DEPARTMENT OF MEDICAL LABORATORY
SCIENCE, FACULTY OF HEALTH SCIENCE AND TECHNOLOGY,
IN PARTIAL FULFILLMENT OF THE
REQUIREMENT FOR THE AWARD OF MEDICAL LABORATORY SCIENCE (BMLS)
ABSTRACT / SUMMARY
Research
studies in Nigerian have been done primary in the areas of epidemiology,
clinical practice. Virology, laboratory diagnosis and the management of the
human immune deficiency virus. Therapy for infection with human immunodeficiency virus (HIV) type
1 and type 2 has largely focused on the treatment and management of the HIV
disease (AIDS) rather than the infection therefore opportunistic infection such
as tuberculosis, diarrhea herpes zoster virus and other skin conditions, and
tumors are essentially the targets for therapy. In the management of HIV 1 and
HIV type 2, zalcitabine in combination with saquinavir mesylate is used
(department of haematology, college of medicine of unilag, idi-araba Lagos)
when the combined anti-retroviral drugs were evaluated into a patients with HIV
infection the results was seen after six (6) months of therapy. Efficacy was
evaluated by improvement in the CD4cell count and disappearance clinical signs
and symptoms from the patient’s base line condition. Another way of managing
immunodeficiency Virus (HIV) in Nigeria is by the funding of HIV and AIDS
programmes, which promotes the treatment, care and education of HIV positive
patients in Nigeria. This seminar also introduces the use of herbals in the
management of human immunodeficiency virus by world health organization (WHO).
The herbs alleviates AIDS symptoms.
TABLE OF CONTENT
Certification
……………………………………………………………….. i
Dedication
…………………………...……………………………………. ii
Acknowledgement..………………………………………………………iii
Summary
…………………………………………………………………..iv
Table
of content...…………………………………………………………iv
Introduction…………………………………………………………......….1
The
classification of HIV disease ………………………………………..2
Overview
of the origin of HIV infection in Nigeria……………….……..3
Epidemiology
of HIV infection in Nigeria ……………………………….5
Overview
of the HIV epidemic……………………………………………6
Epidemiological
factor………………………………………..………….11
Mode
of transmission of HIV infection …………………...……………11
Major
mode of transmission of HIV infection in Nigeria………….…..12
Control
and HIV prevention of HIV infection in Nigeria………...…….14
Management
of HIV infection in Nigeria……………………………….18
Role
of drugs in the management of HIV/AIDS in Nigeria…………..18
The
use of antiretroviral drugs in the management of
HIV infection in Nigeria………………………………………………….20
Management
of HIV infection in Nigeria with zalcitabine in combination with saquinavir mesylate-
by akinsete et al;
2000…………………………...………….22
Management of HIV in Nigeria
using herbals which alleviatesaids symptoms, by world health organization
(who)……………………….23
Management
of HIV infection in Nigeria by funding for
HIV
and aids programmes………………………………………..……..26
Factors influencing the accessibility of
HIV/AIDS-related
drugs in Nigeria……………………………………………………….….27
Challenges associated with the effective management
of HIV infection in Nigeria………………………………………...……..29
Conclusion………………………………...…………………….………..32
References……………………………………………………..…………33
INTRODUCTION
HIV
was classified as member of the genus lentivirus, part of the family retroviridae.
Many species are infected by lentiviruses which are characteristically
responsible for long duration illnesses with a long incubation period (Jawtz, et
al; 2007).
Human
immunodeficiency virus (HIV) causes progressive impairment of the
body’s cellular immune system, leading to increased susceptibility to
infections and tumors and the fatal condition AIDS (Acquired immunodeficiency
syndrome). In the management of the HIV infection, treatment initiated before
advanced stage reduces plasma HIV RNA concentration to undetectable values in
most motivated patients who have access to the antiretroviral drugs. Many HIV
infected people remain unaware of their HIV infection, and they continue to
transmit the infection to others and when diagnosed, have very advanced and often
difficult-to-treatment late-stage disease.
HIV/AIDS is a global crisis, a
challenge to human life and dignity with ability to erode social and economic
development. It has great influence on stability, life expectancy and economic
development. It is a major public health problem with sub-Saharan Africa
severely affected by the epidemic. HIV has the potential of hindering the
realization of the Millennium Development Goals and its spread promotes
poverty, and has unleashed immense suffering on different countries and
communities worldwide. (UNGAS, 2001).
THE CLASSIFICATION OF HIV DISEASE
- HIV-1
- HIV-2
The HIV-1
Based
on the enveloped sequence, HIV-1 comprises three (3) distinct virus groups (M,
N and O); the predominant M group contains at least ten subtypes (Cheesbrough; 2000)
In
Africa, subtype C is found in southern Africa (inducing zambia, zimbabwe,
Malawi), subtype E is found in central Africa, Thailand and other counters of
southern Asia while subtype E and B is found in south’s America. (Pope M. et al., 1997)
Differences
in the case of transmission, virulence and disease progression may occur
between strains. Group O containing a distinct F group of heterogeneous
viruses, which are of low prevalence and have been found in west Africa,
particularly Cameroon (cheesbrough; 2000).
HIV-2.
HIV-2
is found mostly in west Africa, including Senegal, Guinea Bissau, Ghana, Cotod’
ivore, Mali (cheesbrough; 2000). Most
HIV-2 infections reported from Brazil, Angola, and Portugal could usually be
traced back to a west Africa contact. HIV-2 is less easily transmitted than
HIV-1 and the period between initial infection and illness is longer in HIV-2.
