Lauren Martínez, RN MSW  Director of Prevention Services from the U.S.

    Janet Stansky requested that we clarify the advantages of providing HAART. From a patient's point of view, living a healthier, longer life is clearly advantageous as she pointed out.  HAART is also vital to society as a whole because it reinforces efforts to prevent HIV infection.

    Dr. Dijiba spoke of Botswana. In that country, when it became known that the mining company, Debswana, was planning to provide HAART to its employees, AIDS testing increased by 30% in the company's hospital. When there was no hope for treatment, many people had no incentive to find out their HIV status. They saw no reason to be burdened with the knowledge that they were carrying a fatal virus if  there was nothing they could do to treat it.  However, the possibility of receiving treatment was incentive enough to draw many people into the hospital for testing, and testing is key to preventing HIV infection. If a person knows that he or she is HIV negative, we can provide education and support so that this person might continue to be HIV negative. On the other hand, in the case of a positive test, we can ensure that this person receives social support, treatment for opportunistic infections as needed, and education that may decrease the likelihood that he or she will transmit the virus to others.

    As people see that AIDS is not necessarily fatal, I believe this will help remove much of the stigma* associated with HIV/AIDS. People living with AIDS often face discrimination on the job, rejection by their families, and violence from those who do not understand the disease. Diabetes and high blood pressure are common chronic illness that do not have "cures," but they can be managed. If AIDS can be seen in that light, the disease will become less stigmatized and more people will seek testing.

    Until AIDS becomes less stigmatized, it is helpful that our clinics are not known solely as AIDS treatment centers. Dr. Dijiba mentioned the use of directly observed therapy or DOT to provide ARVs. In fact, we have been employing DOT to treat patients with tuberculosis (TB)*. The same health workers that have been delivering TB medications can be trained to administer ARVs and monitor patients for side effects. A patient's family, neighbors, or co-workers will not know if the health worker is visiting to administer medications for TB, HIV, or any other illness. This fact will help maintain patient confidentiality and safety.

    As long as I mentioned TB, I think it is important to recognize that in some sub-Saharan countries, as many as 70% of TB patients are HIV positive. "TB kills one out of three people with AIDS worldwide.** People dually infected with HIV and TB have a 100 times greater risk of developing active TB and becoming infectious compared to people not infected with HIV." For this reason, treating TB is one way of preventing deaths from HIV. If a person who is dually infected with HIV and TB receives effective treatment for the tuberculosis, he or she will not transmit it to another individual. Remember, TB is transmitted in a much less intimate manner than HIV. In other words, treatment is prevention.

    HAART also assists in preventing HIV infection because effective treatment decreases a patient's viral load, that is, the amount of HIV in his or her blood. This person is then less likely to transmit the virus to a partner during unprotected sex. To be clear, even with an undetectable viral load, the virus can still be transmitted, the chances are just reduced. You may ask, why would a person who is receiving HAART have unprotected sex? Presumably this person would know about the risks of HIV transmission. My answer would be that, unfortunately, not all sex is consensual* and, given their status in society*, women frequently cannot refuse to have sex or insist that their partners use condoms. Women's  lack of education, job opportunities, and access to land for farming often causes them to turn to prostitution to support themselves and their children. We may need to consider setting up an treatment program that provides ARVs to sex workers. Since they have many different sex partners and can potentially transmit HIV to a large number of people, targeting sex workers could reduce HIV infection rates in our service areas. Jack suggests that we treat 50 patients with HAART the first year. Perhaps we could treat 25 patients from the general population and 25 sex workers.

*=Essential
**=Greater Depth
***=Advanced Knowledge