HIV/AIDS UPDATE (2 HOURS)
Course Description
“HIV/AIDS
Update” is a home study continuing education course for rehabilitation
professionals. This course presents
updated information about HIV/AIDS including sections on transmission,
symptomology, testing, treatment, behavioral management, and legal issues.
Course Rationale
This course
was designed to give the student information about advances being made in the
understanding of HIV/AIDS so that they may limit risk of accidental
occupational exposure and provide optimal care for those infected with HIV. This course also addresses many of the legal
issues that are associated with the care and treatment of individuals with HIV.
Course Objectives
After
completing the independent Home Study Program, the therapist/assistant will be
able to:
1. Understand the scope and impact of HIV/AIDS
worldwide.
2. Identify and differentiate the
transmission modes of HIV infection
3. List the signs and symptoms of HIV
infection and AIDS
4. Identify and differentiate between
commonly used screening and confirmatory tests
5. Recognize current treatment
recommendations for HIV infection
6. Recognize current prevention and
treatment strategies for opportunistic infections
7. Recognize and understand key social
intervention strategies
8. Identify available resources for
additional HIV/AIDS information
9. Understand and apply all of the laws
and statutes that pertain to the rights of individuals with HIV/AIDS, and to
their care and treatment.
Course Instructor
Michael
Niss PT
Method of Instruction
Text-based
online home study course
Target Audience
Physical
therapists, physical therapist assistants, occupational therapists, and
occupational therapist assistants
Course Educational Level
This course
is applicable for introductory learners.
Course Prerequisites
None
Continuing Education
Credits
Two (2)
hours of continuing education credit (2 NBCOT PDUs/2 contact hours)
AOTA - .2 AOTA CEU, Category 1: Domain of OT – Client Factors, Context
Category 3: Professional Issues – Legal, Legislative
Criteria for issuance of
Continuing Education Credits
A
documented score of 70% or greater on the written post-test.
Determination of Continuing
Education Credits
HIV/AIDS Update
will require at least 2 hours to complete.
This estimate is based on the accepted standard for home based
self-study courses of approximately 10-12 pages per hour. The complete text of
this course is 27 pages (excluding References and Post Test)
page
Goals and
Objectives 1 Start Hour 1
Course Outline 2
Overview 3-4
Scope
of the HIV/AIDS Pandemic 3
HIV/AIDS
in the Developing World 3
The
Future of the Epidemic 3-4
Access
to Treatment 4
Human
Immunodeficiency Virus (HIV) 4-5
Acquired
Immune Deficiency Syndrome (AIDS) 5
How HIV
Affects the Immune System 6
HIV
Transmission 6-8
Signs and
Symptoms 8-9
HIV 8
AIDS 8-9
HIV Testing 9-10
Rationale 9-10
Types of HIV
Tests 10-12
Screening Tests 10-11
Confirmatory Tests 11-12
Confidentiality 12 End of Hour 1
Pretest and
Posttest Counseling 12-14 Start
of Hour 2
Pretest Counseling 12-13
Posttest Counseling 13-14
Management
of HIV Infection 14-15
General Considerations 14
Ranges of Services Needed 15
Antiretroviral
Drugs 15-17
Treatment Regimens and Adherence 16-17
Preventing
and Treating Opportunistic Infections 17
Other
Management Issues 17-19
Nutrition 17-18
Alternative Therapies 18
End-of-Life Issues 18
Pregnant Women with HIV 18-19
Sexually Transmitted Infections 19
Key
Interventions and Strategies 19-21
Behavior Change Communication (
Voluntary HIV Counseling and
Testing 19-20
Community Interventions 21
Behavior
Change 21-23
“Stages of Change” Model 22
Risk Assessment 22-23
Future of
Prevention 23-24
Microbicides 23-24
Vaccines 24
Omnibus AIDS
Act 24-26
Resources 27
References 28
Post-Test 29-30 End of Hour 2
Overview
Scope of
the HIV/AIDS Pandemic
HIV infection and AIDS are among the most
pressing concerns facing health providers worldwide. Although the impact of
HIV/AIDS is serious in both developed and developing countries, it is most
profound in the developing world, where resources to prevent, diagnose, and
manage HIV infection are scarce.
The Joint United Nations Program on
HIV/AIDS (UNAIDS) estimates that more
than 40 million men, women, and children worldwide are now living with
HIV/AIDS, of which 28 million are in Sub-Saharan Africa. In this region, 1 in
10 adults ages 15 to 49 is living with the virus, and in seven countries more
than 20% of the population is infected. Women, especially young women, are
becoming infected at alarmingly increasing rates. A great many infected people
do not know they carry HIV and so may be spreading the virus to others
unknowingly.
