JOMO KENYATTA UNIVERSITY

OF
AGRICULTURE & TECHNOLOGY

SCHOOL OF OPEN, DISTANCE AND

eLEARNING

IN COLLABORATION WITH
FACULTY OF SCIENCE

DEPARTMENT OF ZOOLOGY

P.O. Box 62000, 00200

Nairobi, Kenya

SZL 2111 HIV/AIDs

LAST REVISION ON April 17, 2013

K. O. OGILA

(kogila@jkuat.ac.ke)
 JOMO KENYATTA UNIVERSITY
OF
AGRICULTURE & TECHNOLOGY

SCHOOL OF OPEN, DISTANCE AND eLEARNING

P.O. Box 62000, 00200

Nairobi, Kenya

E-mail: elearning@jkuat.ac.ke

SZL 2111: HIV/AIDs

LAST REVISION ON April 17, 2013

SZL2111 HIV/AIDs

This presentation is intended to covered within one week. The notes,

examples and exercises should be supplemented with a good textbook.

Most of the exercises have solutions/answers appearing elsewhere and

accessible by clicking the green Exercise tag. To move back to the same

page click the same tag appearing at the end of the solution/answer.

Errors and omissions in these notes are entirely the responsibility of

the author who should only be contacted through the Department

of Curricula & Delivery (SODeL) and suggested corrections may
be e-mailed to elearning@jkuat.ac.ke.

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SZL2111 HIV/AIDs

SZL 2111: HIV/AIDs

Course description
General introduction: Public health and hygiene, human reproductive system,

sex and sexuality. History of sexually transmitted diseases (STDs); History

of Human Immunodeciency virus/ Acquired Immune deciency Syndrome

(HIV/AIDS), Comparative information on trends, global and local distribu-

tion, Justication of importance of course. Biology of HIV/AIDS; Overview

of immune system, natural immunity to HIV/AIDS. The AIDS virus and its

life cycle, disease progression, transmission and diagnosis. Discordant cou-

ples. Treatment and Management; nutrition, prevention and control; Abstain,

Be faithful, Condom use, Destigmatize HIV/AIDS (ABCD) methods and an-

tiretroviral drugs and vaccines. Pregnancy and AIDS. Management of HIV/

AIDS patients. Social and cultural practices: Religion and AIDS. Social stigma

on HIV/AIDS. Behavioral change. Voluntary Counseling and Testing Services.

Gender and HIV/AIDS. Drug and alcohol abuse and HIV/AIDS. Poverty and

AIDS. Families and AIDS orphans. Government policies: Global policies of

AIDS. Legal rights of AIDS patients. AIDS Impact: Family /society setup,

population, agriculture, education, health, industry, development, economy

and other sectors.

Prerequisite: none

Course aims
1. To bring about behavioral change

2. To prevent HIV/AIDS and reduce the threat it poses to youth/students

3. To promote HIV/AIDS education as a means of producing better and

more integrated sense of health education in the student

Learning outcomes
Upon completion of this course you should be able to know;

1. Biology of HIV

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SZL2111 HIV/AIDs

2. Transmission of HIV

3. Disease progression and symptoms

4. Treatment of HIV/AIDs Various strategies of managing of HIV/AIDs

5. How to prevent and control of HIV/AIDs

6. Social and cultural practices that contribute to spread of HIV/AIDs

7. Policies and rights of people living with HIV/AIDs

8. Implications of HIV/AIDs on various sectors

Instruction methodology
ˆ Lectures: oral presentation generally incorporating additional activities

e.g writing on chalk board, exercises, class questions and discussions or

student presentation.

ˆ Tutorials to give the students more attention.

ˆ Assignments and Demonstrations.

Assessment information
The module will be assessed as follows;

ˆ 10% of marks from two (2) assignments to be submitted online

ˆ 20% of marks from two written CAT to be administered at JKUAT main

campus or one of the approved centres

ˆ 70% of marks from written Examination to be administered at JKUAT

main campus or one of the approved centres

v
Contents
1 General introduction 2
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.2 Justication of the course . . . . . . . . . . . . . . . . . . . . 3

1.2.1 Reasons for HIV/AIDS education/ why train in HIV/AIDS

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.3 Denition of Terminologies . . . . . . . . . . . . . . . . . . . . 5

1.4 Public Health and Hygiene . . . . . . . . . . . . . . . . . . . . 7

1.4.1 Public health programs may include: . . . . . . . . . . 7

ˆ Vaccination . . . . . . . . . . . . . . . . . . . 7

ˆ Rural and Urban Health Clinics . . . . . . . 8

ˆ Disease Tracking and Epidemiology . . . . . 8

ˆ Sanitation and Pollution Control . . . . . . . 8

ˆ Medical Research . . . . . . . . . . . . . . . 8

ˆ Public Education Campaigns . . . . . . . . . 9

1.5 Types of HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.6 Origin, Theories and History of HIV/AIDS . . . . . . . . . . 11

1.6.1 Mysterious origins . . . . . . . . . . . . . . . . . . . . 12

1.6.2 Religious Theories (God's wrath and witch craft) . . . 12

1.6.3 Monkey origin theories . . . . . . . . . . . . . . . . . . 13

ˆ Hunter theory . . . . . . . . . . . . . . . . . 13

ˆ Oral Polio Vaccine (OPV) theory . . . . . . 13

ˆ The contaminated needle vaccine . . . . . . . 14

ˆ The colonialism theory . . . . . . . . . . . . 15

1.6.4 The conspiracy theory . . . . . . . . . . . . . . . . . . 15

1.6.5 The calculated theory . . . . . . . . . . . . . . . . . . 15

2 Sex education and Human sexuality 19

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2.1 What is sex education? . . . . . . . . . . . . . . . . . . . . . . 20

2.1.1 Aims of sex education . . . . . . . . . . . . . . . . . . 20

2.1.2 Myths surrounding sexuality . . . . . . . . . . . . . . 20

2.2 Sexually Transmitted Diseases . . . . . . . . . . . . . . . . . . 20

2.2.1 How do you know that you have an STD? . . . . . . . 21

2.2.2 How STDs are transmitted . . . . . . . . . . . . . . . . 21

ˆ Factors that enhance chances of getting infected

with STD . . . . . . . . . . . . . . . . . . . . 22

2.2.3 Prevention and Control of STIs . . . . . . . . . . . . . 23

ˆ Importance of early diagnosis and treatment . 23

2.2.4 Basic information on some common STDs . . . . . . . 23

2.2.5 Relationship between HIV and Sexually transmitted in-

fections . . . . . . . . . . . . . . . . . . . . . . . . . . 28

3 The Immune system 32

3.1 Overview of the Immune System . . . . . . . . . . . . . . . . 33

3.1.1 The bone marrow . . . . . . . . . . . . . . . . . . . . 33

3.1.2 Types of Immunity . . . . . . . . . . . . . . . . . . . . 33

ˆ Innate/ Inborn/Natural/Non-specic immunity;

. . . . . . . . . . . . . . . . . . . . . . . . . 33

ˆ Acquired/ Adaptive / Specic Immunity . . 34

ˆ Cells of the Immune System . . . . . . . . . . 35

3.1.3 Stages in an immune response . . . . . . . . . . . . . . 38

ˆ Recognition stage . . . . . . . . . . . . . . . . 38

ˆ Proliferation stage . . . . . . . . . . . . . . . 39

ˆ Response stage . . . . . . . . . . . . . . . . . 40

ˆ Eector stage . . . . . . . . . . . . . . . . . . 40

3.1.4 Role of antibodies in Humoral Immune Responses . . . 41

3.1.5 Types of Immunoglobulins . . . . . . . . . . . . . . . . 42

3.1.6 Cellular (or cell mediated) immune response . . . . . . 42

ˆ Role of T lymphocytes . . . . . . . . . . . . . 43

ˆ Roles of null lymphocytes and natural killer

cells in cellular immune responses . . . . . . . 44

3.1.7 Complement System . . . . . . . . . . . . . . . . . . . 45

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3.2 Immunodeciency . . . . . . . . . . . . . . . . . . . . . . . . 45

3.2.1 Autoimmune disorders . . . . . . . . . . . . . . . . . . 47

3.2.2 Neoplastic disease . . . . . . . . . . . . . . . . . . . . 48

3.2.3 Chronic illness and surgery . . . . . . . . . . . . . . . 48

3.2.4 Special problems . . . . . . . . . . . . . . . . . . . . . 49

3.2.5 Role of immune system in HIV pathogenesis . . . . . . 49

4 Biology of HIV 53
4.1 Nature of HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

4.2 The Structure of HIV . . . . . . . . . . . . . . . . . . . . . . . 54

4.3 The Life Cycle of HIV/ HIV Replication . . . . . . . . . . . . 56

5 Disease progression and symptoms 60

5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

5.1.1 Exposure vs. Infection . . . . . . . . . . . . . . . . . . 61

5.1.2 Infection vs. Disease . . . . . . . . . . . . . . . . . . . 61

5.2 Stages of HIV Infection . . . . . . . . . . . . . . . . . . . . . 62

5.2.1 Primary HIV infection . . . . . . . . . . . . . . . . . . 62

5.2.2 Clinical asymptomatic HIV infection/ Latent phase . . 62

ˆ Initial Infection Symptoms include: . . . . . 63

5.2.3 Symptomatic HIV infection/AIDS Related Complex (ARC)

phase . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

5.2.4 Progression of HIV to AIDS . . . . . . . . . . . . . . . 64

5.2.5 Other Complications in HIV Patients . . . . . . . . . 65

5.2.6 Factors that lead to faster development of HIV infection

to full- blown AIDs . . . . . . . . . . . . . . . . . . . . 66

5.3 Opportunistic Infections . . . . . . . . . . . . . . . . . . . . . 67

6 Transmission and diagnosis of HIV 72

6.1 Transmission of HIV . . . . . . . . . . . . . . . . . . . . . . . 73

6.1.1 Modes of HIV Transmission . . . . . . . . . . . . . . . 73

6.1.2 Factors that increase chances of MTCT/ Determinants 75

6.1.3 Prevention of MTCT (PMTCT) . . . . . . . . . . . . 76

6.2 Diagnosis of HIV and AIDs . . . . . . . . . . . . . . . . . . . 77

6.2.1 The Enzyme-Linked Immunosorbent Assay (ELISA) . 77

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SZL2111 HIV/AIDs

6.2.2 The Western blot assay . . . . . . . . . . . . . . . . . 77

6.2.3 PCR . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

6.2.4 CD4+Cell count . . . . . . . . . . . . . . . . . . . . . 77

6.2.5 Measuring viral load . . . . . . . . . . . . . . . . . . . 78

6.3 STIs, STDs, FGM and HIV/AIDS . . . . . . . . . . . . . . . 79

6.3.1 Common examples of STIs/ STDs . . . . . . . . . . . 79

6.3.2 Relationship between HIV & STDs/STIs . . . . . . . 79

6.3.3 Dangers/ risks of STDs/STIs . . . . . . . . . . . . . . 80

6.3.4 Why teenagers don't seek treatment . . . . . . . . . . 80

6.3.5 FGM (Female Genital Mutilation) . . . . . . . . . . . 81

ˆ Types of FGM . . . . . . . . . . . . . . . . . 81

ˆ Eects of FGM leads to conditions that favours

HIV survival . . . . . . . . . . . . . . . . . . 81

7 Prevention and treatment of Hiv/Aids 84

7.1 Prevention and control of mother to child transmission . . . . 85

7.2 Prevention and control of transmission through blood and other

blood products . . . . . . . . . . . . . . . . . . . . . . . . . . 85

7.3 HIV Post exposure prevention . . . . . . . . . . . . . . . . . 86

7.3.1 Ways in which HIV cannot be transmitted . . . . . . . 86

7.4 Treatment of HIV . . . . . . . . . . . . . . . . . . . . . . . . . 86

7.4.1 Nucleoside analogues reverse transcriptase inhibitors . 87

7.4.2 Non-nucleoside reverse transcriptase inhibitors (NNRTIs) 87

7.4.3 Protease inhibitors . . . . . . . . . . . . . . . . . . . . 87

7.4.4 Entry inhibitors . . . . . . . . . . . . . . . . . . . . . . 87

7.4.5 Limitations of antiretroviral therapies . . . . . . . . . 88

ˆ Drug resistance . . . . . . . . . . . . . . . . 88

ˆ Drug side eects . . . . . . . . . . . . . . . . 89

ˆ Cost of treatment . . . . . . . . . . . . . . . . 89

7.4.6 Development of new HIV drugs and vaccine . . . . . . 89

7.4.7 Challenges in Developing AIDS Vaccines . . . . . . . . 90

7.4.8 Treatment of opportunistic infections . . . . . . . . . . 91

ˆ Support mechanisms . . . . . . . . . . . . . . 91

7.4.9 Steps involved in HIV testing in VCT . . . . . . . . . . 93

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ˆ Pretest counseling . . . . . . . . . . . . . . . 93

ˆ Advantages of testing . . . . . . . . . . . . . 93

ˆ Disadvantages . . . . . . . . . . . . . . . . . . 94

ˆ Post test counseling . . . . . . . . . . . . . . 94

ˆ Role of VCT centers . . . . . . . . . . . . . . 95

ˆ General reactions to testing HIV positive . . 95

8 Concept of positive living 100

8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

8.2 Home Based Care . . . . . . . . . . . . . . . . . . . . . . . . . 103

8.2.1 Rationale for Home Based care . . . . . . . . . . . . . 104

8.2.2 Advantages of organized home based care . . . . . . . 104

8.2.3 Components of home based care . . . . . . . . . . . . 105

8.2.4 Aspects of nutrition in comprehensive care of HIV/AIDS

patients . . . . . . . . . . . . . . . . . . . . . . . . . . 105

ˆ Advantages of good nutrition to PLWA . . . . 106

ˆ Principles of nutrition support for PLWA . . . 107

8.3 Management of pregnancy in HIV/AIDS . . . . . . . . . . . . 108

8.3.1 Reducing the risk of transmission during pregnancy . . 108

ˆ Conception . . . . . . . . . . . . . . . . . . . 109

ˆ The pregnancy . . . . . . . . . . . . . . . . . 109

ˆ Delivery . . . . . . . . . . . . . . . . . . . . . 110

ˆ Breastfeeding . . . . . . . . . . . . . . . . . . 110

ˆ Testing babies for HIV . . . . . . . . . . . . . 110

9 Behavioral patterns and the spread of Hiv /Aids 113

9.1 Individual Behavioral Patterns and the spread of HIV /AIDS 114

9.1.1 Behaviour change could play a greater role in reducing

HIV infection . . . . . . . . . . . . . . . . . . . . . . . 115

9.1.2 Safe sex and safer behaviors . . . . . . . . . . . . . . . 115

9.2 Role of Gender in HIV/AIDS Transmission . . . . . . . . . . . 116

9.2.1 Cultural, social, biological and economic pressures make

women more vulnerable HIV that men. . . . . . . . . . 116

9.2.2 Remedy to above problem . . . . . . . . . . . . . . . . 117

9.3 Drug/Alcohol Use and Abuse and the Spread of HIV/AIDS . 118

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9.3.1 Relationship between drug use and HIV . . . . . . . . 120

10 Implications of Hiv/Aids And International Responses to

the Hiv/Aids Pandemic 123
10.1 To the individual . . . . . . . . . . . . . . . . . . . . . . . . . 124

10.2 To the family . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

10.3 To the community . . . . . . . . . . . . . . . . . . . . . . . . 125

10.3.1 How to solve negative eects . . . . . . . . . . . . . . . 126

10.4 Multi - Sectoral Impacts of HIV/AIDS . . . . . . . . . . . . . 126

10.4.1 Impact on Industry and business sector . . . . . . . . . 126

10.4.2 Impact on agriculture . . . . . . . . . . . . . . . . . . . 126

10.4.3 Impact on education . . . . . . . . . . . . . . . . . . . 127

10.4.4 Impact on health sector . . . . . . . . . . . . . . . . . 128

10.4.5 Impact on economic growth . . . . . . . . . . . . . . . 128

10.5 Responses of African Governments to HIV - AIDS epidemic . 129

10.5.1 Formation of institution to coordinate and ght HIV

pandemic . . . . . . . . . . . . . . . . . . . . . . . . . 129

10.5.2 Declaring HIV a national disaster . . . . . . . . . . . 129

10.5.3 Some of the strategies adopted by the Kenyan govern-

ment to ght the spread of HIV/AIDS . . . . . . . . . 129

Solutions to Exercises . . . . . . . . . . . . . . . . . . . . . . . 136

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SZL2111 HIV/AIDs

LESSON 1
General introduction
Learning outcomes
Upon completing this topic, a student should be able to:

ˆ Dene of terms related to HIV/AIDS

ˆ Understand the meaning of public health and its role in disease infection

ˆ Understand origins, theories and history of HIV/AIDS

ˆ Know various types of HIV

ˆ Global distribution and trends of HIV/AIDS

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1.1. Introduction
HIV/AIDS is the worst pandemic the world has experienced in the last half

of the 20th century. It has decimated whole population of people in certain

region. If one becomes infected with HIV, the virus begins to attach the

immune system. A person infected with HIV can look and feel perfectly well

for many years and may not even know they are infected. Over a period of

time, it is highly likely that HIV will damage the immune system and when this

happens, one become vulnerable to illness often referred to as opportunistic

infections that a healthy immune system would usually be able to ght o,

and this leads to a condition known as AIDS - Acquired Immunodeciency

Syndrome. AIDS is a collection of infections (usually severe) and cancers that

may develop in people who are HIV positive. A person is said to have AIDS

when they have developed one of these specic illness, this is usually after a

signicant period of time often many years. Some people will receive an AIDS

diagnosis when their T-cell count drops below 200 copies per cubic ml of blood.

The eects that HIV infection may have on an individual vary dramatically.

At one end of the spectrum a person may remain very well with virtually no ill

eects. At the other end of the spectrum a person may have an AIDS diagnosis

and develop a life threatening opportunistic infection. Currently there is no

cure or vaccine for HIV/AIDS. Once a person contracts HIV, they will remain

infected with the virus for life and are able to transmit the virus to others.

1.2. Justication of the course

Education is an important component of preventing the spread of HIV. Aims

of HIV/AIDS training,

ˆ To prevent new infections from taking place. i.e.

 By giving people information about HIV - what HIV and AIDS are,

how they are transmitted, and how people can protect themselves

from infection.

 Teaching people how to put this information to use and act on it

practically for e.g. how to get and use condoms, how to suggest and

practice safer sex, how to prevent infection in a medical environment

or when injecting drugs.

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ˆ To improve quality of life for HIV positive people i.e. by -

 Enabling and empowering them to improve their quality of life.

 To be able to access medical services and drug provision

 To be able to nd appropriate emotional and practical support and

help

 Teaching them about the importance of not passing on the virus

ˆ To reduce stigma and discrimination. - Discrimination against positive

people can help the AIDS epidemic to spread

ˆ To help people focus upon the person than the disease and be more

caring to the person.

ˆ To provide knowledge on modes of transmission especially to those af-

fected and how to cope with the infected.

ˆ To initiate and sustain behavior changes necessary to reduce the rate of

developing infections through safer sex practices.

1.2.1. Reasons for HIV/AIDS education/ why train in HIV/AIDS

ˆ HIV infection is lifelong and there is no cure

ˆ HIV is infectious, and those infected will remain infectious throughout

their lives.

ˆ Fear arises from uncertainty of unpredictable medical conditions and

reactions of people especially of those close to them.

ˆ Information and knowledge is incomplete about HIV care and prevention

and at times even conicting.

ˆ The infected and aected are likely to have abroad of physical, psycho-

logical and social needs which may need adjustments e.g. nances.

ˆ Good management can contain some of these problems, early identica-

tion and intervention.

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SZL2111 HIV/AIDs

ˆ It provides knowledge needed to initiate and sustain change in risky

behavior.

ˆ It helps the infected nd a new or perhaps dierent approach to using

safer sex and responsible social relationships.

ˆ It helps those who are infected to leave with the infection.

1.3. Denition of Terminologies

Any specialized eld of study has some terms (jargons) that only professional

in that eld comprehend clearly their meaning with reference to the subject.

HIV/AIDS education is a subject that has borrowed heavily from medical

sciences and therefore learners need to familiarize themselves with some terms

that are commonly used in the subject

1. Rate - This is the amount of something in relation to something else

shown as a proportion or percentage. Often it reects the idea of specic

time. For example, imagine that 10,000 cases of AIDS have been reported

to the ministry of health over the past ten years. You could tell someone

this information alone, or you could say that the country only has a

population of 100,000 people, and the rate of AIDS is 0.1, or 10% (10,000

cases divided by 100,000 people).

2. Incidence-This is how often new cases of a disease appear in a population

during a set period of time, usually one year. For example, if you wanted

to know the incidence of HIV in a village, you could test all the people in

the village and record that information as your baseline. Then test all of

the same people one year later. Count the number of people who did not

have HIV during the rst test but did have the virus during the second

test. Divide this number by the total number of uninfected people in the

village. The result is the incidence of HIV in this village (the number of

new infections per person per year).

3. Prevalence - This is the proportion of people who have a disease in a

community at any one point in time. In the example above, the preva-

lence of HIV would be 10% the rst year (100 cases among 1,000 people

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SZL2111 HIV/AIDs

living in the village) and 15% the second year (150 cases among 1,000

people living in the village).

4. Bias-This occurs when an unexpected factor aects the results of a study.

For example, imagine you want to nd out how many pregnant women

in your town have HIV. You test all the pregnant women who come to

your medical clinic over a three-month period. Since people with HIV

are more likely to be sick and come to the clinic, and you tested all

pregnant women who came to the clinic, you will nd more women with

HIV than if you tested every pregnant woman in the town. Testing only

sick pregnant women inuenced your results. Your study was aected

by bias. Bias can happen even when you are trying to avoid it. If you

ask questions with a tone that tells people that you want them to answer

in a certain way, you can bias your results. For example, if you want

to know how many people inject drugs but ask, "You do not use those

illegal, deadly drugs do you?" then fewer people will answer yes than

really do use drugs. Your results will be biased.

5. Endemic- This term describes characteristic of a particular place or

among a particular group or area of interest or activity. From disease

point of view, the term is used to describe a disease occurring within a

specic area, region, or locale e.g. Malaria is endemic in a lot of Africa

countries. The term can also be used to describe a species of organ-

ism that is conned to a particular geographical region, for example, an

island or river basin.

6. Epidemic  This is an outbreak of a disease that spreads more quickly

and more extensively among a group of people than would normally be

expected. Among the diseases that have occurred in epidemic propor-

tions throughout history are bubonic plague, inuenza, smallpox, ty-

phoid fever, tuberculosis, cholera, bacterial meningitis, and diphtheria.

Occasionally, childhood diseases such as mumps and German measles

become epidemics.

7. Epidemiology-This is the study of the incidence and distribution of dis-

eases in large populations, and the conditions inuencing the spread

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SZL2111 HIV/AIDs

and severity of disease. For example in the study of the acquired im-

munodeciency syndrome (AIDS) epidemic in the early 1980s, both the

National Cancer Institute (U.S.) and the Pasteur Institute (France) re-

ported discovering that a retrovirus which came to be known as the

human immunodeciency virus (HIV) was the main cause of the disease.

8. Pandemic  a widespread epidemic that aects people in many dierent

countries, across several continents e.g. HIV/AIDS

1.4. Public Health and Hygiene

Public Health is the protection and improvement of the health of entire popu-

lations through community wide action, primarily by governmental agencies.

Most people think of public health workers as physicians and nurses, but a

wide variety of other professionals work in public health, including veterinar-

ians, sanitary engineers, microbiologists, laboratory technicians, statisticians,

economists, administrators, attorneys, industrial safety and hygiene special-

ists, psychologists, sociologists, and educators. Public health workers engage

in activities outside the scope of ordinary medical practice and these include

inspecting and licensing restaurants; conducting rodent and insect control pro-

grams; and checking the safety of housing, water, and food supplies etc. Hy-

giene is the science dealing with the preservation of health or the practice or

principles of cleanliness. In the public domain, Public health ocers mainly

manage this practice.

1.4.1. Public health programs may include:

• Vaccination
This is the process of making the body resistant to a specic disease by using

a vaccine (a chemical that stimulates the body to create antibodies to ght

a specic infectious organism). Vaccination programs protect people against

disease such as measles, mumps, diphtheria, and other childhood infectious

diseases. When small outbreaks of infectious disease threaten to grow into

epidemics, public health ocials may initiate new vaccination programs.

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SZL2111 HIV/AIDs

• Rural and Urban Health Clinics

Public health agencies operate local clinics that provide free or reduced-cost

medical services to individuals, especially infants and children, pregnant and

nursing women, people with drug abuse problems, physical disabilities, and

other conditions. Public health clinics routinely screen patients for a number

of infectious diseases and may provide free treatment if patients test positive.

Each clinic tracks the incidence of certain communicable diseases in its area,

and reports this information to national and international public health oces.

