HIV- Management

HIV- Management 
In HIV infection there is intense and persistent viral replication which leads to gradual depletion of CD4 cells. The primary goal in managing the HIV patients is to prevent this process of replication to as low as possible and to maintain it as long as possible.  With this there is lower risk of clinical progression of the disease and prevention of opportunistic infection.
Classes of ANTIRETROVIRAL DRUGS: Anti retroviral drugs act by inhibiting the multiplication of the virus. The drugs mainly target 2 key enzymes the virus requires to multiply.These are PROTEASE , REVERSE TRASCRIPTASE. Drugs inhibiting the Reverse Transcriptase enzyme are divided into two types – Neucleoside Reverse Transcriptase Inhibitors (NRTIs) & Non-Neucleoside Reverse Transcriptase Inhibitors (NNRTIs).
Combination Therapy: HIV virus has the ability of developing resistance if any one drug is used alone. Hence current guidelines are to use at least 3 antiretroviral drugs in combination. This is the same principle used in the treatment of tuberculosis. This triple drug regime is commonly called HAART ( Highly Active Antiretoviral Therapy). HAART has been shown to inhibit viral replication to levels below the limit of detection.

Antiretroviral Drugs                                                                Incomplete list

Nucleoside Reverse Transcriptase Inhibitors (NRTIs) Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs) Protease Inhibitors (PIs)
Zidovudine  Nevirapine  Indinavir 
Stavudine  Efavirenz  Nelfinavir 
Lamivudine  Delavirdine  Ritonavir 
Didanosine   Saquinavir
Zalcitabine Amprenavir 
   Abacavir  Lopinavir / Rotinavir 
Initiating Antiretroviral Therapy: The antiretroviral therapy is started in persons with sign of compromised immune system or indication of presence of Opportunistic infection.
CD4+ cell count less than 500 cells/ micoliter or increase of viral load to more than 5,000 – 10,000 copies/ milliliter. are indications of reduced immune strength. All symptomatic patients with symptoms suggestive of active infection – wasting, thrush or unexplained fever for > 2 wks. should be started with antiretroviral drugs irrespective of the viral load. Proper counseling of the patients is also very important before commencing the therapy. Patients is told about the fact that the therapy has to be life long and it is not curative. Cost of the therapy and side effects should be known to the patient. Adherence to the treatment process should be thoroughly stressed. The patient should know that even if he or she is keeping fine transmission of the infection to others is possible and safe sex methods should be practiced.  

Commonly used initial Antiretroviral regimens

Antiretroviral drug regimens are comprised of one choice each from column A and B. 

Column A

Column B

Efavirenz Stavudine + Didanosine
Indinavir Stavudine + Lamivudine
Nelfinavir Zidovudine + Lamivudine
Nevirapine Zidovudine + Didanosine
HIV positive patients should be kept up to date on immunizations.
Pneumococcal vaccine: Booster at 5 years.
Hepatitis B vaccine.
Influenza vaccine: yearly.

How to get rid of Tobacco Smoking

for those who smoke

How to get rid of Tobacco Smoking
Tobacco is a serious but preventable risk factor for the heart diseases. It has a large habit forming potential. The strong addiction to smoking needs equally strong motivation and determination to get rid of this habit. But it is not an impossible task. Those who on this habit have no option but to get rid of this addiction if they wish to prevent heart and lung problems and to avoid expensive cardiac surgery like cardiac bypass or angioplasty in the future.
A smoker has to makeup his mind to quit smoking. It has to be 100 percent, as anything less that this would not do. It should be understood that it is far easier for a confirmed smoker not to smoke a single cigarette than to struggle with a reduced number. Thus one has to aim at quitting completely. There is nothing like a “reduction in smoking”.

The rewards of quitting smoking are enormous. The extra risk of heart problems start reducing the moment you stop smoking and it should practically disappear in two to three years.

If you can stop smoking and throw away your pack of cigarette for good, nothing like it. If not, you can do it in two or three stages, but with a clear resolve that the goal is complete abstinence and under no circumstances the interim stage be allowed to become the goal.
It is a fact that one cigarette leads to another, because it not only satisfies the craving for the nicotine but also produces craving for more. You would have noticed that when you get up in the morning the craving for the cigarette is the minimum. but after the first smoke the craving increases. It is therefore important to recognize that the easiest cigarette to resist is the first cigarette of the day. Similarly if you are confined to bed due to some illness and have not smoked for a few days, the craving appreciably diminishes.
Thus, if you cannot stop smoking all of a sudden, then you should do it in 3 stages.
In the first stage reduce the number to exactly half, realizing fully that this is a temporary and merely the first battle against tobacco. Continue this for a month. You’ll notice that craving for the cigarette has considerably reduced.
In the second stage, reduce the number of cigarettes to 4 or 5, and continue for another month. At this stage you’ll find that the craving has become so little that it is not difficult to stop the cigarette smoking.
In the third or the final stage, take the final plunge and say goodbye to smoking forever. Do not keep any cigarettes at home. Throw away all the things like ash trays, cigarette tighter or anything that may remind you of smoking.

Make your house a real Non Smoking Zone

In the first few days you may need some substitute like chewing gums or cardamom. Make use of them but be sure not to allow any temptation to overpower you to take to cigarettes.

It should be understood that the nicotine addiction is like any other addiction and can wake up again any time if you smoke even one cigarette. You may be tempted to argue with yourself that you will only smoke 3 or 4 cigarettes a day. But this does not work. It has worked with no one and it would not work with you also. The four cigarettes would soon become 40.

Once you have stopped smoking it should be complete abstinence forever.

