8883.pdf
Media
- extracted text
-
A Comprehensive Approach to the
Prevention Care and Control of
HIV/AIDS
RUHSA DEPARTMENT,
Christian Medical College, Vellore.
RUHSA Campus P.O.
Vellore District
Pin Code - 632 209.
S.India.
Introduction
Over the past twenty years, HIV/AIDS has emerged as one of the
biggest killer diseases of humankind. The disease has crossed the 40
million mark (20u3) of those infected, leaving millions dead. This
disease has not only devastated the lives of those infected but also
their families, communities and the economies of many countries.
While those infected with the HIV virus are the most vulnerable,
even the family members who are not infected become vulnerable.
There is a need for the entire community to be fully aware of the
epidemiology of this disease starting from its cause, means of spread,
its manifestations, proactive care and its prevention.
This booklet is an attempt to provide full comprehensive knowledge
on HIV/AIDS and the surrounding issues, so that it will help people
take steps to strengthen themselves and their communities to fight
and prevent this disease.
At present, there are two major approaches to HIV/AIDS control.
One very successful approach has been the targeted intervention
approach focusing on high-risk groups. This approach has been very
popular in India and around the world. In the past fifteen years of
HIV/AIDS control, the anticipated results have not been fully met
and there is a need to present another potentially more effective but
difficult comprehensive approach to HIV/AIDS control.
There is clear indication that if India is to control HIV/AIDS then
a program suitable to India has to be planned, taking into account
its own history, culture and the potential for change. It is also
becoming clear that a pure medical or epidemiological model is
inadequate to handle this problem. Therefore, this booklet takes a
very strong culture-specific approach with the firm belief that if
people are fully informed on every facet of the disease and
surrounding issues, then people will make correct informed choices.
This booklet has been designed and presented to be a tool for health
and development workers for organising HIV/AIDS control programs
and for empowering the general community.
Dr. Rajaratnam Abel
Head of RUHSA Department,
Christian Medical College, Vellore
4
The History of HIV/AIDS
In 1981, a team of doctors in the US was finding many patients with
failed immune systems. This failure of the immune system was named
‘Acquired Immune Deficiency Syndrome’ or AIDS for short.
Further research found that AIDS is caused by a virus called the
‘Human Immunodeficiency Virus’ or HIV for short. AIDS is now
found all over the world with epidemic rates in Africa and Asia. The
first HIV infection in India was identified in 1986 in Chennai, and
diagnosed at the Virology Centre of the Christian Medical College
(CMC) of Vellore. The incidence of HIV/AIDS in India is now es
timated at 0.7% of the adult population or 3.97 million adults.
According to a study by the ‘AIDS Prevention And Control’ (APAC)
organisation the prevalence of HIV in Tamil Nadu is 1.8% or
450 000 people.3
The National AIDS Control Organisation (NACO) reports that 57,781
people are living with AIDS (where the disease has past the infection
and asymptomatic stages) in India with 24,667 of those people living
in Tamil Nadu. That equates to 42.7% of people with AIDS living
in Tamil Nadu. This is shown in figure 1.
Figure 1
AIDS Cases in India and Tamil Nadu
Rest of India
57%
5
In figure 2 the sexwise breakup of is HIV/AIDS shown the disease
is most among males.
AIDS Cases among Males and Females in India
Figure 3 Presents the modes of HIV/AIDS transmission. The sexual
mode is the most common far outstripping the other known modes.
Figure 3
Modes of Transmission of HIV/AIDS
6
In Figure 4 the age wise prevalence of the disease is shown. The
30-44 years age group has the largest proportion and it is followed
by the 15-29 years age group.
I.
Total blood samples screened in clinic
2.
HIV Positive
473
64
(13.5)
3.
Total Antenatal women screened
4.
HIV Positive
942
5
(0.53)
5.
Cumulative HIV+ diagonised for K.V Kuppam
64
6.
Cumulative AIDS deaths
23
7.
HIV /AIDS orphans (no parents)
3
8.
HIV positive Males
38
9.
HIV Positive females
22
7
Understanding HIV/AIDS
The Human Immunodeficiency Virus (HIV) is the vims that causes
Acquired Immune Deficiency Syndrome (AIDS). It is a disease
that affects people all over the world, including India and Tamil
Nadu.
HIV and AIDS effects the immune system by reducing the amount
of white blood cells the body produces. These white blood cells
fight bacteria, infections and diseases to keep us healthy. A well
functioning immune system keeps the body healthy and free from
prolonged infections and diseases. Due to HIV reducing the amount
of white blood cells the body produces, the effectiveness of the
immune system is decreased. Without white blood cells, the im
mune system is unable to fight infection and disease. When people
are suffering from AIDS, they can become sick easily and die from
other infections or disease.
STAGES OF HIV/AIDS
1.
The first stage is infection:
This is when someone becomes infected with HIV. About 50%
of people may suffer a small reaction to the infection that will
be like a cold or flu. Aside from this, there are no immediate
signs or symptoms to indicate that someone has become
infected. The first stage can last from 6 months to 5 years
before the second stage begins.
2.
The second stage is called the asymptomatic stage:
During this stage there are no symptoms but the HIV virus is
multiplying and destroying the immune system and the person’s
immune CD4 cells. The person will feel and look healthy.
3.
The third stage is called the latent stage:
During this stage, minor signs and symptoms of HIV/AIDS
will begin to appear. In cases where the person is treated
properly and they lead a healthy life, they may recover and go
back to the-asymptomatic stage. This does not mean that HIV/
AIDS is being cured, as the person will still develop this stage
and the next stage in the future.
8
4.
The fourth stage is full-blown AIDS:
Within 6 to 12 months of the symptoms appearing, the disease
becomes advanced and the person becomes severely ill. It is
during this stage when opportunistic illnesses take hold and the
person dies.
SIGNS AND SYMPTOMS OF HIV/AIDS9
The major signs of HIV/A/DS are :
o
o
o
Weight loss of more than 10% of the person’s body weight ;
Diarrhoea for more than one month;
Prolonged fever for more than one month.
The minor signs of H1V/AIDS are :
o Coughing for more than a month ;
o Skin rashes and itching ;
o Swollen lymph glands ;
o Herpes Zoster ;
o Fungal infections in the mouth.
Other possible symptoms can include:
o
o
o
o
o
Speech impairment;
Memory loss;
Changes in vision;
Changes in intellectual abilities;
Muscle and joint pains.
If someone is suffering from 2 major symptoms and 1 minor symp
tom, then they should consult their local doctor for a blood test, to
check for HIV.
Because the person living with HIV/AIDS has a weaker immune
system, many diseases and infections take the opportunity to attack
the person’s body. These are called Opportunistic Infections. The
diseases and infections often occur in the last stage of AIDS, and the
person dies from the opportunistic diseases or infections. Some ex
amples are: o tuberculosis; ® pneumonia; o cancers; o prolonged
gastrointestinal infections and ® prolonged fungal infections in the
mouth, digestive tract and skin.
9
[DIAGNOSIS OF HIV OR AIDS
A blood test is needed to test for HIV or AIDS. If someone has been
at risk, for example shared unclean needles with an infected person
or had unprotected sex with a commercial sex worker, then they
need to get a blood test to check for HIV and STDs. For HIV to be
detected there is a period of three months before the test can detect
any evidence for HIV. This is called the window period. After being
at risk, it is best to wait three months before being tested or the
person can be tested and have another test in three months. Being
safe is better than being unsure. It is advisable to consult with a
doctor.
If someone does not feel comfortable visiting their regular doctor,
they can have the test at CMC or RUHSA. There are doctors who
know about HIV/AIDS and can help counsel people through the
process. CMC and RUHSA provide private and confidential pre and
post test counselling for people who feel that they may have been
at risk. The test results are not shared with the person’s family.
Laboratory Tests available for HIV/AIDS
1.
2.
3.
4.
5.
