HIV AND AIDS

List of Abbreviations
CCC Comprehensive Care Center
PEP Post Exposure Prophylaxis
PLWHIV People Living with HIV/ AIDS
PMTCT Prevention of Mother to Child
Transmission
STI Sexually Transmitted infection
VCT Voluntary Counselling and Testing
VD Venereal Diseases

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Table of Contents
Acknowledgement..............................................Error! Bookmark not defined.
List of Abbreviations.........................................................................................1
Module Introduction.........................................................................................4
Module Competencies.......................................................................................5
Module Outcomes.............................................................................................5
Module Learning Strategies..............................................................................5
Module Learning Logistics/Resources...............................................................5
MODULE ASSESSMENT...................................................................................5
UNIT 1: INTRODUCTION..................................................................................6
Unit Objectives..............................................................................................6
By the end of this unit, the learner should be able to:...................................6
1.1 Human physiology................................................................................6
1.2 Sex and Sexuality.................................................................................6
UNIT 2: SEXUALLY TRANSMITTED DISEASES (STD).......................................7
Unit Objectives..............................................................................................7
By the end of this unit, the learner should be able to:...................................7
2.1 Comparative information on trends; global and local distribution............7
2.2 Sexually Transmitted Infections...............................................................8
2.3 The relationship between other STI and HIV/AIDS................................14
2.4 Prevention of HIV infection and PEP......................................................15
2.5 HIV........................................................................................................16
UNIT 3: BIOLOGY OF HIV AND AIDS..............................................................35
Unit Objectives............................................................................................35
3.1 Overview of immune system...................................................................35
3.2 Natural immunity to HIV and AIDS........................................................36
3.3 The AIDS virus and its life-cycle............................................................40
UNIT 4: TREATMENT AND MANAGEMENT.....................................................53
4.1 Nutrition.............................................................................................53

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 4.2 Prevention and control........................................................................58
4.3 Pregnancy and AIDs..............................................................................60
4.4 Management of PLWHIV/AIDS...............................................................62
UNIT 5: CULTURAL PRACTICES.....................................................................66
Unit Objectives............................................................................................66
5.1 Religion and AIDS..................................................................................66
5.2 Social stigma and destigmatization of HIV and AIDS..............................66
5.3 Behavioral change.................................................................................67
5.4 Voluntary Counseling and Testing (VCT) Services..................................67
5.5Families and AIDS Orphans....................................................................68
UNIT 6: LEGAL RIGHTS OF PEOPLE LIVING WITH HIV/AIDS........................70
Unit Objectives............................................................................................70
6.1 Ethical Issues........................................................................................70
UNIT 7: IMPACT OF AIDS ON FAMILY SET-UP/SOCIETY...............................71
Unit Objectives............................................................................................71
6.1 Impact of HIV/ AIDS on Family and Society...........................................71
REFERENCES................................................................................................76

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Module Introduction
HIV and AIDS module is designed to equip the learner with knowledge, skills
and attitude to enable them to be able to demonstrate understanding of
various aspects of HIV and AIDS.

The module takes 60 contact hours: 36 hours for theory and 24 hours for
practical. Learners undertaking this module will have both theory and practical
assessments. The formative assessment will be in the form of continuous
assessment tests, assignments, clinical and field assessments and promotional
examination whereas summative assessment will be done in form of final
qualifying examination.

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Module Competencies
Demonstrate understanding of various aspects of HIV and AIDS.

Module Outcomes
1. Describe the modes of transmission and spread of HIV and AIDS.
2. Explain the methods of testing and screening for HIV and AIDS.
3. Test for HIV infection.
4. Describe the policies and methods used in treatment and management of
HIV and AIDS.
5. Discuss the impact of HIV and AIDS on social; cultural; economic and
religious factors on the spread and management of HIV and AIDS.
6. Discuss the public health importance of STIs
7. Explain the Integrated management of HIV and AIDS

Module Learning Strategies

Lectures, demonstrations, group discussions individual assignments and case
studies

Module Learning Logistics/Resources

Laptop computer, projector and white board and whiteboard markers

Module Assessment
CAT(s) accounts for 40% of the total marks
End of Semester Examination Accounts for 60% of the Total Marks

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 UNIT 1: INTRODUCTION
Unit Objectives
By the end of this unit, the learner should be able to:
1. Understand human physiology and sex and sexuality

1.1 Human physiology

Human physiology is the science of the mechanical, physical, and biochemical
functions of normal humans or human tissues or organs.

1.2 Sex and Sexuality

Sex refers to person’s identity based on their physical characteristics (e.g.
having a penis, vagina, beard or breasts, etc.), genes and hormones.

Sexuality encompasses nearly every aspect of our being, from attitudes and
values, to feelings and experiences. It is influenced by the individual, family,
culture, religion e.t.c

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 UNIT 2: SEXUALLY TRANSMITTED DISEASES (STD)

Unit Objectives
By the end of this unit, the learner should be able to:
1. Explain different sexually transmitted diseases and their characteristics

Some diseases of the reproductive system are spread from one person to
another through sex (anal, oral or vaginal). Such diseases are referred to as
sexually transmitted infections abbreviated as STIs. They are also known as
venereal diseases (VD).

If a healthy person has sex with an infected person, he or she will be infected
with the STI. STIs mainly affect the sexual organs (genitals) and are
transmitted to another person mainly through body fluids during sexual
intercourse. These body fluids include blood, saliva, semen, vaginal fluids and
breast milk.

2.1 Comparative information on trends; global and local distribution

Global 1985 1995 2005

statistics
International
AIDS
society-USA
North 620,000 1.2M 1.9M
America
South 140,000 1.1M 1.9M
America
North Africa 940 260,000 400,000
Sub-Saharan 700,000 13.3M 22.4M
Africa
Asia 220 3M 8.1M

UNAIDS/WHO-May 2006

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2.2 Sexually Transmitted Infections
2.2.1 The key characteristics of the main STI in Kenya grouped by major
syndromes

Common STI Syndromes

• Urethral discharge
• Genital Ulcer Disease
• Lower abdominal pain
• Abnormal vaginal discharge
• Ophthalmia neonatorum
Vaginal Discharge
• Neisseria Gonorrhoea – Greenish – yellow discharge
• Chlamydia trachomatis – scanty muco-purulent discharge.
• Trichomonas Vaginalis – Frothy, profuse, greenish-yellow foul-smelling
discharge
• Candida albicans – white, curd-like discharge
a) Syphilis
It is a Sexually Transmitted Infection, which attacks the skin
Causes
It is caused by bacteria Treiponema pallidum.
 It can be transmitted from mother to fetus where usually will be stillborn
or die after birth
 The bacteria penetrate mucosal layer and skin easily and enter into blood
and lymph.
 The first sign of infection is a sore that appears 2-5 weeks after having sex
with an infected person. The sore is called a chancre. The sore is
irregularly shaped. The chancre may look like a pimple, blister or an open
sore. The sore can sometimes appear in the mouth, on the lips, by the
anus or on a finger.

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  After a few days, the sore disappears. After several weeks or months, a
painful rash or pimples appear all over the body. Painful sores develop in
the mouth. The sore is usually painless. It appears on the penis in males
 In females, it appears in the vagina and sometimes in the vulva. If it is
inside the vagina, the woman may not know that she is infected.
 The chancre has bacteria that can easily be passed on to another person
during sexual contact.
 Ring-shaped patches also appear on the skin.
 The signs may disappear on their own without treatment, but the disease
continues to spread in the body.
 After many years, the disease can spread to any part of the body and
attack some organs such as the heart and the brain. The disease can
cause joint pains and paralysis.
 It can also cause heart disease. The infection may also be passed from an
infected mother to her developing child in the womb.

Brief over view

1st Stage
• Symptoms begin 1-12 weeks after infection

• Red, Painless, open sore (chancre) on the mouth or sex organ

• Sore goes away after 1-5 weeks

2nd Stage
• Symptoms begin 1-6 months after sore appears

• Non-itchy rash on the body

• If untreated, pink skin rash will appear all over the body. Fever, joint
pain, anemia, hair loss will occur if still untreated.

• Flu-like symptoms
Latent syphilis
• There are no signs or symptoms but a blood test is positive.

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Late Syphilis
• Untreated syphilis may progress.

• After 2-15 years, the heart and brain may be affected.

• At this time, the disease cannot be passed to other people.

Prevention of syphilis
 Syphilis can be prevented by:
 Not having sexual intercourse with infected persons
 Abstinence for unmarried persons
 Married persons should be faithful to their partners
 Avoid engaging in sex with multiple partners
 For blood transfusion, use blood which has been screened.

Treatment
Penicillin is the only known treatment, but only effective during early stages of
symptoms
b) Gonorrhea
Cause
Gonorrhea is caused by bacteria (. It is spread through sexual intercourse or
from infected mother to child during child birth. Sharing of personal clothes
such as underpants, towels and swimming costumes can also spread the
diseases.

• Symptoms begin 2-21 days after infection organs

• Discharge from penis or vagina
• Pain/burning sensation during urination or bowel movement
• Blindness in babies of infected mothers
• Difficulty urinating
• Lower abdominal pain (pelvic area)
• Most women and some men have no symptoms
In males
It first attacks the urethra then spreads to other sexual organs
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There is pain when passing out urine
Some drops of pus from the penis can be seen
Difficulty when passing urine and sometimes, the urine may not come out at
all
The testicles may become swollen
After several months, the knees and other body joints begin to swell
In females
- It attacks the vagina, then later may spread to other parts of the
reproductive system
- The signs take a longer time to appear in females than in males
- The female, starts to experience a little pain when urinating
- She notices some pus discharge from the vagina
- Lower abdominal pain may be experience and at times unusual bleeding
- After several months or years, she starts to feel pain in the lower part of
the abdomen
- The females may become infertile and experience problems with
menstruation or have cervical cancer
- A baby born to gonorrhea-infected mother may get eye infection and if
not treated the body may become blind.
Prevention of gonorrhea
1) By not having sexual intercourse with the infected person
2) Abstinence
3) Being faithful
4) Avoiding multiple sex partners
5) Seeking medical treatment early if infected together with your partner
help prevent later complications
Treatment
Penicillin and tetracycline antibiotic drugs are effective, but sometimes bacteria
might be resistant to these drugs
c) Chancroid

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It is a sexually transmitted infection. Also known as soft chancre, venereal sore
or human genital ulcer disease
Cause
It is caused by bacteria (Haemophilisducreyi). The first sign of infection
appears from 3-5 days and up to 2 weeks. After sexual contact with the
infected person
- A sore develops inside the vagina in females or penis in males
- The sore may sometimes appear on hand in females, thighs or head of
penis
- The shape of the sore can be oval or round
- The chancroid sores are surrounded by a narrow red border which soon
becomes filled with pus
- Within four days, the sore breaks open leaving a painful open sore.
- The infection spreads to other parts by rubbing, scratching or physical
contact
- If not treated, the chancroid bacteria infects the lymph glands in the
groin
- The lymph glands in the groin may swell creating a pus-filled bulge
known as a bubo. The sore can also affect the rectum.
The infection is spread through sexual contact with open or runny sores of
infected people
Prevention and control of chancroid
Chancroid can be prevented by avoiding sex with an infected person and
seeking early treatment when infected.
d) Chlamydia
Caused by bacterium named Chlamydia trachomatis
Signs and symptoms
• Symptoms begin 7 - 21 days after infection
• Discharge from the sex organs
• Burning or pain while urinating

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 • Unusual bleeding from the vagina
• Pain in the pelvic area
• Most women and some men have no symptoms
e) Genital Ulcer Disease( GUD)
GUD is one of the most common syndromes that affect men and women. In
men, GUD occurring under the prepuce may present as a discharge.

