SOCIAL ISSUES:
1. DISCRIMINATION:
Discimination is an unfair treatment of a person or group on the basis of prejudice.
discrimination against people with HIV/AIDS is still pervasive in most parts of the country;
discrimination touches every aspect of the lives of people with HIV/AIDS;
discrimination is becoming more subtle and hard to redress;
discrimination has a significant impact on the health and well-being of people with HIV/AIDS and of populations affected by HIV/AIDS.
2. STIGMA:
"Stigma remains the single most important barrier to public action. It is a main reason why too many people are afraid to see a doctor to determine whether they have the disease, or to seek treatment if so. It helps make AIDS the silent killer, because people fear the social disgrace of speaking about it, or taking easily available precautions. Stigma is a chief reason why the AIDS epidemic continues to devastate societies around the world."
From early in the AIDS epidemic a series of powerful images were used that reinforced and legitimised stigmatisation.
• HIV/AIDS as punishment (e.g. for immoral behaviour)
• HIV/AIDS as a crime (e.g. in relation to innocent and guilty victims)
• HIV/AIDS as war (e.g. in relation to a virus which must be fought)
• HIV/AIDS as horror (e.g. in which infected people are demonised and feared)
• HIV/AIDS as otherness (in which the disease is an affliction of those set apart)
3. WORK PLACE ISOLATION:
Persons living with HIV/AIDS often face enormous resistance from employers: "Every study of AIDS-related discrimination to date has found that the largest category of complaints concerns employment. Sometimes employers refuse to hire or retain HIV-infected workers because of ignorance and fear about how HIV is transmitted. Sometimes employers act out of fear regarding increased health insurance costs. And sometimes employers are simply responding to the fear and ignorance of the individual's co workers. Whatever the cause, the result is an unwarranted limitation on work place opportunity: the person with HIV disease is fired from a job, or not
hired for a job, or not promoted, or not given a raise, even though the person is qualified to work and able to keep working."
4. DENIAL OF EDUCATION:
A large segment of people affected by HIV is in the age group of 15-24 years. Many of them being students have had their problems further compounded by the denial of educational facilities in some form or the other. Such student have sometimes been singled out through placement in separate class rooms.They were discriminated to such an extend that some instances of isolation inside glass booths placed in a corner of the class were also reported.
5. FAMILY DISINTEGRATION:
At the family level ,an adult with HIV will severely compromise house hold resources as the functional capacity to work is reduced ,medical expenditures increases and income of both the infected individual and those who care for that person is lost. Reduced income in turn threatens food supply, the ability to pay for the education or health of surviving family members. And there are also cases in which the affected individual is forsaken by the members for certain reasons.
ETHICAL ISSUES:
1. CONFIDENTIALITY:
Because of the sensitivity of HIV-related information, many countries have adopted laws that provide additional protection to HIV-related medical records. except to public health authorities.
2. INFORMED CONSENT FOR HIV TESTING:
HIV testing was recognized as different from other blood tests because it presented serious psychosocial risks, such as rejection by family; discrimination in employment; and/or restricted or no access to health care, insurance, and housing. In recognition of these circumstances and to encourage testing, special procedures were adopted for obtaining consent for an HIV test, such as pretest counseling and specific informed consent.
3. PRENATAL HIV TESTING:
The primary strategy to prevent perinatal HIV transmission is to maximize prenatal HIV testing of pregnant women. Hence under mandatory newborn HIV testing, newborns are tested for HIV, with or without the mother's consent, if the mother's HIV status is unknown at delivery.
4. PARTNER NOTIFICATION:
It allows the doctors to discuss with the HIV infected patients about their active partners. (those whom they may have exposed to HIV infection through sex or needle sharing.) The Health Department or physicians can then notify people who are at risk about where to get counseling, testing, and treatment if they are infected.
LEGAL ISSUES:
1) Liberty, autonomy, security of the person and freedom of movement:
• People with HIV or AIDS have the same rights to liberty and autonomy, security of the person and to freedom of movement as the rest of the population.
• No restrictions should be placed on the free movement of HIV-infected people, and they may not be segregated, isolated or quarantined in prisons, schools, hospitals or elsewhere merely because of their HIV-positive status.
2) HIV Testing
(a) When may a person be tested for HIV
• No person may be tested for HIV infection without his or her free and informed consent (except in the case of anonymous epidemiological screening programmes undertaken by authorised agencies such as the national, provincial or local health authorities.)
• In all other cases – such as HIV testing for research purposes or when a person’s blood will be screened because he or she is a blood donor – the informed consent of the individual is legally required.
• Where an existing blood sample is available, and an emergency situation necessitates testing the source patient’s blood (e.g. when a health care worker has been put at risk because of an accident such as a needlestick injury), HIV testing may be undertaken without informed consent - but only after informing the source patient that the test will be performed and after assuring him or her that privacy and absolute confidentiality will be maintained.
• If an existing blood sample is not available for testing in an emergency situation, the patient must give his or her informed consent for blood to be drawn for the HIV test to be done.
• Routine testing of a person for HIV infection for the perceived purpose of protecting a health care professional from infection is impermissible - regardless of consent.
• Proxy consent for an HIV test may be given where an individual is unable to give consent. Proxy consent is consent by a person legally entitled to grant consent on the behalf of another individual. For example, a parent or guardian of a child below the age of consent to medical treatment may give proxy consent to HIV testing of the child.
(b) Informed consent, pre- and post-HIV test counselling
• Informed consent, which includes pre-HIV test counselling, is compulsory before HIV testing may be carried out.
• Informed consent means that the person has been made aware of, and understands, the implications of the test.
• The person should be free to make his or her own decision about whether to be tested or not, and may in no way be coerced or forced into being tested.
• Pre-test counselling should occur before an HIV test is undertaken. It should take the form of a confidential dialogue between the client and a suitable, qualified person where relevant information is given and consent obtained.
• Post-test HIV counselling should take place as part of the process of informing an individual of an HIV test result.
• Anonymous and confidential HIV antibody testing with pre- and post-HIV test counselling should be available to all. Persons who test HIV positive should have access to continuing support and health services.
3. Confidentiality and privacy
• People with HIV infection and AIDS have the right to confidentiality and privacy about their health and HIV status.
• Health care professionals are ethically and legally required to keep all information about clients or patients confidential.
• Information about a person’s HIV status may not be disclosed to anybody without that person’s fully informed consent.
• After death, the HIV status of the deceased person may not be disclosed to anybody without the consent of his or her family or partner – except when required by law.
4. Health and support services, public benefits, medical schemes and insurance
• Because people with HIV or AIDS in South Africa have the right to equal access to public benefits and opportunities, HIV testing should not be required as a precondition for eligibility to such advantages.
• People with HIV/AIDS have the same rights to housing, food, social security, medical assistance and welfare as all other members of our society.
• Public measures should be adopted to protect people with HIV or AIDS from discrimination in employment, housing, education, child care and custody and the provision of medical, social and welfare services.
• Medical schemes may not discriminate unfairly- directly or indirectly – against any person on the basis of his or her state of health.
• People with HIV infection or AIDS (and those suspected of being at risk of having HIV or AIDS), should be protected from arbitrary discrimination in insurance. Insurance companies may not unfairly refuse to provide an insurance policy to any person solely on the basis of HIV/AIDS status.
5.Education on HIV and AIDS
• All people have the right to proper education and full information about HIV and AIDS, as well as the right to full access to and information about prevention methods.
• Public education with the specific objective of eliminating discrimination against persons with HIV or AIDS should also be provided.
6.The responsibilities of the media
• Persons with HIV infection or AIDS have the right to fair treatment by the media and to observance of their rights to privacy and confidentiality.
• The public has the right to informed and balanced coverage of, and the presentation of, information and education on HIV and AIDS.
7.The right to safer sex
• All persons have the right to insist that they or their sexual partners take appropriate precautionary measures to prevent the transmission of HIV.
• The especially vulnerable position of women in this regard should be recognised and addressed - as should the especially vulnerable position of youth and children.
• People have a moral and legal obligation to tell their sex partners if they are HIV positive. They must also ensure that their sex practices are as safe as possible (e.g. by using condoms). Disclosing HIV infection to sex partners is a part of one’s duty to protect others from potential exposure to the virus.
8.The rights of prisoners
• Prisoners with HIV infection or AIDS should enjoy the same standards of care and treatment as other prisoners.
• Prisoners with HIV/AIDS should have access to the kind of special care that is equivalent to that enjoyed by other prisoners with other serious illnesses.
• Prisoners should have the same access to education, information and preventive measures (condoms) as the general population.
9. Duties of persons with HIV or AIDS
• Persons with HIV or AIDS have the duty to respect the rights, health and physical integrity of others, and to take appropriate steps to ensure this when necessary.
NATIONAL AIDS CONTROL PROGRAMMES (NACP):
EVOLUTION AND STRUCTURE:
• National AIDS Control Organization (NACO) established in 1992 with $ 84 million loan from the World Bank.
• In 1999, phase II of the National AIDS Control Program (NACP-II) initiated with another loan from the World Bank for $ 191 million. The National AIDS control policy adopted in 2002
• NACO has established State AIDS Control Societies (SACS) in most states to administer prevention and care activities
• Within the ministry of health and family welfare, the National AIDS Control Program is implemented as a vertical, stand alone program
• 64% of the budget allocated for prevention; 15% to care and support programs (excludes ARV drugs); 15% for technical capacity; and 6% for inter-sectoral collaboration
OBJECTIVES OF THE PROGRAM AND POLICY:
• In the second phase, the program aims to achieve 90% awareness levels and 90% condom use among “high risk” categories, and keep HIV prevalence below 5% in high prevalence states
• The project aims to train 600-100 NGO in conducting interventions among high-risk groups defined as sex workers, truck drivers, injecting drug users, migrant laborers and men having sex with men.
The main project components are
1. targeted interventions for the "high-risk" populations
2. preventive interventions for the "general" population
3. low cost care for HIV positive persons
PROGRAM AND POLICY PRIORITY:
• Emphasis on awareness in design of IEC, VCT, school based education
• National policy aims to reinforce "traditional Indian moral values" among youth
• STI control based on strengthening of STI clinics at the tertiary levels where drugs, reagents, training and other laboratory facilities provided
• Condom programming – decline in free distribution and increase in social marketing approaches
• Vulnerability of women articulated in terms of gender inequality and poverty, but no specific strategies identified
• Recent plans to introduce MTCT programs in all district hospitals
• Program document says that government will review and reform criminal laws in context of HIV, strengthen anti-discrimination laws and support services to educate HIV affected people about their rights
SIX KEY COMPONENTS:
1. Targeted interventions and “risk group” approach
2. Condom programming
3. STI control
4. IEC and Family health awareness campaign
5. HIV testing and counseling (VCT)
6. Mother to child transmission (MTCT)
SOCIAL SUPPORT SYSTEMS FOR PLHIV:
Social workers are one of the strongest sources of social support associated with high levels of medication compliance in patients with HIV/AIDS.
Today, social workers help clients cope with HIV/AIDS in a wide variety of settings, including home health agencies, hospitals, infectious disease clinics, and AIDS service organizations. While the doctor’s relationship with the patient seldom extends beyond the clinic or hospital doors, the social worker’s concern reaches into every area of the client’s daily life, confronting the challenges the client faces every day. One of the greatest challenges is remaining compliant with complicated treatment regimens.
The family and the environment remain the social support system to the client.
SUPPORT GROUPS:
The very AIDS Support Group mention of AIDSprovokes a picture of a person ridden with feelings of guilt and shame. There are many people who cannot bear with the idea of getting a HIV infection. They are scared to talk to anyone about it and also terrified how it will affect their family. Persons with HIV infection get terminated from their jobs and has no access to social services.
A support group helps one to deal and survive with the truth, horror, pain and deep sorrow. A community which shares and cares together. Help comes from all directions. Your experiences will also give another person hope!
COMMUNITY HEALTH PROGRAMMES:
It focuses on the health, development and wellbeing of individuals and their families; and through them the community at large. The program has been envisaged to address key issues affecting life at various stages.
It includes:
• Making Pregnancy Safe (MPS)
• Child Health and Development (CHD)
• Adolescent Health and Development (AHD)
• Nutrition for Health and Development (NHD)
• Reproductive Health and Research (RHR)
• Strengthening Public Health
POSITIVE WOMEN’S NETWORK:
Positive Women Network (PWN+) is an All-India network of HIV positive women, focused on improving the quality of life of women and children living with HIV/AIDS. We support one another, fight for our rights, and sensitize society about our needs.
Activities include…
• Organizing self-help and support groups
• Counselling
• Providing access to information and medicines
• Developing models for generating income and creating livelihoods among Women Living with HIV/AIDS (WLHA)
• Organising national consultations, public hearings, projects and workshops
• Forming regional networks of WLHA
• Carrying out research on key issues affecting women and children
The five core strategies of PWN+ are:
• Strengthen community outreach systems to identify and enhance the greater involvement and participation of women living with HIV/AIDS (WLHA)
• Scale up advocacy initiatives based on the experiences of WLHA, and the innovative strategies and interventions undertaken by the Positive Women Network and each of the state chapters
• Network with like-minded, supportive and influential institutions, stakeholders and groups that can address the concerns of WLHA
• Improve delivery mechanisms and modalities of all types of services for women vulnerable to, and living with HIV/AIDS
• Expand capacity building programmes and to work through WLHA wherever possible
{HIV/AIDS brings with it a fear of rejection, stigma, discrimination and harassment. Women living with the virus have described a sense of fatalism that sets in and a darkness that descends on their lives.
Living Positive is a means of converting a life filled with fear and fatalism into one of hope and meaning. It involves knowing that something can be done to make your life better, and that there are people who can walk with you on your journey.
Know your Rights
First, you have to know your entitlements. As a woman living with HIV/AIDS, you have a right to:
• Live free from violence
• Choose when to get married
• Choose who you marry
• Own your share of property
• Learn the skills you need for employment
• Get employment opportunities
• Guarantee your child a secure future
• Receive proper healthcare
• Get necessary information
• Get proper counseling
• Have reproductive choices
• Confidentiality regarding your HIV status
• Access drug rehabilitation services
Get help
Get access to information, medicines and advice
• Visit our Drop-In centres, which are open from 9:30 am - 5:30 pm on weekdays. You can get information on various issues (eg: legal matters, health advice etc.), help with medicines and/or doctor’s appointments, or just come to chat and relax.
•
• Talk to us about anything you need to. If something is worrying you, tell us and we will help. We can talk to you over the phone, visit you at hospital, or you can even come in to meet us face to face. We guarantee to maintain confidentiality. No one will learn about your HIV+ status.
Get emotional support
Join one of our support groups, and gain strength from the ‘togetherness’. Experience has shown us that there is a lot to be gained from sharing your problems and supporting other women in your situation.
Find a means of earning your own income
• Start a business of your own: Thirteen women living with HIV/AIDS decided to create a means of earning their own livelihood. Starting out with no business knowledge and almost no money they worked towards starting an enterprise. With our help, The New Modern Garments Store, is now a flourishing enterprise.
• Join an existing venture:Social Light Communications is a design and print company that helps organizations develop communication material, and in doing so provides an income for women living with HIV/AIDS.
• Make and market products: The WE Shop provides marketing support for products made by women living with HIV/AIDS who are deprived of basic rights.
Find Inspiration
What does it take to survive the challenges of HIV/AIDS? Where do you find the energy to fight for what you need? How do you keep going when your world is falling apart? Can life ever really be normal again?
Across India, women living with HIV/AIDS find reasons to live and paths to happiness. Hear their stories. Learn what pulled them through…
Join the community
There are thousands of women Living Positive. They are all going through what you are. Why walk alone? Join our network and benefit from their experience, support and guidance. }
Wednesday, April 21, 2010
HIV 2 & 3
HIV/Aids is often called the “silent epidemic” due to its very long incubation period - meaning that a person can be infected for many years without showing any symptoms. An HIV positive person may not even know that he or she is infected and unknowingly also infect other people through unprotected sexual intercourse.
HIV SYMPTOMS
Early symptoms of HIV infection develop in 50 to 90 percent of people who are infected, usually beginning two to four weeks after exposure to HIV. However, there have been instances in which up to 10 months have passed between exposure and the first signs and symptoms of HIV infection. The initial group of signs and symptoms is referred to as primary or acute HIV infection.
Because the signs and symptoms of primary HIV may be similar to other common illnesses such as the flu, most people do not initially realize that they have HIV.
1. Body wide symptoms — The most common, body wide signs and symptoms of primary HIV include fever (temperature above 100.4ºF or 38ºC), sore throat, headache, and muscle and joint pain. These flu-like symptoms last approximately two weeks.
During the second week of the illness, most people also have painless swelling of certain lymph nodes, including those in the armpits and in the neck. Although the lymph nodes decrease in size after the first few weeks, swelling can linger. Some people develop mild enlargement of the spleen (known as splenomegaly). The spleen is an abdominal organ, located under the left lower ribs.
2. Skin, mouth, genital symptoms — A characteristic feature of primary HIV infection is open sores or ulcers. These sores or ulcers can develop in the mouth, the esophagus (the tube that extends from the mouth to the stomach), the anus, or the penis. The ulcers are usually swollen and painful.
Many people also develop a rash or reddish swelling of the skin about two to three days after fever. The rash usually affects the face, neck, and upper chest or may be more widespread, involving the scalp, arms and legs, and the palms and soles. The rash usually lasts approximately 5 to 8 days.
3. Digestive symptoms — Many people with primary HIV infection develop nausea and vomiting, diarrhea, lack of appetite (known as anorexia), and weight loss. Rarely, more severe abnormalities of the digestive system develop, such as inflammation of the liver or the pancreas.
4. Respiratory symptoms — A dry cough is usually the only respiratory symptom associated with primary HIV infection.
5. Opportunistic infections — After becoming infected with HIV, the immune system may not function as well to protect the body from certain organisms. These organisms can cause infections known as "opportunistic infections". While these opportunistic infections are more common in people who have had HIV for many years, they can occur in people with primary HIV infection as well.
One of the most common opportunistic infections is yeast infection of the mouth or esophagus. Yeast infections are caused by Candida, a fungal organism that is normally found on the skin and in the mouth, intestinal tract, and vagina in healthy individuals.
Phases of infection:
Although HIV-infection can theoretically be divided into different phases, it is important to note that HIV-infection cannot in practice be precisely demarcated into separate and distinct phases with easily identifiable boundaries. The health of the HIV positive person will depend on the health of his or her immune system (on CD4 cell count and viral load in the blood, as well as on the exposure to infections and diseases in the environment). HIV/Aids is seen as a chronic disease nowadays, because HIV positive people can live with the infection for many years if they look after their immune systems. Especially antiretroviral medication made it possible for many individuals who have been very sick with HIV/Aids, to become fully functioning again - with a low, or even undetectable viral load. It is also not possible to say exactly what symptoms and diseases will be associated with HIV-infection in a specific person. Because of the unique way in which HIV attacks and disarms the immune system, all kinds of bacteria, fungi, protozoa, viruses and cancers are able to invade the body. That is the reason why we talk about Aids as a syndrome - a collection of many illnesses and infections.
HIV-infection can, however, theoretically be divided into the following phases or stages:
1. The primary HIV infection phase (or acute sero-conversion illness). Graphic of HIV symptoms: Phase 1 (sero-conversion)
2. The asymptomatic latent phase. Graphic of HIV symptoms: Phase 2
3. The minor symptomatic phase. Graphic of HIV symptoms: Phase 3
4. The major symptomatic phase and opportunistic diseases. Graphic of HIV symptoms: Phase 4, and How to recognise Phase 4.
5. AIDS-defining conditions: the severe symptomatic phase. Graphic of HIV symptoms: Phase 5, and How to recognise Phase 5.
1. The primary HIV infection phase (or acute sero-conversion illness)Graphic, Phase 1.
The acute phase of HIV infection (also called acute sero-conversion illness) begins as soon as sero-conversion has taken place. Sero-conversion means the point in time when a person’s HIV status converts or changes from being HIV negative to HIV positive. This also usually coincides with the time when an HIV antibody test will show that a person is HIV positive.
Sero-conversion usually occurs four to eight weeks after an individual has been infected with the HI virus. About 30%-60% of people infected with HIV develop flu-like symptoms such as sore throat, headache, mild fever, fatigue, muscle and joint pains, swelling of the lymph nodes, rash, and (occasionally) oral ulcers. These symptoms usually last from between one and two weeks.
Because of the rapid replication of the virus, the HIV viral load is usually very high during the acute phase. Immediate and aggressive treatment with anti-retroviral therapy (ART) at this stage may be effective in reducing the viral load to undetectable levels, or even in eradicating the virus.
2. The asymptomatic latent phase
The second phase of HIV infection is the asymptomatic latent or silent phase. In this stage, an infected person displays no symptoms. Infected individuals are often not even aware that they are carrying the HI virus in this stage, and may therefore unwittingly infect new sex partners.