HIV-1 is more virulent and is the causes of the majority of HIV infections
globally (cheesbrough; 2000).
Comparison of HIV Species
|
Species
|
Virulence
|
Infectivity
|
Prevalence
|
Inferred origin
|
|
HIV-1
|
High
|
High
|
Global
|
Common
chimpanzee
|
|
HIV-2
|
Lower
|
Low
|
West
Africa
|
Sooty
management
|
OVERVIEW OF THE ORIGIN OF HIV INFECTION
IN NIGERIA
Human immunodeficiency virus (HIV) in humans
originated from cross-species infections by simian viruses in rural Africa
probably due to direct contact with infected primate blood (Morgan et al; 2002)
Sequence
evolution analysis, places the introduction of Simian immunodeficiency virus into
humans that gives rise to HIV-I group at about 1930 presumably, such transmission
occurred repeatedly over the ages, but particularly social, economic and behavioral changes that occurred in the 20th
century provided circumstance that allowed these virus infection to expand and become
well established in humans and reach epidemic proportions.
The
first recognized cases of AIDS occurred in the USA in the early 1980s. a number
of gaymen in New York city and California suddenly began to develop rare
opportunistic infections and cancers that seemed stubbornly resistant to any
treatment. At this time, AIDS did not yet have a name, but quickly became
obvious that all the men were suffering from a common syndrome. The human
immunodeficiency virus (HIV) causes acquired Immuno deficiency syndrome (AIDS)
HIV attacks the Immune system, weakens it, and exposes the body to
opportunistic infections, a variety of illnesses and cancers contracting
several opportunistic infections (or one of a number of specific infections)
often leads health care workers to suspect and test for HIV (UNAIDS, 2000)
Most common symptoms of
opportunistic infections in Nigeria
|
Symptoms
|
%
of patients
|
|
Prolonged
fever
|
73.12
|
|
Chronic
diarrhea
|
53.05
|
|
Chronic
cough
|
50.19
|
|
Tuberculosis
|
15.15
|
|
Dermatitis
|
25.03
|
|
Lymphadenopathy
|
39.92
|
|
Herpes
zoster
|
9.88
|
|
Genital
ulcers
|
8..03
|
|
Candidiasis
|
6.58
|
Source:
Akinsette 1998 (43% according to Idigbe et
al., 2000)
The first case of HIV/AIDS in Nigeria was reported in
1986. in 1991, the federal ministry of health conducted the first sentinel
sero-prevalence survey in Nigeria. In this survey, and in subsequent surveys
conducted in 1993,, 1999, and 2001, population selected to estimate HIV
Sero-prevalence were pregnant women attending antenatal clinics (ANCs),
patients with sexually transmitted infections (STIs), patients with Tuberculosis,
and female commercial sex workers (UNAIDS, 2000).
EPIDEMIOLOGY OF HIV INFECTION IN NIGERIA
AIDS
was discovered first in the united states in 1980s as a new disease entity in
homosexual men: 20 years later, AIDS has become a world wide epidemic that
continues to expand (Nester et al; 2004)
As
of January 2006, the Joint united nations programme on HIV/AIDS (UNAIDS) and
the world health organization (WHO) estimate that AIDS has killed more than 25
million people since it was first recognized on December 1981, making it one of
the most destructive pandemics in recorded history. In 2005, AIDS claimed an
estimated 3.3 million lives, of which more than, 570,000 were children. It is
now estimated that about 0.6% of the world’s living population is infected with
HIV (Jawetz; 2007, Nester; 2004).
In
2010, an estimated 48, 079 adults and adolescent were diagnosed with HIV
infection; of these 79% of diagnoses among males and 21% were among females.
HIV has remained localized primarily to West Africa ((Jawetz et al; 2007, Nester et al; 2007).
OVERVIEW OF THE HIV EPIDEMIC
Nigeria
has the second highest number of people living with HIV in the world after
South Africa. (UNAIDS, 2009) UNAIDS estimated 33.4 million people living with
HIV in 2008 in the world. Nigeria, with about 2.98 million people living with
HIV, makes about 9% of the global HIV burden. However, there is gender
inequality in the distribution with males accounting for 1.23million and female
accounting for 1.72 million in the HIV estimates and projections for 2008.
Women are more affected in the defining Feature of the epidemic with policy
implications for prevention of mother to child transmission. Hence, addressing
gender inequality is crucial in the control of the epidemic. Nigeria recorded
the first case of acquired immunodeficiency syndrome (AIDS) in 1986. Heterosexual
sex remains the primary mode of transmission for HIV and accounts for 80 – 95%
of HIV infections in Nigeria. Tracking the course of HIV epidemic in Nigeria
requires good reporting and surveillance system. Thus, Nigeria through the
Federal Ministry of Health instituted regular surveillance system using
clinical-based and population-based surveys to monitor the epidemic. This is
needed to obtain reliable information about HIV prevalence and behaviors
associated with HIV epidemic in relation to temporal changes, geographic
distribution, magnitude, and mode of transmission. Furthermore, this
surveillance system provides opportunities to monitor trend in prevalence,
create awareness about early response, inform priority setting for new
interventions and measure the effectiveness of public health interventions in
the control of the epidemic. (Ainsworth M, Teokul W, 2000).
