I have HIV and pressure, what can I do?

Question 24

November 24, 2017

I have HIV and pressure, what can I do?

Dear doctor, I am HIV positive and have been on ARVs for the last ten years.

I am doing well; my CD4 count has always been high and my viral load is undetectable. I am really grateful to God that ARVs have given me a new lease of life because when I was started on ARVs, I had AIDS.

My challenge now is that I have developed high blood pressure and the drugs I need to treat it are very expensive! Unlike ARVs that are given free at my clinic, I have to buy them myself.

I often miss taking them and though I do not feel anything the doctors have warned me that the pressure could damage my kidneys. 

What do I do now because the truth is that I cannot afford buying those expensive drugs, which I have to take daily the way I do ARVs? Nelson.

Answer

Dear Nelson, what you describe here is the experience of many people living with HIV (PLHIV), whose lives have been saved by ARVs. Because of the opportunity to live longer, sometimes coupled with unhealthy lifestyles plus side effects of some ARVs; many PLHIV are being plagued by what are known as non-communicable diseases (NCDs). 

These include: high blood pressure, cancer, diabetes and psychiatric conditions such as depression and psychosis associated with HIV. Unfortunately, most antiretroviral therapy (ART) programmes that give free ARVs, do not have budgets for treating these diseases, all of which as you have noticed are very expensive to treat.

Unfortunately, as you have been told even if you have a high CD4 count and you viral load is undetectable; high blood pressure if left untreated will affect your health adversely. So, our advocacy efforts must now broaden beyond advocating for availability of ARVs for all who need them. 

We have done very well in this area and now over one million Ugandans are on ART. We must advocate for improved and sustainable health for all. This includes prevention and treatment of NCDs like diabetes, cancer and high blood pressure. However, for your case, you may have to get a few people who know you well; people who saw you dying of AIDS but now they see you are "doing well" and share with them your current problem. 

Many of them who see you looking healthy may not know you are in danger of death if you continue living with poorly controlled high blood pressure. 

This is called disclosure, which many of us PLHIV have used to galvanize support that has helped us to not only access expensive treatment like ART but also psycho-social support needed when living with incurable diseases like HIV, many cancers and high blood pressure.

Question 23

I cannot leave alcohol, yet I feel bad after taking ARVs

Dear doctor, I am a 22-year-old sex worker. Unfortunately, I recently discovered I am HIV positive when one of my regular clients insisted we go for an HIV test because he wanted to marry me. 

He was still negative. I was immediately started on ARVs but two months into the treatment, I am not coping well. I feel so weak and drowsy most of the time and so for some days I have to skip taking the drugs or change and take them during day if I have to go out at night to work; otherwise we would have no food or money for rent. 

I also get terrible dreams when I go sleep. It is even worse when I swallow them and take some alcohol, which I often do considering the nature of my work. What can be done to help me? Janet.

Answer

Dear Janet, it is unfortunate that maybe because of the environment at the clinic you attend or fear of being blamed and discriminated against because of being a sex worker you did not open up to your doctor concerning what you do for a living.  

He could have put you on a user-friendly regimen instead of the one you are on that most likely contains Efavirenz. Efavirenz though a good drug, has those effects of causing drowsiness on top of bringing nightmares to some people. 

That is why it is advisable that you take it at night when going to sleep. Ideally, every patient or client should be treated differently after through history taking, clinical examination and laboratory investigation, so that proper advice and counsel are given. 

This was not done for you. Differentiated service delivery is necessary in HIV and AIDS care because the "one size fits all" model, which we often use clearly does not work for all. 

No wonder many are failing on regimens that are helping others. What you need is to open up to your doctor concerning the work you do and the challenges you are encountering with the ARVs you are on. 

What would actually work for you is to substitute Efavirenz with another drug like Nevirapine, if it is not contraindicate or Dolutegravir if it is available.

Question 22

Don't all ARVs work in the same way?

Dear doctor, 
I have been on ARVs for over three years. I usually take one tablet once at night. Apart from causing drowsiness soon after taking them and making me sleepy, there has actually been no other serious bad effect I have felt while on them. Recently, I went to visit my sister and delayed to come back and so my drugs ran out. However, my sister whom I did not know was also taking ARVs gave a bottle of hers but there were sixty tablets instead of the usual thirty that I take. So, I have been taking one tablet of these daily but realized they are not as strong as mine because they didn't make me feel dizzy. When I went back to my clinic for review, I was told that my drugs had been changed. What I wanted to know is whether to continue with the new ones, which do not make drowsy or  go back to the old ones. Don't all these drugs work in the same way? Dorothy.

