COURSE OUTLINE

• WEEK ONE
Introduction to HIV/AIDS; sexually transmitted infections; trends and transmission of HIV; history
of HIV
• WEEK TWO
Biology of HIV; Life cycle; diagnosis; immune system; immunity and HIV; virus structure
• WEEK THREE
Origin theories of HIV; progression from HIV to AIDS; treatment of HIV (drugs classes and
function); vaccines
• WEEK FOUR
CAT 1
• WEEK FIVE
Nutrition and HIV; factors that contribute to the spread of HIV
• WEEK SIX
Management of HIV; government policies; VCT and its importance; impact of HIV on society
• WEEK SEVEN
Reactions of testing positive; behavioural changes; gender and HIV
• WEEK EIGHT
Management of HIV; ABCD method, proper condom use;
• WEEK NINE
Home based care and living positively
• WEEK TEN
Pregnancy and HIV; Vertical transmission; discordant couples; conception with HIV, management
of MTC transmission
• WEEK ELEVEN
Myths surrounding HIV and exposure to risk behaviour
Social and cultural practises that contribute to the spread of HIV
WEEK TWELVE
Religion and HIV; human sexuality
CAT 2
• WEEK THIRTEEN
Revision
• WEEK FOURTEEN
Exams
 1. WEEK ONE

INTRODUCTION TO HIV/AIDS; SEXUALLY TRANSMITTED INFECTIONS; TRENDS AND TRANSMISSION OF

HIV; HISTORY OF HIV

INTRODUCTION TO HIV/AIDS

• HIV (Human Immunodeficiency Virus) is the virus that leads to the development of AIDS(Acquired
Immune Deficiency Syndrome).
• 2-3 million people die annually from HIV/AIDS with an approximated 34 million people having the
disease globally.
• Sub-Saharan countries are the most affected by the epidemic.
• In Kenya, an estimated 1.5 million people are living with the virus and about 1.2 million children
have been orphaned by it. It is estimated that 80,000 people died from AIDS related illnesses in
2009.
• There are two types of the HIV virus, HIV-1 and HIV-2 although most cases are caused by HIV-1.
• The virus attacks a specific type of cell, the CD4+ T lymphocyte that is a crucial member of our
immune systems. As a result, the number of circulating CD4 cells decreases leading to the
development of AIDS where the patient has severely compromised immunity.
• Death usually results from the development of opportunistic infections such as pneumonia and
TB.

TRANSMISSION

• Once infected, HIV can be found in all body fluids including blood, semen, vaginal secretions,
urine, tears, saliva and breast milk.
• The main mode of transmission is through unprotected sexual intercourse. With 44% of cases
resulting from sex between men and 34% from heterosexual intercourse. The risk of infection
increases with anal intercourse.
• There are no reported cases of transmission via kissing, sharing of food or drink, casual contact
with an infected person or from mosquito bites.
• Other risk factors include improper screening of blood and organ donations, non-sterile drug
injection equipment and infection from mother to child.
Risk Behaviour Rate of Transmission

Receptive anal intercourse with infected partner 1/100 – 1/500 contacts

Heterosexual intercourse (infected male partner) 1/500 – 1/1000 contacts

 Heterosexual Intercourse (Infected female partner) 1/1000 – 1/2000 contacts

Needle stick injury 1/250 (approx.)

Child delivered of infected mother 1/3 – 1/8

Table 1: Rates of HIV transmission. The table details the likelihood of contracting HIV according to
risk behaviour. Women are more prone to infection from an infected partner than men are.
Other groups that display high prevalence include commercial sex workers, truck drivers, cross-
border mobile populations and men who have sex with men (MSM).

• There is yet no cure for AIDS; the best precautionary measures are changes in social and sexual
behaviour.
• HIV prevalence tends to differ according to location, gender and age. Nearly half of all new
infections in 2008 in Kenya were transmitted during heterosexual sex whilst in a relationship and
20% during casual heterosexual sex.
• In 2008/09 HIV prevalence among women was twice as high as that for men at 8% and 4.3%
respectively. This disparity is even greater in young women aged 15-24 who are four times more
likely to become infected with HIV than men of the same age.
• In 2000, there was peak prevalence in Kenya which has shown a decrease of 6.3%, partially due to
increased awareness and education as well as increased death rates.
• Whilst many people in Kenya are still not being reached with HIV prevention and treatment
services, access to treatment is increasing. More than half of adults who need treatment are
receiving it, with around 100,000 additional adults on treatment in 2010 than in 2009.

SEXUALLY TRANSMITTED INFECTIONS (STI)

• HIV can be categorised as a sexually transmitted infection as this is its main mode of transmission.
However, it has been shown that the risk of contracting HIV increases (2-5 times) should the
person have an existing sexually transmitted infection. Also, if a person infected with HIV also has
an STI, they are more likely to transmit HIV to their partner.
• There are more than 30 different sexually transmissible bacteria, viruses and parasites some of
these include: Gonorrhoea, syphilis, Chlamydia, Herpes, Human Papillomavirus (HPV), vaginal
trichomoniasis, etc...
• Some of these infections, like chlamydia and HIV in some cases, can be present but without any
symptoms and if left untreated can have dire implications on maternal, reproductive and new
born health.
• Consequently it is important to go for regular testing and to practise safe sex i.e. use of female
and/or male condoms.

GONORRHOEA
 • Is caused by Neisseria gonorrhoeae.
• Is spread through contact with the penis, vagina, mouth, or anus. Ejaculation does not have to
occur for gonorrhoea to be transmitted or acquired.
• Some men do not get symptoms, but these normally appear 1-14 days post infection
• Symptoms and signs include a burning sensation when urinating, or a white, yellow, or green
discharge from the penis, sometimes painful or swollen testicles.
• In women, the symptoms of gonorrhoea are often mild, but most women who are infected have
no symptoms.
• The initial symptoms and signs include a painful or burning sensation when urinating, increased
vaginal discharge, or vaginal bleeding between periods. Women with gonorrhoea are at risk of
developing serious complications from the infection.
• Is caused by Neisseria gonorrhoeae.
• Is spread through contact with the penis, vagina, mouth, or anus. Ejaculation does not have to
occur for gonorrhoea to be transmitted or acquired.
• Some men do not get symptoms, but these normally appear 1-14 days post infection
• Symptoms and signs include a burning sensation when urinating, or a white, yellow, or green
discharge from the penis, sometimes painful or swollen testicles.
• In women, the symptoms of gonorrhoea are often mild, but most women who are infected have
no symptoms.
• The initial symptoms and signs include a painful or burning sensation when urinating, increased
vaginal discharge, or vaginal bleeding between periods. Women with gonorrhoea are at risk of
developing serious complications from the infection.

HERPES

• Is caused by the herpes simplex viruses type 1 (HSV-1) –causes oral herpes or type 2 (HSV-2)-
causes genital herpes.
• Signs typically appear as one or more blisters on or around the genitals or rectum. The blisters
break, leaving tender ulcers (sores) that may take two to four weeks to heal the first time they
occur. The blisters are likely to return weeks to months after first appearing but for a shorter
period and not as severely.
• Other than the sores, primary signs of infection include flu-like symptoms, such as fever and
swollen glands.
• Herpes stays in the body indefinitely although the number of outbreaks decreases over years.
• The virus is found in and released from the sores but also between outbreaks where the skin does
not appear to have sores.
• There is no treatment that can cure herpes, but antiviral medications can shorten and prevent
outbreaks during the period of time the person takes the medication.

SYPHILIS

• Syphilis is passed from person to person through direct contact with a syphilis sore.
• Sores occur mainly on the external genitals, vagina, anus, or in the rectum. Sores also can occur
on the lips and in the mouth. There is usually only one but multiple sores can occur.
• Transmission of the organism occurs during vaginal, anal, or oral sex.
• Many people infected with syphilis do not have any symptoms for years, yet remain at risk for
late complications if they are not treated.
• The primary stage of syphilis is usually marked by the appearance of a single sore (called a
chancre), but there may be multiple sores.
 • Skin rash and mucous membrane lesions characterize the secondary stage. This stage typically
starts with the development of a rash on one or more areas of the body. The rash usually does
not cause itching. Rashes associated with secondary syphilis can appear as the chancre is healing
or several weeks after the chancre has healed.
• The latent (hidden) stage of syphilis begins when primary and secondary symptoms disappear.
• This latent stage can last for years. The late stages of syphilis can develop in about 15% of people
who have not been treated for syphilis, and can appear 10–20 years after infection was first
acquired.
• In the late stages of syphilis, the disease may subsequently damage the internal organs, including
the brain, nerves, eyes, heart, liver, bones, and joints. Signs and symptoms of the late stage of
syphilis include difficulty coordinating muscle movements, paralysis, numbness, gradual
blindness, and dementia. This damage may be serious enough to cause death.
• Syphilis is easy to cure in its early stages. A single intramuscular injection of penicillin, an
antibiotic, will cure a person who has had syphilis for less than a year. Additional doses are
needed to treat someone who has had syphilis for longer than a year.
• Treatment will prevent the progression of the disease but will not reverse the damage already
done.

HUMAN PAPILLOMAVIRUS

• Genital human papillomavirus is the most common STI.

• There are more than 40 HPV types that can infect the genital areas of males and females.
• These HPV types can also infect the mouth and throat. Most people who become infected with
HPV are asymptomatic.
• In 90% of cases, the body’s immune system clears HPV naturally within two years.
• If not cleared from the body, the infection can cause genital warts, warts in the throat (recurrent
respiratory papillomatosis, or RRP) and Cervical cancer and other, less common but serious
cancers, including cancers of the vulva, vagina, penis, anus, and oropharynx (back of throat
including base of tongue and tonsils).
• HPV is passed on through genital contact, most often during vaginal and anal sex. HPV may also
be passed on during oral sex and genital-to-genital contact.
• Most common types of HPV that can lead to disease and cancer.
• Girls and women: Two vaccines, Cervarix and Gardasil, are given in three shots at the ages of 11
and 12 or between 13 and 26.
• Boys and men: One available vaccine, Gardasil, provides protection from genital warts and most
HPV associated cancers for males between 9 and 26 years.
 New
Adult Infected Infected adults infections in
Region population adults per 1,000 1999
(millions) (millions) population (millions)

North 14
156 3 19
America

Western 17
203 4 20
Europe

North Africa & 10

165 3.5 21
Middle East

Eastern
Europe & 22
205 6 29
Central
Europe

Sub-Saharan 69
269 32 119
Africa

South &
Southeast 955 48 50 151
Asia

East Asia 18
815 6 7
&Pacfic

Australia & 1
11 0.3 27
New Zealand

Latin America 38
260 18.5 71
&Carribean

Total 3040 116.5 - 340

HISTORY OF HIV/AIDS

• The virus is believed to have crossed species from monkeys to humans in Africa.
• It bears close resemblance to SIV (simian immunodeficiency virus).
• First cases described in the US in the early 1980s.
• A number of gay men in New York and California suddenly began to develop rare opportunistic
infections and cancers that seemed stubbornly resistant to any treatment. At this time, AIDS did
 not yet have a name, but it quickly became obvious that all the men were suffering from a
common syndrome.
• The virus itself falls under the category lent virus which is a type of retrovirus.
• Lent viruses are identified by the lengthy time between infection and when the first symptoms
appear.
• Four of the earliest known instances of HIV infection are as follows:
• A plasma sample taken in 1959 from an adult male living in what is now the
Democratic Republic of the Congo.
• A lymph node sample taken in 1960 from an adult female, also from the
Democratic Republic of the Congo.
• HIV found in tissue samples from an American teenager who died in St. Louis in
1969.
• HIV found in tissue samples from a Norwegian sailor who died around 1976.
• Analysis of samples collected from these early cases was used to determine the origin of HIV.
• The origin of HIV was determined to be between 1884 and 1924 in West Africa.
• Colonisation and increased global travel have contributed to the spread of the disease around the
world.
• Further spread can be blamed on the beginning of blood donations for therapeutic purposes as
well as intravenous drug usage.