• HIV alters the natural history of syphilis and Chancroid, where more
aggressive lesions may manifest.

• HIV transmission is enhanced in presence of ulcerative STIs.

f) Herpes
Symptoms begin 2-30 days after infection
 Painful blister-like lesions on or around the genitals or in anus or
mouth
 Recurring outbreaks of blisters
 Flu-like feelings
 Itching and burning sensation around the sex organs before the
blisters appears
 Blisters last 1-3 weeks
 Blisters disappear but the individual still has herpes
 Blisters may recur
g) GENITAL HERPES
Caused by a virus named Epstein – Barr virus (EBV) and is the most difficult
STI to control or treat.
Signs and symptoms
• Symptoms begin 2-30 days after infection
• Painful blister-like lesions on, around the genitals, or in anus or mouth
• Recurring outbreaks of blisters
• Flu-like feelings

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 • Itching and burning sensation around the sex organs before the blisters
appears
• Blisters last 1-3 weeks
• Blisters disappear but the individual still has herpes. Blisters may
recur
h) Genital Warts
Caused by the human papillomavirus (HPV)
 Can be detected by pap smear during gynecologic exam
 Can be removed by physical or chemical means but virus cannot be
cured and wards often reappear.
 Small painless fleshy bumps on and inside the genitals and throat.
 Often no visible symptoms

2.3The relationship between other STI and HIV/AIDS

There is a direct relationship between STDs and HIV:
• STI primarily disrupt the integrity of the skin/mucosal barrier, enabling
HIV easy access to the body.
• The presence of genital ulcers is known to increase the risk of HIV
transmission by 10 to 100 times.
• STI that primarily cause inflammation, such as gonorrhea,
trichomoniasis, and chlamydia, weaken the skin barrier to HIV.
• Increased viral shedding has been reported in genital fluids of patients
with STI/RTI.
• STI treatment has been demonstrated to significantly reduce HIV viral
shedding.
• The behaviour that puts a person at risk of contracting STDs (e.g., drug
or alcohol abuse because it impairs judgement about sexual behaviour,
multiple partners, non systematic use of condoms) puts the same person
at risk of contracting HIV infection.
• STDs increase the amount of HIV in the body.

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 • People with HIV and STIs/STDs are also more likely to shed blood and
pus through genital sores, exposing their sexual partners to HIV.
• In addition, the immune systems of people with STIs send immune cells
to these genital lesions to fight the infections there. These immune cells–
CD4+ cells–are the cells to which HIV attaches.
• As a result, men and women with HIV and STIs have many more HIV
particles concentrated near their penis and vagina, respectively, than do
HIV+ people without STIs.
• An individual with HIV eventually suffers damage to the immune system,
making him or her more susceptible to contracting other infections,
including STIs.

2.4 Prevention of HIV infection and PEP

The main mode of HIV transmission is heterosexual and homosexual contact.
Transmission may also occur due to:
 Occupational exposure
 Non-occupational exposure
Health professionals are in contact with patients and infected clinical
material.They can get infection thro ’injury by contaminated needles and
scapels or with infected body fluids. This is occupational exposure

Non-occupational modes of transmission include: sexual assault e.g. Rape or

sodomy,sharing needles by Intravenous drug users and road traffic accidents

Post Exposure Prophylaxis(PEP)- This is the use of Anti-retroviral drugs for a

short time to prevent likelihood of HIV infection following exposure. It involves
avoiding exposure and using drugs once exposed

PEP recommendations following sexual assault in adults and adolescents are

as follows:
For any exposure deemed to be significant:

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TDF+ 3TCTwice a day for 28 days
OR
AZT + 3TCTwice a day for 28 days
Give as soon as possible (<72hr) after exposure
(Refer to the “National Guidelines on the Management of Rape/Sexual Violence” )

2.5 HIV
2.5.1 Testing and counselling

The natural evolution of HIV infection can be considered in the following

stages
Group I—Acute HIV Infection
 The acute seroconversion illness resembles glandular fever, with
adenopathy and flu-like symptoms.
 Within 3-6 weeks of infection with HIV, about 50 percent of persons
experience low grade fever, malaise, headache, lymphadenopathy,
sometimes with rash and arthropathy resembling glandular fever. Even
fewer have the rare encephalitic presentation.
 Spontaneous resolution occurs within weeks. During this period there is
a very high level of virus replication occurring in CD4+ cells.
 Tests for HIV antibodies are usually negative at the onset of the illness
but become positive during its course.
 Hence this syndrome has been called ‘seroconversion illness’, though in
many of those infected, seroconversion occurs without any apparent
illness. HIV antigenemia (p24 antigen) can be demonstrated at the
beginning of this phase.
Group II—Asymptomatic or Latent Infection
 A clinically asymptomatic or “latent” period follows the acute infection.
 During this time, there is a high level of ongoing viral replication. They
show positive HIV anti body tests during this phase and are infectious.
 The infection progresses in course of time through various stages, CD4
lymphocytopenia, minor opportunistic infections, persistent generalized

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 lymphadenopathy, AIDS-related complex (ARC), ultimately terminating in
full blown AIDS, with its characteristic infections and malignancies.
 The time from infection to death may be as long as 10 years and is
inevitable in 70 percent of infected persons. The remainder may live as
long as 17 years and form the ‘longterm survivors’ or ‘nonprogressors’
group.
 The mechanisms for such prolonged survival are not clear, though many
viral and host determinants may be responsible.
Group III—Persistent Generalized Lymphadenopathy (PGL)
 Persistent generalized lymphadenopathy (PGL) is pre sent in 25-30
percent of patients who are otherwise asymptomatic.
 This has been defined as the presence of enlarged lymph nodes, at least
1 cm in diameter, in two or more noncontiguous extrainguinal sites, that
persist for at least three months, in the absence of any current ill ness or
medication that may cause lymphadenopathy.
 The rate of progression of patients with PGL to AIDS is no greater than in
those without adenopathy. This by itself is benign but the cases may
progress to ARC or AIDS.

Group IV—AIDS Related Complex (ARC)

 This group includes patients with considerable immunodeficiency,
suffering from various constitutional symptoms or minor opportunistic
infections.
 The typical constitutional symptoms are fatigue, unexplained fever,
persistent diarrhea and marked weight loss of more than 10 percent of
body weight.
 The common opportunistic infections are oral candidiasis, herpes zoster,
hairy cell leukoplakia, salmonellosis or tuberculosis.

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  Generalized lymphadenopathy and splenomegaly are usually present.
ARC patients are usually severely ill and many of them progress to AIDS
in a few months.
 With no treatment, the interval between primary infection with HIV and
the first appearance of clinical dis ease is usually long in adults,
averaging about 8-10 years.
 Death occurs about 2 years later. The acquired immune deficiency
syndrome (AIDS) presents in many ways, all due to the underlying severe
loss of the ability to respond to infectious agents and to control tumors.
 The features classified as group IV include what was known as the AIDS-
related complex or ARC.
AIDS
 This is the endstage disease representing the irreversible breakdown of
immune defence mechanisms, leaving the patient prey to progressive
opportunistic infections and malignancies.
 AIDS may be manifested in several different ways, including
lymphadenopathy and fever, opportunistic infections, malignancies, and
AIDS-related dementia.

Laboratory Diagnosis

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Laboratory procedures for the diagnosis of HIV infection include specific tests
for HIV and tests for immunodeficiency as well. Evidence of infection by HIV
can be detected in three ways:
- Specific tests for HIV infection
- Non-specific tests
- Tests for opportunistic infections and tumor.

2.5.2 Specific Tests for HIV Infection

a. Antigen Detection
 The virus antigens may be detectable in blood after about two weeks
following a single massive infection, as by blood transfusion.
 The major core antigen p24 is the earliest virus marker to appear in
blood and is the one tested for IgM antibody
 Antibodies appear in about 4-6 weeks, to be followed by IgG antibodies
 The appearance of p24 antigenemia and viremia, followed by IgM
antibody response coincides with the acute or seroconversion illness.
 After wards, free p24 antigen disappears from circulation and remains
absent during the long asymptomatic phase, to reappear only when
severe clinical disease sets in.
 The HIV window period is the time after infection has occurred but before
evidence of HIV infection is detectable.
 The HIV diagnostic window represents a vulnerable period particularly
from a blood safety standpoint, and sever al major efforts have been
launched to minimize its duration.
 The p24 antigen capture assay (ELISA) which uses anti-p24 antibody as
the solid phase can be used for this.
 The test is most useful in persons recently exposed to risk of infection, in
whom antibody test is negative. The antigen often becomes undetectable
after antibodies develop (because the p24 protein is complexed with p24

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 antibodies) but may reappear late in the course of infection, indicating a
poor prognosis.
 HIV p24 antigen or HIV RNA is often detectable prior to antibody
responses, and use of sensitive HIV antigen and nucleic acid testing has
reduced the window period to the current minimum.