Answer

Dear Dorothy, 
It is true that ARVs work in a similar way by blocking the multiplication of HIV in the body. However, they are different and that is why they are formulated differently with some taken twelve hourly while others are taken every twenty-four hours. For example, your original drugs most likely consisted of: Tenofovir, Lamivudine and Efavirenz; which have been put together in one tablet that you take once at night. On the other hand the ones your sister gave you most likely consisted of: Zidovudine, Lamivudine and Nevirapine put in one tablet that is taken twelve hourly. So, as you can see they are different except for Lamivudine, which is found in both formulations. MY advice is that you go back to your original regimen because in any case you have been taking half dose of the ones your sister gave you, which are supposed to be taken twice a day. This is very bad! Secondly, try to learn the real names of the drugs you are on. They are usually three different names written on the bottle; instead of just describing them by colour and/or shape because; even though they are all ARVs, they are different. This is treatment literacy and it is very important for anyone who is on antiretroviral therapy, which is treatment for life.

Question 21

I have failed to sleep. I have to take sleeping pills

Dear doctor, I was started on ARVs about six months ago, but I have been struggling because I could hardly walk after taking them due to the drowsiness. Recently my drugs were changed and one of the drugs Efavirenz was changed to Dolutegravir. This has changed my life so much, because compared to Efavirenz, Dolutegravir is so good. However, I have another problem, which is almost the opposite of what I was feeling in the past. I sometimes go to bed but fail to sleep. Can I take sleeping pills? William.

Answer

Dear William, all drugs have side effects although some drugs have more of them than others.  Serious side effects make adherence to the drugs difficult. During your adherence counseling, it should have been mentioned that some people get sleep disturbance or insomnia while on Dolutegravir. For such people we advise them to change and take the drug in the morning instead of taking it at night when they are going to sleep. Lack of sleep during day as you can imagine will not be a problem since you need to stay awake in order to work or carry out activities of daily living. So, you do not need take sleeping pills but to change the time when you take Dolutegravir. Lastly, for all people on ARVs, it is good practice to know the names of ARVs you are on and some of the common side effects they can cause. However, do not be surprised if the mentioned side effects do not happen to you. This does not mean you are on a fake drug. This happens, because not all side effects mentioned about a drug happen to all people who take it.


Question 20

How come I was not given ARVs?

Dear doctor, I recently went for HIV testing and was found to be HIV-positive. I was not surprised because one of my girlfriends recently died of cancer but she was also HIV positive. What surprised me is that the doctors refused to start me on ARVs immediately and yet I hear that is what is supposed to be done. Won't  waiting hurt me? I am really scared following the death of my girlfriend. Andrew.

Answer

Dear Andrew, it is true that under the "test treat" arrangement everyone who tests HIV positive is supposed to be put on ARVs without waiting for his or her CD4 count and regardless of the CD4 count. However, even then due diligence must be done before anyone is initiated on ARVs. ART is not emergency treatment except in cases of post exposure prophylaxis or PEP. For example, it must be established that the person is ready and willing to take the drugs and that he or she understands that the drugs do not cure HIV, but only suppress the multiplication of the virus in the body before he or she is given ARVs. So, most likely your doctor wants you to first undergo adherence counseling plus doing baseline tests on you such as measuring your heamoglobin level and establishing the integrity of your liver and kidneys. You also need to be screened for tuberculosis. These should not take more than two weeks, after which you will be started on a regimen of ARVs that is chosen based on the results of the above mentioned tests. This is because some ARVs are contraindicated or used with caution if you have underlying conditions such as anaemia, TB and liver or kidney disease. So, although you did not start taking ARVs the day you tested positive for HIV, the process has began and that is still, "test and treat".

Question 19

Do ARVs cause mouth sores?

Dear doctor, my sister who is HIV positive and was started on ARVs two months ago has painful sores in her mouth, which are making eating a real ordeal for her. She did not have these sores before starting ARVs and we have been wondering whether it is the ARVs, which have caused this problem. What can be done to help her?  Rebecca.