TRENDS IN HIV

• Already, more than 30 million people around the world have died of AIDS-related diseases.
• In 2010, 2.7 million people were newly infected with HIV, and 1.8 million men, women and
children died of AIDS-related causes.
• 34 million people around the world are now living with HIV.
• It is in Africa, in some of the poorest countries in the world, that the impact of HIV has been most
severe. At the end of 2009, there were 9 countries in Africa where more than one tenth of the
adult population aged 15-49 was infected with HIV.
• In Botswana, 24.8% of adults are now infected with HIV, while in South Africa, 17.8% are infected.
• With a total of around 5.6 million infected, South Africa has more people living with HIV than any
other country.
• An estimated 1.9 million people in sub-Saharan Africa became newly infected in 2010, meaning
that there are now 22.9 million people living with HIV in this region.
• The total number of people living with HIV in Asia is thought to be nearly 4.8 million. Around half
(2.4 million) of these were in India followed by China (740,000), Thailand (530,000) and Myanmar
(240,000).
• The AIDS epidemic in Eastern Europe & Central Asia is rapidly increasing, with a rise of around
250 percent in the total number of people living with HIV since 2001.
• In 2010, some 1.5 million people were living with HIV, compared to 410,000 in 2001
• AIDS claimed an estimated 90,000 lives during 2010, over ten times 2001's figure.
• Outside sub-Saharan Africa, the Caribbean has the highest HIV prevalence. In the most affected
countries of the Caribbean, the spread of HIV infection is driven by unprotected sex between men
and women, although infections associated with injecting drug use are common in some places.
• In high-income nations, HIV infections have historically been concentrated principally among
injecting drug users and gay men.
• These groups are still at high risk, but heterosexual intercourse accounts for a growing proportion
of cases.
 • In the United States, a quarter of people diagnosed with AIDS in 2008 were female, and three
quarters of these women were infected as a result of heterosexual sex.
• Many high-income countries suffer from the belief that HIV is something that affects other
people, not their own populations.
• On a national level, this belief prevents policy makers and budget setters from seeing the
epidemic on their own doorsteps, looking instead to the situation in areas such as Africa.
• Some high-income countries fund medication provision for low-income countries whilst failing to
provide medicines for their own citizens who have HIV/AIDS. For example, many people cannot
afford HIV treatment in America.
• On a national level, this belief prevents policy makers and budget setters from seeing the
epidemic on their own doorsteps, looking instead to the situation in areas such as Africa.
• Some high-income countries fund medication provision for low-income countries whilst failing to
provide medicines for their own citizens who have HIV/AIDS. For example, many people cannot
afford HIV treatment in America.

REVIEW QUESTIONS

• What is the difference between HIV and AIDS?

• Approximately how many people are living with HIV worldwide?
• Can insects transmit HIV?
• Herpes can be transmitted by...
• Which is the most effective at preventing pregnancy, HIV and other sexually transmitted
infections?
• What is the difference between HIV and AIDS?
• Approximately how many people are living with HIV worldwide?
• Can insects transmit HIV?
• Herpes can be transmitted by...
• Which is the most effective at preventing pregnancy, HIV and other sexually transmitted
infections?
• HIV is believed to have evolved from a similar virus found in which animal?
• If someone with HIV has a CD4 count of 350 or less, what does this mean?
• What is the risk of transmitting HIV during oral sex?
• Which country has the highest number of people living with HIV?
• What does the standard HIV test identify?

2. WEEK TWO

BIOLOGY OF HIV; LIFE CYCLE; DIAGNOSIS; IMMUNE SYSTEM; IMMUNITY AND HIV; VIRUS STRUCTURE

THE IMMUNE SYSTEM

• The immune system serves as a means to resist infection.

• It is comprised of two major sub-divisions; the innate and adaptive/acquired immune systems.
 • Its main function is to discriminate between self and non-self thus protecting against invading
organisms and to eliminate modified or altered cells.

THE INNATE IMMUNE SYSTEM

• Recruiting immune cells to sites of infection, through the production of chemical factors.
• Acting as a physical and chemical barrier to infectious agents
• Activation of the adaptive immune system through a process known as antigen presentation.
• The identification and removal of foreign substances present in organs, tissues, the blood and
lymph, by specialized white blood cells.
• Activation of the complement cascade to identify bacteria, activate cells and to promote
clearance of dead cells or antibody complexes.
• The cell types involved with innate immunity are:
• Natural killer cells
• Mast cells
• Eosinophils
• Basophils
• Macrophages
• Neutrophils
• and Dendritic cells

THE ADAPTIVE IMMUNE SYSTEM

• The adaptive immune response provides the vertebrate immune system with the ability to
recognize and remember specific pathogens (organisms that cause disease) to generate
immunity, and to mount stronger attacks each time the pathogen is encountered.
• It is “adaptive” immunity because the body's immune system prepares itself for future
challenges.
• The main cells in this type of immunity are T and B lymphocytes.
• There are two classes of T cells; CD4+ and CD8+. (CD= cluster of differentiation).
• CD4 cells aka T helper (TH) cells can stimulate antibody production by B cells.
• CD8 cells aka cytotoxic T lymphocyte (CTL) are associated with the destruction of abnormal cells
or those with an internalised pathogen i.e. tumour and virus infected cells.

CD4 lymphocytesare involved in:

• The activation of dendritic cells

• The recruitment and activation of specialised CD8 T cells in antiviral responses
• Signalling for B cell expansion, inducing the production of antibodies and their maturation
into plasma and memory cells
• The secretion of cytokines that facilitate the differentiation of a variety of cell types e.g.
Macrophages, eosinophils and other T cells and
• The regulation of other immune responses
1. Immunity and HIV/AIDS
• There have been reported cases of people with a natural immunity to HIV/AIDS.
• 1% of northern Europeans are virtually immune to HIV.
• A genetic defect in those with European or Central Asian ancestry provides the most successful
resistance to HIV as yet identified.
 • Prostitutes in Ghana and Kenya who were repeatedly exposed to the virus showed no signs of
infection.
• Mutations in the genes that code for certain receptors necessary for HIV infection are the main
contributors to this resistance.
• CCR5 is the access key the virus needs to gain entry into its target cells (CD4).
• Immunological studies of the sera of the prostitutes showed that the women were generating
highly specific cytotoxic T-lymphocyte (CTL) responses to both HIV-1 and HIV-2 peptides which
leave them un-infected, suggesting that they have been immunised by exposure to HIV.

STRUCTURE OF HIV

LIFE CYCLE OF HIV

 • HIV life-cycle involves a single HIV virus particle infiltrating a cell and uses it to produce new HIV
particles.
• These particles will be borne in fluid such as blood or semen, since the HIV virus cannot survive
on its own outside the body.
Any cell carrying the CD4 protein on its surface (which we call a CD4+ cell) is susceptible, since
CD4 is the main receptor for HIV. Different strains of HIV target different cells - but T cells and
macrophages, both of which are CD4+, are two important targets for HIV.
• The first step of the HIV life cycle is binding to the cell membrane, followed by membrane fusion,
to get the virus particle's contents into the host cell.
• The second step involves reverse transcription of the HIV's genome from RNA into DNA, and its
integration into the host genome.
• When the virus is integrated into the host's DNA genome (as a provirus) then its information is
also encoded in DNA.

TRANSMISSION

• Once infected, HIV can be found in all body fluids including blood, semen, vaginal secretions,
urine, tears, saliva and breast milk.
• The main mode of transmission is through unprotected sexual intercourse. With 44% of cases
resulting from sex between men and 34% from heterosexual intercourse. The risk of infection
increases with anal intercourse.
• There are no reported cases of transmission via kissing, sharing of food or drink, casual contact
with an infected person or from mosquito bites.
• Other risk factors include improper screening of blood and organ donations, non-sterile drug
injection equipment and infection from mother to child.
DIAGNOSIS

• Upon infection, people are rarely symptomatic but sometimes they may suffer from a brief flu-
like illness within a few weeks of becoming infected, or develop a rash or swollen glands.
• These symptoms do not indicate an HIV infection and could often be associated with other less
severe infections and they usually disappear within a few days or weeks.
• There are a number of tests that are used to find out whether a person is infected with HIV and
arethe most effective way of detecting HIV.
• These include the HIV antibody test, P24 antigen test and PCR test.
• There are other types of HIV testing, which are used once a person has been diagnosed with the
virus. These include the CD4 test and the viral load test.
• The ELISA antibody test (Enzyme-Linked Immunosorbent assay) also known as EIA (enzyme
immunoassay) was the first HIV test to be widely used.
• 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.
• Antibody tests are extremely accurate when it comes to detecting the presence of HIV antibodies.
• ELISA tests are very sensitive and so will detect very small amounts of HIV antibody. However this
high sensitivity limits their specificity providing a small change of getting a false positive result.
• To eliminate the errors that could occur to generate a false positive, additional tests are usually
done to confirm a positive HIV diagnosis.
• All positive test results are followed up with a confirmatory test, such as:
• A Western blot assay – One of the oldest but most accurate confirmatory antibody tests. It is
complex to administer and may produce indeterminate results if a person has a transitory
infection with another virus.
• An indirect immunofluorescence assay – Like the Western blot, but it uses a microscope to detect
HIV antibodies.
• A line immunoassay - Commonly used in Europe. Reduces the chance of sample contamination
and is as accurate as the Western Blot.
• A second ELISA – In resource-poor settings with relatively high prevalence, a second ELISA test
may be used to confirm a diagnosis. The second test will usually be a different commercial brand
and will use a different method of detection to the first.
• Antigen tests are also used to detect HIV.
• 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 viral protein P24.
• Early in HIV infection, P24 is produced in excess and can be detected in the blood serum.
• However due to the low sensitivity of these tests, they are now used as components of fourth
generation tests.
 • Rapid HIV tests are based on the same technology as ELISA tests, but instead of sending the
sample to a laboratory to be analyzed, the rapid test can produce results within 20 minutes.
• Rapid tests can use either a blood sample or oral fluids. They are easy to use and do not require
laboratory facilities or highly trained staff.
• All positive results from a rapid test must be followed up with a confirmatory test, the results of
which can take from a few days to a few weeks.
• 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).
• Home sampling is another technique used to diagnose an HIV infection.
• With a home sampling kit, a person can take a sample (usually a blood sample) and send it to a
laboratory for testing. They can phone up for the results a few days later. If the result is positive
then a professional counselor will provide emotional support and referrals.
• The main advantages of home sampling are convenience, speed, privacy and anonymity.