Rapid blood test - Presumptive test
ELISA test - Presumptive test
Western Blot - Confirmatory test
CD4 cell count
Viral load count
The HIV/AIDS Diagnostic Test at CMC and RUHSA
The CMC Hospital and RUHSA Hospital use a rigorous HIV/AIDS
testing procedure. A two-testing process is used to ensure that posi
tive diagnoses are correct so that people are not misinformed. The
procedure is:
1.
A blood sample is taken from the person and a Rapid test is
done either at RUHSA or CMC
a. If the result is negative, the person is not diagnosed
with HIV but still receives post-test counselling.
10
b.
2.
If the result is positive, the person is told of the result
and another blood sample is taken for further testing.
The second blood sample is tested at CMC only.
If the result is negative, a confirmation test is con
ducted sometimes before informing the person of their
negative status. Post-test counselling is still conducted
to help the person choose a safer lifestyle.
If the result is positive, the person is diagnosed with
HIV. Post-test counselling is conducted with plans for
future follow-up and counselling.
To assess what stage of HIV/AIDS the person is, an immune CD4
cell count is conducted. The more advanced HIV is, the lower the
immune CD4 cell count will be, as it is these cells that the virus
attacks and destroys.
SPREAD OF HIV/AIDS
HIV is considered a delicate virus, this means that it does not sur
vive outside of people’s bodies like other viruses and can be easily
killed by heat. For HIV to be passed on from one person to another
there needs to be an exchange of blood or an exchange of body
fluids from having sex with an infected person.
HIV/AIDS can be transmitted through :
Unprotected sex with an infected person*,
Sharing unsterilised needles, razors and sharps with an infected
person,
Untested blood transfusions and organ transplants that are in
fected with HIV and
An infected pregnant woman passing it on to her unborn child**.
* Unprotected sex refers to sex without the use of a condom.
** The chance of unborn children being infected with HIV from
their mother is approximately 33%. Before beginning a family, it is
important to carefully consider the possible consequences. It is im
portant to realise that the child may not have a normal life and will
be lucky to reach the age of 5, if infected with HIV. Having children
11
to hide the infection of HIV/AIDS will not work if the child
becomes infected. Women infected with HIV, will need to discuss
with a doctor about breastfeeding as it is another form of spreading
HIV but breast milk also contains vital nutrients for newborn babies.
There are four principles of HIV transmission:7
1)
The virus must EXIT the body. HIV can exit a person’s body
through the exchange of blood and from having unprotected
sex.
2)
HIV must then SURVIVE the conditions it is in. It does not
survive outside of the human body, unless it is in moisture.
3)
The virus must then ENTER the blood stream of another
person. It can enter another person’s blood stream via tiny cuts,
wounds or sores on the person’s body.
4)
There must be a SUFFICIENT quantity of the virus to infect
the person.
Due to the need for a sufficient quantity of the virus to infect an
other person, HIV/AIDS cannot be spread through touch, hugging or
sharing clothes.
For example, if Apu has HIV he can pass it on to Anjali through his
blood being exposed to an open cut on her arm or leg; but he
cannot pass it on to her through hugging.
HIV/AIDS does not spread through:
Hugging, shaking someone’s hand or touching. There is no
exchange of blood or bodily fluids with these activities, so the
virus cannot be transmitted.
Sneezing or coughing. There is no exchange of blood from
coughing or sneezing, so HIV will not spread.
Sharing clothes, beds, food, toilets, cups or plates. There is no
exchange of blood here, so the virus will not spread.
Mosquito bites or flies. Unlike Malaria, HIV is killed by
mosquito’s stomach acid and subsequently cannot be passed onto
12
humans. Also, animals and insects do not carry the human strain
of HIV and cannot pass it on.
Kissing someone. Kissing from mouth to cheek cannot pass on
HIV. Mouth to mouth kissing does not pass on the virus unless
there are cuts and/or mouth ulcers where the virus can move
from one person’s blood system to another. The chance of this
is small but it is best only to kiss when there are no sores or
cuts.
If an infected person has an open sore or cut, HIV may spread if the
open cut or sore comes into contact with another person’s open cut
or sore. The chances of this are small, but to be safe, it is important
to keep all open cuts and sores covered with sterile bandages. To
keep safe from infection, sterilise all sharp objects by boiling them
in water for ten minutes before using them again.
COST OF HIV/AIDS ON THE COMMUNITY?
HIV/AIDS has a great impact on the community. It affects the health
and social services, India’s economic growth, and the health of
children.
As the incidence of HIV/AIDS increases, medical costs for treating
people also increases. This is because more doctors, nurses and hos
pitals are needed to meet the increasing number of infected people.
Current medications for people living with HIV/AIDS are also very
costly, compared to other medications. The demand for social
services in supporting people with HIV/AIDS and preventing further
spread increases, subsequently increases the cost to society.
As people become sick, they are unable to work and contribute to
the nation’s economic growth. With epidemic rates of HIV/AIDS, a
large proportion of India’s labour force is unable to work. This slows
economic growth, increasing levels of poverty in the country. More
importantly and directly, people are unable to provide for their
families, increasing their personal circumstances of poverty.
With high incidence of HIV/AIDS in young adults, more and more
children are being born infected with the HIV virus. This prevents
13
their bodies from fully developing a strong immune system to fight
off disease and infection. Unfortunately, this results in children dy
ing within 1 to 5 years of being bom. During this short life, they are
very' sick often and require a lot of medical care.
The greatest impact HIV/AIDS has been in the community however,
where there is the loss of family and community members.5
Case Study: The difference between HIV/AIDS and STDs.
A young man is experiencing pain while urinating and has
lower abdominal pain. He has engaged in risky sexual
behaviour with his girlfriend and has used IV drugs. He visits
a doctor at RUHSA concerned that he has HIV/AIDS. He is
tested for HIV/AIDS and STDs. It is found that he has STDs
but not HIV/AIDS.
The doctor at CMC counsels the young man before the HIV/
AIDS test to assess what risk he has been exposed to. After
the test, despite the negative result, the doctor continues to
counsel the young man about HIV/AIDS and STDs. The
doctor informs the young man of how HIV/AIDS spreads,
how it is transmitted, that there is no cure and the differences
between STDs and HIV/AIDS.
Despite HIV/AIDS being an STD because it can be transmit
ted sexually, the biggest difference between HIV/AIDS and
other STDs are the symptoms. HIV/AIDS have signs and
symptoms that are not based around the genitals. Also, STDs
are curable while HIV/AIDS is not. Many people who are
beginning to learn about HIV/AIDS and STDs often find this
confusing. When being tested for STDs, it is advisable to be
tested for HIV/AIDS at the same time.
A part of the counselling process also involves giving
attention to the young man’s behaviours that put him at risk
of HIV/AIDS. After giving full’information about HIV/AIDS
and STDs, the young man chooses to change his behaviours
to reduce his and his girlfriend’s, risk of HIV/AIDS. He also
encourages his girlfriend to see a doctor to be tested for
STDs and HIV/AIDS.
14
Treatment and HIV / AIDS Care
Currently there is no cure for HIV/AIDS but there is some treatment
available. From December 1, 2003 the government has decided to
make AIDS drugs available for free according to pre-determined
criteria. There are many operational issues that need to be solved
before the drugs are freely available. However, this provides a new
hope.
Medications are not the only way to treat HIV/AIDS. Promoting
optimum health and fitness will help the person keep their immune
system strong. This involves eating healthy and nutritious food and
exercising regularly. Keeping warm in the cooler months to ward off
colds and infections will also help strengthen the immune system. A
list of drugs available and how they work is briefly described.
This list is given only for information on the drugs available for
treatment. As there are serious side effects as well as to prevent all
drugs must be taken only under the direction and supervision of
competent physician. All doctors are not trained adequately to pre
scribe this medicines.