Answer

Dear Rebecca, the sores in your sister's mouth may not be related to ARVs, as you seem to suggest. Therefore, she needs to be assessed and a proper diagnosis made so that definitive treatment can be instituted depending on the cause of the ulcers. Stress, which is common among people living with HIV, can cause what are known as stress ulcers. These can make eating an ordeal for anyone who has them. Others causes of oral sores can be a virus known as herpes simplex or Kaposi's sarcoma; a cancer common in HIV infection.  In general, make sure she maintains strict oral hygiene by using an antiseptic or salt solution, which she should gargle after brushing her teeth. She should not swallow the antiseptic or salt solution after gargling. She should also increase her fluid in take and eat small but frequent meals, which should be soft therefore not requiring much chewing.  Aim at making sure she does not get dehydrated and that she takes in enough food to meet her body requirements and keep her strong. Lastly, your sister needs to be counseled concerning her treatment since treatment with ARVs; also known as antiretroviral therapy (ART) is treatment for life. If she takes it well with good adherence, she will be able to live a good quality life for a long time without succumbing to AIDS.

Question 18

I really fear infecting my baby through breast-feeding. What advice can you give me?

Dear doctor, I am HIV positive and have been on medication with ARVs for six months.  I have a newborn baby who is three months old and a nurse has told me to stop giving my baby Nevirapine because I am on medication. She has told me the risk of me infecting my baby while on ARVs is very small even when I continue breastfeeding him. Is this true? I really fear infecting my baby through breast-feeding. Jane.

Answer

Dear Jane, the main reason many children born to HIV positive mothers get infected with the virus from their mothers either while still in the womb, during delivery or through breastfeeding is because of the mothers having a high viral load. Viral load refers to the amount of HIV in the body of a person living with HIV. The cardinal goal of putting people living with HIV on ARVs is to suppress their viral load. So, if your viral load, which should have been checked after being on the drugs for six months is maximally suppressed and it is undetectable, your child should only have been on Nevirapine for six weeks. However, if the viral load is tested and still detectable the child is kept on the syrup for up to twelve weeks. Make sure that you continue taking your drugs as prescribed in the right doses and at the right time and continue exclusively breastfeeding your baby even after stopping to give him the Nevirapine syrup.

Question 17

November 17, 2017

What is the difference between viral load and CD4 count?

Dear doctor, I am still confused by the difference between viral load and CD4 count, which I was always told that when I swallow my drugs well it would rise and remain high. The last time I asked my doctor for my CD4   count, he told me I didn't need to worry or know it since my viral load was undetectable. What is the difference between the two? Proscovia.

Answer

Dear Proscovia, both CD4 count and viral load are used to measure the efficacy of ARVs. However, whereas the CD4 count is a measure of how badly damaged one's immune system is or how much repair has been done when one is on ARVs, the viral load measures how active HIV is in one's body. The main goal of putting PLHIV on ARVs is to suppress their viral load. ARVs work by blocking the multiplication of HIV in the body. On the other hand, measuring CD4 cells tells us whether one's immune system is able to protect him or her against opportunistic infections or infections that take opportunity of one's weakened immune system to attack him or her. Usually, when one's viral load is maximally and sustainably suppressed, their CD4 count should be high or normal. That is why nowadays monitoring how well one is doing while on ARVs is done by measuring their viral load. Viral load monitoring is thus one of the so-called 90:90:90 goals, which are: ensuring that 90% of all people are tested and know their HIV status, 90% of all people tested and are found to be HIV positive are put on ARVs and lastly ensuring that 90% of the PLHIV on ARVs take their drugs with such good adherence that their viral load is undetectable. This way, we hope to eliminate AIDS by 2030.

Question 16

November 16, 2017

Is it necessary to switch to a new drug, yet am doing well?

Dear doctor, I have been taking ARVs for over three years now and I am doing well. I preferred to pay for my drugs because I realized most of the free ARVs are not branded drugs like the Atripla that I take. Do we have the new drug, Dolutegravir as a branded drug or generic? Secondly, is it really necessary for me to be switched to a new drug when I am doing well on the old one and my viral load is undetectable? Sam.