3. WEEK THREE

ORIGIN THEORIES OF HIV; PROGRESSION FROM HIV TO AIDS; TREATMENT OF HIV (DRUGS CLASSES
AND FUNCTION); VACCINES FOR HIV.

ORIGIN THEORIES FOR HIV

a) It is now generally accepted that HIV is a descendant of a Simian Immunodeficiency Virus because
certain strains of SIVs bear a very close resemblance to HIV. It is also known that certain viruses
can pass between species.
b) The Hunter Theoryis the most commonly accepted theory which states that the virus (SIV) was
transferred to humans as a result of chimps being killed and eaten or their blood getting into cuts
or wounds on the hunter. SIV on a few occasions adapted itself within its new human host and
become HIV. Every time it passed from a chimpanzee to a man, it would have developed in a
slightly different way within his body, and thus produced a slightly different strain.
c) The Oral Polio Vaccine Theory:In this it is said that the virus was transmitted via various medical
experiments (iatrogenically) especially through the polio vaccines. The oral polio vaccine called
Chat was given to millions of people in the Belgian Congo, Ronda and Burundi in the late 1950s.
Then it was cultivated on kidney cells taken from the chimps infected with SIV in order to
reproduce the vaccine. This is the main source of contamination, which later affected large
number of people with HIV. But it was rejected as it was proved that only macaque monkey
kidney cells, which cannot be infected with SIV or HIV, were used to make Chat. Another reason is
that HIV existed in humans before the vaccine trials were carried out.

d) The Contaminated Needle Theory: African healthcare professionals were using one single syringe
to inject multiple patients without any sterilization in between. This could have rapidly have
transferred infection from one individual to another resulting in mutation from SIV to HIV.
e) Colonialism Theory:The colonial rule in Africa was particularly harsh and the locals were forced
into labour camps where sanitation was poor and food was scare. SIV could easily have infiltrated
the labour force and taken advantage of their weakened immune systems. Labourers were being
inoculated with unsterile needles against diseases such as smallpox to keep them alive and
 working. Also many of the camps actively employed prostitutes to keep the workers happy. All
these factors may have led to the transmission and development of AIDS as a disease.
f) The Conspiracy Theory:According to a survey, which was carried among African Americans it was
found that HIV was manufactured as part of a biological warfare programme, designed to wipe
out large numbers of black and homosexual people. There is no evidence to disprove it, cannot
be accepted as there were no genetic engineering techniques at that time of emergence of AIDS.

PROGRESSION

• This refers to the advancement from HIV to AIDS and finally death.
• Once HIV enters the body, the virus infects a large number of CD4+ T cells and replicates rapidly.
• During this acute phase of infection, the blood has a high number of HIV copies (viral load) that
spread throughout the body, seeding in various organs, particularly the lymphoid organs such as
the thymus, spleen, and lymph nodes.
• During this phase, the virus may integrate and hide in the cell’s genetic material. Shielded from
the immune system, the virus lies dormant for an extended period of time.
• 2 to 4 weeks after exposure to the virus, the immune system fights back with killer T cells (CD8+ T
cells) and B-cell-produced antibodies. At this point, HIV levels in the blood are dramatically
reduced.
• At the same time, CD4+ T cell counts rebound, and for some people the number rises to its
original level.
• The immune system eventually deteriorates to the point that the human body is unable to fight
off other infections.
• This deterioration is believed to occur because:
• The lymph nodes and tissues become damaged or 'burnt out' because of the
years of activity;
• HIV mutates and becomes more pathogenic, in other words stronger and more
varied, leading to more T helper cell destruction;
• The body fails to keep up with replacing the T helper cells that are lost.
• The HIV viral load in the blood dramatically increases while the number of CD4+ T cells drops to
dangerously low levels.
• An HIV-infected person is diagnosed with AIDS when he or she has one or more opportunistic
infections, such as pneumonia or tuberculosis, and has fewer than 200 CD4+ T cells/mm3 of
blood.
• The average incubation period from HIV infection until development of AIDS is estimated at
approximately 10 years for young adults.
• The estimate varies with the age at which infection occurs and is significantly shorter in infants
and in older adults and varies even between infection at age 20 and infection at age 40.
• The mode of infection does not appear to play a role in the rate of progression for Intravenous
drug users, sexual infection but it varies in the case of blood transfusions, presumably because of
the higher viral load in infected blood samples.
• Other factors that could influence the progression of HIV to AIDS include the type of HIV the
person has as HIV-1 advances at a faster rate than HIV-2.
• The presence of other illnesses (opportunistic or other) lowers the efficacy of the immune system
and extra strain leads to faster progression of HIV to AIDS.
• There are 4 main classes of patients according to how they respond to HIV infection.
• RAPID PROGRESSORS - this is approximately 10% of HIV-infected people. They progress to AIDS
within the first 2 to 3 years of HIV infection.
• TYPICAL PROGRESSORS - these are the majority of HIV-infected people. They develop AIDS
within a median time of approximately 10 years from initial infection.
• LONG TERM NON PROGRESSORS- approximately 5 to 10% of HIV-infected people do not show
symptoms even after 12 years and have stable CD4+ T cell levels.
• DISCORDANT PARTNER - these are partners where one is positive while the other remains
negative although they are having unprotected sex.
• HIV infection can generally be broken down into four distinct clinical stages:
• Primary infection (seroconversion) phase (clinical stage I),
• Clinically asymptomatic stage (clinical stage II),
• Symptomatic HIV infection stage (AIDS related complex - ARC) (clinical stage III), and
• Progression from HIV to AIDS – Acute AIDS phase (clinical stage IV).
• PRIMARY INFECTION OR SEROCONVERSION PHASE (CLINICAL STAGE I): This stage of infection
lasts for a few weeks and is often accompanied by a short flu-like illness.
• In up to about 20% of people the symptoms are serious enough to consult a doctor, but the
diagnosis of HIV infection is frequently missed.
• During this stage there is a large amount of HIV in the peripheral blood and the immune system
begins to respond to the virus by producing HIV antibodies and cytotoxic lymphocytes (CD8+).
• This process is known as seroconversion. If an HIV antibody test is done before seroconversion is
complete then it may not be positive.
• The window period refers to the period of time before seroconversion is complete and an HIV
test can give a false negative result.
• CLINICALLY ASYMPTOMATIC PHASE (CLINICAL STAGE II): It is very common for people who are
HIV positive to have no signs of damage to their immune system.
• This is called asymptomatic infection (an infection without the presence of any symptoms). This is
not an indication that their immune system is undamaged.
• This stage lasts for an average of ten years and, as its name suggests, is free from major
symptoms, although there may be swollen glands.
• The level of HIV in the peripheral blood drops to very low levels but people remain infectious and
HIV antibodies are detectable in the blood, so antibody tests will show a positive result.
• HIV is not dormant during this stage, but is very active in the lymph nodes. Large amounts of T
helper cells are infected and die and a large amount of virus is produced.
• At this stage, adults and adolescents experience the following clinical features:
• Weight loss <10% of body weight,
• Minor mucocutaneous manifestations (seborrheic dermatitis, prurigo, fungal nail
infections,
• recurrent oral ulcerations, angular cheilitis),
• Herpes zoster within the last five years and Recurrent upper respiratory tract
infections (i.e. bacterial sinusitis).
• SYMPTOMATIC HIV INFECTION (AIDS RELATED COMPLEX - ARC) PHASE (CLINICAL STAGE III):
This is a period of progressive immune deterioration. Over time the immune system loses the
struggle to contain HIV.
• This is for three main reasons:
 • The lymph nodes and tissues become damaged or 'burnt out' because of the
years of activity;
• HIV mutates and becomes more pathogenic, in other words stronger and more
varied, leading to more T helper cell destruction;
• The body fails to keep up with replacing the T helper cells that are lost.
• As the immune system fails, further symptoms develop.
• Initially many of the symptoms are mild, but as the immune system deteriorates they worsen.
• Symptomatic HIV infections are mainly caused by the emergence of opportunistic infections and
cancers that the immune system would normally prevent and is often characterized by multi-
system disease.
• Unless HIV itself can be slowed down the symptoms of immune suppression will continue to
worsen.
• At Clinical Stage III (AIDS Related Complexes ARC), adults and adolescents experience the
following clinical features:
• Weight loss >10% of body weight
• Unexplained chronic diarrhoea, >1 month
• Unexplained prolonged fever (intermittent or constant), >1 month
• Oral candidiasis (thrush)
• Oral hairy leucoplakia
• Pulmonary tuberculosis
• Severe bacterial infections (i.e. pneumonia, pyomyositis)
• PROGRESSION FROM HIV TO AIDS – ACUTE AIDS PHASE:As the immune system becomes more
and more damaged the illnesses that are present become more and more severe leading
eventually to an AIDS diagnosis.
• A person is said to have AIDS when they have developed one of these specific illness, this is
usually after a significant period of time-often many years.
• By definition one is referred to as AIDS positive if the T-lymphocyte count (CD4+) is less than 200
cells/mm3 of blood. Normal human beings have between 800 -1200/mm3 of blood.
• The progression from HIV to AIDS to death is slowed down or regulated by treatment (anti-
retroviral therapy (ART)).
• Prophylactic treatment of opportunistic infections also reduces the likelihood of death in the
patient or at the least extends their life span.