• Disease Tracking and Epidemiology

Threats to public health concerns change over time and epidemiologists and

other ocials continuously evaluate epidemiological trends to determine how

best to meet future public health needs. Epidemiologists and other public

health ocials attempt to break the chain of disease transmission by notifying

people who may be at risk for contracting an infectious disease. Public health

ocials may also ensure that infected people complete treatment programs,

so that the diseases are completely eliminated and the patients are no longer

carriers of the infection.

• Sanitation and Pollution Control

Disease-causing organisms are often transmitted through contaminated drink-

ing water. The single most eective way to limit water-borne diseases is to

ensure that drinking water is clean and not contaminated by sewage. Public

health ocials establish sewage disposal and solid waste disposal systems, and

regularly test water supplies to ensure they are safe. Public health programs

establish and enforce laws for safe food storage and preparation;food-safety

guidelines established by public health ocials.

• Medical Research
Another component of public health is scientic and medical research. Cadres

of doctors and scientists work in laboratories to establish new ways to prevent,

diagnose, treat, and cure disease and disability. Scientists and doctors em-

ployed by the government conduct some biomedical research in public health

facilities to nd better ways to protect human health.

8
SZL2111 HIV/AIDs

• Public Education Campaigns

Many diseases are preventable through healthy living, and a primary public

health goal is to educate the general public about how to prevent non-infectious

diseases. Health promotion also encourages people to take advantage of early

diagnostic tests that can make the outcome of disease more favourable e.g.

early detection of breast cancer, for instance, increasing the chances of a cure.

Detection and proper treatment of high blood pressure reduces the risk of a

stroke, the leading cause of permanent disability in older people.

1.5. Types of HIV

There are 2 main types of HIV:- HIV-1 &HIV-2. Both types are transmitted

by sexual contact, through blood & from mother-to-child. They both appear

to cause clinically indistinguishable AIDS. HIV-2 is less easily transmitted &

the period between initial infection & illness is longer. Its uncommon and

concentrated in West Africa countries, for example, Senegal, Ghana, Mali,

Burkina Faso, Ivory Coast. Most HIV-2 reported in Brazil, Angola, Mozam-

bique and Portugal can be traced back to West African contact. HIV-1 is the

predominant virus world wide & generally when people refer to HIV without

specifying the type they refer to HIV-1.

Example . HIV-1 subtypes

Group M (major)

Group N (new)

Group O (outlier)

The 3 groups may represent separate introduction of Simian Immunode-

ciency Virus (SIV) into humans

ˆ Group O appears to be restricted to West-central Africa

ˆ Group N was discovered in 1998 in Cameroon & is extremely rare.

ˆ More than 90% of HIV-1 infections belong to group M

ˆ There are at least 9 subtypes within group M. They include A, B, C, D,

F, G, H, J, and K.

9
SZL2111 HIV/AIDs

 HIV1A  found across west east axis from Ivory Coast to Djibouti

via Kenya

 HIV1B  found in Thailand, Europe and S.America

 HIV1C  found in East Africa, Botswana and South Africa and is

the commonest subtype globally accounting for 50%

 HIV1D  found in Congo, Kenya, Rwanda, Burundi, Tanzania and

Uganda

 HIV1E  found in Thailand, Cameroon, Central African Republic

and Congo

 HIV1F  found in Cameroon and Congo

 HIV1G  found in Congo and Gabon

 HIV1H, J, K  are rear but found in African continent.

ˆ In Kenya we have subtypes A, C, and D and this makes our country to

be ranked amongst the leading countries with the highest HIV infections.

CRFs-circulating recombinant forms - Occasionally two viruses of dier-

ent subtypes can meet in the cell of an infected person and mix together its

genetic material to create a new hybrid virus in a process similar to sexual re-

production and sometime called viral sex. Many of these strains don't survive

for long but those that infect more than one person are known as CRFs. E.g.

CRF A/B is a mixture of subtype A&B.

10
SZL2111 HIV/AIDs

1.6. Origin, Theories and History of HIV/AIDS

The origin of AIDS and HIV has puzzled scientists ever since the illness rst

came to light in the early 1980s. For over twenty years it has been the subject

of debate and the cause of countless arguments, with everything from a promis-

cuous ight attendant to a suspect vaccine program being blamed. The rst

recognized cases of AIDS occurred in the USA in the early 1980s In 1981. The

virus was discovered among homosexuals in the USA. A number of gay men in

New York and San Francisco suddenly began to develop rare opportunistic in-

fections and cancers that seemed stubbornly resistant to any treatment. They

presented with a syndrome which included mouth rash, skin problems e.t.c. At

this time, AIDS did not yet have a name, but it quickly became obvious that

all the men were suering from a common syndrome. Their bodies' immunity

was weakened and completely suppressed. Medics wrote their investigations

in a journal.

In 1983, it was discovered that the symptoms that were earlier observed

were caused by a certain virus called immunodeciency virus and it was sup-

pressing the immune system. In 1986, it became clear that the virus discovered

in 1981 was spreading fast and many people suered from the same condition.

In 1986, in West Africa, another virus was discovered & they called it immun-

odeciency virus type2. The discovery of HIV, the Virus that causes AIDS

was made soon after. In Kenya, the 1st case was noted in 1983 in KNH &

it was noted that the body of the patient had low immunity. From 1981 to

date the disease has claimed 22m lives & is still spreading. There is now clear

evidence to prove that HIV does cause AIDS. So, in order to nd the source

of AIDS, it is necessary to look for the origin of HIV, and nd out how, when

and where HIV rst began to cause disease in humans.

When and where the HIV virus rst emerged is probably going to remain a

mystery for many years to come. While several theories have been put forward,

there is no conclusive single agreement on the origin of HIV/AIDS. Some of

the mostly acknowledged theories about the origin of HIV include:

ˆ Mysterious origins .

ˆ The tail of the comet theory

ˆ Religious theories (God's wrath and witch craft)

11
SZL2111 HIV/AIDs

ˆ Monkey origin theories

ˆ Conspiracy theories

ˆ The calculation theory

1.6.1. Mysterious origins

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 de-

posited, subsequently infecting nearby people. Although famous astronomer's

names have been linked to this theory in the popular press, these scientists

deny the possibility of this extraterrestrial phenomena and any personal con-

nection to the theory.

1.6.2. Religious Theories (God's wrath and witch craft)

Certain segments of the population have openly stated that their belief that

AIDS is God's wrath since the Scriptures condemn the homosexual practice in

which AIDS was rst observed in the Western world. If one adds to this belief

the mysterious origin of the virus, and the apparently hopeless prospects for

a cure, it will readily be understood how many have come to believe in Divine

intervention, with AIDS being God's way of destroying sinners. If this were

so, it would be dicult to see why God, after watching over thousands of

years of vastly diering "sins', should suddenly decide to settle His score with

homosexuals and drug addicts rather than any other 'sinners'. The Bible

clearly speaks of a future (and imminent) judgment time when all sinners -

no matter what their specic practice will have to pay the penalty for their

sins. It does not tell, however, of a God who prejudges particular situations

and who picks out special groups for early condemnation. Clearly, there are

God-given laws which govern the harmonious interaction of body, mind and

spirit. The origin of HIV/A1DS may be traced to an abuse of some of those

laws pertaining to the physical and emotional or moral development of man

and the presence of sin in the world. It should be recognized that once the

process has started, 'guilty' and `innocent' suer alike nowhere is this more

obvious or more poignant than in the AIDS pandemic. Rather than its being

12
SZL2111 HIV/AIDs

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.

1.6.3. Monkey origin theories

HIV is a lentivirus that attacks the immune system. Lentiviruses are in turn

part of a larger group of viruses known as retroviruses. 'lentivirus' means 'slow

virus' because they take such a long time to produce any adverse eects in the

body and have been found in a number of dierent animals, including cats,

sheep, horses and cattle. The lentivirus of interest in terms of the investiga-

tion into the origins of HIV is the Simian Immunodeciency Virus (SIV) that

aects monkeys. It is generally thought that HIV is a descendant of a Simian

Immunodeciency Virus because certain strains of SIVs bear a very close re-

semblance to HIV-1 and HIV-2, the two types of HIV For example, HIV-2

corresponds to SIVsm, a strain of the Simian Immunodeciency Virus found

in the sooty mangabey (also known as the green monkey), which is indigenous

to western Africa. HIV-1, was until recently more dicult to place. Until

1999, the closest counterpart that had been identied was SIVcpz, found in

chimpanzees, but this virus still had certain signicant dierences from HIV-1.

Below are some of the most common theories about how this 'zoonosis' took

place, and how SIV became HIV in humans. Zoonosis- viral transfer between

animals & humans

• Hunter theory
The most commonly accepted theory is that of the 'hunter'. In this scenario,

SIVcpz was transferred to humans as a result of chimps being killed and eaten

or their blood getting into cuts or wounds on the hunter. Normally the hunter's

body would have fought o SIV, but on a few occasions it adapted itself within

its new human host and become HIV-1. Discoveries such as this have lead to

calls for an outright ban on bush meat hunting to prevent simian viruses being

passed to humans.

• Oral Polio Vaccine (OPV) theory

That HIV was transferred via medical experiments. That HIV could be traced

to the testing of an oral polio vaccine called Chat, given to about a million peo-

13
SZL2111 HIV/AIDs

ple in the Belgian Congo, Ruanda and Urundi in the late 1950s. To be repro-

duced, live polio vaccine needs to be cultivated in living tissue, and Hooper's

belief is that Chat was grown in kidney cells taken from local chimps infected

with SIVcpz. This, he claims, would have resulted in the contamination of

the vaccine with chimp SIV, and a large number of people subsequently be-

coming infected with HIV-1. However, in February 2000 the Wistar Institute

in Philadelphia (one of the original places that developed the Chat vaccine)

announced that it had discovered in its stores a phial of polio vaccine that had

been used as part of the program. The vaccine was subsequently analysed and

in April 2001 it was announced that no trace had been found of either HIV

or chimpanzee SIV. A second analysis conrmed that only macaque monkey

kidney cells, which cannot be infected with SIV or HIV, were used to make

Chat. While this is just one phial of many, most have taken its existence to

mean that the OPV vaccine theory is not possible. The fact that the OPV

theory accounts for just one (group M) of several dierent groups of HIV also

suggests that transferral must have happened in other ways too. The nal

element that suggests that the OPV theory is not credible as the sole method

of transmission is the argument that HIV existed in humans before the vaccine

trials were ever carried out.

• The contaminated needle vaccine

This is an extension of the original 'hunter' theory. In the 1950s, the use

of disposable plastic syringes became commonplace 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 (within a hunter's blood for example) from one person to

another, creating huge potential for the virus to multiply in each new individual

it entered, even if the SIV within the original person infected had not yet

converted to HIV.

14
SZL2111 HIV/AIDs

• The colonialism theory

The colonialism or 'Heart of Darkness' theory is one of the more recent theories

to have entered into the debate. It is again based on the basic 'hunter' premise,

but more thoroughly explains how this original infection could have lead to

an epidemic. During the late 19th and early 20 th 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 sucient

to create poor health in anyone, so SIV could easily have inltrated 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.

1.6.4. The conspiracy theory

Some say that HIV is a 'conspiracy theory' or that it is 'man-made'. A recent

survey carried out in the US for example, identied a signicant number of

African Americans who believe HIV was manufactured as part of a biological

warfare program, designed to wipe out large numbers of black and homosexual

people. Many say this was done under the auspices of the US federal 'Special

Cancer Virus Program' (SCVP), possibly with the help of the CIA. Some

even believe that the virus was spread (either deliberately or inadvertently)

to thousands of people all over the world through the smallpox inoculation

program, or to gay men through Hepatitis B vaccine trials.

1.6.5. The calculated theory

Opponents of the monkey theories argue that viral sequencing of HIV strains

indicate that HIV has been around probably for hundreds of years. This is

latest theory on the origin of HIV when a team of scientists using computer

technology to study the structure of HIV calculated the rate at which the virus

15
SZL2111 HIV/AIDs

mutates for the HIV viral sub-bytes to have a common ancestor. This process

revealed that 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 1970s,

political upheaval, wars, drought, and famine forced many people from these

rural areas to migrate to cities to nd jobs. During this time, the incidence

of sexually transmitted infections, including HIV infection, accelerated and

quickly spread throughout Africa. As world travel became more prevalent,

HIV infection developed into a worldwide epidemic. Studies of stored blood

from the United States suggest that HIV infection was well established there

by 1978. Rather than acquiring HIV from SIV it is thought that HIV mutated

to become ever more infectious. We will probably never know exactly when

and where the virus rst emerged, but what is clear is that sometime in the

middle of the 20th century, HIV infection in humans develop and into the

epidemic of disease around the world that we now refer to as AIDS.

Example . Describe the dierence Between HIV and AIDS?

Solution : HIV is the human immunodeciency virus that causes AIDS (ac-

quired immunodeciency syndrome). When HIV infects someone, the virus

enters the body and begins to multiply and attack immune cells that normally

protect us from disease. It's only when someone with HIV begins to infections

and illnesses that they're diagnosed with AIDS. 

16
SZL2111 HIV/AIDs

Learning Activities
Read more papers and journal articles on current advances in HIV/AIDs re-

search. Visit the reproductive health clinic/ section in a hospital around you

and get to learn various methods used to control HIV/AIDs and other STIs.

Exercise 1.  Revision Questions

Give an account of the limitations of Oral Polio Vaccine Theory as a pos-

sible explanation to the origin of HIV?

Exercise 2.  Describe the dierence Between HIV and AIDS?

17
SZL2111 HIV/AIDs

Assignments
1. Comprehensively discuss the global distribution and trends of HIV/AIDs.

Narrow down specically to Kenya and use current data and information.

2. Discuss myth associated with HIV/AIDs in your community.

References and Additional Reading Materials

1. Maranga R. O, Muya S. M and Ogila K. O (2008) Fundamentals of

HIV/AIDS Education. Signon Publishers.

2. Barry D. S. (1999) AIDS and HIV in Perspectives. CPU. ISBN-13:

9780521627665

3. Ellison G. Parker M., Camphpbell C (2003) Learning from HIV and

AIDS. Cambridge CPU.ISBN-13: 9780521709286.

4. Shavitri Ramaiah (2008) HIV/AIDS; Health solutions. Sterling Publish-

ers Ltd. ISBN-9788120733305.

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SZL2111 HIV/AIDs

LESSON 2
Sex education and Human sexuality
Learning outcomes
By the end of this topic you should be able to;

ˆ To know what sex education entails

ˆ Describe the some of the common STIs

ˆ Understand the Myths surrounding sexuality

ˆ Understand the relationship between STIs and HIV

ˆ Role of sex education as HIV control and management strategy

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SZL2111 HIV/AIDs

2.1. What is sex education?

Sex education, also called sexuality education or sex and relationships edu-

cation. It's the process of acquiring information and forming attitudes and

beliefs about sex, sexual identity, relationships and intimacy. It is also about

developing young people's skills so that they make informed choices about their

behavior, and feel condent and competent about acting on these choices. It

is widely accepted that young people have a right to sex education, partly

because it is a means by which they are helped to protect themselves against

abuse, exploitation, unintended pregnancies, sexually transmitted diseases and

HIV/AIDS.

2.1.1. Aims of sex education

ˆ To reduce the risks of potentially negative outcomes from sexual behavior

like unwanted or unplanned pregnancies and infection with STDs

ˆ To enhance the quality of relationships.

ˆ To develop young people's ability to make decisions over their entire

lifetime.

2.1.2. Myths surrounding sexuality

Myths are commonly held believes that are untrue or without foundations.

Myths are universal; occurring in almost all cultures and attempts to explain

assorted topics on humanity, and may have both religious and non religious

dimensions. The concepts of sex being  a necessary evil and  the less said

about it the better have led to many misconceptions about sex. Most common

sexual myths arise out of ignorance and these circulate more in adolescents and

with lack of information they internalize this and practice and this may lead

to exposure to HIV/AIDS.

2.2. Sexually Transmitted Diseases

Sexually transmitted diseases (STD) are caused by communicable agents (viruses,

bacteria, parasites etc) that are principally transmitted during sexual inter-

course resulting in clinical illness. How, sometimes infection with these agents

does not result in clinical disease but the agents can be transmitted from the

20
SZL2111 HIV/AIDs

host organism to their sexual partners. This has given rise to the term sexually

transmitted infections (STI). Some persons are thus healthy carriers. There

are at least 25 dierent sexually transmitted diseases. What they all have in

common is that they can be spread by sexual contact, including vagina, anal

and oral sex.

2.2.1. How do you know that you have an STD?

Anyone who is sexually active can be at risk from STDs. Some STDs can

have symptoms, such as genital discharge, pain when urinating and genital

swelling and inammation. Many STDs, such as Chlamydia, can frequently

be symptom less. This is why it is advisable to have a sexual health check-

up, to screen for STDs, if you think you have been at risk. It can sometimes

take a long time for STDs to display any symptoms, and you can pass on

any infections during this time, further demonstrating the need to be tested

and treated. If you are in a relationship, and are diagnosed with an STD, it

does not necessarily mean that your partner has been unfaithful. Symptoms

of STDs can present themselves months after infection. Many STDs are very

infectious and can cause long-term or permanent damage, including infertility

if left untreated. Many STDs can be easily passed onto sexual partners, and

some STDs can be passed from a mother to her unborn child too. STDs can

also aid the transmission of HIV.

2.2.2. How STDs are transmitted

STDs are transmitted by infectious agent microscopic bacteria, viruses, para-

sites, fungi, and single-celled organisms called protozoa - that thrive in warm,

moist environments in the body, such as the genital area, mouth, and throat

Most STDs are spread during sexual intercourse (vaginal or anal), but other

forms of sexual contact, such as oral sex, can also spread disease. Some STDs

are passed from an infected mother to her child before birth, when the infec-

tion crosses the placenta and enters the baby's bloodstream; during childbirth,

as the baby passes through the birth canal; or after birth, when the baby

consumes infected breast milk. Some viral STDs, especially AIDS, may be

transmitted by blood. Such STDs may be passed between people who share

infected needles or received through a transfusion of infected blood. Some peo-

21
SZL2111 HIV/AIDs

ple mistakenly believe that STDs can be transmitted through shaking hands

or other casual contact, or through contact with inanimate objects such as

clothing or toilet seats. Such transmissions are extremely rare.

• Factors that enhance chances of getting infected with STD

1. The potential for sexual activity is greatest from adolescence to the third

decade: 15 years and older. The greatest risk occurs in the age group

18-35. However, the trend is towards very early sexual debut, among

teenagers below 15 years of age, as society changes and liberal attitudes

become the norm in formerly traditional societies .

2. Marital status and occupation aect exposure to STDs. Due to industri-

alization and consequent urbanization; there is usually a large group of

single, poorly paid and unemployed young people who live in shanties in

towns. Sexual intercourse, for pleasure and for gain, assumes an impor-

tant role in such circumstances. Prostitution and promiscuity ourish

under these conditions and so do STDs. Promiscuous sexual behaviour is

closely associated with the acquisition and spread of STDs in any group

of people. There are certain factors that may reduce promiscuous be-

haviour in individuals. The more of these factors exist in an individual's

life, the less the risk of STDs .

3. Ethnicity is not a risk factor for STDs, but it is closely associated with

specic cultural practices that may predispose to transmission of STDs.

In some groups, certain celebrations and rituals (e.g., cleansing after the

death of a family member) may involve high-risk sexual practices that

predispose individuals to transmission of STIs, such as infection with

human immunodeciency virus (HIV), the cause of acquired immunod-

eciency syndrome (AIDS). A surviving HIV-positive spouse may have

to have sex with someone else as part of a ritual . Alternatively, "profes-

sional hired cleansers" may infect healthy widows and widowers. Many

such funeral events are also associated with much promiscuity as cele-

brations are held over a week or so with men and women having many

opportunities for casual sex. Conversely, societies with strict moral codes

regarding sex and marriage have a much lower prevalence of STDs .

22
SZL2111 HIV/AIDs

2.2.3. Prevention and Control of STIs

One can minimize the risk of getting infected with STIs by having protected

sex with condoms and getting tested together with sexual partner(s). The

more partners one has, the greater the risk of acquiring an STD. Other ways

to reduce the risk include using dental dams and condoms during oral sex,

clean sex toys after use, clean your hands after having sex, and improving

genital hygiene routines.

• Importance of early diagnosis and treatment

In many resource poor countries, the approach to diagnosis and treatment of

STDs has changed radically in the last few years. The emphasis is now on

recognition of groups of signs and symptoms, or syndromes, rather than strict

etiologic diagnosis based on laboratory ndings as a basis for patient man-

agement. Syndromes are based on the clinical presentation of the commonest

STDs in the particular country, or region within a country, and patients are

treated for the likely STDs that commonly cause that particular combination

of signs and symptoms. The commonest cause of urethral discharge in males in

Africa, for example, is gonorrhea and Chlamydia urethritis, either individually

or in combination. In the new approach, the patient is treated for both infec-

tions. Other causes are considered if there is no improvement (Adler, 1996.,

Holmes, 1990). The advantage of this approach is that even the lowest cadres

in the health service can treat patients eectively with a minimum of retrain-

ing, without requiring the assistance of a laboratory. The main disadvantage

is a certain amount of over-treatment for diseases that are not present, but

this is a small price to pay for increased access to STD treatment services for

the whole community.

2.2.4. Basic information on some common STDs

1. Bacterial Vaginosis - (BV) is not strictly an STD as it is not transmitted

via sexual intercourse. However, it can be exacerbated by sex and is more

frequently found in sexually active women than those who have never had

intercourse. It is caused by an imbalance in the normal healthy bacteria

found in the vagina and although it is relatively harmless and may pass

unnoticed, it can sometimes produce an abundance of unpleasant shy

23
SZL2111 HIV/AIDs

smelling discharge. Whilst there is no clear explanation as to why BV

occurs, there have been suggestions that the alkaline nature of semen

could be one cause, as it may upset the acidic nature of the vaginal

bacteria. Another cause can be the use of an intrauterine contraceptive

device (coil). A woman cannot pass BV to a man, but it is important

she receives treatment as BV can occasionally travel up into the uterus

and fallopian tubes and cause a more serious infection. Treatment for

BV consists of applying a cream to the vagina or taking antibiotics.

2. Balanitis - is often referred to as a symptom of infection, and not nec-

essarily an infection in its own right. It is not strictly an STD, more a

consequence of sexual activity. It only aects men and usually presents

itself as an inammation of the head of the penis, and is more common

in men who are not circumcised. It can be caused through poor hygiene,

irritation due to condoms and spermicides, using perfumed toiletries and

by having thrush. It can be prevented through not using certain toiletries

and by washing under the foreskin. Treatment can consist of creams to

reduce inammation and antibiotics if necessary.

3. Chlamydia - is the most common treatable bacterial STD. It can cause

serious problems later in life if it is not treated. Chlamydia infects the

cervix in women. The urethra, rectum and eyes can be infected in both

sexes. Symptoms of infection may show up at anytime. Often this

is between 1 to 3 weeks after exposure. However, symptoms may not

emerge until a long way down the line.

4. Crabs or Pubic Lice - are small, crab shaped parasites that live on hair

and which draw blood. They live predominantly on pubic hair, but can

also be found in hair in the armpits, on the body and even in facial hair

such as eyebrows. They can live away from the body too, and therefore

can be found in clothes, bedding and towels. You can have crabs and not

know about it, but after 2 to 3 weeks, you would expect to experience

some itching. Crabs are mainly passed on through body contact during

sex, but they can also be passed on through sharing clothes, towels or

bedding with someone who has them. There is no eective way to prevent

yourself becoming infected, though you can prevent others becoming

24
SZL2111 HIV/AIDs

infected by washing clothes and bedding on a hot wash. Lotions can be

bought from pharmacies and applied to the body to kill o the parasites.

Shaving o pubic hair will not necessarily get rid of crabs.

5. Epididymitis - refers to inammation of the epididymitis, a tube system

above the testicles where sperm are stored. It is not always the result

of an STD, but if it is, it is usually due to the presence of Chlamydia or

Gonorrhoea. Symptoms will present themselves in the form of swollen

and painful testicles and scrotum. The best way of preventing it is to

use condoms during sex, as this is the most eective way to prevent

Chlamydia and Gonorrhoea. Epididymitis itself cannot be passed on,

though any other infections that may have caused epididymitis can be

passed on (see Chlamydia and Gonorrhoea sections). Treatment usually

involves treating the underlying infection with antibiotics.

6. Genital herpes - is caused by the herpes simplex virus. The virus can

aect the mouth, the genital area, the skin around the anus and the

ngers. Once the rst outbreak of herpes is over, the virus hides away

in the nerve bres, where it remains totally undetected and causes no

symptoms. Symptoms of the rst infection usually appear one to 26 days

after exposure and last two to three weeks. Both men and women may

have one or more symptoms, including an itching or tingling sensation

in the genital or anal area, small uid-lled blisters that can burst and

leave small sores which can be very painful, pain when passing urine,

if it passes over any of the open sores and a u-like illness, backache,

headache, swollen glands or fever. Find out more about genital herpes.