The
federal Ministry of Health and National Commission with support from NACA and
other relevant stakeholders conducts four main surveys namely:
- National
HIV/AIDS and Reproductive Health Survey Plus (NARHS Plus)- This is a population
based survey that estimates HIV prevalence and obtains information on the
associated factors in addition, it provides information on the sexual and
reproductive health status in the country it is usually conducted every two
years. (Jhap, et al., 20012).
- HIV/STI
Integrated Biological and Behavioral Surveillance Survey (IBBSS)- This survey
is targeted at the most at risk populations whose behaviors or occupations often
place them at higher risk of contracting sexually transmitted infections
including HIV. It estimates HIV prevalence among the most at risk populations
and provides information on drivers of the epidemic among these groups. It is
usually conducted every two years. (Federal Ministry of Health, 2001).
- Antenatal
Care Survey- This is a clinic based sentinel survey to estimate HIV prevalence
among pregnant women attending antenatal clinic. It is conducted every two to
three years. (Federal Ministry of Health, 2004).
- Nigeria Demographic and Health Survey
(NDHS) – it is a nationally representative survey. Prior to 2008 survey, the
last one was in 2003. It is conducted by National Population Commission with
international support. HIV epidemic rose from 1.8% in 1991 and peaked at 5.8%
in 2001. It is currently at 4.6% in 2008 antenatal survey. Figure 1 below shows
a rapid rise in HIV prevalence in the sentinel surveys carried out from 1991 to
2001 (1.8% in 1991 to 4.5% in 1996 and then to 5.8% in 2001). Subsequently, the
trend reversed and took a downward turn from 5.8% in 2001 to 5% in 2003 and
then to 4.4% in 2005.
Although a slight increase was
observed in HIV prevalence from 4.4% in 2005 to 4.6% in 2008. However, in each
of the sentinel survey there were significant variations in the different
states of the federation.
HIV prevalence rate by state
|
State
|
HIV Prevalence
(1999)
|
Estimated HIV
Infection
|
HIV Prevalence
(2001)
|
Estimated HIV
Infection
|
|
Abia
|
3.0
|
50,237
|
3.3
|
34,335
|
|
Adamawa
|
5.0
|
56,510
|
4.5
|
57,149
|
|
Akwa ibom
|
12.5
|
172,90
|
10.7
|
122,169
|
|
Anambra
|
6.0
|
106,721
|
6.5
|
134,325
|
|
Bauchi
|
3.0
|
26,488
|
6.8
|
114,288
|
|
Bayesa
|
4.3
|
17,675
|
7.2
|
49,935
|
|
Benue
|
16.8
|
279,466
|
13.5
|
245,066
|
|
Borno
|
4.5
|
67,633
|
4.5
|
52,140
|
|
Cross River
|
5.8
|
61,152
|
8.0
|
93,582
|
|
Delta
|
4.2
|
61,141
|
5.8
|
15,842
|
|
Ebonyi
|
9.3
|
68,015
|
6.2
|
51,91
|
|
Edo
|
5.9
|
69,772
|
5.7
|
54,828
|
|
Ekiti
|
2.2
|
15,132
|
3.2
|
31,326
|
|
Enugu
|
4.7
|
52,172
|
5.2
|
51,639
|
|
FCT
|
7.2
|
17,044
|
10.2
|
7,127
|
|
Gombe
|
4.7
|
39,860
|
8.2
|
103,620
|
|
Imo
|
7.8
|
73,305
|
4.3
|
79,865
|
|
Jigawa
|
1.7
|
29,387
|
1.8
|
46,043
|
|
Kaduna
|
11.6
|
151,007
|
5.6
|
199,723
|
|
Kano
|
4.3
|
126,056
|
3.8
|
299,197
|
|
Katsina
|
2.3
|
63,075
|
3.5
|
76,544
|
|
Kebbi
|
3.7
|
42,811
|
4.0
|
556,884
|
|
Kogi
|
5.2
|
79,053
|
5.7
|
88,385
|
|
Kwara
|
3.2
|
29,229
|
4.3
|
45,779
|
|
Lagos
|
6.7
|
226,674
|
3.5
|
70,171
|
|
Nasawara
|
10.8
|
63,077
|
8.1
|
49,275
|
|
Niger
|
6.7
|
72,496
|
4.5
|
55,383
|
|
Ogun
|
2.5
|
33,374
|
3.5
|
58,480
|
|
Ondo
|
2.9
|
34,164
|
6.7
|
92,875
|
|
Osun
|
3.7
|
39,462
|
4.3
|
52,125
|
|
Oyo
|
3.5
|
65,591
|
4.2
|
79,561
|
|
Plateau
|
6.1
|
63,662
|
8.5
|
82,076
|
|
Rivers
|
3.3
|
90,805
|
7.7
|
123, 233
|
|
Sokoto
|
2.7
|
45,505
|
2.8
|
45,229
|
|
Taraba
|
5.5
|
38,773
|
6.2
|
60,460
|
|
Yobe
|
1.9
|
7,106
|
3.5
|
24,280
|
|
Zamfara
|
2.7
|
38,877
|
3.5
|
32,162
|
Source:
National AIDS/ STD Control Programme/FMOH, 1999; 2001
EPIDEMOLOGICAL FACTOR
Travel:
International
travel has undoubtedly played a major role in the spread of HIV in the U.S, international
travel by young men making the most of the gay sexual revolution of the late
70s and early 80’s would certainly have played a large part in taking the virus
world wide in Africa, the virus would probably have been spread along truck
routes and between towns and cities within the content itself.