This global epidemic is now far more
extensive than was predicted even a decade ago, and the challenges that HIV
poses vary enormously from region to region. Since the beginning of the
epidemic, AIDS has killed more than 21 million people, and it has replaced
malaria and tuberculosis as the world’s leading cause of death by infectious
disease among adults. AIDS is now the fourth leading cause of death among
adults worldwide, and more than 13 million children have been orphaned by the
epidemic.
A host of economic, political, social,
and cultural factors play a critical role in determining how quickly the
epidemic spreads within a particular region and whether communities and
countries are able to rally the resources needed to combat HIV/AIDS.
Africa, Asia, and Latin America lead the
world in HIV infection, with an estimated two-thirds of the world’s
infections occurring in Africa, followed by 20% in Asia and 4% in Latin America
and the
More than 21 million people have died from
AIDS. However, a staggering 40 million people are currently living with HIV,
and 5 million new infections are expected yearly.
The devastation of the epidemic has clearly
just begun. AIDS has already sharply reduced the rate of population growth in
some countries, and within a few years,
In more developed countries, recent advances
in treatment have dramatically changed the perspectives of those living with
HIV infection, of health workers, and of researchers. Many have now begun to
think of HIV infection as potentially treatable, rather than an automatic death
sentence.
However, most of those living in the
developing world lack access to treatment regimens that have proved effective
in extending lives and treating opportunistic infections, and the costs of such
treatments—which can exceed $10,000 per year—are well outside the reach of most
individuals infected with HIV. Even though there have been price reductions in
some developing countries, treatment is still out of reach for the vast
majority.
Lack of access to treatment has been the
cause of much recent global debate between public health activists and the
pharmaceutical companies that hold the patents to these drugs, and recent
events suggest that some measure of greater access may soon be achieved.
Although
lack of access to treatment regimens is only one of many complex factors
barring progress in the fight against HIV/AIDS in the developing world, many
see improved access as an important first step.
HIV is a member of a group of viruses called
retroviruses.
A retrovirus is a virus that changes itself very rapidly. One reason why HIV is
a particularly serious infection is that it attacks and destroys cells of the
immune
system—called T-cells or CD4 cells—that are designed to fight infections and diseases.
After HIV penetrates these cells, it reprograms the cell so that it begins to
produce many copies of the virus. Eventually, HIV destroys the immune cells.
Another reason why HIV is a very serious infection is that it has the ability
to mutate rapidly. This makes it especially difficult for researchers to find
an effective treatment or vaccine.
There are two types of HIV. HIV-1 is
responsible for the vast majority of infection and cases of AIDS in the world.
HIV-2 is the more common type in
From the time a person is infected with HIV,
the virus begins to damage the immune system. Although an infected person’s
immune system struggles to fight back—and can do so for as many as 10 years or
more in an otherwise healthy adult—the virus continues to destroy these
defenses until the immune system is too weak to fight off infections.
A
person can be infected with HIV and not know it, because any symptoms or
illnesses related to HIV may not occur for many years after infection. Most
people lead healthy and productive lives after HIV infection—in fact, many
people are not aware they are infected because they feel fine. Unfortunately,
even if the infected person feels fine, he or she can pass the infection on to
others.
AIDS is advanced HIV infection—it is the
late stage of the infection, when the immune system is weakened. Advanced
infection with HIV weakens the immune system to the point that it cannot fight
off infections as effectively as usual. The individual becomes more susceptible
to a variety of opportunistic infections and other conditions (e.g., cancer).
Some examples of opportunistic infections include chronic cryptosporida
diarrhea, cytomegalovirus eye infection, mycobacterium avium complex,
pneumocystis pneumonia, and toxoplasmosis. Other AIDS-associated conditions
include invasive cervical cancer, Kaposi’s sarcoma, and lymphoma.
Persons
living with AIDS often have multiple infections, neurological disorders,
extreme weight loss, diarrhea, and cancers. Although an infected person
generally dies as a result of complications of these infections, conditions,
and malignancies, living with AIDS is like living with other chronic diseases:
sometimes the person feels sick, and at other times he or she feels fine and
can go about normal activities.
No one dies from AIDS or HIV; rather, a person with AIDS dies from an infection
or condition that his or her weakened immune system can no longer fight off.
In the
HIV is a retrovirus, a type of virus that stores
its genetic information on a single-stranded
HIV infects one particular type of immune
system cell, called CD4 cells (or T-cells). T-cells coordinate immune regulation and secrete
specialized factors that activate other white blood cells to fight off
infection. In healthy individuals, the number of CD4 cells normally ranges from
450 to 1,200 cells per microliter of blood (T-cell count).
When infected with HIV, a T-cell becomes an
HIV-replicating cell. In other words, the virus binds with the cell, copies
itself into the cell’s
An infected person’s body
tries to fight off HIV infection by aggressively manufacturing antibodies.