TREATMENT AND MANAGEMENT OF HIV/AIDS

• When the disease was first discovered in the early 1980s, the estimated life span for those
diagnosed with HIV was just a few years.
• There are currently 31 drugs approved for use by the FDA for the treatment of HIV infection.
• These treatments do not cure people of HIV or AIDS.
• They suppress the virus, even to undetectable levels, but they DO NOT completely eliminate HIV
from the body.
• By suppressing the amount of virus in the body, people infected with HIV can now lead longer
and healthier lives. However, they can still transmit the virus and must continuously take
antiretroviral drugs in order to maintain a healthy quality of life.
• Antiretroviral therapy (ART) is the recommended treatment for HIV infection. Highly Active
Antiretroviral Therapy (HAART) is used to describe a combination of three or more anti-HIV drugs
taken daily.
• Beginning ART is dependent on:
 • Your overall health
• How well your immune system is working (CD4 count)
• The amount of HIV in your blood (viral load)
• Whether you’re pregnant
• Your ability and willingness to commit to lifelong treatment
• Patients usually begin treatment when their CD4 cell count is below 400/500 cells per mm3, when
they have been diagnosed with AIDS, when the patient has developed HIV related kidney disease
and also if the patient is pregnant.
• There are 6 classes of antiretroviral drugs, classified according to how they treat HIV:
• Non-nucleoside reverse transcriptase inhibitors (NNRTIs),
• Nucleoside reverse transcriptase inhibitors (NRTIs),
• Protease inhibitors (PIs),
• Fusion inhibitors,
• CCR5 antagonists,
• Integrase inhibitors.
• The treatment regimens require drug combinations from at least two of the groups as this is the
most effective way of controlling the virus and also reducing the likelihood of drug resistance.
• Some of the drugs are available in combination i.e. 2+ drugs in one pill.
• NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIS) block reverse transcriptase's
enzymatic function and prevent completion of synthesis of the double-stranded viral DNA, thus
preventing HIV from multiplying.
• NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIS)also block the activity of
reversetranscriptase preventing the multiplication of the HIV virus.
• PROTEASE INHIBITORS (PIS)work by inhibiting the activity of enzymes (proteases) needed to
synthesize complete copies of the HIV virus. When protease is blocked, HIV makes copies of itself
that can't infect new cells. Studies have shown that protease inhibitors can reduce the amount of
virus in the blood and increase CD4 cell counts.
• FUSION INHIBITORS function by interfering with the HIV viral process of getting into the cell
preventing the infection of the cell by HIV.

Figure 1: Model of HIV fusion with a cell. Fusion inhibitors prevent this process from
occurring. They target various proteins such as the viral GP41 and the human CCR5
preventing the transfer of viral material into the host’s cell.
• CCR5 ANTAGONISTSprevent HIV from entering and infecting immune cells by blocking CCR5 cell-
surface receptor.

Figure 2: Cell surface protein interactions during HIV infection. CCR5 is important for viral
entry into the host cell, blocking this protein thus prevents viral entry and subsequent
infection.
• INTEGRASE INHIBITORS interfere with the functioning of Integrase, an enzyme that facilitates the
entry of the viral genome into the host cell’s DNA. Blocking the function of this enzyme interferes
with viral replication, preventing the spread of the virus.
• In addition to HAART, it is important to maintain good nutrition as this contributes to the
effectiveness of HAART as well as regulating opportunistic infections.
• HIV impairs nutritional status by undermining the immune system and nutrient intake, absorption
and use.
• Adults with HIV have 10–30% higher energy requirements than a healthy adult without HIV, and
children with HIV 50–100% higher than normal requirements.
• Consequently, it is important that people with HIV have access to proper nutrition to keep them
healthy and resistant to opportunistic infections.
• AIDS is well known for causing severe weight loss known as “wasting” (fig. 3).
• Body changes are not only seen during AIDS. Less dramatic changes often occur in earlier stages
of HIV infection.
• The weight lost during HIV infection tends to be in the form of lean tissue, such as muscle. This
means there may be changes in the makeup of the body even if the overall weight stays the
same.
• In children, HIV is frequently linked to growth failure. One large European study found that
children with HIV were on average around 7 kg lighter and 7.5 cm shorter than uninfected
children at 10 years old.
• Figure 3: Wasting syndrome. The dramatic weight loss is believed to be due to their increased
energy usage, loss of appetite due to opportunistic infections, diarrhea and nausea as well as
poor nutrient absorption.
• The best way to regulate wasting syndrome and ensuring proper nutrition in HIV/AIDS patients is
to provide food security and nutrition.
• The links between HIV and nutritional status run both ways. It has long been known that weight
loss strongly predicts illness or death among people with HIV.
• More recently it has been found that this applies even to people taking antiretroviral treatment.
Losing as little as 3-5% of body weight significantly increases the risk of death; losing more than
10% is associated with a four- to six-fold greater risk.
• A Zambian study involving nearly 30,000 patients has shown that failure to gain weight six
months after the start of antiretroviral treatment increases the chance of death ten fold when
compared with those who gain over 10 kilos.
• Antiretroviral therapy itself may increase appetite and it is possible to reduce some side-effects
and promote adherence if some of the medicines are taken with food.
• Given the need for adherence in delaying resistance to first-line drugs, nutritional support is
critical to sustaining antiretroviral treatment.
 • Because people with untreated HIV tend to burn more energy, the total number of calories
should be around 10% higher than the usual guideline amounts, and up to 30% higher during
recovery from illness. The balance of fat, protein and carbohydrates should remain the same.
• To avoid malnutrition and wasting away HIV infected persons should always ensure that they take
highly nutritive foods that are well balanced.
• High protein diet to build up infected cells and tissues/strengthen them. They include Soya beans,
lean meat, milk, beef, and eggs.

SIDE EFFECTS OF ANTIRETROVIRAL THERAPY

• Antiretroviral drugs differ in how commonly they cause particular side effects.
• For example, efavirenz (NNRTI) is the drug most associated with psychiatric symptoms, while
protease inhibitors are more likely to raise levels of cholesterol and triglycerides.
• Diarrhea is a common side effect of many antiretroviral drugs, especially protease inhibitors.
• Almost all antiretroviral drugs, as well as many other medications, can cause nausea (feeling sick)
and vomiting, especially during the first few weeks of treatment.
• Rashes often appear as a side effect of antiretroviral treatment. These may be itchy but are
usually harmless and short-lived. However, severe rashes can occur with nevirapine (NNRTI), and
more rarely with some other drugs.
• Lipodystrophy refers to losing or gaining body fat, often in ways that can be disfiguring and
stigmatizing. There are 3 main patterns in which this occurs:
• Losing fat on the face, arms, legs and buttocks, resulting in sunken cheeks, prominent veins on
the limbs, and shrunken buttocks.
• Gaining fat deep within the abdomen, between the shoulder blades, or on the breasts.
• A mixture of fat gain and fat loss.
• Lipid abnormalities are another common side effect of some antiretroviral drugs – particularly
protease inhibitors – and are often seen in people who also have lipodystrophy. They commonly
have high levels of LDL cholesterol, low levels of HDL cholesterol, and high levels of triglyceride in
the blood which are linked to greater risks of heart disease, stroke and diabetes in HIV –ve
people.
• There are more side effects associated with the different types of ARV drugs available in the
market.
• More drugs are being developed that target different molecules on the host and viral cell
surfaces.
• It is important to maintain a healthy diet when one is diagnosed with HIV/AIDS as this can help
limit or completely eliminate some of the side effects as well as improving the efficacy of the
drugs and improving the life span of the patient.
• Other than HAART/ ART and nutrient management, there are alternative therapies that are used
to treat and manage HIV/AIDS.
• These alternative treatments include herbal medicine, acupuncture, relaxation techniques,
massage, meditation and yoga among others.
• The effectiveness of many of these alternative techniques has not been fully researched and they
are mainly to aid with the relief of the various side effects that appear from taking ARV therapy or
from the general progression of HIV.
• Prevention is still the only effective means of controlling the spread of HIV/AIDS especially in light
of viral mutations and drug resistance as well as the cost of treatment.
• Condoms remain 100% effective at stopping the spread of HIV and other STIs.
HIV VACCINES

• There is as yet no vaccine for HIV infection that will either prevent infection or alter the
progression of the virus. This is mainly due to the rapidly mutating virus that effectively evades
the immune system making the design of a functional vaccine very difficult.
• Despite this difficulty there is still work going on to develop a vaccine and a number of clinical
trials have taken place.
• The Thai Phase III HIV vaccine clinical trial, also known as RV144, was the largest HIV vaccine
study ever conducted (2009) and involved more than 16,000 volunteers in Thailand.
• The RV144 trial’s initial report showed that the rate of HIV infection among volunteers who
received the experimental vaccine was 31% lower than the rate of HIV infection in volunteers
who received the placebo.
• Further work has been done based on the data collected after the RV144 vaccine trial and a
number of other trials have taken place (RV305 – booster for initial RV144 vaccine; RV306 –
comparison of additional vaccine boosts to gather immunogenicity data) to further enhance the
efficacy of the vaccine.
• The U.S. Military HIV research program (MHRP) is developing a new vaccine using modified
Vaccinia Ankara (MVA) along with two investigational DNA vaccines to generate a vaccine that is
aimed at providing global protection against HIV infection (multiple sub-types). Trials for this
vaccine are currently underway in Africa and Sweden.
• In addition to this vaccine trial, there are other vaccine designs and strategies that can be further
developed into an effective vaccine.

VACCINE DESIGN VACCINE FUNCTIONALITY CHALLENGES FOR VACCINE

DNA vaccine 1. A few HIV genes are No DNA vaccines have yet
inserted into a been approved for use in
backbone of DNA humans by the FDA.
known as plasmid
2. The vaccine is injected
into muscle of the
recipient where the
HIV genes are
expressed into
proteins.
3. The viral proteins are
degraded into small
peptide fragments,
which are then
presented by
molecules on the cell
surface. T cells
recognizing these
molecules generate an
immune response.

Live Vectors: (Viral and 1. The HIV or SIV genes
Bacterial) are inserted into the
genomes of live,
infectious, but non-
disease-causing forms
of viruses (e.g.,
1. The development of
viral vectors has been
robust, with a few
entering Phase III
trials.
2. Only a few bacterial
 adenovirus) or vectors are under
bacteria (e.g., development in small
BacilleCalmette-Guerin and large animal
(BCG). models, and some
2. These vectors shuttle Phase I trials. The
“foreign” genes along complex nature of
with their own into bacteria hampers the
cells. development of
3. HIV proteins bacterial vector
generated from these systems.
recombinant genes
inside the cell are
either secreted or
displayed on the cell
surface and presented
to the immune system.