The blood Industry
As
blood transfusions became a routine part of medical practice, an industry to
meet this increased demand for blood began to develop rapidly. In some
countries, donors are paid to give blood, a policy that often attracts those
most desperate for cash; among them are intravenous drug users. In the early
stages of the epidemic, doctors were unaware of how easily HIV could be spread
and blood donations remained unscreened.
MODE OF TRANSMISSION OF HIV INFECTION
Nigeria
undertook modes of transmission modeling in 2009 the joint united nations
program on aids (UNAIDS) mode of transmission model was undertaken by the
National country team, with support from UNAIDS and the world bank, and was built
on the world bank epidemiology and response synthesis project in Nigeria, the
model estimates the distribution of new infections and identifies populations
and highest risk for HIV infection. The mode shows that high-risk groups will
significantly contribute to new HIV infections. These high risk groups are
about 1% of the general population, and are men that have sex with men, female
sex workers and injecting drug users. They will contribute almost 23% of no
infections (UNAIDS, 2009). However, people practicing low-risk sex in the
general population will contribute 42% of the infections due to low condom use
and high sexual networking (UNAIDS, 2009)
MAJOR MODE OF TRANSMISSION OF HIV
INFECTION IN NIGERIA
Sexual route:
The
majority of HIV infections are acquired through unprotected sexual relation
having vaginal or anal sex without a condom with someone who is infected.
Heterosexual
spread of HIV is increasing and promises to become the dominant mode of
transmission. In many African counties, sex with multiple partners, traumatic
sex, anal sex, all increases the risk of sexual HIV transmission.
Blood Transfusion:
HIV
transmission through unsafe blood accounts for the second largest source of HIV
infection in Nigeria (Egesie J. and Egesie E, 2011). Not all Nigerian hospitals
have the technology to effectively screen blood and therefore there is a risk
of using contaminated blood. The Nigerian Federal Ministry of Health have
responded by backing legislation that requires hospitals to only use blood from
the National Blood transfusion services, which has far more advantaged
blood-screening technology (Nigeria Exchange, 2008). It is also of concern for
person receiving medical care in regions where there is prevalent substandard
hygiene in the use of injection equipments, such as the reuse of needles in
third world countries. (Reeves and Doms; 2002)
Mother to child transmission:
The
third most important mode of HIV spread is from mother to infant. The
transmission from mother to child varies from 13% to 40% in untreated women Infact
can become infected in uteri during birth process or more commonly through
breast feeding. In the absence of breastfeeding, about 30% of infections occur
uteri and 70% during delivery. Data indicate infection in Africa is due to
breastfeeding (Bell 1997). High material viral loads are risk factors for viral
transmission (Jawetz et al; 2007,
Nester et al; 2007). HIV has been
found at low concentration in saliva, tears and urine of infected individuals,
but there are no recorded cases of infection by these secretions and the potentials
risk of transmission is negligible (Bell, 1997).
Estimated per act risk for acquisition
of HIV per exposure routes
|
S/N
|
Exposure
Routes
|
Estimate Infection per
Chance of infection
|
|
A
|
Blood
transmission
|
90%
|
|
B
|
Child
birth
|
25%
|
|
C
|
Needle-sharing
infection drug use
|
0.67%
|
|
D
|
Receptive
and intercourse
|
0.04-3.0%
|
|
E
|
Percuteneous
needle stick
|
0.30%
|
|
F
|
Receptive
penile-vaginal intercourse
|
0.05-0.30%s
|
|
G
|
Insertive
anal intercourse
|
0.06-0.056%
|
|
H
|
Receptive
fellatio
|
0-0.04%
|
|
I
|
Insertive
fellatio
|
0-00.5%
|
Assuming
no condom is used (Smith and Daniel, 2006)
CONTROL AND PREVENTION OF HIV INFECTION IN
NIGERIA
HIV TESTING
Doctors seeing patients in an HIV clinic
in Nigeria.
In Nigeria there is a distinct lack
of HIV testing programmes. In 2007, just 3 percent of health facilities had HIV
testing and counseling services, (WHO et
al., 2008) and only 11.7 percent of women and men aged 15-49 had received
HIV test and found out the results (UNCASS, 2010). In 2010, there were only 1.4
HIV testing and counseling facilities for approximately every 100,000 Nigerian
adults, which shows how desperately the government needs to scale up HIV
testing services. (WHO et al, 2011)
whilst an estimated 2.2 million people aged 15 years and above received HIV
testing and counseling in 2010, this amounts to only around 31 people per
100,000 of the total adult population (WHO et al, 2011). Moreover, HIV testing
and counseling of pregnant women is central to the prevention of
mother-to-child transmission, yet this remains extremely low with only in 7
pregnant women receiving it in 2010.
EDUCATION
Sex
is traditionally a very private subject in Nigeria, and the discussion of sex
with teenagers is often seen as inappropriate. Attempts at providing sex
education for young people have been hampered by religious and cultural
objections (Odutolu, O et al, 2006).
In 2009 only 23 percent of schools were provided life skills-based HIV
education, and just about 25 percent of men and women between the ages of 15
and 24 correctly identified ways to prevent sexual transmission of HIV and
rejected major misconceptions about HIV transmission (UNGASS, 2010). In some
regions of Nigeria, girls marry relatively young, often to much older men in
north western Nigeria around half of girls are married by age 15 and four out
of five are married by the time they are 18 (the population council, 2007).