DRUGS AVAILABLE FOR HIV/AIDS
Highly Active Anti-Restoviral Therapy (HAART) has
revolutionised HIV treatment, bringing hope to millions of sufferers.
It has resulted in a profound decline in the number of deaths due to
AIDS in the Western World. In USA in recent years the number of
AIDS deaths has decreased by 70%. The benefits of HAART have
been linked with decreased rates of AIDS opportunistic infections.
There are three main classes of drugs :
1.
Protease Inhibitors (PI)
2.
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI)
3.
Nucleoside Reverse Transcriptase Inhibitorss (NRTI)
15
They mainly work by affecting the action of key enzymes
the HIV vims needs to reproduce, thereby preventing HIV from
multiplying. They are used in what is called combination therapy;
therapeutic guidelines recommend combinations of three or four
anti-HIV drugs as treatment for HIV. Prescribed combinations of the
different drugs taken regularly usually leads to a profound decrease
in HIV viral load and a substantial increase in CD4 T-cell count.
N.B. The information listed here is based on anti-HIV drug use
in the developed world, and may not translate to other environ
ments. This section is intended only to provide information on
the various groups of drugs available and the mechanism of
action. Anti-retrovoral therapy is not a cure for HIV/AIDS. All
drugs must be taken only under medical supervision.
Protease Inhibitors
Protease inhibitor drugs work by blocking a key protease
enzyme that HIV needs to reproduce. This results in defective HIV
particles that are unable to infect new cells. Protease Inhibitors are
used in combination therapy with other anti-HIV drugs.
Non Nucleoside Reverse Transcriptase Inhibitors
NNRTI drugs work by blocking the action of the reverse
transcriptase enzyme of HIV. This effect renders the vims unable to
transcribe its genes into a form that world allow them to be incor
porated into the human genes. NNRTI have no action on cells al
ready infected with HIV. This is also the case with NRTI (nucleo
side reverse transcriptase inhibitor) dmgs, but the mechanism of the
NNRTI and NRTI anti-HIV dmgs are different.
Nucleoside Reverse Transcriptase Inhibitors
Nucleoside reverse transcriptase inhibitors (NRTIs) work by
terminating the growing DNA (gene) chain of HIV as it is trying to
reproduce itself. NRTI dmgs obstmct the building blocks of genetic
16
material (RNA or DNA) from being assembled together. NRTI’s block
a crucial step in HIV’s life cycle where the reverse transcriptase
enzyme changes the HIV genetic material (RNA) into the form of
DNA that can be incorporated into an infected cell’s own DNA. This
results in defective HIV particles that are unable to infect new cells,
and prevents the virus from multiplying.
Types and list of drugs currently available are listed below. Onlygeneric names are given trade names differ.
Protease Inhibitors
Non-Nucloeside Reverse Nucloeside Reverse
Transcriptase Inhibitors Transcriptase Inhibitors
amprenavir
delavirdine
indinavir
efaviranez
saquinavir (Soft gel gap) nevirapine
saquinavir (hard gel up)
lopinavir/ritonavir
ritonavir
nelfinavir
zidovudine / lamivudine
lamivudine
zalcitabine
zidovudine
didanosine
stavudine
abacavir
Combination therapy / treatment options
Therapeutic guidelines recommend combinations of three or
four anti-HIV drugs as treatment for HIV. Given the quantity of
different drugs available on the market, the number of possible
different combinations is huge and potentially very confusing. None
theless there are some treatment options that are more commonly
used and generally recommended. These are :
1.
Protease Inhibitor with 1-3 nucleoside reverse transcriptase
inhibitor (NRTI) drugs - (PI + NRTI + NRTI)
2.
Double Protease Inhibitor combinations with 2 NRTI or a an
NRTI + NNRTI-(PI + PI) + 2NRTI or NNRTI
3.
Protease Inhibitor with 2 NRTI durgs and a non-nucleoside
reverse transcriptase inhibitor (NNRTI) (Pl + NNRTI + NRTI
+ NRTI)
17
Even within each treatment option there are numerous
different treatment options and combinations. Some may be affected
by drug interactions between certain kinds of HIV drugs that may be
beneficial or harmful and others have just not been tested yet. The
efficacy and outcomes of the various combinations are also affected
by the patient’s treatment history, e.g. whether they are HIV drug
novice (first time user), if they have a history of developing
resistance to a particular drug or drug type etc.
Dosage
Because the drugs are taken in combinations of the different
types hence the name “Combination Therapy”, the total number of
pills and capsules that have to be swallowed in a day can be quite
large. The number ranges from an almost reasonable 10 pills to 24
or more.
Patient psychology
The patient’s willingness to stick rigidly to the therapeutic
regimen will be just as important as the effectiveness of the drugs
they will be taking. Remember HIV drugs have to be taken for the
rest of the patients’ life. They must be taken at regular intervals to
keep drug concentrations in the blood at high enough levels to pre
vent the development of resistance. And the drugs have unpleasant
side effects. All patient’s must be given as much information and
support as possible. Encouraging the development of patient support
groups will help a great deal.
Cost of treatment
The high cost of HIV drugs has been very much in the news
with drug companies after coming under great pressure finally agree
ing to sell drugs in Africa at discounted prices or at cost. Just how
much will they cost? Which treatment option is the cheapest? It is
for sure cost is going to be the major determinant of which treat
ment protocols will be made available to HIV sufferers in Africa.
Not surprisingly the cheapest treatment option is Treatment
Option 1, but the price varies greatly, depending on what drugs are
18
used. The cheapest combination is Viramune / Epivir / Zerit at S606
per year.
Other combinations are considerably more expensive because
even at so called discount prices, the yearly cost is still considerable
at $1,000 plus, and some drugs are not even offered at discounts. It
is certain that many new different treatment options with unknown
outcomes will be tried out as cost becomes a driving factor.
Special populations
Pregnant women and children - there are special guidelines
for using drugs in this group of people. Consult your doctor or a
website that has information regarding the use of HIV drugs.
COMPONENTS OF CARE
HIV/AIDS is a medical problem that is affected dramatically
by people’s individual social circumstances, it is important to have
a comprehensive treatment program that involves medical and psycho
social care. The following components of care are considered by
CMC
1. Counselling
2. Testing
3. Medical Out patinet and In patient
4. Obstetrics
5. Surgery
6. Infections Control
7. Staff Education
8. HIV/AIDS Team
9. HIV/AIDS Policies
10. Patient’s Support Groups
11. Home-based Care
12. Drug Availability
13. No Discrimination
14.
Networking
19
All these aspects of care need to be considered to reduce the risk of
spread within care settings while recognising issues facing the
PLWHA. This will provide a comprehensive and holistic approach
to HIV/AIDS control and care.
APPROACH TO HIV/AIDS MANAGEMENT
HIV/AIDS management involves more than a medical focus. Due to
the particular ways it can spread and the many misunderstandings of
the disease in the community, a combined psycho-social support
with a medical approach is needed for holistic and comprehensive
HIV/AIDS management.
Psycho-social support begins with the pre and post-test counselling.
In these sessions, the worker should give the patient information
about HIV/AIDS. how it spreads and how it can be prevented. It is
important to gauge how the patient is feeling to help him/her from
feeling overwhelmed and unable to absorb any of the information.
Follow-up counselling is also important. This gives the worker
opportunity to provide general support to the patient along with
giving more information or clarifying any questions the patient has.
These counselling sessions can provide the patient with the latest
information about HIV/AIDS and how to live as healthily as
possible. Follow-up counselling also helps the worker build a strong
relationship with the patieht so that they will continue to seek
treatment to maintain optimum health.
Regular medical check-ups are also important in the management of
the HIV/AIDS patient. The physical health of the patient is vital to
maintain to reduce the risk of opportunistic infections that can claim
the person’s life. Managing the person's health involves providing
illness-prevention, and nutritional information and information on
leading a healthy lifestyle. These can all help extend a person’s life.