Even though the infected person may be ignorant of its presence, the virus nevertheless remains active in the body during this stage and it continues to damage and undermine its victim’s immune system. A positive HIV antibody test is often the only indication of HIV infection during this latent phase.
HIV-infected people can remain healthy for a long time, show no symptoms and carry on with their work in a normal way. Some people remain HIV positive for many years without any manifestation of clinical disease while others may deteriorate rapidly, develop Aids and die within months. In some cases the only symptom during this phase is swollen glands.
3. The minor symptomatic phase of HIV disease
In the third phase of infection, minor and early symptoms of HIV disease usually begin to manifest.
This phase usually starts when people with HIV antibodies begin to present with one or more of the following symptoms:
• Mild to moderate swelling of the lymph nodes in the neck, armpits and groin
• Occasional fevers
• Shingles (or Herpes zoster)
• Skin rashes and nail infections
• Sores in the mouth that come and go
• Recurrent upper respiratory tract infections
• Weight loss up to 10% of the person’s usual body weight
• General feelings of tiredness and non-feeling-well
4. The major symptomatic phase of HIV infection and opportunistic diseases
Major symptoms and opportunistic diseases begin to appear as the immune system continues to deteriorate. At this point, the CD4 cell count becomes very low while the viral load becomes very high.
The following symptoms are usually an indication of advanced immune deficiency:
• Oral and vaginal thrush infections which are very persistent and recurrent (Candida)
• Recurrent herpes infections such as cold sores (herpes simplex)
• Recurrent herpes zoster (or shingles)
• Bacterial skin infections and skin rashes
• Fever for more than a month
• Night sweats
• Persistent diarrhoea for more than a month
• Weight loss (more than 10 percent of the usual body weight)
HIV and malaria
HIV-infected individuals are more prone to severe malaria than non-infected individuals. Malaria also causes a seven-fold increase in the HIV viral load of people with HIV infection. People with HIV infection should therefore take extra precautions when visiting malarial areas.
5. Aids-defining conditions: the severe symptomatic phase
Only when patients enter the last phase of HIV infection can they be said to have full-blown Aids. It usually takes about 18 months for the major symptomatic phase to develop into Aids.
In the final stage of Aids, the symptoms of HIV disease become more acute, patients become infected by relatively rare and unusual organisms that do not respond to antibiotics, the immune system deteriorates, and more persistent and untreatable opportunistic conditions and cancers begin to manifest.
While people with Aids (the last phase of HIV disease) usually die within two years, anti-retroviral therapy and the prevention and treatment of opportunistic infections may prolong this period.
The Aids patient in the final phase is usually plagued by many of the following problems:
• The Aids patient is usually very thin and emaciated due to continuous diarrhoea, nausea and vomiting (which may last for weeks or even for months).
• Conditions in the mouth (such as thrush and sores) may become so painful that the patient is no longer able to eat.
• Women suffer from persistent, recurrent vaginal infections and cervical cancer.
• Persistent generalised lymphadenopathy (PGL) is present - lymph nodes are larger than one centimetre in diameter, in two or more sites other than the groin area for a period of at least three months.
• Severe skin infections, warts and ringworm.
• Respiratory infections, persistent cough, chest pain and fever.
• Pneumonia, especially pneumocystis carinii pneumonia (PCP).
• Severe herpes zoster (or shingles).
• Nervous system problems - often complain of pains, numbness or “pins and needles” in the hands and feet.
• Neurological abnormalities with symptoms such as memory loss, poor concentration, tremor, headache, confusion, loss of vision and seizures. Aids patients may develop infections in the central nervous system or the brain.
• Kaposi’s sarcoma, or a rare form of skin cancer (painless reddish-brown or bluish-purple swelling on the skin and mucous membranes such as in the mouth). Kaposi’s sarcoma can also occur in the lungs and gastro-intestinal tract. It reacts well to chemotherapy or to alpha-interferon, but it can develop invasive open lesions and cause death if not promptly treated. Kaposi’s sarcoma is less common in black Africans.
• Lymphoma or cancer of the lymph nodes.
OPPORTUNISTIC INFECTIONS ASSOCIATED WITH HIV:
People with advanced HIV infection are vulnerable to infections and malignancies that are called 'opportunistic infections' because they take advantage of the opportunity offered by a weakened immune system.
A partial list of the world's most common HIV-related opportunistic infections and diseases includes:
• Bacterial diseases such as tuberculosis, MAC, bacterial pneumonia and septicaemia (blood poisoning)
• Protozoal diseases such as toxoplasmosis, microsporidiosis, cryptosporidiosis, isopsoriasis and leishmaniasis
• Fungal diseases such as PCP, candidiasis, cryptococcosis and penicilliosis
• Viral diseases such as those caused by cytomegalovirus, herpes simplex and herpes zoster virus
• HIV-associated malignancies such as Kaposi's sarcoma, lymphoma and squamous cell carcinoma.
Different conditions typically occur at different stages of HIV infection. In early HIV disease people can develop tuberculosis, malaria, bacterial pneumonia, herpes zoster, staphylococcal skin infections and septicaemia. These are diseases that people with normal immune systems can also get, but with HIV they occur at a much higher rate. It also takes longer for a person with HIV to recover than it takes for someone with a healthy immune system.
When the immune system is very weak due to advanced HIV disease or AIDS, opportunistic infections such as PCP, toxoplasmosis and cryptococcosis develop. Some infections can spread to a number of different organs, which is known as 'disseminated' or 'systemic' disease. Many of the opportunistic infections that occur at this late stage can be fatal.
HIV AND TB:
TB is the leading opportunistic infection in HIV infected patients. Often the first indicator of immune deficiency (AIDS defining Illness). World wide 40 million HIV infected of whom15 million are co infected with TB. Tuberculosis accelerates the progression of HIV infection and HIV increases the likelihood of active TB disease.
Effects of TB on HIV
• Immune activation from TB enhances both systemic and local HIV replication.
• Viral load increases
• CD4+T lymphocyte count falls
• Immune suppression – Opportunistic Infections
• Increased morbidity & mortality due to OI
• One year mortality 20-35 % (four times than TB in HIV negative with TB)
• Cause of death is complication other than TB due to accelerated progression of HIV
• Increased incidence of ADR to ATT
• Increased emergence of drug resistance
AIDS-related Cancers
In the past, people with HIV often got three types of cancer: Kaposi’s Sarcoma, non-Hodgkin’s lymphoma, and cervical cancer (in women). These are called AIDS- related cancers because they occur more often in people whose immune systems have been weakened by HIV/AIDS. Here are some facts about these cancers:
1. Kaposi’s Sarcoma
This cancer grows into reddish-purple patches on your skin that cannot kill you. It can be deadly if it gets in your throat or lungs. A herpes virus causes Kaposi’s Sarcoma.
2. Non-Hodgkin’s lymphoma
This cancer usually starts in the lymph glands, which are part of your immune system and help fight off disease. Lymph glands are mainly in the neck, under the arms, in the groin, and inside the belly. Epstein Barr Virus is a risk factor for this cancer.
3. Invasive cervical cancer
This cancer affects the cervix, the entrance from the vagina to the uterus. Almost all women who get cervical cancer also have HPV. Having HIV and HPV makes cervical cancer grow faster.
Herpes
An outbreak of herpes involves painful sores or ulcers which affect the mouth or genitals. Herpes is caused by a common virus called herpes simplex virus (HSV). This is a common sexually transmitted infection in the UK.
Once you are infected, the virus stays in skin and nerve cells for life. However, you may not know that you are infected with HSV. Most of the time it is dormant and causes no symptoms. From time to time flare-ups do occur, especially if you have a weakened immune system.
Oral and genital herpes
There are two main types of HSV which both cause oral and genital infection.
HSV-1 usually causes oral herpes or cold sores – tingling or painful spots on the edge of the lip where it meets the skin of the face. These can occasionally develop on the nostrils, on the gums or on the roof of the mouth.
HSV-2 is usually the cause of genital herpes - painful genital or anal ulcers, sometimes accompanied with fever, headache, muscle ache and a general feeling of being unwell.
Herpes lesions often start as numbness, tingling or itching. This feeling indicates that the virus is travelling up a nerve to the skin. There it causes small bumps that rapidly develop into small inflamed and fluid-filled blisters. These burst and crust over, typically taking one of week to heal in people with normal immune systems.
Transmission
The virus can be passed from person-to-person by contact between these lesions and e.g. kissing, sexual contact.
Herpes may also be transmitted when sores are not present, if HSV is reproducing. Herpes is more likely to reproduce in people with weak immune systems.
Herpes and HIV infection
Recent infection with genital herpes ulcers increases the chances of a person being infected with HIV.
In people with HIV, herpes attacks tend to be more frequent, more severe and last longer. Sometimes the lesions can become infected with other bacteria or fungi. As well as causing large oral and genital lesions, herpes can occasionally affect the throat, stomach and other organs including the liver, eye and lung. Herpes encephalitis is inflammation of the brain, causing headache, nausea, mental changes, loss of co-ordination and seizures; this is rare in people with HIV but potentially fatal if it does occur.
An HIV-positive person who has herpes ulcers which last for four weeks or longer is diagnosed as having AIDS. It is thought that herpes may act as a 'co-factor' in HIV disease progression, activating HIV and making it easier for HIV to infect certain cells.
Diagnosis
HSV is diagnosed by growing (culturing) the virus from a swab taken from a lesion, or by using a fluorescent screening test to detect the virus. A test that looks directly for the virus’s genetic material is used for research purposes, but is not generally available. Herpes in the oesophagus (gullet) or colon may be examined using fibre-optic instruments.
Treatment and prevention
Herpes infections are treated with aciclovir. Other treatments for herpes include valaciclovir, known by the brand name Valtrex, and famciclovir.
Aciclovir is taken in tablet form (200-800 mg fives times a day for 5 - 10 days) to treat serious attacks of oral herpes and genital or anal ulcers.
Although effective at preventing outbreaks of herpes, once an attack of genital herpes is established aciclovir often provides little benefit.
Aciclovir has very few side-effects.
Aciclovir cannot eliminate HSV virus in nerve cells, so herpes attacks may recur after an attack has been treated. Aciclovir cream is available from chemists to treat cold sores; however, many doctors question how effective it really is.
Aciclovir may be taken on a regular basis (maintenance therapy) to prevent recurrent attacks of herpes (400mg twice daily). Frequent use of aciclovir, for treatment or prevention, can lead to drug resistance. Resistance occurs when the virus is no longer sensitive to the treatment. Drug resistance is uncommon, except among people with very low CD4 cell counts.
Symptoms of Opportunistic Infections Associated with HIV
Disease Symptoms
Pneumonia Fever, fatigue, weight loss, cough, difficulty breathing, night sweats.
Encephalitis Altered mental states, focal paralysis, seizures, severe headaches, fever.
Gastroenteritis Diarrhea, abdominal cramping, nausea, vomiting, fatigue, gas, weight loss, loss of appetite, constipation, dehydration.
Tuberculosis Cough, coughing up blood, weight loss, night sweats, fatigue, fever, swollen glands. May spread to central nervous system, gastrointestinal tract, or skeleton.
Disseminated infection Fever, night sweats, fatigue, weight loss, diarrhea, anemia, abdominal pain, weakness, dizziness, nausea, enlarged glands, enlarged liver and spleen.
Meningitis Headaches, stiffness in the neck, malaise, fever, nausea, fatigue, loss of appetite, altered mental status.
Oral yeast infections White patches on the gums, tongue, or lining of the mouth; loss of appetite.
Vaginal yeast infections Vaginal burning, itching, and discharge.
Histoplasmosis Fever, weight loss, skin lesions, difficulty breathing, anemia, enlarged glands.
CMV retinitis Vision loss, seeing “floaters” or flashing lights.
Enterocolitis Diarrhea, weight loss, abdominal pain.
Encephalitis Headache, fever, focal paralysis, confusion, seizures.
Pneumonitis Cough, difficulty breathing, fever, chest pain.
Herpes simplex virus Painful blisters, ulcers, and/or itching on the lips, anus, or genitals.
Shingles Itching, burning, painful blisters with that erupt in a discrete band on the skin, fever, muscle pain, malaise, rash.
Kaposi's sarcoma Purple or deep-red skin lesions, most commonly on the face, genitals, extremities, and in the mouth; can also involve internal organs.
Genital warts Warts on the genitals or anus.
Anogenital neoplasia Cervical or anal cancer.
Oral “hairy” leukoplakia Painless white lesions (lines or plaques) on the sides of the tongue and insides of the cheeks.
Nervous system tumor Confusion, slowness, personality changes, seizures.
Anabolic steroids
Anabolic steroids are artificial (synthetic) versions of the male hormone testosterone that help build muscle. They also enhance masculine characteristics.
Because they can help the body to form lean muscle, they are sometimes used to treat wasting and weight loss caused by HIV, and doctors sometimes prescribe them to people experiencing fat loss from the limbs because of lipodystrophy. Testosterone supplements are also used to treat low testosterone levels which can develop in people with HIV due to HIV infection, some other infections, anti-HIV drugs and other medicines.
Anabolic steroids are also widely used by body builders and by many people who weight-train at the gym.
Anabolic steroid treatment in people with HIV
The anabolic steroids have been studied as a treatment for wasting caused by HIV, and have been shown to be safe and effective, helping the formation of lean muscle mass. To be most effective, anabolic steroid treatment should be combined with a programme of resistance (weight) training.
Studies have mostly been restricted to men because of concerns about the side-effects of steroid treatment for women.
Anabolic steroids can increase levels of LDL (bad) cholesterol and other side-effects, so their use should be closely monitored particularly if you are taking a protease inhibitor or have any risk factors for heart disease.
Anabolic steroid use for non-medical purposes
Anabolic steroids are often used by people who weight train to improve the effects of training and for aesthetic reasons. They are usually used in four-week cycles, followed by a period off 'treatment'.
The use of anabolic steroids in this way is rarely medically supervised, and this may involve health risks.
Health risks of anabolic steroid use
Anabolic steroids, and testosterone, can damage the liver, and severe liver problems including liver fibrosis, cirrhosis and cancer have been seen in long-term users of anabolic steroids. If you are being prescribed them by your doctor, your liver function will be closely monitored.
Acne, male pattern baldness, sexual dysfunction, shrinking of the testicles, and the shutting down of natural production of testosterone can also be caused by anabolic steroids. Aggression, mood disturbances, stomach pain, an enlarged prostate and water retention can also develop as a consequence of steroid use. Breast enlargement in men and the development of male characteristics in women have also been observed.
When used in a non-medical context, anabolic steroids are often injected. Sharing needles to inject steroids involves the same health risks as sharing needles to inject recreational drugs, including HIV transmission, and infection with hepatitis C virus and hepatitis B virus.
LABORATORY INVESTIGATIONS:
HIV antibody testing is used to screen for and diagnose HIV infections. Early treatment of HIV infection and immune system monitoring can greatly improve long-term health. Also, knowing your HIV status may help you change behaviors that would put you and others at risk.
Antibodies to the HIV virus are often detected by a screening test called an ELISA. The ELISA test is repeated if positive. The ELISA method is very sensitive but requires another test, a Western Blot, to confirm the results because false positives can occur. These tests can be done on blood, urine or oral sample in a doctor’s office or a local clinic. There are several rapid tests available in which results are generated in about 20 minutes. However, these too must have confirmatory testing before a final diagnosis can be made.
(What is a window period?
The ‘window period’ is a term used to describe the period of time between HIV infection and the production of antibodies. During this time, an antibody test may give a ‘false negative’ result, which means the test will be negative, even though a person is infected with HIV. To avoid false negative results, antibody tests are recommended three months after potential exposure to HIV infection.
A negative test at three months will almost always mean a person is not infected with HIV. If an individual’s test is still negative at six months, and they have not been at risk of HIV infection in the meantime, it means they are not infected with HIV.
It is very important to note that if a person is infected with HIV, they can still transmit the virus to others during the window period.)
Antigen test (P24 test)
Antigens are the substances found on a foreign body or germ that trigger the production of antibodies in the body. The antigen on HIV that most commonly provokes an antibody response is the protein P24. Early in HIV infection, P24 is produced in excess and can be detected in the blood serum (although as HIV becomes fully established in the body it will fade to undetectable levels).
P24 antigen tests are not usually used for general HIV diagnostic purposes, as they have a very low sensitivity and they only work before antibodies are produced in the period immediately after HIV infection.
PCR test
A PCR test (Polymerase Chain Reaction test) can detect the genetic material of HIV rather than the antibodies to the virus, and so can identify HIV in the blood within two or three weeks of infection. The test is also known as a viral load test and HIV NAAT (nucleic acid amplification testing).
Babies born to HIV positive mothers are usually tested using a PCR test because they retain their mother's antibodies for several months, making an antibody test inaccurate. Blood supplies in most developed countries are screened for HIV using PCR tests. However, they are not often used to test for HIV in individuals, as they are very expensive and more complicated to administer and interpret than a standard antibody test.
Enzyme-linked immuno sorbent assay (ELISA)
This testing method is a type of immunoassay. It is based on the principle that antibodies will bind to very specific antigens to form antigen-antibody complexes, and enzyme-linked antigens or antibodies can be used to detect and measure these complexes.
To detect or measure an antibody in a person’s blood, a known antigen is attached to a solid surface. A solution containing the patient sample is added. If the patient’s sample contains antibody, it will bind to the antigen. A second antibody (against human antibodies) that is labeled with an enzyme is then added. If the enzyme-linked antibody binds to human antibodies, the enzyme will create a detectable change that indicates the presence and amount of the antibody in the patient sample.
Western blot
n the Western blot procedure, cells that may be HIV-infected are opened and the proteins within are placed into a slab of gel, to which an electrical current is applied. Different proteins will move with different velocities in this field, depending on their size, while their electrical charge is leveled by a surfactant called sodium lauryl sulfate. Some commercialy prepared Western blot test kits contain the HIV proteins already on a cellulose acetate strip. Once the proteins are well-separated, they are transferred to a membrane and the procedure continues similar to an ELISA: the person's diluted serum is applied to the membrane and antibodies in the serum may attach to some of the HIV proteins. Antibodies which do not attach are washed away, and enzyme-linked antibodies with the capability to attach to the person's antibodies determine to which HIV proteins the person has antibodies.
There are no universal criteria for interpreting the Western blot test: the number of viral bands which must be present may vary. If no viral bands are detected, the result is negative. If at least one viral band for each of the GAG, POL, and ENV gene-product groups are present, the result is positive. The three-gene-product approach to Western blot interpretation has not been adopted for public health or clinical practice. Tests in which less than the required number of viral bands are detected are reported as indeterminate: a person who has an indeterminate result should be retested, as later tests may be more conclusive. Almost all HIV-infected persons with indeterminate Western-Blot results will develop a positive result when tested in one month; persistently indeterminate results over a period of six months suggests the results are not due to HIV infection. In a generally healthy low-risk population, indeterminate results on Western blot occur on the order of 1 in 5,000 patients.[13]:However for those individuals that have had high risk exposures to individuals where HIV-2 is most prevalent, Western Africa, an inconclusive Western Blot test may prove infection with HIV-2.
SOCIAL WORK APPROACH TO PLHIV:
■ Clinical services include preventive care with antibiotic prophylaxis for opportunistic
Infections (e.g. cotrimoxazole), insecticide-treated nets, and interventions to improve the quality of drinking water and hygienic practices; treatment and care services for
opportunistic infections; pain alleviation and symptom management; nutritional counseling, assessment and rehabilitation for malnourishment; routine clinical monitoring, including evaluating the need for ART; support for ART adherence;
and end-of-life care. It also includes working with policy makers to develop appropriate policies related to antibiotic prophylaxis and pain control.
■Social care supports community mobilization, leadership development for people living with HIV/AIDS, legal services, linkages to food support and income-generating programs, and other activities to strengthen the health and well-being of affected households and communities.
■Psychological services provide mental health counseling, family care and support groups, memory books, cultural and age-specific approaches for psychological care, identification and treatment of HIV-related psychiatric illnesses, and bereavement preparedness.
■Spiritual care includes assessment, counseling, facilitating forgiveness, and life completion tasks.
■Positive prevention efforts should be incorporated across the spectrum of palliative care services to reduce the risk of transmitting HIV from HIV-positive persons to others. These services include counseling and HIV testing for the entire family, prevention counseling and services, and biomedical interventions that reduce transmission risk (e.g., treatment of sexually transmitted diseases).
■ Comprehensive HIV/AIDS care is a holistic approach to meeting the needs of HIV-positive individuals. These needs are identified and met by different disciplines ranging from medical care to social support. Several studies have been conducted in the Region
to assess the needs of persons living with HIV and AIDS. One such study from India identified the following list of needs:
(1) Clinical and nursing care for the ill to alleviate the symptoms of HIV and AIDS;
(2) Psychosocial support and counseling of individuals tested HIV positive and their families;
(3) Financial support or opportunities for employment for persons discriminated against and rejected from employment due to HIV status;
(4) Assistance to find appropriate housing in a neighborhood that is sympathetic to HIV-positive persons;
(5) Legal assistance to overcome discrimination at work and in the community;
(6) Care and support of orphans and widows after the death of the primary bread winner,
(7) Information and training in HIV/AIDS care and prevention for care givers at home.