Studies have found those who are married to younger age have less knowledge
about HIV and AIDS than unmarried women and are more likely to believe they are
low-risk for becoming infected with HIV. (the population council, 2007). HIV
and AIDS education initiatives need to focus on young married women, especially
as these women are not likely to have access to health information than
unmarried women (the population council, 2007).
CONDOMS
The total number of condoms provided
by international donors has been relatively low. Between 2000 and 2005, the
average number of condoms distributed in Nigeria by donors was 5.9per man, per
year (UNFAA, 2005). Restrictions on condom promotion have hampered HIV
prevention efforts. In 2001, a radio advertisement was suspended by the
advertising practitioners council of Nigeria (APCON) for promoting messages
suggesting that it is acceptable to engage in premarital sex as long as a condom
is used (Population service international, 2003). In 2006, APCON also started
to enforce stricter regulations on condom advertisements that might encourage
indecency (UN Integrated Regional Information Networks, 2006). The number of
female condoms sold in Nigeria has significantly increased from 25,000 in 2003
to 375,000 in 2006 (UNFPA, 2007)
MEDIA CAMPAIGNS AND PUBLIC AWARENESS
Addressing
HIV- related issues in Nigeria through television drama as Nigeria is such a
large and diverse country, media campaigns to raise awareness of HIV is a
practical way of reaching many people in different regions. Radio campaigns like
the one created by the society for family health is thought to have been
successful in increasing knowledge and changing behavior. ‘Future dream,’’ was
a radio serial broadcast in 2001 in nine languages on 42 radio channels. It
focused on encouraging consistent condom use, increasing knowledge and
increasing skills for condom negotiation in single man woman aged 18 and 34
(population services international, 2003). In 2005, a campaign was launched in
Nigeria, in a bid to raise more public awareness of HIV/AIDS. This campaign
took advantage of recent increase in owners of mobile phones and sent text
massages with information about HIV/ AIDS to 9 million people (BBC News, 2009).
Another high profile media campaign is fronted by Femi Kute, the son Fela Kuti,
the famous Afro beat musician who died of AIDS in 1997. He appears on bill
board a long side roads throughout Nigeria with slogan “AIDS: No dey show for
face.‘’ which means you can’t tell someone has AIDS by looking at them (Reuters
News Media, 2003 )
PREVENTION OF MOTHER-TO-CHILD
TRANSMISSION OF HIV
Nigeria’s
programmes to prevent the transmission of HIV form mother to child (PMTCT) started
in July 2002. (National Agency for the control of AIDS, 2010). Despite efforts
to strengthen PMTCT interventions, by 2007 only 5.3 percent of HIV positive
women were receiving antiretroviral drugs to reduce the risk of mother –to
child transmission. This figure had risen to almost 22percent by 2009, but
still remained for short of Universal access target which aim for 80 percent
coverage. (WHO et al, 2010). Single
–dose nevirapine is no longer recommended for the prevention of mother-to-child
transmission. Whildt 19, 733, or 9 percent, of HIV – infected pregnant women
received the most effective antiretroviral treatment regimes for PMTCT in 2010,
around 6, 505 pregnant women still only received single-dose neviroaine (WHO.. et al, 2011). Coverage for infants
remains low; in 2009 only 8 percent of children received antiretroviral for
PMTCT (UNICEF, 2010).
MANAGEMENT OF HIV INFECTION IN NIGERIA
Role of drugs in the management of
HIV/AIDS in Nigeria
The classes of drugs most important
to people living with HIV/AIDS (PLWHA) are
·
Anti-infective
agents to treat or prevent opportunistic infection.
·
Anti-cancer drugs
to treat malignancies, such as Kaposi Sarcome and Lymphoma;
·
Palliative drugs
to relieve pains and discomfort, both physical and mental;
·
ARVS (Antiretrovirals
to limit the damage that HIV dose to the immune system by reducing Viral load.
Based on extensive field research, MSF (Medicines)
bans frontiers (doctors without Borders) asserts that the priority medicines
for resources poor setting are:
(1) Drugs
for the prevention of opportunistic infection particularly Isoniazide and
cotrimoxazole, which are recommended by WHO/UNAIDS;
(2) Palliative
drugs, such as analgesics and antidiarrheas, which have shown to improve the
well being of patients
(3) Antiretrovirals
(ARVS) which can act as preventives of opportunistic infections and help to
extend and improve the quality of live by reducing viral loads;
(4) ARVs
such as AZT and NVP, which can prevent MTCT and can be used as post-exposure
Prophylaxis (Perez –casas and Boulet, 2000).
The use of antiretroviral drugs in the
management of HIV infection in Nigeria.