b. Virus Isolation
 Once infected with HIV, a person remains infected for life.
 The virus is present in circulation and body fluids, within lymphocytes or
cell-free. It can be isolated from CD4 lymphocytes of peripheral blood,
bone marrow and serum.
 The technique of isolation is by cocultivation of the patient’s lymphocytes
with uninfected lymphocytes in the presence of interleukin-2.
 Virus presence is detected by assays for reverse transcriptase and p24
antigen in the culture fluids.
 Virus titers parallel p24 titers, being high soon after infection, low and
antibody bound during the asymptomatic period, and again high towards
the end.
 Virus isolation is to be attempted only in laboratories with adequate
containment facilities because of the risk involved.
 With the advent of PCR, there are now few, if any, diagnostic uses of
virus isolation.
c. Detection of Viral Nucleic Acid
 As the most sensitive and specific test, PCR has become the gold
standard for diagnosis in all stages of HIV infection.
 The PCR tests are complex and costly and are indicated only when
other methods cannot give a definitive result.
 Two forms of PCR have been used, DNA PCR and RNA PCR.
i. DNA PCR

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  In the DNA PCR, peripheral lymphocytes from the subject are lysed
and the proviral DNA is amplified using primer pairs from relatively
constant regions of HIV genome.
 The test is highly sensitive and specific when done with proper
controls.
ii. RNA PCR
 A related test, HIV RNA PCR can be used for diagnosis as well as for
monitoring the level of viremia.
 Levels of RNA can be assayed as copy numbers and indicate the
extent of virus replication in the patient.
 Measurement of plasma virus load is now essential for monitoring
disease progression and response to antiviral therapy.
d. Antibody Detection
 Demonstration of antibodies is the simplest and most widely employed
technique for the diagnosis of HIV infection. The mean time to
seroconversion after HIV infection is 3-4 weeks.
 Most individuals will have detectable antibodies within 6-12 weeks after
infection, whereas virtually all will be positive within 6 months.
 Following sexual exposure to HIV, antibodies may take 2 months to
appear, if infection has taken place.
 Therefore antibody testing will have to be done after 2-6 months to
ascertain whether infection has occurred or not, after a single sexual
exposure.
2.5.3 Screening (E/R/S) tests
i. Enzyme-linked Immunosorbent Assays (ELISA) Tests
 HIV-I ELISA tests were the earliest approved serologic tests for HIV
infection and remain the most sensitive approved commercial assays for
infection.
 Direct solid phase antiglobulin ELISA is the method most commonly
used. The antigen is obtained from HIV grown in continuous T

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 lymphocyte cell line or by recombinant techniques and should represent
all groups and subtypes of HIV-1 and HIV-2.
 The antigen is coated on microtiter wells or other suitable solid surface.
 The test serum is added, and if the antibody is present, it binds to the
antigen.
 After washing away the unbound serum, antihuman immunoglobulin
linked to a suitable enzyme is added, followed by a color-forming
substrate.
 If the test serum contains anti-HIV antibody, a photometrically
detectable colour is formed which can be read by special ELISA readers.
Conversion of substrate to product is quantitated by spectrophotometry.
 Modifications of ELISA in which the antibody in test serum either
competes with enzyme conjugated anti-HIV antibody, or is captured by
antihuman immunoglobulin onto solid phase are more specific.
 Third generation assays employ a sandwich technique using enzyme-
coupled HIV antigens and take advantage of the bi or multivalent nature
of antibodies to improve specificity. ELISA specific for IgM antibody is
also available. Immunometric assays are highly sensitive and specific.

ii. Rapid Tests

 Simple, rapid tests for detecting HIV antibodies are available for use in
laboratories illequipped to perform EIA tests. These tests take less than
30 minutes and do not require expensive equipment.
 A number of ‘rapid tests’ have been introduced for this purpose such as:
a) dot blot assays,
b) particle agglutination (gelatin, RBC, latex, micro beads),
c) HIV spot and comb tests,
d) fluorometric microparticle technologies.

iii. Simple Tests

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  These tests are not as fast as rapid tests. They take 1-2 hours and also
do not require expensive equipment.
 These tests are also based on ELISA principle
2.5.4 Supplemental Tests
i. Western Blot Test
 When EIA-based antibody tests are used for screening populations
with a low prevalence of HIV infections (e.g., blood donors), a positive
test in a serum sample must be confirmed by a repeat test.
 If the repeat EIA test is reactive, a confirmation test is performed to
rule out false-positive EIA results.
 The most widely used confirmation assay is the Western blot
technique, in which antibodies to HIV proteins of specific molecular
weights can be detected.
 In this test, HIV proteins, separated according to their electrophoretic
mobility (and molecular weight) by polyacrylamide gel electrophoresis,
are blotted onto strips of nitrocellulose paper.
 They retain their relative positions achieved on separation.
 The antigen impregnated nitrocellulose is then cut into strips, each
strip having the full complement of vital proteins which were
separated in the gel.
 Each strip is then incubated with a dilution of patient serum.
 Antibodies which attach to the separated viral antigens on the strip
are detected by antihuman immunoglobulin antibody to which
enzyme has been attached.
 The binding of this tracer antibody to the human immunoglobulin is
detected by the addition of the enzyme conjugate followed by
application of a substrate.
 The substrate changes color in the presence of enzyme and
permanently stains the strip.

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  The location or position on the strip at which a patient’s antibodies
attach to viral antigens indicates whether antibody is specific for viral
antigens or directed against non-viral material from the cells in which
the virus was grown.
Interpretation of Westron Blot (WB) Results WB results are scored as negative,
positive, or indeterminate:

 Negative Result
The WHO has suggested that a weakly reactive p17 band may be considered
negative. Antibodies to viral core protein p24 or envelope glycoproteins gp41,
gp120, or gp160 are most commonly detected.
 Positive Result
In a positive serum, bands will be seen with multiple proteins, typically with
p24 (gag gene, core protein), p31 (pol gene, reverse transcriptase) and gp41,
gp120 or gp160 (env gene, surface antigens). A positive reaction with proteins
representing the three genes gag, pol, env is conclusive evidence of HIV
infection. The test may be considered positive even if it shows bands against at
least two of the following gene products: p24, gp41, gp120 /160. However,
interpretation becomes difficult when bands that appear do not satisfy these
criteria. This may happen in early infection but may also be nonspecific.
 Indeterminate Result
Indeterminate results are not uncommon. Indeterminate results may arise from
either insensitive detection of true reactivity (window period) or false reactivity
with principally single-band reactivity. In such cases, the Western blot may be
repeated, later. If no definitive result can be given even then, it may be
necessary to have p24 assay done.

ii. Immunofluorescence Test

In this test, HIV infected cells are acetone fixed on to glass slides and then
reacted with test serum followed by fluorescein conjugated anti-human gamma

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globulin. A positive reaction appears as apple-green fluorescence of cell
membrane under fluorescence microscope.
Many workers have shown that saliva is an acceptable and often favorable
alternative to serum for HIV antibody testing. Blood of HIV-infected individuals
is a hazardous substance that occasion ally leads to HIV infection among
health care workers

2.5.5 Strategies Of HIV Testing

As the Western blot technique is costly, the practice now is to perform either
two different types of ELISA or an ELISA with any of the rapid tests.
A serum positive in both tests is considered positive. When in doubt, retesting
after 1 or 2 months may be useful. There are three strategies of HIV testing:
Strategy I
The serum is tested with one E/R/S test and if reactive, sample is considered
positive and if nonreactive it is considered negative. This strategy is used for
transfusion safety. For this purpose, a highly sensitive and very reliable test kit
must be used.
Strategy II
The serum reactive with one E/R/S test is retested with a second E/R/S test
with higher specificity, based on a different antigen preparation and/or
different test principle. If found reactive on second E/R/S test also, it is
reported as positive, otherwise as negative.
This strategy is used for HIV surveillance.
The majority of individuals seroconvert within 2 months after viral exposure.
HIV infection for longer than 6 months without a detectable antibody response
is very uncommon.
Strategy III
 The serum reactive with two E/R/S tests is retested with a third
E/R/S test.

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  The third test should again be based on different anti gen preparation
or test principle.
 A serum testing reactive with all three E/R/S tests is reported
positive.
 A serum sample nonreactive in third E/R/S is considered
equivocal/borderline. Such individuals should be retested after three
weeks.
 If this sample also provides an equivocal result, the person is
considered to be HIV antibody negative.
 For asymptomatic HIV infection, it is necessary to confirm the
diagnosis with three tests. Symptomatic infections with opportunistic
infections, however, may be subjected to two tests.
 The first test selected for any of the strategies should be of highest
sensitivity and second and third E/R/S test selected should be of
highest specificity.
2.5.6 Non-specific Tests
Immunological Tests
The following parameters help to establish the immunodeficiency in HIV
infection:
 Total leukocyte and lymphocyte count to demonstrate leukopenia and a
lymphocyte count usually below 2000/mm3.
 T cell subset assays. Absolute CD4+ T cell count will be usually less than
200/mm3. T4:T8 cell ratio is reversed.
 Platelet count will show thrombocytopenia.
 Raised IgG and IgA levels.
 Diminished CMI as indicated by skin tests. f. Lymph node biopsy
showing profound abnormalities.
2.5.7 Laboratory Monitoring of HIV Infection
Some laboratory tests are important in monitoring the course of HIV
infection.

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 a) CD4+ T Cell Count
 The most important of these is CD4+ T cell count which reflects the
current immunological competence of the patient. HIV positive
persons should have frequent CD+ T cell counts.
 When the count falls below 500 per mm3, it is an indication of disease
progression and the need for antiretroviral therapy. Counts below 200
denote risk of serious infections.
b) Direct Measurement of HIV RNA
 Direct measurement of HIV RNA becomes necessary, particularly in
the course of treatment.
 This is done usually by two methods, the reverse transcriptase PCR
(RT PCR) assay and the branched DNA (bDNA) assay.
c) Beta-2-Microglobulin and Neopterin
 Beta-2-microglobulin and Neopterin are two substances which have a
predictive value on the progression of HIV disease.
 They can be measured in serum or urine.
 Their concentrations are low in asymptomatic infection and rise with
advancing disease.
2.5.8 Community and Home Based Care and Other Support Services

Home based care is care provided in the home with the support of the client,
family, community and community volunteers, with support supervision and
monitoring provided by trained health workers who work within government
and non - government care facilities. (WHO 1994; NASCOP 2002)

Home-based care (HBC) is the care of persons infected and affected by

HIV/AIDS (PLHA) within the home and community, serving as a link between
hospital or health facility and the client’s home through family participation
and community involvement.

In HBC, the care is extended from the hospital or health facility where the
patient is initially seen to their homes.

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This therefore implies that these patients require certain services which form
the components of HBC.

