CCS 103: HIV and AIDS

Course Purpose: To equip the learner with knowledge, skills and attitudes in understanding
of HIV and AIDS and its effects to the society.

Expected Learning Outcomes

By the end of the course unit the learners should be able to

1. Define common terminologies relating to HIV/AIDS

2. Describe the concepts of HIV, AIDS and STIs
3. Explain the modes of HIV transmission
4. Discuss the factors encouraging spread of HIV infection
5. Describe the effects/impact of HIV/AIDS in present society
6. Discuss the measures to prevention of HIV/AIDS

Introduction of HIV/Definition of terms

- HIV- The initials stands for Human immunodeficiency virus, which is the virus that
causes HIV infection
- AIDS- The initials stands for Acquired immunodeficiency syndrome.
- HIV/AIDS virus enters the body through the mucus membrane or a broken skin
- AIDS is the most advanced stage of HIV infection.
- HIV attacks and destroys the infection-fighting CD4 cells of the immune system.

NB:
- A person can be infected with HIV and not have AIDS
- HIV does not kill, death results from secondary infections

Historical overview of HIV/AIDS

AIDS was first described in 1981

1981- Doctors in US recognized an unusual kind of pneumonia called Pneumocystis carinii

pneumonia (PCP) in homosexual males and intravenous drug users, a condition
previously unreported in healthy adults. Later similar infections were soon described
in Africa, the Caribbean and Europe
1982- Doctors realized that the symptoms and related conditions were due to a
compromised (an ineffective) immune system.
1983/4- Scientist described the cause of this acquired immunodeficiency syndrome
(AIDS) as a retrovirus (RNA virus).
 (Professor Luc Montagnier and others discovered a novel (strange) pathogen: a
retrovirus that invaded CD4 cells that orchestrate cell-mediated immunity and protect
humans from a broad range of viral, mycobacterial, and fungal pathogens)

1984- First case described in Kenya

1986- The term Human Immunodeficiency Virus (HIV) was accepted as international
designation for the retrovirus in a world health organization (WHO) consultative meeting.
- AIDS became an epidemic disease. Most of young people died

• Screening of blood products where available eliminated transmission transmission but

spread of HIV was not easily stoped.
• Condoms were shown to be effective in preventing sexual transmission of HIV, but it
was not long before those who studied AIDS concluded that male condoms alone
would not be enough in settings in which poverty and gender inequality rendered poor
women especially vulnerable to HIV infection.
• Women in turn transmitted HIV to their unborn children or to breastfeeding infants.
• Poor quality health care – including the reuse of syringes, needles, and other medical
paraphernalia – also contributed to the entrenchment of this new epidemic.
1996 – ARVs (antiretroviral drugs) became available in the world

1997 - ARVs were available in private health sector in Kenya

2003 – ARVs were available in public health sector Kenya

2005- 54,000 Kenyans were on ARVs

THEORIES OF ORIGIN OF HIV/AIDS

- When and where the HIV virus first emerged has remained unknown for many years
- However, several theories have been put forward, but none is conclusively agreed on
the origin of HIV/AIDS.

Some of the mostly acknowledged theories about the origin of HIV include the following:
1. Mysterious origin theory
- This theory tries to account for the seemingly mysterious origin of HIV by locating it out of
this world.
- It suggests that viral material was carried in the tail gases of a comet passing close to the
earth and that this material was deposited, subsequently infecting nearby Sate in people.
Although one or two famous astronomers have been linked to this theory in the popular press,
these scientists deny the possibility of extra-terrestrial phenomena and any personal
connection to the theory.

2. Religious theories (God’s wrath and witch craft)

- Certain segments of the population have openly stated that AIDS is God’s wrath since the
Scriptures condemn the homosexual practice in which AIDS was first observed in the
Western world.
- Rather than its being considered a visitation from God, many Africans believe that AIDS is
caused by another supernatural power – witchcraft, and they use anti-witchcraft rituals and
objects to counteract the infection.

3. Monkey origin theories

- HIV is a lentivirus, and like all viruses of this type, it attacks the immune system.
- Lentiviruses are in turn part of a larger group of viruses known as retroviruses.
- The name „lentivirus‟ literally means „slow virus‟ because they take such a long time
to produce any adverse effects in the body.
- They have been found in a number of different animals, including cats, sheep, horses
and cattle.
- The most interesting lentivirus in terms of the investigation into the origin of HIV is
the Simian immunodeficiency Virus (S IV) that affects monkeys.
- The researchers led by Paul Sharp of Nottingham University and Beatrice Hahn of the
University of Alabama made the discovery during the course of a 10-year long study
into the origins of the virus.
- They claimed that chimpanzees were the source of HIV-1 and that the virus had at
some point crossed species from chimps to humans.

4. The Oral Polio Vaccine (OPV) theory

- The journalist Edward Hooper suggested that HIV could be traced to the testing of an oral
polio vaccine called Chat, given to about a million people by the Belgian in Congo, Rwanda
and Burundi in the late 1950s.
- To be reproduced, live polio vaccine needs strain to be cultivated in living tissue, and
Hooper‟s belief is that Chat was grown in kidney cells, taken from local chimps infected with
SlV.
- This, he claims, would have resulted in the contamination of the vaccine with chimp SlV,
and a large number of people subsequently becoming infected with HIV.