There
are two main types of antiretroviral drugs:
* Nucleoside Reverse Transcriptase
Inhibitors (NRTIS)
* Non-nucleoside
Reverse Transcriptase Inhibitors (NRTIS)
(Colebunders, et
al…, 1997)
List
of NRTIS
|
Drug
|
Manufacturing company
|
|
AZT,Z
idovudide (Retrovir)
|
Glaxo
Smith Kline
|
|
ddI,
didanosine (VIdex)
|
Bristol
Myers Squibo
|
|
Ddc,
Zalcitabine (HIVid)
|
Roche
|
|
3TC,
Lamivudine (Epivir)
|
Glaxo
smith Kline
|
|
D4T,
Stavudine (Zerit)
|
Bristol
Myers Squibb
|
|
Abacavir
(Ziagen)
|
Glaxo
Smith Kline
|
|
Combine
pill of AZT &3TC(combivir)
|
Glaxo
Smith Kline
|
|
Combined
pill of AZT, 3TC and Abacavir (Trizivir)
|
Glaxo
Smith Kline
|
(UNA IDS/ Nigeria, 2001)
List
of NNRTI’s
|
drug
|
Manufacturing
company
|
|
Neuirapirie
(Varamune)
|
Boehringer
ingelheim
|
|
Efavirenz
(Sustiva)
|
DU
pont in the U.S; Stocrin-Merck in the nest of the world
|
|
Delavirdine
(REscripita)
|
Pharmacia
and upjohn
|
(UNAIDS/
Nigeria, 2001).
The
drugs selected for the survey in Nigeria, includes the following.
Antiretrovirals : delarvidine, Zindovudine CAZT, efavirenze, indinavir
(ddi), saquinavir, nelfinavir, stavudine, nevirappine, ritonavir, lamiivudine,
zalatabine, AZT/3TC combination.
Antibiotics: Amoxycillin /clavulanate, aproflaxacine,
cotrimoxazole, ceftrioxone, azithromicine antifundals: fluconazole,
ketoconazole, amphotericine B, Itraconazle.
Anti-TB:
ISonizide, Rifampicin, Pyrazinamide.
(UNAIDS
/ Nigeria, 2001).
MANAGEMENT OF HIV INFECTION IN NIGERIA
WITH ZALCITABINE IN COMBINATION WITH SAQUINAVIR MESYLATE- BY JEGEDE-
EKPE ET AL, 2003
ZALCITABINE + SAQUINAVIR MESYLATE
The
anti-retroviral drug was evaluated in 24 adult Nigeria patients with HIV
infection. The result of an interim analysis after a 6-months course of therapy
is presented herein. Patients were given zalcitabine 2.25mg and saquinavir
1800mg per day. Efficacy was evaluated by improvement in the CD 4 cell count
and disappearance or resolution of clinical signs and symptoms from the patent
baseline condition. Tolerability and safety were assessed occurrence of adverse
event and monitoring of biochemical parameters such as alanine, transminase,
alkaline phosphatase and total bilirubin.
The haemogram profile of patients were also monitored, there was
clinical improvement in 79.2% of the patients, a minimal increase in the CD4 cell
count was observed, and the incidence of adverse event was 40%. The
hematological and biochemical profile of the patients were not significantly affected
by the treatment.
Therefore,
a conclusion was made that the drug cocktail comprising zalcitabine and
saquinavir dose posses good potentials for effective management of Nigeria
patients with HIV infection (source, department of haematology, college of
medicine Unilag, Idiaraba Lagos).
MANAGEMENT OF HIV IN NIGERIA USING
HERBALS WHICH ALLEVIATES AIDS SYMPTOMS, BY WORLD HEALTH ORGANIZATION (WHO)
Though
scientists are yet to find a cure for HIV and AIDS, certain traditional
medicines have been shown to help treat many of the symptoms of opportunistic infection
that are part of the disease.
According to living well with HIV/AIDS: A manual on nutritional care and support for people
living with HIV/AIDS by FAO “The effect may not be the same for all people. People
can try this herb and decide for themselves whether they are helpful.
The manual reads: “Remember that all herbs and spices should be used in
moderate amounts. Exceeding these amounts may cause problems and have a toxic
effect.
Aloe Vera
ALOE
helps to relieve constipation: Use extract, boil and drink the concentrated
water. To be used in limited amount; stop immediately if it causes cramps or
diarrhea.
C’alendula flower
It
has anti septic, anti inflammatory and healing functions helps with infections
of the upper digestive tract. Prepare as tea to help digestion.
Cayeme
Stimulates
appetite; helps fight infection, heals ulcers and intestinal inflammation. Add
a pinch to cooked or raw foods for energizing drink; add to fruit juice or
water.
Eucalyptus
Has
an antibacterial function, particularly for lungs and during bronchitis.
Eucalyptus oil from leaves increases the blood low and reduces the symptoms of
inflammation. Prepare tea from the leaves or extracts.
Garlic:
Has
antibacterial, antiviral and antifungal function especially in the, intestine,
lungs and vagina. Helps feeling of weakness, also for throat infections, herps
and diarrhea. Prepare as tea or use in food.
Fennel:
Helps
to increase appetite, combat flatulence and expel gas. Add as spice to food or
prepare tea from the seeds.
Ginger:
Improve
digestion, energies, relieves diarrhea, and stimulates appetite used for
treatment of common cold flu and nausea, prepare as a ginger tea or use as
spic.
Lemon:
Has
antibacterial functions and helps digestion. Add lemon juice to food or drinks.
Peppermint:
May
help nausea, reduces colic (Abdominal pain and cramps) helps to control
diarrhea and stops vomiting, also used for relieving tension and sleeplessness.
Prepare as tea, by boiling the leaves for about 10 minutes.
Thyme:
Has
antiseptic and antifungal function. Relaxes nervous coughing and increases
mucosal secretion. Stimulates digestion and the growth of the good intestinal
flora in the guts. Use as mouth wash or as a vaginal douche.
Indeed, preliminary result on the evaluation of herbal
preparations used for the management of
HIV/AIDS in many African countries have shown encouraging results that there
have been improvements of quality of life and clinical conditions of patients
treated with such herbal preparations.