7. Genital warts - are small eshy growths which may appear anywhere

on a man or woman's genital area. They are caused by a virus called

the Human Papilloma Virus (HPV). Warts can grow on the genitals, or

on dierent parts of the body, such as the hands. After you have been

infected with the genital wart virus it usually takes between 1 and 3

months for warts to appear on your genitals. You or your partner may

notice pinkish/white small lumps or larger cauliower-shaped lumps on

the genital area. Warts can appear around the vulva, the penis, the

scrotum or the anus. They may occur singly or in groups. They may

25
SZL2111 HIV/AIDs

itch, but are usually painless. Often there are no other symptoms, and

the warts may be dicult to see. If a woman has warts on her cervix,

this may cause slight bleeding or, very rarely, an unusual coloured vaginal

discharge. Find out more about genital warts.

8. Gonorrhoea - is a bacterial infection. It is sexually transmitted and

can infect the cervix, urethra, rectum, anus and throat. Symptoms of

infection may show up at anytime between 1 and 14 days after exposure.

It is possible to be infected with gonorrhoea and have no symptoms.

Men are far more likely to notice symptoms than women.

9. Gut Infections - can be passed on during sex. Two of the most common

infections are Amoebiasis and Giardiasis. They are bacterial infections,

and when they reach your gut they can cause diarrhoea and stomach

pains. Gut infections can be passed on when having sex with someone

who is infected, especially during activities that involve contact with fae-

ces, such as rimming and anal sex. Infection can be prevented through

using condoms, dental dams or latex gloves. Sex toys should be thor-

oughly cleaned after use and hands washed after any contact with faeces.

Anti-diarrhoea treatments should be enough to treat most infections, but

antibiotics can also be used.

10. Hepatitis - causes the liver to become inamed. There are various dif-

ferent types of hepatitis, the most common being hepatitis A, B and C.

Each of these viruses acts dierently. Hepatitis can be caused by alcohol

and some drugs, but usually it is the result of a viral infection. Find out

more about hepatitis.

11. Molluscum - is a skin disease caused by the Molluscum Contagiosum

Virus. It appears as small bumps on the skin, and can last from a couple

of weeks to a few years. Molluscum cause small, pearl-shaped bumps

the size of a freckle on the thighs, buttocks, genitalia and sometimes the

face. They are passed on through body contact during sex and through

skin-to-skin contact. Transmission can be prevented by using condoms,

by avoiding skin-to-skin contact with someone who is infected and by

not having sex until they have been treated. In most cases molluscum

26
SZL2111 HIV/AIDs

do not need treatment and will disappear over time. However, they can

be frozen o or a chemical can be painted on.

12. Non-Specic Urethritis (NSU) - is an inammation of a man's urethra.

This inammation can be caused by several dierent types of infection,

the most common being Chlamydia. NSU may be experienced months or

even in some cases years into a relationship. The symptoms of NSU may

include pain or a burning sensation when passing urine, a white/cloudy

uid from the tip of the penis that may be more noticeable rst thing in

the morning, feeling that you need to pass urine frequently. Often there

may be no symptoms, but this does not mean that you cannot pass the

infection on to your partner(s).

13. Scabies - is caused by a parasitic mite that can get under the skin and

cause itching. The mites are very small and cannot be seen, and many

people do not now they have them. They can cause itching, and this

can start between 2 to 6 weeks after infection. Signs of infection can

be red lines under the skin of the hands, buttocks and genitals. The

most common way of becoming infected is through body contact during

sex, though it is also possible to be infected through sharing towels and

clothes with someone who is infected. This route however is uncommon.

There is no eective way to prevent yourself becoming infected, though

you can prevent others becoming infected by washing clothes and bed-

ding on a hot wash. Lotions can be bought from pharmacies and applied

to the body to kill o the parasites.

14. Syphilis - is not a common infection in the UK but it is more common

in some other countries. It is a bacterial infection. It is usually sexually

transmitted, but may also be passed from an infected mother to her

unborn child. The signs and symptoms of syphilis are the same in both

men and women. They can be dicult to recognise and may take up to

3 months to show after having sexual contact with an infected person.

Syphilis has several stages. The primary and secondary stages are very

infectious.

15. Thrush, also known as Candidiasis - is yeast which lives on the skin and

27
SZL2111 HIV/AIDs

is normally kept in check by harmless bacteria. If this yeast multiplies

however, it can cause itching, swelling, soreness and discharge in both

men and women. Women may experience a thick white discharge and

pain when passing urine. Men may experience the same discharge in

the penis and diculty pulling back the foreskin. Thrush can be passed

on when having sex with someone who is infected, but also if you wear

too tight nylon or lycra clothes or if you are taking certain antibiotics.

Sometimes the cause may be unclear however. Transmission can be

prevented by using condoms during sex and by men washing underneath

their foreskin. Treatment for thrush involves taking or applying anti

fungal treatments. Thrush can reoccur, especially in women.

16. Trichomonas Vaginosis - also known as Trich is caused by a parasite that

is found in women's vagina's and men's urethra's. Often there are not

any symptoms. If symptoms are present, they can include pain when

urinating and discharge in men and discharge, soreness when having sex

and when urinating and inammation of the vulva in women. Trans-

mission normally occurs through having oral, anal or vaginal sex with

an infected person. Treatment consists of taking antibiotics, and the

infection should not reoccur.

17. AIDS - this is a fatal disease that, once symptoms and signs develop,

causes death in less than 2 years (Porth 1998). The virus causing this

disease is transmitted most commonly through unprotected sexual inter-

course. There is no cure or vaccine, although onset of symptoms can be

delayed by the use of antiretroviral drugs. Communities must be taught

how to prevent AIDS by limiting sexual activity to one faithful partner.

The male and female condoms are an eective method of preventing

AIDS and other sexually transmitted diseases when used consistently

for casual sexual contacts.

2.2.5. Relationship between HIV and Sexually transmitted infec-

tions
ˆ STDs enhances HIV transmission by causing open sores and skin injuries

in sex organs through which the HIV enters.

28
SZL2111 HIV/AIDs

ˆ A lot of T-lymphocytes (cells found in the blood and in the lymphatic

tissues that ght infections) are mobilized to ght the STD infections

and since these are the targets of HIV, a lot of them are infected by HIV

and destroyed and the patient goes down faster with the HIV.

ˆ The mode of transmission for the STDs is also the same as mode of

transmission of HIV.

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SZL2111 HIV/AIDs

Exercise 3.  Revision Questions

Explain any six sexuality myths that have lead to high risk sexual behaviors

among youths in Kenya today

Example . Briey describe the sexual transmission of HIV/AIDS

Solution : The risk of transmission through unprotected vaginal sex is thought

to be lower than anal sex, though still highly signicant. However, where there

is a risk of vaginal tears or sores e.g. in the presence of sexually transmitted

infection, the risk of transmission is increased signicantly. HIV transmission

through oral sex is a much debated subjected. However, the virus is present in

blood and semen, which means that in theory, this is a possible transmission

route. There may be an increased risk if there is ejaculation, bleeding gums,

lips, or inammation caused by common throat infections. The sharing of sex

toys also carries a risk of HIV transmission. If more than one person is going

to use a vibrator or dildo, is essential that it is cleaned thoroughly between

uses or covered with afresh condom before each use. . 

30
SZL2111 HIV/AIDs

References and Additional Reading Materials

1. Maranga R. O, Muya S. M and Ogila K. O (2008) Fundamentals of

HIV/AIDS Education. Signon Publishers.

2. Barry D. S. (1999) AIDS and HIV in Perspectives. CPU. ISBN-13:

9780521627665

3. Ellison G. Parker M., Camphpbell C (2003) Learning from HIV and

AIDS. Cambridge CPU.ISBN-13: 9780521709286.

4. Shavitri Ramaiah (2008) HIV/AIDS; Health solutions. Sterling Publish-

ers Ltd. ISBN-9788120733305.

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SZL2111 HIV/AIDs

LESSON 3
The Immune system
Learning outcomes
Upon completing this topic, you should be able to :

ˆ Have an overview of the Human Immune system(IS)

ˆ Understand various types of immunity

ˆ Describe various stages of immune response

ˆ What is immunodeciency?

ˆ Various disorders and diseases associated with immune system

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SZL2111 HIV/AIDs

3.1. Overview of the Immune System

Immune system is a system of biological structures and processes within an

organism that protects against diseases by identifying and killing pathogens

and tumor cells. The immune system is made up of organs that are involved

in ghting invasion by foreign bodies. They include;

3.1.1. The bone marrow

The bone marrow is the production site of the white blood cells(WBC) involved

in immunity WBC involved includes the B-lymphocytes (B cells) and the T

lymphocytes (T cells). The B-lymphocytes mature in the bone marrow and

then enter the circulation. T lymphocytes move from the bone marrow to

the thymus, where they mature into several kinds of cells capable of dierent

functions Lymphoid organs The Lymphoid tissues include the thymus gland,

the spleen, the lymph nodes, the tonsils and adenoids, and similar tissues in

the gastrointestinal, respiratory, and reproductive systems The lymph nodes

are distributed throughout the body. They are connected by lymph channels

and capillaries, which remove foreign material from the lymph before it enters

the bloodstream. The lymph nodes also serve as centers for immune cell

proliferation. The remaining lymphoid tissues, such as the tonsils and adenoids

and other mucoid lymphatic tissues, contain immune cells that defend the body

against microorganisms

3.1.2. Types of Immunity

• Innate/ Inborn/Natural/Non-specic immunity;
Present at birth Provide non-specic immunity to any foreign invador regard-

less of invadors' composition. Operates under certain mechanisms or factors

ˆ Physical/mechanical barrier

 Skin protects from entry of pathogens to our body

 Respiratory tracts- the hairs /cilia along the tract leads to coughing

& sneezing in presence of microorganism hence act as lters to clear

the pathogens from upper respiratory tract.

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SZL2111 HIV/AIDs

ˆ Biochemical factors Acidic gastric juices e.g. Hydrochloric acid in the

stomach. Enzymes present in sweat, saliva and breast milk respond by

destroying invading microorganisms. Blood protein factors e.g. interfer-

ons, compliments, acute phase proteins destroy by puncturing holes in

the body.

ˆ Genetic - control People may become carriers but not sick

ˆ Cellular factors - WBCs participate both in natural & acquired immune

responses. The cells ght invading foreign bodies by releasing cell medi-

ators. Other cells (non-granular) e.g. monocytes & macrophages are

phagocytic i.e. engulf, digest &kill microorganism Inammatory re-

sponses. The inammatory response is a major function of the natu-

ral (nonspecic) immune system elicited in response to tissue injury or

invading organisms. Chemical mediators assist this response by: Mini-

mizing blood loss Walling o the invading organism. Activating phago-

cytes and promoting formation of brous scar tissues. Regeneration of

injured tissue.

• Acquired/ Adaptive / Specic Immunity

Immunologic responses are acquired during life. Are not present at birth.

They develop as a result of immunization/vaccination. Also developed after

contracting a disease i.e. weeks or months after exposure to the disease, the

body produces an IR sucient to defend against re-infection. The two types

of acquired immunity: active and passive. In active acquired immunity, the

immunologic defenses are developed by the person's own body. This immu-

nity generally lasts many years or even a lifetime. Passive acquired immunity

is temporary immunity transmitted from another source that has developed

immunity through previous disease or immunization. For example, gamma-

globulin and antiserum, obtained from the blood plasma of people with ac-

quired immunity, are used in emergencies to provide immunity to diseases when

the risk for contracting a specic disease is great and there is not enough time

for a person to develop adequate active immunity.

Both types of acquired immunity involve humoral and cellular (cell-mediated)

immunologic responses. It's divided into 2 forms

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SZL2111 HIV/AIDs

1. Humoral immunity (AMI) Involves antibodies produced by B cells The

antibodies recognize & bind specically to foreign antigens & may cause

one of the following: -Break/ splitdown the membrane of Ag (lysis) -Coat

the Ag making it easier for phagocytosis (opsonization) -Neutralize activ-

ities of toxins/ virus/ bacteria (neutralization) -Direct killing of foreign

Ag ( cytotoxicity / cell killing) -Clump parasites together (agglutination)

2. Cell mediated immunity (CMI) - Two most important T cell subtypes

are involved in CMI T helper and T killer cells

• Cells of the Immune System

1. T-Cells  T lymphocytes are divided into two major subsets that dier

in functions and identity (functionally and phenotypically (identiably)

dierent).

(a) The T helper subset, (CD4+ T cell) - The main function is to aug-

ment or potentiate immune responses by the secretion of specialized

factors that activate other WBCs to ght o infection. They in-

teract with B cells or T killer cells & help them respond to foreign

agents. T helper1-controls intracellular pathogens (CMI)

(b) T helper2 - controls extra cellular pathogens (AMI) b)T killer/suppressor

subset (CD8+ T cell). These cells are important in directly killing

certain tumor cells, viral-infected cells and sometimes parasites.

They directly bind to foreign agents, attack & kill those cells thus

eliminating them from the body. The CD8+ T cells are also im-

portant in down-regulation of immune responses.

NB: Both types of T cells can be found throughout the body. They often

depend on the secondary lymphoid organs (the lymph nodes and spleen)

as sites where activation occurs, but they are also found in other tissues

of the body, most conspicuously the liver, lung, blood, and intestinal and

reproductive tracts.

2. Natural Killer Cells (NK) Are similar to the killer T cell subset (CD8+

T cells). They directly kill certain tumors such as melanomas, lym-

phomas and viral-infected cells, most notably herpes and cytomegalovirus-

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SZL2111 HIV/AIDs

infected cells. NK cells, unlike the CD8+ (killer) T cells, kill their targets

without a prior sensitization. But kill more eectively when activated

by T h cell.

3. B Cells  The major function of B lymphocytes is the production of

antibodies in response to foreign proteins of bacteria, viruses, and tumor

cells. Antibodies are specialized proteins that specically recognize and

bind to one particular protein that specically recognize and bind to

one particular protein. Antibody production and binding to a foreign

substance or antigen, is critical as a means of signaling other cells to

engulf, kill or remove that substance from the body.

4. Granulocytes or Polymorphonuclear (PMN) Leukocytes -It is a group

of WBCs. Granulocytes are composed of three cell types identied as

neutrophils, eosinophils and basophils, based on their staining charac-

teristics with certain dyes. These cells are important in the removal of

bacteria and parasites from the body. They engulf these foreign bodies

and degrade them using their powerful enzymes.

(a) Neutrophils -a/c60% - complete dvpt in the BM -enter blood &

remain incirculation for 10hours - leave thro capillary wall & enter

connective tissue - after a day or 2 they enter the digestive tract or

urinary tract & are swept out of the body by waters.

(b) Eosinophils a/c 3% of circulating WBCs - help control allergic

reactions & helminth infections

(c) Basophils- a/c less than 1% - controls allergic reactions, inamma-

tory reactions, clotting process & fat metabolism

5. Macrophages  They are often referred to as scavengers or antigen-

presenting cells (APC). This is because they pick up and ingest foreign

materials and present these antigens to other cells of the immune system

such as T cells and B cells. This is one of the important rst steps in

the initiation of an immune response. Stimulated macrophages exhibit

increased levels of phagocytosis and are also secretory. Monocytes - they

cross capillary wall, enter tissue & dierentiate to macrophages, - destroy

bacteria, dead cells and other matters - Are CD4+

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SZL2111 HIV/AIDs

6. Dendritic Cells  Dendritic cells function as APCs. In fact, they are

more ecient APCs than macrophages. These cells are usually found in

the structural compartment of the lymphoid organs such as the thymus,

lymph nodes and spleen. They are also found in the bloodstream and

other tissues of the body. It is believed that they capture antigen or bring

it to the lymphoid organs where an immune response is initiated. They

are extremely hard to isolate. Recent nding is that dendritic cells bind

high amount of HIV, and may be a reservoir of virus that is transmitted

to CD4+ T cells during an activation event. Cells that possess CD4

markers include:

ˆ T helper cells

ˆ Macrophages

ˆ Monocytes

ˆ Colon cells

ˆ Dendritic cells

ˆ Retinal cells

NB: HIV attaches to any CD4+ cell. Immune response to invasion

When bacteria, viruses or other pathogens overcome the body's natural immu-

nity and gain entry into the blood system, three specic mechanism of acquired

immunity are initiated. They include:

ˆ The phagocytic immune response

ˆ The humoral or antibody immune response

ˆ The cellular or cell mediated immune response

1. Phagocytic immune response

ˆ The rst line of defense, the phagocytic immune response, involves

the WBCs (granulocytes and macrophages), which have the ability

to ingest foreign particles. These cells move to the point of attack,

where they engulf and destroy the invading agents.

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2. Humoral or Antibody immune response

ˆ The humoral response is characterized by production of antibodies

by the B-lymphocytes in response to a specic antigen. Although

the B-lymphocyte is ultimately responsible for the production of an-

tibodies, both the macrophages of natural immunity and the special

T-cell lymphocytes of cellular immunity are involved in recognizing

the foreign substance and in producing antibodies.

3. Antigen recognition

ˆ The part of the invading or attacking organism that is responsi-

ble for stimulating antibody production is called an antigen (or an

immunogen). For example, an antigen can be a small patch of pro-

teins on the outer surface of the microorganism. A single bacterium,

even a single large molecule, such as a toxin (diphtheria or tetanus

toxin), may have several such antigens, or markers, on its surface,

thus inducing the body to produce a number of dierent antibod-

ies. Once produced, an antibody is released into the bloodstream

and carried to the attacking organism. There it combines with the

antigen, binding with it like an interlocking piece of a jigsaw puzzle

3.1.3. Stages in an immune response

• Recognition stage
ˆ The immune system's ability to recognize antigens as foreign, or non-self,

is the initiating event in any immune response (g 2.2). The body must

rst recognize invaders as foreign before it can react to them. The body

accomplishes recognition using lymph nodes and lymphocytes for surveil-

lance. Lymph nodes are widely distributed internally and externally near

the body's surfaces. They continuously discharge small lymphocytes into

the bloodstream. These lymphocytes patrol the tissues and vessels that

drain the areas served by that node.

ˆ Lymphocytes are found in the lymph nodes and in the circulating blood.

The volume of lymphocytes in the body is impressive. These lympho-

38
SZL2111 HIV/AIDs

cytes recirculate from the blood to lymph nodes and from the lymph

nodes back into the bloodstream, in a never-ending series of patrols.

Some circulating lymphocytes can survive for decades. Some of these

small, hardy cells maintain their solitary circuits for the lifetime of the

person.

ˆ The exact way in which circulating lymphocytes recognize antigens on

foreign surfaces is not known; however, theorists think that recognition

depends on specic receptor sites on the surface of the lymphocytes.

Macrophages play an important role in helping the circulating lympho-

cytes process the antigens. When foreign materials enter the body, a

circulating lymphocyte comes into physical contact with the surfaces

of these materials. Upon contact, the lymphocyte, with the help of

macrophages, either removes the antigen from the surface or in some

way picks up an imprint of its structure, which comes into play with

subsequent re-exposure to the antigen.

ˆ In a streptococcal throat infection, for example, the streptococcal organ-

ism gains access to the mucous membranes of the throat. A circulating

lymphocyte moving through the tissues of the neck comes in contact with

the organism. The lymphocyte, familiar with the surface markers on the

cells of its own body, recognizes the antigens on the microbe as dierent

(non-self ) and the streptococcal organism as antigenic (foreign). This

triggers the second stage of the immune responseproliferation.

• Proliferation stage
ˆ The circulating lymphocyte containing the antigenic message returns

to the nearest lymph node. Once in the node, the sensitized lympho-

cyte stimulates some of the resident dormant T and-lymphocytes to en-

large, divide, and proliferate. T lymphocytes dierentiate into cytotoxic

(or killer) T cells, whereas-lymphocytes produce and release antibodies.

Enlargement of the lymph nodes in the neck in conjunction with a sore

throat is one example of the immune response.

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SZL2111 HIV/AIDs

• Response stage
ˆ In the response stage, the changed lymphocytes function either in a

humoral or a cellular fashion. The production of antibodies by the-

lymphocytes in response to a specic antigen begins the humoral re-

sponse. Humoral refers to the fact that the antibodies are released into

the bloodstream and so reside in the plasma (uid fraction of the blood).

ˆ With the initial cellular response, the returning sensitized lymphocytes

migrate to areas of the lymph node (other than those areas containing

lymphocytes programmed to become plasma cells). Here, they stimulate

the residing lymphocytes to become cells that will attack microbes di-

rectly rather than through the action of antibodies. These transformed

lymphocytes are known as cytotoxic (killer) T cells. The T stands for

thymus, signifying that during embryologic development of the immune

system, these T lymphocytes spent time in the thymus of the developing

fetus, where they were genetically programmed to become T lymphocytes

rather than the antibody-producing-lymphocytes. Viral rather than bac-

terial antigens induce a cellular response. This response is manifested

by the increasing number of T lymphocytes (lymphocytosis) seen in the

blood smears of people with viral illnesses, such as infectious mononu-

cleosis.

ˆ Most immune responses to antigens involve both humoral and cellular re-

sponses, although one usually predominates. For example, during trans-

plantation rejection, the cellular response predominates, whereas in the

bacterial pneumonias and sepsis, the humoral response plays the domi-

nant protective role.

• Eector stage
ˆ In the eector stage, either the antibody of the humoral response or the

cytotoxic (killer) T cell of the cellular response reaches and couples with

the antigen on the surface of the foreign invader. The coupling initiates

a series of events that in most instances results in the total destruction of

the invading microbes or the complete neutralization of the toxin. The

events involve interplay of antibodies (humoral immunity), complement,

and action by the cytotoxic T cells (cellular immunity).

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SZL2111 HIV/AIDs

Production of B-Lymphocytes
ˆ B-lymphocytes stored in the lymph nodes are subdivided into thousands

of clones, each responsive to a single group of antigens having almost

identical characteristics. When the antigenic message is carried back

to the lymph node, specic clones of the-lymphocyte are stimulated to

enlarge, divide, proliferate, and dierentiate into plasma cells capable

of producing specic antibodies to the antigen. Other-lymphocytes dif-

ferentiate into-lymphocyte clones with a memory for the antigen. These

memory cells are responsible for the more exaggerated and rapid immune

response in a person who is repeatedly exposed to the same antigen.

3.1.4. Role of antibodies in Humoral Immune Responses

ˆ Antibodies are large proteins called immunoglobulins because they are

found in the globulin fraction of the plasma proteins. Each antibody

molecule consists of two subunits, each of which contains a light and a

heavy peptide chain. The sub-units are held together by a chemical link

composed of disulde bonds. Each subunit has a portion that serves as a

binding site for a specic antigen referred to as the Fab fragment. This

site provides the "lock" portion that is highly specic for an antigen.

An additional portion, known as the Fc fragment, allows the antibody

molecule to take part in the complement system.

ˆ Antibodies defend against foreign invaders in several ways, and the type

of defense employed depends on the structure and composition of both

the antigen and the immunoglobulin. The antibody molecule has at least

two combining sites, or Fab fragments. One antibody can act as a cross-

link between two antigens, causing them to bind or clump together. This

clumping eect, referred to as agglutination, helps clear the body of the

invading organism by facilitating phagocytosis. Some antibodies assist

in removing oending organisms through opsonization. In this process,

the antigenantibody molecule is coated with a sticky substance that

also facilitates phagocytosis.

ˆ Antibodies also promote the release of vasoactive substances, such as

histamine and slow-reacting substance, two of the chemical mediators

41
SZL2111 HIV/AIDs

of the inammatory response. In addition, antibodies are involved in

activating the complement system.

3.1.5. Types of Immunoglobulins

The body can produce ve dierent types of immunoglobulins. (Immunoglob-

ulins are commonly designated by the abbreviation Ig.) Each of the ve types,

or classes, is identied by a specic letter of the alphabet (IgA, IgD, IgE, IgG,

and IgM). Classication is based on the chemical structure and biologic role

of the individual immunoglobulin. The following list summarizes some out-

standing characteristics of the immunoglobulins: 

ˆ IgG (75% of Total Immunoglobulin) ˆ Appears in serum and tissues

(interstitial uid) ˆ Assumes major role in blood borne and tissue infec-

tions ˆ Activates complement system ˆ Enhances phagocytosis ˆ Crosses

placenta

ˆ IgA (15% of Total Immunoglobulin) ˆ Appears in body uids (blood,

saliva, tears, breast milk, and pulmonary, gastrointestinal, prostatic, and

vaginal secretions) ˆ Protects against respiratory, gastrointestinal, and

genitourinary infections ˆ Prevents absorption of antigens from food ˆ

Passes to neonate in breast milk for protection

ˆ IgM (10% of Total Immunoglobulin) ˆ Appears mostly in intravascular

serum ˆ Appears as the rst immunoglobulin produced in response to

bacterial and viral infections ˆ Activates complement system

ˆ IgD (0.2% of Total Immunoglobulin) ˆ Appears in small amounts in

serum ˆ Possibly inuences B-lymphocyte dierentiation, but plays un-

clear role

ˆ IgE (0.004% of Total Immunoglobulin) ˆ Appears in serum ˆ Takes part

in allergic and some hypersensitivity reactions ˆ Combats parasitic in-

fections

3.1.6. Cellular (or cell mediated) immune response

ˆ It is called cellular because it involves production of special cells T lym-

phocytes (or T cells) that are primarily responsible for cellular immu-

42
SZL2111 HIV/AIDs

Figure 3.1: Cellular (or cell mediated) immune response

nity. These lymphocytes spend time in the thymus, where they are pro-

grammed to become T cells rather than antibody-producinglymphocytes

(Figure 2.3). Several types of T cells exist, each with designated roles

in the defense against bacteria, viruses, fungi, parasites, and malignant

cells. T cells attack foreign invaders directly rather than by producing

antibodies.