2.5.9 Rationale For HBC

The concept of HBC has been adopted because:

 Health institutions have many limitations such as shortage of health

workers, few hospital beds and a shortage of other resources
 People with chronic illnesses need continuity of care to prolong their lives
and reduce their suffering
 People with debilitating illnesses are discharged from health institutions
where there trained professionals and sent to home to be care for by
untrained relatives with no professional backup or support
 The care givers at home are often women with no training in nursing or
how to protect themselves from risks related to infections and injuries as
a result of the care they give

Key Players in HBC

- The patient/client
- Family members and care givers
- Home care team
- Health workers
- Community
- Government

Objectives of Home-Based Care

1. To facilitate the continuity of the patient’s care from the health facility
to the home and community.
2. To promote family and community awareness of HIV/AIDS prevention
and care.

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 3. To empower the PLWHA, the family, and the community with the
knowledge needed to ensure long-term care and support.
4. To raise the acceptability of PLWHAs by the family/community, hence
reducing the stigma associated with AIDS.
5. To streamline the patient/client referral from the institutions into the
community and from the community to appropriate health and social
facilities.
6. To facilitate quality community care for the infected and affected.
7. To mobilize the resources necessary for sustainability of the service.

Principles of Home-Based Care

 Ensuring appropriate, cost-effective access to quality health care and
support to enable persons living with HIV/AIDS to retain their self-
sufficiency and maintain quality of life.
 Encouraging the active participation and involvement of those most
affected, the persons living with HIV/AIDS.
 Fostering the active participation and involvement of those most able to
provide support the community at all levels.
 Targeting social assistance to all affected families, especially children.
 Caring for caregivers, in order to minimize the physical and spiritual
exhaustion that can come with the prolonged care of the terminally ill.
 Ensuring respect for the basic human rights of PLWHAs.
 Developing the vital role of home-based care as the link between
prevention and care.
 Taking a multi-sector approach to care and support.
 Addressing the reproductive health and family planning needs of persons
living with HIV/AIDS.
 Instituting measures to ensure the economic sustainability of home care
support.

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  Building and supporting referral networks/ linkages and collaboration
among participating entities.
 Building capacity at all levels household, community, institution.
 Addressing the differential gender impact of the HIV/AIDS epidemic and
care for persons living with HIV/AIDS.

Components of HBC
 Clinical care. Makes early diagnosis, prescribes rational treatment
and plans for follow-up care of HIV-related illnesses.
 Nursing care is the art of assisting individuals , who are either sick or
well to do those things they would have done if they had the strength,
knowledge or will to do.It aims at alleviating physical and
psychological symptoms as well as minimizing the level of functions of
the sick person therefore facilitating rest.
 Counseling and psycho-spiritual care. Reduces stress and anxiety,
promotes positive living, and helps persons make informed decisions
on testing for HIV, changing their behavior, planning for the future,
and involving sexual partner(s) in such decisions.
 Social support. Provides information about support groups and
welfare services and refers patient to them, provides legal advice for
individuals and families, including surviving family members, and
where feasible, provides material assistance.
Advantages of HBC
Advantages to patient/client:
 Patient is cared for in familiar environment hence suffers less
stress/anxiety and illness is more tolerable
 When people are cared for in their homes, they continue to participate
in family matters
 When patient is at their home, they experience greater sense of
belonging

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  When one is in close contact with familiar people they are likely to
accept their condition thus quicker recovery
Advantages to the family:
 Care given at home less expensive than in hospital
 Care at home prevents separation and holds family members together
 Education of families on disease conditions helps them understand
these disease better and accept the patients
Advantages to the community:
 Costs of visiting a sick person in hospital are reduced
 Community cohesiveness is maintained, thus ensuring community is
able to respond to other members’ needs
 Training on HBC helps community to be aware of various illnesses
affecting their own and are hence able to counteract harmful myths
and beliefs and therefore actively participate in prevention efforts
Advantages to the health care system:
 Services that could otherwise be inaccessible to communities in remote
hardship areas can be realized through HBC training
 HBC reduces pressure on hospital services and hence the health care
system

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2.5.10Link betweenHIV&AIDS and TB and Other STIs

• HIV&AIDS has demonstrated link with Tuberculosis, sexually,

transmitted Infections and other Opportunistic infections.

• Tuberculosis is a fatal opportunistic infection amongst people who have

tested HIV positive. Tuberculosis is a serious highly infectious disease
which can be passed from one person to another.The presence of
Sexually transmitted Infections greatly increases the chances of
transmitting HIV and re-infection to those already infected.

• The weakened immune system caused by HIV infection renders the body
more susceptible to all type of infections

• Screening and prompt treatment of Tuberculosis, sexually transmitted

Infections and other opportunistic infections is critical in the prevention
and control of HIV infection

2.5.11 Safety and Infection Prevention

Measures toTake at Home and Community Level.

• Safety precautions should be observed to prevent new HIV infections and

re-infections to the client, care giver and the general population.

• Home and community care programmes should empower clients and

care givers with knowledge and skills though training in infection
prevention and other safety precautions.

Protecting the patient

• The client should be empowered with knowledge and skills on self care to
avoid spread of infection and for self protection against infections.

• Clients should also be empowered to take self responsibility of infection

control to avoid self infection as well as transmitting infections.

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Protecting the care giver

• There is presently no cure for HIV&AIDS and all persons involved in the
direct care of clients, whether professional or volunteers must be
informed of the possibility of contacting the HIV virus through contact
with contaminated body fluids .

• All care givers ought to be trained in basic procedures for handling body
fluids and practicing infection prevention procedures such as wearing
gloves, other protective gears or using disinfectants.

• Care givers who are accidentally exposed to infection should be managed

following the current guidelines on post exposure prophylaxis.

Protecting the community

• The community should be empowered with knowledge and skills on

infection prevention and universal safety precautions.

• The community ought to be made aware of existing polices on the

deliberate transmission by the infected.

• Any client found to be guilty of deliberately infecting others will be liable

to prosecution as per the existing policies.

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Page 35 of 77
 UNIT 3: BIOLOGY OF HIV AND AIDS

Unit Objectives
By the end of this unit, a student should be able to:

1. Explain the biology of HIV in relation to immunity

3.1 Overview of immune system

Immune system - A complex system of cellular and molecular components
having the primary functions of distinguishing self from not self and of defense
against foreign organisms or substances

 The normal immune system protects the body by recognizing antigens

like invading bacteria and viruses and reacting to them.

 It consists of lymphoid organs and tissues, including the bone marrow,

thymus gland, lymph nodes, spleen, tonsils, adenoids, appendix, blood
and lymphatic vessels.

 All components are vital in the production and development of

lymphocytes or white blood cells.

 When the immune system is weakened or destroyed by a virus such as

HIV, the body is vulnerable to opportunistic infections.

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3.2 Natural immunity to HIV and AIDS.

3.2.1 Components of the immune system

i) Component of blood and body tissues
ii) White Blood Cells (WBCs) also known as leukocytes are the key players
in immune function

There are 3 main types of leukocytes

i) Granulocytes- have granules in their cytoplasm that produce chemicals
(mainly histamine) for immune response. They include:
-Neutrophils attack bacteria

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-Eosinophils attack helminths and mediate allergies
-Basophils- associated with asthma and allergies
ii) Monocytes- Small WBCs which eventually become macrophages
-Macrophages act as clearing cells. They clear huge
particles by engulfing and digesting them using cytoplasmic enzymes
iii) Lymphocytes- They are the key players in the immune system.They
are responsible for two types of immune responses- humoral (involves
antibodies) and cellular (involves cells) immunity.
-B-lymphocytes make antibodies. They mature in the bone marrow. They
use antibodies (immune proteins) to target bacteria.
-T-lymphocytes- constitute cellular immunity. These cells mature in the
Thymus.
i) Responsible for attacking viruses, fungi and some bacteria
ii) T-helper cells central in orchestrating the function of other immune
cells
iii) T killer cells destroy infected cells
iv) Suppressor T-cells suppresses the immune reaction after the agent is
destroyed.

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 3.2.1 Mechanism of Body Defense

Multiplication of the virus in the human host

– When the virus enters the human body, it aims for the white blood cells
(the T-cells).
– The virus is ingested by the host white cell where it attacks the nucleus.
The infected host cell then begins to manufacture viral particles. These
particles, called virions, are discharged into the body fluids and the
blood. They enter other white cells and continue to multiply.

3.2.3 Effects of HIV on the immune system

– Host cells infected with HIV have a very short lifespan. Therefore, HIV is
continuously produced by using new host cells to replicate itself. Up to
10 million individual viruses are produced daily.
– In the first 24 hours after exposure, the virus attacks or is captured by
dendritic cells (type of phagocyte) in the mucous membranes and skin.
– Within five days of exposure, infected cells make their way to lymph
nodes and eventually to the peripheral blood, where viral replication
becomes very rapid.
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 – HIV causes severe damage to and eventually destroys the immune
system by utilizing the DNA of T- lymphocytes to replicate. In the
process, the HIV destroys the lymphocytes.
– The pathogenesis of HIV infection is largely attributable to the decrease
in the number of T cells (a specific type of lymphocyte) that bear the CD4
receptor (CD4+). The immune status of a child or adult living with HIV
can be assessed by measuring the absolute number (per mm3) or
percentage of CD4+ cells, and this is regarded as the standard way to
assess and characterize the sevProgressive depletion of CD4+ T cells is
associated with progression of HIV disease and an increased likelihood of
opportunistic infections and other clinical events associated with HIV,
including wasting and deatherity of HIV-related immunodeficiency.
In summary, HIV affects the immune system in the following ways:
I. HIV attaches to cells of the immune system with special surface markers
called CD4 receptors. They include: T- helper lymphocytes, macrophages,
monocytes, dendritic cells and microglial cells.
II. The virus enters the cell and alters the genetic processes of the cell
resulting to its replication (multiplication)
III. The virus causes cell dysfunction in twofold: reduction in numbers and
impairment in function HIV causes immune deficiency by depleting CD4
cells especially the T-helper cells.