5. The Hunters‟ Theory

- The most commonly accepted theory.
- In this scenario, simian immunodeficiency virus (SIV) was transferred to humans as a
result of chimpanzee being killed and eaten, or their blood getting into cuts or wounds
of people in the course of hunting.
- Normally, the hunter's body would fight off SIV, but on a few occasions the virus
adapted itself within its new human host and became HIV

6. The Contaminated Needle Theory

- In the 1950s, the use of disposable plastic syringes became common place around the world
as a cheap, sterile way to administer medicines.
- However, to African healthcare professionals working on inoculation and other medical
programmes, the huge quantities of syringes needed would have been very costly.
- It is therefore likely that one single syringe would have been used to inject multiple patients
without any sterilisation in between.
- This would rapidly have transferred any viral particles from one person to another

7. The Colonialism Theory

- It was first proposed in the year 2000, by Jim Moore, an American specialist in
primate behaviour, who published his findings in the journal AIDS Research and
Human Retroviruses.
- During the late 19th and early 20th century, much of Africa was ruled by colonial
forces.
 - In areas such as French Equatorial Africa and the Belgian Congo, colonial rule was
particularly harsh and many Africans were forced into labour camps where sanitation
was poor, food was scare and physical demands were extreme.
- These factors alone would have been sufficient to create poor health in anyone, so
SIV could easily have infiltrated the labour force and taken advantage of their
weakened immune systems to become HIV.
- A stray and perhaps sick chimpanzee with SIV would have made a welcome extra
source of food for the workers.
- Moore also believes that many of the labourers would have been inoculated with
unsterile needles against diseases such as smallpox (to keep them alive and working),
and that many of the camps actively employed prostitutes to keep the workers happy,
creating numerous possibilities for onward transmission.
- One final factor Moore uses to support his theory, is the fact that the labour camps
were set up around the time that HIV was first believed to have passed into humans -
the early part of the 20th century.
8. Conspiracy theories
Laura Bogart of RAND (Research And Developmant) Corporation (created in 1948, is a non-
profit institution in USA which help improve policy and decision making through research
and analysis) and Sheryl Thorburn of Oregon State University, stated that:
i) One in seven African Americans surveyed believed HIV was created by the
Government to control the black population.
ii) One in three said they believed that HIV was produced in government laboratory,
iii) More than half said there was a cure for HIV/AIDS that was being withheld from
the poor.
Therefore, this resulted to mistrust of the Government and the health profession, and believe
that HIV was designed to wipe out large numbers of black and homosexual people.

9. The calculation theory

- This is the latest theory on the origin of HIV.
- Opponents of the simian-human transmission remain unimpressed by the evidence in
of the monkey theories and argue that viral sequencing of HIV strains indicate that
HIV has been around probably for hundreds of years.
 - In 2000 when a team of scientists using computer technology to study on the structure
of HIV calculated the rate at which the virus mutates for the HIV viral sub-types to
have a common ancestor.
- This process revealed HIV originated around 1930 in rural areas of Central Africa,
where the virus may have been present for many years in isolated communities.
- The virus probably did not spread because members of these rural communities had
limited contact with people from other areas.
- But in the 1960s and 1 970s, political upheaval, wars, drought, and famine forced
many people from these rural areas to migrate to cities to find jobs.
- During this time, the incidence of sexually transmitted infections, including HIV
Infection accelerated and quickly spread throughout Africa.

Distribution of HIV/AIDS
Global
Regional HIV and AIDS statistics and features 2017

Adults and children living Adults and Adult and

with HIV children child
newly infected deaths due to
with HIV AIDS
Eastern and 19.6 millions 800 000 380 000
Southern (17.5million-22.0 million) [650 000–1.0 [300 000–510
Africa million] 000]
Western and 6.1 millions 370 000 280 000
Central Africa (4.4 million -8.1 million) [220 000–570 [180 00–410
000] 000]
Middle East 220000 18 000 9800
and North (150000-300000) [10 000–31 000] [6400–15 000]
Africa
Asia and the 5.2 million 280 000 170 000
Pacific (4.1 million -6.7 million) [210 000–390 [110 000–280
000] 000]
Latin America 1.8 million 100 000 37 000
(1.5million-2.3million) [77 000–130 000] [26 000–51
000]
Caribbian 310000 15 000 10 000
(260000-420000) [11 000–26 000] [7100–17 000]
Eastern 1.4 million 130 000 34 000
Europe and (1.3 million -1.6 million) [120 000–150 [25 000–41
Central Asia 000] 000]
Western and 2.2 million 70 000 13 000
Central (1.9 million -2.4million) [57 000–84 000] [9900–18 000]
Europe and
North America
Total 36.9 million 1.8 million 940 000
[1.4 million–2.4 [670 000–1.3
million million]

Global summary of the AIDS epidemic (2017)

Number of people Total 36.9 million [31.1 million–43.9
living with HIV million]
(prevalence rate) Adults
35.1 million [29.6 million–41.7
million]

Women (15+ 18.2 million [15.6 million–21.4

years) million]

1.8 million [1.3 million–2.4

Children (<15 million]
years)
People newly Total 1.8 million [1.4 million–2.4
infected (incidence million]
rate) Adults 1.6 million [1.3 million–2.1
with HIV in 2017 million]
Children (<15
years) 180 000 [110 000–260 000]
AIDS-related Total 940 000 [670 000–1.3 million]
deaths
in 2017 Adults 830 000 [590 000–1.2 million]

Children (<15 110 000 [63 000–160 000]

years)

Adults and children estimated to be living with HIV 1990–2017

Adults and children newly infected with HIV 1990–2017

Adult and child deaths due to AIDS 1990–2017

Regional
Local distribution ( in Kenya), KAIS (Kenya Aids Indicator Survey) Report 2015
(Nascop, 2015)
 MODES OF HIV TRANSMISSION

i) Sexual transmission of HIV/sexual activities:

This is the most common mode of transmission/acquisition of HIV worldwide
- Heterosexual (male/female), mainly vaginal sex. This result to direct contact with
semen or vaginal and cervical secretions
- Homosexual (men having sex with men), mainly anal sex
- Oral sex
- Digital sex eg shared vibrators used by women
ii) Parenteral (HIV transmission through infected blood & products)
– Transfusion of infected blood or blood products
– Exposure to infected blood or body fluids through contaminated sharps.
Example; IDU ( injection drug users) through needle-sharing, or needle prick;
or traditional practices eg uvulectomy, sharing of skin piercing instruments,
female genital mutilation and tattooing
– Donated organs
iii) MTCT- Maternal- to -Child Transmission of HIV (Vertical transmission)
- Trans placental during pregnancy
- During labor/delivery
- Breastfeeding

Transmission Route as a percentage

Sexual intercourse 70-80%

Mother-to-child-transmission 5-10%
Blood transfusion 3-5%
Injection Drug use 5-10%
Health care –e.g. needle stick <0.01%
injury

Factors not associated with risk of HIV transmission

• Air or water

• Insects, including mosquitoes or ticks

• Casual contact, like shaking hands, hugging or sharing dishes/drinking glasses
• Drinking fountains (a fountain designed to provide drinking water)
• Toilet seats
HIV is not spread through the air and it does not live long outside the human body.
 THE IMMUNE SYSTEM

Understanding the Cells of the immune system

NB: CD means cluster of Differenciation

CD4+ cells are helper cells that activate B cells, killer cells, and macrophages (large cell of
immune system that engulfs, and digest cellular debris, foreign substances) when a specific
target antigen is present.