Answer

Dear Sam, as you know branded drugs are very expensive. So for countries like Uganda, which have large numbers of people living with HIV (PLHIV) who need to be put on ARVs; using generic drugs is the most prudent thing. Secondly, generic drugs are not inferior to branded ones because the active pharmaceutical ingredient in both is the same.  The only difference is that branded drugs are made by the originators of the drug while generic copies, which are cheaper are made by others companies who obtain licenses to manufacture such drugs for the benefit of low and middle income countries who incidentally have the highest number of PLHIV. The Dolutegravir being given out at the moment at a few centres in and around Kampala is a brand from ViiV pharmaceuticals. However, we hope to have the generic formulation of the drug in combination with Tenofovir and lamivudine next year when all PLHIV who are on regimens that contain Efavirenz like the Atripla you are on will be switched. Lastly, feeling well and having your viral load suppressed does not mean you should not be put on a better drug that is more durable, easier to swallow and has fewer side effects. For example, the Atripla you are on contains 600mg of Efavirenz, which will be replaced with only 50mg of Dolutegravir!  So, don't let what is good prevent you from getting something that is better.

Question 15

November 15, 2017

My mother forgets and takes her medicine twice, what can we do?

Dear doctor, my mother who is HIV positive has been diagnosed with cancer of the liver and of late we have noticed that she has lost her memory. For example, she sometimes forgets she has taken medication and takes it a second time plus forgetting people's names. We have been told that the memory loss could be due to deficiency of some vitamins in her diet and that food supplements would help. Which diet would be best for such a patient? Norah

Answer

Dear Norah, proper nutrition is very important in prevention of disease and in helping the healing process, which is always ongoing due to the wear and tear the body goes through. So, it is important that diets, especially of sick people, the young and elderly are rich in all the ingredients of a balanced diet in addition to being free of substances that could cause diseases such as some cancers. For example a diet that is deficient in vitamin B12 may lead to someone being prone to depression, mental confusion, poor memory or dementia, chronic fatigue and sometimes difficulty in maintaining body balance. This is because vitamin B12 is needed in maintaining the health of nerve cells that form the bulk of brain tissue responsible for cognitive functions such as remembering and so on. So, in such cases food supplements rich in vitamin B12 may help. On the other hand dementia among older persons also known as senile dementia may be part of the aging process; not necessarily due food deficient in nutrients. Lastly, as mentioned before, liver cancer can be caused by presence of a substance known as aflatoxin that is usually found in poorly stored cereals that end up becoming damp and can attract mold. This should be avoided as a cancer preventive measure.

Question 14

November 14, 2017

What is the danger of taking my ARVs after a meal?

Dear doctor, I am HIV positive and was recently started on ARVs, which I take as one tablet before I go to sleep as I advised by my doctor. The only problem is that he also advised me not to take the drugs soon after eating especially a fatty meal, which is confusing because I would like to take my drugs after the evening meal then go to sleep. What is the danger of taking my ARVs soon after a meal?  Richard.

Answer

Dear Richard, quite often the absorption of drugs, ARVs inclusive is affected by the conditions in your stomach, which of course are determined by whether, it is empty or full plus the kind of food or drink you have taken.  So, not all people living with HIV who are on ARVs are given the same instructions. You, however, received instructions of taking your ARVs when your stomach is empty, which means taking them one hour before taking a meal, or waiting for two hours after you have eaten then take them because you are on a regimen that contains a drug known as Efavirenz. Efavirenz is combined with Tenofovir and Lamivudine to form a fixed dose combination that you take as one tablet once at night. The reason behind taking Efavirenz on an empty stomach is that it is absorbed faster if taken when your stomach is full and this means you will experience more side effects than if it taken on an empty stomach and absorbed more slowly. However, this is not the case with other ARVs like Dolutegravir that is going to replace Efavirenz when rolled out next year because it has fewer side effects and no food restrictions. So, for now follow your doctor's instructions to avoid increased side effects of Efavirenz until next year when hopefully it will be replaced by Dolutegravir.

Question 13

November 13, 2017

Dear doctor, I have been started on ARVs and take one tablet once at night. The problem though is that sometimes being a fisherman I go fishing at night and on such nights I don't take the drugs to avoid dosing. On the whole I take most of my tablets but at the end of a month I have like four or five tablets left. Will this affect me negatively?  Bosco.

Answer

Dear Bosco, it is important that you take all your drugs as prescribed by your medical service provider. This is because when we take a drug by mouth, it first enters the gastro-intestinal tract or stomach and intestines where it dissolves and gets absorbed through the walls of intestines. The drug eventually passes through the liver and enters blood circulation that distributes it to all parts of the body before it is removed or excreted from the body through kidneys.