3.2.4 Overview of CD4 cells

– CD4 cells are destroyed by HIV and gradually decrease in number
– As the CD4 cell count decreases, the immune system is weakened and
HIV-infected patients become vulnerable to opportunistic infections
– Without treatment, HIV-infected individuals progress predictably to
symptomatic disease , AIDS, and death
CD4 Cells
– White blood cells (T cells)

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 – part of our immune system destroyed by HIV
– normal level 500-1200
– Marker of immune function – when the CD4 count is high people
generally are well (>500) – when the CD4 count is low people are said to
be immuno-suppressed and can acquire opportunistic infections (<200)

3.3 The AIDS virus and its life-cycle

 HIV belongs to a family of viruses called retroviruses. Unlike regular
viruses, which have DNA (deoxyribonucleic acid) as their genetic
material, retroviruses have RNA (ribonucleic acid).
 Retroviruses also contain an enzyme called reverse transcriptase, which
allows the retrovirus's genetic material to imitate the host cell's genetic
material.
 The human immunodeficiency virus also belongs to a subfamily of
retroviruses called lentiviruses. Lenti means "slow," so lentiviruses are
retroviruses that have a long delay between the time they initially infect a
person and the time the person starts to show serious symptoms
(Anderson, 1992)

Basic biologic characteristics of HIV

– It is a strict – obligate human pathogen
– It mutates
– It is an RNA virus, i.e. it has only one type of genetic material.
The Ribose Nucleic Acid (RNA) has 4 genetic bases;
1. Adenine
2. Cytosine
3. Guanine
4. Uracil
Other cells have both DNA and RNA genetic material.
• Deoxy Nucleic Acid (DNA) also has 4 genetic bases:
1. Adenine

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 2. Cytosine
3. Guanine
4. Thymine

3.3.1 Structure of HIV

– Has an outer double lipid membrane (derived from host membrane) •
Lipid membrane is lined by a protein matrix.
– Lipid membrane is studded with the surface glycoprotein gp120 and
trans-membrane gp41
– These glycoprotein spikes surround the cone-shaped protein core.
– gp120 binds to 2 receptors on T cells & phagocytes: CD4 molecule and
chemokine receptor
– gp41 facilitates fusion of viral and cell membranes

3.3.2 Anatomy of HIV Virus

– The outer coat of the virus is called the viral envelope or lipid membrane.
– The viral envelope is composed of two layers of fat molecules.
– HIV gets its outer envelope from its host. As newly formed HIV particles
break through a host cell's surface in a process called "budding," they
wrap themselves in fat molecules from the host's outer membrane
(NIAID, 2001).

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 – The complex proteins that protrude through the surface of the viral
envelope are frequently called spikes. These spikes are HIV's landing
gear, attaching the virus to a host cell and fusing the two together.
– Within the viral envelope of a mature HIV particle is a bullet-shaped core
called the capsid? The capsid surrounds two single strands of HIV's
single-strand genetic material, ribonucleic acid (RNA).
– Each strand of RNA has a copy of the virus's genes. These genes contain
the information that HIV uses to make new virus particles. HIV has only
nine genes, in comparison to human cells, which have an average of
30,000-50,000 genes. The capsid also houses two molecules of HIV
reverse transcriptase.
– Reverse transcriptase is an enzyme that allows the HIV's RNA to change
into double-strand deoxyribonucleic acid (DNA), so that it can pass into
the host cell's nucleus, commandeer the host cell, and begin reproducing
itself (NIAID, 2001).

III.3.3 HIV replication cycle

- Binding and fusion

- Viral genome enter host cell
- Viral genome is replicated and transcribed
- Viral mRNA are translated and proteins processed
- Particles assemble inside host, then burst or bud to exterior •
Free viral particles in tissues/environmentLife cycle of AIDS virus.

Binding
This step consists of several interactions between the host cell and the virus. The first one involves the 
attachment of the virus through the gp 120 and gp 41 to the CD4 cell receptor of the host cell. 
Thereafter, there is an interaction between a CD4 cell coreceptor and the gp120 complex. This step is th
e most important one in the process, without which no infection occurs. This works like a 

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key and a lock. It is also important to remember as one of the sites for medicines called coreceptor anta
gonists.

Fusion and entry

This step involves the fusion of the membranes of the host cell and that of the virus. This step is t
he target of drugs such as enfurvitide.

Reverse Transcription By now the virus has uncoated itself by engaging in the last two steps 
and only the nucleus  and its contents(RNA, reverse transcriptase, integrase, and other viral 
proteins) enter the host cell cytoplasm. Using one of its enzymes, reverse transcriptase, the virus is able 
to transform from a SSRNA to a DNA. 

Integration
The HIV virus having taken a DNA status is in a form similar to the host cell’s nucleus:
DNA. It is thus transported into the host nucleus and integrates into the host cell DNA. This is aided by
the viral enzyme Integrase. Once this happens, the cell becomes infected permanently until it dies.

Protein production

The infected host cell’s mechanisms are then taken over by the virus. DNA gives rise to RNA pa
rt of which makes proteins by use of Protease
enzyme. The virus is now able to use the host cell’s transcription mechanisms to make new RNAs and 
messenger RNA(mRNA). The latter is released into the cytoplasm of the host cells and translated into l
ong protein complexes, often known as polypeptide chains.  The polypeptides are broken further into th
e constituent proteins and enzymes.
The other RNAs become the genomic RNA material that will eventually start off this cycle again.

Viral assembly and buddingThe second last step is the assembly of the proteins, enzymes and 
RNAs into virions. The RNA
and proteins move to the cell surface, and new immature viruses bud off from the host cell taking with t
hem part of the host cell’s membrane. These budding are said to leave ‘holes’ within the 
membrane of the host cell, a factor that contributes towards the death of the CD4 cells.

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 Virus maturationThe protease enzyme is involved in this final step by way of releasing individu
al HIV proteins. You recall that this enzyme also took part in the protein production step above. It thus 
acts both within the host cell’s cytoplasm and after release of the virus.  

-
- A core, which is made up of several proteins- P24 (the main
protein), P16, P9 and P6
- Within the capsid are two identical single stranded viral RNA that
contain the Viral genetic material
- Viral enzymes
- Although HIV can infect a number of cells in the body, its main
targets are T-cells called CD4 positive (CD4+) cells. T-cells are a
kind of lymphocyte, which are cells that the body's immune system
makes to fight off dangerous invaders.
- In most cells and normal viruses, DNA is first converted to RNA in
a process called transcription, and then RNA is turned into
proteins in a process called translation. HIV is different, though,
and must first convert its RNA into DNA in a process called reverse
transcription. For reverse transcription, HIV uses an enzyme called
reverse transcriptase. The viral DNA that results from reverse
transcription contains the instructions HIV needs to hijack a T-
cell's genetic machinery and begin reproducing itself (Pieribone,
2002/2003).
- The first step to replication is a process called transcription.
Transcription creates a strand of genetic code that the host cell's
protein-making machinery can read. During transcription, an
enzyme called RNA polymerase separates the two halves of DNA
like a zipper. One of these halves is then used to create a new
strand of RNA, called messenger RNA (mRNA). HIV's genes may
actually accelerate the process of transcription.

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 - During translation, structures in the host cell's cytoplasm (that is,
the area outside of the nucleus) use the mRNA as a blueprint for
building proteins and enzymes. These new proteins and enzymes
will eventually come together to make a new HIV particle.
- The newly made proteins and enzymes, as well as viral RNA, come
together just inside the host cell's membrane.
- At the last step of the viral cycle, a viral enzyme called protease
cuts the long chains of proteins and enzymes in the HIV particle
core, making the particle infectious. At this stage, the HIV particle
is said to be mature.

3.3.4 Types of HIV

There are two types of HIV:
I) HIV type 1(HIV-1): This type is found worldwide and it is the main
cause of the global pandemic. It consists of three groups: the ‘major’
group M, the ‘outlier’ group O and the ‘new’ group N. Group O appears
to be restricted to West-Central Africa and group N discovered in 1998 in
Cameroon is extremely rare. More than 90% of HIV infections are due to
HIV-1 group M. Within group M there are known to be at least nine
genetically distinct sub-types. They include A, B, C, D, F, G, H, J and K.
In Kenya the commonest subtypes are A and D. However, a person can
be infected with different subtypes, or with recombinant viruses with
features of more than one subtype.

ii) HIV type 2(HIV-2): Found mainly in parts of West Africa, Mozambique
and Angola. It has limited spread to other countries. It causes a similar
illness to HIV-1 including AIDS. However, it is less efficiently transmitted
(5 to 8 fold less efficient than HIV-1 in early stage disease and rarely the
cause of vertical transmission), is associated with a lower viral load, is

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 less aggressive and has slower rate of both CD4 cell decline and disease
progression.
– The commonest type in Kenya is HIV-1 with subtype C as the most
predominant in East Africa.
– It is important to note that super infection with the two types of HIV
virus does occur. In these cases, the second infection occurs several
months after the first infection. It is not yet documented how commonly
super infection occurs and in which circumstances it does occur.
Overview
– HIV is a chronic viral infection with no known cure
– HIV multiplies inside the CD4 cells, which play a critical role in the
immune system
– The immune system protects our body from becoming sick with
infections
CDC and WHO Staging of HIV

Primary HIV Infection

– Unrecognized acute retroviral syndrome
– Acute febrile illness 2-4 weeks post exposure often with
lymphadenopathy and skin manifestations
Clinical Stage 1
The “window period”
• The “window period” refers to the period between entry of the HIV into the
body and the production of anti-bodies by the host under attack.
• During this time, the viruses multiply in the body, but they cannot be
detected because the antibodies are few in number or are not present yet. This
can range from 6 weeks to 12 weeks.
• Each bacterium or virus induces the body to produce a very specific kind of
antibody. The HIV antibodies are specific only to HIV.
– Asymptomatic

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 – Acute retroviral syndrome
Clinical Stage 2
– Moderate unexplained weight loss (<10% of presumed or measured body
weight)
– Recurrent respiratory infections (sinusitis, tonsillitis, otitis media, and
pharyngitis)
– Herpes zoster
– Angular cheilitis
– Recurrent oral ulceration
– Papular pruritic eruptions
– Seborrheic dermatitis
– Fungal nail infections
Clinical Stage 3
– Unexplained severe weight loss (>10% of presumed or measured body
weight)
– Unexplained chronic diarrhea for >1 month
– Unexplained persistent fever for >1 month (>37.6ºC, intermittent or
constant)
– Persistent oral candidiasis (thrush)
– Oral hairy leukoplakia
– Pulmonary tuberculosis (current)
– Severe presumed bacterial infections (e.g., pneumonia, empyema,
pyomyositis, bone or joint infection, meningitis, bacteremia)
– Acute necrotizing ulcerative stomatitis, gingivitis, or periodontitis
– Unexplained anemia (hemoglobin <8 g/dl)
– Neutropenia (neutrophils <500 cells/µL)
– Chronic thrombocytopenia (platelets <50,000 cells/µL)
Clinical Stage 4
– HIV wasting syndrome, as defined by the CDC
– Pneumocystis pneumonia