Blood
test to monitor their level of immunity (CD4 and CD8 counts) have also shown an
improvement and in some cases there has been a significant decrease in viral
load.
Management of HIV infection in Nigeria
by funding for HIV and AIDS Programmes.
It has been estimated that the
Nigerian government are contributing around 5 percent of the funds for the
antiretroviral treatment programmes (Health Reform foundation of Nigeria 2007).
The majority of the funding comes from development partners. The main donors
are PEPFAR, the Global Fund and the World Bank. In 2002, the World Bank loaned
US $90.3 million to Nigeria to support the 5-year HIV/AIDS programme
development project (Health Reform Foundation of Nigeria, 2007). In May 2007,
it was announced that the World Bank were to allocate a further US $ 50 Million
loan for the programme. (The World Bank, 2008).
Through the President’s Emergency
Plan For AIDS Relief (PEPFAR), the United States has allocated a large amount
of money to Nigeria. In 2008 PEPFAR provided approximately US$ 448million to
Nigeria for HIV/AIDS prevention, treatment and care (PEPFAR< 2008) the third
highest amount out of PEPFAR’s is to focus countries. By the end of 2008, the
Global Fund had disbursed US $ 95million in funds for Nigeria to expand treatment/management,
prevention and prevention of mother-to-child transmission programmes, (the Global
Fund, 2009). Much of this were given to the Nigeria government to fund the
expansion of antiretroviral treatment.
FACTORS
INFLUENCING THE ACCESSIBILITY OF HIV/AIDS-RELATED DRUGS IN NIGERIA
1. Generic
production. The presence or absence of generic competition in the
open market is a key determinant of pricing levels. Competition brings down
prices dramatically. For example, fluconazole is not patented in Thailand.
Before fluconazole was produced as a generic in 1998, Pfizer sold it for US$7
per 200mg capsule. Then, three Thai companies began production and Pfizer
dropped its price to US$3.6, even though generic companies were charging much
less (Biolab was charging US$0.6). After initially responding to generic
competition, Pfizer increased its price in Thailand to US$6.2 in March 2000,
while Biolab’s price decreased its price to US$0.3 (20.7 times cheaper than
Pfizer’s price). Multinational 20 companies have had to contend with similar
competition from CIPLA in India. Glaxo Welcome’s lamivudine (3TC) 150mg tablet
costs 78 percent less in India than in the United States. Brazil generically
manufactures a great deal of its ARV drug supply, which is sold at a fraction
of the price globally. A generic form of zidovudine is 14 times cheaper in
Brazil than in the United States (Peréz-Casas and Boulet, 2000a).
2. Cost-drivers,
tariffs, and taxation. In addition to multinational monopoly
pricing regimes, costs within a country make essential drugs even more out of
reach for Nigerians. The executive secretary of the Nigerian Pharmaceutical
Group, Kunle Okelola, noted that the following add-ons create substantially
higher drug costs:
A. Shipping
and handling usually is about 20—30 percent of the drug price.
B. Additional
costs exist for shipping to health facilities (inland transportation cost).
C. Taxes
paid on imported drugs are 25 percent.
D. Imported
raw materials are 5 percent.
E. There
should be no value-added tax (VAT) on pharmaceuticals; however, some are still
made to pay 5 percent (a cost that is now in the process of being
eliminated).
F. Prices
are marked up by manufacturers, importers, suppliers, and retailers to ensure
profits for everyone.
G. There
is no excise duty on locally made products (Ikoro, 2001).
3. Differential pricing: Comparing prices between countries is inherently difficult because of the problem of comparing official exchange rates and real currency values; differences in pharmaceutical distribution channels (private versus public sector, retail versus wholesale); different strengths and pharmaceutical dosages; price fluctuations overtime, and so forth. However, companies often price the same drugs in different countries at different prices. (UNICEF et al., 2000)
3. Differential pricing: Comparing prices between countries is inherently difficult because of the problem of comparing official exchange rates and real currency values; differences in pharmaceutical distribution channels (private versus public sector, retail versus wholesale); different strengths and pharmaceutical dosages; price fluctuations overtime, and so forth. However, companies often price the same drugs in different countries at different prices. (UNICEF et al., 2000)
CHALLENGES
ASSOCIATED WITH THE EFFECTIVE MANAGEMENT OF HIV INFECTION IN NIGERIA
1. Challenges
of availability of affordable laboratory-monitoring tests and trained manpower
required for the implementation of HIV therapy
Few laboratories in resource-constrained countries can afford to perform laboratory- monitoring tests required for the implementation of HIV therapy. Flow cytometric techniques are expensive and require a significant infrastructure to perform. In addition, the measurement of quantities of virus in the blood known as viral load is an important clinical parameter to evaluate the severity of disease and to monitor the efficacy of therapy. These expensive laboratory tests require complex technologies not previously used in much of the developing world. Scientists are devising new methodologies that they hope will be as sensitive as existing methodologies yet more cost effective. The laboratory infrastructure is the most expensive and specialized part of any institutional framework for HIV/ AIDS cares (Stephenson, 2002). In Nigeria, policymakers and decision makers have tended to view laboratories in the narrow context of HIV screening. At the onset of the ART program no laboratory in the country had the full capacity needed to monitor treatment response and toxicity properly. Only a handful of institutions had the capacity to perform CD4+ counts, a necessary test for decision-making in HIV therapy. The federal government program provided the training and technical capacity for CD4+ tests to be performed in the 25 treatment centers using a manual microscopic technique, This technology is labour intensive, and one laboratory scientist cannot reliably perform more than 10 tests a day. This pace cannot accommodate the expansion of ART in these