ˆ Cellular reactions are initiated by the binding of an antigen with an anti-

gen receptor located on the surface of a T cell. This may occur with or

without the assistance of macrophages. The T cells then carry the anti-

genic message, or blueprint, to the lymph nodes, where the production

of other T cells is stimulated. Some T cells remain in the lymph nodes

and retain a memory for the antigen. Other T cells migrate from the

lymph nodes into the general circulatory system and ultimately to the

tissues, where they remain until they either come in contact with their

respective antigens or die.

• Role of T lymphocytes
Two major categories of eector T cells are helper T cells and cytotoxic T

cells. These cells participate in destroying foreign organisms. Other T cells

include suppressor T cells and memory T cells. T cells interact closely with-

cells, indicating that humoral and cellular immune responses are not separate,

43
SZL2111 HIV/AIDs

unrelated processes but rather branches of the immune response that can and

do aect each other.

1. Helper T cells (helper CD4 cells) are activated upon recognition of anti-

gens and stimulate the rest of the immune system. When activated,

helper T cells secrete cytokines that attract and activate-cells, cytotoxic

T cells, natural killer cells, macrophages, and other cells of the immune

system (Laurence J. 1995). Separate subpopulations of helper T cells

produce dierent types of cytokines and determine whether the immune

response will be the production of antibodies or a cell-mediated immune

response. Helper T cells produce lymphokines, one category of cytokines.

These lymphokines activate other T cells (interleukin-2, or IL-2), natural

and cytotoxic T cells (interferon-gamma), and other inammatory cells

(tumor necrosis factor). Helper T2 cells produce IL-4 and IL-5, lym-

phokines that activate-cells to grow and dierentiate (Laurence J. 1995,

Roit I; et al 1989)).

2. Cytotoxic T cells (killer T cells) attack the antigen directly by altering

the cell membrane and causing cell lysis (disintegration) and releasing

cytolytic enzymes and cytokines. Lymphokines can recruit, activate,

and regulate other lymphocytes and WBCs. These cells then assist in

destroying the invading organism.

3. Suppressor T cells, has the ability to decrease B-cell production, thereby

keeping the immune response at a level that is compatible with health

(e.g. sucient to ght infection adequately without attacking the body's

healthy tissues). Memory T cells are responsible for recognizing antigens

from previous exposure and mounting an immune response.

• Roles of null lymphocytes and natural killer cells in cellular im-

mune responses
Null lymphocytes and natural killer (NK) cells are other lymphocytes that

assist in combating organisms. These are distinct from-cells and T cells and

lack the usual characteristics of-cells and T cells.

1. Null lymphocytes, a subpopulation of lymphocytes, destroy antigens al-

ready coated with antibody. These cells have special Fc receptor sites on

44
SZL2111 HIV/AIDs

their surfaces that allow them to couple with the Fc end of antibodies

(antibody-dependent, cell-mediated cytotoxicity, Beattie, T et al 2002).

2. Natural killer cells, another subpopulation of lymphocytes, defend against

microorganisms and some types of malignant cells. NK cells are capa-

ble of directly killing invading organisms and producing cytokines. The

helper T cells contribute to the dierentiation of null and NK cells (Lau-

rence J. 1995).

3.1.7. Complement System

ˆ Circulating plasma proteins, which are made in the liver and activated

when an antibody couples with its antigen, are known as complement.

These proteins interact sequentially with one another in a cascade or

"falling domino" eect. This complement cascade alters the cell mem-

branes on which antigen and antibody complex form, permitting uid to

enter the cell and leading eventually to cell lysis and death. In addition,

activated complement molecules attract macrophages and granulocytes

to areas of antigen antibody reactions. These cells continue the body's

defense by devouring the antibody-coated microbes and by releasing bac-

terial agents.

ˆ Complement plays an important role in the immune response. Destruc-

tion of an invading or attacking organism or toxin is not achieved merely

by the binding of the antibody and antigens; it also requires activa-

tion of complement, the arrival of killer T cells, or the attraction of

macrophages.

3.2. Immunodeciency
ˆ When some or one of the components of the immune system is lacking,

disorders or abnormalities arises and this is referred to as an immunode-

ciency. These abnormalities or disorders are either as a result of genetic

abnormally (congenital) or are acquired within the course of life due to

a number of factors

 Old age

45
SZL2111 HIV/AIDs

 Nutrition

 Autoimmune disorder

 Neoplastic disease

 Chronic illness and surgery

 Medication

 Lifestyle and other factors

 Stress

1. Age - People at the extremes of the lifespan are more likely to develop

problems related to immune system functioning than are those in their

middle years. Frequency and severity of infections are increased in el-

derly people, possibly from a decreased ability to respond adequately to

invading organisms. Both the production and the function of T and B

-lymphocytes may be impaired. The incidence of autoimmune diseases

also increases with aging, possibly from a decreased ability of antibodies

to dierentiate between self and non-self. Failure of the surveillance sys-

tem to recognize mutant, or abnormal, cells may be responsible for the

high incidence of cancer associated with increasing age.

2. Declining function of various organ systems associated with increasing

age also contributes to impaired immunity. Decreased gastric secretions

and motility allow normal intestinal ora to proliferate and produce in-

fection, causing gastroenteritis and diarrhea. Decreased renal circula-

tion, ltration, absorption, and excretion contribute to risk for urinary

tract infections. Moreover, prostatic enlargement and neurogenic bladder

can impede urine passage and subsequently bacterial clearance through

the urinary system. Urinary stasis, common in elderly people, permits

the growth of organisms. Exposure to tobacco and environmental tox-

ins impairs pulmonary function. Prolonged exposure to these agents

decreases the elasticity of lung tissue, the eectiveness of cilia, and the

ability to cough eectively. These impairments hinder the removal of

infectious organisms and toxins, increasing the elderly person's suscep-

tibility to pulmonary infections and cancers. Finally, with aging, the

46
SZL2111 HIV/AIDs

skin becomes thinner and less elastic. Peripheral neuropathy and the

accompanying decreased sensation and circulation may lead to stasis

ulcers, pressure ulcers, abrasions, and burns. Impaired skin integrity

predisposes the aging person to infection from organisms that are part

of normal skin ora.

3. Nutrition - Adequate nutrition is essential for optimal functioning of the

immune system. Vitamin intake, essential for DNA and protein synthe-

sis, if inadequate, may lead to protein-calorie deciency and subsequently

to impaired immune function. Vitamins also help in the regulation of

cell proliferation and maturation of immune cells. Excess or deciency

of trace elements (i.e., copper, iron, manganese, selenium, or zinc) in the

diet generally suppresses immune function. Fatty acids are the build-

ing blocks that make up the structural components of cell membranes.

Lipids are precursors of vitamins A, D, E, and K as well as cholesterol.

Both excess and deciency of fatty acids have been found to suppress

immune function.

4. Depletion of protein reserves results in atrophy of lymphoid tissues, de-

pression of antibody response, reduction in the number of circulating T

cells, and impaired phagocytic function. As a result, susceptibility to

infection is greatly increased. During periods of infection and serious

illness, nutritional requirements may be exaggerated further, potentially

contributing to depletion of protein, fatty acid, vitamin, and trace ele-

ments and an even greater risk of impaired immune response and sepsis.

3.2.1. Autoimmune disorders

In general, autoimmune disorders are more common in females than in males.

This is believed to be the result of the activity of the sex hormones. The ability

of sex hormones to modulate immunity has been well established. There is ev-

idence that estrogen modulates the activity of T lymphocytes (especially sup-

pressor cells), whereas androgens act to preserve IL-2 production and suppres-

sor cell activity. The eects of sex hormones on B -cells are less pronounced.

Estrogen activates the autoimmune-associated B-cell population that expresses

the CD5 marker (an antigenic marker on the-cell). Estrogen tends to enhance

47
SZL2111 HIV/AIDs

immunity, whereas androgen tends to be immunosuppressive.Autoimmune dis-

orders include lupus erythematosus, rheumatoid arthritis, or psoriasis

3.2.2. Neoplastic disease

Immunosuppression contributes to the development of cancers; however, can-

cer itself is immunosuppressive. Large tumors can release antigens into the

blood, and these antigens combine with circulating antibodies and prevent

them from attacking the tumor cells. Furthermore, tumor cells may possess

special blocking factors that coat tumor cells and prevent destruction by killer

T lymphocytes. During the early development of tumors, the body may fail

to recognize the tumor antigens as foreign and subsequently fail to initiate

destruction of the malignant cells. Hematologic cancers, such as leukemia and

lymphoma, are associated with altered production and function of WBCs and

lymphocytes. All treatments that an individual has received or is currently re-

ceiving, such as radiation or chemotherapy, are vital. Radiation destroys lym-

phocytes and decreases the population of cells required to replace them. The

size or extent of the irradiated area determines he extent of Immunosuppres-

sion. Whole-body irradiation may leave the patient totally immunosuppressed.

Chemotherapy also destroys immune cells and causes Immunosuppression.

3.2.3. Chronic illness and surgery

ˆ Chronic illness may contribute to immune system impairments in var-

ious ways. Renal failure is associated with a deciency in circulating

lymphocytes. In addition, immune defenses may be altered by acidosis

and uremic toxins. In diabetes, an increased incidence of infection has

been associated with vascular insuciency, neuropathy, and poor control

of serum glucose levels. Recurrent respiratory tract infections are asso-

ciated with chronic obstructive pulmonary disease as a result of altered

inspiratory and expiratory function and ineective airway clearance. Ad-

ditionally, surgical removal of the spleen, lymph nodes, or thymus or or-

gan transplantation may place an individual at risk for impaired immune

function.

48
SZL2111 HIV/AIDs

3.2.4. Special problems

ˆ Conditions such as burns and other forms of injury and infection may

contribute to altered immune system function. Major Burns or other

factors cause impaired skin integrity and compromise the body's rst line

of defense. Loss of large amounts of serum with burn injuries depletes the

body of essential proteins, including immunoglobulins. The physiologic

and psychological stressors associated with surgery or injury stimulates

cortisol release from the adrenal cortex; increased serum cortisol also

contributes to suppression of normal immune responses.

1. Medications

 In large doses, antibiotics, corticosteroids, cytotoxic agents, sal-

icylates, nonsteroidal anti-inammatory drugs, and anesthetics

can cause immune suppression.

2. Lifestyle and Other Factors

 Like any other body system, the immune system functions de-

pend on the function of other body systems. Poor nutritional

status, smoking, excessive consumption of alcohol and exposure

to environmental radiation and pollutants have been associated

with impaired immune function.

3.2.5. Role of immune system in HIV pathogenesis

ˆ The immune system is responsible for body defense against attack from

pathogenesis

ˆ It is made up of white blood cells which include granulocytes such as

neutrophils and basophils, and agranulocytes such as monocytes and

lymphocytes.

ˆ T-helper lymphocytes have a CD4+ marker that the HIV use for entry

into the cell and replicates

ˆ T-helper lymphocytes are important in immune regulation because when

they are activated they recruit other immune cell involved in immune

responses.

49
SZL2111 HIV/AIDs

ˆ HIV uses the CD4+ cells to replicate and produce more viral particles.

ˆ CD4 are killed and destroyed as viral production progresses

ˆ Cytotoxic T-lymphocytes with CD8+ marker target any virally infected

CD4+ cells and kills them

ˆ Macrophages which have a CD4+ marker too act as reservoir and are

also killed by cytotoxic

ˆ As virtually infected cells are killed by cytotoxic T-lymphocytes and

more of the CD4+ cells destroyed as a result of viral replication, their

numbers goes down.

ˆ The immune system is depleted of these crucial cells involved in body

defense and becomes vulnerable to attack by opportunistic pathogens.

Example . Briey describe the sexual transmission of HIV/AIDS

Solution : The risk of transmission through unprotected vaginal sex is thought

to be lower than anal sex, though still highly signicant. However, where there

is a risk of vaginal tears or sores e.g. in the presence of sexually transmitted

infection, the risk of transmission is increased signicantly. HIV transmission

through oral sex is a much debated subjected. However, the virus is present in

blood and semen, which means that in theory, this is a possible transmission

route. There may be an increased risk if there is ejaculation, bleeding gums,

lips, or inammation caused by common throat infections. The sharing of sex

toys also carries a risk of HIV transmission. If more than one person is going

to use a vibrator or dildo, is essential that it is cleaned thoroughly between

uses or covered with afresh condom before each use. . 

50
SZL2111 HIV/AIDs

Exercise 4.  Revision Questions

Discuss the role of immune system in HIV pathogenesis

51
SZL2111 HIV/AIDs

References and Additional Reading Materials

1. Maranga R. O, Muya S. M and Ogila K. O (2008) Fundamentals of

HIV/AIDS Education. Signon Publishers.

2. Barry D. S. (1999) AIDS and HIV in Perspectives. CPU. ISBN-13:

9780521627665

3. Ellison G. Parker M., Camphpbell C (2003) Learning from HIV and

AIDS. Cambridge CPU.ISBN-13: 9780521709286.

4. Shavitri Ramaiah (2008) HIV/AIDS; Health solutions. Sterling Publish-

ers Ltd. ISBN-9788120733305.

52
SZL2111 HIV/AIDs

LESSON 4
Biology of HIV
Learning outcomes
By the end of this topic you should be able to;

ˆ To know the nature of HIV

ˆ Describe the structure of HIV

ˆ Understand the Life cycle of HIV

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SZL2111 HIV/AIDs

4.1. Nature of HIV

HIV can't grow or reproduce on its own. It requires cell of living organisms

to infect & reproduce. HIV is specic to CD4+ cells in the human body i.e.

cells with surface molecule called Cluster of Dierentiation 4. Cells carry-

ing this molecule are called CD4+ cells. Therefore HIV cant survive in the

animal blood, because its only human blood that contains CD4+cells. HIV

is a lentivirus. Like all viruses in this group it attacks the immune system.

Lentiviruses are in turn part of a larger group of viruses called retroviruses.

The term "retrovirus" stems from the fact that these kinds of viruses are capa-

ble of copying RNA into DNA. The name lentivirus means slow virus. This is

because they take such a longtime to produce any adverse eects in the body.

4.2. The Structure of HIV

Outside of a human cell, HIV exists as roughly spherical particles (sometimes

called virions). The surface of each particle is studded with lots of little spikes.

An HIV particle is around 100-150 billionths of a meter in diameter. That's

about the same as 0.1 microns or 4 millionths of an inch or one seventieth

of the diameter of a human CD4+ white blood cell. Unlike most bacteria,

HIV particles are much too small to be seen through an ordinary microscope.

However they can be seen clearly with an electron microscope.

NB: The proteins gp120 and gp41 together make up the spikes that project
from HIV particles, while p17 forms the matrix and p24 forms the core.

Structurally HIV consist of

1. The viral envelope - HIV has a diameter of 1/10,000 of a millimeter

and is spherical in shape. The outer coat of the virus, known as the

54
SZL2111 HIV/AIDs

viral envelope, is composed of two layers of fatty molecules called lipids,

taken from the membrane of a human cell when a newly formed virus

particle buds from the cell. Embedded in the viral envelope are proteins

from the host cell as well as 72 copies (on average) of a complex HIV

protein (frequently called "spikes") that protrudes through the surface

of the virus particle (virion). This protein, known as Env, consists of

a cap made of three molecules called glycoprotein (gp) 120, and a stem

consisting of three gp41 molecules that anchor the structure in the viral

envelope. Much of the research to develop a vaccine against HIV has

focused on these envelope proteins.

2. Viral core/capsid - The viral core (or capsid) is usually bullet-shaped

and is made from the protein P24. The core contains:

(a) Two copies of identical strands of RNA - HIVs' genetic material

i. Almost all organisms, including most viruses, store their genetic

material on long strands of DNA.

ii. Retroviruses are the exception because their genes are com-

posed of RNA (Ribonucleic Acid).

iii. RNA has a very similar structure to DNA. However, small dif-

ferences between the two molecules mean that HIV's replica-

tion process is a bit more complicated than that of most other

viruses.

(b) Three viral enzymes: required for HIV replication

ˆ Reverse transcriptase (RT)- converts viral RNA to ds DNA

ˆ Integrase- integrates DNA produced by RT into human DNA

ˆ Protease/proteinase- cuts proteins into segments & facilitates

assemblance of new viral copies.

3. Matrix - Just below the viral envelope is a layer called the matrix, which
is made from the protein p17 which maintains the integrity of the virus

structure & transport genetic material.

4. Double layered lipid envelope -

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SZL2111 HIV/AIDs

ˆ HIV particles surround themselves with a coat of fatty material

known as the viral envelope (or membrane).

ˆ Projecting from this are around 72 little spikes, which are formed

from the proteins gp120 which protrudes from the surface & binds

CD4+ cells and gp41. which is embedded within the envelope & is

for entry/fusion.

4.3. The Life Cycle of HIV/ HIV Replication

1. Attachment - The gp120 on the surface of the virus particle bind to

the CD4 receptor on the surface of human T cell and the viral envelope

fuses with the human T cell membrane.

2. Entry - The contents of the HIV particle are then released into the cell,
leaving the envelope behind.

3. Reverse Transcription - Once inside the cell, the HIV enzyme reverse
transciptase converts the viral RNA into DNA, which is compatible with

human genetic material(DNA)

4. Integration - This DNA is transported to the cell's nucleus, where it

is spliced into the human DNA by the HIV enzyme integrase. Once

integrated, the HIV DNA is known as provirus.

5. Transcription - HIV provirus may lie dormant within a cell for a long
time. But when the cell becomes activated, it treats HIV genes in the

same way as human genes. First it converts them into messenger RNA

(using human enzymes).

6. Translation - Then the messenger RNA is transported outside the nu-

cleus, and is used as a blueprint for producing new HIV proteins and

enzymes.

7. Assembly & Budding - Among the strands of messenger RNA pro-

duced by the cell are complete copies of HIV genetic material. These

gather together with newly made HIV proteins and enzymes to form

new viral particles, which are then released from the cell. The enzyme

56
SZL2111 HIV/AIDs

protease plays a vital role at this stage of HIV's life cycle by chopping up

long strands of protein into smaller pieces, which are used to construct

mature viral cores.

8. Maturation & release - The newly matured HIV particles are ready

to infect another cell and begin the replication process all over again. In

this way the virus quickly spreads through the human body. And once a

person is infected, they can pass HIV on to others in their bodily uids.

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SZL2111 HIV/AIDs

Exercise 5.  Revision Questions

Discuss the life cycle of HIV.

Example . Are there other ways to avoid getting HIV through sex?

Solution : The male condom is the only widely available barrier against sexual

transmission of HIV. Female condoms are fairly unpopular in the U.S. and

still relatively expensive, but they are gaining acceptance in some developing

countries. Eorts are also under way to develop topical creams or gels called

"microbicides," which could be applied prior to sexual intercourse to kill HIV

and prevent other STIs that facilitate HIV infection. 

58
SZL2111 HIV/AIDs

Revision questions or guidelines

1. The knowledge of HIV life cycle has advanced the ght against HIV

through designing of antiretroviral drugs. Using appropriate examples,

discuss this statement.

2. Control of HIV/AIDs is directly linked to the knowledge of the trans-

mission of the causative agent. Discuss in detail this statement.

3. The use of antiretroviral drugs is facing various challenges. Highlight

and briey discuss the major limitation to the use of ARVs.

4. Anything else you would like to suggest

References and Additional Reading Materials

1. Maranga R. O, Muya S. M and Ogila K. O (2008) Fundamentals of

HIV/AIDS Education. Signon Publishers.

2. Barry D. S. (1999) AIDS and HIV in Perspectives. CPU. ISBN-13:

9780521627665

3. Ellison G. Parker M., Camphpbell C (2003) Learning from HIV and

AIDS. Cambridge CPU.ISBN-13: 9780521709286.

4. Shavitri Ramaiah (2008) HIV/AIDS; Health solutions. Sterling Publish-

ers Ltd. ISBN-9788120733305.

59
SZL2111 HIV/AIDs

LESSON 5
Disease progression and symptoms
Learning outcomes
Upon completing this topic, you should be able to understand:

ˆ Stages of HIV infection

ˆ Factors that leads to faster progression fro HIV to full blown AIDs

ˆ Opportunistic infections

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SZL2111 HIV/AIDs

5.1. Introduction
HIV infects cells of the immune system and the central nervous system. The

main cell HIV infects is T helper cell which is a crucial part of the immune

system, because it co-ordinates the actions of other cells of the immune system.

A large reduction in the number of T helper cells seriously weakens the immune

system.

5.1.1. Exposure vs. Infection

When HIV+ individual encounters an uninfected person, this does not always

result in transmission of HIV to the uninfected person. Only a fraction of the

exposed people will be infected. Dierent kinds of exposure between infected

& uninfected individuals have dierent probabilities of leading to infection.

Those who are exposed & become infected do not show sign of illnesses right

away.

5.1.2. Infection vs. Disease

Among individuals who become infected with HIV, not everybody will develop

physical symptoms. Most viral infections don't show physical symptoms, but

most people infected with HIV ultimately develop some disease symptoms.

These disease symptoms are caused by damage or destruction of cells & tissues

in the infected person. In some cases the damage may result from direct

killing of cells by virus. In the case of AIDS, most of physical symptoms are

the indirect result of damage to the immune system by HIV. Factors such as

age, sex, genetic make-up, nutrition, environmental factors,& encounters with

other infectious agents can inuence the exact nature of the symptoms in a

particular individual.

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SZL2111 HIV/AIDs

5.2. Stages of HIV Infection

There are four stages of HIV infection and they include:

1. Primary H IV infection, window period & sero conversion

2. Clinically asymptomatic stage,

3. Symptomatic HIV infection,

4. Progression from HIV to AIDS.

5.2.1. Primary HIV infection

This is the initial stage where one obtains the virus through the various modes

of transmission. It can be divided into:

1. Window period - This stage of infection lasts for a few weeks to about
3 months and is often accompanied by a short u-like illness or no signs.

HIV cannot be detected in blood screening although HIV is present in

blood & the blood in not 100% free of HIV. The virus cannot be seen in

the rst 21 days. During this time a person can still transmit the virus

to another person. It is the most crucial stage.

2. Sero conversion - This is the development of the anti-bodies. Im-

mune system begins to respond to HIV by producing HIV antibodies

and cytotoxic lymphocytes. If an HIV antibody test is done before se-

roconversion is complete then it may not be positive. In this stage a

person may have u like illnesses, fever, fatigue, sore throat, joint pains

& lymphadenopathy Some will not experience any illnesses at this stage.

5.2.2. Clinical asymptomatic HIV infection/ Latent phase

The presence of HIV without 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. 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. This period can

last for many years (5  15 years)

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SZL2111 HIV/AIDs

• Initial Infection Symptoms include:

ˆ Mononucleosis-like illness (sore throat, swollen glands, fever) & skin rash

ˆ Encephalopathy i.e. Brain infections - brain swelling & inammation of

the brain lining or meninges

ˆ This causes headache, fever, brain functions impairment, diculty in

concentration, remembering or solving problems

ˆ Personality changes may also occur

NB: Asymptomatic period  some type of balance exist between HIV infection
& the immune system in the infected person

5.2.3. Symptomatic HIV infection/AIDS Related Complex (ARC)

phase
Over time the immune system loses the struggle to contain HIV due to the

following main reasons:

1. The lymph nodes and tissues become damaged or 'burnt-out' because of

the years of activity;

2. HIV mutates and becomes more pathogenic, i.e. stronger and more

varied, leading to more T helper cell destruction;

3. The body fails to keep up with replacing the T helper cells that are

lost. As the immune system fails, so symptoms develop. Initially many

of the symptoms are mild, but as the immune system deteriorates the

symptoms worsen. When the viral load reaches a critical amounts, the

immune system is suppressed to such a degree that other infections which

under normal circumstances will not be dicult to resist gain entrance

i.e. opportunistic infections. Opportunistic infections  they take advan-

tage of the impairment of the immune system & sometimes are caused

by organisms that don't cause infections/ diseases in man. Symptoms

of HIV infection in this stage. Two or more of the following signs /

symptoms may occur:

ˆ Chronic fever

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SZL2111 HIV/AIDs

ˆ Lethargy (fatigue/ tiredness)

ˆ Continuous diarrhea - Eczema (allergy of the face)

ˆ More than 10% weight loss - Psoriasis (itchy pimples)

ˆ Lymphadenopathy

ˆ Dermatitis (itchy skin)

ˆ Night sweats

ˆ Oral candidiasis (sores in mouth)

ˆ Dementia (short term memory loss)

Incubation period - is the length in time between initial infection &

becoming symptomatic. It varies between people & depends on a length

of factors

5.2.4. Progression of HIV to AIDS

As the immune system becomes more and more damaged the illnesses that

present become more and more severe leading eventually to an AIDS diagnosis.