It is particularly difficult for the immune
system to fight off HIV infection for a number of reasons, including the
following:
HIV
is spread through three main modes. These modes of transmission are as a result
of exposure to body fluids (blood, semen, vaginal fluids, and breast milk) of
infected individuals. Specifically, HIV can be transmitted through:
1. Sexual contact:
2. Blood contact:
3. Mother-to-child transmission (
Although
any exposure through one of these methods can lead to HIV infection, not every
exposure results in transmission of the infection.
Many
myths exist about how HIV is transmitted, and many myths are culturally
specific. It is important that people realize that HIV is actually quite
difficult to transmit. For example, it is far less transmissible than hepatitis
B or some other STIs.
HIV is NOT transmitted through:
In addition, HIV is not transmitted through
tears, sweat, saliva, vomit, feces, or urine. Although these substances can
contain HIV, they do not contain the virus in amounts significant enough to
cause infection. Extensive, continuing studies of new HIV infections over the
last 20 years in many countries have not uncovered any cases of infection
through these substances. To date, there is no documentation of HIV
transmission through these substances. Blood, semen, vaginal secretions, and
breast milk are the only body fluids through which HIV transmission has been
documented.
It
is theoretically possible to transmit the virus through deep kissing if the
gums have open sores or are bleeding, but this is highly unlikely. Even so,
transmission in this case would be through blood rather than through saliva.
HIV Infection
During
the early and middle stages of HIV infection, most people have no symptoms
at all. Immediately after infection, some people may develop mild, temporary
flu-like symptoms or persistent swollen lymph nodes.
As the infection progresses, those infected
may begin to develop more symptoms and to experience feelings of decreased
energy. These subtle symptoms may be easily attributed to systemic infections,
such as tuberculosis, or to other conditions common to people living in poverty
in low-resource settings.
Some of the symptoms that people with HIV
may have include:
AIDS is late-stage HIV infection. In
addition to the signs and symptoms of HIV infection described above, a person
with AIDS generally loses weight (wasting syndrome) and becomes ill with
opportunistic infections such as chronic cryptosporida diarrhea,
cytomegalovirus eye infection, mycobacterium avium complex, pneumocystis
pneumonia, and toxoplasmosis. Other AIDS-associated conditions include
invasive cervical cancer, Kaposi’s sarcoma, and lymphoma.
The
U.S. Centers for Disease Control and Prevention (CDC) defines someone as having
AIDS if he or she has any one of a number of conditions indicating severe
immunosuppression, or HIV infection in an individual with a CD4 (T-cell) count
less than 200 cells per microliter (less than half of what is considered to be
the bottom of the normal range).
The most frequently used HIV tests detect
the presence of antibodies to HIV, not the actual virus itself. A positive HIV
antibody test indicates the presence of antibodies to the virus. A negative
test result indicates either no antibodies or an undetectable level of
antibodies to the virus. It is possible that these tests can miss infection in
a person who was recently infected with HIV and has not yet developed enough
antibodies to show a positive result.
The period of time from infection with HIV
until the body has developed detectable antibody levels is called the window period.
The window period is approximately three months on average. A person who is
worried that he or she may have been exposed to infection should be encouraged
to seek testing, and the counselor should explain that if the test comes back
negative, it should be repeated after three months to confirm the result
because the person could have been infected but still may be in the window
period. During this period, a person may not test positive even if he or she is
infected with HIV.
HIV testing should always be done
voluntarily and never mandated or coerced. If people have a desire to know
whether or not they are infected, they have a right to know. It is strongly
recommended that clients be counseled both before and after testing. Where
testing is readily available, a person who thinks he or she might have been
exposed to HIV should consider being tested for a number of reasons:
HIV
counseling and testing can be important decision-making tools for clients and
service providers and can help even uninfected clients understand their risk
for HIV. In addition, testing enables health care providers to offer
information to infected clients about living with HIV infection and assist them
in obtaining any available support services, including treatment, emotional and
practical support, prevention of
There are two broad categories of HIV tests:
screening tests and confirmatory tests. Using these two
types of test together can lead to highly accurate and reliable diagnosis of
HIV infection.
Screening tests are used for initial testing
because they are easier to perform than confirmatory tests, well suited to
testing large numbers of samples, and less costly. They are highly sensitive
and result in few false negatives (i.e., most infected people test positive).
However, screening tests are not as specific as confirmatory tests, so in a
small percentage of cases the test result will be positive even if the person
is not infected. Therefore, providers should never give results from screening
tests that have not been verified through a confirmatory test.
The
most common screening tests are enzyme-linked immunosorbent assay (ELISA)
tests. These tests measure antibodies to HIV. Different types of ELISA tests
are available. Most require serum specimens, though one uses urine and another
uses an oral specimen.
Serum tests. Traditional screening tests use a blood sample. About
two dozen types of ELISA tests are in use around the world.