centers and in other centers that would rely on them for laboratory support. Through a generous donation from MTN Nigeria, a telecommunications company, APIN was able to equip two federal treatment centers—at University College Hospital and Jos University Teaching Hospital—with flowcytometry—based instruments (Imade et al., 2005), which allow technicians to process more than 100 CD4÷ tests daily. The instruments cut the cost of the tests four- to fivefold. All Harvard PEPFAR program sites are now equipped with these instruments. Many other programs in Nigeria, particularly the other PEPFAR programs, have opted for that investment as well. Similarly, when the ART program started in Nigeria, only one centre had the capacity to perform viral load tests routinely; these tests are used to measure the virus level in the blood of infected individuals and thereby allow clinicians to assess treatment efficacy. This centre, the Nigerian Institute of Medical Research, had been upgraded and equipped by a grant from the Ford Foundation. APIN, a project based at the Harvard School of Public Health (HSPH) and sponsore1d by the Bill & M1inda Gates (Stephenson et al., 2002)
Few laboratories in resource-constrained countries can afford to perform laboratory- monitoring tests required for the implementation of HIV therapy. Flow cytometric techniques are expensive and require a significant infrastructure to perform. In addition, the measurement of quantities of virus in the blood known as viral load is an important clinical parameter to evaluate the severity of disease and to monitor the efficacy of therapy. These expensive laboratory tests require complex technologies not previously used in much of the developing world. Scientists are devising new methodologies that they hope will be as sensitive as existing methodologies yet more cost effective. The laboratory infrastructure is the most expensive and specialized part of any institutional framework for HIV/ AIDS cares (Stephenson, 2002). In Nigeria, policymakers and decision makers have tended to view laboratories in the narrow context of HIV screening. At the onset of the ART program no laboratory in the country had the full capacity needed to monitor treatment response and toxicity properly. Only a handful of institutions had the capacity to perform CD4+ counts, a necessary test for decision-making in HIV therapy. The federal government program provided the training and technical capacity for CD4+ tests to be performed in the 25 treatment centers using a manual microscopic technique, This technology is labour intensive, and one laboratory scientist cannot reliably perform more than 10 tests a day. This pace cannot accommodate the expansion of ART in these centers and in other centers that would rely on them for laboratory support. Through a generous donation from MTN Nigeria, a telecommunications company, APIN was able to equip two federal treatment centers—at University College Hospital and Jos University Teaching Hospital—with flowcytometry—based instruments (Imade et al., 2005), which allow technicians to process more than 100 CD4÷ tests daily. The instruments cut the cost of the tests four- to fivefold. All Harvard PEPFAR program sites are now equipped with these instruments. Many other programs in Nigeria, particularly the other PEPFAR programs, have opted for that investment as well. Similarly, when the ART program started in Nigeria, only one centre had the capacity to perform viral load tests routinely; these tests are used to measure the virus level in the blood of infected individuals and thereby allow clinicians to assess treatment efficacy. This centre, the Nigerian Institute of Medical Research, had been upgraded and equipped by a grant from the Ford Foundation. APIN, a project based at the Harvard School of Public Health (HSPH) and sponsore1d by the Bill & M1inda Gates (Stephenson et al., 2002)
2. Challenges of deciding the optimal time to start
antiretroviral treatment
Highly Active Antiretroviral Therapy (HAART) has changed the landscape of HIV- related care in the developed world with marked reduction in mortality and morbidity (Cameron et al., 1998). This possibility however is beyond the reach of a vast majority of HIV-infected in sub Saharan Africa. Following the development of HAART, many physicians were quite aggressive in treating patients at virtually any stage of this human retroviral disease. Increasing concern related to drug toxicities, pill burden, cost and ability of patients to adhere to strict and complicated regimens, have complicated the decision-making process for physicians and patients alike (Volberding, 2000). Despite promised price-reduction and increased availability of generic drugs in some countries, cost remains a major factor in deciding when to start therapy.
Highly Active Antiretroviral Therapy (HAART) has changed the landscape of HIV- related care in the developed world with marked reduction in mortality and morbidity (Cameron et al., 1998). This possibility however is beyond the reach of a vast majority of HIV-infected in sub Saharan Africa. Following the development of HAART, many physicians were quite aggressive in treating patients at virtually any stage of this human retroviral disease. Increasing concern related to drug toxicities, pill burden, cost and ability of patients to adhere to strict and complicated regimens, have complicated the decision-making process for physicians and patients alike (Volberding, 2000). Despite promised price-reduction and increased availability of generic drugs in some countries, cost remains a major factor in deciding when to start therapy.
CONCLUSION
HIV which was classified as member of the genus
lentivirus, part of the family retroviridae, when properly managed with some
cocktails of antiretroviral drugs, anti-infective agent, anti-cancer drugs,
palliative drugs can promote the effective suppression of viral replication,
the reconstitution of the immune system, and improvement of the physical well
being of the study population. The management of HIV can also reduce the rapid
spread of the infection through sexual route, blood transfusion,
mother-to-child transmission e.t.c.
Finally,
a lot of care is also required for already positive individuals, because it
keeps them happy and healthy.
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