must continue to receive medication and counseling and live disciplined normal life with the precautions advised. They need to focus on dietary and nutritional considerations and ensure balanced diet rich in vitamin C. Regular exercise is also important to keep immune system effective. PHAs are and tend to be isolated. This eventually aggravates the situation for all including inflicting frustration and desperation in PHAs leading to detrimental results for all. Understandably, it is not easy for PHAs in Bangladesh to seek and acquire reliable companion but there is no alternative to keep on trying.
Dependable association will contribute directly in their physical and mental health. Briefly they have to strive for a complete health condition as defined by the WHO. Finally, as long as no cure is available containment of the disease is the imperative both at individual and collective levels. There is no scope for confusion that PHAs are the most important source of their strength. Hard as it may sound, if the PHAs do not take best care of themselves nobody is going to help them.
PHAs can enlist service and support from others, including from other PHAs only by demonstrating sincere and responsible attitude to contain the disease and live a disciplined healthy life. Health professionals: Naturally, like any other sick person, health professionals are the most important persons far PHAs. Here health professionals include all from the specialists to auxiliary and service personnel. Attaining containment of AIDS is a direct function of services extended and attitude demonstrated by health personnel toward the PHAs. This applies to both micro and macro scenario. Therefore, it is essential that they adhere to the professional ethics and code of conduct in responding to PHAs. Paradoxically, it is often forgotten by the professionals that failure to comply professional conduct exact at least as much harm to others as to the service requester.
By provoking/compelling a service requester to withdraw means destroying the tracks of a potential known hazard and loosing all opportunities to contain it to say the least. Breach of privacy, denial of service, humiliation, disrespectful attitude etc. are some of the elements that drive PHAs out of medical supervision. It must be understood that the professional failing to meet his/her standards and obligation may remain immune from the detrimental effects of his/her failure. But his/her unwillingness/inability to comply indicate there are similar other noncompliances.
S/he is exposed/vulnerable to such noncompliance and face double jeopardy as s/he does not even know what s/he is vulnerable against. It is thus a non-negotiable minimum that health professionals (as well as others) render their service with professional efficiency and sincerity and remain free from being corrupt by personal bias, prejudice, superstition and such other counter productive notions in professional matters. It is undeniable that if the independent and larger health personnel community does not live up to their professional training the dependent and atomized PHAs would not be able to act in the desired manner.
WE It has been mentioned that the greatest obstacle PHAs face are social. While we tend to refer to society and use the expression 'social' in an abstract way society in nothing but a collective form of individuals including every one of us. All the PHAs, the health professional and all the rest of us together constitute the society. Of the three, PHAs are the smallest and 'we' are the largest constituent of the society with health professional in the middle.
Besides being the smallest and the weakest) constituent, PHAs are also the victims. On the other hand the professionals are also part of the 'we'. It is thus obvious that 'we' have the greatest responsibilities and most power to shape the realities of the PHAs. Due to misconceptions, social taboo and other reasons, we have developed a kind of antagonism toward the PHAs. Often we are not aware of it but the antagonism harbored in our subconscious is active and reflected in our actions and attitude. There is no basis for the antagonism, nor does it help us in any way.
Insteade it breeds a situation more hazardous for us. Our prejudiced behaviors doubly victimize the PHAs. They feel indignant, cast out. We refuse their possibility of healthy human life by obstructing their rights. These unjust and unjustified discrimination and degradation often flare up a counter antagonism to society (us) among some PHAs. Driven by the antagonism fueled by frustration and helplessness these PHAs converge in the society and live a reckless life. We must remember that our stigma forces PHAs not to seek medication and/or withdraw from medication, supervision. Thus, we compelled the identified/suspected PHA erase the track and become an unidentifiable source of hazard to which we all are vulnerable.
Resultantly, the PHA's life is likely to be cut short but a long legacy of the same disease has already been established for all of us. At the end, our intolerance, disgrace, fear, irrationality caused more harm for us than to the PHAs. We can have a completely different and much safer society for us if we treat the PHAs rationally and fairly. Suspected/proven PHAs need to be guaranteed the life a person with any other ailment enjoys. It is no favor, it is their right and only by not infringing upon their rights we can prove ourselves to be right conscious citizenry. Because every right conscious person is obliged to respect right of others. Rights and responsibility are complementary.
Their rights encroached. PHAs can not be expected to be responsible and they can be only as responsible as we would be. Until an effective cure is available, responsible attitude of suspected/identified PHAs is our only safe guard against AIDS. It is 'us', the greater and stronger part of the society, will have to take the lead so that the smaller and weaker part feels responsible and does not grow big enough to weaken the whole society. It is our responsibility more for our own wellbeing than for anything else.
Dr. Mustafa Abdur Rahim
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