INITIAL ASSESSMENT AND INTERVENTION:
The identification of the needs of individuals and families affected by HIV/AIDS is the beginning of the planning process. To assist in this effort, WHO has developed a manual "Group interview techniques to assess the needs for people with AIDS”
Practical steps are outlined to conduct a rapid needs assessment and methods of analyzing data. Initial assessment involves the following:
(1) Voluntary counseling and testing (VCT) facilitates an entry point in the continuum of comprehensive care. Here people with HIV infection can come to learn and accept their HIV stereo-status and get access to effective care and prevention interventions.
(2) Clinical management of symptomatic infection with early and appropriate diagnosis and rational treatment, nutritional support, discharge planning and referral to other service providers;
(3) Nursing care to relieve the physical discomfort of illness, hygiene and infection control promotion, palliative and terminal care, training of family members in home care and preventive education and condom promotion;
(4) Pre - and post-test counseling to help individuals make informed decisions on HIV testing. This should also include a supportive and accepting environment in which coping, behavior change and positive living are promoted and should continue with follow-up counseling for the patient and other so identified;
(5) Care at home and in the community, including the training of relatives and volunteers in the provision of care, treatment of common symptoms and palliative care.
Promotion of good nutrition, psychological and emotional support, spiritual support and counseling;
(6) Formation of community support groups to provide emotional support to PLHIV and their care providers. Opportunities for developing income-generating projects could be explored in these groups;
(7) Eliminating the stigma of HIV/AIDS and developing of positive attitudes in the community towards persons and families living with HIV/AID S. This includes health care workers in both private and public health institutions;
(8) Social support or referral to appropriate social welfare services to meet the needs for housing, employment, legal support, and to monitor and prevent discrimination, and
(9) Partnership-building between various providers (clinical, social, support groups) in order to be accessible through mutual referrals.
AIDS Risk Reduction Model (ARRM)
The AIDS Risk Reduction Model (ARRM), introduced in 1990, provides a framework for explaining and predicting the behavior change efforts of individuals specifically in relationship to the sexual transmission of HIV/ AIDS.
STAGE 1: Recognition and labeling of one's behavior as high risk
Hypothesized Influences:
• Knowledge of sexual activities associated with HIV transmission;
• Believing that one is personally susceptible to contracting HIV;
• Believing that having AIDS is undesirable;
• Social norms and networking.
STAGE 2: Making a commitment to reduce high-risk sexual contacts and to increase low-risk activities
Hypothesized Influences:
• Cost and benefits;
• Enjoyment (e.g., will the changes affect my enjoyment of sex?);
• Response efficacy (e.g., will the changes successfully reduce my risk of HIV infection?);
• Self-efficacy;
• Knowledge of the health utility and enjoyability of a sexual practice,
• Social factors (group norms and social support), are believed to influence an individual's cost and benefit and self - efficacy beliefs.
STAGE 3: Taking action.
This stage is broken down into three phases:
1) Information seeking;
2) Obtaining remedies;
3) Enacting solutions.
Depending on the individual, phases may occur concurrently or phases may be skipped.
Hypothesized Influences:
• Social networks and problem-solving choices (self-help, informal and formal help);
• Prior experiences with problems and solutions;
• Level of self-esteem;
• Resource requirements of acquiring help;
• Ability to communicate verbally with sexual partner;
• Sexual partner's beliefs and behaviors.
In addition to the stages and influences listed above, the authors of the ARRM
(Catania et al., 1990) identified other internal and external factors that may motivate individual movement across stages. For instance, aversive emotional states (e.g., high levels of distress over HIV/AIDS or alcohol and drug use that blunt emotional states) may facilitate or hinder the labeling of one's behaviors. External motivators, such as public education campaigns, an image of a person dying from AIDS, or informal support groups, May also cause people to examine and potentially change their sexual activities.
Limitations:
A general limitation of the ARRM model is its focus on the individual.
BEHAVIOR CHANGE COMMUNICATION:
I. INTRODUCTION
Behavior change communication (BCC) is an interactive process with communities to develop tailored messages and approaches using a variety of communication channels to develop positive behaviors; promote and sustain individual, community and societal behavior change; and maintain appropriate behaviors.
In the context of the AIDS epidemic, BCC is an essential part of a comprehensive program that includes both services (medical, social, psychological and spiritual) and commodities (e.g., condoms, needles and syringes). Before individuals and communities can reduce their level of risk or change their behaviors, they must first understand basic facts about HIV and AIDS, adopt key attitudes, learn a set of skills and be given access to appropriate products and services. They must also perceive their environment as supporting behavior change and the maintenance of safe behaviors, as well as supportive of seeking appropriate treatment for prevention, care and support.
In most parts of the world, HIV is primarily a sexually transmitted infection (STI). Development of a supportive environment requires national and community-wide discussion of relationships, sex and sexuality, risk, risk settings, risk behaviors and cultural practices that may increase the likelihood of HIV transmission.
A supportive environment is also one that deals, at the national and community levels, with stigma, fear and discrimination, as well as with policy and law. The same issues apply in parts of the world where unsafe injection of illegal drugs is the chief source of new infections.
Effective BCC is vital to setting the tone for compassionate and responsible interventions. It can also produce insight into the broader socioeconomic impacts of the epidemic and mobilize the political, social and economic responses needed to mount an effective program.
II. THE ROLE OF BEHAVIOR CHANGE COMMUNICATION
BCC is an integral component of a comprehensive HIV/AIDS prevention, care and support program. It has a number of different but interrelated roles.
Effective BCC can:
Increase knowledge:
BCC can ensure that people are given the basic facts about HIV and AIDS in a language or visual medium (or any other medium that they can understand and relate to).
Stimulate community dialogue:
BCC can encourage community and national discussions on the basic
facts of HIV/AIDS and the underlying factors that contribute to the epidemic, such as risk behaviors and risk settings, environments and cultural practices related to sex and sexuality, and marginalized practices (such as drug use) that create these conditions. It can also stimulate discussion of healthcare- seeking behaviors for prevention, care and support.
Promote essential attitude change:
BCC can lead to appropriate attitudinal changes about, for example, perceived personal risk of HIV infection, belief in the right to and responsibility for safe practices and health supporting services, compassionate and non-judgmental provision of services, greater open-mindedness concerning gender roles and increasing the basic rights of those vulnerable to and affected by HIV and AIDS.
Reduce stigma and discrimination:
Communication about HIV prevention and AIDS mitigation should address stigma and discrimination and attempt to influence social responses to them.
Create a demand for information and services:
BCC can spur individuals and communities to demand information on HIV/AIDS and appropriate services.
Advocate:
BCC can lead policymakers and opinion leaders toward effective approaches to the epidemic.
Promote services for prevention, care and support:
BCC can promote services for STIs, intravenous drug users (IDUs), orphans and vulnerable children (OVCs); voluntary counseling and testing (VCT) for mother-to-child transmission (MTCT); support groups for PLHA; clinical care for opportunistic infections; and social and economic support. BCC is also an integral component of these services.
Improve skills and sense of self-efficacy:
BCC programs can focus on teaching or reinforcing new skills and behaviors, such as condom use, negotiating safer sex and safe injecting practices. It can contribute to development of a sense of confidence in making and acting on decisions.
III. BCC GOALS
Behavior change communication goals need to be developed in the context of overall program goals and specific behavior change goals. The following highlights the place of BCC goals within an overall program.
Program goal: Reduce HIV prevalence among young people in urban settings in X country.
Behavior change goals:
Increase condom use
Increase appropriate STI care-seeking behavior
Delay sexual debut
Reduce number of partners
BCC goals:
Increase perception of risk or change attitudes toward use of condoms
Increase demand for services
Create demand for information on HIV and AIDS
Create demand for appropriate STI services
Interest policymakers in investing in youth-friendly VCT services (services must be in place)
Promote acceptance among communities of youth sexuality and the value of reproductive health services for youth (services must be in place)
BCC goals are related to specific issues identified when assessing the situation, knowledge, attitudes and skills that may need to be changed to work toward behavior change and program goals.
IV. GUIDING PRINCIPLES
• BCC should be integrated with program goals from the start. BCC is an essential element of HIV prevention, care and support programs, providing critical linkages to other program components, including policy initiatives.
• Formative BCC assessments must be conducted to improve understanding of the needs of target populations, as well as of the barriers to and supports for behavior change that their members face (along with other populations, such as stakeholders, service providers and community).
• The target population should participate in all phases of BCC development and in much of implementation.
• Stakeholders need to be involved from the design stage.
• Having a variety of linked communication channels is more effective than relying on one specific one.
• Pre-testing is essential for developing effective BCC materials.
• Planning for monitoring and evaluation should be part of the design of any BCC program.
• BCC strategies should be positive and action-oriented.
• PLHA should be involved in BCC planning and implementation.
STEPS IN DEVELOPING A BCC STRATEGY:
State program goals
Program goals are designed in coordination with national HIV and AIDS strategies. Clearly identifying overall program goals is the first step in developing a BCC strategy. Specific FHI program goals are established after reviewing existing data, epidemiological information and in-depth program situation assessments.
Involve stakeholders
Key stakeholders need to be involved early on in every step of the process of developing HIV/AIDS programs and their BCC components. Stakeholders include policymakers, opinion leaders, community leaders, religious leaders and members of target populations, including PLHA. Their active participation at appropriate stages of BCC strategy development is essential. A stakeholders’ meeting should be held at the planning stage to obtain guidance and commitments to the process and to develop coordination mechanisms.
Identify target populations
To develop communication, it is important to identify the target populations as clearly as possible. Target populations are defined as primary or secondary. Primary populations are the main groups whose HIV/AIDS-related behavior the program is intended to influence. Secondary populations are those groups that influence the ability of the primary population to adopt or maintain appropriate behaviors. For example, an HIV program may seek to increase condom use among sex workers and clients (primary populations). But to achieve this objective, it may be necessary to change the behavior or gain the support of brothel owners and police (secondary populations).
Target populations include:
• Individuals at high risk or vulnerability, such as sex workers, their clients, youth, migrant workers,
• IDUs, or uniformed services personnel
• People providing services, such as health workers, private practitioners, pharmacists, counselors andsocial service workers
• Policymakers, such as politicians
• Leaders and authorities, formal and informal, including law-enforcement, social and religious leaders
• Local communities and families
Conduct formative BCC assessments
A formative BCC assessment should start by seeking out all available studies, including data from in-depth assessments or rapid ethnographic assessments, behavioral surveillance surveys and other related studies. After synthesizing this information, a formative BCC assessment protocol can be developed. The formative BCC assessment should collect information on:
• Risk situations, showing in detail how decisions are made in different situations, including what influences the decisions and settings for risk
• Why individuals and groups practice the behaviors they do, and why they might be motivated to change (or unable to change) to the desired behaviors
• Perceptions of risk and risk behaviors
• Influences on behavior, such as barriers or benefits
• Insights of opinion leaders
• Patterns of service use and opinions about these services
• Perceptions of stigma and discrimination
• Future hopes, fears and goals
• Media and entertainment habits
• Health care-seeking behaviors
• Positive deviants, or those most willing to model change
• Media resources
Formative BCC assessments make use of qualitative methods, such as focus group discussions, key informant interviews, direct observation, participatory learning methods, rapid ethnographic assessments, mapping and in-depth interviews. Where possible, the organizations that are directly engaged with the population, such as community-based and non-governmental groups, should participate in the formative BCC assessment with assistance from appropriate research institutions.
Segment target populations
Based on the formative BCC assessment, target populations can then be segmented. For example, sex workers can be grouped more specifically according to work location (street, home, and brothel), income level, ethnicity, or language.
Population segments are often defined by psychosocial and demographic characteristics. Psychosocial characteristics include the knowledge, attitudes and practices typically demonstrated by a given group or audience; or by their role in society, their formal and informal responsibilities and their level of authority.
Demographic characteristics include age, place of residence (or work), place of birth, religion and ethnicity. In addition, structural factors and settings (e.g., in the workplace, risk settings, border settings) should also be considered. For example, if sex workers and truck drivers are the target population, border crossings and truck stops constitute risk settings.
Define behavior change objectives
Whether the target population is a particular group or the general public, it is important first to refer to the HIV/AIDS program behavior change objectives. What changes in behavior does the program intend to achieve? While behavior changes may not have been specified in project documents, they can be inferred from project goals. Following are some common behavior change objectives:
• Increased safer sexual practices (more frequent condom use, fewer partners)
• Increased incidence of healthcare-seeking behavior for STIs, TB and VCT (for example, calls or visits to facilities)
• Increased use of universal precautions to improve blood safety
• Adherence by medical practitioners to treatment guidelines
• Increased use of new or disinfected syringes and needles by IDUs
• Decline in stigma associated with HIV/AIDS
• Reduced incidence of discriminatory activity directed at PLHA and other identified high- risk groups
• Improved attitudes and behavior among healthcare, social service and other service delivery workers who interact with PLHA, SWs, IDUs and other marginalized groups
Design BCC strategy and Monitoring and Evaluation (M&E) Plan
A BCC strategy is best designed in a participatory fashion, including members of target populations, organizations planning to work with them and stakeholders. Designing a BCC strategy is more than a matter of developing messages and media materials for dissemination. It is necessary to find the right mix of approaches to involve target populations—that is, to get their attention—and to promote and enable action.
A well-designed BCC strategy should include:
• Clearly defined BCC objectives
• An overall concept or theme and key messages
• Identification of channels of dissemination
• Identification of partners for implementation (including capacity-building plan)
• A monitoring and evaluation plan
Choose partners
In developing a BCC strategy, it is important to identify key partners who can help design and implement its components. Partners may include NGOs, government counterparts, media outlets, graphic designers, local traditional entertainers, members of target populations and other program implementers. It is essential to plan for capacity-building of partners.
Develop communication products
Development of specific communication support materials should be based on decisions made about channels and activities. They can include:
• Print materials for peer educators, such as flip charts and picture codes
• Print materials to support health workers on specific care issues
• Television spots for general broadcast
• Promotional materials about the project, for advocacy
• Scripts for theater and street theater
• Radio or television soap opera scripts
Conduct pre-testing
Pre-testing is key to ensuring that themes, messages and activities reach the intended target populations. It is important to pre-test at every stage with all audiences for whom the communication is intended, both primary and secondary. Pre-testing should be done of themes, messages, prototype materials, training packages, support tools and BCC formative assessment instruments.
Pre-testing of media, messages and themes should evaluate:
1. Comprehension
2. Attraction
3. Persuasion
4. Acceptability
5. Audience members’ degree of identification
Several versions should be pre-tested and audience reactions compared.
Implement and monitor
In the implementation phase, all elements of the strategy go into operation. An especially important element is management. All partners, programmers and channels of the BCC strategy must be closely coordinated.
There must be links among critical program elements, such as supply and demand. If populations discover that VCT services being promoted by BCC messages and materials are unavailable, the programs will suffer. Timing and coordination are key to managing a program effectively. Because the BCC strategy is linked to other parts of the prevention and care effort, BCC specialists must work as members of a broader team and coordinate their activities. Coordinators of each component of the team should keep others informed of their progress and activities. Ongoing communication with partners about areas outside of prevention and care It is essential to budget adequately for all steps needed to develop a BCC campaign and program.
It is important that monitoring be carried out as planned. Often monitoring receives inadequate attention, both in terms of collecting information and, still more often, in making sure it gets fed back in usable form to people who need it for decision-making and field implementation. Specific personnel must be designated to make sure that the monitoring plan is developed with input from the people who will use it; to make sure that everyone involved knows the expected outcomes and has the appropriate tools and skills; and to make sure that there is budget and time enough to carry the plan out.
Evaluate
Evaluation refers to the assessment of a project’s implementation and its success in achieving predetermined objectives of behavior change. BCC interventions should be evaluated against their stated objectives and in reference to a baseline that may be qualitative or quantitative (or both). For large-scale interventions, baseline quantitative research may be repeated to demonstrate changes in knowledge, attitudes and reported behaviors relative to communication and project-level behavior change objectives. Change can also be assessed through qualitative research into target-group responses to interventions. Qualitative evaluation involves examining data that are designed to illustrate changes in audience behavior.
Elicit feedback and modify the program
As programs evolve, target populations acquire new knowledge and behaviors, and communication needs may change. The needs of target populations must be periodically reassessed to understand where they stand along the behavior change continuum. Monitoring and evaluation studies should lead directly to modifications of the overall program, as well as of the BCC strategies, messages and approaches.
Day-to-day monitoring will provide information for making adjustments in short-term work planning.
Periodic program reviews can be designed to take a more in-depth look at program progress and larger-scale adjustments or redesign. Involving stakeholders, target audiences and partners as much as possible will provide a better look at what is happening; help make appropriate decisions; and make sure that the people affected by any decisions will be fully aware of them.
Post-exposure prophylaxis (PEP)
If you have had unprotected sex (or shared drug injecting equipment) with somebody you know is HIV-positive, or is from a group at high risk of HIV, such as gay men, then you may be able to get a short course of HIV treatment to try to prevent you becoming infected with HIV.
This is called post exposure prophylaxis, or PEP for short.
The professional organisation of the UK's sexual health doctors has guidelines recommending the circumstances in which PEP should be used.
Purpose of PEP
PEP has been used for many years for healthcare workers who have had possible exposure to HIV, for example, after accidentally pricking themselves with needles used on people who were known to be HIV-positive or at risk of HIV.
PEP is not a ‘cure’ for HIV. Rather, PEP may prevent HIV from entering cells in the body and so prevent you from becoming infected with HIV. PEP isn’t 100% effective. However, there have been very few reports of HIV infection after the use of PEP.
Timing of PEP
To have the best chance of being effective you need to start taking PEP as soon as possible after the possible exposure to HIV and within 72 hours. However, the guidelines state that PEP may still be considered for possible HIV exposure in high risk groups.
Medicine used for PEP
PEP normally consists of three anti-HIV drugs, from two of the different classes,usually two nucleoside analogues (NRTIs) plus a boosted protease inhibitor.
PEP should be taken for a month, and it is important to take all the doses, at the right time and in the right way.
Where to get PEP
Go to a sexual health clinic. If they operate an appointments system and are fully booked, explain that it’s an emergency and that you need to be seen. If it is a weekend, go to the accident and emergency department, who will contact an HIV specialist who is able to prescribe PEP.
Access to PEP
There are guidelines stating when PEP should be considered. It is recommended if you have had unprotected inservitve or receptive anal, or vaginal sex with someone who is known to be HIV-positive.
It is also recommended if you have had unprotected receptive anal sex with someone whose HIV status is not known.
It may be considered if you have had insertive anal sex, insertive or receptive vaginal sex, or fellatio (cock sucking) with ejaculation with someone whose HIV status is known or unknown. It may also be considered for semen splashes in the eye if a person if known to be HIV-positive.
The sooner PEP is accessed the better. The guidelines state that it should be provided within 72 hours of the possible HIV exposure, but that it may be provided after this time for high risk groups.
Despite these guidelines, some people who have had possible HIV exposure, including gay men have had difficulty getting PEP. In these circumstances, you may find this information from THT helpful.
Side-effects
HIV treatment can cause side-effects which tend to be worst when you first start taking them, and if you are taking PEP you could experience some unpleasant side-effects such as feeling sick, being sick, diarrhoea, tiredness, and generally feeling unwell.
If you have been exposed to a strain of HIV that is resistant to some anti-HIV drugs then it’s possible that PEP won’t work.
If you are already HIV-positive, but don’t know it, there is a chance of developing drug resistance when you take PEP if you don’t take your doses properly. This could limit your treatment options in the future.
Other things to consider
PEP is not 100% effective, so it would make good sense not to rely on access to PEP if you are having unprotected sex or sharing drug injecting equipment. Condoms, when used properly, are an effective way of preventing the spread of HIV and most other sexually transmitted infections, and never share needles or injecting equipment.
HIV SYMPTOMS
Early symptoms of HIV infection develop in 50 to 90 percent of people who are infected, usually beginning two to four weeks after exposure to HIV. However, there have been instances in which up to 10 months have passed between exposure and the first signs and symptoms of HIV infection. The initial group of signs and symptoms is referred to as primary or acute HIV infection.
Because the signs and symptoms of primary HIV may be similar to other common illnesses such as the flu, most people do not initially realize that they have HIV.
1. Body wide symptoms — The most common, body wide signs and symptoms of primary HIV include fever (temperature above 100.4ºF or 38ºC), sore throat, headache, and muscle and joint pain. These flu-like symptoms last approximately two weeks.
During the second week of the illness, most people also have painless swelling of certain lymph nodes, including those in the armpits and in the neck. Although the lymph nodes decrease in size after the first few weeks, swelling can linger. Some people develop mild enlargement of the spleen (known as splenomegaly). The spleen is an abdominal organ, located under the left lower ribs.