In order for the drug to be effective against HIV, it must reach a concentration in the blood that is high enough to suppress the virus. You can only reach and maintain the required concentration if you take the correct number of pills as prescribed by the health care worker,do not miss a dose or take a dose too late. So, when you keep missing doses of your medicine like you say you often do; it means during those times the concentration of ARVs drops below the optimum concentration required thereby allowing HIV to multiply. We aim at taking at least 95% of our drugs. So, missing five out the thirty tablets you are supposed to take per month is not good. What can be done for you is to remove the drug that makes you dizzy from the combination you are taking. Discuss this possibility with your doctor and find out whether this can be done for you because nowadays it is possible to get such a drug  that has fewer side effects and will not make you drowsy.

Question 12

November 12, 2017

Dear doctor, I recently went with a friend for HIV testing. He was told he was negative but counseled to go back for checking again after three months so that they can confirm his status. Unfortunately for me, I was found to be HIV positive and was given ARVs to begin taking immediately. However, I have not taken them because I wonder why for me they never gave me the option of repeating the test after sometime to confirm that I was actually positive before giving me ARVs the way my friend was treated.  Please advise. Musa.

Answer

Dear Musa, the question you ask is important and should have been addressed if you had got comprehensive pre and post-test counseling that all HIV testing centres should provide. Secondly, although now we encourage all people who test HIV positive to be started on ARVs as soon as possible regardless of their CD4 count, they should be given comprehensive pre-ART counseling after complying or accepting to start taking the drugs so that they can adhere to the treatment by taking the drugs in their right doses and at the right time as instructed by the health service providers. No body should be forced to start taking ARVs. Most people would comply when the benefits of ART are explained to them and the few who may not be ready should be given time to make up their mind. Lastly, the reason your friend was told to go back for testing after three months is because sometimes people who have just got infected with HIV test negative when they actually have the virus. This is known as the window period, which is the time between getting infected with HIV and when one forms antibodies that are detected by the HIV test. On the other hand, when you test HIV positive on screening, your blood is subjected to another test that actually confirms you are indeed infected and it is not a false positive. That is why you were not given time to go back later since the principle of window period does not apply in your case. So, start taking your ARVs, so that HIV does not continue multiplying in your body and damaging your immune system.

Question 11

November 11, 2017

Dear doctor, I have been taking ARVs that I take as one tablet at night and apart from the usual dizziness and drowsiness, which I get after taking the tablet I had got used to the medicine. Recently, my doctor told me they had received better medicine, which wouldn't make me feel dizzy or drowsy and so changed my drugs to two tablets that I take once at night. Granted, they don't make me drowsy but the problem is that they are two tablets instead of the one I have been used to. Can't I stay on my old medicine? Annette.

Answer

Dear Annette, you should count yourself lucky in that you are among the few who have been selected to pilot the new drug known as Dolutegravir (DTG) that is going to replace Efavirenz, the drug that has side effects like dizziness and drowsiness and in some people causes nightmares.  Efavirenz is combined with Tenofovir, and Lamivudine to form the one tablet that you have been taking once at night. The amount of Efavirenz in that tablet also known as the "active pharmaceutical ingredient" (API) is 600mg. This is going to be replaced by DTG whose API is only 50 mg and as you may have noticed the second tablet is very small and so very easy to swallow on top of not having nasty side effects like making you have strange dreams or causing dizziness. The other good thing is that starting next year we hope to have DTG in a fixed dose combination with Tenofovir and lamivudine, which means you will be taking the three as one tablet just like you have been taking in the past. Only that the tablet will be smaller because of DTG, which has a smaller API. So, as more research is carried out and better drugs like DTG that are more durable, easier to swallow and have fewer side effects are introduced; we should not shun them because they will make our quality of life even better. 

Question 10

November 10, 2017

An HIV-positive person spat at me, why was I denied PEP?

Dear doctor, recently I had a quarrel with someone who is HIV positive and he spat in my face. I quickly went and washed my face and eyes with water, but my wife insisted I should be put on PEP. However, when I went to a clinic I was denied the drugs because they said the risk was very small. Now I am so scared. Won't I get AIDS? Harry.

Answer

Dear Harry, before ARVs are given to a person as Post Exposure Prophylaxis (PEP), an assessment must be made and ARVs given only when there is risk of HIV transmission. Body fluids that are considered infectious are blood, sexual fluids and breast milk in the case of breastfeeding HIV positive mothers.  Body fluids such as tears, non-bloodstained saliva, urine and tears do not pose a significant risk of transmitting HIV. So, it is unlikely that you will get infected with HIV following the spitting incident. I, however, hope you were tested for HIV when you went to the clinic instead of assuming you are HIV negative. This is because many people who carry the virus actually do not know it and now we encourage health care providers to offer an HIV test to who ever visits a clinic. This is known as provider initiated counseling and testing (PICT), which is different from voluntary counseling and testing (VCT). This will help us to identify all or at least 90% of all HIV positive people so that they are put on ARVs.