It's the most advanced stage of HIV infection. At this time when CD4 cell

count has gone down below 200 CD4 cells/ml, HIV develops to one or more

severe opportunistic infections or cancer. The infection / cancer may be life

threatening due to the weakened immune system.

Common symptoms in this stage/ Initial Disease Symptoms

An infected individual may have symptoms from more than one of these

classes;

1. HIV wasting syndrome: - Sudden unexplained loss in body weight (

>10% of total body weight), unexplained chronic diarrhea (>1 month),

Chronic weakness, unexplained prolonged fever usually at night that

causes night sweats (>1 month) and brain damage due to high temp

that causes fevers

2. Lymphadenopathy syndrome (LAS)/ persistent generalized lymphadenopa-

thy (PGL): Lymph glands enlargement is persistent. They swell in groin,

armpits, head & neck but are not painful. Some infected people may ex-

perience both LAS & Wasting Syndrome

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SZL2111 HIV/AIDs

3. Neurologic disease - direct damage of the brain by HIV or by other agent.

Damage of parts of the nervous system can also cause dierent neurologic

symptoms. For example:

(a) Dementias - Impaired mental functions, forgetfulness, loss of mental

functions. Diculty reasoning & performing mental tasks. Depres-

sion, social withdrawals & personality changes. Unable to care for

themselves eventually. Coma & death may follow.

(b) Spinal cord damage/ swelling (myelopathy) - Spinal cord transmits

nerve impulses to the muscles of the body. Because of this, damage

may result in weaknesses or paralysis of voluntary muscles/ limbs.

(c) Peripheral nerve swelling/ damage (neuropathy) - these nerves sense

pain. When damaged can cause burning or stinging sensations in

the hands or feet or occurrence of numbness

NB: individual patients may experience a mixture of any of these ill-

nesses Others include: Coughs & gasping of breath, Seizure- lack of

coordination, Diculty or pain during swallowing, Psychotic symptoms

- mental confusion & forgetfulness, Loss of vision, Severe headache, Nau-

sea, Abdominal crump & vomiting, Extreme fatigue, Cancers-m of blood,

and Coma. HIV+ patient can die any moment at this stage.

5.2.5. Other Complications in HIV Patients

This manifest when immune system is weak and they include:

a) Common brain infections - Tumors, Swelling of the brain, Nerve damage.

They can cause Headache & confusion, Poor coordination of feet, Blind-

ness, Enlarged lymph nodes, Fever, sore throat, weaknesses

b) Common skin infections - When immune system is damaged in HIV pa-

tients the skin conditions tend to persist more & they become dicult

to treat. In most cases these conditions are caused by bacteria, viruses

or fungi.

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SZL2111 HIV/AIDs

5.2.6. Factors that lead to faster development of HIV infection to

full- blown AIDs
1. Age - Persons who get infected after the age of 35years move faster from
HIV infection to full blown AIDS than those who get infected in their

mid 20s. Children who get infected at birth die faster simply because

their immune system is not well developed at their tender age.

2. Type of HIV contracted - There are two well known types: HIV1

and HIV2. HIV1 is harsher on people hence kills faster than HIV2.

3. Mode of transmission - HIV got through blood transfusion kills faster

than one got through sexual contact. This is because the amount of virus

channeled into the bloodstream is in large quantity.

4. Ill - health & other types of infections - People who are already

sick & then get infected move faster than those infected when healthy.

Tropical diseases such as malaria, typhoid & intestinal worms makes

patients to develop AIDS faster

5. Nutritional status - Those infected & are not eating enough of well-

balanced foods are more likely to develop AIDS faster

6. Lifestyle - People who expose themselves to re-infection with other

strains of HIV or STIs / STDs and other illnesses move faster from

HIV to AIDS

7. Opportunistic infections - If they are not competently treated, then

the HIV+ person develops AIDS faster.

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SZL2111 HIV/AIDs

5.3. Opportunistic Infections

1. Examples of fungal infections

(a) PCP - Inammation of the lungs caused by infection with fungus

called Pneumocystis carinii. Inamed areas of lungs appear as white

spots in x-rays. It's the leading cause of death in AIDS patients i.e.

about 50% of AIDS patients will eventually develop PCP

(b) Candida - Fungus is similar to baker's yeast. It is found on skin

& mucosal surfaces (mouth, vagina). In mouth they appear like

white plaques that feel furry. Antifungal e.g. mycostatin can be

used. They are dicult to completely eliminate. They can spread

to oesophagus & cause painful burning sensation when eating i.e.

oesophagitis. 50% of AIDS patients will experience candidacies.

(c) Systemic mycosis - Soil fungus that can cause generalized infections

in AIDS patients. Exist in either mold like or yeast like form & are

called dimorphic. There are of 3 types - Histoplasmosis, Coccid-

iomycosis, & Cryptococcus. They cause lung infections in healthy

patients. In AIDS patients, the brain, skin, bone, liver & lymphatic

tissue may also be highly infected.

2. Example of Bacterial infections - Components of I.S. responsible for con-

trolling the common bacteria are less aected by HIV infection, thus

adult AIDS patients do not generally suer infections with common bac-

teria

(a) Mycobacterium - Infection with Mycobacterium avium intracellular

is most common in AIDS patients. It does not cause disease in

healthy people but it causes TB-like disease in the lungs of AIDS

patients. Also causes infection of BM & presence of bacteria in

blood at high levels. Patients will have fevers & low no. of white

blood cells. Mycobacterium tuberculosis that causes TB is also

common in AIDS patients.

3. Example of Viral infections

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SZL2111 HIV/AIDs

(a) Cytomegalovirus (CMV) - Common virus that infect people inn

childhood with no symptoms but may cause mononucleosis-like ill-

ness (sore throat, swollen glands, fevers) in adults. Congenital in-

fections(fetus) can also lead to permanent brain damage. In AIDS

patients CMV infect retinas of the eyes causing blindness & also

adrenal glands leading to hormonal imbalance. CMV can cause

pneumonia, fevers, rash & gastroenteritis in AIDS patients. CMV

pneumonia in patients with PCP is fatal

(b) Varicella (shingles) - Painful rash condition that occurs on human

trunk. Latent varicella zoster (that causes chicken pox in childhood)

is reactivated when the I.S. is compromised. Antiviral drugs e.g.

acyclovir is sometimes used to control shingles

4. Example of Protozoan infections:

(a) Cryptosporidium gastroenteritis - It is caused by protozoan called

cryptosporidium. It infect lining of the intestinal tract & causes

diarrhea (gastroenteritis). In normal/ healthy people diarrhea lasts

a few days but in AIDS patients it is prolonged & severe. That

is about 20-50 watery stools per day accompanied by abdominal

cramps & weight loss

(b) Toxoplasmosis - It is caused by Toxoplasma gondii that causes

asymptomatic infections in healthy adults. In AIDS patients it

causes brain infections with symptoms similar to brain tumors (e.g.

convulsions, dementias).

5. Examples of Cancers:

(a) Kaposi's sarcoma (KS) - Are tumors of blood vessels. In non -

AIDS patients KS is seen in older men of Jewish ancestry. Initially

few tumors appear as pink, purple or brown skin lesions located on

arms or legs. Eventually they spread & become widely distributed

in most linings of the body. They are dicult to control if they

spread to the lungs. Chemotherapy can eradicate them.

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SZL2111 HIV/AIDs

(b) Lymphomas - Cancers derived from B cells of immune system are

the common type of lymphomas in AIDS patients. Epstein-Barr

virus causes mononucleosis but it can also transform normal B cell

into cancer cell. Unusual lymphoma that spread to the brain also

occur in AIDS patients.

(c) Cervical cancers - Its common in female AIDS patients. Infections

with certain strains of Human Papilloma Virus (HPV) that cause

warts in the genital tract is an underlying cause of cervical cancer.

Cancer caused or induced by HPV develops faster when immune

system is compromised in AIDS patients.

(d) Hairy leukoplakia - Abnormal condition of the mouth in which white

plaques appear on the surface of the tongue. This is due to abnor-

mal growth of papillae cells of the tongue. They can't be scrapped

o. They resemble cancer cells.

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Exercise 6.  Revision Questions

The progressions of HIV to AIDs involve dierent stages of clinical devel-

opments. Discuss

Example . Factors that lead to faster development of HIV infection to full

- blown AIDS

Solution : Age - Persons who get infected after the age of 35years move faster

from HIV infection to full blown AIDS than those who get infected in their mid

20s. Children who get infected at birth die faster simply because their immune

system is not well developed at their tender age. Type of HIV contracted -

There are two well known types: HIV1 and HIV2. HIV1 is harsher on people

hence kills faster than HIV2. Mode of transmission - HIV got through blood

transfusion kills faster than one got through sexual contact. This is because

the amount of virus channeled into the bloodstream is in large quantity. Ill

- health & other types of infections - People who are already sick & then get

infected move faster than those infected when healthy - Tropical diseases such

as malaria, typhoid & intestinal worms makes patients to develop AIDS faster

Nutritional status - Those infected & are not eating enough of will balanced

foods are more likely to develop AIDS faster. Lifestyle - People who expose

themselves to re-infection with other strains of HIV or STIs/STDs and other

illnesses move faster from HIV to AIDS. Opportunistic infections - If they are

not competently treated, then the HIV+ person develops AIDS faster. 

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References and Additional Reading Materials

1. Maranga R. O, Muya S. M and Ogila K. O (2008) Fundamentals of

HIV/AIDS Education. Signon Publishers.

2. Barry D. S. (1999) AIDS and HIV in Perspectives. CPU. ISBN-13:

9780521627665

3. Ellison G. Parker M., Camphpbell C (2003) Learning from HIV and

AIDS. Cambridge CPU.ISBN-13: 9780521709286.

4. Shavitri Ramaiah (2008) HIV/AIDS; Health solutions. Sterling Publish-

ers Ltd. ISBN-9788120733305.

71
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LESSON 6
Transmission and diagnosis of HIV
Learning outcomes
Upon completing this topic, you should be able to understand:

ˆ Various methods used in diagnosis of HIV

ˆ The modes of HIV transmission

ˆ Pregnancy and HIV/AIDS

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6.1. Transmission of HIV

ˆ HIV is present in semen, vaginal/ cervical secretions & body uids. It

may be present in tears, urine, csf, breast milk &infected discharges,

saliva. HIV is spread when an infected individual come into contact

with infected body uids or cells. How HIV is NOT transmitted.

ˆ There is no evidence to show that HIV can be transmitted by:

 casual social contact e.g. shaking hands, hugging

 sneezing or coughing

 shared facilities & equipment e.g. toilets, swimming pools

 non wet kissing

 sharing food & utensils

 insect bites e.g. mosquitoes - HIV only lives for a short time and

does not reproduce in an insect

 Injecting with sterile needles

 Protected sex - If an unbroken latex condom is used, there is no

risk of HIV transmission. There are myths saying that 'some very

small viruses can pass through latex' - this is not true.

6.1.1. Modes of HIV Transmission

1. Sexual contact - Any unprotected (no condom) penetrative sex whether
vaginal, anal or oral can transmit HIV from infected individual to unin-

fected sexual partner.

(a) Heterosexual contact (man &woman) a/c 70%-80% of all HIV trans-

mission.

(b) Homosexual contact a/c 5-10%

(c) Oral sex is low risk but oral ulcers, bleeding gums, genital sores &

presence of STIs (gonorrhea, syphilis & genital ulcers) do increase

the risk of hiv transmission

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(d) Rape, & sodomy victims could get infected if the attacker is HIV+.

The victims should seek prompt medical attn because early treat-

ment with ARVs can greatly reduce chances of HIV infection. They

will also require specialized counseling & psychological /psychiatric

care Factors that inuence transmission through sexual contact

(e) The risk of HIV transmission through sexual contact is inuenced

by a number of factors:

i. level of virus in the body

ii. number of sexual partners

iii. sex  male/female

iv. age

v. STDs/STIs

vi. Condom use

2. Intravenous Drug Use/ Contaminated Piercing Instruments -

I.V. drug use is the administration of drugs of addiction e.g heroin into

the blood stream by injecting into the veins. Most drug users tend to

shoot in groups & often share needles. It therefore becomes very easy

for transmission /infection to occur from one infected group member to

another. It's a signicant modes in the developed countries accounting

for 5-10% of HIV infections. Procedures such as ear piercing & circum-

cisions when done with poorly cleaned & unsterile instruments can lead

to HIV transmission.

3. Occupational exposure/ Infection in the health-care setting -

Occupational exposure is the accidental exposure of healthcare workers

(e.g doctors &nurses) to body uids from an infected patient in their

care. This is most frequently due to needle pricks or cuts with surgical

instruments. Infection can also occur due to contact with infected blood,

laboratory samples especially through broken skin.

4. Mother - to - child transmission (MTCT) - Also called Vertical

/ perinatal transmission & it accounts for 13-40% HIV infections. It's

possible for HIV to be transmitted from HIV+ mothers to unborn child.

This occurs in 3 ways:

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SZL2111 HIV/AIDs

(a) During pregnancy- The virus crosses from mother's blood to child

through the placenta. Although there's no exchange of blood be-

tween mother & child, researchers believe that the foetus can get

HIV through the placenta i.e through diusion. It accounts for

about 35% HIV infections

(b) During birth  Through exposure to mother's blood & other secre-

tions. It accounts for 65% HIV infections

(c) After birth- through breast feeding. Breast milk contains minimal

quantities of HIV. It accounts for 15% HIV infections.

6.1.2. Factors that increase chances of MTCT/ Determinants

ˆ high level of HIV in mother's blood & other body uids (maternal viral

load)

ˆ duration of exposure to maternal secretions during delivery

ˆ inadequate nutrition

ˆ pre-term delivery- premature babies are more prone to infection because

the immune mechanism is still very weak/ immature

ˆ Maternal immune response- maternal CD4 cell count

ˆ prolonged membrane rupture-increased risk if more than 4hours

ˆ obstetrical procedures- e.g. vacuum assisted delivery

ˆ unprotected sexual intercourse

ˆ presence & amount of virus in the genital tract

ˆ Placenta barrier- breaches in barrier leads to mixing of maternal and

foetal cells

ˆ Presence and amount of HIV in genital tracts

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6.1.3. Prevention of MTCT (PMTCT)

ˆ Prevent HIV infection in women i.e. encouraging teenage girls to delay

sexual relationships & discordant couples to use of condoms.

ˆ Reduce the number of HIV exposed pregnancies i.e. Women who are

HIV infected can use family planning methods to prevent pregnancies.

ˆ ART- to infected pregnant women.e.g. AZT (zidovudine/ azidothymidine-

Nov `94) is taken in the last week of pregnancy and nevirapine is given

at the onset of labour & to the HIV exposed babies within 3 days after

birth

ˆ Preventing malaria - A woman who is infected with both HIV and

malaria has an increased chance of passing HIV to her baby. Anti-

malarial drug treatment during pregnancy is therefore an important part

of preventing MTCT

ˆ Reducing trauma and shortening exposure of the baby to the virus during

labour and delivery i.e. Modied obstetrical practices which include

 make sure that the mother gives birth within 4 hours after mem-

brane ruptures (water breaks),

 avoid routine episiotomy,

 avoid prolonged labour,

 minimum use of vacuum or forceps delivery, and

 Electing to use caesarian section.

ˆ Appropriate choice of feeding infants i.e. breastfeeding exclusively with-

out any supplements followed by abrupt but timely weaning or replace-

ment feeding from birth without any breast milk.

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6.2. Diagnosis of HIV and AIDs

A number of tests are used to conrm the presence of antibody to HIV and to

assist in diagnosing HIV infection.

6.2.1. The Enzyme-Linked Immunosorbent Assay (ELISA)

ˆ The test identies antibodies directed specically against HIV. The ELISA

test does not establish a diagnosis of AIDS. Rather, it indicates that the

person has been exposed to or infected with HIV. People whose blood

contains antibodies for HIV are said to be seropositive. HIV antibodies

do not reach detectable levels in the blood for one to three months. This

period is known as sero conversion during which antibody production

to viral proteins take place.  Window period is the time during which

antibody detection using Elisa is negative. In some cases it may take

even 6 months for the antibody levels to get high enough for detection.

6.2.2. The Western blot assay

ˆ It is another test that can identify HIV antigens and is used to conrm

seropositivity as identied by the ELISA. This is a method that detects

very low antigen levels such that one may test HIV negative by ELISA

but test positive through western blot. Babies born of HIV mother have

antibodies to HIV that were passed on during pregnancy through the

placenta. However these antibodies diminish with time such that by

15 months the child may test negative. Use of Western, blot conrms

presence of HIV antigen and this rules out whether babies are positive

because of HIV itself or because of maternal antibodies.

6.2.3. PCR
ˆ It is also used to detect HIV in high-risk seronegative people before

the development of antibodies, to conrm a positive ELISA, to screen

neonates, and to determine the exact strain of virus that is present.

6.2.4. CD4+Cell count

ˆ Once a patient is diagnosed positive the extent of damage to the im-

mune system is determined by CD4+ cell count (T-helper cell count).

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SZL2111 HIV/AIDs

The number of CD4 cells present is a direct indicator of the immune

system's ability to ght o opportunistic infections. The test to measure

CD4 cells requires a sample of blood to be taken and measurement is

made of the number of CD4 cells in a cubic milliliter of blood and will

give a picture of the health of the immune system-whether it is improv-

ing or declining. The CD4 count of a person who is not infected with

HIV may lie anywhere between 500 and 1200.A drop in an HIV positive

persons CD4 count usually occurs over a number of years. A CD4 count

between 500 and 200 indicate that some damage to the immune system

has occurred and a count below 350 or rapid decline is an indication that

one should consider anti-HIV treatment.

6.2.5. Measuring viral load

ˆ Measuring viral load is essential to determine how active the viral repli-

cation is if one is taking anti-HIV medication, then it is also a direct

indicator of how successful it is in suppressing viral replication. The

viral load test requires the collection of a blood sample and estimates

the number of HIV particles in the sample by looking for HIV genes.

The level of viral load is generally seen as a good indicator of whether

to start ant-HIV treatment. An undetectable viral load is an indication

that both the risk of developing AIDS and the risk of developing drug

resistance has been reduced. A high viral load is an indication of high

levels of HIV in body uids while undetectable viral load indicates a

reduction in levels of HIV in these uids but the risk of transmitting the

virus is still present

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SZL2111 HIV/AIDs

6.3. STIs, STDs, FGM and HIV/AIDS

STDs are diseases that are transmittable from an infected person to another

through sexual intercourse. STIs is a term applied to infections that are trans-

mitted primarily through sexual contact be it vaginal, oral, or anal intercourse.

They don't necessarily involve sexual activity but the organisms that cause

STIs enters mostly through the soft & thin skin that cover the inner surfaces

i.e. mucus membrane of the vagina, urethra, anus & mouth. However, in

some instances exposure to sores or other types of skin to skin contact may be

insucient to transmit the infection.

6.3.1. Common examples of STIs/ STDs

ˆ Syphilis

ˆ Gonorrhea

ˆ Candidacies

ˆ Hepatitis B & C.

ˆ Chancroids ( genital sores)

ˆ Genital herpes (Herpes Simplex V)

ˆ Genital warts( Human Papilloma V)

ˆ Bacterial vaginosis.

ˆ Trichomoniasis

6.3.2. Relationship between HIV & STDs/STIs

STIs/STDs increase the risk of HIV infection by mobilizing a high population

of T cells to ght the STI/STD. Since the T cells are the target cells for

attack by HIV, such a large population will inevitably provide breeding ground

for HIV. STDs/STIs also increase the risk of acquiring or transmitting the

virus. Both are transmitted through sexual contact & to unborn baby during

pregnancy or at birth.

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SZL2111 HIV/AIDs

6.3.3. Dangers/ risks of STDs/STIs

ˆ Increased risks of getting infected with HIV or the risk of infecting others

ˆ High incidences of infertility e.g. pelvic inammatory disease if untreated

result in infertility or tubal pregnancies.

ˆ Future problems with pregnancies & child birth

ˆ Mental disorders & deaths especially in syphilis Treatment of STDs/STIs

ˆ STDs/STIs require medical examination & medical treatment. Any per-

son who has contracted STD/STI & is receiving treatment should also:

 Receive counseling from a qualied health worker on how to avoid

future infections

 Take all medicines prescribed exactly according to all the instruc-

tions

 Inform all sexual partners of the need to get examined & treated

 Abstain from further risky sexual behaviors

 Use condoms for protection

6.3.4. Why teenagers don't seek treatment

ˆ Lack of condentiality

ˆ Hostility of service providers

ˆ Stigma attached to STIs/STDs

ˆ Financial constraints for the youth who are unemployed e.g. anti-fungal

drugs( diunisal pessaries) - clears most infection and it costs Ksh.1500

per tablet

ˆ Ignorance of availability of service providers

NB: these concerns could be addressed through training service providers to be

youth friendly & availing information, education & communication materials

to the youth

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6.3.5. FGM (Female Genital Mutilation)

It's a destructive invasive procedure usually performed on girls before puberty.

It involves surgically removal of part or the whole clitoris using razor blades,

knives, and scissors. Since the victims are young they are unable to give

their informed consent. FGM is forced on approximately 6000girls per day

world wide. Because of poverty & lack of medical facilities the procedure is

frequently done under less hygienic conditions & often without anaesthesia. A

person who is not medically trained usually circumcises about 20 girls of same

age group.

• Types of FGM
1. Sunna - its most widely practiced in sub-Saharan and middle east. It

involves removal of the tip of the clitoris.

2. Intermediate-it's where the whole clitoris and adjacent parts such as

labia major and labia minor are removed.

3. Pharoic - it's the total removal of the clitoris, labia minor, labia major
and where the two sides of the vulva are drawn together and then fas-

tened leaving a small opening for urinating and menstruating. This is

especially in Somalia.

• Eects of FGM leads to conditions that favours HIV survival

They include;

ˆ An abnormal anatomy with anatomical distortion

ˆ Partial closure of the vagina

ˆ Incomplete healing brought about by infections i.e. acids & organisms

from urine

ˆ Scar formation which may be excessive

ˆ Urinary tract infection f ) Inammation of the genital area

ˆ Chronic urinary retention - urine is broken down to urea & uric acid

accumulates in joints & causes gout.

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Exercise 7.  Revision Questions

Discuss various methods used in HIV/AIDS diagnosis

Example . What is CDC's guidance on ART and preventing the sexual

transmission of HIV?

Solution :
Know your HIV status-get tested: Knowing whether or not you have HIV

is the rst step toward keeping yourself healthy and avoiding passing infection

on to others. Continue to get tested regularly if you engage in ongoing risk

behavior.

If you are HIV infected, know about ART: See a healthcare provider and

nd out if you should be on ART. Even if you do not need ART at rst, keep

your appointments for check-ups so that you will be able to start when you

do need it. Current guidelines suggest that ART be started when the CD4

cell count is between 350-500. However, it may be started when CD4 counts

are greater than 500, depending upon your situation. For example, pregnant

women and people with certain medical conditions should start earlier, at

higher CD4 counts. ART can also be started earlier to help prevent HIV

transmission to partners at risk for infection. Ask your healthcare provider

about when the time is right for you.

If you are on ART, take it correctly and consistently: ART drugs work best

when the right doses are taken at the right times. Not taking them properly

gives the virus a chance to multiply and sometimes become resistant to the

medications. Taking ART as recommended will give you the best chance of

staying healthy, and will probably help lessen the chance of infecting others.

Whether you are infected or not, know what to do to prevent transmission

of HIV: Eective ART and an undetectable viral load will probably decrease

the risk of transmission, but ART alone will not prevent all new infections. For

additional protection, other prevention methods-abstinence, sex only within a

mutually monogamous relationship, and condoms-should be used.

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SZL2111 HIV/AIDs

Revision questions or guidelines

1. What are the advantages of pre-test counseling?

2. Explain the expected reactions that might be encountered by an HIV

positive individual.

3. State the advantages of knowing ones HIV status.

4. What are the components of home-based care of HIV/AIDS patients?

5. VCT is a powerful weapon in the ght against HIV/AIDS. Explain the

role of VCT centers as a HIV/AIDS management strategy.

6. Anything else you would like to suggest

References and Additional Reading Materials

1. Maranga R. O, Muya S. M and Ogila K. O (2008) Fundamentals of

HIV/AIDS Education. Signon Publishers.

2. Barry D. S. (1999) AIDS and HIV in Perspectives. CPU. ISBN-13:

9780521627665

3. Ellison G. Parker M., Camphpbell C (2003) Learning from HIV and

AIDS. Cambridge CPU.ISBN-13: 9780521709286.

4. Shavitri Ramaiah (2008) HIV/AIDS; Health solutions. Sterling Publish-

ers Ltd. ISBN-9788120733305.