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 – Recurrent severe bacterial pneumonia
– Chronic herpes simplex infection (oro-labial, genital, or ano-rectal site for
>1 month or visceral herpes at any site)
– Esophageal candidiasis (or candidiasis of trachea, bronchi, or lungs)
– Extra-pulmonary tuberculosis
– Kaposi sarcoma
– Cytomegalovirus infection (retinitis or infection of other organs)
– Central nervous system toxoplasmosis
– HIV encephalopathy
– Cryptococcosis, extra-pulmonary (including meningitis)
– Disseminated non-tuberculosis mycobacteria infection
– Progressive multifocal leuko-encephalopathy
– Candida of the trachea, bronchi, or lungs
– Chronic cryptosporidiosis (with diarrhea)
– Chronic isosporiasis
– Disseminated mycosis (e.g., histoplasmosis, coccidioidomycosis,
penicilliosis)
– Recurrent non-typhoidal Salmonella bacteremia
– Lymphoma (cerebral or B-cell non-Hodgkin)
– Invasive cervical carcinoma
– Atypical disseminated leishmaniasis
– Symptomatic HIV-associated nephropathy
– Symptomatic HIV-associated cardiomyopathy
3.3.5 Disease progression (epidemiology)
Historical Background of HIV
Although HIV causes disease only in humans, it may have evolved from a
similar virus called Simian Immuno- deficiency Virus, which causes an AIDS-
like illness in some monkeys and chimpanzees.
Unfortunately, the AIDS epidemic continues today in Africa and much of Asia,
where antiretroviral therapy is not available and health care is seriously

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inadequate. Over 95% of AIDS cases and deaths occur outside the United
States.
In 1981- doctors in United States recognize Pneumocystis Carinii Pneumonia
(PCP) among homosexual males, a condition previously unreported in healthy
adults.
In 1983/4- scientists described the cause of the acquired immunodeficiency
syndrome as a retrovirus. The virus is given the following names:
Lymphadenopathy Associated Virus (L.A.V.), AIDS Associated Virus (ARV),
Human T- lymphotropic Virus III (HTLV-III).
Between 1983 and 1985, 26 cases of AIDS were reported in Kenya. Sex workers
were the first group affected – a study from 1985 reported an HIV prevalence of
59 percent amongst a group of sex workers in Nairobi.
Towards the end of 1986 there were an average of four new AIDS cases being
reported to the World Health Organization each month. This totaled to 286
cases by the beginning of 1987, 38 of which had been fatal.
By 1987 HIV appeared to be spreading rapidly among the population – an
estimated 1-2 percent of adults in Nairobi were infected with the virus, and HIV
prevalence among pregnant women in the capital had increased from 6.5
percent to a staggering 13 percent between 1989 and 1991.
By 1994 an estimated 100,000 people had already died from AIDS and around
1 in 10 adults were infected with HIV.

Historical Background of HIV in Kenya

 1984 – The first case in Kenya was described.
 1986- Human Immunodeficiency Virus (HIV) was accepted as the
international designation for the retrovirus in a WHO consultative
meeting.
 1996- ARVs became available in the world
 1997- ARVs became available in the private sector in Kenya

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  1997: UNAIDS (Joint United Nations Programme on HIV/AIDS) is
formed. The Kenyan Parliament approves a 15 year national AIDS policy
and forms the National AIDS Council.
 1998: incidence is thought to have peaked globally at around 3.4%. A
large number of Kenyan public sector employees die as a result of AIDS.
The Great Lakes Initiative on AIDS (GLIA) is established.
 1999- President Moi declares AIDS a national disaster
 2000: an estimated 27.5 million people are living with AIDS, globally.
Kenya develops a five year National AIDS Strategic Plan and plans AIDS
education for all schools and colleges.
 The Millennium Development Goals (MDG) are adopted by the
international community and reducing the spread and impact of HIV are
included in this initiative.
 2001: the Global Fund to Fight AIDS, TB and Malaria (Global Fund) is
formed by the World Bank.
 2002: the new president, MwaiKibaki, declares ‘Total War on AIDS’.
 2003- ARVs became available in the public sector in Kenya
 2006- Approximately 90,000 Kenyans are taking ARV treatment.
 2007- Approximately 140,000 Kenyans are taking ARV treatment

Epidemic Global Update

HIV/AIDS is the fourth biggest killer in the world (2004). There was an
estimated 40 Million people living with HIV by end of 2004 and about one-third
of People Living with HIV/AIDS are between 15-24 years with young women
being more vulnerable. Currently, one in 100 adults in the sexually active age
brackets (15-49) is living with HIV Most people are however still unaware that
they are infected with HIV. The UNAIDS and the World Health Organization
(UNAIDS & WHO, 2006) estimated that over 34 million people were infected
with HIV/AIDS, while 13 million people around the world had died from the
disease.

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Every 24 hours, an estimated 7,000 people are infected with HIV and more
than 1 million contract a sexually transmitted infection (STI). Currently, an
estimated 33.3 million people are living with HIV today, and in Sub-Saharan
Africa—the region hit hardest by the pandemic—the majority of 15- to 24-year-
olds living with HIV is female (Engender health, 2011).

Epidemic Update: Sub-Saharan Africa

Over the past 2 decades HIV has spread worldwide with devastating
epidemiological consequences particularly in sub Saharan Africa. In 2004
according to WHO, HIV was the leading cause of death. Between 25.0-28.2
million people were living with HIV infection by end of 2003 and 10-15% of the
patients need ARVs. There were an estimated 3-3.4 million new HIV infections
in 2003. Seventy percent of the people living with HIV/AIDS (PLWHAs) are
found in sub Saharan Africa. By 2010 an estimated 106 million children under
age 15 had lost one or both parents with 25 million of this group orphaned due
to HIV/AIDS.

3.3.6 Transmission and diagnosis.

Transmission: The movement of pathogens (infectious agents) from a reservoir

(source) to a susceptible host.

Mode of transmission: The method through which an infectious agent moves

from the reservoir to the susceptible host. Once a pathogen has exited the
reservoir, it needs a mode of transmission to the host through a portal of entry.
Transmission can be by direct or indirect contact or through airborne
transmission.

Transmission of HIV infection

 For transmission of HIV infection to occur, infectious virus must survive

long enough to pass to a susceptible person and infect target cells.

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  The virus particle is a very fragile one. As a result, the virus quickly
becomes inactivated when exposed to drying effects of air or light. It is
also quickly inactivated by contact with water and soap (FHI, 2003).

3.3.7 HIV transmission

 A high enough concentration: HIV is found in all body fluids of
infected people.

 An entry route: HIV can only be passed on to another person if the

fluids get into that

 Efficient transmission: HIV is a weak virus and this also affects

transmission. The virus can only survive outside the body for a very
short time and must be able to enter a new host immediately.

 HIV is found in most body fluids, but is most often transmitted by

i. Blood

ii. Semen

iii. Cervical and vaginal secretions

iv. Breast milk

Modes of transmission
HIV is mainly transmitted through:
i) Unprotected sexual intercourse with an infected person
ii) Exposure to blood, blood products, body fluids and tissue transplants
iii) During pregnancy, birth, or breastfeeding from infected mother to
child.
The table below illustrates the proportional distribution of various modes
of transmission

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 UNIT 4: TREATMENT AND MANAGEMENT
Unit objectives

By the end of this unit, a student should be able to:

1.Understand different management strategies for HIV/SIDS

4.1 Nutrition
Nutrition in HIV disease HIV infection is often associated with poor nutrition
due to a number of reasons including:

 Increasing energy requirements

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  Decreased appetite
 Reduced intake due to painful oral and esophageal OIs
 Malabsorption
 Unavailability of sufficient food due to household food insecurity and
poverty. For symptomatic PLWHAs, energy needs increase by 20 – 30% in
adults and 50 – 100% in children experiencing weight loss.

Nutritional Concerns for HIV– Infected People

 Availability of a balanced diet on a continuous basis

 Factors that negatively impact food intake and utilization
 Drug / nutrient interactions
 Interventions to help cope with nutrition-related chronic conditions

The link between nutrition and HIV/AIDS+

 Increases nutrient requirement and at the same time impairs nutrient
intake and absorption.
 Increases risk of malnutrition through altered food intake and/ or its
nutrient absorption and utilization.
 Poor nutrition increases risk of OIs and accelerates progression of HIV to
AIDS.
 Malnutrition and HIV are synergistic and together create a vicious cycle
that additively weakens the immune system.

Effects of HIV/AIDS on nutrition

HIV affects nutrition in three sometimes overlapping ways:
 It is associated with symptoms that cause a reduction in the amount of
food consumed.
 It interferes with the digestion and absorption of nutrients consumed.
 It changes metabolism, or the way the body transports, uses, stores and
excretes many of the nutrients.
Decreased food consumption

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HIV/AIDS is associated with conditions that result in reduced food intake.
Decreased food consumption may result from:
 Inability to eat or swallow because of painful sores in the mouth and
throat
 Loss of appetite as a result of fatigue, depression, and other changes in
the mental state
 Side effects of medications, including nausea, loss of appetite, a metallic
taste in the mouth, diarrhea, vomiting, and abdominal cramps
 Reduced quantity and quality of food in the household as a result of the
inability to work or reduced income because of HIV- related illness.
Nutrient and food absorption
 HIV infection also interferes with the body’s ability to absorb nutrients,
an effect that occurs with many infections.
 Poor absorption of fats and carbohydrates can occur at any stage of HIV
infection in both adults and children and results in excess nutrient loss
 Poor absorption is caused by :-
 HIV infection of the intestinal cells, which may damage the gut,
even in people with no other symptoms of infection
 Increased incidence of opportunistic infections such as diarrhea,
which is a common cause of weight loss in people living with HIV.
Poor absorption of fat reduces the absorption and use of fat-
soluble vitamins such as vitamins A and E. This can further
compromise nutrition and immune status.
Water and Fluid requirement
Water is an essential nutrient. Water is important because
 it transports nutrients,
 removes waste,
 assists metabolic activities,
 provides lubrication to moving parts,
 Helps regulate body temperature.