  • Whenever you have that craving, try deep breathing when either standing or sitting. Having a glass of water and exercising also helps to decrease the craving.
  • When you feel like taking tobacco, think of your children and the effect on their future if you develop any of the dangerous diseases caused by tobacco.
  • Use the 4 Ds when the craving for smoking/tobacco hits you:
    • Do something else
    • Delay smoking/tobacco consumption
    • Deep breathing
    • Drink water
  • Use positive self-talk.
  • Practice relaxation techniques (yoga, walking, meditation, dancing, music etc.) every day.
  • Be active, and eat a healthy diet!

Tobacco Facts

Tobacco Facts 
  • Tobacco smoke contains more than 4,000 identified chemical compounds, 43 of which are known to cause cancer in humans or animals.
  • The terms “light” and “mild” are grossly misleading, since they imply a healthier cigarette or tobacco product and smokers regulate their nicotine intake by the intensity, volume or frequency of puffing to get their desired nicotine dose.
  • Smokers who don’t quit in their early thirties have a 50% chance of dying of a tobacco-related disease. 
 Smokeless Tobacco

  • There are forms of smokeless tobacco – Tobacco is taken in various ways – Tobacco with betel leaves, Chewing tobacco (khaini), Guthkha, Tobacco snuff.
  • Smokeless tobacco is not safer than cigarettes-it contains many dangerous chemicals, including cancer-producing chemicals.
  • Long-term smokeless tobacco users begin to develop oral tissue abnormalities within a year.
  • Smokeless tobacco can result in non-cancerous and pre-cancerous oral lesions, gum recession, gingivitis, tooth caries, abrasion and stains.
 Passive Smoke (ETS)

  • Environmental tobacco smoke (ETS) [passive smoke] is a Group A carcinogen and it causes 30 times as many lung cancer deaths as all air pollutants combined.
  • Exposure to passive smoke increases the risk of lower respiratory tract infections, asthma, ear infections and Sudden Infant Death Syndrome in children
Health Risks

  • Nicotine produces cancer. Cancers caused by Tobacco
    • Oral cancers
    • Oropharyngeal cancers
    • Laryngeal cancers
    • Hypopharyngeal cancer
    • Lung cancer
    • Esophageal cancer
    • Urinary bladder cancer 
  • Nicotine causes increases in heart rate, blood pressure, and blood flow from the heart; narrowing of blood vessels; decreased oxygen in the blood; increased fatty acids, glucose, cortisol and other hormones in the blood; increased risk of hardened arteries and blood clotting. 
Pregnancy and Smoking
Many women, particularly teenage girls, have taken up smoking in recent years. A study revealed that smoking among pregnant teens has increased, with as many as 29% of non-Hispanic white teens smoking during pregnancy.The health benefits of quitting smoking are significant for the unborn children of pregnant women.

  • Pregnant women who smoke are at much greater risk of miscarriage, stillbirth, pre-term delivery, low-birth weight, and infant mortality.
  • If the pregnant woman stops smoking before pregnancy or during the first 3-4 months of pregnancy, the risks of low birth weight are reduced.
  • Even though the use of the nicotine replacement patch during pregnancy is controversial, many experts agree that the benefits of quitting outweigh the potential toxicity of nicotine found in NRT treatments. 
Chewing Tobacco



Phosgene is the chemical compound with the formula COCl2. It is a colorless gas which gained importance as a chemical weapon during World War I.Phosgene was synthesized by the British chemist John Davy in 1812 by exposing a mixture of carbon monoxide and chlorine to sunlight.

In low concentrations, its odor resembles freshly cut hay or grass.

It is also an industrial reagent in synthesis of pharmaceuticals and other organic compounds. In addition to its industrial production, small amounts occur naturally from the breakdown and the combustion of organochlorine compounds, such as those used in refrigeration systems.Phosgene is produced by passing purified carbon monoxide and chlorine gas through a bed of porous activated carbon, which serves as a catalyst.

Upon ultraviolet (UV) radiation in the presence of oxygen, chloroform slowly converts into phosgene. To suppress this photodegradation, chloroform is often stored in brown-tinted glass containers.

The great majority of phosgene is used in the production of isocyanates, The isocyanates are precursors to polyurethanes.

Significant amounts are also used in the production of polycarbonates. Polycarbonates are an important class of engineering thermoplastic found, for example, in lenses in eye glasses.

Phosgene is an insidious poison as the odor may not be noticed and symptoms may be slow to appear.  Its high toxicity arises from the action of the phosgene on the proteins in the pulmonary alveoli, which are the site of gas exchange. The damage to the alveoli disrupts the blood-air barrier, causing suffocation.Sodium bicarbonate may be used to neutralise liquid spills of phosgene. Gaseous spills may be neutraised with ammonia.
Following the extensive use of phosgene gas in combat during World War I, it was stockpiled by various countries as part of their secret chemical weapons programs.Phosgene was frequently used by the Imperial Japanese Army against the Chinese during the Second Sino-Japanese War.
Chemical Weapons

Tear gas

Tear gas
Among the first uses of chemicals as weapons, Tear inducing agents were used.During the first World War, the French army were the first to employ gas, using 26 mm grenades filled with tear gas (ethyl bromoacetate) in August 1914. The small quantities of tear gas used were not even detected by the Germans. Active agent was later changes to chloroacetone.In October 1914, German troops fired fragmentation shells filled with a chemical irritant against British positions at Neuve Chapelle.

These days a type of Tear Gas is routinely used by police to disperse rowdy crowd of demonstrators.

Chemical Weapons