Effect of HIV on the immune system

 • HIV virus attaches to the cells of the immune system through special markers
called CD4 receptors
• The following immune cells have CD4 receptors
- T lymphocytes- CD4 cells
- Macrophages
- Monocytes
- Dendritic cells
Therefore, HIV infection of the CD4 cells causes cell dysfunction and death.

Viral load

- A viral load test measures the number of HIV viral particles per millilitre of blood.
- A low viral load indicates that treatment is effective.
- A high viral load (≥ 1,000 copies/ml) in a person on treatment indicates either that
the medication is not being taken properly or that the virus is becoming resistant to
the medication.
On exposure to HIV infection, there is 2-4 week period of intense viral replication and widespread of
virus characterised by:
- High blood Viral load, often greater than 1 million copies/ml.
But within the first 6 months to 1 year after infection, the persons’ immune
response brings the viral load down to a steady level which is sometimes called the
viral load set point.
- In the absence of ART (antiretroviral drugs), the viral load will increase over the
course of several years, and then rises more rapidly when the patient develops
symptoms. The viral load set point can be used to predict HIV disease progression;
the higher the set point, the more quickly the patient will progress to AIDS.

CD4 cell count

There is rapid decline in CD4 count since;
The HIV virus destroys CD4+ T-cell.
There is destruction of mature CD4+ cells, CD4+ progenitor cells (i.e cells which has to
differentiate into a specific type cell) in bone marrow, the thymus, and peripheral lymphoid
organs; as well as CD4+ cells within the nervous system, such as microglia. The result of this
destruction is failure of T-cell production and eventual immune suppression.

Immune depletion
a) The CD4+ count in the blood decreases remarkably during primary
infection, resulting to immunodeficiency. The CD4 T cell depletion is in
two fold:
- Reduction in numbers
- Impairment in function
The virus targets CD4+ cells in the lymph nodes and the thymus during this time, making the
HIV-infected person vulnerable to opportunistic infections and limiting the thymus’s ability
to produce T lymphocytes.
HIV antibody testing using an enzyme-linked immunosorbent assay (ELIZA) or enzyme
immunoassay may yield positive or negative results depending on the time of seroconversion.
DNA PCR and RNA PCR will be positive, because seroconversion can take up to 2–8 weeks
to occur. The average time to seroconversion is 25 days.

b) During the asymptomatic stage ( latent)

- Patients enter a stage of asymptomatic disease phase lasting 2-10 years.
- Characterised by gradual decline in CD4 count ( rate depends on viral load)
- Long term non progressors
i. rare
ii. ≥ 10-15 years survival
iii. CD4 ≥ 500: low viral load

c) During the symptomatic disease and AIDS

• The viral load continues to rise causing;
- Increase demands on immune system as production of CD4 cells cannot match
destruction
- Increased susceptibility to common infections (URTI, pneumonia, skin etc)
- Late-stage diseases is characterised by a CD4 count ≤ 200cells /ul and the
development of opportunistic infections, eg selected tumors, wasting, and
neurological complications.

Factors encouraging transmission of HIV:

Behavior factors
• Promiscuity
This is a major cause of HIV across the globe, but Africa has its share of challenges as
many individuals have more than one sexual partner. Prostitution is rife in the
continent and people do not take issues to do with infidelity seriously. Multiple sexual
partner risks HIV transmission, as well as having sex with single HIV infected person.
- Unprotected sexual intercourse (infected person)
• Drug and alcohol use
 - Drug and alcohol abuse is rampant among the youth.
- Sharing of injections among drug users is the most common HIV transmission
method.
- Alcoholics are often unable to make wise decisions pertaining engaging in
sexual activities exposing themselves to a myriad of risks.
Biological factors

Disease status of the source

- Related to degree of immunosuppression of the individual and viral load
- High risk during primary infection and late disease when viral load is high
Presence of untreated sexually transmitted infections (STIs) in source person and person at
risk
- Both ulcerative and non-ulcerative STIs are importance cofactors
- Related to high viral load in genital secretions during STIs
- infection and the disturbance of genital mucosa
Circumcision status
- Uncircumcised men are twice likely to acquire HIV infection than circumcised
men. They are also likely to acquire STIs
Gender differences is susceptibility
- Female genital anatomy presents a large surface area with more of the cells
that HIV requires to gain entry
Gender
- In many cultures it is accepted for men to have many sexual relationship
- Women suffer gender inequality
- Many women are unable to negotiate condom use

Social Economic factors

• Ignorance
Even though a majority of the population knows about HIV/AIDS, people ignorantly
continue to participate in activities and practices that encourage transmission. People
ignore simple measures such as protecting themselves during intercourse knowing too
well the consequences that come with unprotected sex.
• Illiteracy
Illiteracy levels are still high with some people still having no idea how HIV/AIDS is
transmitted. Even though many maybe aware, they lack knowledge about both
transmission and prevention leading them to engage in risky behavior that exposes
them to the virus. Myths, beliefs and misconceptions about HIV/AIDS are easily
believed by illiterate people.
• Poverty
Especially in developing countries which have significant sections of the population
that live below the poverty line. Poor people are often forced to do anything to earn a
living including engaging in unprotected sex exposing them to HIV/AIDS
• HIV/AIDS stigma/ denial
Stigma associated with HIV still remains high and for this reason, many people do
not go for HIV testing for fear of their status being known by the community. Stigma
also causes many to avoid taking ARV drugs in the presence of others to avoid being
discovered they have HIV/AIDS. Because of this, the virus continues to spread.
• Cultural factors
Africa is known across to be the bedrock of rich culture. However, some cultural
practices continue to promote the spread of HIV across the continent. Polygamy, wife
 inheritance and FGM (Female Genital Mutilation) have been blamed for fuelling the
spread of HIV/AIDS especially among populations in rural Africa where these
practices are held in high esteem.
• Lack of access to maternal services
Women especially in rural area lack proper access to maternal services which forces
them to deliver children at home without help and supervision from qualified medical
personnel. As a result of this, many cases of mother-to-child HIV transmission have
been reported as HIV expectant women have no idea what they need to do to prevent
passing on the virus to their unborn child
• Tribal conflicts and civil wars
Tribal conflicts and civil wars hinder healthcare access to individuals with HIV/AIDS.
On the other hand, the increasing number of refugees and refugee camps lead to
desperation with drug abuse and prostitution cases being on the increase

