6 курс / Кардиология / Kartikeyan_HIV and AIDS-Basic Elements and Properties
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reached by systematically inducing complete physical, mental, and emotional relaxation. A group of four yoga poses – headstand (Sirsasana), shoulder stand (Sarvangasana), bridge pose (Setu Banda Sarvangasana), and plough pose (Halasana) – is believed to promote strength and flexibility, relieve pressure on abdominal organs, and increase blood circulation. Certain poses assist in relieving fatigue, diarrhoea, anxiety, and depression. Some poses require a bench or chair for support. Head, back, or buttocks may be supported using blankets, pillows or bolsters. In the Iyengar system of yoga, the sequencing of postures is important (www.lifepositive.com).
17.11.1 – Primary Sequence of Yoga Poses
The primary sequence of yoga poses for HIV-infected persons are – ardha mukha vakrasana (headstand), pinca mayurasana (peacock pose – optional), ardha mukha svanasana (“dog pose” with head supported by a block), sirsasana (headstand – contraindicated for persons with neck problems), viparita dandasana (supported inverted staff pose), setu banda sarvangasana (supported bridge pose), sukhasana (cross leg pose, leaning forward, head supported), salamba sarvangasana (supported shoulder stand), ardha halasana (supported plough pose), viparita karani (legs rested on wall with buttocks supported), supta badhda konasana (supine angle pose with back and head supported), and savasana (relaxation pose with head and back supported) (www.lifepositive.com).
17.11.2 – Alternative Sequence of Yoga Poses
Individuals who cannot attain the full yoga pose may try the alternative sequence of poses. This comprises – ardha mukha svanasana (“dog pose” with head supported by a block), janu sirsasana (head/knee forward bend with head supported), triang mukhaipada paschimottanasana (three part forward bend with head supported), seated forward bend or halasana (using support), ardha baddha padmma paschimottanasana (half-bound lotus forward bend with head supported), paschimottanasana (stretch with head supported), ardha salamba sarvangasana (supported shoulder stand), setu banda sarvangasana (supported bridge pose), viparita karani (legs rested on wall with buttocks supported), supta badhda konasana (supine angle pose with back and head supported), and savasana (relaxation pose with head and back supported) (www.lifepositive.com).
17.11.3 – Benefits of Yoga
Though yoga cannot replace professional counselling, yoga techniques are known to help in reducing excessive fear, feeling of loneliness, depression, anxiety, and in learning stress-coping skills. Meditation helps in self-awareness and in building inner strength through relaxation (www.lifepositive.com).
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17.12 – OTHER ALTERNATIVE THERAPIES
Aromatherapy: Essential oils extracted from flowers, herbs, or minerals are inhaled to relieve stress and pain (McKnight & Scott, 1997).
Chiropractic: Also called “osteopathic medicine” or “spinal manipulation”, this system originated in the western countries and involves the manipulation of joints. It has been found to be effective for many types of pain (Tan, 2000a).
Coenzyme Q (CoQ10): This is found in high concentrations in mammalian heart, liver, kidney, and muscle. In persons with immune dysfunction, HIV infection, congestive cardiac failure, and muscular dystrophy, its levels are abnormally low. Toxicity has not been reported with oral administration of CoQ10 for inhibiting replication of HIV in infected cells (McKnight & Scott, 1997).
Dinitro Chlorobenzene (DNCB): This potentially hazardous chemical was first used as a treatment for warts (Happle, 1985), and is also used in colour photography. When applied to skin, DNCB causes delayed-type hypersensitivity. The first topical application of DNCB may produce a chemical burn in addition to the normal pruritic rash. Advocates of DNCB claim that it can clear up all manifestations of HIV disease except for Pneumocystis pneumonia. They believe that ARV drugs, long-term use of acupuncture, more than short-term use of most herbs, and high doses of vitamins reduce the action of DNCB. Though this chemical appears to restore cutaneous immune responses that are lost when HIV disease progresses, these skin responses may not be a good indicator of overall immune health. There is very little research (none recent) to support the benefits of DNCB and its long-term side effects are not known. Since DNCB is inexpensive and cannot be patented, it is difficult to find a sponsor to pay for the clinical trials (Fact Sheet 725, 2006).