20
What to do when a person dies from HIV/AIDS'4
After someone dies from AIDS, it is important to use hygienic
methods while handling the body. Keep hands protected, clean and
disinfect any soiled clothes or sheets. Wash hands regularly while
handling the body or washing cloths. Remember to keep all wounds
covered.
Soon after the person dies, the person can be buried or cremated but
it is best to do this within one day. It is advisable that people do not
fall over the body or touch it too much; body fluids can be excreted
from orifices that contain the virus.
HOME BASED CARE
HIV is not easily transmitted but it is important to follow a few
rules when living with someone who is HIV+.
q
After contact with body fluids or soiled sheets and clothes wash
your hands with soap and water.
o
Cover all wounds with a bandage or cloth.
o
Immediately clean any spilt blood with disinfectant (such as
bleach) and wear gloves. If you do not have gloves, put a plas
tic bag over your hands for the cleaning.
o
Use gloves or plastic or a big leaf to handle soiled items.
o
Do not share: razors, needles, toothbrushes or any other items
that pierce the skin or come in contact with blood.
o
Keep bedding, clothes and eating utensils clean. This will
reduce the chances of someone with HIV/AIDS catching ill
nesses or infections.
o
For women, use menstrual pads straight from the package. Pads
that have been handled may hold bacteria that can cause
infections. Dispose of all used pads by wrapping them in paper
or plastic or leaf and burning with your rubbish. Wash your
hands after this with soap and water. For women who use old
cloth when menstruating, bum the cloth afterwards.
08883
Z?zzzo
J
■?(■£' 3>2-S
When cleaning soiled clothes and sheets, follow these three easy
steps :
1.
Keep them separate from the other laundry and wash soon.
2.
Hold any unstained part of the cloth and wash off the blood/
diarrhoea/body fluids. Ideally, soak the clothes in disinfectant
for 20 minutes.
3.
Wash in soapy water and hang out to dry as normal.
People living with HIV/AIDS are at a higher risk of getting
sick because their immune system is weaker. It is therefore, very
important to maintain hygiene in the home. For a hygienic home:
©
Wash your hands with soap and water regularly.
o
Wash clothes and sheets regularly with disinfectant.
©
Keep all eating and cooking utensils clean and disinfected.
©
Wash all vegetables and fruit before eating.
©
Keep food covered from flies and insects.
•
Prevent mosquitos breeding in your home by ensuring you have
effective drainage and disposing of waste water.
©
Keep soiled and dirty items away from children. Wash every
thing they put in their mouths and their toys.
©
Try spitting into a container or try not to spit.
©
Cover your mouth and nose when coughing or sneezing. Wash
your hands afterwards.
Malaria has greater effects on people living with AIDS than
the general community. Avoid malaria by :
©
Using bed nets to protect people while sleeping ;
•
Using insecticides to kill mosquitos in the home ;
©
Draining any standing water and
©
Use wire net to insect-proof windows in the home.
07
Prevention of HIV/AIDS
From the Ugandan experience, it can be seen that education is the
key to reducing the incidence of HIV/AIDS in India. It is important
to talk about HIV/AIDS with your family, friends and community to
promote awareness and help prevent the disease.
Sex and reproductive health education is also important for young
people in society. Parents should try to talk openly about sex, repro
ductive health, relationships and marriage with their adolescent chil
dren. This will help them better understand their bodies and to make
correct choices about sex and relationships.
Teachers also play a role where it is important for them to educate
their students about reproductive health, their bodies, sex and related
issues. Increased knowledge around bodies and reproductive health
helps empower young people to make correct choices in their lives.
This education can also help prevent the spread of HIV/AIDS.
THE ROLE OF CONDOMS
Condoms (N1RODH) are made of thin latex designed to go over the
penis during sex. They prevent the exchange of fluids from the man
(penis), to his partner. By preventing the exchange of fluids, HIV/
AIDS cannot be spread and pregnancy is prevented. They can only
be used once, and after their use the end should be tied and disposed
of thoughtfully.
Condoms cost about from Rs 1.50 for I or Rs 10 for 3 and they can
be purchased front petty shops, local clinics, family planning offices
and Government hospitals. They are available free in private health
clinics (NIRODH) and at HIV/AIDS institutions.
Condoms should ALWAYS be used when a person infected with
HIV/AIDS or a STD wants to have sex with another person, regard
less of whether they are infected too. They should also ALWAYS be
used when having sex with a commercial sex worker or having sex
outside of marriage.
23
How to Use a Condom
1.
2.
3.
4.
5.
6.
7.
8.
©
o
o
Open the packet carefully; making sure the condom is not
tom.
Squeeze tip of condom and put it on end of the hard penis.
Continue squeezing tip while unrolling condom until it
covers the entire penis.
Always put a condom on before entering your partner;
After ejaculation, hold the rim of the condom and pull
penis out before it gets soft.
Slide condom off without spilling the liquid (semen) inside
it.
Tie and wrap the condom (in paper or plastic) then throw
away with the rubbish. Wash hands afterwards.
Bum or bury the used condom with the other trash.
Condoms can only be used once, dispose of the used
condom by tying a knot in the loose end and dispose
thoughtfully.
Condoms have expiry dates; check the expiry date before
purchasing condoms.
If the package is damaged, do not use the condom.
PREVENTING MOTHER TO CHILD TRANSMISSION
Transmission of HIV from mother to an urbom foetus is a known
form of spread of the disease. Without intervention about 15 to 30
percent mother to child transmission (MTCT) takes place during
pregnancy and delivery and an additional 10 to 20 percent postpartum
(via) breast milk. Technology now exists to prevent MTCT. In principle
the mother is provided selected HIV drugs just prior to delivery,
delivery is often by lower segment caesarian section, administration of
HIV drugs to both mother and the newborn infant and finally avoiding
breastfeeding. The entire process is being developed so all HIV positive
pregnant women should be referred to centres where this mother to child
prevention programme is being carried out for necessary follow up.
24
BREAST FEEDING AND HIV/AIDS
Whether a HIV positive mother should breast feed her new bom
infant is one area which has raised significant controversy with strong
advocates supporting both for breast feeding and against. What
triggered off the debate was an initial recommendation by the UN that
mothers HIV positive should be free to breast feed or provide formula
feeds. Therefore the question has arisen “Should infected mothers
breastfeed?” There are four principles that govern the answer to this
question, although much more research is needed in all three areas.
1.
The rate of transmission of HIV is variable and is likely to be based
on a least two known factors, namely the stage of the HFV infection
and Vitamin A status in the mother.
2.
It is possible that not all children who are born negative will
become positive following breast feeding, because breast milk might
have some protective effects.
3.
The HIV status of the infant may be suspect as the antibodies tested
might be the maternal antibodies passed to the infant through the
mother’s immunologically rich breast milk.
4.
Even if a mother decides not to breast feed, other breast milk
substitutes than formula feeding must be considered. These include
heat treating expressed breast milk, breast milk bank, wet nursing,
animal milk or home made formulas.
The knowledge in this area is incomplete. Mothers will need to
make the choice of either breastfeeding or not. If they decide not to
breast feed, mothers from developing countries should consider
alternatives to formula feeds keeping that the option last.
25
Messages on HIV/AIDS
Through RUHSA’s HIV/AIDS projects, messages are promoted to
the general community to encourage HIV/AIDS preventive behaviours.
These messages are frequently re-evaluated and reformed. They have
an action-focus to better promote behaviour change within the
community. Different messages are used to target different groups in
society to match their specific lifestyles and cultures.
Community:
o
©
e
©
Suspect HIV/AIDS if there is a sudden weight loss, prolonged
fever or diarrhoea, not responding to usual treatment.
Get a blood test for HIV if you suspect the disease, after contact
with blood, body fluids or risky sexual behaviours.
Accept people with HIV/AIDS, especially within the family,
without segregating them.
Support people with HIV/AIDS and their families, care for them
like any person who ill.