83
SZL2111 HIV/AIDs

LESSON 7
Prevention and treatment of Hiv/Aids
Learning outcomes
Upon completing this topic, you should be able to understand:

ˆ Prevention and control of mother to child transmission

ˆ HIV Post exposure prevention

ˆ Classes of drugs used against HIV

ˆ Limitations of antiretroviral therapies

ˆ Development of new HIV drugs and vaccine

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SZL2111 HIV/AIDs

7.1. Prevention and control of mother to child transmission

There are certain factors that may reduce the risk of transmission from mother

to baby. They includes:

ˆ Taking anti-HIV therapy during pregnancy and delivery e.g. AZT which

reduces the viral load.

ˆ An elected caesarean section instead of normal delivery

ˆ Not breast feeding where there is access to safe, adequate milk sub-

stitutes. Breast feeding should be avoided because the HIV virus is

present in breast milk. Also it is not uncommon for mothers to experi-

ence cracked or bleeding nipples while breastfeeding, therefore increase

the risk of viral transmission.

ˆ Mothers who are HIV positive should not donate breast milk to breast

milk barks, neither should they express milk to be bottle fed to their

baby.

7.2. Prevention and control of transmission through blood and other

blood products
ˆ Screening all donated blood especially for transfusion.

ˆ Careful handling of blood and body uids

ˆ Avoidance of sharp injuries, needles, knives, clips, sharp objects in hos-

pital working situation

ˆ Used needles should be disposed in the right tray.

ˆ Never pick up a sharp object without looking

ˆ Use of gloves (heavy gloves) when you sense danger

ˆ Avoid skin/mucous membrane contaminations. Equipments should be

thoroughly and properly sterilized. This is because HIV is very sensitive

and easily destroyed by boiling at least 5 minutes and is susceptible to

a wide range of disinfectants

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SZL2111 HIV/AIDs

7.3. HIV Post exposure prevention

Studies show that under certain circumstances, administering antiretroviral

drugs within 24 hours (preferably within one to two hours) after exposure to

HIV can protect a person from becoming infected with the virus. Although the

eectiveness of post exposure antiretroviral therapy following sexual exposure

to HIV remains uncertain, the Center for Disease Control, USA, recommends

that health-care personnel exposed to HIV infection from a needle stick or

other accident take antiretroviral drugs.

7.3.1. Ways in which HIV cannot be transmitted

ˆ Kissing (except in cases of deep kissing where copious amount of saliva

is exchanged), touching, hugging or shaking hands

ˆ Sharing crockery and cutlery

ˆ Coughing or sneezing

ˆ Contact with toilet seats

ˆ Insect or animal bites e.g. mosquitoes, bedbugs.

ˆ Swimming pools

ˆ Eating food prepared by someone with HIV.

7.4. Treatment of HIV

ˆ The four main classes of drugs used against HIV are:

 Nucleoside Analogue Reverse Transcriptase Inhibitors

 Non-nucleoside Analogue Reverse Transcriptase Inhibitors

 Protease Inhibitors

 Entry Inhibitors

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SZL2111 HIV/AIDs

7.4.1. Nucleoside analogues reverse transcriptase inhibitors

These impede the action of reverse transcriptase, the HIV enzyme that con-

verts the virus's genetic material into DNA. During this conversion process,

these drugs incorporate themselves into the structure of the viral DNA, ren-

dering the DNA useless and preventing it from instructing the infected cell to

make additional HIV. Examples include AZT, didanosine (sold under the trade

name Videx), zalcitabine (HIVID), stavudine (Zerit), lamivudine (Epivir), and

abacavir (Ziagen)

7.4.2. Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

They use a dierent mechanism to block reverse transcriptase. These drugs

bind directly to reverse transcriptase, preventing the enzyme from converting

RNA to DNA. Three NNRTIs are available: nevirapine (Viramune), delavir-

dine (Rescriptor), and efavirenz (Sustiva).

7.4.3. Protease inhibitors

These cripple protease, the enzyme vital to the formation of new HIV. When

these drugs block protease, defective HIV forms that is unable to infect new

cells. These drugs are taken orally and act against HIV directly. As the chem-

icals produced by the new DNA attempts to make copies of HIV, the protease

inhibitors act against them and prevent them from working correctly. New

particles of HIV produced in the presence of protease inhibitors are immature

and non-infections. Examples are saquinavir (Invirase), ritonavir (Norvir),

indinavir (Crixivan), nelnavir (Viracept), and amprenavir (Agenerase).

7.4.4. Entry inhibitors

They are known as entry inhibitors because the rst stage of the process,

whereby HIV enters a CD4 cell is the binding or fusion of the HI virus with a

particular part of outer wall of the CD4. The entry inhibitor is a drug speci-

cally designed to t between the HIV particle and the point of the CD4 cell to

which it needs to bind to gain entry and therefore prevent this happening.This

is the newest class of anti-HIV drug. The best known drug in this class is T-20,

which is taken by injection into a muscular part of the body.

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SZL2111 HIV/AIDs

7.4.5. Limitations of antiretroviral therapies

ˆ ARVs have a number of limitations. They include drug resistance, side

eect and costs of treatment:

• Drug resistance
ˆ Clinical studies of treatment with antiretroviral drugs have showed that

their benets are short-lived when a single drug is used alone. This

short-term eectiveness 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 design current antiretroviral drugs to im-

pede the activity of these enzymes. The structure of the virus's enzymes

changes if the virus mutates. Drugs no longer work against the enzymes,

making the drugs ineective against viral infection, and resistance sets.

ˆ Genes mutate during the course of viral replication, so the best way to

prevent mutation is to halt replication. Studies have shown that the

most eective treatment to halt HIV replication employs a combination

of three drugs taken together, for instance, a combination of two Nucle-

oside Analogues with a Protease Inhibitor. This regimen is called triple

therapy (also known as Highly Active Antiretroviral Therapy - HAART)

and it maximizes drug potency while reducing the chance for drug resis-

tance. The combination of three drugs is often referred to as an AIDS

cocktail. In HIV-infected patients who have undergone triple therapy,

the viral loads reduced signicantly, sometimes to undetectable levels.

ˆ Despite phenomenal success, triple therapy has some drawbacks. This

multidrug therapy is quite complicated, requiring patients to take any-

where from 5 to 20 pills a day on a specic schedule. Some drugs must

be taken with food, while others cannot be taken at the same time as

certain other pills. Even the most organized people nd it dicult to

take pills correctly. Yet, just one or two lapses in treatment may cause

the virus to develop resistance to the drug regimen

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SZL2111 HIV/AIDs

• Drug side eects

ˆ Many people also nd it dicult to deal with the unpleasant side eects

produced by antiretroviral drugs. Common side eects include nausea,

diarrhea, headache, fatigue, abdominal pain, kidney stones, anemia, and

tingling or numbness in the hands and feet. Some patients may develop

diabetes mellitus, while other patients develop collections of fat deposits

in the abdomen or back, causing a noticeable change in body congura-

tion. Some antiretroviral drugs produce an increase in blood fat levels,

placing a patient at risk for heart attack or stroke. Some patients suer

more misery from the drug treatment than they do from the illnesses

produced by HIV infection.

ˆ To decrease the toxic eects of drugs and to defer costly therapy, it

advisable to delay drug treatment for HIV infection in people showing

no symptoms and who have been infected with HIV for more than six

months. The new guidelines call for delaying treatment until an infected

person's CD4 cells fall below 350 cells per microliter of blood or the

HIV viral load exceeds 30,000 per microliter of blood. Evidence suggests

that delaying treatment poses no harm to infected people and, in fact,

benets them by deferring the toxic side eects of the drugs.

• Cost of treatment
ˆ 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

health-care facilities. As a result, the most eective therapies currently

available remain beyond the reach of the majority of HIV-infected people

worldwide.

7.4.6. Development of new HIV drugs and vaccine

ˆ Scientists continue to develop more powerful HIV treatments that have

fewer side eects and fewer resistance problems. Some drugs under in-

vestigation block the HIV enzyme integrase from inserting viral DNA

into the infected cell. Other drugs prevent HIV from binding with a

CD4 cell in the rst place, thereby barring HIV entry into cells.

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SZL2111 HIV/AIDs

ˆ Some scientists focus on ways to fortify the immune system. A biologi-

cal molecule called interleukin-2 shows promise in boosting the immune

system's arsenal of infection-ghting cells. Interleukin-2 stimulates the

production of CD4 cells. If enough CD4 cells can be created, they may

trigger other immune cell responses that can overpower HIV infection.

ˆ In other research, doctors hope to bolster the immune system with a vac-

cine. Most vaccines available today, including those that prevent measles

or poliomyelitis, work by helping the body to create antibodies. Such

vaccines mark specic infectious agents, such as the measles and polio

viruses, for destruction. But many experts believe that an eective HIV

vaccine will need to do more than just stimulate anti-HIV antibodies.

Studies are underway to develop vaccines that also elevate the produc-

tion of T cells in the immune system. Scientists hope that this dual

approach will prime the immune system to attack HIV as soon as it ap-

pears in the body, perhaps containing the virus before it spreads through

the body in a way that natural immune defenses cannot.

7.4.7. Challenges in Developing AIDS Vaccines

ˆ HIV continually mutates and recombines. This may mean that a vaccine

would need to protect the person against many strains of the virus. Vac-

cines against other viruses have only had to protect the person against

one or a limited number of strains.

ˆ HIV infects helper T cells, the immune cells that orchestrate the immune

response. It is very dicult to design a vaccine that, to be eective, needs

to activate the very cells the virus infects. HIV can be transmitted as

both free virus and in infected cells. This may mean that both arms

of the immune system (humoral and cellular mediated) may need to be

stimulated.

ˆ Researchers do not know what constitutes an eective immune response

to HIV. It might be antibodies, activated immune cells, perhaps a third

immune response, or a combination of immune responses. Researchers

lack an ideal animal model for AIDS vaccine testing

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7.4.8. Treatment of opportunistic infections

ˆ In addition to antiretroviral therapy to combat HIV infection, eective

drug treatments are available to ght many of the medical complications

that result from HIV infection. Doctors try to prevent infections before

they begin to avoid taxing a patient's weakened immune system unnec-

essarily. A doctor instructs an HIV-infected person on ways to avoid

exposure to infectious agents that produce opportunistic infections com-

mon in people with a weakened immune system. Doctors usually pre-

scribe more than one drug to forestall 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 pneumo-

nia. Patients suering from recurring thrush may be given the antifungal

drug uconazole for prolonged periods. For people with CD4 cell counts

of less than 100 cells per microliter, doctors may prescribe clarithromycin

or azithromycin to prevent Mycobacterium avium infections.

• Support mechanisms
ˆ A person diagnosed with HIV infection faces many challenges, includ-

ing choosing the best course of treatment, paying for health care, and

providing for the needs of children in the family while ill. In addition

to these practical considerations, people with HIV infection must cope

with the emotional toll associated with the diagnosis of a potentially

fatal illness. The social stigma that continues to surround a diagnosis of

AIDS because of the disease's prevalence among gay men or drug users

causes many people to avoid telling family or friends about their illness.

People with AIDS often feel incredibly lonely as they try to cope with

a devastating illness on their own. Loneliness, anxiety, fear, anger, and

other emotions often require as much attention as the medical illnesses

common to HIV infection.

ˆ Counseling centers and churches provide individual or group counseling

to help people with HIV infection or AIDS share their feelings, problems,

and coping mechanisms with others. Family counseling can address the

emotions of other family members who are disturbed by the diagnosis

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of HIV infection in another family member. Grief counseling also helps

people who have lost friends or family members to AIDS.

ˆ Voluntary Counselling and Testing Services (VCT) Counselling is ad-

vice or guidance, especially as provided by a professional in a given eld.

Counselors are people who are trained to help others to understand their

problems, identify and develop solutions, and make their own decisions

about what to do. Counselling involves being with them, listening to

them talk about their problems and fears, helping them to increase their

own self-esteem, and when necessary giving correct and useful informa-

tion based on what they need to know at that point in time. Voluntary

counselling and testing (VCT) is an important strategy for management

of HIV/AIDS. It is a powerful weapon in the ght against HIV/AIDS

since it is associated with behaviour change that reduces HIV transmis-

sion and serves as a point of entry into care for those testing.

ˆ The national VCT programme uses four models of service delivery:

 integrated,

 stand-alone,

 community-based

 and mobile.

ˆ In integrated sites, a VCT centre is usually located within the grounds of

health facilities such as hospitals, health centres or dispensaries. Stand-

alone sites are usually not associated with any existing medical institu-

tion and usually have sta fully devoted to VCT. They are largely op-

erated by non-governmental agencies and are usually located in densely

populated urban areas. In the community-based sites, VCT is either

integrated into other social services or implemented as the sole activity

of a local community-based organization (CBO) or a faith-based orga-

nization (FBO). In the mobile sites VCT is provided as an outreach to

remote or hard-to-reach communities where other models of VCT are

either not feasible or unavailable.

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ˆ There may be any number of reasons why a person may want to undergo

a test to discover whether they are HIV positive.

 Medical reasons for testing

* Pregnancy

* STDs

* Legal insurance,

* visas, s

* cholarships

 Voluntary testing

* Desire to know HIV status

* For those expecting to marry/for future partnership.

* Experiencing symptoms indicative of HIV.

7.4.9. Steps involved in HIV testing in VCT

• Pretest counseling
HIV counseling is an eective public health intervention because it promotes

the health of HIV infected persons and plays a role in reducing HIV transmis-

sion. Aims of a pretest counseling Ensure you have a full understanding of the

implications of the test and are able to make an informed decision whether

to test. Ensure informed consent (to carry out the test) is gained from you.

Give you the opportunity to discuss routes of HIV transmission Discuss the

implications and support needs that may follow either appositive or negative

test result. Consider ways to reduce transmission or contraction of the virus in

the future. Encourage you to consider and evaluate the impact the result may

have on you emotionally, physically and in relation to your lifestyle. Helps to

identify risk factors and symptoms that may indicate that the patient is HIV

infected. During the pretest counseling the person thinks of someone to share

the results with. To reduce the internalized stigma by providing information

about HIV in a neutral environment.

• Advantages of testing
1. Ability to seek medical intervention when one tests positive and this

prevent complications of AIDS.

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2. To prevent transmission to others

3. To make healthy life style changes -eat well, exercise.

4. Important also to know cause for various symptoms.

• Disadvantages
1. Increased fear of illness and death

2. Fears related to family relations/parenting

3. Guilt of past relationships and sexual behaviour

4. Stigma associated with HIV/AIDS

The patient should be helped to understand the antibody test. Body produces

antibodies to HIV that are found in the blood. Positive test mean the person

is HIV infected. There is a period of 3-6 months during which antibodies may

not show up in the blood and test will reveal the person to be negative. This

is the window period. Tests giving negative results should be repeated again

after 3 and 6 months respectively.

• Post test counseling

If the person test positive:

ˆ Explain to them that there is chance of not developing full blown AIDS

by medical intervention -ARVs, antibiotics and antifungal, nutrition and

reducing stress, and change of lifestyle through positive living.

If results are negative:

ˆ Clarify that the test did not yield positive results does not means that

the person does not have HIV or has not developed HIV.

ˆ Let the person know that there is need to repeat test after 3 months

however don't forget to congratulate the person.

ˆ Discusses methods to reduce risk of transmission and avoiding risky be-

haviours.

ˆ Discuss the current risk situations of the patient and help to develop

strategies to increase prevention of transmission.

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• Role of VCT centers

1. VCT has taken a central role in enlightening and guidance of HIV/AIDS

disease.

2. Contribute immensely in the control of HIV/AIDS

3. Involve testing and availing the results to people in minutes.

4. Before testing the people are prepared rst for both positive and negative

results before allowed to know their status. Importance of knowing one's

HIV status includes:

(a) Preventing the uninfected person from contracting the disease

(b) Enhancing abstinence for the infected helps in controlling the dis-

ease through self awareness and putting up ways on how to abstain

or get involved in safe sex

5. Counseling also helps in ensuring reduced spread of the virus by those

people who have been infected but had not shown symptoms.

6. Counseling infected people, majority of who have lost hope, helps in

ensuring positive living.

7. Help to reduce the revenge attitude for those innocently infected and

may opt to die with many or commit suicide.

8. Counseling enables the public who includes the relatives of the infected to

stop stigmatizating those infected to be able to live normal lives knowing

that someone cares for them.

9. Testing also helps the government to keep statistics on the prevalence of

the disease hence policy development or strategic planning.

• General reactions to testing HIV positive

Each of these feelings or reactions is part of a normal response to a situation

of great stress.

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ˆ A person might move from one response to the next in a progression

leading nally to acceptance of their situation, or more commonly their

feelings will keep changing. One day they might feel rejected and lonely

- the next day hopeful and energetic. One day depressed, another day

angry.

ˆ Shock - No matter how much someone prepares, it is a shock to learn

that one has HIV infection or AIDS. A person might feel confused and

not know what to do. It is good for people to be with someone they

trust at this time.

ˆ Denial - At rst they might not be able to believe that they really have

HIV or AIDS They might think 'The doctor must be wrong' or "It can't

be true - I feel so strong". Not wanting to believe is a strong force that

people may use subconsciously to protect themselves from the threat

posed by AIDS.

ˆ Anger - People might become very angry when they learn that they have

HIV or AIDS This is a common feeling and can come when they blame

themselves or the person they think gave them HIV. Some may even

blame God. Talking to someone can help a person overcome feeling of

anger and help them accept their situation.

ˆ Bargaining - A person with AIDS might try to bargain, thinking that

God will cure me if I stop having sex or the ancestors will make me

better if I slaughter a goat or I will be good and AIDS will go away.

People with HIV or AIDS need to be helped to get through the feeling

of bargaining.

ˆ Fear - People with HIV or AIDS fear many things, for example:

 Pain of losing their job

 Other people knowing that they are infected

 Rejection

 Leaving their children

 Death.

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ˆ Loneliness - A person with AIDS might often feel lonely. This feeling

may come and go for a long time and depends on the support given by

family and friends. Anyone who has AIDS must be helped to remember

that they are not alone; that they are surrounded by family, friends and

a community that cares about them. Many other people have HIV or

AIDS.

ˆ Self-consciousness - When a person has HIV or AIDS they might think

everyone is looking at them or talking about them. This may make

them want to hide. Sometimes a person with AIDS may feel unworthy

of friendship.

ˆ Depression - If a person nds out that they have HIV or AIDS they may

feel there is no good reason for living. They may feel useless, and want

to stay at home, not eat, and not talk to anyone. Depression can make

someone weak both in mind and body.

ˆ Acceptance - After some time, a person with HIV or AIDS will usually

begin to accept their situation. This will help the person to feel better.

Such a person will feel more peaceful in their mind, and will begin to

think about the best ways to live.

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Revision Questions

Example . Prevention involves tackling the most important modes of trans-

mission. Discuss briey how to prevent sexual transmission.

Solution : Taking anti-HIV therapy during pregnancy and delivery e.g. AZT

which reduces the viral load. HIV positive mothers to choose an elected cae-

sarean section instead of normal delivery. Not breast feeding where there is

access to safe, adequate milk substitutes. Breast feeding should be avoided

because the HIV virus is present in breast milk. Also it is not uncommon for

mothers to experience cracked or bleeding nipples while breastfeeding, there-

fore increase the risk of viral transmission. Mothers w ho are HIV positive

should not donate breast milk to breast milk barks, neither should they ex-

press milk to be bottle fed to their baby.

Exercise 8.  Discuss the role of Voluntary Counseling and Testing (VCT)

centers in HIV/AIDs management

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Revision questions or guidelines

1. Discuss HIV/AIDS prevention and control strategies

2. Explain the factors that account for the continued rise in women infected

with HIV compared to men.

3. Anything else you would like to suggest

References and Additional Reading Materials

1. Maranga R. O, Muya S. M and Ogila K. O (2008) Fundamentals of

HIV/AIDS Education. Signon Publishers.

2. Barry D. S. (1999) AIDS and HIV in Perspectives. CPU. ISBN-13:

9780521627665

3. Ellison G. Parker M., Camphpbell C (2003) Learning from HIV and

AIDS. Cambridge CPU.ISBN-13: 9780521709286.

4. Shavitri Ramaiah (2008) HIV/AIDS; Health solutions. Sterling Publish-

ers Ltd. ISBN-9788120733305.

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LESSON 8
Concept of positive living
Learning outcomes
Upon completing this topic, you should be able to understand the following:

ˆ Components of home based care

ˆ Relationship between good nutrition and management of HIV

ˆ Reducing the risk of transmission during pregnancy

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8.1. Introduction
The rst stage of positive living is accepting wholly HIV is part of you and

this cannot be changed and start taking good care of yourself: 

1. Breath - When you get overwhelmed, take three deep breaths. Breathing

better is one of the most important things you can do to maintain your

health. It improves everything from chronic health problems, stress re-

lated disorders to our sporting performance. Whether you want to boost

your workout, ease stress or improve your health, learning to breathe

properly can enhance your quality of life. Look for fresh air, like the

around lakes, forests, near rivers and water falls, at the seashore and

after a rainstorm that is know to contain abundant negatively charged

ions.. This kind of air is refreshing and gives people a lift. House plants

also do more than enhance the appearance of the home and oces. They

enrich the air with oxygen and absorb carbon dioxide. Some even remove

toxic pollutant from the air we breathe (Ang'awa 2005). ˆ Bad air and

poor breathing habits interfere with breathing, reducing the oxygen de-

livered to the blood and impairing performance and mood and promotes

negative emotions like depression, irritability, headaches and feelings of

fatigue and exhaustion because the body is robbed of this vital element

(Ang'awa 2005)

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 - Attend HIV/AIDS seminars, workshops

or any education forum.

4. Physical exercise - Necessary for all parts of the body

5. Reduces stress

(a) Keep busy

(b) Do not concentrate on self.

(c) No self pity, concentrate on development

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(d) Do not overwork.

6. Express yourself, ask for support -

(a) Talk to your friends

(b) Share feelings with your partner, friends and family

(c) Professional counselor, therapists and clergy can oer support

7. Embrace your own spirituality

(a) Faith based organizations have ministers who support HIV positive

people

(b) If you feel angry with God, acknowledge it. HIV is a virus not a

punishment.

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 - Pledge that HIV stops with you. Do not de-

liberately seek to infect others. Use condoms to pr others and avoid

re-infection.

12. Talk to other people with HIV - group therapy works. Join support

groups

13. Healthy and diet - eat well balanced diet with lots of proteins and vita-

mins Avoid food poisoning as much as possible Avoid alcohol, drug and

substance abuse

14. Attend to opportunistic infections immediately

15. Have hope about many things. For example:

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It is important to have hope. Hope lifts spirits and gives strength to face

each situation. Hope can help each person to ght HIV and AIDS - to live

positively and to live longer. Remember, even if a person has hope today, it

is possible to feel angry or depressed tomorrow. This is normal. Even people

without HIV or AIDS go up and down emotionally every day. The important

thing is to try to instill the feelings of hope again and again.

8.2. Home Based Care

Home based care means - any form of concern given to sick people in their own

dwellings. It can mean the things people might do to take care of themselves

or the care given to them by the family or it can be extended from the hos-

pital or health facility to the patient's home through family participation and

community support (Gilks et al. 1998., MOH 2002c). Care includes physical,

psychosocial and spiritual activities. The term family here refers to the person

(or people) with the main responsibility for caring for a person with AIDS in

the home. In fact, the person providing such care may be a blood relative,

a relative by marriage (a spouse for example), a friend, a neighbour or some

other person.

The overall goal of home based care is - to ensure a high standard of human,

holistic care that meets the needs of People living with HIV/AIDS (PLWA's).

PLWA's have basic, physical, economic and psychosocial needs. These can be

met at the familiar home environment and may lead to an improvement of

the quality of life for PLWA's. Home based care establishes an important link

between health professionals and the caregivers at home.

HIV /AIDS aect all aspects of social and economic life in Kenya. The

health sector is aected by an increased burden of caring for those infected.

It is responsible for delivering eective treatment of opportunistic infections,

providing compassionate care and implementing many prevention programs

such as STD control, condom promotion and distribution and health education

and provision of Anti retroviral drugs (ARVs).

It is estimated that 51 % of the bed occupancy in public hospitals in Kenya

is by AIDS patients1. The national health systems cannot cope with the

accelerating demand as increasing number of people with full blown AIDS

develop opportunistic infections. The nancial investments required to treat

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AIDS are beyond national budgets. Not only is the cost of care beyond health

care systems, but it is beyond the reach for the individual and the family.

Family, friends and the community must ll the "care gap" at large. This

group of care givers has the capacity and resources to do more than the national

health care systems: they take care of the sick, replace their labor/income, care

for their dependants, and help defray costs associated with the illness, provide

palliative care of PLWA's and quality life in death. The use of caregiver is

instrumental in reducing the stigma associated with HIV/AIDS. Thus, the

concept of home based care.

8.2.1. Rationale for Home Based care

ˆ 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

ˆ PLWA's need continued quality care to prolong lives and reduce suering

ˆ There are limitations on hospital care, including limited resources that

aect the care that can be given to PLWA's. Continued hospitalization

of PLWA's may lead to depletion of family and community savings and

investments.