Massage: Many traditional medical systems use a wide variety of massage techniques that involve systematic application of pressure to soft tissues of the body, often with the help of oils. These techniques promote circulation of blood and lymph and may thus help in the healing process. Massage therapies have been found to be useful in relieving stress-related ailments (Tan, 2000b).
Meditation: There are many forms of meditation that have similar principles and involve the deliberate suspension of the stream of consciousness. Studies have found meditation to be useful for lowering blood pressure and relieving chronic pain. Biofeedback involves use of monitoring equipment to measure degree of relaxation in a person (Tan, 2000b).
Mind–Body Techniques: Visualization is a process in which persons are guided to imagine themselves in a state of vibrant health, in the belief that through such mental images, the immune system may be directed to fight HIV. Guided imagery is a process where the subject is asked to focus mentally on selected images, such as relief from pain. Other mind–body techniques include hypnosis,
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humour therapy, biofeedback training, and listening to inspirational or relax- ation-inducing audiotapes (www.lifepositive.com).
Music Therapy: Music therapists believe that music (preferably instrumental) should have a frequency of 70–80 beats per minute, corresponding to human heart beat and should have a low pitch. Music therapy has been used to help overcome anxiety, insomnia, and phobias and to relieve stress (Tan, 2000b).
Native American Healing: Most Red Indian (Native American) tribes have healing traditions based on the tribe’s beliefs about how individuals fit in the web of life that includes the tribe, all humanity, the Earth, and the universe. Healing is believed to occur when the person is restored to harmony and connected to universal powers. Healing techniques do not follow written guidelines; they differ from tribe to tribe and from patient to patient. Healers use herbs, “sweat lodges”, ceremonial smoking of tobacco, talking circles, shamans, animal spirits, or “vision quests” (Fact Sheet 708, 2006).
Reiki: It is believed that when the reiki master lays his or her hand on a subject, there is a natural flow of healing energy that percolates to sites in the body, where it is needed (McKnight & Scott, 1997).
Vitamins and Minerals: High-dose vitamin C (ascorbic acid) is most commonly used in the belief that it will enhance immune function (McKnight & Scott, 1997).
17.13 – SIDE EFFECTS AND INTERACTIONS
There is a widespread belief among the public that complementary medicines are safe, because they are “natural”. Many of these products have not been subjected to evaluation of efficacy and adverse effects. Lack of systematic data, together with a misplaced perception of safety, and frequent non-disclosure of use to health care personnel may lead to occurrence of unrecognized side effects due to use of these products (ADRAC, 2005).
Side Effects: Aristolochia species (renal failure), bee products (anaphylaxis), black cohosh or Cimicifuga racemosa (reportedly causes liver failure, requiring its transplantation), and Echinacea species (allergic reactions). Caffeine content of guarana (Paullina cupana) may cause overdose (ADRAC, 2005).
Drug Interactions: A large number of substances including glucosamine and cranberry juice (Vaccinium species) increase the activity of warfarin, causing bleeding. Herbs having similar interaction with warfarin include garlic (A. sativum), Korean ginseng (Panax ginseng), and Gingko biloba (ADRAC, 2005). St. John’s Wort (H. perforatum) may reduce plasma concentrations of a number of drugs and is also serotonergic. (Hall, 2003; ADRAC, 2005).
Serotonin Syndrome: Serotonin syndrome is a toxic state caused mainly by excess serotonin within the central nervous system. Most cases are self-limiting, but the condition can range in severity from mild to life-threatening and result in a variety
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of mental, autonomic and neuromuscular changes. This condition is not an idiosyncratic reaction but a dose-related range of toxic symptoms. Drugs implicated in severe serotonin syndrome include L-tryptophan (precursor of serotonin), tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), pethidine, tramadol, buspirone, amphetamines, anorectics, lithium, and LSD. If two serotonergic drugs are co-administered, the manifestations of the syndrome are severe. Management involves withdrawal of the serotonergic drugs, supportive care, and use of serotonin antagonists like cyproheptadine (Hall, 2003).