Prevention and control of HIV infection

Prevention and control of HIV/AIDS involves tackling the most important modes of
transmission i.e.
i) Prevent sexual transmission
ii) Mother to child transmission
iii) Blood/ blood products transmission

General principles for HIV prevention

• The main AIM for HIV/AIDS prevention is to avoid & minimise the risk of transmission of
the HIV virus from an infected person to an uninfected person.
• Prevention measures currently recommended at individual and community levels are based
on our knowledge on how the virus is transmitted.
• There are two main Strategies involved in prevention of HIV transmission
1) Personal strategies
2) Public health strategies

Personal strategies
• Abstinence
• Monogamous Relationship
• Protected Sex
• Use of Sterile needles
• Avoid drugs and alcohol
• Keeping healthy/strong immune system
• Avoid stress
• Develop a positive attitude
• Behaviour change: the stages of Behaviour change that an individual passes through,
from being completely unaware to making positive Behaviour changes include.
The most widely known personal strategy is the use of the „ABCD rules‟:

• “A” stands for “Abstinence”, which means refraining from sexual intercourse.

- It is the only 100 % effective method of not acquiring HIV/AIDS.

- Refraining from sexual contact: oral, anal, or vaginal.
- Abstinence is the most effective way to prevent sexual HIV transmission, as
there is no possibility of direct contact between infected blood or sexual fluids
and the other person’s body.
- However, many sexually active people find it difficulties to maintain
abstinence for long periods, hence making it unrealistic option.
- The only disadvantage is that it cannot be applied in circumstances of forced
sexual relations e.g. rape.

• “B” stands for “Be faithful”, which means maintaining faithful relationships with a
long-term partner.
- Faithfulness (the “B” rule of Being faithful)
- To minimise transmission of HIV, it is essential for both partners or the
multiple partners in polygamous relationships to be faithful to each other.
- They should also know their status of HIV before starting unprotected sexual
intercourse.
- However it’s advisable to maintain a Monogamous relationship

A mutually monogamous (only one sex partner) relationship with a person who is not
infected with HIV
- HIV testing before intercourse is necessary to prove your partner is not
infected
• “C” stands for, use of Condoms”, which means maintaining consistent use of condoms in
sexual relations.
- A new condom should be used for each sexual act.
- A damaged condom can allow HIV to penetrate and result to HIV infection,
hence should never be used.
- Condoms have expiration dates and one should always check the package
before use.
- Avoid damage of condoms by always using water-based lubricants (eg KY
jelly). Oil-based lubricants, such as Vaseline or creams, can cause condoms to
break and should not be used.
- Use condoms (female or male) every time when having sex (vaginal or anal)

When Using A Condom Remember To:

- Make sure the package is not expired.
- Make sure the package is of good quality.
- Make sure to check the package for damages
- Do not open the package with your teeth for risk of tearing
- Never use the condom more than once

• “D” stands for, use of Drugs (ARV Drugs), or it can also stand for DE stigmatization.
i) Stigma is an act of identifying, labelling, undesirable qualities targeted towards
those who are perceived as being shamefully different and deviant from social
ideal.
ii) An attribute that is significantly discrediting used to set affected persons or groups
apart from the normalised social ideal
Remove the stigma so that;
- Infected people are not neglected
- Not seen as very bad people, Irresponsible
- Freely talk about AIDS and create awareness

Individual Strategies to prevent HIV through Blood transmission includes

- Avoiding the sharing & use of toothbrush
- Avoiding the sharing & use of sharps objects e.g. blades, needles/syringes,
knives
- Used needle should be disposed in the right place
- Never pick a sharp object without looking
- Use of PPEs ( personal protective equipment) eg gloves especially by hospital
staffs
- Avoid skin/mucous membrane contamination with HIV infected blood or
fluids
- Avoiding harmful traditional practices e.g. (milk teeth extraction, female
genital mutilation, Tattoos/body piercing, traditional birth attendants).
- Careful handling of blood and blood products

COMMUNITY/PUBLIC HEALTH HIV STRATEGIES

• Screening of all donated blood and blood products.
• Educating the public on safer sex practices and providing free VCT (voluntary
counselling and testing) services.
 • Identifying & treating STDs (sexually transmitted diseases) & STIs (sexually
transmitted infections.)
• Use of sterile needle and syringe.
• Supply of condoms to communities for safe sex practices.
• Equipment (especially medical) should be thoroughly and properly sterilised (HIV
is very sensitive and easily destroyed by boiling for at least 5 minutes

OTHER METHODS FOR PREVENTION

i) Reduce sexual transmission of HIV by having protected sex
ii) Ensure that people living with HIV (PLWA) receive antiretroviral treatment.
iii) Mouth to mouth recovery (resuscitation) to be minimised
iv) Health care workers with open sores should be off from duty until the condition
heals
v) Health care workers to wear gloves and aprons when handling patients.
vi) Protecting drug users from becoming infected with HIV.
vii) Empowering young people to protect themselves from HIV.
viii) Ensure blood donors are HIV negative

Prevention of Mother to child transmission (PMTCT)

Pregnant mothers have 30-40% chance of infecting their children. Both parents are
responsible for Prevention of Mother-To- Child-Transmission transmission of HIV