Question 9

November 9, 2017

How come some drugs are being given out selectively?

Dear doctor, is it true that the new drug called Dolutegravir is still under research and that is why it is being given to few selected people to see whether it works or not? My brother who has been taking one tablet of ARVs once at night was recently changed to two tablets, one of them being Dolutegravir because he often complained of feeling drowsy and sleepy after taking his drugs. Pamela.

Answer

Dear Pamela, Dolutegravir has been approved by the Food and drugs authority in the USA and cleared for use in the treatment of HIV. It is also in the WHO and our own ministry of health guidelines. In the past it has been used as a third line drug but now we are going to use it as a first line drug because of its efficacy in suppressing the viral load and its being more user friendly, with fewer side effects and even cheaper to manufacture. It is widely used in North America and Europe and in Africa Botswana has adopted it and uses it in combination with Lamivudine and Tenofovir instead of Efavirenz, which we use here. In Uganda it is going to be used more widely next year, when it will replace Efavirenz 600mg, which as you mentioned cannot be tolerated by some people due to side effects like drowsiness, nightmares and sometimes convulsions. Uganda together with Kenya and Nigeria chose to first pilot it in a few people before massive roll out because there is limited evidence concerning its use among pregnant women and PLHIV who are treatment with TB medicines. So, 6500 PLHIV in Uganda, 6500 in Nigeria and 20,000 in Kenya are going to be started on Tenofovir, lamivudine and Dolutegravir instead of the old regimen of Tenofovir, lamivudine and Efavirenz in the next twelve months and priority is being given to those who cannot tolerate Efavirenz like your brother. So, do not discourage him from swallowing his drugs as Dolutegravir is one of the safest ARVs we now have and we hope it is going to improve people's adherence to ART and therefore increase viral load suppression, which is the cardinal goal of ART.

November 8, 2017

Question 8

ARVs fractured my mother. What can we do?

Dear doctor, my mother who is on ARVs that she takes once at night recently started feeling pain in her left leg and when the doctor did an X-ray, she was found to be having a fracture and yet she had not fallen at all! He said the problem was caused by one of the drugs she is on. They changed her drugs but we are worried and wonder what else could happen as she continues taking ARVs. Farida.

Answer

Dear Farida, all drugs ARVs inclusive have side effects and some can be serious like what has happened to your mother getting what is known as a pathological fracture, which can occur without a fall or physical injury. That is why we always advocate for provision of ARVs that have fewer and less serious side effects, are easier to swallow and can be used for a long time. What happened is that her bones became weakened by one of the drugs known as Tenofovir, which affects bone metabolism. Tenofovir is combined with Lamivudine and Efavirenz to form one tablet taken once at night by many people living with HIV (PLHIV) who are on first line ARVs in Uganda. That is why PLHIV who are on ARVs especially regimens that contain Tenofovir must have regular monitoring by doing kidney and liver function tests plus analyzing their urine so that if there are any abnormities caused to bones, liver or kidneys, they can be detected early and remedial action taken. Lastly, you should encourage your mother to continue taking her drugs but under the regular monitoring of a qualified medical worker since the offending drug has been removed from her regimen of ARVs.

November 7, 2017

Question

Dear doctor I am HIV positive and generally doing well. My CD4 count is high and the viral load is undetectable. However, I still struggle with taking my drugs. I take one table at night, which makes me drowsy and so I have to go to bed always after taking them. So, on some days like when we have overnight prayers at church and I have to participate, I skip it. Is this harmful because I take most of my tablets anyway. James.