2. Skin, mouth, genital symptoms — A characteristic feature of primary HIV infection is open sores or ulcers. These sores or ulcers can develop in the mouth, the esophagus (the tube that extends from the mouth to the stomach), the anus, or the penis. The ulcers are usually swollen and painful.
Many people also develop a rash or reddish swelling of the skin about two to three days after fever. The rash usually affects the face, neck, and upper chest or may be more widespread, involving the scalp, arms and legs, and the palms and soles. The rash usually lasts approximately 5 to 8 days.
3. Digestive symptoms — Many people with primary HIV infection develop nausea and vomiting, diarrhea, lack of appetite (known as anorexia), and weight loss. Rarely, more severe abnormalities of the digestive system develop, such as inflammation of the liver or the pancreas.
4. Respiratory symptoms — A dry cough is usually the only respiratory symptom associated with primary HIV infection.
5. Opportunistic infections — After becoming infected with HIV, the immune system may not function as well to protect the body from certain organisms. These organisms can cause infections known as "opportunistic infections". While these opportunistic infections are more common in people who have had HIV for many years, they can occur in people with primary HIV infection as well.
One of the most common opportunistic infections is yeast infection of the mouth or esophagus. Yeast infections are caused by Candida, a fungal organism that is normally found on the skin and in the mouth, intestinal tract, and vagina in healthy individuals.
Phases of infection:
Although HIV-infection can theoretically be divided into different phases, it is important to note that HIV-infection cannot in practice be precisely demarcated into separate and distinct phases with easily identifiable boundaries. The health of the HIV positive person will depend on the health of his or her immune system (on CD4 cell count and viral load in the blood, as well as on the exposure to infections and diseases in the environment). HIV/Aids is seen as a chronic disease nowadays, because HIV positive people can live with the infection for many years if they look after their immune systems. Especially antiretroviral medication made it possible for many individuals who have been very sick with HIV/Aids, to become fully functioning again - with a low, or even undetectable viral load. It is also not possible to say exactly what symptoms and diseases will be associated with HIV-infection in a specific person. Because of the unique way in which HIV attacks and disarms the immune system, all kinds of bacteria, fungi, protozoa, viruses and cancers are able to invade the body. That is the reason why we talk about Aids as a syndrome - a collection of many illnesses and infections.
HIV-infection can, however, theoretically be divided into the following phases or stages:
1. The primary HIV infection phase (or acute sero-conversion illness). Graphic of HIV symptoms: Phase 1 (sero-conversion)
2. The asymptomatic latent phase. Graphic of HIV symptoms: Phase 2
3. The minor symptomatic phase. Graphic of HIV symptoms: Phase 3
4. The major symptomatic phase and opportunistic diseases. Graphic of HIV symptoms: Phase 4, and How to recognise Phase 4.
5. AIDS-defining conditions: the severe symptomatic phase. Graphic of HIV symptoms: Phase 5, and How to recognise Phase 5.
1. The primary HIV infection phase (or acute sero-conversion illness)Graphic, Phase 1.
The acute phase of HIV infection (also called acute sero-conversion illness) begins as soon as sero-conversion has taken place. Sero-conversion means the point in time when a person’s HIV status converts or changes from being HIV negative to HIV positive. This also usually coincides with the time when an HIV antibody test will show that a person is HIV positive.
Sero-conversion usually occurs four to eight weeks after an individual has been infected with the HI virus. About 30%-60% of people infected with HIV develop flu-like symptoms such as sore throat, headache, mild fever, fatigue, muscle and joint pains, swelling of the lymph nodes, rash, and (occasionally) oral ulcers. These symptoms usually last from between one and two weeks.
Because of the rapid replication of the virus, the HIV viral load is usually very high during the acute phase. Immediate and aggressive treatment with anti-retroviral therapy (ART) at this stage may be effective in reducing the viral load to undetectable levels, or even in eradicating the virus.
2. The asymptomatic latent phase
The second phase of HIV infection is the asymptomatic latent or silent phase. In this stage, an infected person displays no symptoms. Infected individuals are often not even aware that they are carrying the HI virus in this stage, and may therefore unwittingly infect new sex partners.
Even though the infected person may be ignorant of its presence, the virus nevertheless remains active in the body during this stage and it continues to damage and undermine its victim’s immune system. A positive HIV antibody test is often the only indication of HIV infection during this latent phase.
HIV-infected people can remain healthy for a long time, show no symptoms and carry on with their work in a normal way. Some people remain HIV positive for many years without any manifestation of clinical disease while others may deteriorate rapidly, develop Aids and die within months. In some cases the only symptom during this phase is swollen glands.
3. The minor symptomatic phase of HIV disease
In the third phase of infection, minor and early symptoms of HIV disease usually begin to manifest.
This phase usually starts when people with HIV antibodies begin to present with one or more of the following symptoms:
• Mild to moderate swelling of the lymph nodes in the neck, armpits and groin
• Occasional fevers
• Shingles (or Herpes zoster)
• Skin rashes and nail infections
• Sores in the mouth that come and go
• Recurrent upper respiratory tract infections
• Weight loss up to 10% of the person’s usual body weight
• General feelings of tiredness and non-feeling-well
4. The major symptomatic phase of HIV infection and opportunistic diseases
Major symptoms and opportunistic diseases begin to appear as the immune system continues to deteriorate. At this point, the CD4 cell count becomes very low while the viral load becomes very high.
The following symptoms are usually an indication of advanced immune deficiency:
• Oral and vaginal thrush infections which are very persistent and recurrent (Candida)
• Recurrent herpes infections such as cold sores (herpes simplex)
• Recurrent herpes zoster (or shingles)
• Bacterial skin infections and skin rashes
• Fever for more than a month
• Night sweats
• Persistent diarrhoea for more than a month
• Weight loss (more than 10 percent of the usual body weight)
HIV and malaria
HIV-infected individuals are more prone to severe malaria than non-infected individuals. Malaria also causes a seven-fold increase in the HIV viral load of people with HIV infection. People with HIV infection should therefore take extra precautions when visiting malarial areas.
5. Aids-defining conditions: the severe symptomatic phase
Only when patients enter the last phase of HIV infection can they be said to have full-blown Aids. It usually takes about 18 months for the major symptomatic phase to develop into Aids.
In the final stage of Aids, the symptoms of HIV disease become more acute, patients become infected by relatively rare and unusual organisms that do not respond to antibiotics, the immune system deteriorates, and more persistent and untreatable opportunistic conditions and cancers begin to manifest.
While people with Aids (the last phase of HIV disease) usually die within two years, anti-retroviral therapy and the prevention and treatment of opportunistic infections may prolong this period.
The Aids patient in the final phase is usually plagued by many of the following problems:
• The Aids patient is usually very thin and emaciated due to continuous diarrhoea, nausea and vomiting (which may last for weeks or even for months).
• Conditions in the mouth (such as thrush and sores) may become so painful that the patient is no longer able to eat.
• Women suffer from persistent, recurrent vaginal infections and cervical cancer.
• Persistent generalised lymphadenopathy (PGL) is present - lymph nodes are larger than one centimetre in diameter, in two or more sites other than the groin area for a period of at least three months.
• Severe skin infections, warts and ringworm.
• Respiratory infections, persistent cough, chest pain and fever.
• Pneumonia, especially pneumocystis carinii pneumonia (PCP).
• Severe herpes zoster (or shingles).
• Nervous system problems - often complain of pains, numbness or “pins and needles” in the hands and feet.
• Neurological abnormalities with symptoms such as memory loss, poor concentration, tremor, headache, confusion, loss of vision and seizures. Aids patients may develop infections in the central nervous system or the brain.
• Kaposi’s sarcoma, or a rare form of skin cancer (painless reddish-brown or bluish-purple swelling on the skin and mucous membranes such as in the mouth). Kaposi’s sarcoma can also occur in the lungs and gastro-intestinal tract. It reacts well to chemotherapy or to alpha-interferon, but it can develop invasive open lesions and cause death if not promptly treated. Kaposi’s sarcoma is less common in black Africans.
• Lymphoma or cancer of the lymph nodes.
OPPORTUNISTIC INFECTIONS ASSOCIATED WITH HIV:
People with advanced HIV infection are vulnerable to infections and malignancies that are called 'opportunistic infections' because they take advantage of the opportunity offered by a weakened immune system.
A partial list of the world's most common HIV-related opportunistic infections and diseases includes:
• Bacterial diseases such as tuberculosis, MAC, bacterial pneumonia and septicaemia (blood poisoning)
• Protozoal diseases such as toxoplasmosis, microsporidiosis, cryptosporidiosis, isopsoriasis and leishmaniasis
• Fungal diseases such as PCP, candidiasis, cryptococcosis and penicilliosis
• Viral diseases such as those caused by cytomegalovirus, herpes simplex and herpes zoster virus
• HIV-associated malignancies such as Kaposi's sarcoma, lymphoma and squamous cell carcinoma.
Different conditions typically occur at different stages of HIV infection. In early HIV disease people can develop tuberculosis, malaria, bacterial pneumonia, herpes zoster, staphylococcal skin infections and septicaemia. These are diseases that people with normal immune systems can also get, but with HIV they occur at a much higher rate. It also takes longer for a person with HIV to recover than it takes for someone with a healthy immune system.
When the immune system is very weak due to advanced HIV disease or AIDS, opportunistic infections such as PCP, toxoplasmosis and cryptococcosis develop. Some infections can spread to a number of different organs, which is known as 'disseminated' or 'systemic' disease. Many of the opportunistic infections that occur at this late stage can be fatal.
HIV AND TB:
TB is the leading opportunistic infection in HIV infected patients. Often the first indicator of immune deficiency (AIDS defining Illness). World wide 40 million HIV infected of whom15 million are co infected with TB. Tuberculosis accelerates the progression of HIV infection and HIV increases the likelihood of active TB disease.
Effects of TB on HIV
• Immune activation from TB enhances both systemic and local HIV replication.
• Viral load increases
• CD4+T lymphocyte count falls
• Immune suppression – Opportunistic Infections
• Increased morbidity & mortality due to OI
• One year mortality 20-35 % (four times than TB in HIV negative with TB)
• Cause of death is complication other than TB due to accelerated progression of HIV
• Increased incidence of ADR to ATT
• Increased emergence of drug resistance
AIDS-related Cancers
In the past, people with HIV often got three types of cancer: Kaposi’s Sarcoma, non-Hodgkin’s lymphoma, and cervical cancer (in women). These are called AIDS- related cancers because they occur more often in people whose immune systems have been weakened by HIV/AIDS. Here are some facts about these cancers:
1. Kaposi’s Sarcoma
This cancer grows into reddish-purple patches on your skin that cannot kill you. It can be deadly if it gets in your throat or lungs. A herpes virus causes Kaposi’s Sarcoma.
2. Non-Hodgkin’s lymphoma
This cancer usually starts in the lymph glands, which are part of your immune system and help fight off disease. Lymph glands are mainly in the neck, under the arms, in the groin, and inside the belly. Epstein Barr Virus is a risk factor for this cancer.
3. Invasive cervical cancer
This cancer affects the cervix, the entrance from the vagina to the uterus. Almost all women who get cervical cancer also have HPV. Having HIV and HPV makes cervical cancer grow faster.
Herpes
An outbreak of herpes involves painful sores or ulcers which affect the mouth or genitals. Herpes is caused by a common virus called herpes simplex virus (HSV). This is a common sexually transmitted infection in the UK.
Once you are infected, the virus stays in skin and nerve cells for life. However, you may not know that you are infected with HSV. Most of the time it is dormant and causes no symptoms. From time to time flare-ups do occur, especially if you have a weakened immune system.
Oral and genital herpes
There are two main types of HSV which both cause oral and genital infection.
HSV-1 usually causes oral herpes or cold sores – tingling or painful spots on the edge of the lip where it meets the skin of the face. These can occasionally develop on the nostrils, on the gums or on the roof of the mouth.
HSV-2 is usually the cause of genital herpes - painful genital or anal ulcers, sometimes accompanied with fever, headache, muscle ache and a general feeling of being unwell.
Herpes lesions often start as numbness, tingling or itching. This feeling indicates that the virus is travelling up a nerve to the skin. There it causes small bumps that rapidly develop into small inflamed and fluid-filled blisters. These burst and crust over, typically taking one of week to heal in people with normal immune systems.
Transmission
The virus can be passed from person-to-person by contact between these lesions and e.g. kissing, sexual contact.
Herpes may also be transmitted when sores are not present, if HSV is reproducing. Herpes is more likely to reproduce in people with weak immune systems.
Herpes and HIV infection
Recent infection with genital herpes ulcers increases the chances of a person being infected with HIV.
In people with HIV, herpes attacks tend to be more frequent, more severe and last longer. Sometimes the lesions can become infected with other bacteria or fungi. As well as causing large oral and genital lesions, herpes can occasionally affect the throat, stomach and other organs including the liver, eye and lung. Herpes encephalitis is inflammation of the brain, causing headache, nausea, mental changes, loss of co-ordination and seizures; this is rare in people with HIV but potentially fatal if it does occur.
An HIV-positive person who has herpes ulcers which last for four weeks or longer is diagnosed as having AIDS. It is thought that herpes may act as a 'co-factor' in HIV disease progression, activating HIV and making it easier for HIV to infect certain cells.
Diagnosis
HSV is diagnosed by growing (culturing) the virus from a swab taken from a lesion, or by using a fluorescent screening test to detect the virus. A test that looks directly for the virus’s genetic material is used for research purposes, but is not generally available. Herpes in the oesophagus (gullet) or colon may be examined using fibre-optic instruments.
Treatment and prevention
Herpes infections are treated with aciclovir. Other treatments for herpes include valaciclovir, known by the brand name Valtrex, and famciclovir.
Aciclovir is taken in tablet form (200-800 mg fives times a day for 5 - 10 days) to treat serious attacks of oral herpes and genital or anal ulcers.
Although effective at preventing outbreaks of herpes, once an attack of genital herpes is established aciclovir often provides little benefit.
Aciclovir has very few side-effects.
Aciclovir cannot eliminate HSV virus in nerve cells, so herpes attacks may recur after an attack has been treated. Aciclovir cream is available from chemists to treat cold sores; however, many doctors question how effective it really is.
Aciclovir may be taken on a regular basis (maintenance therapy) to prevent recurrent attacks of herpes (400mg twice daily). Frequent use of aciclovir, for treatment or prevention, can lead to drug resistance. Resistance occurs when the virus is no longer sensitive to the treatment. Drug resistance is uncommon, except among people with very low CD4 cell counts.
Symptoms of Opportunistic Infections Associated with HIV
Disease Symptoms
Pneumonia Fever, fatigue, weight loss, cough, difficulty breathing, night sweats.
Encephalitis Altered mental states, focal paralysis, seizures, severe headaches, fever.
Gastroenteritis Diarrhea, abdominal cramping, nausea, vomiting, fatigue, gas, weight loss, loss of appetite, constipation, dehydration.
Tuberculosis Cough, coughing up blood, weight loss, night sweats, fatigue, fever, swollen glands. May spread to central nervous system, gastrointestinal tract, or skeleton.
Disseminated infection Fever, night sweats, fatigue, weight loss, diarrhea, anemia, abdominal pain, weakness, dizziness, nausea, enlarged glands, enlarged liver and spleen.
Meningitis Headaches, stiffness in the neck, malaise, fever, nausea, fatigue, loss of appetite, altered mental status.
Oral yeast infections White patches on the gums, tongue, or lining of the mouth; loss of appetite.
Vaginal yeast infections Vaginal burning, itching, and discharge.
Histoplasmosis Fever, weight loss, skin lesions, difficulty breathing, anemia, enlarged glands.
CMV retinitis Vision loss, seeing “floaters” or flashing lights.
Enterocolitis Diarrhea, weight loss, abdominal pain.
Encephalitis Headache, fever, focal paralysis, confusion, seizures.
Pneumonitis Cough, difficulty breathing, fever, chest pain.
Herpes simplex virus Painful blisters, ulcers, and/or itching on the lips, anus, or genitals.
Shingles Itching, burning, painful blisters with that erupt in a discrete band on the skin, fever, muscle pain, malaise, rash.
Kaposi's sarcoma Purple or deep-red skin lesions, most commonly on the face, genitals, extremities, and in the mouth; can also involve internal organs.
Genital warts Warts on the genitals or anus.
Anogenital neoplasia Cervical or anal cancer.
Oral “hairy” leukoplakia Painless white lesions (lines or plaques) on the sides of the tongue and insides of the cheeks.
Nervous system tumor Confusion, slowness, personality changes, seizures.
Anabolic steroids
Anabolic steroids are artificial (synthetic) versions of the male hormone testosterone that help build muscle. They also enhance masculine characteristics.
Because they can help the body to form lean muscle, they are sometimes used to treat wasting and weight loss caused by HIV, and doctors sometimes prescribe them to people experiencing fat loss from the limbs because of lipodystrophy. Testosterone supplements are also used to treat low testosterone levels which can develop in people with HIV due to HIV infection, some other infections, anti-HIV drugs and other medicines.
Anabolic steroids are also widely used by body builders and by many people who weight-train at the gym.
Anabolic steroid treatment in people with HIV
The anabolic steroids have been studied as a treatment for wasting caused by HIV, and have been shown to be safe and effective, helping the formation of lean muscle mass. To be most effective, anabolic steroid treatment should be combined with a programme of resistance (weight) training.
Studies have mostly been restricted to men because of concerns about the side-effects of steroid treatment for women.
Anabolic steroids can increase levels of LDL (bad) cholesterol and other side-effects, so their use should be closely monitored particularly if you are taking a protease inhibitor or have any risk factors for heart disease.
Anabolic steroid use for non-medical purposes
Anabolic steroids are often used by people who weight train to improve the effects of training and for aesthetic reasons. They are usually used in four-week cycles, followed by a period off 'treatment'.
The use of anabolic steroids in this way is rarely medically supervised, and this may involve health risks.
Health risks of anabolic steroid use
Anabolic steroids, and testosterone, can damage the liver, and severe liver problems including liver fibrosis, cirrhosis and cancer have been seen in long-term users of anabolic steroids. If you are being prescribed them by your doctor, your liver function will be closely monitored.
Acne, male pattern baldness, sexual dysfunction, shrinking of the testicles, and the shutting down of natural production of testosterone can also be caused by anabolic steroids. Aggression, mood disturbances, stomach pain, an enlarged prostate and water retention can also develop as a consequence of steroid use. Breast enlargement in men and the development of male characteristics in women have also been observed.
When used in a non-medical context, anabolic steroids are often injected. Sharing needles to inject steroids involves the same health risks as sharing needles to inject recreational drugs, including HIV transmission, and infection with hepatitis C virus and hepatitis B virus.
LABORATORY INVESTIGATIONS:
HIV antibody testing is used to screen for and diagnose HIV infections. Early treatment of HIV infection and immune system monitoring can greatly improve long-term health. Also, knowing your HIV status may help you change behaviors that would put you and others at risk.
Antibodies to the HIV virus are often detected by a screening test called an ELISA. The ELISA test is repeated if positive. The ELISA method is very sensitive but requires another test, a Western Blot, to confirm the results because false positives can occur. These tests can be done on blood, urine or oral sample in a doctor’s office or a local clinic. There are several rapid tests available in which results are generated in about 20 minutes. However, these too must have confirmatory testing before a final diagnosis can be made.
(What is a window period?
The ‘window period’ is a term used to describe the period of time between HIV infection and the production of antibodies. During this time, an antibody test may give a ‘false negative’ result, which means the test will be negative, even though a person is infected with HIV. To avoid false negative results, antibody tests are recommended three months after potential exposure to HIV infection.
A negative test at three months will almost always mean a person is not infected with HIV. If an individual’s test is still negative at six months, and they have not been at risk of HIV infection in the meantime, it means they are not infected with HIV.
It is very important to note that if a person is infected with HIV, they can still transmit the virus to others during the window period.)
Antigen test (P24 test)
Antigens are the substances found on a foreign body or germ that trigger the production of antibodies in the body. The antigen on HIV that most commonly provokes an antibody response is the protein P24. Early in HIV infection, P24 is produced in excess and can be detected in the blood serum (although as HIV becomes fully established in the body it will fade to undetectable levels).
P24 antigen tests are not usually used for general HIV diagnostic purposes, as they have a very low sensitivity and they only work before antibodies are produced in the period immediately after HIV infection.
PCR test
A PCR test (Polymerase Chain Reaction test) can detect the genetic material of HIV rather than the antibodies to the virus, and so can identify HIV in the blood within two or three weeks of infection. The test is also known as a viral load test and HIV NAAT (nucleic acid amplification testing).
Babies born to HIV positive mothers are usually tested using a PCR test because they retain their mother's antibodies for several months, making an antibody test inaccurate. Blood supplies in most developed countries are screened for HIV using PCR tests. However, they are not often used to test for HIV in individuals, as they are very expensive and more complicated to administer and interpret than a standard antibody test.