Viral Proteins or Viral Chemically synthesized pieces Peptide-based preparations

Peptides
Virus-like Particles (VLPs)
of HIV peptides or proteins require the addition of an
that elicit strong T and B cell adjuvant to enhance
responses. immunogenicity. At present,
alum is the only adjuvant
authorized by FDA for general
medical use, however many
products are being tested, and
some are in clinical trials.
1. Empty, non-infectious VLPs represent an exciting
shells of the HIV new strategy for HIV vaccines
envelope protein; they but it has been difficult to
mimic the outer coat make them reproducibly.
of the virus but lack a
genome inside and
cannot reproduce.
2. Because VLPs
resemble the virus,
they can induce high
titers of neutralizing
antibodies to protect
against viral challenge.

4. WEEK FOUR

CAT 1

5. WEEK FIVE

NUTRITION AND HIV

• HIV and nutrition are intimately linked. HIV infection can lead to malnutrition, while poor diet can
in turn speed the infection’s progress.
• As HIV treatment becomes increasingly available in the poorest parts of the world, critical
questions are emerging about how well the drugs work in people if they are short of food.
Uncertainty also surrounds the role of vitamins and other supplements.
• And for those already receiving treatment, side effects such as body fat changes are a daily
concern.
• HIV/AIDS is well known for causing severe weight loss known as “wasting”.
• Whereas starving people tend to lose fat first, the weight lost during HIV infection tends to be in
the form of lean tissue, such as muscle. This means there may be changes in the makeup of the
body even if the overall weight stays the same.
• One factor behind HIV-related weight loss is increased energy expenditure. Though no one knows
quite why, many studies have found that people with HIV tend to burn around 10% - 30% more
calories while resting, compared to those who are uninfected and children with HIV 50–100%
higher than normal requirements.
• But faster metabolism is not the only problem. In normal circumstances, a small rise in energy
expenditure may be offset by eating slightly more food or taking less exercise.
• There are two other important reasons why people with HIV may lose weight or suffer childhood
growth failure.
• The first factor is decreased energy intake or, to put it simply, eating less food. Once HIV has
weakened the immune system, various infections can take hold, some of which can affect
appetite and ability to eat. For example, sores in the mouth or throat may cause pain when
swallowing, while diarrhoea or nausea may disturb normal eating patterns.
• Someone who is ill may be less able to earn money, shop for food or prepare meals. Stress and
psychological issues may also contribute.
• Secondly, weight loss or growth failure can occur when the body is less able to absorb nutrients –
particularly fat – from food, because HIV or another infection (such as cryptosporidium) has
damaged the lining of the gut. Diarrhoea is a common symptom of such malabsorption.
• Current antiretroviral drug treatments control HIV infection and prevent severe wasting, as well
as other AIDS-related conditions. Emaciated people tend to regain weight once they begin
treatment, and stunted children start to grow faster. Nevertheless, the drugs do not eliminate
wasting.
• Studies have found that relatively small weight loss (between 5% and 10% over six months) is
quite common among people with HIV who are taking treatment and not trying to lose weight.
• Although this might not seem like much, losses of this size have been linked to an increased risk
of illness or death, as discussed below.
• In addition, some antiretroviral drugs have been linked to a problem called lipodystrophy.
Whereas HIV-related wasting tends to deplete lean tissue, lipodystrophy involves changes in fat
distribution. Prolonged treatment is sometimes associated with losing fat from the face, limbs or
buttocks, or gaining fat deep within the abdomen, between the shoulder blades, or on the
breasts.
• Antiretroviral treatment can also contribute to lipid abnormalities by raising LDL cholesterol,
lowering HDL cholesterol, and raising triglyceride levels in the blood. This may result in higher
risks of heart disease, stroke and diabetes.
• Other side effects of antiretroviral treatment include insulin resistance, which can occasionally
lead to diabetes.
• Researchers have found that people with HIV are more likely to show signs of micronutrient
deficiencies, compared to uninfected people.
• Micronutrients are vitamins and minerals that the body needs to maintain good health.
• Specifically they have found low levels of vitamin A, vitamin B12, vitamin C, vitamin D,
carotenoids, selenium, zinc and iron in the blood of various populations.
• A Zambian study involving nearly 30,000 patients has shown that failure to gain weight six
months after the start of antiretroviral treatment increases the chance of death ten-fold when
compared with those who gain over 10 kilos.
• This is not just an issue for developing countries; for example a study of people receiving
antiretroviral treatment in Sydney, Australia found that one in three did not have access to
nutritious food, and one in five said they regularly went hungry.
• Without food or the right nutrition, taking antiretroviral drugs can be so painful that people
simply don’t. In a choice between taking pills with no immediate or obvious effect, and eating
food to survive, food will almost certainly take priority every time.
• A health worker in Zimbabwe, where malnutrition is widespread, explained that taking
antiretroviral drugs on an empty stomach is like digesting razor blades. The result is that many
simply do not take them.
• Weight gain is an issue for all AIDS patients on antiretroviral therapy. Nutritionists advise that to
manage increasing weight, patients should cut fat and calories, but not eliminate the good fats,
such as monounsaturated fats and Omega 3 polyunsaturated fat.
• Because AIDS-related illnesses can cause loss of lean body mass and wasting, people with AIDS
need to consume more protein. It is also important to maintain calcium in the diet for bone
health, blood clotting, nerve transmission, and regulating heartbeat.
• Carbohydrates round out the healthy diet by lowering cholesterol, lowering glucose absorption,
alleviating constipation, and facilitating movement through the bowel.
• Aside from a well-balanced diet, it is important to prepare food safely and to know the source of
any drinking water.
• Many experts recommend a daily multivitamin (usually without iron, except in menstruating
women or people with iron deficiency).
• The World Health Organization recommends vitamin A supplements every 4-6 months for young
children living with HIV in resource-poor settings.
• Adequate nutrition is essential for optimal functioning of the immune system, without which
susceptibility to infection is greatly increased.
• Balanced nutrition helps the body to:
 Increase resistance to infection and disease and improve the energy supply.
 Boost the immune system and therefore reduce the frequency of episode of
morbidity.
 Lessen severity of infection, improve the response to treatment for opportunistic
infections such as TB, and speed the rate of recovery.
 Replace lost micronutrient and provide the body with all essential nutrient
required for good health.
 Preserve muscle mass, slow or stop the loss of lean tissue, prevent weight loss,
and improve body strength and energy.
 Delay the rate of progression of HIV to AIDS and the further advance of AIDS
itself.
 Keep PLWAs alive and able them to lead an active life; this in turn reduces their
dependence, thus allowing them to take care of themselves.
• Carbohydrate foods are required in large quantities to provide the much required energy to
strengthen patients who are weak. They include Whole meal cereals, cassava, potatoes, and
cooked bananas.
• Vitamins and minerals help bodies’ in fighting diseases and keep opportunistic infections
checked. They also help in a quick recovery and disease management. Vitamins are obtained from
fresh vegetables, fruits, fresh juices.
• Fluids help in cleaning the immune system, blood purification and to improve the appetite.
Frequency of food intake should be high to avoid or reverse weight loss.
 6. WEEK SIX

MANAGEMENT OF HIV; GOVERNMENT POLICIES; VCT AND ITS IMPORTANCE; IMPACT OF HIV ON
SOCIETY

GOVERNMENT STRATEGIES ON HIV MANAGEMENT

• In March 2004, the President launched the country into a war against HIV/AIDS and formed a
cabinet committee.

• The committees’ approach lies in mobilizing communities in every corner of the country to
effectively fight the AIDS pandemic.

• Some of the strategies adopted by the Kenyan government to fight the spread of HIV/AIDS
include:

1. Public education campaigns

2. HIV/AIDS seminars and workshops

3. Mainstreamed HIV/AIDS lessons in formal education system.

4. De-stigmatization campaigns

5. Free distribution of condoms

6. Provision of treatment to HIV/AIDS patients

7. Provision of VCT centers all over the country

8. Discouragement of detrimental socio-cultural practice

9. Gender advocacy

10. Poverty eradication

7. WEEK SEVEN

REACTIONS OF TESTING POSITIVE; BEHAVIOURAL CHANGES; GENDER AND HIV

REACTIONS TO INFECTION

• Once a person has been diagnosed with HIV, there are a umber of reactions that they go
through:
1. Shock
2. Denial
3. Anger
4. Bargaining
5. Fear
6. Loneliness
7. Depression
8. Acceptance
• People with HIV/AIDS have fear for many things: Pain, illness, losing their jobs, rejection, stigma,
leaving their children and death.
 • The final stage is acceptance and at this point the person can begin to live positively with their
disease.
• The steps necessary for living positively include:
1. Breathe: When you get overwhelmed, take three deep breaths. Breathing improves
health and reduces stress.
2. Refuse to be a victim: Focus on what you can do, Focus on living with HIV and not dying
of AIDS, Live one day at a time, Seek support not pity
3. Educate yourself about HIV by attending HIV/AIDS seminars, workshops or any education
forum
4. Physical exercise
5. Keep busy: Do not concentrate on self. No self pity, concentrate on development and Do
not overwork.
6. Express yourself, ask for support
7. Embrace your own spirituality
8. Think and act positively
9. Seek out people who are honest, trustworthy and supportive
10. Cry when you need to let it out, as it creates room for positive feelings
11. Accept responsibility.
12. Talk to other people with HIV - group therapy works
13. Maintain a healthy diet and attend to opportunistic infections immediately

ROLE OF GENDER AND SPREAD OF HIV

• Although women are making efforts towards equality with men, a lot of them still do not have
control over their lives.
• Cultural, social, biological and economic pressures make women more vulnerable to HIV than
men. These include:
1. Men still dictate matters regarding sex
2. Girls have been taught to leave decision making on sex matters to males whose needs
and demands are expected to dominate.
3. Male predominance often comes with intolerance for predatory and violent sexuality
4. Biological makeup and reproductive anatomy of the female body makes her to be more
vulnerable to contract HIV than men
5. Poverty
6. Prostitution
7. Cultural practices
8. Social evils
9. Ignorance

• These issues and their implications on women can be combated in the following ways:

i. Combating ignorance

ii. Provide women friendly services

iii. Make female condoms available

iv. Build safer norms

v. Educate boys and men to respect girls and women

 vi. Reinforce women’s economic independence

vii. Reduce vulnerability through policy changes

8. WEEK EIGHT

MANAGEMENT OF HIV; VCT, ABCD METHOD, PROPER CONDOM USE;

VOLUNTARY COUNSELLING AND TESTING (VCT)

• Voluntary HIV counselling and testing is the process by which an individual undergoes counselling
to enable him/her to make an informed choice about being tested for the human
immunodeficiency virus (HIV). This decision must be entirely the choice of the individual and he
or she must be assured that the process will be confidential.

• VCT is not only a key component of both HIV prevention and care programmes but is the gateway
to both prevention and care.