Youth:
o
Talk openly with your parents and teachers about issues con
cerning your life.
© Encourage your peers to share information about HIV/AIDS with
your friends and family.
o Ask your parents and teachers, if you are confused about HIV/
AIDS information.
• ■ It is important to your family, community and your health that
you wait until you are married before you have sex.
© Get a blood test if you have had risky unprotected sex.
o Find a partner who accepts you having HIV if you are found to
be HIV+ and plan to marry.
® If you must then have sex, always use a condom.
Married Couples :
©
Be mutually faithful to one another enjoying sex within
marriage.
26
0
o
o
0
Control your sexual desire to avoid risky behaviour.
Meet your partner’s sexual needs as much as possible.
Find privacy in your home, make time for each other.
If you cannot be faithful to your partner, always use condoms.
Parents :
o Talk openly with your children about sexual images shown on
TV and in magazines and advertisements.
o Encourage your children to talk openly about relationships,
marriage and sexual behaviours.
o Know your adolescent children’s friends, spending habits and
where they sleep and fascilisate safe life styles.
People Living with HIV/AIDS :
o
o
o
q
o
o
o
Always use condoms to avoid HIV infection or if you decide to
avoid pregnancy.
If you can afford it, take anti HIV treatment which helps to
control the disease, not cure it.
Eat healthy nutritious foods to help your immune system.
Keep your surroundings clean to avoid infections and illness.
Seek support of trained counsellors.
Pregnant women should consult their doctor about medications,
antenatal care and delivery.
You can still live a happy life if you are HIV+.
Health Staff :
o
Always use Universal Precautions.
o
e
Follow institutional protocols, if risky contact occurs during
patient care.
Use only sterile needles, syringes, screened blood and organs.
o
Use gloves when working with bodily fluids.
o
Talk with your patients about HIV and counsel those HIV+.
o
Be supportive of HIV+ patients to avoid stigma.
27
[ yniversal Precautions for Health Workers
‘Universal Precaution’ is the term used to describe routine safe
working practices to protect hospital staff and patients from
infections by blood and body fluids. They are designed to prevent
the spread of infections and protect the health worker. Workers are
able to catch infections and disease through blood, blood products
and body fluids, coming in contact with: needles or sharps, injuries,
micro cuts and abrasions and mucous membranes of the nose and
eyes.
To practice universal precautions, health workers should wear sterile
gloves at all times, use sterile needles and syringes, use sterile
instruments, wear protective clothing, use safe waste disposal
facilities and good working practice. Linen should be soaked with
1% sodium hypochlorite (Dakins) for 30 minutes. Thermometers
need to be sterilised in sterilising solution for at least 5 minutes,
after every use.
Universal precautions also need to be practiced at an institutional
level, where the hospital provides adequate materials, educating the
health workers at all levels. This includes all medical instruments
and equipment, furniture, fans, lights and curtains. Educating
co-workers about universal precautions is needed to improve and
increase the practice of universal precautions. Hospitals and health
clinics should have an infection policy that is written in a language
that all staff can understand. This will lead to a cleaner and safer
hospital for patients and a safer working environment for the health
worker.
CMC and RUHSA’s Needle Stick Injury Policy
CMC and RUHSA have a needle stick injury policy to reduce the
chances of HIV/AIDS transmission and to ensure a high quality
standard of care.
28
When handling needles, it is important to take care and to throw the
needle into the sharps container as soon as it has been used. This
will reduce any risk of it being used again and possibly spreading
HIV/AIDS or other infections. Use gloves at all times when you are
handling needles.
When a needle stick injury occurs it is important to follow these
guidelines:
I.
As soon as the injury occurs, dispose of the needle into
the sharps container safely and quickly.
2.
Check the patient’s records to see if they have been tested
for HIV/AIDS.
a.
If they have been tested and the result was negative,
there is no need for concern and the worker does not
need to be tested.
b.
If the patient is HIV+, the worker is to be tested for
HIV/AIDS.
c.
In cases where the patient has not been tested for HIV/
AIDS, tests are to be conducted for the patient and
health worker. The blood samples are to be taken to
CMC for the rapid test.
3.
If the test for the patient comes back positive, further
testing is required combined with a comprehensive
treatment for HIV/AIDS.
4.
The needle stick injury incident is to be reported to the
worker’s supervisor so that it can be recorded and
hopefully prevented in the future.
29
Some do’s and don’ts to prevent HIV / AIDS
•
Abstain from sex before marriage.
o
Be faithful to your wife or husband.
•
If you cannot do these, always use condoms
•
Do not share needles, razors, sharps or toothbrushes with a per
son who has HIV. If you do not know, make sure that all
instruments are sterilised by boiling them in water for ten
minutes before using.
©
Insist on new sterilised needles and utensils when in hospital.
o
Insist on new, sterile razor blades for shaving at barber shops.
•
If needing a blood transfusion or organ transplant, insist on
blood that has been tested for HFV/AIDS.
©
Intravenous Drug Users should take extra care because of the
higher risk of contracting HIV/AIDS through infected needles.
©
People suffering from HIV/AIDS should carefully consider hav
ing children due to the risk of spreading HIV/AIDS.
NETWORKING
One of the surest means of overcoming vulnerability is to
organise a network among those who are HIV positive. A
network helps to share experiences with one another and
strengthens one another. Further it gives an opportunity
to share resources available that could be used by those
who are HIV positive. However it is not easy for everyone
to join a network of positive people. Health workers and
counsellors can encourage thse who are HIV + to join a
network. However there should be no pressure on anyone
"^to^tein a network. When they join a network then those
- who'are, HIV positive have a tremendous sense of satisfaction^irid %‘elonging not witnessed earlier.
-------------------------------------------------------30
HIV/AIDS and Vulnerability
Vulnerable Groups in HIV/AIDS
The following categories of individuals are vulnerable both to the
disease and its after effects. Understanding who is vulnerable is an
early step in empowering people to take steps to prevent the disease
or to overcome its effects. The communication for Health India
Network (CHIN) has identified the following as those vulnerable
because of HIV / AIDS.
O People Living with HIV/AIDS (PLWHA):
O Infected Individuals
<> Affected individuals in the family who are not infected:
spouses, children, grandparents
(These people are only vulnerable when proper home care
precautions are not taken)
❖ Commercial Sex Workers (CSWs)
❖ Intravenous Drug Users
<> Migrant Workers:
O Construction workers
O Farm Labourers
O Those travelling outside their home for work:
<> Truck Drivers and Helpers
O Travelling Salesmen
O Police Officers and Armed Forces
O Adolescents
O Professional Blood Donors
❖ Pregnant Women
O People with Disabilities
<> Care Providers
31
08883
t-34
❖ Health Workers
The term 'high-risk' is also used to describe people who are vulner
able to contracting HIV/AIDS. At RUHSA it is believed that the
people who are most vulnerable and at risk are the people who do
not know about HIV/AIDS. It is therefore very important for
everyone to share information about this disease so that its spread
can be controlled and prevented.
'Vulnerability with HIV/AIDS
HIV/AIDS is unlike other viruses and diseases. It is a medical prob
lem that has many social issues effecting its prevalence, spread and
control. Many of the issues arise from a lack of education and
understanding of reproductive health, sex and HIV/AIDS.
The health of someone with HIV/AIDS is of critical importance.
Because the HIV/AIDS disease kills the immune system of an
infected person, they are more susceptible to infections and disease.
When AIDS is full blown, the person is more susceptible to oppor
tunistic infections and diseases, which can kill them. Due to
ill-health the person’s and their family’s income is greatly affected as
they cannot work as often as they need to maintain an income to
properly feed themselves and their family. This can lead to a greater
risk of malnutrition, disease and infections.