Several factors may reduce the risk transmission of HIV from mother to the child. These
include:
▪ Protect the mother from being infected
▪ Knowing their HIV status early
▪ Having Skilled care at birth
▪ Early prenatal /postnatal visit
▪ Exclusive breastfeeding for six months
▪ Having good maternal nutrition, improves immunity
▪ Completing timely immunization
▪ Taking anti HIV therapy during pregnancy and delivery eg AZT
(zidovudine drug) reduces the viral load
▪ HIV positive mothers should not donate breast milk to breast milk
bank

Male circumcision
- The fore skin retain vaginal fluid during and after sexual activity
- Hence, male circumcision is recommended
Management of STDs (sexually transmitted infections)

- STDs enhances HIV transmission by causing open sores and skin injuries
in sex organs through which the HIV enters.
- A lot of CD4 cells are mobilized to fight the STD infections and since these
are the targets of HIV, a lot of them are destroyed and the person or
individual goes down faster with the HIV.
- The mode of transmission for the STDs is also the same as the mode of
transmission of HIV.
 - Hence, Increase education on recognition of STD symptoms, encourage use of
condom, and treatment of STDs are methods of preventing HIV transmiision.

VCT
- Is voluntary without coercion or persuasion for testing
- Ensure there is confidentiality with client only
- Health education- is given on facts about HIV, and risks for infection and
reinfection
- Counselling – assesses clients personal risk behaviour and exposure to HIV
infection and help him/her to explore ways on how to reduce it.
- Pre-test- dialog and explanation by a professional counsellor – explain, test
and implication of the results
- Post- test- explains test results and how to cope with implications, positive or
negative results.

TREATMENT: ARVs/CARE
Introduction
- Human Immunodeficiency Virus (HIV) research has made remarkable
progress since the virus was discovered in the early 1980s
- Preventive efforts have reduced the number of new cases of the disease, and
for people already living with HIV/AIDS; the survival rate is increasing
because of advances in drug therapy. While no medical treatment cures AIDS,
in the relatively short time since the disease was first recognized, new methods
of treating the disease have developed rapidly.
- Health-care professionals focus on three areas of therapy for people living
with HIV infection or AIDS:
Antiretroviral therapies use;
a) Drugs, Nutrition, Counselling, to suppress HIV replication
b) Medications and other treatments that fight the opportunistic infections and cancers
that commonly accompany HIV infection
c) HIV/TB collaborative activities
d) Nutrition (which should include a balanced diet)
e) Home and community based care (HCBC)
f) Support mechanisms (Psychosocial support) that help people deal with the
emotional repercussions as well as the practical considerations of living with a
disabling, potentially fatal disease.

Antiretroviral Drugs (ARVs)

- The primary goal of anti-retroviral therapy is to slow down disease
progression, thereby preventing opportunistic infections and an AIDS
diagnosis.
- It is through controlling the HIV multiplication in the body and subsequent
damage to the immune system that this is achieved.

The Limitations of antiretroviral drugs

ARVs have a number of limitations which include
i. Drug resistance.
Benefits are short-lived when a single drug is used alone.
This short-term effectiveness results when HIV mutates, or changes its genetic structure,
becoming resistant to the drug.
The genetic material in HIV provides instructions for the manufacture of critical enzymes
needed to replicate the virus. Scientists have designed current antiretroviral drugs to impede
the activity of these enzymes.
The structure of the virus’s enzymes changes if the virus mutates and the drugs no longer
work against the enzymes, making the drugs ineffective against viral infection and resistance
sets in. Since gene mutation occurs during the course of viral replication, the best way to
prevent mutation is to halt replication.
Studies have shown that the most effective treatment to halt HIV replication employs a
combination of three ARV drugs taken together
This regimen, called triple therapy (also known as Highly Active Antiretroviral Therapy-
(HAART), maximizes drug potency while reducing the chance for drug resistance.

ii. Side effects of ARVs.

Common side effects include nausea, diarrhoea, headache, fatigue, loss of appetite, skin
rushes, pancreatitis, fever, abdominal pain, kidney stones, anaemia, and tingling or numbness
in the hands and feet, Diabetes mellitus, and deposition of fat in the abdomen or back etc.

iii. High cost of treatment.

The greatest drawback to triple therapy is its high cost, which is well beyond the means of
people with low incomes or those with limited healthcare facilities. As a result, the most
effective therapies currently available remain beyond the reach of the majority of HIV-
infected people worldwide.

iv. Stigma.
Discrimination and stigma: The rights of people living with HIV often are violated because
of their presumed or known HIV status, causing them to suffer both the burden of the disease
and the consequential loss of other rights. Stigmatization and discrimination may obstruct
their access to treatment and may affect their employment, housing and other rights. This, in
turn, contributes to the vulnerability of others to infection, since HIV-related stigma and
discrimination discourages individuals infected with and affected by HIV from contacting
health and social services. The result is that those most needing information, education and
counselling will not benefit even where such services are available.

v. Non-adherence to recommended dose and treatment schedule.

Treatment of opportunistic infections

• Its very necessary to prevent infections before they begin to avoid burdening patient’s
already weakened immune system.
• An HIV-infected person must avoid as much as possible exposure to infectious agents that
produce opportunistic infections common in people with a weakened immune system.
• Doctors try to usually prescribe more than one drug to treat the infections.
• For example, for those who have a history of pneumocystic pneumonia and a CD4 cell
count of less than 200 cells per microliter, doctors may prescribe the antibiotics,
sulfamethoxazole and trimethoprim to prevent further bouts of pneumonia.

Support mechanisms
• There are many challenges faced by people living with HIV/AIDS, including choosing the
best course of treatment, paying for health care, and providing for the needs of children in the
family while ill.
• Other include emotional stress, social stigma, loneliness, anxiety, fear, anger, and other
emotions often require as much attention as the medical illnesses common to HIV infection.
• Counselling centres and churches should provide individual or group counselling to help
people with HIV infection or AIDS share their feelings, problems, and coping mechanisms
with others.