• In order to respond effectively to options for each, it is preferable for one to know one’s
serostatus.

• The development of increasing numbers of effective and accessible medical and supportive
interventions for people living with HIV/AIDS (PLWHA) means that VCT services are being more
widely promoted and developed and many developing countries are gradually instituting VCT as
part of their primary health-care package.

• VCT has also been shown to be a cost-effective HIV-prevention intervention.

• Knowing and accepting one’s HIV status enables more informed planning for the future, including
for one’s dependents.

• Programme experiences have also shown that VCT is one of the factors that help to reduce
stigma and secrecy surrounding HIV/AIDS.

• The counsellors themselves are trained in rapid HIV testing and are able to perform pre-test
counselling, post test counselling and rapid testing during a one hour session.

• VCT acts as an entry point to prevention and care services and the intervention itself, with its
focus on risk reduction, has been demonstrated to impact behaviour change in a large-scale
international randomised trial of voluntary counselling and testing.

• Since the year 2000 the Kenyan government has opened over 390 VCT centres in all areas of the
country and hundreds of thousands of asymptomatic Kenyans have come voluntarily to know
their HIV status. The commitment to the expansion of VCT services and the accompanying media
campaigns have led to a widespread change in perception.

MODELS OF VCT

1. INTEGRATED
2. STAND ALONE
3. MOBILE
4. COMMUNITY BASED
COMMON SAFER SEX STRATEGIES-ABCD

• The ABC approach to preventing the sexual transmission of HIV has been defined and adopted by
a variety of organisations, governments and non-governmental organisations ever since the term
was first used in 1992.

• According to UNAID's 2004 Global Report on the AIDS Epidemic, 'ABC' stands for:

• Abstinence (not engaging in sex, or delaying first sex)

• Being safer, by being faithful to one's partner or reducing the number of sexual
partners

• Correct and consistent use of condoms

• De-stigmatisation

• However, there are those who believe instead that 'one size fit all' approach should be
abandoned altogether. Instead, some argue, prevention strategies must be tailored to the local
context, and be based on the key drivers of the local epidemic.

• There is now general agreement that where the ABCD approach is used, it should be balanced
and that it should also been seen as part of a wider prevention strategy that, if appropriate,
includes circumcision for men, harm reduction for injecting drug users, and PMTCT for pregnant
women.

CONDOM USE

• Studies into the effectiveness of condoms have shown that if a latex condom is used correctly
every time you have sex, this is highly effective in providing protection against HIV.

• The evidence for the effectiveness of condoms is clearest in studies of couples in which one
person is infected with HIV and the other not (discordant couples).

In a study of discordant couples in Europe, among 123 couples who reported consistently using
condoms, none of the uninfected partners became infected. In contrast, among the 122 couples
who used condoms inconsistently, 12 of the uninfected partners became infected. A recent
review of 14 studies involving discordant couples concluded that consistent use of condoms ledto
an 80% reduction in HIV incidence.

• In addition, correct and consistent use of latex condoms can reduce the risk of other STDs,
including chlamydia, genital herpes, gonorrhoea and syphilis.

• “The male latex condom is the single, most efficient, available technology to reduce the sexual
transmission of HIV and other sexually transmitted infections”. UNAIDS, WHO and UNFPA

• Condoms must be used consistently and correctly to provide maximum protection.

• Consistent use of condoms means using a condom from start to finish with each act of
intercourse.

• Correct condom use should include:

 • Use a new condom for each act of intercourse

• Put on the condom as soon as erection occurs and before any sexual contact
(vaginal, anal or oral).

• Hold the tip of the condom and unroll it onto the erect penis, leaving space at the
tip of the condom, yet ensuring that no air is trapped in the condom's tip.

• Adequate lubrication is important, but use only water-based lubricants on latex

condoms. Oil-based lubricants such as petroleum jelly (Vaseline), cold cream,
hand lotion or baby oil can weaken the latex condom and are not recommended.

• Withdraw from the partner immediately after ejaculation, holding the condom
firmly to keep it from slipping off.

• The main reason that condoms sometimes fail to prevent HIV/STD infection or pregnancy is
incorrect or inconsistent use, not the failure of the condom itself.

• Condom manufacturing was revolutionised by the discovery of rubber vulcanisation in the 1800s
by Goodyear and Hancock. This meant that it was possible to mass produce rubber goods
including condoms quickly and cheaply.

• n 1957, the very first lubricated condom was launched in the UK by Durex.

• The use of the condom increased strikingly in many countries following the recognition of HIV
and AIDS in the 1980's. Condoms also became available in pubs, bars, grocery stores and
supermarkets.

• The female condom has been available in Europe since 1992 and it was approved in 1993 by the
FDA.

• The 1990s also saw the introduction of coloured and flavoured condoms.

• According to the United Nations Population Fund (UNFPA), an estimated 10.4 billion male
condoms were used worldwide in 2005.

• Of these, around 4.4 billion condoms were used for family planning and 6.0 billion condoms for
HIV prevention.

• It has been estimated that in 2015, nearly 18 billion condoms will be needed in low- and middle-
income countries.

• The UNFPA estimates that at least 13.1 billion condoms were needed in 2005 to significantly
reduce the spread of HIV, and another 4.4 billion were required for family planning.

• Many countries depend on donations of condoms from outside agencies such as the UNFPA and
the U.S. Agency for International Development (USAID).

• The number of condoms donated in 2005 was only 2.3 billion - representing less than 15% of the
need.

• Although numbers rose sharply to 3.1 billion in 2007, they have subsequently decreased again to
2.4 billion in 2008.
ABSTINENCE

• An abstinence based approach to sex education focuses on teaching young people that abstaining
from sex until marriage is the best means of ensuring that they avoid infection with HIV, other
sexually transmitted infections and unintended pregnancy.

• Many supporters of abstinence based approaches to sex education also believe that it is morally
wrong for people to have sex before they are married.

• The main difference between abstinence based and comprehensive approaches to sex education
is that comprehensive approaches do not focus either solely or so closely on teaching young
people that they should abstain from sex until they are married.

• Although comprehensive approaches do explain to young people the potential benefits of

delaying having sex until they are emotionally and physically ready, they also make sure that they
are taught how to protect themselves from infections and pregnancy when they do decide to
have sex.

• Many supporters of abstinence based sex education have a background in or connection to

Christian organisations that have strong views about sex and sexuality.

• Not only do they often believe that sex should only take place in the context of marriage, but
some are also opposed to same sex relationships and abortion.

• In contrast, most supporters of comprehensive sex education regard having sex and issues to do
with sexuality as matters of personal choice that should not be dictated by religious or political
dogmas.

• They see sex education as being about providing young people with the means by which they can
protect themselves against abuse and exploitation as well as unintended pregnancies, sexually
transmitted diseases and HIV/AIDS.

BE FAITHFUL

DESTIGMATISATION

MALE CIRCUMCISION

• Scientific trials have shown that male circumcision can reduce a man’s risk of becoming infected
with HIV during heterosexual intercourse by up to 60 percent.

• These findings have led to the decision by UNAIDS and the World Health Organization (WHO) to
recommended circumcision as an important new element of HIV prevention.

• Since the decision was made the demand for circumcision has been increasing.

• In Zimbabwe 700 men requested to be circumcised within just two weeks of the government
starting the roll out of voluntary medical male circumcision (VMMC) services for HIV prevention.

• Mathematical models have predicted that one new HIV infection could be averted for every 5 to
15 men who are newly circumcised.
• It has also been suggested that six million new HIV infections and three million deaths could be
prevented in twenty years if all men in sub-Saharan Africa became circumcised.

• Since the 1980s, scientists have suspected that male circumcision might reduce rates of HIV
transmission during sex.

• They observed that circumcised men are less likely to have HIV than uncircumcised men, and HIV
is less common among populations that traditionally practise male circumcision than in
communities where the procedure is rare.

• However, for a long time it was unclear to what extent this was an effect of circumcision itself
and whether other factors might also play a role.

• To settle this issue, three trials were set up in sub-Saharan Africa, which together involved more
than 11,000 previously uncircumcised men. Each man was randomly assigned to one of two
categories: one group had their foreskins removed at the start of the study and the others
remained uncircumcised.

• All men received extensive counselling on HIV prevention and risk reduction techniques. During
the trials, researchers collected information about the men’s sexual behaviour to check whether
it varied between the two groups; they found no significant differences.

• The results of the circumcision trials were as follows:

Result in
Location Participants Report published circumcised
men

60% fewer
South Africa 3,274 July 2005
infections

53% fewer
Kenya 2,784 February 2007
infections

51% fewer
Uganda 4,996 February 2007
infections

• Taken together, these findings provide conclusive evidence that male circumcision, if performed
safely in a medical environment, roughly halves the risk of a man becoming infected with HIV
through heterosexual sex.

• There are several possible reasons why circumcision has this effect.

• The foreskin creates a moist environment in which HIV can survive for longer in contact
with the most delicate parts of the penis, and

• The inner surface of the foreskin contains cells that are especially vulnerable to infection
by HIV.
 • A study of Ugandan men before and after circumcision concluded that observed
decreases in anaerobic bacteria may play a role in reducing the risk of HIV acquisition.

• Removing the foreskin also means that the skin on the head of the penis tends to become
tougher and more resistant to infection. In addition, any small tears in the foreskin that
occur during sex make it much easier for the virus to enter the body.

• The effect of circumcision on male-to-female HIV transmission has not been extensively
researched.

• One particular trial involving 922 HIV infected men in Uganda found circumcision did not reduce
HIV transmission to uninfected female partners.

• Although more research is needed in this area, it is evident that women will benefit from the
scale-up of voluntary medical circumcision programmes in the long-term: properly carried out
circumcision programmes have the potential to lower HIV prevalence among the male
population, therefore reducing a woman's risk of exposure to men infected with the virus.

• It has been calculated that in the long-term, mass VMMC programmes could reduce the incidence
of transmission from males to females by 46%.

• The greatest advantage of circumcision is that it is a one-off procedure, with no ongoing costs or
supply issues to worry about. Once a boy or man has undergone the procedure he will benefit
from the preventive effect for the rest of his life.

• However, there are also disadvantages to circumcision as a universal HIV prevention approach
which is why on its own, it is not a solution to the global HIV epidemic.

• Effectiveness: Circumcision is much less effective than condom use at preventing HIV
transmission.

• If used correctly every time a person has sex, condoms provide highly effective protection against
HIV infection, whereas circumcision only prevents around 50 percent of infections.

• Even if a man has been circumcised, he must still abstain, be faithful or use condoms to
substantially cut his risk of infection.

• Moreover, unlike condoms, circumcision does not prevent pregnancy.

• Hazards of the procedure: Unlike other methods of preventing HIV transmission during sex,
circumcision requires medical intervention.