Grape Fruit Juice: Health care providers should be aware that there are several groups of drugs that interact with grape fruit juice (Bailey et al., 1998). Bitter Seville oranges also interact with drugs (ADRAC, 2002). Grape fruit juice can inhibit the amount of drug available for absorption, which may increase its pharmacological or toxic effects. Significant interactions have been found to occur with some of the HMG-CoA reductase inhibitors (statins) and saquinavir, among many other drugs (McNeece, 2002). Grape fruit juice inhibits a cytochrome P450 enzyme (CYP3A4) in the intestinal cells, but not in the hepatocytes (ADRAC, 2002). Patients should be advised to avoid consuming grape fruit and its juice altogether when taking certain medicines because the interacting effect may persist for up to 3 days after ingestion (ADRAC, 2003).
17.14 – APPROACH TO ALTERNATIVE THERAPIES
17.14.1 – Guidelines for Patients
Many individuals harbour the notion that medicines that have been used for several centuries must be safe. However, many traditional remedies have not been evaluated for their side effects especially if used for prolonged periods. Traditional medicines are generally more affordable as compared to Western allopathic medicine. However, in recent times, many traditional and alternative medicines have become expensive because of the fad that has grown around natural medicines (Tan, 2000b). Even if the unproven treatments are affordable, patients must know that health insurance will not defray costs and that use of unproven treatments may delay use of proven treatments (Fact Sheet 206, 2006). The PDR Family Guide to Natural Medicines and Healing Therapies published by Ballantine Books, New York (www.randomhouse.com/BB/) contains information on many alternative therapies and herbal remedies along with a review of scientific literature for each of these therapies. The book has a “Western” perspective and may be useful for readers seeking scientific information. The Ayurvedic Institute (www. ayurveda.com/) established in 1984 in Albuquerque, New Mexico (USA) is one of the leading Ayurvedic schools and Ayurvedic health spa outside of India.
17.14.2 – Dos and Don’ts
When choosing to use traditional or alternative therapies, individuals must generally avoid medicines with multiple ingredients because they increase the risk of
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harmful interactions. Individuals must be wary of products and their promotional literature that carry:
(a)Testimonies and anecdotes, which are not adequate proof of a therapy’s efficacy
– placebos may work for some persons because of the element of faith or belief
(b)Claims of “approval” by government agencies
(c)Offers of instant cures for a wide range of diseases or claiming to be effective for incurable diseases, such as AIDS or cancers
(d)Claims of being free of side effects: medicines, or therapeutic techniques cannot be completely free of side effects particularly when they have to be used for prolonged periods
(e)Claims of being “ancient cures” or cures from a far-away land
(f)No mention of their ingredients – if ingredients are listed, it is better to check out their safety and effectiveness.
Claims of “detoxifying” or “purifying” the body (Tan, 2000b).
Products being promoted by discrediting competing products or other medical systems, promotional materials that use pseudoscientific language, and products being promoted as “completely natural” are better avoided. The latter ride on the “back to nature” fad and may be adulterated (Tan, 2000b). Asian, particularly Chinese and Indian herbal medicines have been found to be contaminated with toxic heavy metals and adulterated with undeclared allopathic drugs, such as steroids, antibiotics, and analgesics that could have long-term harmful effects (Ernst, 2002; Tan, 2000b). One should be suspicious if words such as “amazing breakthrough” or “miraculous cure” are used in promotional material. To avoid government regulations, the product may be available privately for a short period of time or only from one source (Fact Sheet 206, 2006).
17.14.3 – The Indian Approach
Practitioners of indigenous systems of medicine, such as Ayurveda, Unani, Siddha and Homeopathy (known by the acronym – AYUSH in India), provide the bulk of health care to rural Indians. Of the estimated 400,000 Ayurvedic physicians in India, about 90 per cent serve the rural areas (DGHS, 2004). Most of them are local residents and are close to the community socially and culturally. In addition, many of the Ayurvedic dispensaries are run by the State Governments. The Government of India has established a National Institute of Ayurveda in Jaipur and a National Institute of Homeopathy in Kolkata. A Central Council of Indian Medicine was established in 1971 to prescribe minimum standards of education in Indian Medicine.