ART in special circumstances

- Occupational exposure
- Sexual assault
- Expectant mothers
- Unborn babies

LEGAL AND ETHICAL ASPECTS OF ART

• The broad ethical issues that arise in ART are:

- Availability
- Affordability
- Accessibility
• The best way to deal with scarcity of ART
- Principle of justice – effective socially available medical treatment should not
be denied because of inability to pay
- Greatest good to the greatest number. Interventions that save lives or reduce
suffering to the majority have stronger ethical claim than those benefit few
individuals.
• Legal and ethical questions arising includes:
- Do they need post exposure prophylaxis
- How does one deal with issues of consent and confidentiality of HIV results
- Do they need to know the HIV status of the patient and vice versa (disclosure)

Other ethical issues in HIV

• AUTONOMY
- respect for the individual and their ability to make decisions
about their own health and future.
• BENEFICIENCE
- actions are intended to benefit the patient or others;
• NON-MALFEASANCE
- actions intended not to harm or bring harm to the patient and
others; and
• JUSTICE
- being fair or just to the wider community in terms of the
consequences of an action.

Examples of HIV/AIDS that requires Ethical consideration

Misperception, stigma, & discrimination
• AIDS legal issues:
- Behaviors endangering public health (BEPH) often present
the most difficult ethical issues
- Mandatory testing for persons sentenced for drug and sex related
crimes
- Management of substantial exposures to health care and public
safety workers, rarely requiring mandatory testing of sources
• Strong Public Health help – to clarify the problem and provide ethical & moral assistance
– may be needed to help achieve HIV/STD control in some communities
• Many people with HIV will not disclose their HIV status to family and friends, let
alone employers.
• Some with HIV do not disclose to sex and needle sharing partners at risk (whose status is
HIV negative or unknown).

When may a provider disclose HIV status of a client

• Duty to protect both patient and others
• Duty to protect patient’s rights
• Duty to not bring harm to patient and others
• Duty to be fair and just to the wider community
When serious harm may occur to a third party, whether or not a criminal offense, e.g. threat
of serious harm to a named person
• When a doctor believes a patient to be the victim of abuse and the patient is unable to give
or withhold consent to disclose
• When, without disclosure, a doctor could not act in the overall best interests of a child or
young person who is his/her patient and incapable of consenting to disclosure
• When, without disclosure, the task of preventing or detecting a serious crime by the police
would be prejudiced or delayed.

General public health messages to patients

Disclose to partners (akin to informed consent)
• Disclosure protects you medically, legally and ethically
• Careless spread of HIV can lead to legal consequences,
including court-ordered confinement

Role of public health

Partner Notification
- Partner Counseling and Referral Services (PCRS) – current
terminology
- Contact Tracing
• Behaviors Endangering Public Health
- High proportion have co-morbidities (mental illness, substance abuse,
e.g.)
- Due process steps
• 1st – no anonymous reports; certainty of status & counseling
messages being delivered
• Order to cease & desist
• Potential court action a- detention (90 days max)
• Court actions beyond public health (based on
victim’s report)
 IMPACT OF HIV
HIV/AIDS and Human Capacity
▪ HIV/AIDS affects human capacity in different ways:
i) It robs sectors, enterprises and undertakings of qualified and experienced
personnel
ii) It creates the need for additional personnel (e.g. in nursing care)
iii) It creates the need for persons with new understandings and skills
iv) Because of the way it removes young and productive adults, it has negative
effects on the transfer of skills
▪ Education
a) Reduction in demand

- fewer children to educate

- fewer children wanting to be educated
- fewer children able to afford education
- fewer children able to complete their schooling
b) Reduction in supply
- The loss through mortality of trained teachers;
- The reduced productivity of sick teachers;
- The reduction in the system's ability to match supply with demand because of
the loss, through mortality or sickness, of education officers, inspectors,
finance officers, building officers, planning officers, management personnel;
- The closure of classes or schools because of population decline in catchment
areas and the consequent decline in enrolments.
c) Reduction in availability of resources

- Reduced public funds for the system, owing to the AIDS-related decline in
national income and pre-emptive allocations to health and AIDS-related
interventions;
- The funds that are tied down by salaries for sick but inactive teachers;
- Reduced community ability to contribute labour for school developments
because of AIDS-related debilitation and/or increasing claims on time and
work capacity because of loss of active community members.

d) HIV/AIDS affects the potential clientele for education because of

- The rapid growth in the number of orphans;
- The massive strain which the orphans phenomenon is placing on the extended
family and the public welfare services;
- The need for children who are heading households, orphans, the poor, girls,
and street children to undertake income-generating activities.
e) HIV/AIDS affects the process of education because of
- The new social interactions that arise from the presence of AIDS-affected
individuals in schools
- Community views of teachers as those who have brought the sickness into
their midst
- The erratic school attendance of pupils from AIDS-affected families
- The erratic teaching activities of teachers, who are personally infected, or
whose immediate families are infected, by the disease
- The increased risk that young girls experience of sexual harassment because
they are regarded as ‘safe’ and free from HIV infection.

f) HIV/AIDS affects the role of education because of

- New counselling roles that teachers and the system must adopt;
- The need for a new image of the school as a centre for the dissemination of
messages about HIV/AIDS to its own pupils and staff, to the entire education
community, and to the community it serves;
- The need for the school to be envisaged as a multi-purpose development and
welfare institution, delivering more than formal school education as
traditionally understood.
g) HIV/AIDS affects the organisation of schools because of the need to
- Adopt a flexible timetable or calendar that will be more responsive to the
income-generating burdens that many pupils must shoulder;
- Provide for schools that are closer to children's homes;
- Provide for orphans and children from infected families, for whom normal
school attendance is impossible, by bringing the school out to them instead of
requiring them to come in to some central location;
- Examine assumptions about schooling, such as the age at which children
should commence, the desirability of making boarding provision for girls, the
advisability of bringing together large numbers of young people in relatively
high-risk circumstances.

h) HIV/AIDS affects the planning and management of the education system because of
- the imperative of managing the system for the prevention of HIV
transmission;
- the loss through mortality and sickness of various education officials charged
with responsibility for planning, implementing, and managing policies,
programmes and projects;
- the need for all capacity-building and human resource planning to provide for
(a) potential personnel losses, (b) developing new approaches, knowledge,
skills and attitudes that will enable the system to cope with the epidemic's
 impacts and will monitor how it is doing so, and (c) establishing intra-sectoral
epidemic-related information systems;
- the need for more accountable and cost-effective financial management at all
levels in response to reduced national, community and private resources for
education;
- the need for sensitive care in dealing with personnel and the human rights
issues of AIDS-affected employees and their dependants.

i) The planning and management of the system, and

j) HIV/AIDS affects donor support for education because of
- Donors concern to promote capacity-building and develop a self-sustaining
system both of which are inhibited by the widespread incidence of HIV/AIDS;
- Donors' concern lest the effectiveness of their inputs be undermined by the
impacts of the epidemic;
- Donor uncertainty about supporting extended training abroad for persons from
heavily infected countries.