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• PLHIV must drink a lot of safe, clean water. The recommended water intake
for good health is at least 2 litres (or 8 glasses of 250ml per day).
Characteristics of HIV – related malnutrition
 Weight loss which in late stages has been described as ‘slim disease’
and eventually severe wasting.
 Progressive muscle wasting and loss of fat under skin giving rise to
accelerated aging.
 Reduced immune competence leading to increased susceptibility to
infections.
 Hair changes especially thinning and losing of hair.
 Diarrhea and poor absorption of nutrients

Critical Nutrition Practices for PLHIV in Kenya

1. Have periodic nutritional status assessments, especially weight, at least
every 2nd month for symptomatic clients and every 3rd month for
asymptomatic clients
2. Increase energy needs according to the disease stage.
3. Maintain high levels of sanitation, food hygiene, and food/water safety at all
times
4. Practice positive living behaviors, including practicing safer sex, avoiding or
moderating use of alcohol and cigarettes, moderating consumption of junk
foods, and managing depression and stress.
5. Carry out physical activity or exercises to strengthen or build muscles, and
increase appetite and health.
6. Drink plenty of clean safe water (8 glasses in a day). All water used to
swallow medicines and to prepare juices should be clean and safe (e.g. filtered
and boiled, or treated).
7. Seek prompt treatment for all opportunistic infections and other diseases,
and manage symptoms with dietary practices, especially illnesses that may
interfere with food intake, absorption and utilization.

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8. Those on medicine, including ARVs, should manage the drug-food
interactions and diet related side-effects by preparing and following a drug-food
schedule, and should use dietary approaches to manage side-effect symptoms.
If taking traditional remedies (herbs, medicines) or other nutritional
supplements, the clinician should be informed.
9. Children (below 6 months) born to HIV+ mothers whose mothers/caregivers
have opted for exclusive replacement feeding, should be supplemented with
50,000 I.U of Vitamin A, and if not on commercial infant formula, put on
multivitamins every day.
Common nutritional problems
 Anemia
 Anorexia
 Nausea
 Diarrhea and vomiting
 Constipation
 Dry mouth
 Muscle wasting/ weight loss
 Taste changes

Safe Food Handling/Preparation

PLWHA have an increased susceptibility to gastrointestinal infections.
Important hygiene and food safety messages are:
 Always wash hands before food preparation and eating and after defecating
 Cook food thoroughly
 Avoid contact between raw foodstuffs and cooked foods
 Wash fruits and vegetables before serving
 Use safe water that is boiled or filtered if feasible
 Always wash hands with soap before eating and after visiting the toilet, and
handling food.

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 Always wash and rinse fresh fruits and vegetables in clean water or clean
with mild disinfectants, and thoroughly rinse with clean water.
 Wash hands with soap and thoroughly rinse before preparing and
consuming meals.
 Store food/water appropriately to prevent contamination of food by bacteria
and moulds.
 Avoid eating any food that seems spoilt, e.g. mouldy foods or stale left-overs,
even if they are re-heated.
 Keep the home free from human and animal feces.
 Wear shoes whenever walking on damp soil or when walking in latrines.
 Maintain personal hygiene (clean mouth and brush teeth at least in the
morning and in the evening; bathe every day).
 Maintain good hygiene in the kitchen and especially in areas where cutting
or handling of foods take place.
 Avoid spending long hours in crowded rooms, poorly ventilated rooms, or
interacting with TB infected persons.

4.2 Prevention and control

a) Abstinence

This means not having sexual intercourse until marriage

 It is the best method to prevent transmission of infections sexually

 Requires self-discipline and alot of self-control
 Abstaining does not mean avoiding relationship with members of the
opposite sex-healthy relationship should be encouraged

Problems with condom use

 May have structural defects

 If improperly stored may get torn-excessive heat

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  Some people are allergic to latex which is used to manufacture the
condoms
 May get ruptured during use or may slip into the vagina if penis is not
firmly erect
b) Being faithfulto one sexual partner
c) Condom use

Condoms offer duo protection i.e.

 Against unwanted pregnancies

 Against STDS including HIV/AIDS

To be effective must be used correctly and consistently. This way it is 98 %

effective in preventing HIV and 95-97 % in preventing pregnancy

4.2.1 Anti-retroviral drugs and vaccines

At present 2 main classes available locally

a) Reverse Transcriptase Inhibitors (RTIs)
1. Nucleoside and Nucleotide RTIs (NRTIs and NtRTI)
2. Non-nucleoside RTIs (NNRTIs)
Inhibit reverse transcriptase enzyme by:

 Copies viral RNA to viral DNA

 Essential step before the virus can be integrated into host genome
 Drugs in this group include ;


Zidovudine,Lamivudine,Stavudine,Efavirenz,abacavir,emtricitabine,tenof
ovir

b) Protease Inhibitors (PI)

 Work at the last step of the viral replication cycle

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  Prevent HIV assembly and release

 Protease cuts polypeptides into effective viral proteins

 Protease inhibitors block this process

 Includes ;Indinavir,Ritonavir,Saquinavir

c)Other Classes:New Antiretroviral Drugs

Standard 1st line regimen for adults and adolescents

Preferred 1st line

Tenofovir (TDF)+ Lamivudine(3TC)+Nevirapine(NVP)/Efavirenz(EFV) or

Alternative 1st line

Zidovudine(AZT)+Lamivudine(3TC)+Nevirapine(NVP)/Efavirenz(EFV)

Standard 2nd line regimen for adults and adolescents

Preferred 2nd line

Zidovudine(AZT) +Lamivudine(3TC) +Lopinavir/Ritonavir or

Preferred 2nd line

Tenofovir + Lamivudine(3TC) + Lopinavir(LPV)/Ritonavir(RTV)

Goals of ART

 Restoration and preservation of the immune function

 Reduction in the viral load
 Improve the quality of life
 Reduce HIV related morbidity and mortality

4.3 Pregnancy and AIDs.

• Pregnancy does not accelerate the progression of HIV disease to AIDS

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 • Patients with AIDS are more likely to suffer from pregnancy-related
complications

MTCT can occur

 During Pregnancy

 During labor and delivery

 After birth through breast feeding

Effective prevention of mother-to-child HIV transmission involves a

combination of strategies. These include:

a) Primary prevention strategies - involve protecting young women from getting

infection. This may be done through

 Active promotion and support for abstinence

 Providing young people with correct information regarding their

sexuality

 VCT to know ones status

 Promoting monogamy with HIV negative partner

 Promoting condom use

 Avoiding intergeneration sex

 Treatment of sexually transmitted diseases

b) Reduce number of births among HIV infected individuals

 Voluntary prevention of unintended pregnancies among HIV-infected

women

 Integration of Voluntary Counseling and Testing with family planning

services

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  Use of effective family planning methods for all women who desire them

c) Prevent Mother-to Child Transmission of HIV in pregnant women

a) Quality antenatal care – including screening and treatment of STDs,

intermittent treatment for malaria, which if present can increase risk of
HIV crossing the placenta from the mother’s blood to the baby’s blood
and giving supplements of important nutrients and minerals

b) Provision of routine HIV counseling and voluntary HIV testing services

c) Safe delivery

d) Treatment with anti-retroviral drugs where indicated

e) ARV prophylaxis: involves giving the mother and the baby antiretroviral
drugs around the time of birth to reduce risk of transmission,
particularly around the time of birth

 Infant feeding counseling to guide informed choice. Where appropriate,

the mother is encouraged to avoid breastfeeding the baby entirely. If not
practicable however, the mother is counseled on how to breastfeed safely

 Long-term care of the baby and mother.

4.4 Management of PLWHIV/AIDS.

Holistic care: It is a caring approach that takes into consideration a person’s
spiritual, social, emotional and physical needs.

Comprehensive care concept: Refers to the holistic approach towards the

management of a person infected with HIV.

Benefits of Comprehensive Care

 Encourages disclosure of status, thus helping prevent ongoing transmission

 Promotes positive living
 Promotes good nutrition and encourages living a healthy lifestyle

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 Manages opportunistic and sexually transmitted infections medically
 Provides treatment with antiretroviral therapy
 Provides home-based care and end-of-life support

Components of comprehensive care

 Physical care
 Social care
 Psychological/emotional care
 Spiritual care

Clinical care

 Access to HIV-related drugs

 Counseling and testing
 Prophylaxis of opportunistic infections (OIs)
 Management of HIV-related illnesses, including OIs
 Interventions to reduce mother- to- child transmission
 Clinical HIV/AIDS care for mothers and infants
 Support systems such as functional laboratories and drug management
systems
 Nutritional support
 Health education
 Adequate universal precautions

Palliative care

WHO definition: • An approach that improves the quality of life of patients

and their families facing the problem associated with life- threatening
illness, through the prevention and relief of suffering by means of early
identification and impeccable assessment and treatment of pain and other
problems, physical, psychosocial and spiritual.

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  Palliative care is part of the comprehensive care for PLWHA • Many
advances have been made in the treatment of HIV/AIDS; however, there
still is no cure.
 While ARVs and OI management can improve the lives of many HIV-
infected patients, some infected patients on therapy will still die
 Many of these patients will experience gradual increase in health
problems over several years

Goals of Palliative Care

 Palliative care aims to achieve optimal quality of life for PLWHA and their
families and minimize suffering through mobilizing clinical, psychological,
spiritual, and social care throughout the entire course of HIV infection.
 To provide support and care that makes life comfortable for patients
throughout all phases of a disease so they can live as fully and comfortable
as possible
 As their disease progresses, the need for symptomatic relief will be more
important than treatment.
 Routine, confidential counseling and testing is an essential component of
palliative care to identify those who need or will need palliative care, family
members who could also be infected and in need of care and, family
members and partners not infected and in need of prevention.

Comprehensive Care Centers (CCCs)

All CCCs should provide care and support services in accordance with
approved Ministry Of Health clinical and service delivery guidelines. Each CCC
should be staffed by a care and support team that provides an integrated
service. The team should consist of the following cadres: Medical
officer/Clinical officer, Nurse, Nutritionist, Laboratory technologist/

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Technician, Counselor, Records information clerk and Pharmacist/
Pharmaceutical Technologist.

The CCC has multiple entry points. They include all testing and counseling
services including diagnostic testing, VCT, Prevention of Mother to Child
Transmission (PMTCT) units, STI services and community/home based care
programs.

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 UNIT 5: CULTURAL PRACTICES

Unit Objectives
By the end of this unit, a student should be able to:

1. Understand the cultural aspects as they pertain to HIVand AIDS

5.1 Religion and AIDS

Strengthening existing faith and helping the PLWHA in spiritual growth boosts
the spiritual aspect of life. This plays a great part in encouraging the person to
have a positive view of life and to forgive others and self for any misconceptions
and blames.
The PLWHA will therefore be able to:
 Accept forgiveness by others.
 Forgive others.
 Have reassurance that God accepts them.
 Allow religious groups to offer support.
 Have freedom of worship according to faith, which should be respected
by the health worker and the care providers.
 Call a religious leader of choice for sacraments and fulfillment of other
needs.