REFERENCES
ADRAC, 2002, Interactions with grape fruit juice. Austr Adv Drug Reactions Bull 21(4): 2. ADRAC, 2003, Interactions with grape fruit juice – Amendment. Austr Adv Drug Reactions Bull
22 (2): 4.
ADRAC, 2005, Adverse reactions to complementary medicines. Austr Adv Drug Reactions Bull 24(1): 2.
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Bailey D.G., Malcolm J., Arnold O., and Spence D., 1998, Grape fruit juice interaction. Br J Clin Pharmacol 46: 101–110.
Bannerman R.H., Burton J., and Chieh C.W. (eds.), 1983, Traditional medicine and health care coverage. Geneva: World Health Organization.
Carson C.F. and Riley T.V., 1994, The antimicrobial activity of tea-tree oil. Med J Austr 160: 236. Chaudhury R.R. and Rafei U.M. (eds.), 2003, Traditional medicine in Asia. New Delhi: WHO-
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Directorate General of Health Services (DGHS), 2004, Health statistics of India. New Delhi: Government of India.
Ernst E., 2002, Toxic heavy metals and undeclared drugs in Asian herbal medicines. Trends Pharmacol Sci 23: 136–139.
Foster S., 1990, Echinacea: nature’s immune enhancer. Rochester, NY: Healing Arts Press. Golleridge C.L. and Riley T.V., 1996, ‘Natural’ therapy for infectious diseases. Med Jour Austr 164:
94–95.
Hall M., 2003, Serotonin syndrome. Austr Prescr 26(3): 62–63.
Happle R., 1985, The potential hazards of dinitrochlorobenzene. Arch Dermatol 121: 330–332. Johnson M.G. and Vaughn R.H., 1969, Death of Salmonella typhimurium and Escherichia coli in the
presence of freshly reconstituted garlic and onion. Appl Microbiol 17: 903–905.
Li G.Q., Duke C.C., and Roufogalis B.D., 2003, The quality and safety of traditional Chinese medicine. Austr Prescr 26(6): 128–130.
McKnight I. and Scott M., 1997, HIV and complementary medicine. In: Managing HIV (G.J. Stewart, ed.). North Sydney: Australasian Medical Publishing.
McNeece J., 2002, Grape fruit juice interactions. Austr Prescr 25: 37.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 206. How to spot HIV/AIDS fraud. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 10 August.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 501. Candidiasis. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 16 March.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 700. Alternative and Complementary therapies. University of New Mexico Health Sciences Center. www. aidsinfonet.org. Revised 16 March.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 702. Ayurvedic medicine. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 5 September.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 703. Chinese acupuncture. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 23 May.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 704. Chinese herbalism. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 23 May.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 708. Native American traditional healing. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 23 May.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 722. Cat’s claw (Uña de Gato). University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 2 May.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 725. DNCB (Dinitrochlorobenzene). University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 9 March.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 726. Echinacea. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 19 April.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 727. Essiac. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 22 June.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 729. St. John’s Wort (Hypericin). University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 18 July.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 731. Marijuana. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 5 September.
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New Mexico AIDS Education and Training Center, 2006, Fact Sheet 735. Silymarin (milk thistle). University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised 6 April.
Scott M. and Irvine S.S., 1997, What do people with HIV, their carers and families want of their medical carers? In: Managing HIV (G.J. Stewart, ed.). North Sydney: Australasian Medical Publishing.
Sepkowitz K.A., 2001, AIDS – the first 20 years. N Engl J Med 344: 1764–1772.
Tan M.L., 2000a, Traditional and alternative medicine. AIDS Action. Asia-Pacific edition. 49: 1–2. Tan M.L., 2000b, Making the right choice in traditional and alternative medicine. AIDS Action.
Asia-Pacific Edition. 49: 2–3.
Tochikura T.S., Nakashima S., Ohashi Y., and Yamamoto N., 1988, Inhibition (in vitro) of replication of the cytopathic effects of human immunodeficiency virus by an extract of the culture medium of Lentinus edodes mycelia. Med Microbiol Immunol 177: 235–244.
