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.