• To carry out the procedure safely requires considerable resources; otherwise it can be very risky.

• Side effects of poorly performed circumcision can include serious bleeding and damage to the
rest of the penis.

• If tools are not sterilised before each use then they can transmit infections: there is a real risk
that circumcision could actually spread HIV if not performed properly.

• Also, newly circumcised men must wait a few weeks for their wounds to heal before having sex; if
they don't they are likely to face an increased risk of HIV infection through their broken skin.
 • Effects on risk taking: If people become too confident about the protective effects of
circumcision, they may engage in more high-risk sexual behaviour.

• Men who have been circumcised might stop using condoms, or be keener to visit sex workers.

• Women might find it harder to insist on condom use by circumcised partners.

• It is even possible that, in areas where circumcision is already widespread, publicity of the
scientific findings could increase transmission of HIV.

• However, to date, there have been no reports of condom use being abandoned where
circumcision programmes have been implemented.

• Additionally, in places where circumcision has become popular, it can also be used as a good
entry-point for men to learn their HIV status, and therefore reduce the risk of infecting sexual
partners.

• Resources required: Safe circumcision, as performed in the clinical trials, demands considerable
resources including trained staff, a clean clinic and sterile tools. Estimated costs vary between
$25 and $500 per person in Africa.

• Effects on transmission of other STDs: Some studies show that circumcision has an effect on the
transmission of other sexually transmitted diseases.

• For example, the HIV transmission and male circumcision trial conducted in Rakai, Uganda, found
that in addition to reducing the incidence of HIV infection, male circumcision also reduced the
incidence of herpes simplex virus type 2 (HSV-2) and the prevalence of human papillomavirus
(HPV) among men and adolescent boys.

• Results from the trial also showed a reduced prevalence and incidence of HPV infections among
the female partners of the circumcised adolescent and adult men.

9. WEEK NINE

HOME BASED CARE AND LIVING POSITIVELY

HOME BASED CARE (HBC)

• This refers to any form of concern or care given to a sick person in their own home.

• Care includes physical, psychosocial and spiritual activities which will help improve their quality of
life.

• The reasoning behind the establishment of home based care includes:

1. The people living with HIV/AIDS are discharged from hospital where trained professionals
are and sent home where they are usually cared for by untrained relatives

2. PLWA's need continued quality care to prolong lives and reduce suffering

3. There are limitations on hospital care, including limited resources that affect the care that
can be given to PLWA's.
 4. Continued hospitalization of PLWA's may lead to depletion of family and community
savings and investments.

ADVANTAGES OF HBC

• It affects the socioeconomic, psychosocial and medical well being of the patient, the family, the
community and the health care system.

• It provides comfort of a familiar environment to the PLWA,

• It is less expensive for families

• It helps counteract the myths and mistaken beliefs about HIV/AIDS

• It encourages people to take steps to prevent infection.

• It encourages community participation in the care of PLWA's and thus maintains community
cohesiveness in responding to community members' needs.

• It eases the demand on the national health system by reducing crowding in hospitals, thus better
care is given to those who really need to be in hospital.

DISADVANTAGES OF HBC

• Stigmatization

• Expensive for those who cannot afford

• Affects workforce by family members having to stay at home to take care of PLWAs

• Absenteeism in school by children who must take care of their parents

• Risk of contracting HIV/AIDs due to ignorance and facilities at home like gloves, sterilizing agents
etc.

COMPONENTS OF HBC

• Clinical management - This includes early diagnosis, rational treatment and planning for follow up
care of HIV related illness

• Nursing care - This includes care to promote and maintain good health, hygiene and nutrition

• Counseling and psycho social care - This includes reducing stress and anxiety, promoting positive
living, and helping individuals to make informed decisions on HIV testing, plan for the future and
behavior change

Social support - This includes information and referral to support groups, welfare services and
legal advice for individuals and families and where possible provision of material assistance

10. WEEK TEN

PREGNANCY AND HIV; VERTICAL TRANSMISSION; DISCORDANT COUPLES; CONCEPTION WITH HIV,
MANAGEMENT OF MTC TRANSMISSION

PREGNANCY AND HIV/AIDS

• Transmission of HIV form mother to child (vertical transmission) is one on the main modes of
transmission of HIV with a high likelihood of transmission (1/3-1/8 chance of infection).
• For women who are pregnant or are planning on getting pregnant, it is recommended that they
take an HIV test.
• HIV testing is provided to pregnant women in two ways: opt-in or opt-out testing.
• In areas with opt-in testing, women may be offered HIV testing. Women who accept testing will
need to sign an HIV testing consent form.
• In areas with opt-out testing, HIV testing is automatically included as part of routine prenatal
care. With opt-out testing, women must specifically ask not to be tested and sign a form refusing
HIV testing.
• The Centers for Disease Control and Prevention (CDC) recommends that opt-out testing be
provided to all pregnant women.
• A mother who knows early in her pregnancy that she is HIV infected has more time to make
important decisions. She and her health care provider will have more time to decide on effective
ways to protect her health and prevent mother-to-child transmission of HIV.
• The most common HIV test is the HIV antibody test and results usually take a few days to obtain
but longer if a positive result was found as further confirmation needs to take place and this can
take a few weeks.
• If a pregnant woman is infected with HIV, she can transmit the virus to her baby during
pregnancy, labour and delivery, or breastfeeding. Without treatment, around 15-30 per cent of
babies born to HIV-infected women will become infected with HIV during pregnancy and delivery.
A further 5-20 per cent will become infected through breastfeeding.
• Because HIV can be transmitted through breast milk, women infected with HIV should not
breastfeed their babies. Baby formula is a safe and healthy alternative to breast milk.
• Although the risk is very low, HIV can also be transmitted to a baby through food that was
previously chewed (pre-chewed) by a mother or caretaker infected with HIV. To be safe, babies
should not be fed pre-chewed food.
• Anti-HIV medications are used at the following times to reduce the risk of mother-to-child
transmission of HIV:
• During pregnancy, pregnant women infected with HIV receives a regimen(combination)
of at least three different anti-HIV medications.
• During labour and delivery, pregnant women infected with HIV receive intravenous (IV)
AZT (Zidovudine) and continue to take the medications in their regimens by mouth.
• After birth, babies born to women infected with HIV receive liquid AZT for 6 weeks.
(Babies of mothers who did not receive anti-HIV medications during pregnancy may be
given other anti-HIV medications in addition to AZT.)
• In addition to taking anti-HIV medications to reduce the risk of mother-to-child transmission of
HIV, a pregnant woman infected with HIV may also need anti-HIV medications for her own health.
Some women may already be on a regimen before becoming pregnant.
• However, because during pregnancy some anti-HIV medications may not be safe to use or may be
absorbed differently by the body, the medications in a woman’s regimen may change.
• Taking anti-HIV medications during pregnancy reduces the amount of HIV in an infected mother’s
body. Having less HIV in the body reduces the risk of mother-to-child transmission of HIV.
• Some anti-HIV medications also pass from the pregnant mother to her unborn baby through the
placenta. The anti-HIV medication in the baby’s body helps protect the baby from HIV infection.
This is especially important during delivery when the baby may be exposed to HIV in the mother’s
genital fluids or blood.
• After birth, babies born to women infected with HIV receive anti-HIV medication. The medication
reduces the risk of infection from HIV that may have entered the babies’ bodies during delivery.
• When to start taking anti-HIV medications depends on a person’s health, how much HIV has
affected your body, and how far along you are in your pregnancy.
• Women who need anti-HIV medications only to prevent mother-to-child transmission of HIV can
consider waiting until after the first trimester of pregnancy to take anti-HIV medications.
However, starting medications earlier may be more effective at reducing the risk of mother-to-
child transmission of HIV.
• All pregnant women infected with HIV should be taking anti-HIV medications by the second
trimester of pregnancy.
• Women diagnosed with HIV later in pregnancy should start taking anti-HIV medications as soon
as possible.
• For couples who want to get pregnant and one of them is HIV positive, there are a number of
interventions that can reduce the risk of HIV transmission between them when they are
attempting to conceive a child.
• If a couple decide they want to conceive a child through unprotected sex, they should first seek
advice on how to limit the risk to each other and to their baby.
• It is worth noting that someone is less likely to transmit HIV if they are receiving effective
antiretroviral treatment, and also if neither they nor their partner has any other sexually
transmitted infections.
• If the woman is HIV positive and the man is HIV negative, they can conceive without HIV
transmission occurring by using artificial insemination (the process by which sperm is placed into
a female's genital tract using artificial means rather than by natural sexual intercourse).
• This simple technique provides total protection for the man, but does nothing to reduce the risk
of HIV transmission to the baby.
• If the man is HIV positive and the woman is HIV negative, a technique called Sperm washing can
be used to prevent HIV transmission from an HIV positive man to his partner during conception.
• Sperm washing involves:
• separating sperm cells from seminal fluid,
• testing these cells for HIV, then
• Inserting the cells into the woman's womb (intrauterine insemination), or directly into
the egg (in vitro fertilisation or intracytoplasmic sperm injection).
• Sperm washing is a very effective way to reduce the risk of HIV transmission during conception,
but it is not widely available and can be difficult to access, even in well resourced countries.
• Alternatives to sperm washing have been researched, such as the method of using PrEP and
timed intercourse when the HIV-positive male partner is taking antiretroviral drugs.
• PrEP stands for pre-exposure prophylaxis and refers to a form of treatment that can be taken
before exposure to a disease in an attempt to prevent infection.
• In respect to HIV, PrEP consists of antiretroviral drugs to be taken before potential HIV exposure
in order to reduce the risk of HIV infection.
• The antiretroviral drugs that are currently being tested for PrEP treatment are tenofovir and
emtricitabine or tenofovir alone. Taken once a day, these drugs have limited side effects and slow
development of associated drug resistance.
• In a situation when both partners are HIV positive, it might still be sensible for them not to
engage in frequent unprotected sex, because there might be a small risk of one re-infecting the
other with a different strain of HIV.
ARVs and their risks for pregnant women
• A regimen of ARVs is the recommended means of controlling vertical transmission however some
of the drugs used to treat HIV/AIDS can be potentially harmful to the child.
• There may be a link between the use of some PIs and high blood sugar (hyperglycemia) or
diabetes.
• For some women, the risk of hyperglycemia increases in pregnancy. It is unclear if taking PIs adds
to this risk.
• Two NNRTIs, Sustivaand Viramune, should be used in pregnant women only under certain
conditions:
Sustiva may cause birth defects that develop during the first few months of pregnancy.
Therefore, if possible, use of Sustiva should be avoided in the first trimester of pregnancy.
Atripla, a combination pill that contains Sustiva, should also be avoided in the first
trimester of pregnancy. After the first trimester, Sustiva or Atripla can be used safely.
• Viramune increases the risk of very serious liver damage in women with CD4 counts
greater than 250 cells/mm3. Viramune should only be started in pregnant women with
CD4 counts higher than 250 cells/mm3if the benefits very clearly outweigh the risks.
Women who begin using Viramune during pregnancy are carefully monitored for early
signs of liver damage. Women taking Viramune without problems before they become
pregnant can safely continue to take the medication. Liver damage from Viramune use in
pregnancy has not been seen in women already taking the medication without side
effects.
• Using NRTIs can sometimes lead to lactic acidosis, a condition caused by the buildup of a specific
acid in the blood. Women should not take the combination of Zeritand Videxduring pregnancy
because the combination has caused deaths from lactic acidosis and liver failure. Women taking
NRTIs during pregnancy are watched carefully for signs of lactic acidosis.
• Talk to your health care provider about the safety of anti-HIV medications during pregnancy.
There are many anti-HIV medications to choose from that will keep you and your baby healthy.
• Aside from taking ART drugs, alternative methods to reduce the risk of transmission of HIV from
mother to child include pre labour caesarean section (PLCS).
• A caesarean section is an operation used to deliver a baby through its mother’s abdominal wall.
When a mother is HIV positive it is done to protect the baby from direct contact with her blood
and other bodily fluids.
• However, research suggests that with many women now taking ARV combination therapy during
pregnancy, having a caesarean isn’t a significant factor in preventing the transmission of HIV from
mother to baby. Unless you are ill with HIV or have a detectable viral load it usually won’t be
recommended by your health care provider, as having a caesarean does itself have some risks for
the woman.
• One exception to this is if you are taking AZT on its own, when a PLCS may still be recommended.
• Because breast feeding is one way through which the HIV virus can be passed from mother to
child, it is recommended that breast feeding is avoided with formula being used as a substitute.
• In situations where formula is unavailable or unaffordable or in situations where there is no
access to clean and safe drinking water, breast milk can be used exclusively.
• Mixed feeding is when a baby is fed with breast milk and other liquids such as formula, glucose
water, gripe water or traditional medicine.
• It is now thought that there is a higher risk of a baby becoming HIV positive from mixed feeding
than exclusive formula feeding alone or breastfeeding.
 • Mixed feeding may damage the lining of the baby’s stomach and intestines making it easier for
HIV in breast milk to infect the baby but when taking ARVs to prevent mother to child
transmission, the risk is reduced and is currently recommended by the WHO.