5.2 Social stigma and destigmatizationof HIV and AIDS

AIDS-related stigma and discrimination refers to prejudice, negative attitudes,
abuse and maltreatment directed at people living with HIV/AIDS.
This stigma may manifest in ignoring the needs of those infected or affected in
psychological or even physical harm on those who are stigmatized.
PLWHAs need company and association without stigma or discrimination.
Recreation and exercise at clubs/groups of their choice should be facilitated by
family and community members. PLWHAs need to be considered as people of
value and having rights to be respected. They should not be cut off from

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activities they enjoy, e.g., political rallies, church/ mosque/temple, and
spiritual gatherings.
The social needs of PLWHAs include:
 Respect.
 Love and acceptance from others.
 Company of those around them.
 A source of income/income-generating activity.
 Right to own, inherit, and bequeath property.
 Confidentiality regarding their condition by all who know about it.
 Help with the activities of daily living.

5.3 Behavioral change

Behaviour change communication this includes:
 Communication targeting safe sexual behaviour,
 Delay of onset of first sexual contact,
 Reduction in the number of sexual partners
 Mutual faithfulness among other communications

5.4 Voluntary Counseling and Testing (VCT) Services.

Advantages of being tested
– You can receive treatment and increase the quality and duration of your life.
– You can make the decision to take care of yourself and those around you.
– You can develop a social and emotional support system during the early
stages of the disease.
– You can benefit from new types of medicine as they are developed.
– You can make informed decisions for example, the decision to get pregnant or
not.
– You can inform your partner and take precautions so that he/she does not
get infected.
– You can choose to abstain from having sex and indulging in other behaviours
that may risk others’ chances of getting infected.

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Disadvantages of being tested
– Learning that a person is infected with HIV can be very distressing. The
degree of distress depends on how well the person is prepared for the news,
how well the person is supported by family and friends and on the person’s
cultural and religious attitude towards illness and death.
– A person who learns s/he is infected with HIV is likely to suffer from feelings
of uncertainity, fear, loss, grief, depression, denial and anxiety, the person
must make a variety of adjustments.
– Partners and family are likely to suffer from the consequences of HIV testing
as well as the infected person whether they are also infected or not.
– A person who has tested positive for HIV may be discriminated against, if the
information is revealed.

5.5Families and AIDS Orphans

Needs of the Family.
 Families and caregivers, have physical, psychological, and
social/spiritual needs that must be met in order to maintain family
solidarity and well-being.
Needs of Orphans. They need:
 Acceptance by those around them resulting in a sense of belonging.
 Basic needs like food, shelter, clothing, education, love.
 Legal interventions in cases of property inheritance.
 Protection from exploitation.

Students activity
Assignment- Discuss- government and global policies on AIDS and
- Poverty and AIDS
-Drug abuse and AIDS

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Page 70 of 77
 UNIT 6: LEGAL RIGHTS OF PEOPLE LIVING WITH HIV/AIDS

Unit Objectives
By the end of this unit, a student should be able to:

1. Explain the legal rights of people living with HIV/AIDS

6.1 Ethical Issues

 Negative discrimination against persons infected or affected by HIV/AIDS
is not allowable
 Every person infected or affected by the epidemic remains an equal
member of the society with equal rights
 Stigmatization of people with AIDS is equally unlawful and objectionable
 Mandatory testing for HIV/AIDS should be prohibited
 Prior and informed consent for those being tested with pre and post-test
counseling and guarantee of confidentiality

Students activity
Assignment- Explain Human Rights and relate them to people living with HIV/
AIDS

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 UNIT 7: IMPACT OF AIDS ON FAMILY SET-UP/SOCIETY

Unit Objectives
By the end of this unit, a student should be able to:

1. Explain the impact of HIV/AIDS

6.1Impact of HIV/ AIDS on Family and Society

The impact of HIV/AIDS is cross-sectional and systemic leading to wider and
deeper poverty for individuals and countries.

What distinguishes HIV/AIDS from other fatal diseases is that:

(a) It primarily affects the most productive age group of men and women
between 15 and 49 years—the main breadwinners and heads of households
raising families and supporting the elderly—and their children;

(b) Its full impact is revealed only gradually (given a median survival period of
around 9 years in developing countries);

(c) There is no cure while drugs that can prolong life are not available to the
large majority of infected people in developing countries.

Household Impact

 Overall impact is devastating – particularly at family and household level

because of the increased burden on the extended family due to loss of
income, increased health care expenditure and reduced agriculture
production. Life expectancy reduced by 20 years from 67 years to 47
years and there is increase in dependency ratio by an extra 8 members
per family earner
 Household income has reduced due to loss of bread winner or morbidity
which makes them unproductive thus there is decreased food production
and lack of basic necessities in the households.

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  HIV/AIDS brings a major strain on household resources since there are
expenses incurred such as healthcare expenses and funeral costs.
Emotionally, household members are affected while taking care of a
person sick with AIDS due to the various demands.

Impact on Social Structures

Due to the HIV/AIDS pandemic, numbers of orphans are large and growing.
This eventually affects the social support systems such as children’s homes
which in the long run become overwhelmed due to the numbers

The impact on children

The pandemic not only causes children to lose their parents or guardians, but
sometimes their childhood as well. As parents and family members become ill,
children take on more responsibility to earn an income, produce food, and care
for family members. It is harder for these children to access adequate nutrition,
basic health care, housing and clothing.

HIV/AIDS impact on population growth

On population, there is dropping in life expectancy. UN predicts 4- 11.3% drop

in some African countries by 2005. Low fertility rates (25-40%) are witnessed
among infected women due to increased partner morbidity and mortality,
avoidance of pregnancy and direct effect by the HIV which causes amenorrhea.

The impact on enterprises and workplaces

HIV and AIDS dramatically affect labor, setting back economic and social
progress. The vast majority of people living with HIV in Africa are between the
ages of 15 and 49 - in the prime of their working lives. AIDS damages
businesses by squeezing productivity, adding costs, diverting productive
resources, and depleting skills. Company costs for health-care, funeral benefits
and pension fund commitments are likely to rise as the number of people
taking early retirement or dying increases. Also, as the impact of the epidemic

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on households grows more severe, market demand for products and services
can fall. The epidemic hits productivity through increased absenteeism.

HIV/AIDS on Health Systems

In health care, there are high costs of treating HIV and related infections &
cancers, increased bed occupancy by HIV related problems and patients stay
longer in hospitals. The HIV pandemic has led to increasing child mortality and
resurgence of tuberculosis

The impact of HIV/AIDS on Health professionals

Health workers have to cope with death and dying of patients and may
experience depression associated with witnessing the decline and deaths of
patients due to identification with patients. There is work overload and
burnout associated with extra time demands of terminal AIDS care among the
patients who have been admitted in the institutions.

Impact on Agriculture

 Absenteeism caused by HIV-related ill-nesses and the loss of labor from

AIDS-related deaths may lead to the reduction of the area of land under
cultivation and to declining yields resulting in reduced food production
and food in-security. The loss of labor may also lead to declines in crop
variety and to changes in cropping systems.
 The reduction in labor supply through the loss of workers to HIV/AIDS
at crucial periods of planting and harvesting could significantly reduce
the size of the harvest, affecting food production.

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  Loss of knowledge about traditional farming methods and loss of assets
will occur as members of rural households are struck by the disease and
are not able to pass on their know-how to subsequent generations.
HIV/AIDS has caused shifts of production from cash crops to food crops
in AIDS-affected households.
 HIV/AIDS has caused a decline in the supply of labor for food and
livestock production. The HIV and AIDS epidemic adds to food insecurity
in many areas, as agricultural work is neglected or abandoned due to
household illness.

Impact on economy

 Labor Supply: The loss of young adults in their most productive years
will affect overall economic output.
 Costs: The direct costs of AIDS include expenditures for medical care,
drugs, and funeral expenses Indirect costs include lost time due to
illness, recruitment and training costs to replace workers, and care of
orphans

Mechanisms by which AIDS affects macroeconomic performance

 AIDS deaths lead directly to a reduction in the number of workers

available. As younger, less experienced workers replace these experienced
workers, worker productivity is reduced. A shortage of workers leads to
higher wages, which leads to higher domestic production costs. Higher
production costs lead to a loss of international competitiveness which can
cause foreign exchange shortages.
 Lower government revenues and reduced private savings (because of
greater health care expenditures and a loss of worker income) can cause a

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 significant drop in savings and capital accumulation. This leads to slower
employment creation in the formal sector, which is particularly capital
intensive. Reduced worker productivity and investment leads to fewer jobs
in the formal sector. As a result some workers will be pushed from high
paying jobs in the formal sector to lower paying jobs in the informal sector.

Impact on education sector

The education sector is also affected as AIDS claims the lives of teachers and
has contributed to serious teacher shortages across the world, especially in
Africa. Additionally, the disease continues to affect school attendance and
enrollment among children affected by HIV/AIDS.

Impact on People Living with HIV/AIDS (PLWHAs)

There are adverse consequences for people living with HIV/AIDS (PLWHA),
which include stigmatization and discrimination. It is also common for people
with HIV to lose their income as their health deteriorates and are unable to
work. Sometimes, people with HIV are abandoned by their families and forced
to live in isolation and destitution.

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 REFERENCES
1. Bertozzi S, Padia N. S, Wegloreit, Demaria L. M, Fieldman B, Gayle H, Gold
J, Grant R and Islod M T (2004) HIV/AIDS Prevention and Treatment.
Disease Control Priorities. Vol 1 (18), PP 331-361, Brother Medical
Publishers.

2. Dyk V. A (2001) HIV/AIDS Care and Counselling. 2nd Ed. Cape town.
Pearson Education SA.

3. Katoch, V. M., (2012). Textbook of MICROBIOLOGY. First Edition ed. New

Delhi: Jaypee

4. KMTC (2005); Instructors Manual

5. KMTC (2005); Student Manual
6. Ministry of Health, (2001). AIDS in Kenya, background, projections,
impacts, interventions,

7. Ministry of Health, (2002). National Home-based care programme and

service guidelines,

8. Ministry of Health, (2005). Guidelines for Antiretroviral drug therapy in

Kenya, Kenya:

9. Ministry of Health, (2007). Kenya AIDS indicator survey, Kenya: National

Aids and STI control

10. Ministry of Health, (2009). Ministry of Public Health and Sanitation,

Kenya. National Guidance

11. National Aids and STI control programme (NASCOP).

12. Willis R. J. B (2002)The AIDS Pandemic. London. Stranborough Press

Ltd.

13. Woodley H, What L, Clyden P, Geffen n, Flowler S. and Perez N(2008) HIV
and Nutrition. Nairobi Publishing Resource solution.

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