Lack of knowledge and understanding of HIV/AIDS leads to many
myths, stereotypes and stigmas attached to people living with
HIV/AIDS. These misconceptions lead to discrimination and a denial
of rights for People Living with HIV/AIDS (PLWHA). Spouses,
children, parents, in-laws, friends, the community and employers,
often reject PLWHA. Rejecting PLWHA in the community denies
them their right to participate freely in society and often leads to
further discrimination.
Medical and health workers who are not properly informed about
HIV/AIDS and who carry misconceptions can also break people’s
human right to proper health care and treatment through discrimina
tion, denial of services and counselling or by keeping these services
inaccessible to poorer people infected with HIV/AIDS. The denial of
health care and treatment can range from a denial of assistance for
32
small infections to a refusal of using life-saving equipment or by not
expanding health care programs to meet the needs of al) people
infected with HIV/AIDS. When proper medical services are denied,
people infected with HIV/AIDS are more likely to turn to Quack
Doctors and pay highly for “cures” or “remedies” that do not work.
This is exploitation and can have trickle down effects on the person’s
family.
People’s rights are also broken when medical and counselling
services are not kept confidential or private. If confidentiality is
broken, the chances of discrimination within the community increase.
When a person is diagnosed as having HIV/AIDS it is up to them
to inform their family members and/or future wife/husband. The
health worker’s role is to counsel the person through the process and
to support them in informing others of their status. Telling the person’s
family of the person’s HIV status may feel like the right thing to do
to prevent further spread of the disease but it is breaking confiden
tiality and is unethical. RUHSA and CMC provide confidential and
private HIV/AIDS testing and counselling.
Men are seen as having a more important role in the family and
community that often results in men receiving medical treatment
before women in a family where both spouses have HIV/AIDS. It
could be that the man works and requires medicines to continue
earning an income or that the woman’s role in the home is too
important for her to leave to seek hospital care. People with HIV/
AIDS, regardless of gender require treatment and care to help them
live as healthy and as long as possible.
For Commercial Sex Workers (CSW), earning a livable wage seems
to be more important than their health. Often CSW’s clients take
advantage of this and demand that condoms are not used or that they
pay less for the service when a condom is used. This puts the CSW
at greater risk of HIV/AIDS and poverty. The client is also put at
greater risk of HIV/AIDS.
Men having sex with other men are also at risk of contracting HIV/
AIDS. It is not unnatural for two men to have sex but there is a
greater risk of HIV/AIDS and using a condom is very important.
33
Discrimination of PLWHA continues because people are often un
aware of their rights. Everyone, including PLWHA, has the right to:
©
Participate freely in society;
o
Be treated equally like everyone else in the community;
©
Access to proper healthcare, treatment and counselling;
o
Confidentiality and privacy in healthcare settings;
©
Have a wife/husband and children;
e
Full employment;
©
Education about their bodies, HIV/AIDS and reproductive health;
o
Access to legal rights.
RUHSA’s First HIV/AIDS Couple
Over 10 years ago a young man was diagnosed with HIV/
AIDS and later his wife. Lesions on the man’s skin indi
cated a progression to the full-blown AIDS stage. The couple
was counselled to use condoms to prevent pregnancy But
since, it has been realised that this denies people’s rights to
have children. Today, there are programs available for women
to take medications while pregnant to reduce the chances of
spreading HIV/AIDS to the unborn child.
The couple was encouraged to live a life satisfying one
another but due to gender inequalities, within a week the
wife was sent away stating that it was her fault that her
husband was HIV+. They were advised against quacks that
offer fake cures for high prices. Out of desperation, the
husband was exploited and paid a huge sum of money for
traditional medicines that did not help. Due to misunder
standings and stigma in the community, when the husband
died his wife was not allowed to go to his funeral; and
when she died no one from the husband’s family went to
her funeral.
34
HIV/AIDS and Sexually Transmitted
Diseases
Sexually Transmitted Diseases or STDs for short are infections
and diseases that are spread from one person to another through
unprotected sex. If a person has a STD, their chances of contracting
HIV/AIDS are increased, because they are more likely to have open
sores on their genitals, which increase the entry places for HIV.
The signs and symptoms of STDs for men are :'°
o
A rash, blisters, ulcers or sores around the genitals.
o
Lower abdominal pain.
o
Pain or burning sensation while passing urine.
o
Discomfort during sexual intercourse.
o
Inguinal swelling.
o
Painful scrotal swelling.
o
Coloured discharge from the penis.
©
Itching around the genitals.
The signs and symptoms of STDs for women are :
o
Excessive white discharge from the vagina which may be foul
smelling.
o
Itching around the genitals.
o
Lower abdominal pain.
o
Pain during sexual intercourse.
o
Inguinal swelling.
o
Genital ulcers.
o
Swelling of the vulva.
If a person has any of these symptoms, it is important for you to
consult a doctor and seek treatment. A blood test to check for HIV
is also advisable at the same time.
35
FREQUENTLY ASKED QUESTIONS
1)
Can I catch HIV/AIDS from a mosquito?
No. HIV is a delicate virus that gets destroyed in the mosquito’s
body by its stomach acid, so it cannot be spread to people.
Also, there isn’t enough exchange of blood between a mosquito
and humans for HIV to be spread.
2)
If I kiss someone who has HIV, will I catch it ?
Mouth to cheek kissing will not spread HIV/AIDS. The chances
of HIV being spread through mouth to mouth kissing are also
very small, it may only pccur if the infected person has an open
cut or sore in their mouth.
3)
Can I tell by looking at someone if they have HIV/AIDS ?
No. You cannot tell by looking at someone if they are HIV+ or
not. When people are very sick with AIDS they will look like
anyone else when they are sick.
4)
How can we stop HIV/AIDS in our community?
The only way to stop the spread of HIV/AIDS in our commu
nity is to prevent further infections. These means abstaining
from sex before marriage, being faithful to your partner, or if
you are unable to do these, use a condom. Using sterile sharp
instruments and insisting on sterile needles and tested blood in
hospital settings can also prevent the spread of HIV/AIDS.
Further educating people around you about HIV/AIDS will also
help fight against HIV/AIDS.
5)
Where can I be tested for HIV/AIDS ?
Your local doctor should be able to advice you where to test for
HIV/AIDS. If you feel uncomfortable consulting your local
doctor, you can be tested at RUHSA or CMC Hospital.
If you get tested at RUHSA or CMC Hospital, there is pre
testing counselling to determine what risk you have been at of
36
contracting HIV and your test is kept completely confidential.
This means that even if a family member or friend comes with
you, they will not be told about why you are visiting the doctor.
You will also have post-test counselling where doctors or coun
sellors are available to support you through your options. These
services are offered without judgement and confidentiality is
maintained.
6)
Can menstrual blood spread HIV/AIDS ?
Yes. Make sure you dispose of menstrual blood hygienically and
thoroughly. If you use disposable products, wrap them up in
paper or leaf and throw away. If you use old cloth, bum them
after they have been used. If you cannot afford to burn them,
please sterilise them and dry them in the sunlight. Wash your
hands afterwards.
7)
I’m HIV+, if I take more of my medications, will I be cured ?
No. The medications can extend a person’s life for some time
but will not work forever or cure the person. It is best to prevent
spreading HIV/AIDS than trying to find a cure.
8)
How do I relate with a HIV/AIDS + person ?
Anyone who is infected with HIV/AIDS is still human and de
serves to be treated with the same respect and dignity that you
would expect when you are unwell. People who have HIV/AIDS
need extra care, love and acceptance from family, friends and
the community.
If you live with someone who has HIV/AIDS it is important to
make sure that you follow the home care guidelines above. Re
member, regular social contact cannot spread the vims.
9)
Can HIV + Children go to regular schools ?
As HIV + AIDS does not spread by contacts that does not
exchange body fluids, sitting in a class with a HIV + individual
is not a risk for other children. Teachers, school children and
parents should be very clear and that there is no need to segre
gate or isolate a child from the regular school.
37
“Can I get married ?”