Answer

Dear James, many PLHIV who are on ARVs experience similar challenges. They have to tolerate some side effects like drowsiness or experiencing nightmares because they don't have access to alternate safer drugs, which are easier to swallow and have fewer side effects. We, however, now have a window of hope. For example, we now know that instead of taking 600mg of Efavirenz, the drug that makes you drowsy and is combined with Tenofovir and lamivudine to form the one table you swallow once at night; you can take 400mg of the same drug and your viral load will continue being suppressed without making you feel drowsy. The other drug, which can replace Efavirenz, is called Dolutegravir. Dolutegravir can be used in combination with lamivudine and Tenofivir instead of Efavirenz . This is known as treatment optimization, which should be done for all PLHIV. Nobody should have to tolerate taking drugs if there are better products like Efavirenz 400 mg and Dolutegravir, which are more durable, easier to swallow and have fewer side effects. So, discuss these possibilities with your service provider and enjoy good quality life while on ARVs. Lastly, I am writing this from Paris France at IAS 2017, a big international conference on HIV and AIDS. A lot of this information has been shared here. Our fellow PLHIV in developed countries no longer use many of the drugs we are using. However, while we are still advocating and lobbying for optimization of our ARVs, continue taking the current ones because as the saying goes, "a bird in the hand is worth two in the bush".

November 6, 2017

Question

Dear doctor, I am HIV negative but my husband is HIV positive and doing well on ARVs. I knew he was HIV positive before we got married and because I love him, I agreed to the arrangement. We have been married for four years and we would like to have a baby but because we always use condoms when we have sex I cannot of course conceive. Recently he told me that we could try and have a baby but I am so scared because it means I could easily get infected and probably give birth to an HIV positive baby. Our families don't know what we are going through because we have not disclosed our predicament to them. Please advise. Jackie.

Answer

Dear Jackie, discordance, which you have described in the question above, is fairly common. Secondly, discordance is the basis of majority of new HIV infections and so we must deal with it firmly basing on scientific knowledge, which is now widely available. For example we now know that people living with HIV (PLHIV) who are on ARVs and have undetectable viral loads are actually not very infectious. In short, "undetectable is equal to un transmittable". We also know that if HIV negative people who are in discordant relationships are put on ARVs at a time of increased risk, such as when they have to have unprotected sex because they want to have a baby the risk of them acquiring HIV is significantly reduce. So, instead of living in fear, learn the facts. Encourage your husband to take his ARVs with good adherence and when his viral load is undetectable discuss with your doctor who will arrange to put you on ARVs before you have unprotected during the time of your menstrual cycle when you can conceive. This is known as PrEP or pre-exposure prophylaxis. Using two or more methods as described above to prevent HIV transmission is known as combination prevention and it is more effective than depending on only one. Lastly, all people need to know this so that PLHIV or their HIV negative partners are not stigmatized isolated and made to live in fear and shame.

November 5, 2017

Question

Dear doctor, I am HIV positive but my wife is negative. I am doing well on ARVs. We, however, have never used condoms and yet we have been living together for over ten years during which she has had four children who are HIV negative. Does this mean she could be immune to the disease or could it be that she is actually infected but it does not show and she could pass on the disease to our child since we would like to have another baby? Robert.

Answer

Dear Robert, the condition you describe here is known as discordance and it fairly common. Unfortunately, if not well handled, it is the reason behind the many new HIV infections that happen especially among married and cohabiting couples. Your wife is not immune to HIV but what could have helped her to remain negative is the fact that you are on ARVs, which when taken with good adherence drastically reduce the risk of HIV transmission. Secondly, the risk of transmission among couples that practice consensual sex is lower than in cases of non-consensual sex such as rape. However, now that you know, you need to adopt safer sex, which means you use condoms whenever you have sex.  When you want to have a baby you should ensure that your viral load is maximally suppressed then you can have unprotected sex for a period. During such encounters, it is wise for your wife to be put on ARVs, a practice known as pre exposure prophylaxis (PreP). Your doctor will guide you how this can be done once you share with him or her plans of wanting to have another baby with your HIV negative wife.

November 4, 2017

Question

Dear doctor, my mother who is in her fifties is HIV positive and has been on Septrin for close to ten years because her CD4 count has always been high. However, recently when she went to collect her Septrin the doctor out of the blue put her on ARVs and told her that it was now a government directive that all people who are HIV positive should be put on ARVs! She is now so disturbed and has refused to start taking the drugs because she feels she does not need them. Why should people who have high CD4 counts and are not sick be put on these strong drugs? Janat.

