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WHO 2009 GUIDELINES FOR ANTI-RETROVIRAL THERAPHY: ITS IMPLICATION FOR PRIMARY CARE PHYSICIAN

2. Practice of Universal Precautions

Because it is almost impossible to tell if a patient who presents to a primary health physician for ailments unrelated to HIV such as cuts and bruises from trauma or motor-vehicle accidents, is in fact infected with HIV; staff working in these clinics must be educated on the practice of universal precautions to avoid possible occupational related HIV transmission. Consequently, the unsafe or even dangerous practice of reusing syringes and sutures or needles, improper disposal of paraphernalia contaminated by body fluids, and performing minor surgical procedures without proper protection should be avoided. Needle-prick injuries from these unsafe practices are possible with potential for transmission of HIV.

It is recommended that all primary health care clinics have a carefully drawn out algorithm in the event of a needle-prick injury to ensure speedy diagnosis of possible HIV transmission as well as early access to post-exposure prophylaxis.

3. Drug-drug interactions

As access to ART becomes more accessible, HIV positive individuals will invariably live longer. Studies have demonstrated that a HIV positive individual started early on ART with access to proper care and monitoring can expect to live between 20 to 50 years from the time of ART initiation.¹² A possible consequence to this is that these individuals will go on to develop other age related or ART related diseases such as diabetes mellitus, dyslipidemia and ischemic heart disease. Chronic smokers may develop chronic obstructive pulmonary disease, while alcoholics may develop liver diseases.

These chronic diseases would necessitate the use of anti-hyperglycemic agents, cholesterol lowering agents and other medications on top of their ART. A substantial number of HIV infected people from the younger age group also indulge in recreational drug use such as ecstasy and amphetamine abuse.

All these would create a new therapeutic dilemma: that of possible drug-drug interactions. For instance, prescribing ergotamine for migraine in a HIV positive patient who is on protease inhibitors as part of his ART can lead to fatal consequences as protease inhibitors can raise ergotamin levels in the body to toxic levels by inhibiting its metabolism. Similarly, nevirapine hastens the clearance of drugs metabolized via the cytochrome P450 pathway in the liver such as ketoconazole, oral contraceptives, anti-histamines, statins, and antiepileptics such as phenytoin or carbamazepine which in turn may result in under-dosing.

Table 1: Interactions between illicit drugs and ARVs

Source: World Health Organization. HIV/AIDS treatment and care for injecting drug users. Clinical protocol for the WHO European Region. Copenhagen, Denmark, WHO, 2006.

Table 2: Interactions between drugs commonly used to treat PLWHA and ARVs

Source: World Health Organization. HIV/AIDS treatment and care for injecting drug users. Clinical protocol for the WHO European Region. Copenhagen, Denmark, WHO, 2006.

Careful drug history should be elicited from HIV infected patient on ART by the attending primary care physician in order to avoid potential adverse effects from drug-drug interactions.

In conclusion, primary care physicians have a significant role in early diagnosis of HIV infected people, ensuring wider access to early ART, ensuring the welfare of health care workers attending to possible HIV positive patients and safe long term follow up of HIV positive patients needing medications for non-HIV related ailments.

REFERENCES

1. Rapid advice: antiretroviral therapy for HIV infection in adults and adolescents. World Health Organization (WHO); 2009. [Online]. [Link]
2. Ministry Sets Up Task Force To Tackle HIV Epidemic Among Women. Bernama.com; 16 August  2008. [Online]. [Link]
3. UNGASS Country Progress Report – Malaysia, 2008. [Online]. [Full text]
4. Robbins GK, Spritzler JG, Chan ES, et al. Incomplete reconstitution of T cell subsets on combination antiretroviral therapy in the AIDS Clinical Trials Group protocol 384. Clin Infect Dis. 2009;48(3):350-61. [PubMed] [Full text]
5. Emery S, Neuhaus JA, Phillips AN, et al. Major clinical outcomes in antiretroviral therapy (ART)-naive participants and in those not receiving ART at baseline in the SMART study. J Infect Dis. 2008;197(8):1133-44. [PubMed] [Full text]
6. Moh R, Danel C, Messou E, et al. Incidence and determinants of mortality and morbidity following early antiretroviral therapy initiation in HIV-infected adults in West Africa. AIDS. 2007;21(18):2483-91. [PubMed] [Full text]
7. Severe P, Pape JW, Fitzgerald DW. A randomized clinical trial of early versus standard antiretroviral therapy for HIV-infected patients with a CD4 cell count of 200-350 Cells/ml (CIPRAHT001). 49th Interscience Conference on Antimicrobial Agents and Chemotherapy. San Francisco; 2009.
8. Tabarsi P, Saber-Tehrani AS, Baghaei P, et al. Early initiation of antiretroviral therapy results in decreased morbidity and mortality among patients with TB and HIV. J Int AIDS Soc. 2009;12(1):14. [PubMed] [Full text]
9. Douglas MD, Chu P, Santos GM, et al. Decreases in community viral load are associated with a reduction in new HIV diagnosis in San Francisco. 17th Conference on Retroviruses and Opportunistic Infections. San Francisco; 2010. [Online]. [Link]
10. Donnell D, Kiarie J, Thomas K, et al. ART and risk of heterosexual HIV-1 transmission in HIV-1 Serodiscordant African couples: A multinational prospective study. 17th Conference on Retroviruses and Opportunistic Infections. San Francisco; 2010. [Online]. [Link]
11. Skidmore S, Devendra S, Weaver J, et al. A case study of delayed HIV-1 seroconversion highlights the need for Combo assays. Int J STD AIDS. 2009;20(3):205-6. [PubMed]
12. Cooper DA. Life and death in the cART era. Lancet. 2008;372(9635):266-7. [PubMed]