▪ Health sector
- Additional national resources absorbed by AIDS care and
responses, at the cost of important medical and other needs
- Medical, personnel, agency and NGO resources diverted to
AIDS issues
- Already limited and over-stretched public capacity is further
extended with AIDS concerns
▪ Family
- Enhancing gender inequities by affecting women and girls
more than men and boys
- Household resources consumed by medical costs, cleaning,
transport, funerals, mourning
- Limited resources spread more thinly over larger numbers
- amalgamated families
- orphan care
- increased dependency ratio
- Labour resources going to AIDS care and away from
productive work
- Impacts are almost always very severe emotionally—distress,
shock, anger, denial, grief, stigma, isolation
- The disease has severe implications for household well-being:
- Income reduction (job loss; reduced ability of infected person
to work and produce; time spent on patient care is time taken
from productive activities)
 - Increased health-related expenditures (medicines, special
foodstuffs, soap and cleaning materials, clinic-related use of
resources & time—patient transport, getting medicines)
- Some households disappear
- Impacts may be masked by complex extended family and other
relationships between households
- Ripple effects—more demands on other households, or less to
give to households that had previously been getting assistance
- Vulnerability of female-headed and child-headed households
▪ HIV/AIDS as a national disaster
- Reduce life expectancy,
▪ Economic sector
- Slows economic growth
- deepens poverty
- Costs of goods and services increase as enterprises raise costs
to offset those arising from HIV/AIDS:
- lower productivity
- smaller markets
- increased medical costs
- high funeral costs
- early payment of terminal benefits
- higher insurance cost

IN SUMMARY
▪ In all countries, HIV/AIDS is
- Reversing decades of health, economic and social progress
- Reducing life expectancy
- Slowing economic growth
- Deepening poverty
- Contributing to and exacerbating food shortages
- Creating a growing human capacity crisis
- Enhancing gender inequities by affecting women and girls
more than men and boys

MEASURES OF PREVENTION
i) A B &Correct and consistent use of male condoms Female condoms;
ii) Screening of blood before transfusion
iii) Post Exposure Prophylaxis;
iv) Needle exchange programs for drug users
v) Voluntary Counselling and Testing
vi) Post rape care
vii) Relation between HIV and drug abuse
 viii) Education
ix) Knowledge of status
x) Prevention and timely treatment of STIs
xi) Proper precautions in medical and other settings where contact with bodily fluids
likely (including IVDU)
xii) PMTCT through
– Primary prevention of HIV in women
– Prevention of unwanted pregnancy in HIV + women
– Provision of adequate antenatal care of positive women
– ART and ARV drugs for the PMTCT
xiii) PEP in sexual assault

Post Exposure prophylaxis (PEP)

- Is a short term ART (antiretroviral drug treatment) to reduce the likelihood of
HIV infection within 72 hours of exposure to facilitate interruption of HIV
transmission eg during rape
- It involves reaction with a combination of 3 ART drugs, which are taken for
28 days
- For health providers, PEP is given is given as part of a comprehensive
universal prevention package to infectious hazards at work.

Post rape care

General considerations

i) Introduce yourself to the survivor;

ii) Reassure the survivor that he/she is in a safe place now;
iii) Explain the steps of the procedures you are about to undertake;
iv) Obtain written informed consent.
v) Obtain medical history;
vi) Examine the survivor from head to toe;
vii) Take both medical and forensic specimens at the same time;
viii) Record the findings in the PRC form.
Medical management

Is aimed at managing any life threatening injuries and providing other post-rape services to
reduce the chances of the survivor contracting any sexually related infections including
pregnancy.
The management of any life threatening injuries, and extreme distress should take precedence
over all other aspects of post-rape care. Include:
a) Obtaining Consent
b) History Taking and Examination
c) Head to Toe Examination for Adults
d) The Genito-Anal Examination for Adults
e) Investigations to include:
 Urine
- Urinalysis – microscopy, Urine analysis for epithelial cells
- Pregnancy test
- High vaginal swab for evidence of spermatozoa
Blood
- HIV Test
- Haemoglobin level
- Liver Function Tests
- VDRL

Management of Physical Injuries

a) Post traumatic vaccination with tetanus toxoid

b) Clean abrasions and superficial lacerations
c) If stitching is required

Post Exposure Prophylaxis (PEP)

Is the administration of a combination of antiretroviral drugs (ARV’s) for 28 days after the
exposure to HIV that has to be started within 72 hours after the assault. The client is also
given:
- Prophylaxis of Sexually Transmitted Infections. STI
prophylaxis should be offered to all survivors of sexual
violence.
- Psycho-Social Support
- Filling of the Post Rape Care (PRC) Form
- The Kenya Police Medical Examination (P3) Form

Voluntary counseling and testing (VCT)

The VCT process consists of pre-test, post-test and follow-up counselling. HIV counselling
can be adapted to the needs of the clients and can be for individuals, couples, families and
children.

The content and approach vary considerably for men and women, and with various groups,
such as counselling for young people, men who have sex with men (MSM), injecting drug
users (IDUs) or sex workers.

The content and approaches may also reflect the context of the intervention, e.g. counselling
associated with specific interventions such as tuberculosis preventive therapy (TBPT) and
interventions to prevent mother-to-child transmission of HIV (MTCT).