SUMMARY

• Although MTC transmission carries the highest risk of infection, with effective treatment, it is
increasingly less likely that the child will contract HIV.
• Partners who are HIV positive can also conceive and limit the chance of infecting their child by
sticking to a strict drug regimen as well as using safe conception techniques such as IVF.
• With the variety of drugs available to treat HIV/AIDS, it is possible for a mother to put placed in a
treatment plan that will limit or eliminate any harmful effects that the drugs might have on her
and her unborn child.
• It is also vital that mothers to be get tested as soon as they find out they are pregnant or if they
wish to be pregnant so that appropriate measures can be taken.

11. WEEK ELEVEN

MYTHS SURROUNDING HIV AND EXPOSURE TO RISK BEHAVIOUR THAT PROMOTES THE SPREAD OF HIV

MYTHS AND PRACTISES THAT CONTRIBUTE TO THE SPREAD OF HIV

• There are a variety of myths and social practises that contribute to the spread of HIV by
encouraging high risk behaviour.

• Some social practises that do this include:

• Premarital sex-sex before marriage, involves both fornication and adultery.

• Extra marital sex-involves having sex besides the matrimonial spouse.

• Corporal adornment - of body parts which involves piercing of some body parts such as
ear, nose, tattooing portions of the body etc.

• Cohabitation - trial marriage.

• Festival seasons - during certain occasions such as Christmas, valentine day etc., there is a
strong behaviour towards sexual involvement.

• Sex for expediency - this is a relationship for the purpose of material gain of one kind of
another.

• Sex for livelihood - this means commercial sex work, and involves exchange sex for
money. Prostitution is the old name given to this kind of activity.

• Resistance to condom use - the use of condom is a new norm in sexual union among
African. It is culturally unknown and the suggestion of its use suggests sign of mistrust.
 • Drug and alcohol use and abuse - use of hard drugs and alcohol predisposes those
involved to risky sexual behaviour in the context of HIV/AIDS.

• Internet and pornography - these are stimulating sexually to the mind and individuals
especially the youngster may be tempted to copy and put into practice what they view
thus becoming vulnerable to contract HIV/AIDS.

• Lack of recreational facilities - due to overdevelopment in urban centres, there is no

longer space for playgrounds and other recreational facilities. The youth become idle and
to reduce idleness they engage in risky behaviours that predisposes them to HIV/AIDS
infection.

Social stigma- because of this, HIV positive individual hide their status and behave
normally while they go on infecting other people.

• Cultural practises that contribute to the spread of HIV:

• Sex for ritual purposes - these arise from the belief in the powers of an external force,
usually in the form of a spirit which can befall a person if some prescribed traditional
rituals are not carried out.

• Male and female circumcision - the same knife is used repeatedly without sterilization
this leading to risk of blood contamination with HIV.

• Polygamy- this practice is resilient in a number of communities. Given the evidence that
many sexual partner increases one chances of being exposed to HIV, polygamy and
extramarital relationships which are culturally tolerated play a part in the spread of
HIV/AIDS.

• Spouse inheritance - this is a cultural practice which promotes the exchange of sexual
partners after death in a family. In its formal sense it involves marrying off the surviving
partner to a relative of the deceased. Given the fact that most cases of HIV transmission
are as a result of heterosexual relationships and that AIDS as the cause of death is usually
not disclosed to the relatives, inheritance of spouses has pose high risk of exchanging the
HIV virus, thus feeling the HIV pandemic.

• Cultural taboos - people attribute HIV/AIDS to witchcraft or a curse arising from violating
some cultural taboos. Most people tend to believe that HIV/AIDS does not exist.

• Youth between the ages of 15 and 24 are the most at risk of contracting HIV and one of the
reasons for this is that there are a number of myths on sex and sexuality that affect people in this
age group.

• These include:

• “Women also ejaculate during sexual intercourse”, whereas the truth is not all Women
ejaculate during sexual intercourse.

• “Simultaneous orgasms are a must for sexual satisfaction” but this is not true.
• “The common belief that one engages in sex to enhance fertility in the future”. This is not
true except that youths who get involved in sexual intercourse in a big way expose
themselves to a lot of risk including infection with HIV/AIDS

• “People have to multiply to fill the earth and the bible encourages people to give one
another”. This is a literal translation of a biblical command but people are supposed to
multiply in spiritual sense and is a corruption of the bible.

• “Abstaining from sex leads to sickness and madness and practice makes perfect”: Not
true, nobody has ever fallen sick or become mad for not engaging in sexual intercourse.

• “Having a venereal disease is considered a badge of honour that confirms manhood”.

Venereal diseases are as bad as any other disease and therefore confer no honour to any
man.

• “Venereal disease is cured if the man has sex with a virgin”. This is not true as the
Venereal disease sufferer will transmit the disease to the virgin.

• “Special food and exercise will make the penis grow big”. Not true. Whatever that is good
for other body parts is also good for sex organs.

• “Men have stronger sexual urges than women. Men sex drive is believed to be boundless
and irrepressible”. Not true as sexual urges are equal in both sexes.

• “It is generally said that Africans are promiscuous”. This is not true. Promiscuity is not
necessary an African trait has other races have promiscuous people too.

• “A man cannot be satisfied by one woman”.

• “One can't get pregnant during the first sex intercourse. It is a common belief that there
is a grace period between the first sexual encounter and getting pregnant”. This one isn’t
true because as long as the female has begun menstruation and is healthy, she can get
pregnant.

• “One can't get pregnant during unprotected sex if the man pulls out before he
ejaculates”. This is not true. Some small amounts of sperm containing semen may be
deposited in the vagina before ejaculation. Others remain in the urethra after ejaculation
and can fertilize an ovum.

• “A woman is not considered to be a female if she cannot conceive a child”. The femininity
of a person is not judged by the ability to conceive a child. There are other criteria

• “Birth control and family planning are dismissed as a western concept thus devalued”.
Many African communities practiced different birth control methods even before the
onset of western civilization.

• “Imparting sex education to youngsters will lead them to promiscuity.” Talking to

youngsters on sex or imparting sex education will not lead to promiscuity. Even
without sex education, people indulge in promiscuity. In fact, more married
people have promiscuous relations than youngsters. Educating the young on sex
and sexual behaviour helps them to develop a healthy and positive attitude
 towards sexuality. More importantly, better interpersonal relationship will
develop leading to a harmonious family and marital life.

12. WEEK TWELVE

RELIGION AND HIV; HUMAN SEXUALITY

NB: for the human sexuality, a general overview can be given but I have some documentaries that give
detailed explanation to human sexuality.

• Homophobia is generally defined as hostility towards and/or fear of gay people, but can also refer
to stigma arising from social ideologies about homosexuality.
• Negative feelings or attitudes towards non-heterosexual behaviour, identity, relationships and
community, can lead to homophobic behaviour. This is the root of the discrimination experienced
by many lesbian, gay, bisexual and transgender (LGBT) people. Homophobia manifests itself in
different forms, for example homophobic jokes, physical attacks, discrimination in the workplace
and negative media representation.
• Although in many societies gay men and lesbians are more accepted than in the past,
homophobia continues to be prominent around the world. The global HIV and AIDS epidemic has
always been closely linked with attitudes towards gay men; a group that is particularly affected
by HIV and AIDS
• At the beginning of the HIV and AIDS epidemic, gay men in many countries were frequently
singled out for abuse as they were seen to be responsible for the spread of HIV. This view was
fuelled by sensational reporting in the press, which became progressively anti-gay. Headlines
such as, “Alert over ‘gay plague’”, and “‘Gay plague’ may lead to blood ban on homosexuals”
demonised the gay community. Groups in the USA monitoring homophobic violence reported an
increase in incidents when public awareness about AIDS in America increased in the 1980s
• In many African countries, such as Zimbabwe and Zambia, homophobia is legitimised by
governments. Criminalisation of homosexuality remains strong in 36 countries in Africa, and gay
people face persecution and violence from police, employers, hospitals and community
organisations.
• Strong religious traditions in many places severely threaten LGBT equality and some European
governments are failing to fully enforce the protection of LGBT individuals from homophobia.

CAT 2

13. WEEK THIRTEEN

Revision

14. WEEK FOURTEEN

Exams