Enzyme-linked immuno sorbent assay (ELISA)
This testing method is a type of immunoassay. It is based on the principle that antibodies will bind to very specific antigens to form antigen-antibody complexes, and enzyme-linked antigens or antibodies can be used to detect and measure these complexes.
To detect or measure an antibody in a person’s blood, a known antigen is attached to a solid surface. A solution containing the patient sample is added. If the patient’s sample contains antibody, it will bind to the antigen. A second antibody (against human antibodies) that is labeled with an enzyme is then added. If the enzyme-linked antibody binds to human antibodies, the enzyme will create a detectable change that indicates the presence and amount of the antibody in the patient sample.
Western blot
n the Western blot procedure, cells that may be HIV-infected are opened and the proteins within are placed into a slab of gel, to which an electrical current is applied. Different proteins will move with different velocities in this field, depending on their size, while their electrical charge is leveled by a surfactant called sodium lauryl sulfate. Some commercialy prepared Western blot test kits contain the HIV proteins already on a cellulose acetate strip. Once the proteins are well-separated, they are transferred to a membrane and the procedure continues similar to an ELISA: the person's diluted serum is applied to the membrane and antibodies in the serum may attach to some of the HIV proteins. Antibodies which do not attach are washed away, and enzyme-linked antibodies with the capability to attach to the person's antibodies determine to which HIV proteins the person has antibodies.
There are no universal criteria for interpreting the Western blot test: the number of viral bands which must be present may vary. If no viral bands are detected, the result is negative. If at least one viral band for each of the GAG, POL, and ENV gene-product groups are present, the result is positive. The three-gene-product approach to Western blot interpretation has not been adopted for public health or clinical practice. Tests in which less than the required number of viral bands are detected are reported as indeterminate: a person who has an indeterminate result should be retested, as later tests may be more conclusive. Almost all HIV-infected persons with indeterminate Western-Blot results will develop a positive result when tested in one month; persistently indeterminate results over a period of six months suggests the results are not due to HIV infection. In a generally healthy low-risk population, indeterminate results on Western blot occur on the order of 1 in 5,000 patients.[13]:However for those individuals that have had high risk exposures to individuals where HIV-2 is most prevalent, Western Africa, an inconclusive Western Blot test may prove infection with HIV-2.
SOCIAL WORK APPROACH TO PLHIV:
■ Clinical services include preventive care with antibiotic prophylaxis for opportunistic
Infections (e.g. cotrimoxazole), insecticide-treated nets, and interventions to improve the quality of drinking water and hygienic practices; treatment and care services for
opportunistic infections; pain alleviation and symptom management; nutritional counseling, assessment and rehabilitation for malnourishment; routine clinical monitoring, including evaluating the need for ART; support for ART adherence;
and end-of-life care. It also includes working with policy makers to develop appropriate policies related to antibiotic prophylaxis and pain control.
■Social care supports community mobilization, leadership development for people living with HIV/AIDS, legal services, linkages to food support and income-generating programs, and other activities to strengthen the health and well-being of affected households and communities.
■Psychological services provide mental health counseling, family care and support groups, memory books, cultural and age-specific approaches for psychological care, identification and treatment of HIV-related psychiatric illnesses, and bereavement preparedness.
■Spiritual care includes assessment, counseling, facilitating forgiveness, and life completion tasks.
■Positive prevention efforts should be incorporated across the spectrum of palliative care services to reduce the risk of transmitting HIV from HIV-positive persons to others. These services include counseling and HIV testing for the entire family, prevention counseling and services, and biomedical interventions that reduce transmission risk (e.g., treatment of sexually transmitted diseases).
■ Comprehensive HIV/AIDS care is a holistic approach to meeting the needs of HIV-positive individuals. These needs are identified and met by different disciplines ranging from medical care to social support. Several studies have been conducted in the Region
to assess the needs of persons living with HIV and AIDS. One such study from India identified the following list of needs:
(1) Clinical and nursing care for the ill to alleviate the symptoms of HIV and AIDS;
(2) Psychosocial support and counseling of individuals tested HIV positive and their families;
(3) Financial support or opportunities for employment for persons discriminated against and rejected from employment due to HIV status;
(4) Assistance to find appropriate housing in a neighborhood that is sympathetic to HIV-positive persons;
(5) Legal assistance to overcome discrimination at work and in the community;
(6) Care and support of orphans and widows after the death of the primary bread winner,
(7) Information and training in HIV/AIDS care and prevention for care givers at home.
INITIAL ASSESSMENT AND INTERVENTION:
The identification of the needs of individuals and families affected by HIV/AIDS is the beginning of the planning process. To assist in this effort, WHO has developed a manual "Group interview techniques to assess the needs for people with AIDS”
Practical steps are outlined to conduct a rapid needs assessment and methods of analyzing data. Initial assessment involves the following:
(1) Voluntary counseling and testing (VCT) facilitates an entry point in the continuum of comprehensive care. Here people with HIV infection can come to learn and accept their HIV stereo-status and get access to effective care and prevention interventions.
(2) Clinical management of symptomatic infection with early and appropriate diagnosis and rational treatment, nutritional support, discharge planning and referral to other service providers;
(3) Nursing care to relieve the physical discomfort of illness, hygiene and infection control promotion, palliative and terminal care, training of family members in home care and preventive education and condom promotion;
(4) Pre - and post-test counseling to help individuals make informed decisions on HIV testing. This should also include a supportive and accepting environment in which coping, behavior change and positive living are promoted and should continue with follow-up counseling for the patient and other so identified;
(5) Care at home and in the community, including the training of relatives and volunteers in the provision of care, treatment of common symptoms and palliative care.
Promotion of good nutrition, psychological and emotional support, spiritual support and counseling;
(6) Formation of community support groups to provide emotional support to PLHIV and their care providers. Opportunities for developing income-generating projects could be explored in these groups;
(7) Eliminating the stigma of HIV/AIDS and developing of positive attitudes in the community towards persons and families living with HIV/AID S. This includes health care workers in both private and public health institutions;
(8) Social support or referral to appropriate social welfare services to meet the needs for housing, employment, legal support, and to monitor and prevent discrimination, and
(9) Partnership-building between various providers (clinical, social, support groups) in order to be accessible through mutual referrals.
AIDS Risk Reduction Model (ARRM)
The AIDS Risk Reduction Model (ARRM), introduced in 1990, provides a framework for explaining and predicting the behavior change efforts of individuals specifically in relationship to the sexual transmission of HIV/ AIDS.
STAGE 1: Recognition and labeling of one's behavior as high risk
Hypothesized Influences:
• Knowledge of sexual activities associated with HIV transmission;
• Believing that one is personally susceptible to contracting HIV;
• Believing that having AIDS is undesirable;
• Social norms and networking.
STAGE 2: Making a commitment to reduce high-risk sexual contacts and to increase low-risk activities
Hypothesized Influences:
• Cost and benefits;
• Enjoyment (e.g., will the changes affect my enjoyment of sex?);
• Response efficacy (e.g., will the changes successfully reduce my risk of HIV infection?);
• Self-efficacy;
• Knowledge of the health utility and enjoyability of a sexual practice,
• Social factors (group norms and social support), are believed to influence an individual's cost and benefit and self - efficacy beliefs.
STAGE 3: Taking action.
This stage is broken down into three phases:
1) Information seeking;
2) Obtaining remedies;
3) Enacting solutions.
Depending on the individual, phases may occur concurrently or phases may be skipped.
Hypothesized Influences:
• Social networks and problem-solving choices (self-help, informal and formal help);
• Prior experiences with problems and solutions;
• Level of self-esteem;
• Resource requirements of acquiring help;
• Ability to communicate verbally with sexual partner;
• Sexual partner's beliefs and behaviors.
In addition to the stages and influences listed above, the authors of the ARRM
(Catania et al., 1990) identified other internal and external factors that may motivate individual movement across stages. For instance, aversive emotional states (e.g., high levels of distress over HIV/AIDS or alcohol and drug use that blunt emotional states) may facilitate or hinder the labeling of one's behaviors. External motivators, such as public education campaigns, an image of a person dying from AIDS, or informal support groups, May also cause people to examine and potentially change their sexual activities.
Limitations:
A general limitation of the ARRM model is its focus on the individual.
BEHAVIOR CHANGE COMMUNICATION:
I. INTRODUCTION
Behavior change communication (BCC) is an interactive process with communities to develop tailored messages and approaches using a variety of communication channels to develop positive behaviors; promote and sustain individual, community and societal behavior change; and maintain appropriate behaviors.
In the context of the AIDS epidemic, BCC is an essential part of a comprehensive program that includes both services (medical, social, psychological and spiritual) and commodities (e.g., condoms, needles and syringes). Before individuals and communities can reduce their level of risk or change their behaviors, they must first understand basic facts about HIV and AIDS, adopt key attitudes, learn a set of skills and be given access to appropriate products and services. They must also perceive their environment as supporting behavior change and the maintenance of safe behaviors, as well as supportive of seeking appropriate treatment for prevention, care and support.
In most parts of the world, HIV is primarily a sexually transmitted infection (STI). Development of a supportive environment requires national and community-wide discussion of relationships, sex and sexuality, risk, risk settings, risk behaviors and cultural practices that may increase the likelihood of HIV transmission.
A supportive environment is also one that deals, at the national and community levels, with stigma, fear and discrimination, as well as with policy and law. The same issues apply in parts of the world where unsafe injection of illegal drugs is the chief source of new infections.
Effective BCC is vital to setting the tone for compassionate and responsible interventions. It can also produce insight into the broader socioeconomic impacts of the epidemic and mobilize the political, social and economic responses needed to mount an effective program.
II. THE ROLE OF BEHAVIOR CHANGE COMMUNICATION
BCC is an integral component of a comprehensive HIV/AIDS prevention, care and support program. It has a number of different but interrelated roles.
Effective BCC can:
Increase knowledge:
BCC can ensure that people are given the basic facts about HIV and AIDS in a language or visual medium (or any other medium that they can understand and relate to).
Stimulate community dialogue:
BCC can encourage community and national discussions on the basic
facts of HIV/AIDS and the underlying factors that contribute to the epidemic, such as risk behaviors and risk settings, environments and cultural practices related to sex and sexuality, and marginalized practices (such as drug use) that create these conditions. It can also stimulate discussion of healthcare- seeking behaviors for prevention, care and support.
Promote essential attitude change:
BCC can lead to appropriate attitudinal changes about, for example, perceived personal risk of HIV infection, belief in the right to and responsibility for safe practices and health supporting services, compassionate and non-judgmental provision of services, greater open-mindedness concerning gender roles and increasing the basic rights of those vulnerable to and affected by HIV and AIDS.
Reduce stigma and discrimination:
Communication about HIV prevention and AIDS mitigation should address stigma and discrimination and attempt to influence social responses to them.
Create a demand for information and services:
BCC can spur individuals and communities to demand information on HIV/AIDS and appropriate services.
Advocate:
BCC can lead policymakers and opinion leaders toward effective approaches to the epidemic.
Promote services for prevention, care and support:
BCC can promote services for STIs, intravenous drug users (IDUs), orphans and vulnerable children (OVCs); voluntary counseling and testing (VCT) for mother-to-child transmission (MTCT); support groups for PLHA; clinical care for opportunistic infections; and social and economic support. BCC is also an integral component of these services.
Improve skills and sense of self-efficacy:
BCC programs can focus on teaching or reinforcing new skills and behaviors, such as condom use, negotiating safer sex and safe injecting practices. It can contribute to development of a sense of confidence in making and acting on decisions.
III. BCC GOALS
Behavior change communication goals need to be developed in the context of overall program goals and specific behavior change goals. The following highlights the place of BCC goals within an overall program.
Program goal: Reduce HIV prevalence among young people in urban settings in X country.
Behavior change goals:
Increase condom use
Increase appropriate STI care-seeking behavior
Delay sexual debut
Reduce number of partners
BCC goals:
Increase perception of risk or change attitudes toward use of condoms
Increase demand for services
Create demand for information on HIV and AIDS
Create demand for appropriate STI services
Interest policymakers in investing in youth-friendly VCT services (services must be in place)
Promote acceptance among communities of youth sexuality and the value of reproductive health services for youth (services must be in place)
BCC goals are related to specific issues identified when assessing the situation, knowledge, attitudes and skills that may need to be changed to work toward behavior change and program goals.
IV. GUIDING PRINCIPLES
• BCC should be integrated with program goals from the start. BCC is an essential element of HIV prevention, care and support programs, providing critical linkages to other program components, including policy initiatives.
• Formative BCC assessments must be conducted to improve understanding of the needs of target populations, as well as of the barriers to and supports for behavior change that their members face (along with other populations, such as stakeholders, service providers and community).
• The target population should participate in all phases of BCC development and in much of implementation.
• Stakeholders need to be involved from the design stage.
• Having a variety of linked communication channels is more effective than relying on one specific one.
• Pre-testing is essential for developing effective BCC materials.
• Planning for monitoring and evaluation should be part of the design of any BCC program.
• BCC strategies should be positive and action-oriented.
• PLHA should be involved in BCC planning and implementation.
STEPS IN DEVELOPING A BCC STRATEGY:
State program goals
Program goals are designed in coordination with national HIV and AIDS strategies. Clearly identifying overall program goals is the first step in developing a BCC strategy. Specific FHI program goals are established after reviewing existing data, epidemiological information and in-depth program situation assessments.
Involve stakeholders
Key stakeholders need to be involved early on in every step of the process of developing HIV/AIDS programs and their BCC components. Stakeholders include policymakers, opinion leaders, community leaders, religious leaders and members of target populations, including PLHA. Their active participation at appropriate stages of BCC strategy development is essential. A stakeholders’ meeting should be held at the planning stage to obtain guidance and commitments to the process and to develop coordination mechanisms.
Identify target populations
To develop communication, it is important to identify the target populations as clearly as possible. Target populations are defined as primary or secondary. Primary populations are the main groups whose HIV/AIDS-related behavior the program is intended to influence. Secondary populations are those groups that influence the ability of the primary population to adopt or maintain appropriate behaviors. For example, an HIV program may seek to increase condom use among sex workers and clients (primary populations). But to achieve this objective, it may be necessary to change the behavior or gain the support of brothel owners and police (secondary populations).
Target populations include:
• Individuals at high risk or vulnerability, such as sex workers, their clients, youth, migrant workers,
• IDUs, or uniformed services personnel
• People providing services, such as health workers, private practitioners, pharmacists, counselors andsocial service workers
• Policymakers, such as politicians
• Leaders and authorities, formal and informal, including law-enforcement, social and religious leaders
• Local communities and families
Conduct formative BCC assessments
A formative BCC assessment should start by seeking out all available studies, including data from in-depth assessments or rapid ethnographic assessments, behavioral surveillance surveys and other related studies. After synthesizing this information, a formative BCC assessment protocol can be developed. The formative BCC assessment should collect information on:
• Risk situations, showing in detail how decisions are made in different situations, including what influences the decisions and settings for risk
• Why individuals and groups practice the behaviors they do, and why they might be motivated to change (or unable to change) to the desired behaviors
• Perceptions of risk and risk behaviors
• Influences on behavior, such as barriers or benefits
• Insights of opinion leaders
• Patterns of service use and opinions about these services
• Perceptions of stigma and discrimination
• Future hopes, fears and goals
• Media and entertainment habits
• Health care-seeking behaviors
• Positive deviants, or those most willing to model change
• Media resources
Formative BCC assessments make use of qualitative methods, such as focus group discussions, key informant interviews, direct observation, participatory learning methods, rapid ethnographic assessments, mapping and in-depth interviews. Where possible, the organizations that are directly engaged with the population, such as community-based and non-governmental groups, should participate in the formative BCC assessment with assistance from appropriate research institutions.
Segment target populations
Based on the formative BCC assessment, target populations can then be segmented. For example, sex workers can be grouped more specifically according to work location (street, home, and brothel), income level, ethnicity, or language.
Population segments are often defined by psychosocial and demographic characteristics. Psychosocial characteristics include the knowledge, attitudes and practices typically demonstrated by a given group or audience; or by their role in society, their formal and informal responsibilities and their level of authority.
Demographic characteristics include age, place of residence (or work), place of birth, religion and ethnicity. In addition, structural factors and settings (e.g., in the workplace, risk settings, border settings) should also be considered. For example, if sex workers and truck drivers are the target population, border crossings and truck stops constitute risk settings.
Define behavior change objectives
Whether the target population is a particular group or the general public, it is important first to refer to the HIV/AIDS program behavior change objectives. What changes in behavior does the program intend to achieve? While behavior changes may not have been specified in project documents, they can be inferred from project goals. Following are some common behavior change objectives:
• Increased safer sexual practices (more frequent condom use, fewer partners)
• Increased incidence of healthcare-seeking behavior for STIs, TB and VCT (for example, calls or visits to facilities)
• Increased use of universal precautions to improve blood safety
• Adherence by medical practitioners to treatment guidelines
• Increased use of new or disinfected syringes and needles by IDUs
• Decline in stigma associated with HIV/AIDS
• Reduced incidence of discriminatory activity directed at PLHA and other identified high- risk groups
• Improved attitudes and behavior among healthcare, social service and other service delivery workers who interact with PLHA, SWs, IDUs and other marginalized groups
Design BCC strategy and Monitoring and Evaluation (M&E) Plan
A BCC strategy is best designed in a participatory fashion, including members of target populations, organizations planning to work with them and stakeholders. Designing a BCC strategy is more than a matter of developing messages and media materials for dissemination. It is necessary to find the right mix of approaches to involve target populations—that is, to get their attention—and to promote and enable action.
A well-designed BCC strategy should include:
• Clearly defined BCC objectives
• An overall concept or theme and key messages
• Identification of channels of dissemination
• Identification of partners for implementation (including capacity-building plan)
• A monitoring and evaluation plan
Choose partners
In developing a BCC strategy, it is important to identify key partners who can help design and implement its components. Partners may include NGOs, government counterparts, media outlets, graphic designers, local traditional entertainers, members of target populations and other program implementers. It is essential to plan for capacity-building of partners.
Develop communication products
Development of specific communication support materials should be based on decisions made about channels and activities. They can include:
• Print materials for peer educators, such as flip charts and picture codes
• Print materials to support health workers on specific care issues
• Television spots for general broadcast
• Promotional materials about the project, for advocacy
• Scripts for theater and street theater
• Radio or television soap opera scripts
Conduct pre-testing
Pre-testing is key to ensuring that themes, messages and activities reach the intended target populations. It is important to pre-test at every stage with all audiences for whom the communication is intended, both primary and secondary. Pre-testing should be done of themes, messages, prototype materials, training packages, support tools and BCC formative assessment instruments.
Pre-testing of media, messages and themes should evaluate:
1. Comprehension
2. Attraction
3. Persuasion
4. Acceptability
5. Audience members’ degree of identification
Several versions should be pre-tested and audience reactions compared.
Implement and monitor
In the implementation phase, all elements of the strategy go into operation. An especially important element is management. All partners, programmers and channels of the BCC strategy must be closely coordinated.
There must be links among critical program elements, such as supply and demand. If populations discover that VCT services being promoted by BCC messages and materials are unavailable, the programs will suffer. Timing and coordination are key to managing a program effectively. Because the BCC strategy is linked to other parts of the prevention and care effort, BCC specialists must work as members of a broader team and coordinate their activities. Coordinators of each component of the team should keep others informed of their progress and activities. Ongoing communication with partners about areas outside of prevention and care It is essential to budget adequately for all steps needed to develop a BCC campaign and program.
It is important that monitoring be carried out as planned. Often monitoring receives inadequate attention, both in terms of collecting information and, still more often, in making sure it gets fed back in usable form to people who need it for decision-making and field implementation. Specific personnel must be designated to make sure that the monitoring plan is developed with input from the people who will use it; to make sure that everyone involved knows the expected outcomes and has the appropriate tools and skills; and to make sure that there is budget and time enough to carry the plan out.
Evaluate
Evaluation refers to the assessment of a project’s implementation and its success in achieving predetermined objectives of behavior change. BCC interventions should be evaluated against their stated objectives and in reference to a baseline that may be qualitative or quantitative (or both). For large-scale interventions, baseline quantitative research may be repeated to demonstrate changes in knowledge, attitudes and reported behaviors relative to communication and project-level behavior change objectives. Change can also be assessed through qualitative research into target-group responses to interventions. Qualitative evaluation involves examining data that are designed to illustrate changes in audience behavior.
Elicit feedback and modify the program
As programs evolve, target populations acquire new knowledge and behaviors, and communication needs may change. The needs of target populations must be periodically reassessed to understand where they stand along the behavior change continuum. Monitoring and evaluation studies should lead directly to modifications of the overall program, as well as of the BCC strategies, messages and approaches.
Day-to-day monitoring will provide information for making adjustments in short-term work planning.