Establishing good rapport and showing respect and understanding will make problem solving
easier in difficult circumstances. The manner in which news of HIV positive result is given is
very important in facilitating adjustment to news of HIV infection.
At a VCT setting;
- Is voluntary without coercion or persuasion for testing
- Ensure there is confidentiality with client only
- Health education- is given on facts about HIV, and risks for infection and
reinfection
- Counselling – assesses clients personal risk behaviour and exposure to HIV
infection and help him/her to explore ways on how to reduce it.
- Pre-test- dialog and explanation by a professional counsellor – explain, test
and implication of the results
- Post- test- explains test results and how to cope with implications, positive or
negative results.

Needle exchange programs for drug users

Syringe Services Program is a community-based public health program that provides comprehensive
harm reduction services such as;

• Sterile needles, syringes, and other injection equipment

• Safe disposal containers for needles and syringes
• HIV and hepatitis testing and linkage to treatment
• Education about overdose prevention and safer injection practices
• Referral to substance use disorder treatment, including medication-assisted treatment
• Referral to medical, mental health, and social services
• Tools to prevent HIV, STDs, and viral hepatitis including counselling, condoms, and
vaccinations
Screening of blood before transfusion

- All blood donated is screened for evidence of the presence of infection before
releasing it for clinical or manufacturing use.
- Screening of all blood donations is mandatory for the following infections;
HIV, Hepatitis B and C, Syphilis
- Screening is performed using highly sensitive and specific assays
- Quality-assured screening of all donations should be in place.
- Only blood and blood components from donations that are nonreactive in all
screening tests is released for clinical or manufacturing use.
- All screen reactive units are clearly marked, stored separately and securely
until they are disposed of safely or kept for quality assurance or research
purposes, in accordance with national policies.
- Confirmatory testing of screen reactive donations should be undertaken for
donor notification, counselling and referral for treatment, deferral or recall for
future donation, and look-back on previous donations.

RELATION BETWEEN HIV AND DRUG ABUSE

Drug abuse
A drug is any substance (other than food that provides nutritional support) that, when inhaled,
injected, smoked, consumed, absorbed through the skin, or dissolved under the tongue causes
a physiological (and often psychological) change in the body.
a) A drug is a chemical which is given to people in order to treat or
prevent an illness or disease.
b) Drugs are substances that some people take because of their pleasant
effects, but which are usually illegal.
c) A drug is any chemical substance which when taken into the body can
affect one or more of the body’s functions.
d) For instance, when one feels pain and is given aspirin, the pain
reduces or disappears. The aspirin modifies how the body works so
that the pain is not felt at all.
e) Similarly, when one smokes bhang, he experiences changes in the
mind for example he may see or hear things that are not there.
The term drug therefore, includes those substances useful to the body and those that harm the
body. They may be legal or illegal.
The use of narcotic drugs and other substances that harm or threaten the physical, mental,
social and economic well-being of the user, his or her family and society at large is referred
to as drug abuse or substance abuse.

Drug and substance abuse is one of the major challenge facing Kenya today and has
implications on political, economic, and social stability of the country.
Drugs and substance abuse has also brought about social economic hardships contributing
misery which has increased crime, violence and a drain on human material resources.
Drug and substance abuse is a silent disaster that claims many lives every year in Kenya.
There is also a strong link between drug abuse and HIV/AIDS

Modes of drug administration

• Administered orally - through the mouth
• Administered by injection
• Through inhalation
• Applied directly to the skin
• Inserted in the rectum

Some of the reasons for using drugs include

• Pain relief and treatment
• Control emotion
• Relaxation
• Tension relief
• Boredom relief
• Increase sexual performance
• As sedative to induce sleep

DRUG ABUSE IS CHARACTERIZED BY

• Taking more than the recommended dose of prescription drugs such as anti- depressants
without medical supervision, or using government-controlled substances such as marijuana,
cocaine, heroin, or other illegal substances.
• Abusing Legal substances, such as alcohol and nicotine
Abuse of drugs and other substances can lead to physical and psychological dependence

Intoxication & drunkenness

• Eg when one takes Alcohol, the Alcohol goes directly from the digestive system into the
blood and within minutes it spreads to the entire body, including the brain.
• The brain gets the highest concentration because it gets more blood than any other part of
the body.
• The more the blood the more the alcohol
• Intoxication & drunkenness starts in the brain

Drugs commonly abused in kenya

- Tobacco
- Alcohol
- Cocaine
- Marijuana
- Bhang
 - Heroin etc

General Symptoms of Drug Abuse

- Isolating from family and friends who don’t use drugs
- Spending time with new friends or friends who get high or
drink
- Never having money or often asking to borrow money, even for
small items
- Showing up late to work/school or not showing up at all
- Losing a job
- Doing little to find a job if out of work
- Paying less attention to basic hygiene
- Changes in sleeping habits
- Extremely private about possessions, including their bag, room,
or car
- Lying about using or drinking
- Sneaking away to get high or drunk

Relationship between drug use and HIV/AIDS

a) Shared needles/syringes for use in drug application can carry HIV and hepatitis
viruses. Infected blood drawn into the needle is injected along with the drug by the
next user
b) Drug use is linked with unsafe sexual activity
c) A lot of people believe that sex and drugs should go together. Drug users might trade
sex for drugs
d) Others claim that sexual activity is more enjoyable when they are using drug
e) Drug use including alcohol increases the chance of not using protection during sex,
leading to acquiring/transmitting HIV/AIDS
f) A lot of drugs interfere with the proper functioning of the antiretroviral drugs
g) One who is a drug addict might forget to take his ARV therapy leading to a delay in
treatment and increment of viral load
h) There may be also an overdose which can be disastrous

The role of alcohol in the spread of HIV/AIDS

a) People with alcohol use disorders are more likely to contract HIV than the general
populations as they are more likely to engage in behaviour that place them at risk of
contracting HIV.
b) Similarly people with HIV are more likely to abuse alcohol in their life time. In
persons already infected, the combination of heavy drinking and HIV has been
associated with increased medical and psychiatric complications, delay in seeking
treatment and poor HIV treatment outcome.
c) Heavy alcohol use has been correlated with a high risk sexual behaviour including
- Multiple sex partners
- Unprotected sexual intercourse
- Sex with high risk partners