Website: www.lifepositive.com/Body/body-holistic/AIDS/hiv-treatment.asp. Accessed on 15 August 2006.
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SECTION FOUR
PREVENTION AND CONTROL
CHAPTER 18
STRATEGIES FOR PREVENTION AND CONTROL
Abstract
At present, information, education and communication (IEC), contact tracing (partner management), cluster testing, and condom promotion are the available measures for effectively preventing the spread of HIV epidemic. Education of various subgroups in the population helps making life-saving choices. “Safer sex” refers to any sexual act without direct contact with body fluids of the sexual partner.
India has adopted a six-pronged approach to ensure safety of blood and blood products, which includes mandatory licensing of all blood banks and testing of every unit of blood for blood-borne pathogens, including HIV. ARV drugs are used for prolonging the life of HIV-infected individuals, preventing transmission from mother to child, and decreasing the complications of immune suppression. Other strategies for controlling HIV epidemic include early diagnosis and treatment of STIs, integration of HIV-related activities with primary health care, and targeted interventions. Specific prophylactic measures are universal biosafety precautions, concurrent disinfection and decontamination, and prevention of opportunistic infections.
Key Words
Antiretroviral drugs, Cluster testing, Condom promotion, Contact tracing, Harm reduction, Information, education, and communication, Needle exchange programmes, Out-of- school youth, Partner management, President’s Emergency Plan for AIDS Relief, Safer sex, Sex workers, Targeted interventions, Truck drivers, Universal biosafety precautions
18.1 – INFORMATION, EDUCATION AND COMMUNICATION
Information, education and communication (IEC) is a “pre-planned, concerted effort, with specific objectives, focussed towards specific programme goals, in order to reach specific target audiences” (NIHFW, 1996). Knowledge, attitude and practice (KAP) studies act as a barometer of the level of knowledge, the prevailing attitudes, and the type of behaviour. KAP studies should be undertaken before and after IEC programmes, in order to know the impact of these programmes (NIHFW, 1996). The objective of each of the components of IEC is clear and specific, and is focused towards specific programme goals. The information component strives to generate awareness in the target audience and improve their knowledge by dissemination of information, either in individual, group, or mass settings. Education component deals with the development of
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favourable attitudes. Communication component aims at bringing about desired behaviour changes, through motivation and persuasion.
18.1.1 – Approaches
Mass Approach: This is used to sensitise the community, and other large groups, about the programme. Various media used for mass approach include film and puppet shows, exhibitions, television and radio programmes, print media, and drama, or films with participation of popular artistes.
Group Approach: This is used to create interest among smaller target groups to accept specific health-related programmes. This approach allows for discussion with intended beneficiaries in order to clarifying their doubts about a particular programme, or intervention. The methods comprise discussion with members of women’s organisations, and youth clubs, training camps for village leaders or panchayat (village council) members and other opinion leaders in the community, and targeting members of fan clubs of celebrities such as film stars and sports persons (NIHFW, 1996).
Individual Approach: This involves meeting decision-makers in the family namely mothers-in-law, husbands, grandparents, or meeting peer groups. Flash cards, charts, and posters may be used in this approach (NIHFW, 1996).
18.1.2 – IEC for Control of HIV Epidemic
Currently, the only available approach for effectively preventing the spread of HIV epidemic is education of various subgroups in the population, to enable making life-saving choices. The topics and modes of presentation will vary according to target group.
General Population: Among the general population, particularly adolescents, education programmes need to emphasise the importance of sexual discretion (avoiding multiple sexual partners and indiscriminate sexual intercourse with strangers, and use of condoms). Piercing of nose, ear, or circumcision is to be done only in health facilities.
High-Risk Groups: Persons with high-risk behaviour should be advised to refrain from donating blood, body organs, semen, or other tissue. HIV-infected women and women at high risk need to be advised about the possible risk of transmission to unborn or newborn baby.
18.1.3 – Ethical and Socio-Cultural Issues
Since the apprehensions about HIV infection and epidemic among the lay persons are not based on scientific facts, public education would be the best antidote. It is said that fear is bred in the unknown. Educators and persons