Diagnosed 10 years earlier, a well-built young man with
HIV, still looking healthy voiced his problem: "Doctor, in
my village I am one of the most eligible bachelors. So
many parents are proposing their daughters in marriage;
my parents are pressuring me to get married. Knowing my
HIV status, I have put off marriage for many years. Doctor,
can I get married?”
Deciding to get married will involve considering many
factors. It will involve revealing your status to prospective
spouse and risk the community finding out and facing
possible discrimination and rejection. If you find someone
who accepts you with your status, how will you feel about
dying young and leaving your wife? Will she be able to re
marry afterwards? You will need to use condoms during
sex and think carefully about having children. There will
be a lot of pressure to have children but having children
will involve putting your wife at great risk of HIV/AIDS.
It will also mean that your unborn child will also be at
risk. To have children, you could consider adoption, but
will you feel uncomfortable with the fact that you will die
young, leaving a child to grow up with just one parent who
may also contract HIV/AIDS and die, leaving an orphan
child. Will you be able to find anyone who will take care
of the child? If you do find anyone, will they take care of
the child if the child has HIV/AIDS?
If you choose to stay a bachelor, you will face community
pressure and questioning as to why you are not married.
Ultimately, the decision is yours, but consideration of the
above issues is important.
38
Overcoming stigma in HIV/AIDS
In the history of mankind leprosy was one of the most
stigmatising disease. As the leprosy bacillus caused destruction,
anaesthetic parts of the body were badly deformed. Today many
individuals who had leprosy are well accepted in their families and
society. Tuberculosis was the other disease that produced stigma
although not to the same extent as leprosy.
The initial stigma associated with HIV I AIDS was as severe
as that associated with leprosy and at times even worse. In leprosy
the trauma of disease was not as rapid in HIV / AIDS. Further in
HIV / AIDS the disease was associated with multipartner hetero
sexual behaviour very often with commercial sex workers. Thus very
clearly HIV / AIDS became associated with what the community
considered as bad behaviour. Therefore the community tended to
justify the stigma associated with HIV / AIDS.
However as the mechanism of the spread of the disease was
clearly understood, especially the ways it does not spread, it became
easy to educate the community to accept the HIV / AIDS individual
as a person who has any other disease. The message that such
persons deserve the love and affection of their relatives, further being
backed by pictures of leaders of various professions mingling and
moving with those with HIV / AIDS, it tended to gradually decrease
the stigma.
However ore of the factors that contributed significantly to
the stigma situation was the response of the medical profession. The
refusal to admitting, treating, conducting delivery or carrying
surgeries for those HIV positive contributed significantly to the
problem of stigma.
While on one side there were a significant section of the
community that accepted HIV positive individuals, from time to
time stories of stigma associated with stigma was widely published
in the media. One of the major news for a considerable period of
time was the refusal of admission for two HIV infected children in
a school in Kerala. Even with Government pressure the children
39
could not be admitted and alternate arrangements had to be made
because the parents of other children were strongly against the
children’s admissions.
The other story is from Andhra Pradesh. A HIV positive
woman was reported to have been stoned to death. Although
conflicting reputs were received this only added further fire to stigma.
Then .of course there is the Mumbai story. Some of those
who were HIV + attended a AIDS conference in Africa. On their
return they were quarantined because they did not have Yellow fever
vaccination. The story was in the news sufficiently long enough to
keep stigma alive.
On the other hand the formation of networks by those who
are positive, by boldly revealing their identity as HIV positive, they
have taken great strides to destigmatise HIV / AIDS. However the
feedback from a group of HIV positives indicates the fear
experienced by those who are HIV positive.
Voices of HIV positive women
On December 1, 2003 the Indian Health Minister
announced that drugs would be made available free of cost to
those who are HIV positive and meeting certain clinical
criteria. In an attempt to influence policies that would be
evolved, a group of HIV + women were asked the question if
they would be happy if separate clinics as for tuberculosis
could be organised. Their response was spontaneous “Please do
not organise separate clinics for HIV / AIDS. Let it be in the
crowded clinics so that we can get lost in the general clinic. A
special clinic would force us to reveal our identity. Although
there is much acceptance in the community still there are people
who look down up on and pass hurting comments at us.”
Still more conscious efforts are needed to destigmatise the
disease. It is quite possible that as in the West with the
availability of free drugs and with those HIV positive going
back to work and leading a near normal life, stigma might
come down further.
40
The Experience in Uganda
In the early 1990s, Uganda was experiencing an HIV/AIDS
epidemic with approximately 15% of the general
population diagnosed with HIV. By 2001, the rate of HIV
diagnosis fell to' approximately 5%s. The level of HIV did
not decline by itself; it was through changes in the
knowledge, attitudes and behaviours of the Ugandan people.
The Uganda Government supported the awareness of issues
surrounding HIV/AIDS along with promoting open
communication between people, villages and Local
Governments to fight the epidemic. The fight against HIV
focused on education and information to bring about
behaviour changes. The information and education was
aimed at the general population and not just the ‘high-risk’
groups, to ensure that everyone knew about the disease.
Specialised programs were used for young people and
women that promoted empowerment and sex education
within schools. This approach led to the reduction in
pre-marital sex for young people and a better understand
ing of HIV/AIDS. Combined with the mass education
approach and specialised programs for youth and women,
Uganda fought the stigma attached to being HIV+.
One can learn from the Uganda experience that if we do
not have sex outside of marriage, educate everyone about
HIV/AIDS and do not discriminate against those who have
the virus and disease, the incidence of HIV/AIDS in our
community will fall.
41
Taking a stand
The experience from Uganda goes to support the stand that
RUHSA has taken over the years. In most health problems when one
streategy works and appears the most suitable, policy makers usually
tend to focus only on the one successful strategy and leave out all
the others. This happened with Vitamin A solution in the early stages
giving very little importance to the horticultural approach. In protein
energy malnutrition growth monitoring was the only answer almost
ignoring many other equally effective strategies. And so with HIV /
AIDS it was condoms. It was almost considered heretic to speak
against the one accepted strategy. Funding agencies would politely
decline to give any funds to those organisations not opting for the
accepted strategy of promoting condoms.
Based on RUHSA’s experiences in controlling Vitamin. A
deficiency and PEM using comprehensive approaches, a clear stand
was taken indicating that a condom centric approach is not suitable
to India. The reasons were clearly evident from the literature and
behaviour of people.
1.
Fifty years of condom promotion in India resulted in only a
maximum of 7% of eligible couples using condoms.
2.
The age at marriage for girls was low because parents ‘pro
tected’ their daughters from pre marital sex.
3.
Various studies have indicated that premarital sex is relatively
low compared to other countries although there is higher rate of
premarital sex among the urban, especially the elite and slum
populations.
Having taken a very definite stand RUHSA adopted a com
prehensive approach which is described next. In developing and imple
menting a comprehensive programme RUHSA had to face harsh
comments and criticisms probably faced by many the world over.
42
RUHSA'S COMPREHENSIVE APPROACH TO
HIV/AIDS PREVENTION AND CONTROL
i
Recognising the limitations of a targeted intervention for
HIV/AIDS prevention and control, RUHSA has always promoted a
comprehensive approach in response to this problem. This is how
RUHSA reached this position.
RUHSA started its HIV/AIDS programme long after the
entry of many other NGOs into this field. When the first HIV
positive case was identified in K.V.Kuppam, only then did RUHSA
begin work in this area. However, before entry into this field RUHSA
organised a Consultation Conference inviting NGO partners already
active in this area. Surprisingly the recommendation that stood out
conspicuously was to follow the ABC approach as follows:
* Abstinence from sex before marriage.
* Being faithful within marriage.
Condom use during situations of high risk sexual behaviour.
Therefore, the following major strategies were adopted to build
up the knowledge of the people on HIV/AIDS moving away from
limiting it only to awareness.
*
A.