Periodic program reviews can be designed to take a more in-depth look at program progress and larger-scale adjustments or redesign. Involving stakeholders, target audiences and partners as much as possible will provide a better look at what is happening; help make appropriate decisions; and make sure that the people affected by any decisions will be fully aware of them.
Post-exposure prophylaxis (PEP)
If you have had unprotected sex (or shared drug injecting equipment) with somebody you know is HIV-positive, or is from a group at high risk of HIV, such as gay men, then you may be able to get a short course of HIV treatment to try to prevent you becoming infected with HIV.
This is called post exposure prophylaxis, or PEP for short.
The professional organisation of the UK's sexual health doctors has guidelines recommending the circumstances in which PEP should be used.
Purpose of PEP
PEP has been used for many years for healthcare workers who have had possible exposure to HIV, for example, after accidentally pricking themselves with needles used on people who were known to be HIV-positive or at risk of HIV.
PEP is not a ‘cure’ for HIV. Rather, PEP may prevent HIV from entering cells in the body and so prevent you from becoming infected with HIV. PEP isn’t 100% effective. However, there have been very few reports of HIV infection after the use of PEP.
Timing of PEP
To have the best chance of being effective you need to start taking PEP as soon as possible after the possible exposure to HIV and within 72 hours. However, the guidelines state that PEP may still be considered for possible HIV exposure in high risk groups.
Medicine used for PEP
PEP normally consists of three anti-HIV drugs, from two of the different classes,usually two nucleoside analogues (NRTIs) plus a boosted protease inhibitor.
PEP should be taken for a month, and it is important to take all the doses, at the right time and in the right way.
Where to get PEP
Go to a sexual health clinic. If they operate an appointments system and are fully booked, explain that it’s an emergency and that you need to be seen. If it is a weekend, go to the accident and emergency department, who will contact an HIV specialist who is able to prescribe PEP.
Access to PEP
There are guidelines stating when PEP should be considered. It is recommended if you have had unprotected inservitve or receptive anal, or vaginal sex with someone who is known to be HIV-positive.
It is also recommended if you have had unprotected receptive anal sex with someone whose HIV status is not known.
It may be considered if you have had insertive anal sex, insertive or receptive vaginal sex, or fellatio (cock sucking) with ejaculation with someone whose HIV status is known or unknown. It may also be considered for semen splashes in the eye if a person if known to be HIV-positive.
The sooner PEP is accessed the better. The guidelines state that it should be provided within 72 hours of the possible HIV exposure, but that it may be provided after this time for high risk groups.
Despite these guidelines, some people who have had possible HIV exposure, including gay men have had difficulty getting PEP. In these circumstances, you may find this information from THT helpful.
Side-effects
HIV treatment can cause side-effects which tend to be worst when you first start taking them, and if you are taking PEP you could experience some unpleasant side-effects such as feeling sick, being sick, diarrhoea, tiredness, and generally feeling unwell.
If you have been exposed to a strain of HIV that is resistant to some anti-HIV drugs then it’s possible that PEP won’t work.
If you are already HIV-positive, but don’t know it, there is a chance of developing drug resistance when you take PEP if you don’t take your doses properly. This could limit your treatment options in the future.
Other things to consider
PEP is not 100% effective, so it would make good sense not to rely on access to PEP if you are having unprotected sex or sharing drug injecting equipment. Condoms, when used properly, are an effective way of preventing the spread of HIV and most other sexually transmitted infections, and never share needles or injecting equipment.
HIV 1
Acquired immune deficiency syndrome or acquired immunodeficiency syndrome (AIDS) is a disease of the human immune system caused by the human immunodeficiency virus (HIV).
This condition progressively reduces the effectiveness of the immune system and leaves individuals susceptible to opportunistic infections and tumors. HIV is transmitted through direct contact of a mucous membrane or the bloodstream with a bodily fluid containing HIV, such as blood, semen, vaginal fluid, preseminal fluid, and breast milk.
This transmission can involve anal, vaginal or oral sex, blood transfusion, contaminated hypodermic needles, exchange between mother and baby during pregnancy, child birth, breastfeeding or other exposure to one of the above bodily fluids.
AIDS is now a pandemic. In 2007, it was estimated that 33.2 million people lived with the disease worldwide, and that AIDS killed an estimated 2.1 million people, including 330,000 children. Over three-quarters of these deaths occurred in sub-Saharan Africa, retarding economic growth and destroying human capital.
Genetic research indicates that HIV originated in west-central Africa during the late nineteenth or early twentieth century. AIDS was first recognized by the U.S. Centres for Disease Control and Prevention in 1981 and its cause, HIV, identified in the early 1980s.
Although treatments for AIDS and HIV can slow the course of the disease, there is currently no vaccine or cure. Antiretroviral treatment reduces both the mortality and the morbidity of HIV infection, but these drugs are expensive and routine access to antiretroviral medication is not available in all countries. Due to the difficulty in treating HIV infection, preventing infection is a key aim in controlling the AIDS pandemic, with health organizations promoting safe sex and needle-exchange programmes in attempts to slow the spread of the virus.
SYMPTOMS:
The symptoms of AIDS are primarily the result of conditions that do not normally develop in individuals with healthy immune systems. Most of these conditions are infections caused by bacteria, viruses, fungi and parasites that are normally controlled by the elements of the immune system that HIV damages.
Opportunistic infections are common in people with AIDS. These infections affect nearly every organ system.
People with AIDS also have an increased risk of developing various cancers such as Kaposi's sarcoma, cervical cancer and cancers of the immune system known as lymphomas. Additionally, people with AIDS often have systemic symptoms of infection like fevers, sweats (particularly at night), swollen glands, chills, weakness, and weight loss. The specific opportunistic infections that AIDS patients develop depend in part on the prevalence of these infections in the geographic area in which the patient lives.
Epidemiology:
The AIDS pandemic can also be seen as several epidemics of separate subtypes; the major factors in its spread are sexual transmission and vertical transmission from mother to child at birth and through breast milk. Despite recent, improved access to antiretroviral treatment and care in many regions of the world, the AIDS pandemic claimed an estimated 2.1 million (range 1.9–2.4 million) lives in 2007 of which an estimated 330,000 were children under 15 years. Globally, an estimated 33.2 million people lived with HIV in 2007, including 2.5 million children. An estimated 2.5 million (range 1.8–4.1 million) people were newly infected in 2007, including 420,000 children.
Sub-Saharan Africa remains by far the worst affected region. In 2007 it contained an estimated 68% of all people living with AIDS and 76% of all AIDS deaths, with 1.7 million new infections bringing the number of people living with HIV to 22.5 million, and with 11.4 million AIDS orphans living in the region. Unlike other regions, most people living with HIV in sub-Saharan Africa in 2007 (61%) were women.
Adult prevalence in 2007 was an estimated 5.0%, and AIDS continued to be the single largest cause of mortality in this region.
South Africa has the largest population of HIV patients in the world, followed by Nigeria and India. South & South East Asia are second worst affected; in 2007 this region contained an estimated 18% of all people living with AIDS, and an estimated 300,000 deaths from AIDS. India has an estimated 2.5 million infections and an estimated adult prevalence of 0.36%.Life expectancy has fallen dramatically in the worst-affected countries; for example, in 2006 it was estimated that it had dropped from 65 to 35 years in Botswana.
In the United States, young African-American women are also at unusually high risk for HIV infection. This is due in part to a lack of information about AIDS and a perception that they are not vulnerable, as well as to limited access to health-care resources and a higher likelihood of sexual contact with at-risk male sexual partners.
There are also geographic disparities in AIDS prevalence in the United States, where it is most common in rural areas and in the southern states, particularly in the Appalachian and Mississippi Delta regions and along the border with Mexico. Approximately 1.1 million persons are living with HIV/AIDS in the United States, and more than 56,000 new infections occur every single year.
HIV/AIDS situation in India:
India is one of the largest and most populated countries in the world, with over one billion inhabitants. Of this number, it's estimated that around 2.3 million people are currently living with HIV. HIV emerged later in India than it did in many other countries. Infection rates soared throughout the 1990s, and today the epidemic affects all sectors of Indian society.
“Unlike developed countries, India lacks the scientific laboratories, research facilities, equipment, and medical personnel to deal with an AIDS epidemic. In addition, factors such as cultural taboos against discussion of sexual practices, poor coordination between local health authorities and their communities, widespread poverty and malnutrition, and a lack of capacity to test and store blood would severely hinder the ability of the Government to control AIDS if the disease did become widespread.”
“HIV infection is now common in India; exactly what the prevalence is, is not really known, but it can be stated without any fear of being wrong that infection is widespread… it is spreading rapidly into those segments that society in India does not recognise as being at risk. AIDS is coming out of the closet.”
CURRENT ESTIMATES:
In 2006 UNAIDS estimated that there were 5.6 million people living with HIV in India, which indicated that there were more people with HIV in India than in any other country in the world. In 2007, following the first survey of HIV among the general population, UNAIDS and NACO agreed on a new estimate – between 2 million and 3.1 million people living with HIV.
In 2008 the figure was confirmed to be 2.5 million, which equates to a prevalence of 0.3%. While this may seem a low rate, because India's population is so large, it is third in the world in terms of greatest number of people living with HIV. With a population of around a billion, a mere 0.1% increase in HIV prevalence would increase the estimated number of people living with HIV by over half a million.
The national HIV prevalence rose dramatically in the early years of the epidemic, but a study released at the beginning of 2006 suggests that the HIV infection rate has recently fallen in southern India, the region that has been hit hardest by AIDS.20 In addition, NACO released figures in 2008 suggesting that the number of people living with HIV has declined.
HIV PREVALANCE IN DIFFERENT STATES:
Andhra Pradesh
Andhra Pradesh in the southeast of the country has a total population of around 76 million, of whom 6 million live in or around the city of Hyderabad. The HIV prevalence at antenatal clinics was 1% in 2007. This figure is smaller than the reported 1.26% in 2006, but is still highest out of all states. HIV prevalence at STD clinics was very high at 17% in 2007. Among high-risk groups, HIV prevalence was highest among men who have sex with men (MSM) (17%), followed by female sex workers (9.7%) and IDUs (3.7%).26
Goa
Goa, a popular tourist destination, is a very small state in the southwest of India (population 1.4 million). In 2007 HIV prevalence among antenatal and STD clinic attendees was 0.18% and 5.6% respectively. The Goa State AIDS Control Society reported that in 2008, a record number of 26,737 people were tested for HIV, of which 1018 (3.81%) tested positive.
Karnataka
Karnataka, a diverse state in the southwest of India, has a population of around 53 million. HIV prevalence among antenatal clinic attendees exceeded 1% from 2003 to 2006, and dropped to 0.5% in 2007. Districts with the highest prevalence tend to be located in and around Bangalore in the southern part of the state, or in northern Karnataka's "devadasi belt". Devadasi women are a group of women who have historically been dedicated to the service of gods. These days, this has evolved into sanctioned prostitution, and as a result many women from this part of the country are supplied to the sex trade in big cities such as Mumbai. The average HIV prevalence among female sex workers in Karnataka was just over 5% in 2007, and 17.6% of men who have sex with men were found to be infected.
Maharashtra
Maharashtra is a very large state of three hundred thousand square kilometres, with a total population of around 97 million. The capital city of Maharashtra - Mumbai (Bombay) - is the most populous city in India, with around 14 million inhabitants. The HIV prevalence at antenatal clinics in Maharashtra was 0.5% in 2007. At 18%, the state has the highest reported rates of HIV prevalence among female sex workers. Similarly high rates were found among injecting drug users (24%) and men who have sex with men (12%).
Tamil Nadu
With a population of over 66 million, Tamil Nadu is the seventh most populous state in India. Between 1995 and 1997 HIV prevalence among pregnant women tripled to around 1.25%. The State Government subsequently set up an AIDS society, which aimed to focus on HIV prevention initiatives. A safe-sex campaign was launched, encouraging condom use and attacking the stigma and ignorance associated with HIV. Between 1996 and 1998 a survey showed that the number of men reporting high-risk sexual behaviour had decreased.
In 2007 HIV prevalence among antenatal clinic attendees was 0.25%. HIV prevalence among injecting drug users was 16.8%, third highest out of all reporting states. HIV prevalence among men who have sex with men and female sex workers was 6.6% and 4.68% respectively.
Manipur
Manipur is a small state of some 2.4 million people in northeast India. Manipur borders Myanmar (Burma), one of the world's largest producers of illicit opium. In the early 1980s drug use became popular in northeast India and it wasn't long before HIV was reported among injecting drug users in the region. Although NACO report a state-wise HIV prevalence of 17.9% among IDUs, studies from different areas of the state find prevalence to be as high as 32%.
Estimated adult HIV prevalence is the highest out of all states, at 1.57%.
Mizoram
The small northeastern state of Mizoram has fewer than a million inhabitants. In 1998, an HIV epidemic took off quickly among the state's male injecting drug users, with some drug clinics registering HIV rates of more than 70% among their patients. In recent years the average prevalence among this group has been much lower, at around 3-7%.44 HIV prevalence at antenatal clinics was 0.75% in 2007.
Nagaland
Nagaland is another small northeastern state where injecting drug use has again been the driving force behind the spread of HIV. In 2003 HIV prevalence among IDUs was 8.43%, but has since declined to 1.91% in 2007. HIV prevalence at antenatal clinics and STD clinics was 0.60% and 3.42% respectively in 2007.
TARGET GROUPS:
1. SEX WORKERS:
Sex work is very widespread in India, and occurs on a much larger scale than in many other countries. Women often get involved as a result of poverty, marital break-up, or because they are forced into it. HIV prevalence among sex workers varies between districts and states, although there has been a general decline in prevalence in recent years. One study found prevalence ranged between 2 percent and 38 percent (averaging at 14.5 percent) among districts in the four high prevalence south Indian states Andhra Pradesh, Maharashtra, Tamil Nadu and Karnataka.
In the city of Mysore, southern India, around a quarter of sex workers are infected with HIV. This situation is not surprising given that in one study only 20 percent of sex workers had always used condoms with commercial clients in the past month.
Sex workers are often labeled as key risk group in the context of HIV and AIDS. Historically, the AIDS epidemic in India was first identified amongst sex workers and their clients, before other sections of society became affected.
MEANS OF TRANSMISSION:
MULTIPLE PARTNERS, INCONSISTENT CONDOM USAGE:
In general, sex workers have relatively high numbers of sexual partners. This in itself does not necessarily increase their likelihood of becoming infected with HIV – if they use condoms consistently and correctly then they will probably be protected no matter how many people they have sex with. The reality, however, is that sex workers and their clients do not always use condoms. In some cases, this is because sex workers have no access to condoms, or are not aware of their importance. Clients may refuse to pay for sex if they have to use a condom, and use intimidation or violence to enforce unprotected sex.
“Sex workers have told us that when they ask a client to use a condom, he offers double the price to have sex without the condom. These women are trying to provide for their children and families, so they take the offer.” - Ndeye Astou Diop, Aboya (an organisation that works with HIV-positive women in Senegal)
MODES OF PREVENTION:
There are several steps that can be taken towards achieving these goals. Effective measures include the provision of condoms; educating sex workers and their clients about HIV; encouraging peer education (where sex workers inform one another about HIV); helping sex workers to group together; reducing the stigma that communities attach to sex work; and ensuring that laws and policies respect sex workers’ human and citizen rights.
2. MALE SEX WITH MALE:
The term men who have sex with men (MSM) refers to all men who have sex with other men. With MSM, there are two main forms of sexual activity that carry greater risks, anal and oral sex, although not all MSM engage in them. MSM may also have greater risks in that they can switch sex roles.
In MSM, HIV transmission can involve anal or oral sex, blood transfusion, contaminated hypodermic needles, or other exposure to one of the above bodily fluids. Regardless of the gender of the receptive partner, anal sex carries a higher risk of infection than most sex acts, but most penetrative sex acts carry some risk. The main route of transmission is through unprotected sex. Properly used condoms can reduce this risk. The adult prevalence rate in the United States is 0.7%, with over 1 million people currently living with HIV. In the United States from 2001–2005, the highest transmission risk behaviors were sex between men (40–49% of new cases) and high risk heterosexual sex (32–35% of new cases). HIV infection is increasing at a rate of 12% annually among 13-to-24-year-old American men who have sex with men. Experts attribute this to "AIDS fatigue" among younger people who have no memory of the worst phase of the epidemic in the 1980s and early 1990s, as well as "condom fatigue" among those who have grown tired of and disillusioned with the unrelenting safer sex message. The increase may also be because of new treatments. In developing countries, HIV infection rates have been characterized as skyrocketing among MSM. Studies have found that less than 5% of MSM in Africa, Asia, and Latin America have access to HIV-related health care.
A large study in Andhra Pradesh found that 42% of MSM in the sample were married, that 50% had had sexual relations with a woman within the past three months and that just under half had not used a condom.33 As such, unprotected sex between men can also present a risk to any women that they may subsequently have sex with.
3. TRUCK DRIVERS:
Truck drivers are a very high-risk group for HIV infection. Louis Hollander, the chairman of Trucking against AIDS, says about 45% of truck drivers are HIV-positive. Contributing factors are that truck drivers are away from their families for long periods of time and that there are high numbers of sex workers at truck stops. Many areas that truck drivers travel through are rife with poverty and unemployment so women are ready to sleep with them in exchange for money to survive.
India has one of the largest road networks in the world, involving millions of drivers and helpers. Truck drivers spend long periods of time away from home, and it is common practice for them to have relations with sex workers while on the road. A 2008 study showed that nearly a third of the long-distance truckers had paid for sex in the past twelve months.
A startling study indicates that almost 40 percent of India's truck drivers and their helpers are infected with AIDS virus. "The findings are certainly alarming. One in every three truckers visits commercial sex workers. The shocking part is that only 18 percent of them use condoms.”
Their highly mobile lifestyle requires a lot of travel. In other stopover town locations they visit other commercial male/female sex workers thereby potentially transmitting the virus.
4. STREET CHILDREN:
No one knows how many street children are at risk of contracting, or have died of, HIV/AIDS. They are not even listed as a vulnerable group, like commercial sex workers and homosexuals. Yet the sexual exploitation and drug abuse that is an inevitable part of their lives, points to a serious problem in urgent need of attention, says Charumathi Supraja
Street children are not basically depraved, lazy, trouble-mongerers. They are deprived, abjectly neglected children who are barely visible except as a threat or nuisance. Runaway children, missing children, children orphaned by AIDS, children of street dwellers (who do not keep in touch with their parents or vice versa) land up on the streets. If social service organisations do not interrupt their induction into street life, they turn into ‘hard-core’ street children. Such children are highly mobile, abused at multiple levels and totally deprived of adult affection and normal adult influence. They survive the threats of street life by joining gangs that introduce them to strategies like “sex for comfort, pleasure and money” and “drugs for bliss and loss of pain”. Lacking a nutritious environment in more ways than one, these children fall prey to the worst diseases that affect neglected groups and communities. HIV-AIDS is just one of them
In 2001-2002, a clinical child and adolescent psychologist from the Netherlands, Meindert Schaap, conducted in-depth research on the sexual life-worlds of 25 teenage street boys, aged 12-16. The research showed ‘an early onset of sexual activity and a very rapid sexual career among street boys. Same-sex activities (mutual masturbation and anal sex) are far more common than sex with girls. Most street boys have sex with multiple partners and have had sexual encounters with (street) prostitutes.’
The motives to engage in sex include ‘pleasure, immediate lust-reduction and material gain (food, money, drugs).’ Meindert recorded that ‘sexual activities may start as experimenting for pleasure but soon become a sort of commodity as well as …an addictive means to get immediate pleasure. Only a relatively small part of the boys' sexual activities involve real force and are considered to be abusive. All in all, sex is not a big deal: “You eat, you drink, you have sex”.’
The study also found that only a few street boys seemed to have reasonably good knowledge of sexual health. The misconceptions were widespread and included beliefs like anal sex with boys is harmless and that ‘HIV/AIDS can be easily recognised by sight and that HIV is easily spread by mouth.’ Condoms are used, if at all, for heterosexual activities.
ID USERS:
Nationally, HIV prevalence among injecting drug users (IDUs) appears to have declined slightly in recent years to around 7 percent in 2006. However, transmission through injecting drug use is still a major driving factor in the spread of HIV in India, particularly in north-eastern areas, such as Manipur and Nagaland. One study found HIV prevalence ranged from 23 percent to 32 percent in different areas of Manipur.27 In 2006 new sites of high HIV prevalence among IDUs were identified in Punjab, Tamil Nadu, West Bengal, Kerala and Maharastra.
The alarming levels of infection occurring through needle-sharing have implications that extend beyond networks of drug users. Some of those who inject drugs are also sex workers or truck drivers, and many are sexually active, which can result in infection being passed on to their partners. Experts have argued that there needs to be more information aimed at both injecting drug users and their sexual partners.29
The Indian government’s approach to drug use is based around law-enforcement and prosecution, with very little done in terms of treating drug users or helping them to stop using drugs. Harm reduction – a method of HIV prevention that has been successful in other countries, which acknowledges that drug use occurs and seeks ways to reduce HIV transmission in this context – has not been adopted in the government’s drug policies.