8.2.2. Advantages of organized home based care

ˆ It aects the socioeconomic, psychosocial and medical well being of the

patient, the family, the community and the health care system.

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

ˆ It is less expensive for families

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

ˆ It encourages people to take steps to prevent infection.

ˆ It encourages community participation in the care of PLWA's and thus

maintains community cohesiveness in responding to community mem-

bers' needs.

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ˆ 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.

8.2.3. Components of home based care

ˆ Clinical management - which includes early diagnosis, rational treatment

and planning for follow up care of HIV related illness

ˆ Nursing care - which includes care to promote and maintain good health,

hygiene and nutrition

ˆ Counseling and psycho social care - which includes reducing stress and

anxiety, promoting positive living, and helping individuals to make in-

formed decisions on HIV testing, plan for the future and behavior change

ˆ Social support - which includes information and referral to support groups,

welfare services and legal advice for individuals and families and where

possible provision of material assistance

8.2.4. Aspects of nutrition in comprehensive care of HIV/AIDS pa-

tients
Nutrition implies the process of absorbing nutrients from food and processing

them in the body in order to keep healthy or to grow. Adequate food security

in the household is requisite for optimum nutrition, health and survival (FAO

2002). But HIV/AIDS reduces the household's ability to produce and buy food

by taking away the adult labour that would otherwise be engaged in agricul-

tural production or in earning an income. At the same time, HIV disease

increases health expenditure. The capacity of an aected household to ob-

tain an adequate amount and variety of food, and to adopt appropriate health

and nutritional responses to HIV/AIDS, especially for the already vulnerable

ones, is grossly reduced. On the other hand both HIV/AIDS and malnutrition

compromise the immune system, resulting in increased susceptibility to severe

illnesses, which reduce the quality of life and shorten life expectancy. Mal-

nutrition due to HIV/AIDS is linked to inadequate food intake, poor uptake

of food into the body, and poor use and storage of nutrients. Each of these

factors must be considered in providing the most appropriate nutritional care

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SZL2111 HIV/AIDs

for the HIV-positive person. Reduced food intake in persons with HIV may

be due to painful sores in the mouth and throat, loss of appetite, or fatigue.

The main causes of loss of appetite are infections and depression. Other causes

include side eects of medication such as nausea and vomiting, and inadequate

access to and availability of appealing foods. Poor absorption of nutrients re-

sults when HIV damages the small intestine and alters the healthy bacteria

of the digestive system, causing malabsorption of fats and carbohydrates and

frequent episodes of diarrhea. Intestinal infections also cause diarrhea, with

loss and waste of nutrients. Infections, including HIV itself, lead to increased

requirements for energy and protein, inecient use of nutrients, and loss of

nutrients. Energy requirements are likely to increase by 10% to maintain body

weight and physical activity in adults and growth in symptomatic children.

• Advantages of good nutrition to PLWA

ˆ Good nutrition entails eating a well-balanced diet that contains all the

nutrients the body needs for growth and proper functioning. Balanced

nutrition helps the body to:

ˆ Increase resistance to infection and disease and improve the energy sup-

ply.

ˆ Boost the immune system and therefore reduce the frequency of episode

of morbidity.

ˆ Lessen severity of infection, improve the response to treatment for op-

portunistic infections such as TB, and speed the rate of recovery.

ˆ Replace lost micronutrient and provide the body with all essential nu-

trient required for good health.

ˆ Preserve muscle mass, slow or stop the loss of lean tissue, prevent weight

loss, and improve body strength and energy.

ˆ Delay the rate of progression of HIV to AIDS and the further advance

of AIDS itself.

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ˆ 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

and to delay early orphan hood of their children.

Studies show that nutrition interventions can positively aect nutrition status

(FAO 2002), the immune system and even personal esteem, by maintaining

body weight, improving eectiveness of medication and prolonging life. Sup-

plementing micronutrients has been shown to increase life expectancy of sub-

jects with fewer than 200 CD4 cells per millilitre1. A number of micronutrient

supplements including vitamin A, zinc and iron have been found to boost the

immune system in a person with HIV infection. Multivitamins can reduce the

risk of death and improve immune function.

• Principles of nutrition support for PLWA

Good nutrition can therefore play an important role in the comprehensive man-

agement of HIV/AIDS, as it improves the immune system, boosts energy, and

helps recovery from opportunistic infections. The following basic principles

are being advocated for all programmes of HIV/ AIDS patient management,

counselling or education: 

ˆ Nutritional education and counselling

ˆ Water and food safety intervention to prevent diarrhoea

ˆ Income-generating activities to enhance food security

ˆ Nutritional supplementation

ˆ Meal designing and planning using locally available foodstus

ˆ To avoid malnutrition and wasting away HIV infected persons should al-

ways ensure that they take highly nutritive foods that are well balanced.

ˆ High protein diet to build up infected cells and tissues/strengthen them.

They include Soya beans, lean meat, milk, beef, eggs.

ˆ 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.

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ˆ Vitamins and minerals help bodies' in ghting diseases and keep oppor-

tunistic infections checked. They also help in a quick recovery and disease

management. Vitamins are obtained from fresh vegetables, fruits, fresh

juices.

ˆ Fluids help in cleaning the immune system, blood purication and to

improve the appetite (anorexia).

ˆ Frequency of food intake should be high to avoid or replace weight loss

8.3. Management of pregnancy in HIV/AIDS

The introduction of combination therapy and the impact it has had on im-

proving the health of HIV-positive women, together with the enormous strides

made in reducing the risk of transmission from mother to baby has led more

HIV positive women contemplating having children. It is advisable to plan a

pregnancy well in advance, more so for HIV positive women. Unfortunately,

prior planning is not possible for all HIV positive women some will learn of

their HIV diagnosis at routine antenatal visit. The women will be promptly

referred for additional costs and informed of treatment options to safeguard

their own health and the health of their unborn child. Ideally HIV positive

women should be seen by specialist midwife and/or obstetrician throughout

their pregnancy. This will ensure that both the pregnancy and their HIV can

be closely monitored and any additional information, treatment and support

made available. HIV positive women should discuss the prospect of pregnancy

before hand, ensuring they have the information to ensure the best possible

chance of a safe, healthy pregnancy and delivery.

8.3.1. Reducing the risk of transmission during pregnancy

This is achieved by antiretroviral therapy. From conception onwards there is

a risk of viral transmission from mother to baby. This is increased if;

ˆ The mother has high viral load

ˆ She is old

ˆ She smokes during pregnancy

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ˆ She has unprotected sex during pregnancy.

ˆ She uses illicit drugs during pregnancy

ˆ She has no antiretroviral therapy during pregnancy and delivery

ˆ Membrane rapture more than 4 hours before delivery

ˆ Delivery is natural and not by caesarean section.

ˆ Delivery is prolonged or dicult

ˆ Cervical or vaginal infection is present

ˆ Membranes are inamed

ˆ The mother breastfeeds

Primarily, viral load is the most important factor to inuence the risk of trans-

mission. A high viral load substantially increases the risk of transmission to

either a negative partner or unborn child. For this reason, the control of viral

load from conception, throughout the pregnancy and during delivery by use

of antiretroviral therapy is crucial at specic pregnancy stages.

• Conception
Conceiving a child in relationship where one partner is HIV positive and the

other HIV negative presents unique challenges. If the woman is the HIV

positive partner, articial insemination oers the best chance of conception

while not risking transmission to her partner.

For some couples, assisted conception is not an option and they may choose

not to use a condom while trying to conceive a child naturally, this of course

increases the risk of HIV transmission to the negative partner. In these in-

stances it may be wise to restrict unprotected sex to the fertile period of the

woman's cycle.

• The pregnancy
Optimum health, which for an HIV-positive woman means a low viral load

and a healthy CD4 count in addition to good general health, oers the best

chance for a healthy pregnancy and baby. There is no evidence to suggest that

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pregnancy accelerates HIV progression. It has been observed that CD4 counts

drop in pregnancy, but this is also seen in HIV-negative women. CD4 count

usually returns to a pre-pregnancy level soon after delivery.

ARVs such as AZT are used to reduce the risk of transmission during

pregnancy. AZT is taken orally after the 14th week of pregnancy and intra-

venously during labour. Administering AZT syrup to newborns for the rst

six weeks can further reduce transmission. AZT reduces the risk of mother to

child transmission by lowering the mother's viral load during pregnancy and

delivery and may act as a post exposure treatment for newborns. It is the

only antiretroviral that has been thoroughly tested for use in pregnancy. For

women who are already taking antiretroviral therapy and other discover they

are pregnant after 14 weeks, it is usually advisable that they continue with the

establishment therapy as well as AZT.

• Delivery
There are conicting opinions regarding whether HIV positive mothers should

undergo a vaginal delivery or a planned caesarean section to reduce the risk of

transmission to their baby. Until recently all HIV positive mothers were urged

to have an elective caesarean. The decision relating to mode of delivery is one

that should be reached after all factors have been considered by the mother

and her doctor.

• Breastfeeding
HIV- positive mothers should not breastfeed their babies as this increases the

risk of transmission especially if the mother has a cracked or bleeding nipples

and if the baby if teething.

• Testing babies for HIV

All babies born to HIV positive mothers will be tested to ascertain whether

the virus has been transmitted. Initial testing is undertaken when the child

is 48 hours old. Negative children are tested again at day 14 when PCR will

identify approximately 90% of infected children. If at 14 days they still test

negative, then the test is repeated again at 4-8 weeks and then again at 16-26

weeks of age. If they return two negative results, when they are over 6 month

of age, it can be conrmed that the virus has not been transmitted.

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Exercise 9.  Revision Questions

Describe how early detection and treatment of sexually transmitted infec-

tions (STIs) are important?

Exercise 10.  Explain if one might have been exposed to HIV  is there

anything I can do?

Example . Why is HIV testing and counselling important?

Solution : More than 90% of people infected with HIV do not know their

HIV status. Voluntary testing and counseling have proved to be an eective

public health strategy as they result in reduced risk behaviours and increased

condom use. Testing and counselling serve as entry points to HIV/AIDS care

and support. 

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SZL2111 HIV/AIDs

Revision questions or guidelines

1. Discuss ways employed by the Kenyan government to reduce the impact

of HIV/AIDs.

2. Socio-economic and cultural factors greatly contribute to the rapid spread

of HIV/AIDS. Discuss.

3. Empowering women in Kenya will contribute towards lowering new cases

of infection with HIV. Discuss this statement siting examples.

4. Discuss the role of religion in ght against HIV.

5. Anything else you would like to suggest

References and Additional Reading Materials

1. Maranga R. O, Muya S. M and Ogila K. O (2008) Fundamentals of

HIV/AIDS Education. Signon Publishers.

2. Barry D. S. (1999) AIDS and HIV in Perspectives. CPU. ISBN-13:

9780521627665

3. Ellison G. Parker M., Camphpbell C (2003) Learning from HIV and

AIDS. Cambridge CPU.ISBN-13: 9780521709286.

4. Shavitri Ramaiah (2008) HIV/AIDS; Health solutions. Sterling Publish-

ers Ltd. ISBN-9788120733305.

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SZL2111 HIV/AIDs

LESSON 9
Behavioral patterns and the spread of Hiv /Aids
Learning outcomes
Upon completing this topic, you should be able to know policies and rights of

PLWHAs with relation to:

ˆ Individual Behavioral Patterns and the spread of HIV /AIDS

ˆ Role of gender in transmission of HIV /AIDS

ˆ Drug/Alcohol use and use and the spread of HIV/AIDS

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9.1. Individual Behavioral Patterns and the spread of HIV /AIDS

Behaviour can be dened as all those process by which an organism senses the

external world and the internal state of its body and responds to changes which

perceives. Many of such process will take place inside the nervous system and

may not be directly observable. An organism may respond by involving in a

violent activity or incomplete inactivity, but all are equally behaviour. The

spread of HIV primarily depends on individual's sexual behaviour patterns how

often men and women have sex and who they have sex with. Not everyone's

sex life is the same and patterns of sexual behaviour are strongly inuenced by

social, cultural and psychological factors over which men and women have little

control. In most societies, men are generally expected to be strong leaders,

to be primary providers of their family's food, shelter and defend themselves,

their families and societies from aggressors. Virility-the ability to perform sex

is almost an essential component of masculinity in almost every society. Young

people are expected to prove their sexual prowess and there is under spread

belief that a man's need for sex is beyond control. For men anything that

appears to interfere with their sex lives such as appeal to abstinence or use of

condoms is a threat to their masculinity. Impelled by these attitudes, men on

average report more sexual partners than women. The implication of this are

that women are likely to contract HIV but less likely to transmit the virus to

other sexual partners while men are more likely to contract and transmit the

virus. In the long term this means that more women than men will contract

HIV. Compounding this situation is the fact that many men do not consider sex

as a consensual activity. Sex has to take place when man decides and without

a condom if he chooses. Wives are often beaten or ejected from their home. If

they refuse to submit to their husbands and many women are at risk outside

the home if they refuse to submit to their husbands and many women are at

risk outside the home. In such instances, women nd it impossible to protect

themselves from infection with HIV or other STI's. In prisons or other single

sex environments some men rape other men either as a substitute for sex with

a woman or to establish power over their victims. In other situations, however,

sex between men may be an expression of mutual desire or the result of ones

desire and other's nancial need. There is need to change men attitudes and

subsequent behaviours. Men do not protect themselves because male attitudes

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tell them not to; while women do not protect themselves because men do not

allow them to.

9.1.1. Behaviour change could play a greater role in reducing HIV

infection
If individuals could:

1. Postpone their rst sexual intercourse.

2. Practice safe sexual practices

3. Reduce the number the number of sexual partners

4. Prevent and treat STDs

5. Avoid traumatic sexual intercourse

6. Make sex a consensual activity, openly discuss sex issues etc.

9.1.2. Safe sex and safer behaviors

ˆ Practice abstinence.

ˆ Reduce the number of sexual partners to one.

ˆ Always use latex condoms with a water-soluble lubricant containing the

spermicide nonoxynol 9 and do not reuse condoms.

ˆ Do not use cervical caps or diaphragms without using a condom as well.

ˆ Always use dental dams for oral female genital or anal stimulation.

ˆ Avoid anal intercourse because this practice may injure tissues.

ˆ Avoid manual - anal intercourse (sting).

ˆ Do not ingest urine or semen.

ˆ Avoid having sex with people who are injecting drug users.

ˆ Engage in nonpenetrative sex such as body massage, social kissing (dry),

mutual masturbation, fantasy, and sex lms.

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ˆ If female, avoid pregnancy if you or your sexual partner is HIV seropos-

itive.

ˆ Inform prospective sexual partners of your HIV-positive status.

ˆ Notify previous and present sexual partners if you learn that you are

HIV seropositive.

ˆ If HIV seropositive, do not have unprotected sex with another HIV-

seropositive person because cross-infection with another HIV strain can

increase the severity of the disease.

ˆ Do not share needles, razors, toothbrushes, sex toys, or other blood-

contaminated articles.

ˆ If HIV seropositive, do not donate blood, plasma, body organs, or sperm

9.2. Role of Gender in HIV/AIDS Transmission

Although women are making eorts towards equality with men, a lot of them

still do not have control over their lives especially their bodies.

9.2.1. Cultural, social, biological and economic pressures make women

more vulnerable HIV that men.
1. Men still dictate matters regarding sex - for example, when to have sexual

intercourse irrespective of whether a woman wants it or not. Also use of

condom relies on the man.

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 vio-

lent sexuality - this carries double standards whereby women are blamed

or thrown out for indelity whether real or suspected while men are

allowed to have multiple sexual partners.

4. Biological makeup and reproductive anatomy of the female body makes

her to be more vulnerable to contract HIV than men - sex takes place

inside the body of the woman and the female genitalia is prone to tears

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and wear. These tears and wears and/or sores provide entry route for

the virus.

5. The female reproductive system is also in direct and longer contact with

the male semen deposited during sexual intercourse. If the semen has

HIV, then it becomes easier for her to contract the virus.

6. Poverty - failure to respect the human rights of girls in terms of equal

access to school, training, employment opportunities etc. reinforces their

economic dependence on men. A woman who is in a stable relationship

and is economically dependent on her husband cannot aord to jeopar-

dize his support even when she suspects that he is HIV positive. If she

insists on a condom use she is accused of being unfaithful or the man

reacts violently.

7. Prostitution-a lot of women go into prostitution as a way of income

generating activity. A lot of them end up acquiring HIV/AIDS. For some

women, prostitution is a choice while others are forced by circumstances

into it to exchange sex for basic necessities of life for themselves and

their children.

8. Cultural practices-a number of cultural practices have increased the vul-

nerability of women to contracting HIV. These include wife inheritance,

polygamy, early marriages and resistance to condom use.

9. Social evils - they include rape, sodomy, homosexuality, premarital, ex-

tramarital sex, and drug and alcohol abuse.

10. Ignorance - majority of women are poorly educated and lack informa-

tion on their bodies, HIV/AIDS and other sexually transmitted diseases.

They are therefore unable to protect themselves.

A vulnerable woman is one who is lacking in power or control over her risk of

HIV infection.

9.2.2. Remedy to above problem

1. Combating ignorance:

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(a) improve the access of girls to formal education,

(b) ensure they have information on their bodies, HIV/AIDS and other

STD's, and

(c) equip them with skills to say NO to unsafe sex.

2. Provide women friendly services

(a) girls and women should have access to appropriate health care and

HIV/STD prevention services,

(b) make condoms and STD care are available where women don't feel

embarrassed.

3. Make female condoms available - female condoms though expensive should

be made available.

4. Build safer norms - support organizations advocating against behavioral

traditions which have become deadly with the advent of HIV/AIDS e.g.

genital mutilation, child abuse, rape, sexual coercion.

5. Educate boys and men to respect girls and women - this enables them to

engage in responsible sexual behavior and to share their responsibility for

protecting themselves, their partners and their children from HIV/AIDS

and STDs.

6. Reinforce women's economic independence - increase and strengthen

existing training opportunities for women, credit programmes, saving

schemes and women's cooperatives and link them with AIDS prevention

activities.

7. Reduce vulnerability through policy changes - policies from communities

to national level must be reshaped if women's vulnerability to HIV is to

be reduced. Human rights and legal rights should be improved.

9.3. Drug/Alcohol Use and Abuse and the Spread of HIV/AIDS

A drug can be dened as any substance that aects the function of living

cells, used in medicine to diagnose, cure, prevent the occurrence of diseases

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and disorders, and/or prolong the life of patients with incurable conditions

Drug abuse is characterized by taking more than the recommended dose of

prescription drugs such as barbiturates (depressants) without medical super-

vision, or using government-controlled substances such as marijuana, cocaine,

heroin, or other illegal substances. Legal substances, such as alcohol and nico-

tine, are also abused by many people. Abuse of drugs and other substances

can lead to physical and psychological dependence. Drug abuse can cause a

wide variety of adverse physical reactions. Long-term drug use may damage

the heart, liver, and brain. Drug abusers may suer from malnutrition if they

habitually forget to eat, cannot aord to buy food, or eat foods lacking the

proper vitamins and minerals. Individuals who abuse injectable drugs risk

contracting infections such as hepatitis and HIV from dirty needles or needles

shared with other infected abusers. One of the most dangerous eects of illegal

drug use is the potential for overdosing that is, taking too large or too strong

a dose for the body's systems to handle. A drug overdose may cause an indi-

vidual to lose consciousness and to breathe inadequately. Without treatment,

an individual may die from a drug overdose. Drug addiction is marked by a

compulsive craving for a substance. Successful treatment methods vary and in-

clude psychological counseling, or psychotherapy, and detoxication programs

medically supervised programs that gradually wean an individual from a drug

over a period of days or weeks. Detoxication and psychotherapy are often

used together. The illegal use of drugs was once considered a problem unique

to residents of poor, urban neighborhoods. Today, however, people from all

economic levels, in both cities and suburbs, abuse drugs. Some people use

drugs to relieve stress and to forget about their problems. Genetic factors

may predispose other individuals to drug addiction. Environmental factors

such as peer pressure, especially in young people, and the availability of drugs,

also inuence people to abuse drugs. People with alcohol use disorders are

more likely to contract HIV than the general population. 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,

poor HIV treatment outcome. People who abuse alcohol are more likely to

engage in behaviors that place them at risk of contracting HIV. Heavy alcohol

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use has been correlated with a high risk sexual behaviors including:

ˆ Multiple sex partners

ˆ Unprotected intercourse

ˆ Sex with high risk partners

9.3.1. Relationship between drug use and HIV

ˆ Shared needles/syringes for use in drug application can carry HIV and

hepatitis viruses.

ˆ Drug use is linked with unsafe sexual activity.

ˆ Infected blood drawn into the needle is infected along with the drug by

the next user.

ˆ A recent study has shown that HIV can survive in a used syringe for at

least 4 weeks.

ˆ A lot of people believe that sex and drugs should go together. Drug users

might trade sex for drugs.

ˆ Others think that sexual activity is more enjoyable when they are using

drugs.

ˆ Drug use including alcohol increases the chance of not using protection

during sex, leads to acquiring/transmitting HIV/AIDS.

ˆ A lot of drugs interfere with the proper functioning of the antiretroviral

drugs.

ˆ One who is a drug addict might forget to take his ARV therapy - delay

in treatment and increment of viral load.

ˆ A probability of overdose which is fatal

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Exercise 11.  Revision Questions

Discuss gender vulnerability of HIV infection in females relative to male

counterparts

Example . Discuss the eects of stigma and discrimination on the spread

of HIV/AIDS

Solution : Stigma (attitude) can be dened as a discrediting attribute that

is used to separate the aected persons or groups apart from the normalized

orders, or  an act of identifying, labeling or attributing undesirable qualities

targeted towards those who are perceived as being shamefully dierent and

deviant from the social ideal . Discrimination (act) is an action or treatment

based on the stigma, sanction, harassment, scapegoat and violence based on

infection or association with HIV/AIDS . 

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Revision questions or guidelines

1. Using appropriate examples discuss the rights of people living with HIV/AIDs

at the work place.

2. During Volutary Conselling and Testing explain how the health worker

should conduct him/herself to ensure the rights of the person visiting

that clinic are observed.

3. Sex education is a right for every youth. Discuss in detail what this

entails.

4. Anything else you would like to suggest

References and Additional Reading Materials

1. Maranga R. O, Muya S. M and Ogila K. O (2008) Fundamentals of

HIV/AIDS Education. Signon Publishers.

2. Barry D. S. (1999) AIDS and HIV in Perspectives. CPU. ISBN-13:

9780521627665

3. Ellison G. Parker M., Camphpbell C (2003) Learning from HIV and

AIDS. Cambridge CPU.ISBN-13: 9780521709286.

4. Shavitri Ramaiah (2008) HIV/AIDS; Health solutions. Sterling Publish-

ers Ltd. ISBN-9788120733305.

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LESSON 10
Implications of Hiv/Aids And International Responses
to the Hiv/Aids Pandemic
Learning outcomes
Upon completing this topic, you should be able to know:

ˆ Impacts of HIV on individuals, families, community

ˆ Demographic impacts - population

ˆ Multi - sectoral impact (Education, Agriculture, Economy, Health, In-

dustry and Business)

ˆ Responses of African Governments to HIV - AIDS epidemic

ˆ Strategies adopted by the Kenyan government to ght the spread of

HIV/AIDS

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10.1. To the individual

ˆ Feeling of hopelessness

ˆ Self pity

ˆ Depression

ˆ Suicidal thoughts

ˆ Shame

ˆ Anger

ˆ Denial

ˆ Revenge

ˆ Fear of death

ˆ Social withdrawal - segregation of infected

ˆ Opportunistic infections

ˆ Inability to work

ˆ Reduced life expectancy

ˆ Loss of job

ˆ Lack of faith in God or religion

ˆ Poverty due to medical expenses

ˆ Disruption of persons future plans

ˆ Discrimination at work place and social stigmatization

ˆ Change of sexual behavior

ˆ Poor relationship with spouse, children and relatives

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10.2. To the family

ˆ Marital instability and breakup - lack of peace in couples

ˆ Children are deprived of parental care and support

ˆ Sense of anticipating grief

ˆ Shame to the family

ˆ Loss of bread winner

ˆ Lack of emotional support/direction

ˆ Strained nances

ˆ Burden of children to the relatives and family friends

ˆ Orphans & vulnerable children have their growth aected, reduced ac-

cess to basic education & increased risk of acquiring HIV due to lack of

parental guidance

10.3. To the community

ˆ Reduction of productivity

ˆ Development retardation

ˆ Expensive funerals

ˆ High hospital occupancy

ˆ Financial burden for insurance companies

ˆ Increase in number of street children

ˆ Increased infant mortality rate

ˆ Dependency ratio goes up

ˆ Increased widows, widowers & orphans

ˆ Loss of many lives (human potential)

ˆ Increased diseases which were at one time in control e.g. TB

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10.3.1. How to solve negative eects

ˆ Creation of homes for orphans

ˆ Provision of free education to orphans

ˆ Introduction of Voluntary Counseling and Testing Centers

ˆ Adoption of orphans in the community

ˆ Destigmatization

10.4. Multi - Sectoral Impacts of HIV/AIDS

10.4.1. Impact on Industry and business sector
ˆ Industry and business sector forms the basis for production and supply.

ˆ Labour is required for this production to occur

ˆ HIV/AIDS has eect on labour due to:- increased absenteeism, decreased

productivity, reduced number of employees through death, loss of accu-

mulated skills and declining morale.