HIV/AIDS EDUCATION
A strong HIV/Education was promoted in K. V. Kuppam
Block the operational area of RUHSA. This consisted of a number
of specific activities.
1.
2.
3.
4.
5.
6.
7.
Educating all barbers in the block to ensure a new blade is used
for every customer.
School children rallies.
Video programmes in the community.
Cultural programmes linked with public meetings.
Educating policemen.
Street Plays.
Puppet Shows.
43
RUHSA had developed a set of clear messages for each category
of individuals and these messages are used in different educational
activities.
B. SEX EDUCATION
Recognising this was an important approach to preparing adolescents
for low risk sexual behaviour, considerable efforts were made to make
this programme acceptable to the community. This took two forms
as described below:
1. Camps for adolescent girls
Five days cramps were organised for school girls at RUHSA
Campus. While the primary focus was empowering the young girls
and increasing their own self esteem, sex education was also taught
to them starting from menstrual hygiene.' moving to sexuality,
HIV/AIDS and respecting the community focus on abstinence
before marriage. This was a participatory, fun and learning process.
As there was no emphasis on condoms this was well received
although there were large number of parents who would not
allow their girls to participate in such programmes.
2. School based education
Once the need for sex education and its acceptance was realised, to
reach a larger number of school children and to make it more cost
effective and sustainable the sex education was moved over to the
class rooms. Each year for the past nearly 6- 7 years sex education
including education on HIV/AIDS has been provided to girls and
boys of the 9th and 11th Standards. Again to ensure acceptability
in the community condom use was not promoted. The RUHSA team
was an effective alternative to school teachers who were shy to teach
on HIV/AIDS.
C.
PEER EDUCATION
School children both boys and girls and younger married women
were the community peer educators. They were given complete
knowledge in HIV/AIDS, as well as on communication skills. One
of the main purposes was to ensure that young people abstained
from sex before marriage and married people retained sex within
marriage. This was a short time bound programme.
44
D.
VOLUNTARY TESTING AND COUNSELLING
RUHSA's laboratory and its link up with the tertiary hos
pital at Vellore were used to provide this service. Initially all blood
samples were sent for ELISA test and confirmatory Western Blot
test. Later with the advent of rapid tests this was provided at the
RUHSA laboratory itself. As the numbers were low we were able
to provide both pre and post test counselling. With the advent of
free treatment to prevent mother to' child transmission, now the tests
are done routinely for all pregnant women with only postest coun
selling being practiced for this category.
HOSPITAL BASED CARE
E.
Those needing hospital-based care are provided this service. This
includes primarily those needing treatment for opportunistic
infections based on hospital admissions and out patient care for
those needing preventive medications for opportunistic infections.
There is no hospice care for the terminally ill and dying, as this is
primarily an acute care centre with an average stay of 4-5 days.
F.
HOME BASED CARE
Probably based on the small numbers of cases as well as an
effective home based care programme, most HIV + diagnosed indi
viduals are effectively taken care of in the community. Both through
the general education of the community and focused education of
the infected individual's family members, effective care provided at
home. Some philanthropic support is also encouraged. Family
members are taught to provide appropriate care during different stages
of the diseases and even at death.
6. CONDOM PROMOTION
Discussion with the community indicated that there were two views
on condoms promotion, with parents insisting condom promotion will
increase sexual promiscuity and some youth asking for condom use
education. RUHSA fell back on the culturally acceptable principle
of abstinence before marriage as introduced in the initial consulta
tion. RUHSA's message on condom is clear - "If you cannot abstain
from sex before marriage or be faithful within marriage then always
use a condom.” The experience from Zambia indicates the relevance
of the ABC approach by RUHSA
45
Conclusion
An excellent editorial in the British Medical Journal by Arthur J
Ammann, President, Global Strategies for HIV Prevention, from USA
lucidly explains the background of the experience RUHSA has at
tempted to pursue. Excerpts from the editorial are quoted below :
“Some argue that there is not enough money; others that it is too
difficult to change the behaviours that contribute to the spread of
HIV. But if behaviour cannot be changed then no amount of money
is going to make a big difference in prevention because every
successful form of prevention requires change in behaviour”.
"Being serious about HIV prevention also means changing the
behaviour of those who overtly or subtly undermine known methods
of prevention”.
“Advocates of abstinence who say that condoms don't work and
advocates of condoms who say that abstinence does not work are
both wrong. Data from developed and developing countries show
that programmes that incorporate abstinence, mutual monogamy,
delayed sexual intercourse, and condoms work together to reduce the
number of new HIV infections.' Programmes and messages that
truncate known public health measures are dishonest and cost human
lives.” .
"A notable impact on prevention cannot occur if large portions of the
population are left uneducated. There is not enough time to wait for
"trickle down" or "from the centre out" approaches to building
education and training infrastructure. One need only travel two hours
from major urban areas in developing countries to observe that HIV,
but not HIV education, has reached them."
"Many of the current educational tools focus on individuals with
moderate to high levels of literacy. Information about HIV and AIDS
is often not available to healthcare workers, teachers, and students,
46
or for that matter, to community, village, and religious leaders.
Currently available information must be translated and adapted to
diverse conditions, especially those that exist in rural areas. Because
of the low priority given to funding education and training it is not
surprising that so many individuals lack basic knowledge on how to
prevent HIV infection. Without education at all levels in the
community major reservoirs of HIV infection and transmission will
continue unabated.”
“Behaviour change does result in a decrease in new HIV infections
whether in rich countries such as the US and Europe or in poor
ones such as Uganda and Zambia.”
“However, without more extensive progress we are deluding ourselves
into thinking that the epidemic can be controlled. Behaviour change
must encompass all levels-governments, non-governmental
organisations, schools, religions, community leaders, and
individuals."
How can I tell my spouse ?
A man came one day with a history of fever of nearly one
month duration. He looked healthy and was in good
company. The routine blood tests were done and appropri
ate medicines were given. He came back a month later and
had similar complaints. This time a rapid HIV test was
carried out after counselling, and it was positive. Then he
shared his story. He was a driver and had been involved in
unprotected sex. As it was over a month since he went out
on his last trip he had arranged to go out again the follow
ing week. Being positive he was counselled to use condoms
with his wife. Immediately he responded, “How can I do
that ? My wife will suspect me. How can I tell my wife
that I am HIV positive ?” There are many like this driver.
Probably there are many more like his wife most likely in
nocently faithful. How can the spouses of high risk indi
viduals be educated and empowered to protect themselves ?
47
Bibliography
1
'Everyone's Problem’ in ‘What you Must Know About AIDS’,
The Week, Aug 19, 2001
2
UNAIDS website: www.unaids.org, 2001.
3
APAC “Community Prevalence of Sexually Transmitted Diseases
in Tamil Nadu: A Report”, APAC, 1998 Chennai, India.
4
COPE ‘The Four Principles of HIV Transmission' in ‘HIV/AIDS
Information and Resources', COPE, Adelaide, Australia 1998.
5
APAC ‘The Challenge of AIDS in South East Asian Countries'
Chapter 3 in ‘Health Education in South East Asia: Special Issue
on AIDS’, Chennai, 1998 ; 13 (4).
6
Hogle, J. Ph.D. (2002) ‘What Happened in Uganda? Declining
HIV Prevalence, Behavior Change, and the National Response.'
US Agency for International Development.
7
NACO “What You Must Know About AIDS", The Week, August,
2001, Malayala Manorama Press, Kottyam, India.
8
APAC “STD Syndromes", Chennai, India.
9
WHO “Living Positively with AIDS" Chapter 3 in “Handbook on
AIDS Homecare”, WHO, Delhi, India, 1996.
10
Chandy, G. “Hospital Infection Control Manual: CMC Hospi
tal" (2nd ed) Chummy, Vellore, India, 1999.
" Ammann AJ. Preventing HIV.
48
BMJ 2003;326:1342-1343.
Position: 2629 (2 views)