Answer

Dear Janat, what the doctor probably meant is that it is now government policy and practice to put all people living with HIV on ARVs in line with WHO guidelines.  This is known as "test and treat all ", where at least 90% of all people who are HIV positive are put on ARVs. However, no body is forced to take medication if he or she has not been convinced concerning the benefits of such treatment. So, since antiretroviral treatment (ART) isn't emergency treatment but treatment for life; more time needs to be spent counseling your mother and explaining to her the benefits of starting ART early, so that she is convinced and can adhere to the treatment once she starts. She needs to know that treating HIV is similar to repairing a tear in a cloth: the earlier you do it the better the outcome. The other advantage of treating HIV early and suppressing the viral load or amount of HIV in the blood of people infected as soon as possible is that it makes such people less infectious to others. Lastly such person's immune system, which protects him or her from catching diseases, is prevented from being damaged; meaning such a person does not easily develop AIDS. The other thing to remember is that nowadays we have ARVs that are more tolerable, easier to swallow and have fewer side effects and so there is no reason why anyone should keep putting off starting to take them for fear of having nasty side effects.

November 3, 2017

Question

Dear doctor, my sister was recently told she had TB. This was discovered following a cough, which she had had for more than three weeks. She was put on TB drugs and improved a bit but when they checked her sputum after two months she was told she still had TB germs. At the same time she was tested for HIV and found to be positive. Could it be that TB among people with AIDS does not get cured. We are worried! Musa.

Answer

Dear Musa, TB among persons living with HIV even if they have AIDS can be cured. However, the infected person must take the TB medicines with good adherence, meaning he or she must take the drugs in the right doses and at the right time as prescribed by the health service provider. What could have happened is that you your sister did not take the drugs with good adherence and so the TB germs could not be destroyed and may have even developed resistance to the medicines or she was infected with TB from someone who had what is known as "multi drug resistant TB" (MDR TB). This is TB that is resistant to rifampicin and isoniazid, two of the four drugs used in treating the disease. Your sister should be evaluated and counseled concerning what should be done next; including finding out if she has MDR TB, which is treated using a different regimen of TB medicines and for a time longer than the usual six months of TB treatment. She should also be put on ARVs as soon as it is possible and feasible. Lastly, all of you who have been in contact with her should be screened for TB. If these measures are taken, there is no need for being worried.

November 2, 2017

Question

Dear doctor, if an HIV positive mother who is on ARVs and her viral load is undetectable   breastfeeds her baby, will the baby be infected with the disease? Liz.

Answer

Dear Liz, the main reason why people living with HIV transmit HIV to others including women transmitting the virus to their babies via the mother to child transmission route is because such people have high viral loads and therefore very infectious. That is why all of us should embrace the "test and treat" programme of putting all people who test HIV positive on ARVs as soon as possible. So, if the HIV positive mother who is on ARVs and has an undetectable viral load follows the doctors' instructions of putting the child on ARVs soon after birth and exclusively breastfeeding for up to six months; the risk of such a child getting HIV from such a mother is very low. We have seen this work very well for parents who have done it, such that the number of children infected with HIV via the mother to child transmission route dropped from over twenty five thousand in 2011 to the current less than four thousand infections annually. This shows we can eliminate HIV infections among babies if we put in practice the elimination of mother to child transmission of HIV strategies.

November 1, 2017

Question

Dear doctor, I recently had unprotected sex with someone whom I later found out was HIV positive. I have not yet had the guts to go for an HIV test but wanted to know what the early signs of HIV infection are. Secondly, how can some tell that he or she has the virus without doing the HIV test? Jackson.

Answer

Dear Jackson, acute HIV infection could presents with flu-like symptoms like fever, skin rash, generalised body pains and sometimes swelling of the lymph glands; especially in the neck region. There are, however, many other viral illnesses, which could present in a similar manner and many people would never recall having such signs and symptoms. It is therefore important that we do not base a diagnosis on signs and symptoms only but to confirm it by doing an HIV test. The other thing worthy noting is that during the acute phase of HIV infection, the antibody HIV test when done would be negative. The only way you can detect the virus during this early stage of infection is by doing a more advanced test known as the DNA-PCR test. Equally important and of public health significance is that during this period, which could last up to three months; the infected person usually has a very high viral load and is therefore highly infectious. For such a person condoms are recommended if he or she must have sex. For women, getting pregnant during this period puts your unborn baby at higher risk of acquiring HIV through the mother to child route because of the high viral load or amount of HIV found in the blood. Lastly, it is safer to assume that any person whose HIV status you do not know is HIV positive and to always take measures to protect yourself. If exposed like you were, seeking to be put on post-exposure prophylaxis (PEP) by a health service provider trained to offer such a service as soon as possible would have been the best option.