ˆ Increased medical costs for business with medical schemes

ˆ Declining productivity and increased medical costs results in declining

prots

ˆ HIV/AIDS indeed reduces the productivity of the labour force.

10.4.2. Impact on agriculture

ˆ Agriculture is the mainstay of Kenya's economy, followed by tourism

sector

ˆ Lower productivity in farming areas due to illness, absenteeism, death

and loss of farming skills

ˆ Less land is cultivated

ˆ Less labour - intensive crop production

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ˆ Loss of household and farm assets - this is due to diverted time of family

members to taking care of the sick and attending funerals.

ˆ Less crop production

ˆ Less livestock production

ˆ Decline in agricultural income and food production and increased food

insecurity

ˆ Labour productivity is reduced in commercial farming as well as subsis-

tence farming.

10.4.3. Impact on education

ˆ Increased morbidity

ˆ Absenteeism and attrition of teachers

ˆ Reduced number of school-aged children attending school

ˆ Poor performance in classroom

ˆ These result in decline in quality of education and impose higher cost on

education system.

ˆ Pupils are afraid of being taught by infected teachers

ˆ Teachers reported as dying of AIDS are not replaced

ˆ Loss of trained and experienced teachers

ˆ Interruption of teaching programs due to illnesses

ˆ Resources available to support education are diverted to meet HIV/AIDS

related needs

ˆ Children from aected families absent themselves because they take care

of the sick

ˆ Poor attendance and increased number of school drop outs because of

aected families and death of parents.

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10.4.4. Impact on health sector

ˆ Increased demand for health services due to the number of infected per-

sons

ˆ More health resources and workforce are diverted to HIV/AIDS treat-

ment

ˆ Shortage for other health care needs

ˆ Half or more beds in public hospitals are occupied by HIV patients

ˆ Reduced morale of health workers because HIV patients respond poorly

to treatment or die

ˆ HIV infected health workers may have low productivity and morale

ˆ Anti-Retroviral Therapy (ART) is costly

ˆ Laboratory tests to monitor patients are also costly

ˆ Costs of treating opportunistic infections and prophylaxis costs.

10.4.5. Impact on economic growth

ˆ Economic growth is dependent on sustained increase in productive ca-

pacity and real output resulting in growing national income

ˆ Labour, capital and technical progress determine economic growth

ˆ HIV/AIDS aect labour and capital investments

ˆ It aects mostly the most productive members of population thus re-

verses growth in labour supply

ˆ Reduces productivity of infected and aected workers

ˆ Skilled persons die of AIDS reducing economic growth

ˆ Reduced level of domestic savings and investment (crucial for capital

formation) due to medical expenses.

ˆ Reduced income and increased poverty imply decreased purchasing power

of households thus decreased demand for goods and services

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10.5. Responses of African Governments to HIV - AIDS epidemic

10.5.1. Formation of institution to coordinate and ght HIV pan-
demic
The AIDS programme secretariat was established to control the HIV/AIDS

under the guidance of National AIDS committee(NAC). AIDS programme

secretariat was elevated to the status of a National HIV/AIDS programme

(NACP) under the ministry of Health. The National HIV/AIDS programme

and the National STDs control programme (NSTDCP) were merged in 1994 to

form the National HIV/AIDS and STD programme (NASCOP) which assumed

a stronger coordinating role, especially of NGO's and religious groups.

10.5.2. Declaring HIV a national disaster

The government released surveillance data and hosted the rst National confer-

ence on HIV/AIDS. The minister of health rst declared HIV/AIDS a national

crisis while the government and international development partners initiated

social and economic impact assessments. In November 1999, the government

declared HIV/AIDS a national disaster. This was followed by the forma-

tion and establishment of a National HIV/AIDS Control Council (NACC).The

launch of the Kenya National HIV/AIDS plan in December 2000 was the ad-

vent of a new phase of bold war against the HIV/AIDS disaster.

10.5.3. Some of the strategies adopted by the Kenyan government

to ght the spread of HIV/AIDS
Kenya war on HIV/AIDS took a new dimension on 1st December 2003 follow-

ing the launch of constituency AIDS control committees (CACC) by his Excel-

lency President Mwai Kibaki. The launching was done during the worlds AIDS

day commemoration at KICC. -The ocial launch of the National HIV/AIDS

Behavior change communication strategy phase one campaign was also done

the same day by the President. The strategy focuses on supporting people who

are at a risk of contracting AIDS by providing accurate information through

a range of media outlets.  Pamoja Tuangamize Ukimwi was selected as a

campaign slogan.

In March 2004, the President launched the country total war on HIV/AIDS

and formed a cabinet committee which He chairs. The committees' approach

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lies in mobilizing communities in every corner of the country to eectively ght

the AIDS pandemic. The committee discussions revealed the need to include

care for those orphaned by AIDS and the provision of drugs for those infected.

Some of the strategies adopted by the Kenyan government to ght the

spread of HIV/AIDS includes: -

1. Public educational campaigns: The government through its state owned

media has set up sensitization programme to try and educate the public

on the dangers of the disease and also advise them to stay healthy with-

out contracting the disease. This is done through plays; poetry and real-

ity show programs where HIV/AIDS individuals take the opportunity to

air their views and encourage others to take measures to avoid contract-

ing the disease. The government has also gone step ahead in creating

awareness on AIDS prevention using other channels. This includes the

use of billboards, posters, public lectures, pamphlets, performing AIDS

groups etc. The government has also through its ocials advocated the

need to sensitize people through community barazas where government

ocials get the chance to give out the much needed information on the

prevention of AIDS.

2. HIV/AIDS seminars and workshops: These are opened to anybody will-

ing to attend and they are aimed at strengthening prevention activities.

Through these seminars and workshops, people are educated and en-

lightened by professionals on the ways of contracting the virus and the

consequences o0f the disease. People are encouraged to raise questions

which are answered frankly and elaborated. These are also supplemented

by lms concerning HIV/AIDS and STDs.

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

has become a core unit that is studied in primary schools, secondary

schools, middle level colleges and universities. Students gain knowledge

on the mode of transmission, prevention and control. This has helped in

the reduction of spread of HIV since the most sexually active Kenyans,

the youths are taught about the dangers of casual behaviors and unpro-

tected sexual intercourse.

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4. Destigmatization campaigns: The government of Kenya through educa-

tion has helped in reducing stigmatization as many people now takes

this as any other disease. This has helped to remove stigma label on

those infected and hence are no neglected. This has encouraged free talk

about AIDS and thus created awareness amongst Kenyans.

5. Free distribution of condoms: The government has taken the responsi-

bility of distributing condoms free of charge. These are distributed in

hospitals, during rallies on anti-HIV/AIDS campaign. The government

encourages correct and consistent use of latex condoms during sexual in-

tercourse. In this regard the government has zero rated tax on condoms

and other preventive devices to ensure that its citizen can all have access

to all available preventive measures.

6. Provision of treatment to HIV/AIDS patients: The government plays

a role in availing treatment to HIV/AIDS patients. It provides free or

subsidizes ARV drugs and other health services to people suering from

HIV/AIDS. The government has taken the initiative to help prevent

mother to child transmission. HIV positive mothers are given antiretro-

viral drugs during pregnancy and delivery. This includes AZT which

helps in the reduction of the viral load. HIV positive mothers are also

encouraged to undertake caesarian section instead of normal delivery.

The government has also encouraged HIV positive mothers neither to

donate breast milk to milk banks nor to express their breast milk to be

bottle fed to their babies.

7. Provision of VCT centers all over the country: The government has es-

tablished and opened VCT centers all over the country. VCT services

are oered free of charge in most government health facilities. This has

enabled most Kenyans to know their HIV status and through guidance

and counseling, they have been taught on how to live positively for those

aected and how to stay negative for those who are HIV negative. In

VCT centers clients are taught about contracting, transmission, preven-

tion and control.

8. Discouragement of detrimental socio-cultural practice: The government

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SZL2111 HIV/AIDs

in conjunction with NGO's is trying to ght against socio-cultural prac-

tices that have become deadly with the advent of HIV/AIDS. They have

been at the forefront of trying to eradicate such practices which includes

FGM, circumcision done the traditional way, wife inheritance and early

marriages.

9. Gender advocacy: The government is also advocating for gender equality

and thus is teaching women on their basic rights and more so not to

be sexually abused. This has empowered women and exposed them to

the current world where they are recognized and respected equally as

men. The government has enhanced laws against violence on women and

other vulnerable groups in the society including HIV AIDS individuals

to protect them from victimization. Tough laws have been enacted for

imprisonment of anyone involved in rape case. This has gone way in

reducing the spread of HIV/AIDS.

10. Poverty eradication: The government has been at the forefront of try-

ing to eradicate poverty. It has started constituency development fund

through which constituencies throughout the country receive fund from

the central government and channel them to projects that help elevate

the living standards of the local by creating income-generating activities.

The government has also permitted formation and operations of NGO

are that help people at grass root ght poverty. Some of these NGO's

cater for vulnerable groups in the society.

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Exercise 12.  Revision Questions

Describe programs initiated by public health ocials to protect and im-

prove the health of the community

Example . Discuss factors that have contributed to the high prevalence of

HIV/AIDS in Sub-Saharan Africa

Solution : 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. 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. Festival

seasons - during certain occasions such as Christmas, valentine day etc, there

is a strong behavior 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. Sexual

orientation (Homo sexual and lesbianism) - these kinds of sexual orientation

have emerged in urban centers even though they are conducted clandestinely

and are strongly disproved. 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 behavior 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 over

development in urban centers, there is no longer space for playgrounds and

other recreational facilities. The youth become idle and to reduce idleness they

engage in risky behaviors 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. Male and female circumcision

- the same knife is used repeatedly without sterilization this leading to risk of

blood contamination wit HIV. Polygamy - this practice is resilient in a number

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SZL2111 HIV/AIDs

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 o

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. 

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Revision questions or guidelines

1. The eect of HIV epidemic has prompted the Kenyan Government ti

initiate various programs to reduce the spread of HIV among its citizens.

Discuss this statement.

2. Discuss the impact of HIV on education

3. Anything else you would like to suggest

References and Additional Reading Materials

1. Maranga R. O, Muya S. M and Ogila K. O (2008) Fundamentals of

HIV/AIDS Education. Signon Publishers.

2. Barry D. S. (1999) AIDS and HIV in Perspectives. CPU. ISBN-13:

9780521627665

3. Ellison G. Parker M., Camphpbell C (2003) Learning from HIV and

AIDS. Cambridge CPU.ISBN-13: 9780521709286.

4. Shavitri Ramaiah (2008) HIV/AIDS; Health solutions. Sterling Publish-

ers Ltd. ISBN-9788120733305.

135
SZL2111 HIV/AIDs

Solutions to Exercises
Exercise 1. The vaccine used in the program then was discovered in the

stores of the original place that developed it. This was subsequently analyzed.

It was announced that no trace had been found of either HIV or chimpanzee

SIV. A second analysis conrmed that only macaque monkey kidney cells,

which cannot be infected with SIV or HIV, were used to make Chat and not

chimpanzee's as earlier suggested. While this is just one phial of many, most

have taken its existence to mean that the OPV vaccine theory is not possible.

The fact that the OPV theory accounts for just one (group M) of several

dierent groups of HIV also suggests that transferal must have happened in

other ways too. The nal element that suggests that the OPV theory is not

credible as the sole method of transmission is the argument that HIV existed

in humans before the vaccine trials were ever carried out. Exercise 1

Exercise 2. HIV is the human immunodeciency virus that causes AIDS

(acquired immunodeciency syndrome). When HIV infects someone, the virus

enters the body and begins to multiply and attack immune cells that normally

protect us from disease. It's only when someone with HIV begins to infections

and illnesses that they're diagnosed with AIDS. Exercise 2

Exercise 3. Fertility myth - Common belief that one engage in sex to enhance

fertility in future. This not true. People have to multiply to ll the earth, a

literal translation of a biblical command but people are supposed to multiply in

spiritual sense. This is a corruption of the bible. Health Myth - abstaining from

sex leads to sickness and madness, nobody has ever fallen sick or become mad

for not engaging in sexual intercourse. Having a venereal disease is considered

a badge of honor that conrms manhood. Venereal diseases confers no honor

to any man. Venereal disease is cured if the man has sex with a virgin. This

is not true. On the contrary the Venereal disease suerer will transmit the

disease to the virgin. Special food and exercise will make the penis grow big.

This is 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. This is not true. Sexual urge is

equal in both the sexes. It is generally said that Africans are promiscuous This

is not true. Promiscuity is not necessary an African trait has other races have

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promiscuous people too. A man cannot be satised by one woman. This not

true. One can't get pregnant during the rst sex intercourse. Common believe

that there is a grace period between the rst sexual encounter and getting

pregnant - like the payment schedule on credit card. This one isn't true.

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. Other remain in the urethra

after ejaculation and can fertilize an ova. 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. Common belief

that virginity brings problems during birth. This is not true. Imparting sex

education to youngsters will lead them to promiscuity. Educating the young

on sex and sexual behaviour helps them to develop a healthy and positive

attitude towards sexuality . Exercise 3

Exercise 4. The immune system is responsible for body defense against attack

from pathogens. It is made up of white blood cells which include granulocytes

such as neutrophils and basophils, and agranulocytes such as monocytes and

lymphocytes. T-helper lymphocytes have a CD4+ marker that the HIV uses

for entry into the cell and replicates. T-helper lymphocytes are important in

immune regulation because when they are activated they recruit other immune

cell involved in immune responses. HIV uses the CD4+ cells to replicate and

produce more viral particles. CD4 are killed and destroyed as viral production

progresses. Cytotoxic T-lymphocytes with CD8+ marker target any virally

infected CD4+ cells and kills them. Macrophages which have a CD4+ marker

too act as reservoir and are also killed by cytotoxic. As virtually infected cells

are killed by cytotoxic T-lymphocytes and more of the CD4+ cells destroyed as

a result of viral replication, their numbers goes down. The immune system is

depleted of these crucial cells involved in body defense and becomes vulnerable

to attack by opportunistic pathogens. Exercise 4

Exercise 5. Entry in the CD4 + - Binding of GP 120 to CD molecule al-

lows it to bind to co-receptor causing fusion of viral and cell membrane leading

to entry of virus into cell. Reverse transcription - Conversion of viral RNA

into viral DNA under the inuence of reverse transcriptase in the cytoplasm.

Integration - Viral DNA moved into cell nucleus where it is integrated with

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host cell chromosome under the inuence of intergrase. Transcription - Pro-

duction of new viral mRNA molecules for production of viral RNA involving

host cell enzymes. Translation - Viral mRNA is transported to the cytoplasm

to produce viral structural proteins under the inuence of HIV Proteins. As-

sembly and budding - Newly made HIV core proteins enzymes and genome
RNA gather inside cell and they bud o. Maturation - The core of the virus

is immature and therefore un-infectious protease breaks the long protein chains

causing viral particles. Exercise 5

Exercise 6. Primary HIV infection - This is the initial stage where one

obtains the virus through the various modes of transmission. Window period

- This stage of infection lasts for a few weeks to about 3 months and is often

accompanied by a short u-like illness or no signs. HIV cannot be detected

in blood screening although HIV is present in blood & the blood in not 100%

free of HIV. During this time a person can still transmit the virus to another

person. It's the most crucial stage. Sero conversion - This is the development

of the anti-bodies. Immune system begins to respond to HIV by producing

HIV antibodies and cytotoxic lymphocytes. If an HIV antibody test is done

before seroconversion is complete then it may not be positive. In this stage

a person may have u like illnesses, fever, fatigue, sore throat, joint pains

& lymphadenopathy. Some will not experience any illnesses at this stage.

Clinical asymptomatic HIV infection/ Latent phase - The presence of HIV

without 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. This period can last for many years

(5  15 years). Symptomatic HIV infection/AIDS Related Complex (ARC)

phase - Over time the immune system loses the struggle to contain HIV due

to the following main reasons: The lymph nodes and tissues become damaged

or 'burnt out' because of the years of activity; HIV mutates and becomes

more pathogenic, i.e. 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. It varies between people & depends on a length of factors. Progression

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of HIV to AIDS - As the immune system becomes more and more damaged the

illnesses that present become more and more severe leading eventually to an

AIDS diagnosis. It's the most advanced stage of HIV infection. At this time

when CD4 cell count has gone down below 200CD4 cells/ml, HIV develops to

one or more severe opportunistic infections or cancer. Exercise 6

Exercise 7. The Enzyme-Linked Immunosorbent Assay (ELISA) -

Identies antibodies directed specically against HIV. ELISA test does not

establish a diagnosis of AIDS, rather it indicates that the person has been

exposed to or infected with HIV. People whose blood contains antibodies for

HIV are said to be sero positive. HIV antibodies do not reach detectable

levels in the blood for one to three months.  Window period is the time

during which antibody detection using Elisa is negative. In some cases it may

take even 6 months for the antibody levels to get high enough for detection.

The Western blot assay is another test that can identify HIV antigens and

is used to conrm sero positivity as identied by the ELISA. This is a method

that detects very low antigen levels such that one may test HIV negative by

ELISA but test positive through western blot. Babies born of HIV mother

have antibodies to HIV that were passed on during pregnancy through the

placenta. However these antibodies diminish with time such that by 15 months

the child may test negative. Use of Western, blot conrms presence of HIV

antigen and this rules out whether babies are positive because of HIV itself or

because of maternal antibodies. PCR is also used to detect HIV in high-risk

seronegative people before the development of antibodies, to conrm a positive

ELISA, to screen neonates, and to determine the exact strain of virus that is

present. CD4+Cell count - Once a patient is diagnosed positive the extent of

damage to the immune system is determined by CD4+ cell count (T-helper cell

count). The number of CD4 cells present is a direct indicator of the immune

system's ability to ght o opportunistic infections. The test to measure CD4

cells requires a sample of blood to be taken and measurement is made of the

number of CD4 cells in a cubic milliliter of blood and will give a picture of the

health of the immune system-whether it is improving or declining. The CD4

count of a person who is not infected with HIV may lie anywhere between

500 and 1200.A drop in an HIV positive persons CD4 count usually occurs

over a number of years. A CD4 count between 500 and 200 indicate that

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some damage to the immune system has occurred and a count below 350 or

rapid decline is an indication that one should consider anti-HIV treatment.

Measuring viral load - Measuring viral load is essential to determine how

active the viral replication is if one is taking anti-HIV medication, then it is

also a direct indicator of how successful it is in suppressing viral replication.

The viral load test requires the collection of a blood sample and estimates the

number of HIV particles in the sample by looking for HIV genes. The level

of viral load is generally seen as a good indicator of whether to start ant-HIV

treatment. An undetectable viral load is an indication that both the risk of

developing AIDS and the risk of developing drug resistance has been reduced.

A high viral load is an indication of high levels of HIV in body uids while

undetectable viral load indicates a reduction in levels of HIV in these uids

but the risk of transmitting the virus is still present. Exercise 7

Exercise 8. VCT has taken a central role in enlightening and guidance of

HIV/AIDS disease. Involve testing and availing the results to people in min-

utes. Before testing the people are prepared rst for both positive and negative

results before allowed to know their status. Importance of knowing one's HIV

status includes: Preventing the uninfected person from contracting the dis-

ease. Enhancing abstinence for the infected helps in controlling the disease

through self awareness and putting up ways on how to abstain or get involved

in safe sex. Counseling also helps in ensuring reduced spread of the virus by

those people who have been infected but had not shown symptoms. Counsel-

ing infected people, majority of who have lost hope, helps in ensuring positive

living. Help to reduce the revenge attitude for those innocently infected and

may opt to die with many or commit suicide. Counseling enables the public

who includes the relatives of the infected to stop stigmatizing those infected

to be able to live normal lives knowing that someone cares for them. Testing

also helps the government to keep statistics on the prevalence of the disease

hence policy development or strategic planning. Prevention involves tackling

the most important modes of transmission. Discuss briey how to prevent

sexual transmission. Exercise 8

Exercise 9. Early and eective treatment of STIs decreases the amount of

HIV in genital secretions and reduces the risk of its spread to other sexual part-

ners. Early treatment also reduces the risk of contracting HIV from infected

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partners. Furthermore, early diagnosis and treatment of STIs are important

because they can prevent serious complications, such as infertility, ectopic

pregnancy, genital cancer, blinding eye disease, and major nervous system in-

fections in infants, that can occur as a result of an untreated STI.

Exercise 9

Exercise 10. There is a treatment called post-exposure prophylaxis (PEP)

for HIV. PEP is a month-long course of drugs that may prevent a person

from becoming infected with HIV if they begin treatment within three days

of exposure to HIV. If you may have been exposed, contact a health service

as soon as possible for treatment. See the `Further Information' section at the

end of this booklet for service details for PEP. Exercise 10

Exercise 11. Men still dictate matters regarding sex - for example, when to

have sexual intercourse irrespective of whether a woman wants it or not. Also

use of condom relies on the man. Girls have been taught to leave decision

making on sex matters to males whose needs and demands are expected to

dominate. Male predominance often comes with intolerance for predatory and

violent sexuality - this carries double standards whereby women are blamed or

thrown out for indelity whether real or suspected while men are allowed to

have multiple sexual partners. Biological makeup and reproductive anatomy

of the female body makes her to be more vulnerable to contract HIV than

men - sex takes place inside the body of the woman and the female genitalia

is prone to tears and wear. These tears and wears and/or sores provide en-

try route for the virus. The female reproductive system is also in direct and

longer contact with the male semen deposited during sexual intercourse. If the

semen has HIV, then it becomes easier for her to contract the virus. Poverty -

failure to respect the human rights of girls in terms of equal access to school,

training, employment opportunities etc. reinforces their economic dependence

on men. A woman who is in a stable relationship and is economically depen-

dent on her husband cannot aord to jeopardize his support even when she

suspects that he is HIV positive. If she insists on a condom use she is accused

of being unfaithful or the man reacts violently. Prostitution-a lot of women

go into prostitution as a way of income generating activity. A lot of them

end up acquiring HIV/AIDS. For some women, prostitution is a choice while

others are forced by circumstances into it to exchange sex for basic necessities

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of life for themselves and their children. Cultural practices-a number of cul-

tural practices have increased the vulnerability of women to contracting HIV.

These include wife inheritance, polygamy, early marriages and resistance to

condom use. Social evils - they include rape, sodomy, homosexuality, premar-

ital, extramarital sex, and drug and alcohol abuse. Ignorance - majority of

women are poorly educated and lack information on their bodies, HIV/AIDS

and other sexually transmitted diseases. They are therefore unable to protect

themselves. Exercise 11

Exercise 12. Vaccination - This is the process of making the body resistant

to a specic disease by using a vaccine Vaccination programs protect people

against disease.When small outbreaks of infectious disease threaten to grow

into epidemics, public health ocials may initiate new vaccination programs.

Rural and Urban Health Clinics - Public health agencies operate local clinics

that provide free or reduced-cost medical services to individuals, especially

infants and children, pregnant and nursing women, people with drug abuse

problems, physical disabilities, and other conditions. Public health clinics

routinely screen patients for a number of infectious diseases Each clinic tracks

the incidence of certain communicable diseases in its area, and reports this

information to national and international public health oces. Disease Track-

ing and Epidemiology - Threats to public health concerns change over time

and epidemiologists and other ocials continuously evaluate epidemiological

trends to determine how best to meet future public health needs. Epidemiol-

ogists and other public health ocials attempt to break the chain of disease

transmission by notifying people who may be at risk for contracting an in-

fectious disease Public health ocials ensure that infected people complete

treatment programs, so that the diseases are completely eliminated and the

patients are no longer carriers of the infection. Sanitation and Pollution Con-

trol Disease-causing organisms are often transmitted through contaminated

drinking water. The single most eective way to limit water-borne diseases

is to ensure that drinking water is clean and not contaminated by sewage. I

In many parts of the world, public health ocials establish sewage disposal

and solid waste disposal systems, and regularly test water supplies to ensure

they are safe. Environmental pollution is another preventable cause of disease

and disability, and in most countries public health ocials address the adverse

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health eects of air pollution and water pollution. Public health ocials may

work in conjunction with pollution control organizations to establish and en-

force pollution limits and advise the general population when pollution levels

exceed safe limits. Medical Research Cadres of doctors and scientists work

in laboratories around the world to establish new ways to prevent, diagnose,

treat, and cure disease and disability. Scientists and doctors employed by the

government conduct some biomedical research in public health facilities to nd

better ways to protect human health. Public Education Campaigns Many dis-

eases are preventable through healthy living, and a primary public health goal

is to educate the general public about how to prevent noninfectious diseases..

Health promotion encourages people to take advantage of early diagnostic tests

that can make the outcome of disease more favourable e.g. early breast cancer

detection . Exercise 12

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