Good nutrition: wherever possible, a healthy balanced diet should be followed. Alcohol should be consumed only in moderation. A multi-vitamin that does not exceed the daily RDA value should be taken daily. Vitamin D supplementation should also be considered.
Lifestyle: safer sex advice is critical. Even in couples where HIV infection is concordant it is necessary to practice safer sex (use condoms) to prevent super-infection with a resistant virus. Cessation of smoking, alcohol abuse, and substance abuse are also important for a healthy lifestyle. Individuals who inject drugs should be offered harm reduction programmes, including needle exchange and opioid dependence therapies.
Reproduction: couples should be advised on their options for reproduction. This will differ depending on concordance and treatment. The estimated risk for male-to-female HIV transmission is 8 per 10,000 episodes of unprotected vaginal sex. No cases of HIV transmission have been reported in studies of serodiscordant couples in which the infected partner was virologically suppressed with antiretroviral therapy (ART); however, HIV RNA has been detected in the semen of men taking ART who have undetectable levels in their blood. Whether this poses a risk for transmission is unknown. Advice at this stage should be that reproduction is possible and that it can be made as safe as possible, but that reproduction intention needs to be discussed with the practitioner well before conception to ensure best and safest possible scenarios for both partners and the potential infant. For serodiscordant couples, the US Centers for Disease Control and Prevention recommends autologous sperm intrauterine insemination if the woman is HIV-positive, or one of the following options if the man is HIV-positive: use sperm from an HIV-negative donor (the safest option); use ART to suppress infection in the man and have condomless sex near ovulation while the woman is using pre-exposure prophylaxis; or collect and ‘wash’ the sperm to remove HIV-infected cells in conjunction with ART and pre-exposure prophylaxis.
Natural history: patients generally need a sense of what to expect. The information should be based on what is known to be the natural history of HIV in most patients, with a discussion about rapid and long-term controllers but also recognition that most patients fall into the category of slow progressors. Drawing out the relationship between viral activity and CD4 count is a very useful graphic way for patients to understand the relationship between viral activity and the progression of disease better. The message should be tempered by the much more optimistic outlook in the ART era, and patients should be given the understanding that HIV is now a chronic and manageable infectious disease. The need for programme adherence needs to be raised with an ultimate aim of drug adherence when the time comes. Some patients will benefit from comparing HIV to other chronic conditions that require regular monitoring (e.g., diabetes or asthma).
Disclosure: it should be discussed that lifelong care and management will require support from other people in the patient's life. It should be explored who those people may be and how they may be engaged early on so that this support may be forthcoming. Patients sometimes appreciate help with disclosure, especially to sexual partners. A facilitator in this situation can quickly resolve any concerns and fears a sexual partner may have and also assist in further management of the contacts.
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