APPROACH TO PATIENTS WITH SUSPECTED HIV INFECTION:
The moment that an adult or child is suspected of having HIV infection, the issue of his/her care and management is thrust into the spotlight. The responsibility for providing care is usually shared by the professional team, the community, and the patient. Excellent communication between all parties becomes vital especially when the patient is receiving antiretroviral drugs (ARVs), for they must be continued without interruption.
(Cange in rural Haiti is an example of a best practice in such a situation;
there, patients choose trustworthy persons from the community to serve as accompagnateurs who complete regular, direct observation and documentation of the patients taking their medications.)
The first meeting between the healthcare professional and the patient is often at the request of the patient, the family, or a concerned friend. From the first moment of meeting, the professional must focus on beginning a cooperative partnership with the patient, for what often begins is a process of negotiation between the professional caregiver and patient. From the caregiver’s perspective, the primary objective of the partnership is adherence--not just to drug treatment, but to further clinical and laboratory investigations and to any necessary aspects of lifestyle change.
Building trust between these parties is paramount, because the validity and reliability of
Communication depends squarely on trust and trustworthiness. Understanding the patient’s mental and emotional status is vital to the success of communication and, by extension, to the success of treatment. The healthcare worker must also get a clear picture of the patient’s circumstances, including employment, economic status, and social support network.
(For example, in some larger Caribbean countries, the cost of transportation to and from the health clinic or hospital is prohibitive, absorbing monies usually devoted to investigations and therapy. Or, a patient living on the street may be less adherent to medications than someone who has a home.)
Many needs of PLWHA are identical to those of persons with other illnesses, but because of the aura and stigma that often surrounds HIV/AIDS, the patient and the family may have additional requirements as outlined in the following tables.
Table 1: Medical Needs of PLWHA*
• Access to health team
• Means of transport
• Medical monitoring (e.g. interviews, examinations, laboratory tests)
• Patient education
• Nutritional plan of action
• Dietary and/or nutritional supplements
• ARVs and drugs for opportunistic infection (OI) prophylaxis and treatment
• Provision of condoms, when necessary
• Crisis care and terminal care
• Education of significant others (e.g. knowledge, skills, attitudes)
• Supervision and supplies for caregivers at home, hospice, or hospital
• Response to special needs
Table 2: Counselling& Needs of PLWHA†
• Pre- and post-test counselling
• Individual and group support for counselling concerning general life issues
• Counselling regarding interpersonal relationships, sexuality, and sexual issues
• Spiritual counselling
• Discussion and clarification of issues related to personal and family confidentiality
• Counselling and support in preparation for dying, and when necessary, including arrangements for children
Table 3: Counselling& Needs of Family and Friends of PLWHA∞
• Education about HIV, including reassurance about personal safety in long-term social contact situations
• Emotional and spiritual support
• Bereavement counselling
Table 4: Self-Care Needs of PLWHA*
Physical and mental:
• Keeping physically fit
• Maintaining the best possible nutrition
• Living a balanced life including work, rest, recreation, and sleep
• Good personal hygiene and sexual safety in order to avoid unnecessary contact with infection.
Table 5: Social Support Needs of PLWHA†
• Companionship
• Legal advice and services
• Employment
• Income-generating activities
• Occupational therapy
• Cash and kind for short-term support
• Food and shelter
• Means of transport
• Child welfare
• Involvement in community life
PRE – TEST AND POST – TEST COUNSELLING:
The aims of pre-test and post-test discussions are:
• To provide information and support around the testing procedure.
• To minimise the personal impact of diagnosis.
• To change health-related behaviour and to reduce anxiety of the person being tested.
• To educate the patient regarding risk of transmission.
• To obtain informed consent, and to follow up and arrange referrals as indicated.
Summary of pre-test discussion
• Reason for testing and risk assessment
• Timing of risk and option of post-exposure prophylaxis (PEP)
• Need for other STI and blood-borne virus testing
• History of testing
• Confidentiality and privacy issues around testing
• Ensuring there is informed consent for the test
• Natural history and transmission information
• Prevention of transmission and risk reduction through behaviour change
• Implication of a positive or indeterminate test result, including availability of treatment
• Implications of a negative test result
• Explanation of the window period
• General psychological assessment and assessment of social supports in the event of a positive result
• Logistics of the test: time taken for results to become available and the need to return for results
Pre-test discussion has several objectives:
• To provide information about the implications of a
positive or negative result
• To enable informed decision-making about testing
• To communicate the health benefits of testing
• To educate patients about modes of transmission,
safe sex and risk reduction measures
• To prepare for a possible positive result.
HIV Pre-Test Discussion
While pre- and post- test discussion is generally associated with testing for HIV, components of pre- and post- test discussion apply to testing for many sexually transmissible and blood-borne infections.
• Ensure client is aware of the confidentiality surrounding the test
Assess risk factors such as types of sexual behaviour, number of partners:
• Potential for exposure to HIV
• Determine when exposure to risk occurred
Previous testing
• when, where
• is result available?
• what was tested?
Explain the test:
• Why the test is done (treatment, improve outcomes, reduce risk of transmission)
• How the test is done
• What the test tells and does not tell (ie discuss exactly what you are testing for)
• For infections with window periods, discuss implications, advise if and when repeat testing will be necessary
Confidentiality issues:
• Discuss ways the patient should protect their own confidentiality (eg carefully consider who they will tell)
• Inform the patient of legal requirements for and mechanisms of notification in the case of a positive test for a notifiable infection
• Inform the patient of the procedures relating to contact tracing in the case of a positive test
Discuss how and when to obtain results:
• It is strongly recommended all HIV (and probably Hep B and Hep C) results are given in person by medical practitioners or experienced sexual health nurses. It is important to stress to the patient prior to the test that test results will not be given over the phone to ensure the patient does not assume the worst when asked to come into the surgery to get the results. Consider making an appointment to give back the results at the time the test is taken
Discuss implications of a negative result:
• Discuss prevention - don't let people go away with the idea a negative test somehow confers immunity on them for future risk taking behaviour.
• Reinforce the positive aspects of safe sex practises. Opportunity for further education
• May require repeat test if exposure still within 12 week window period
Discuss implications of a positive result:
• What a positive result would mean
• Discuss the options for medical treatment and follow-up
• Consider the availability of family or friends who may be available to talk with if the result is positive (support systems)
• Does the patient have any holidays available if needed to be able to come to terms with the result
• Discuss contact tracing and what this means
• Evaluate patient's coping skills
Risk reduction:
• Stress importance of ongoing risk reduction strategies
• Specifically address any risks identified in history
• Offer follow-up support.
HIV Post-Test Discussion
Summary of post-test discussion giving a negative result:
• Explain the negative test result and the window period (if relevant)
• Reinforce education regarding safe behaviours
• Further discuss anxiety or risk behaviours, Discuss testing for other STIs.
A negative result:
• Review:
- risk behaviours
- what test tells and does not tell
- window period: may require repeat test if exposure still within window period
• Prevention:
- maximise educational opportunity
- don’t let people go away with the idea a negative test somehow confers immunity on them for future risk taking behaviour.
Summary of post-test discussion giving a positive result:
First post-test consultation
• Establish rapport and assess readiness for the result
• Give positive test result
• Avoid information overload
• Listen and respond to needs (the patient may be overwhelmed and hear little after being told the positive result)
• Discuss immediate implications
• Review immediate plans and support
• Reassess support requirements and available services
• Arrange other tests and the next appointment
• Begin contact tracing process and discuss options available to facilitate this
Subsequent consultations
• Treatment options diet and exercise
• Effect of diagnosis on relationships and prevention information
• Issues of disclosure
• Assessment of contact tracing process and difficulties encountered
• Access to life insurance may be affected
• Workplace implications
• Impact of other issues (eg. drug use, poverty, homelessness) on ability to access health care and treatments
• Referral for on-going counselling, social worker, medical specialist as appropriate.
A positive result:
• Before giving the result, check that the person has come for the result. The person may have come for a different reason and may not be ready for you to launch into a discussion of a positive result
• Allow plenty of time
• Explain the result and what it means
• Be straightforward
• Listen, encourage questions
• Be willing to talk
• How much information to give? – be guided by the person’s response and do not overload
Arrange follow-up:
• Offer ongoing medical and psychological support
• Offer referral to another support agency such as Queensland Positive People and the Queensland AIDS Council, as necessary
• Offer referral for management as necessary
• Check there is a trusted support person available
Contact tracing:
• timing of contact tracing will vary according to circumstances
- if others are at immediate risk, contact tracing is a priority
- if a person understands the risk to others and is having difficulty adjusting to the diagnosis, contact tracing may be deferred
SEXUALLY TRANSMITTED INFECTION:
A sexually transmitted disease (STD), also known as sexually transmitted infection (STI) or venereal disease (VD), is an illness that has a significant probability of transmission between humans or animals by means of human sexual behavior, including vaginal intercourse, oral sex, and anal sex.
STI Definition Incubation
Period Mode of Transmission Symptoms Treatment
Gonorrhea Gonorrhea is a common sexually transmitted infection caused by the bacterium Gonococcus. In both men and women if gonorrhea is left untreated, it may spread throughout the body, affecting joints and even heart valves. 2 to 30 days with most symptoms occurring between 4–6 days after being infected. The infection is transmitted from one person to another through vaginal, oral, or anal sexual relations. Men may complain of pain on urinating and thick, copious, urethral pus discharge, scrotal pain or swelling.
Women may complain of vaginal discharge, difficulty in urinating (dysuria), projectile urination, off-cycle menstrual bleeding, or bleeding after sexual intercourse. Antibiotics may be used to treat gonorrhea
Syphilis Syphilis is a sexually transmitted disease caused by the
spirochetal
bacterium.
10 – 90 days after the first exposure. The route of of syphilis is through
sexual contact, although there are examples of
congenital syphilis from mother to child in utero.
A skin lesion often on the penis, vagina or
rectum. Other symptoms common at this stage include fever, sore throat, malaise,
weight loss, headache,
meningismus, and enlarged lymph nodes.
Syphilis can generally be treated with
antibiotics, including
penicillin.
If left untreated, syphilis can damage the heart,
aorta, brain, eyes, and bones.
Herpes Simplex Herpes simplex is a viral disease caused by both herpes simplex virus 1 (HSV-1) and herpes simplex virus 2 (HSV-2). 2 – 21 days. Herpes simplex is most easily transmitted by direct contact with a lesion or the body fluid of an infected individual. Common infection of the skin or mucosa may affect the face and mouth, genitalia, or hands. More serious disorders occur when the virus infects and damages the eye, or invades the central nervous system, damaging the brain. There is no cure for herpes. Once infected, the virus remains in the body for life.
STI Definition Incubation Period Mode of Transmission Symptoms Treatment
Genital warts Genital warts, caused by some types of HPV (human papilloma virus), can appear on the skin anywhere in the genital area as white or flesh-coloured, smooth, small bumps, or larger, fleshy, cauliflower-like lumps. 10 days to one or two months. Genital HPV is transmitted by genital skin-to-skin contact, or through the transfer of infected genital fluids. This is usually during vaginal or anal sex. Warts can appear on or around the penis, the scrotum, the thighs or the anus. In women warts can develop around the vulva or inside the vagina and on the cervix. There is no treatment that can completely eliminate genital warts once a person has been infected. Often outbreaks of genital warts will become less frequent over time, until the body naturally clears the virus and the warts disappear of their own accord.
Chlamydia Chlamydia is caused by the bacterium chlamydia trachomatis. This bacteria can infect the cervix in women and the urethra and rectum in both men and women. Occasionally chlamydia can also affect other parts of the body, including the throat and eyes. Chlamydia symptoms usually appear between 1 and 3 weeks after exposure but may not emerge until much later. By having unprotected vaginal, anal or oral sex with someone who is infected. Chlamydia is known as the ‘silent’ disease as in many people it produces no symptoms. It is estimated that 70-75% of women infected with chlamydia are asymptomatic (have no symptoms) and a significant proportion of men also have no symptoms. The treatment of chlamydia is simple and effective once the infection has been diagnosed. It consists of a short course of antibiotic tablets, which if taken correctly, can be more than 95 percent effective.
This condition progressively reduces the effectiveness of the immune system and leaves individuals susceptible to opportunistic infections and tumors. HIV is transmitted through direct contact of a mucous membrane or the bloodstream with a bodily fluid containing HIV, such as blood, semen, vaginal fluid, preseminal fluid, and breast milk.
This transmission can involve anal, vaginal or oral sex, blood transfusion, contaminated hypodermic needles, exchange between mother and baby during pregnancy, child birth, breastfeeding or other exposure to one of the above bodily fluids.
AIDS is now a pandemic. In 2007, it was estimated that 33.2 million people lived with the disease worldwide, and that AIDS killed an estimated 2.1 million people, including 330,000 children. Over three-quarters of these deaths occurred in sub-Saharan Africa, retarding economic growth and destroying human capital.
Genetic research indicates that HIV originated in west-central Africa during the late nineteenth or early twentieth century. AIDS was first recognized by the U.S. Centres for Disease Control and Prevention in 1981 and its cause, HIV, identified in the early 1980s.
Although treatments for AIDS and HIV can slow the course of the disease, there is currently no vaccine or cure. Antiretroviral treatment reduces both the mortality and the morbidity of HIV infection, but these drugs are expensive and routine access to antiretroviral medication is not available in all countries. Due to the difficulty in treating HIV infection, preventing infection is a key aim in controlling the AIDS pandemic, with health organizations promoting safe sex and needle-exchange programmes in attempts to slow the spread of the virus.
SYMPTOMS:
The symptoms of AIDS are primarily the result of conditions that do not normally develop in individuals with healthy immune systems. Most of these conditions are infections caused by bacteria, viruses, fungi and parasites that are normally controlled by the elements of the immune system that HIV damages.
Opportunistic infections are common in people with AIDS. These infections affect nearly every organ system.
People with AIDS also have an increased risk of developing various cancers such as Kaposi's sarcoma, cervical cancer and cancers of the immune system known as lymphomas. Additionally, people with AIDS often have systemic symptoms of infection like fevers, sweats (particularly at night), swollen glands, chills, weakness, and weight loss. The specific opportunistic infections that AIDS patients develop depend in part on the prevalence of these infections in the geographic area in which the patient lives.
Epidemiology:
The AIDS pandemic can also be seen as several epidemics of separate subtypes; the major factors in its spread are sexual transmission and vertical transmission from mother to child at birth and through breast milk. Despite recent, improved access to antiretroviral treatment and care in many regions of the world, the AIDS pandemic claimed an estimated 2.1 million (range 1.9–2.4 million) lives in 2007 of which an estimated 330,000 were children under 15 years. Globally, an estimated 33.2 million people lived with HIV in 2007, including 2.5 million children. An estimated 2.5 million (range 1.8–4.1 million) people were newly infected in 2007, including 420,000 children.
Sub-Saharan Africa remains by far the worst affected region. In 2007 it contained an estimated 68% of all people living with AIDS and 76% of all AIDS deaths, with 1.7 million new infections bringing the number of people living with HIV to 22.5 million, and with 11.4 million AIDS orphans living in the region. Unlike other regions, most people living with HIV in sub-Saharan Africa in 2007 (61%) were women.
Adult prevalence in 2007 was an estimated 5.0%, and AIDS continued to be the single largest cause of mortality in this region.
South Africa has the largest population of HIV patients in the world, followed by Nigeria and India. South & South East Asia are second worst affected; in 2007 this region contained an estimated 18% of all people living with AIDS, and an estimated 300,000 deaths from AIDS. India has an estimated 2.5 million infections and an estimated adult prevalence of 0.36%.Life expectancy has fallen dramatically in the worst-affected countries; for example, in 2006 it was estimated that it had dropped from 65 to 35 years in Botswana.
In the United States, young African-American women are also at unusually high risk for HIV infection. This is due in part to a lack of information about AIDS and a perception that they are not vulnerable, as well as to limited access to health-care resources and a higher likelihood of sexual contact with at-risk male sexual partners.
There are also geographic disparities in AIDS prevalence in the United States, where it is most common in rural areas and in the southern states, particularly in the Appalachian and Mississippi Delta regions and along the border with Mexico. Approximately 1.1 million persons are living with HIV/AIDS in the United States, and more than 56,000 new infections occur every single year.
HIV/AIDS situation in India:
India is one of the largest and most populated countries in the world, with over one billion inhabitants. Of this number, it's estimated that around 2.3 million people are currently living with HIV. HIV emerged later in India than it did in many other countries. Infection rates soared throughout the 1990s, and today the epidemic affects all sectors of Indian society.
“Unlike developed countries, India lacks the scientific laboratories, research facilities, equipment, and medical personnel to deal with an AIDS epidemic. In addition, factors such as cultural taboos against discussion of sexual practices, poor coordination between local health authorities and their communities, widespread poverty and malnutrition, and a lack of capacity to test and store blood would severely hinder the ability of the Government to control AIDS if the disease did become widespread.”
“HIV infection is now common in India; exactly what the prevalence is, is not really known, but it can be stated without any fear of being wrong that infection is widespread… it is spreading rapidly into those segments that society in India does not recognise as being at risk. AIDS is coming out of the closet.”
CURRENT ESTIMATES:
In 2006 UNAIDS estimated that there were 5.6 million people living with HIV in India, which indicated that there were more people with HIV in India than in any other country in the world. In 2007, following the first survey of HIV among the general population, UNAIDS and NACO agreed on a new estimate – between 2 million and 3.1 million people living with HIV.
In 2008 the figure was confirmed to be 2.5 million, which equates to a prevalence of 0.3%. While this may seem a low rate, because India's population is so large, it is third in the world in terms of greatest number of people living with HIV. With a population of around a billion, a mere 0.1% increase in HIV prevalence would increase the estimated number of people living with HIV by over half a million.
The national HIV prevalence rose dramatically in the early years of the epidemic, but a study released at the beginning of 2006 suggests that the HIV infection rate has recently fallen in southern India, the region that has been hit hardest by AIDS.20 In addition, NACO released figures in 2008 suggesting that the number of people living with HIV has declined.
HIV PREVALANCE IN DIFFERENT STATES:
Andhra Pradesh
Andhra Pradesh in the southeast of the country has a total population of around 76 million, of whom 6 million live in or around the city of Hyderabad. The HIV prevalence at antenatal clinics was 1% in 2007. This figure is smaller than the reported 1.26% in 2006, but is still highest out of all states. HIV prevalence at STD clinics was very high at 17% in 2007. Among high-risk groups, HIV prevalence was highest among men who have sex with men (MSM) (17%), followed by female sex workers (9.7%) and IDUs (3.7%).26
Goa
Goa, a popular tourist destination, is a very small state in the southwest of India (population 1.4 million). In 2007 HIV prevalence among antenatal and STD clinic attendees was 0.18% and 5.6% respectively. The Goa State AIDS Control Society reported that in 2008, a record number of 26,737 people were tested for HIV, of which 1018 (3.81%) tested positive.
Karnataka
Karnataka, a diverse state in the southwest of India, has a population of around 53 million. HIV prevalence among antenatal clinic attendees exceeded 1% from 2003 to 2006, and dropped to 0.5% in 2007. Districts with the highest prevalence tend to be located in and around Bangalore in the southern part of the state, or in northern Karnataka's "devadasi belt". Devadasi women are a group of women who have historically been dedicated to the service of gods. These days, this has evolved into sanctioned prostitution, and as a result many women from this part of the country are supplied to the sex trade in big cities such as Mumbai. The average HIV prevalence among female sex workers in Karnataka was just over 5% in 2007, and 17.6% of men who have sex with men were found to be infected.
Maharashtra
Maharashtra is a very large state of three hundred thousand square kilometres, with a total population of around 97 million. The capital city of Maharashtra - Mumbai (Bombay) - is the most populous city in India, with around 14 million inhabitants. The HIV prevalence at antenatal clinics in Maharashtra was 0.5% in 2007. At 18%, the state has the highest reported rates of HIV prevalence among female sex workers. Similarly high rates were found among injecting drug users (24%) and men who have sex with men (12%).
Tamil Nadu
With a population of over 66 million, Tamil Nadu is the seventh most populous state in India. Between 1995 and 1997 HIV prevalence among pregnant women tripled to around 1.25%. The State Government subsequently set up an AIDS society, which aimed to focus on HIV prevention initiatives. A safe-sex campaign was launched, encouraging condom use and attacking the stigma and ignorance associated with HIV. Between 1996 and 1998 a survey showed that the number of men reporting high-risk sexual behaviour had decreased.
In 2007 HIV prevalence among antenatal clinic attendees was 0.25%. HIV prevalence among injecting drug users was 16.8%, third highest out of all reporting states. HIV prevalence among men who have sex with men and female sex workers was 6.6% and 4.68% respectively.
Manipur
Manipur is a small state of some 2.4 million people in northeast India. Manipur borders Myanmar (Burma), one of the world's largest producers of illicit opium. In the early 1980s drug use became popular in northeast India and it wasn't long before HIV was reported among injecting drug users in the region. Although NACO report a state-wise HIV prevalence of 17.9% among IDUs, studies from different areas of the state find prevalence to be as high as 32%.
Estimated adult HIV prevalence is the highest out of all states, at 1.57%.
Mizoram
The small northeastern state of Mizoram has fewer than a million inhabitants. In 1998, an HIV epidemic took off quickly among the state's male injecting drug users, with some drug clinics registering HIV rates of more than 70% among their patients. In recent years the average prevalence among this group has been much lower, at around 3-7%.44 HIV prevalence at antenatal clinics was 0.75% in 2007.
Nagaland
Nagaland is another small northeastern state where injecting drug use has again been the driving force behind the spread of HIV. In 2003 HIV prevalence among IDUs was 8.43%, but has since declined to 1.91% in 2007. HIV prevalence at antenatal clinics and STD clinics was 0.60% and 3.42% respectively in 2007.
TARGET GROUPS:
1. SEX WORKERS:
Sex work is very widespread in India, and occurs on a much larger scale than in many other countries. Women often get involved as a result of poverty, marital break-up, or because they are forced into it. HIV prevalence among sex workers varies between districts and states, although there has been a general decline in prevalence in recent years. One study found prevalence ranged between 2 percent and 38 percent (averaging at 14.5 percent) among districts in the four high prevalence south Indian states Andhra Pradesh, Maharashtra, Tamil Nadu and Karnataka.
In the city of Mysore, southern India, around a quarter of sex workers are infected with HIV. This situation is not surprising given that in one study only 20 percent of sex workers had always used condoms with commercial clients in the past month.
Sex workers are often labeled as key risk group in the context of HIV and AIDS. Historically, the AIDS epidemic in India was first identified amongst sex workers and their clients, before other sections of society became affected.
MEANS OF TRANSMISSION:
MULTIPLE PARTNERS, INCONSISTENT CONDOM USAGE:
In general, sex workers have relatively high numbers of sexual partners. This in itself does not necessarily increase their likelihood of becoming infected with HIV – if they use condoms consistently and correctly then they will probably be protected no matter how many people they have sex with. The reality, however, is that sex workers and their clients do not always use condoms. In some cases, this is because sex workers have no access to condoms, or are not aware of their importance. Clients may refuse to pay for sex if they have to use a condom, and use intimidation or violence to enforce unprotected sex.
“Sex workers have told us that when they ask a client to use a condom, he offers double the price to have sex without the condom. These women are trying to provide for their children and families, so they take the offer.” - Ndeye Astou Diop, Aboya (an organisation that works with HIV-positive women in Senegal)
MODES OF PREVENTION:
There are several steps that can be taken towards achieving these goals. Effective measures include the provision of condoms; educating sex workers and their clients about HIV; encouraging peer education (where sex workers inform one another about HIV); helping sex workers to group together; reducing the stigma that communities attach to sex work; and ensuring that laws and policies respect sex workers’ human and citizen rights.
2. MALE SEX WITH MALE:
The term men who have sex with men (MSM) refers to all men who have sex with other men. With MSM, there are two main forms of sexual activity that carry greater risks, anal and oral sex, although not all MSM engage in them. MSM may also have greater risks in that they can switch sex roles.
In MSM, HIV transmission can involve anal or oral sex, blood transfusion, contaminated hypodermic needles, or other exposure to one of the above bodily fluids. Regardless of the gender of the receptive partner, anal sex carries a higher risk of infection than most sex acts, but most penetrative sex acts carry some risk. The main route of transmission is through unprotected sex. Properly used condoms can reduce this risk. The adult prevalence rate in the United States is 0.7%, with over 1 million people currently living with HIV. In the United States from 2001–2005, the highest transmission risk behaviors were sex between men (40–49% of new cases) and high risk heterosexual sex (32–35% of new cases). HIV infection is increasing at a rate of 12% annually among 13-to-24-year-old American men who have sex with men. Experts attribute this to "AIDS fatigue" among younger people who have no memory of the worst phase of the epidemic in the 1980s and early 1990s, as well as "condom fatigue" among those who have grown tired of and disillusioned with the unrelenting safer sex message. The increase may also be because of new treatments. In developing countries, HIV infection rates have been characterized as skyrocketing among MSM. Studies have found that less than 5% of MSM in Africa, Asia, and Latin America have access to HIV-related health care.
A large study in Andhra Pradesh found that 42% of MSM in the sample were married, that 50% had had sexual relations with a woman within the past three months and that just under half had not used a condom.33 As such, unprotected sex between men can also present a risk to any women that they may subsequently have sex with.
3. TRUCK DRIVERS:
Truck drivers are a very high-risk group for HIV infection. Louis Hollander, the chairman of Trucking against AIDS, says about 45% of truck drivers are HIV-positive. Contributing factors are that truck drivers are away from their families for long periods of time and that there are high numbers of sex workers at truck stops. Many areas that truck drivers travel through are rife with poverty and unemployment so women are ready to sleep with them in exchange for money to survive.
India has one of the largest road networks in the world, involving millions of drivers and helpers. Truck drivers spend long periods of time away from home, and it is common practice for them to have relations with sex workers while on the road. A 2008 study showed that nearly a third of the long-distance truckers had paid for sex in the past twelve months.
A startling study indicates that almost 40 percent of India's truck drivers and their helpers are infected with AIDS virus. "The findings are certainly alarming. One in every three truckers visits commercial sex workers. The shocking part is that only 18 percent of them use condoms.”
Their highly mobile lifestyle requires a lot of travel. In other stopover town locations they visit other commercial male/female sex workers thereby potentially transmitting the virus.
4. STREET CHILDREN:
No one knows how many street children are at risk of contracting, or have died of, HIV/AIDS. They are not even listed as a vulnerable group, like commercial sex workers and homosexuals. Yet the sexual exploitation and drug abuse that is an inevitable part of their lives, points to a serious problem in urgent need of attention, says Charumathi Supraja
Street children are not basically depraved, lazy, trouble-mongerers. They are deprived, abjectly neglected children who are barely visible except as a threat or nuisance. Runaway children, missing children, children orphaned by AIDS, children of street dwellers (who do not keep in touch with their parents or vice versa) land up on the streets. If social service organisations do not interrupt their induction into street life, they turn into ‘hard-core’ street children. Such children are highly mobile, abused at multiple levels and totally deprived of adult affection and normal adult influence. They survive the threats of street life by joining gangs that introduce them to strategies like “sex for comfort, pleasure and money” and “drugs for bliss and loss of pain”. Lacking a nutritious environment in more ways than one, these children fall prey to the worst diseases that affect neglected groups and communities. HIV-AIDS is just one of them
In 2001-2002, a clinical child and adolescent psychologist from the Netherlands, Meindert Schaap, conducted in-depth research on the sexual life-worlds of 25 teenage street boys, aged 12-16. The research showed ‘an early onset of sexual activity and a very rapid sexual career among street boys. Same-sex activities (mutual masturbation and anal sex) are far more common than sex with girls. Most street boys have sex with multiple partners and have had sexual encounters with (street) prostitutes.’
The motives to engage in sex include ‘pleasure, immediate lust-reduction and material gain (food, money, drugs).’ Meindert recorded that ‘sexual activities may start as experimenting for pleasure but soon become a sort of commodity as well as …an addictive means to get immediate pleasure. Only a relatively small part of the boys' sexual activities involve real force and are considered to be abusive. All in all, sex is not a big deal: “You eat, you drink, you have sex”.’
The study also found that only a few street boys seemed to have reasonably good knowledge of sexual health. The misconceptions were widespread and included beliefs like anal sex with boys is harmless and that ‘HIV/AIDS can be easily recognised by sight and that HIV is easily spread by mouth.’ Condoms are used, if at all, for heterosexual activities.
ID USERS:
Nationally, HIV prevalence among injecting drug users (IDUs) appears to have declined slightly in recent years to around 7 percent in 2006. However, transmission through injecting drug use is still a major driving factor in the spread of HIV in India, particularly in north-eastern areas, such as Manipur and Nagaland. One study found HIV prevalence ranged from 23 percent to 32 percent in different areas of Manipur.27 In 2006 new sites of high HIV prevalence among IDUs were identified in Punjab, Tamil Nadu, West Bengal, Kerala and Maharastra.
The alarming levels of infection occurring through needle-sharing have implications that extend beyond networks of drug users. Some of those who inject drugs are also sex workers or truck drivers, and many are sexually active, which can result in infection being passed on to their partners. Experts have argued that there needs to be more information aimed at both injecting drug users and their sexual partners.29
The Indian government’s approach to drug use is based around law-enforcement and prosecution, with very little done in terms of treating drug users or helping them to stop using drugs. Harm reduction – a method of HIV prevention that has been successful in other countries, which acknowledges that drug use occurs and seeks ways to reduce HIV transmission in this context – has not been adopted in the government’s drug policies.
APPROACH TO PATIENTS WITH SUSPECTED HIV INFECTION:
The moment that an adult or child is suspected of having HIV infection, the issue of his/her care and management is thrust into the spotlight. The responsibility for providing care is usually shared by the professional team, the community, and the patient. Excellent communication between all parties becomes vital especially when the patient is receiving antiretroviral drugs (ARVs), for they must be continued without interruption.
(Cange in rural Haiti is an example of a best practice in such a situation;
there, patients choose trustworthy persons from the community to serve as accompagnateurs who complete regular, direct observation and documentation of the patients taking their medications.)
The first meeting between the healthcare professional and the patient is often at the request of the patient, the family, or a concerned friend. From the first moment of meeting, the professional must focus on beginning a cooperative partnership with the patient, for what often begins is a process of negotiation between the professional caregiver and patient. From the caregiver’s perspective, the primary objective of the partnership is adherence--not just to drug treatment, but to further clinical and laboratory investigations and to any necessary aspects of lifestyle change.
Building trust between these parties is paramount, because the validity and reliability of
Communication depends squarely on trust and trustworthiness. Understanding the patient’s mental and emotional status is vital to the success of communication and, by extension, to the success of treatment. The healthcare worker must also get a clear picture of the patient’s circumstances, including employment, economic status, and social support network.
(For example, in some larger Caribbean countries, the cost of transportation to and from the health clinic or hospital is prohibitive, absorbing monies usually devoted to investigations and therapy. Or, a patient living on the street may be less adherent to medications than someone who has a home.)
Many needs of PLWHA are identical to those of persons with other illnesses, but because of the aura and stigma that often surrounds HIV/AIDS, the patient and the family may have additional requirements as outlined in the following tables.
Table 1: Medical Needs of PLWHA*
• Access to health team
• Means of transport
• Medical monitoring (e.g. interviews, examinations, laboratory tests)
• Patient education
• Nutritional plan of action
• Dietary and/or nutritional supplements
• ARVs and drugs for opportunistic infection (OI) prophylaxis and treatment
• Provision of condoms, when necessary
• Crisis care and terminal care
• Education of significant others (e.g. knowledge, skills, attitudes)
• Supervision and supplies for caregivers at home, hospice, or hospital
• Response to special needs
Table 2: Counselling& Needs of PLWHA†
• Pre- and post-test counselling
• Individual and group support for counselling concerning general life issues
• Counselling regarding interpersonal relationships, sexuality, and sexual issues
• Spiritual counselling
• Discussion and clarification of issues related to personal and family confidentiality
• Counselling and support in preparation for dying, and when necessary, including arrangements for children
Table 3: Counselling& Needs of Family and Friends of PLWHA∞
• Education about HIV, including reassurance about personal safety in long-term social contact situations
• Emotional and spiritual support
• Bereavement counselling
Table 4: Self-Care Needs of PLWHA*
Physical and mental:
• Keeping physically fit
• Maintaining the best possible nutrition
• Living a balanced life including work, rest, recreation, and sleep
• Good personal hygiene and sexual safety in order to avoid unnecessary contact with infection.
Table 5: Social Support Needs of PLWHA†
• Companionship
• Legal advice and services
• Employment
• Income-generating activities
• Occupational therapy
• Cash and kind for short-term support
• Food and shelter
• Means of transport
• Child welfare
• Involvement in community life
PRE – TEST AND POST – TEST COUNSELLING:
The aims of pre-test and post-test discussions are:
• To provide information and support around the testing procedure.
• To minimise the personal impact of diagnosis.
• To change health-related behaviour and to reduce anxiety of the person being tested.
• To educate the patient regarding risk of transmission.
• To obtain informed consent, and to follow up and arrange referrals as indicated.
Summary of pre-test discussion
• Reason for testing and risk assessment
• Timing of risk and option of post-exposure prophylaxis (PEP)
• Need for other STI and blood-borne virus testing
• History of testing
• Confidentiality and privacy issues around testing
• Ensuring there is informed consent for the test
• Natural history and transmission information
• Prevention of transmission and risk reduction through behaviour change
• Implication of a positive or indeterminate test result, including availability of treatment
• Implications of a negative test result
• Explanation of the window period
• General psychological assessment and assessment of social supports in the event of a positive result
• Logistics of the test: time taken for results to become available and the need to return for results
Pre-test discussion has several objectives:
• To provide information about the implications of a
positive or negative result
• To enable informed decision-making about testing
• To communicate the health benefits of testing
• To educate patients about modes of transmission,
safe sex and risk reduction measures
• To prepare for a possible positive result.
HIV Pre-Test Discussion
While pre- and post- test discussion is generally associated with testing for HIV, components of pre- and post- test discussion apply to testing for many sexually transmissible and blood-borne infections.
• Ensure client is aware of the confidentiality surrounding the test
Assess risk factors such as types of sexual behaviour, number of partners:
• Potential for exposure to HIV
• Determine when exposure to risk occurred
Previous testing
• when, where
• is result available?
• what was tested?
Explain the test:
• Why the test is done (treatment, improve outcomes, reduce risk of transmission)
• How the test is done
• What the test tells and does not tell (ie discuss exactly what you are testing for)
• For infections with window periods, discuss implications, advise if and when repeat testing will be necessary
Confidentiality issues:
• Discuss ways the patient should protect their own confidentiality (eg carefully consider who they will tell)
• Inform the patient of legal requirements for and mechanisms of notification in the case of a positive test for a notifiable infection
• Inform the patient of the procedures relating to contact tracing in the case of a positive test
Discuss how and when to obtain results:
• It is strongly recommended all HIV (and probably Hep B and Hep C) results are given in person by medical practitioners or experienced sexual health nurses. It is important to stress to the patient prior to the test that test results will not be given over the phone to ensure the patient does not assume the worst when asked to come into the surgery to get the results. Consider making an appointment to give back the results at the time the test is taken
Discuss implications of a negative result:
• Discuss prevention - don't let people go away with the idea a negative test somehow confers immunity on them for future risk taking behaviour.
• Reinforce the positive aspects of safe sex practises. Opportunity for further education
• May require repeat test if exposure still within 12 week window period
Discuss implications of a positive result:
• What a positive result would mean
• Discuss the options for medical treatment and follow-up
• Consider the availability of family or friends who may be available to talk with if the result is positive (support systems)
• Does the patient have any holidays available if needed to be able to come to terms with the result
• Discuss contact tracing and what this means
• Evaluate patient's coping skills
Risk reduction:
• Stress importance of ongoing risk reduction strategies
• Specifically address any risks identified in history
• Offer follow-up support.
HIV Post-Test Discussion
Summary of post-test discussion giving a negative result:
• Explain the negative test result and the window period (if relevant)
• Reinforce education regarding safe behaviours
• Further discuss anxiety or risk behaviours, Discuss testing for other STIs.
A negative result:
• Review:
- risk behaviours
- what test tells and does not tell
- window period: may require repeat test if exposure still within window period
• Prevention:
- maximise educational opportunity
- don’t let people go away with the idea a negative test somehow confers immunity on them for future risk taking behaviour.
Summary of post-test discussion giving a positive result:
First post-test consultation
• Establish rapport and assess readiness for the result
• Give positive test result
• Avoid information overload
• Listen and respond to needs (the patient may be overwhelmed and hear little after being told the positive result)
• Discuss immediate implications
• Review immediate plans and support
• Reassess support requirements and available services
• Arrange other tests and the next appointment
• Begin contact tracing process and discuss options available to facilitate this
Subsequent consultations
• Treatment options diet and exercise
• Effect of diagnosis on relationships and prevention information
• Issues of disclosure
• Assessment of contact tracing process and difficulties encountered
• Access to life insurance may be affected
• Workplace implications
• Impact of other issues (eg. drug use, poverty, homelessness) on ability to access health care and treatments
• Referral for on-going counselling, social worker, medical specialist as appropriate.
A positive result:
• Before giving the result, check that the person has come for the result. The person may have come for a different reason and may not be ready for you to launch into a discussion of a positive result
• Allow plenty of time
• Explain the result and what it means
• Be straightforward
• Listen, encourage questions
• Be willing to talk
• How much information to give? – be guided by the person’s response and do not overload
Arrange follow-up:
• Offer ongoing medical and psychological support
• Offer referral to another support agency such as Queensland Positive People and the Queensland AIDS Council, as necessary
• Offer referral for management as necessary
• Check there is a trusted support person available
Contact tracing:
• timing of contact tracing will vary according to circumstances
- if others are at immediate risk, contact tracing is a priority
- if a person understands the risk to others and is having difficulty adjusting to the diagnosis, contact tracing may be deferred
SEXUALLY TRANSMITTED INFECTION:
A sexually transmitted disease (STD), also known as sexually transmitted infection (STI) or venereal disease (VD), is an illness that has a significant probability of transmission between humans or animals by means of human sexual behavior, including vaginal intercourse, oral sex, and anal sex.
STI Definition Incubation
Period Mode of Transmission Symptoms Treatment
Gonorrhea Gonorrhea is a common sexually transmitted infection caused by the bacterium Gonococcus. In both men and women if gonorrhea is left untreated, it may spread throughout the body, affecting joints and even heart valves. 2 to 30 days with most symptoms occurring between 4–6 days after being infected. The infection is transmitted from one person to another through vaginal, oral, or anal sexual relations. Men may complain of pain on urinating and thick, copious, urethral pus discharge, scrotal pain or swelling.
Women may complain of vaginal discharge, difficulty in urinating (dysuria), projectile urination, off-cycle menstrual bleeding, or bleeding after sexual intercourse. Antibiotics may be used to treat gonorrhea
Syphilis Syphilis is a sexually transmitted disease caused by the
spirochetal
bacterium.
10 – 90 days after the first exposure. The route of of syphilis is through
sexual contact, although there are examples of
congenital syphilis from mother to child in utero.
A skin lesion often on the penis, vagina or
rectum. Other symptoms common at this stage include fever, sore throat, malaise,
weight loss, headache,
meningismus, and enlarged lymph nodes.
Syphilis can generally be treated with
antibiotics, including
penicillin.
If left untreated, syphilis can damage the heart,
aorta, brain, eyes, and bones.
Herpes Simplex Herpes simplex is a viral disease caused by both herpes simplex virus 1 (HSV-1) and herpes simplex virus 2 (HSV-2). 2 – 21 days. Herpes simplex is most easily transmitted by direct contact with a lesion or the body fluid of an infected individual. Common infection of the skin or mucosa may affect the face and mouth, genitalia, or hands. More serious disorders occur when the virus infects and damages the eye, or invades the central nervous system, damaging the brain. There is no cure for herpes. Once infected, the virus remains in the body for life.
STI Definition Incubation Period Mode of Transmission Symptoms Treatment
Genital warts Genital warts, caused by some types of HPV (human papilloma virus), can appear on the skin anywhere in the genital area as white or flesh-coloured, smooth, small bumps, or larger, fleshy, cauliflower-like lumps. 10 days to one or two months. Genital HPV is transmitted by genital skin-to-skin contact, or through the transfer of infected genital fluids. This is usually during vaginal or anal sex. Warts can appear on or around the penis, the scrotum, the thighs or the anus. In women warts can develop around the vulva or inside the vagina and on the cervix. There is no treatment that can completely eliminate genital warts once a person has been infected. Often outbreaks of genital warts will become less frequent over time, until the body naturally clears the virus and the warts disappear of their own accord.
Chlamydia Chlamydia is caused by the bacterium chlamydia trachomatis. This bacteria can infect the cervix in women and the urethra and rectum in both men and women. Occasionally chlamydia can also affect other parts of the body, including the throat and eyes. Chlamydia symptoms usually appear between 1 and 3 weeks after exposure but may not emerge until much later. By having unprotected vaginal, anal or oral sex with someone who is infected. Chlamydia is known as the ‘silent’ disease as in many people it produces no symptoms. It is estimated that 70-75% of women infected with chlamydia are asymptomatic (have no symptoms) and a significant proportion of men also have no symptoms. The treatment of chlamydia is simple and effective once the infection has been diagnosed. It consists of a short course of antibiotic tablets, which if taken correctly, can be more than 95 percent effective.
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