Urine tests. An ELISA test for detecting HIV in urine samples has
been approved for use in the U.S.; however, its biggest drawback is that there
is no approved confirmatory test for urine samples (in other words, if the
urine ELISA results are positive, a blood sample must then be drawn for
confirmatory testing).
Oral tests. OraSure is an
HIV test that uses mucosal transudate as the sample. (Although some call this a
saliva test, the sample is not saliva, but an oral sample called mucosal
transudate.) The sample is collected by placing the special collection device
between the cheek and gum. The specimen is then sent to a lab for ELISA testing.
Positive ELISA results can be confirmed using the Western blot test. These
tests are more expensive than blood tests. OraScreen, a similar test marketed
for home use, is available in some countries, but it is not approved for use in
the
Rapid
serologic tests provide results in less than 30 minutes. These tests also
measure antibodies to HIV, but by different mechanisms than ELISA tests,
including agglutination tests, immunocomb tests, immunodot tests, and
immunochromatographic membrane tests. Most rapid tests are kits that include
all of the necessary supplies. These tests are relatively simple, involve a
limited number of steps, and are quite accurate when performed correctly. (Most
rapid tests require refrigeration.) While the inherent sensitivity and
specificity of ELISA tests may be greater than those of some of the rapid
tests, the field performance of rapid tests is often as good as or better than
the ELISA because the former is simpler and easier to do in a low-resource setting.
One rapid HIV test is approved for use in the
HIV
Dipstick Test Kit. This is a rapid
(results in approximately 20 minutes), inexpensive (less than $0.50/test) test
that requires no specialized equipment. Sensitivity is more than 99%, and
specificity is more than 98%. The dipsticks are licensed in many countries
around the world and are currently being produced in
A confirmatory test is done when the results
of a screening test are positive. The confirmatory test is expensive and labor
intensive and requires subjective interpretation, but it is very specific (in
other words, false-positive results are extremely rare). The Western blot test is considered by
most to be the “gold standard” for confirmation of positive screening test
results. This test also measures antibodies to HIV, but it is more specific
than screening tests and false positives are minimal. Another, less commonly
used confirmatory test is the immunofluoresence assay (IFA). Positive results
from ELISA or rapid tests are commonly confirmed using a Western blot.
Other
testing strategies besides a screening test followed by a confirmatory test
have been proposed by the WHO and UNAIDS for use in low-resource settings where
the Western blot may not be readily available or affordable. These strategies
include using a combination of two screening tests (ELISA or rapid tests)
without using the Western blot. Studies have shown that the use of two
screening tests together can give results similar to, or in some cases better
than, the use of a screening test followed by a confirmatory test, at a much
lower cost. It is important to note that results will vary depending on the
combination of screening tests used, so it is necessary to evaluate the
intended combination before undertaking widespread implementation.
In addition, there are concerns about
maintaining confidentiality of test results, in part because of the stigma
attached to HIV infection in many settings and the potential for discrimination
against, violence toward, and community rejection of individuals who test
positive. Also, coercion into test taking is a concern in some settings. That
is why testing must always be voluntary and based on the informed consent of
clients. As such, counseling is an integral component of testing.
It
is essential to prevent the exposure of personal information regarding clients’
test results (or even that fact that they had an HIV test) to unauthorized
persons. Private client information must not be made accessible to other
clients or community members through careless record storage, lack of private
space for confidential counseling, or inappropriate discussion of client
information inside or outside the clinic setting.
All individuals who are tested for HIV
should have access to a counseling and education session before the test is
done, and then again once the test results are available.
Pretest counseling provides an opportunity
for counselors and clients to talk about the HIV testing process, the meaning
of positive and negative test results, the client’s potential risks, ways to
reduce risk, and the client’s intended plan of action once he or she has
received the test results.
Pretest counseling should not focus on
getting the client to admit to various behaviors, which may be considered
socially unacceptable or which he or she may feel uncomfortable discussing. The
keys to HIV counseling are to discuss all of the behaviors that may increase
the risk of HIV infection in a client-centered, nonjudgmental way, as well as
to discuss ways to reduce risk.
Pretest counseling and education will help
both the health care provider and the client assess the client’s understanding
of HIV/AIDS, testing, modes of transmission and prevention, along with his or
her ability to handle the results.
In addition, counselors should attempt to
work with clients to develop personalized HIV risk-reduction plans, focusing on
realistic, incremental steps toward behavior change.
It is important to note that before taking
an HIV test, a client should be aware that if the result is positive, he or she
will have an illness that carries a social stigma. In some settings, people
with HIV have been thrown out of their homes, fired from jobs, victimized in
their community, and physically assaulted. Clients need to think through these
possible problems before they decide to be tested.
All individuals who are tested for HIV
antibodies should have access to a posttest counseling and education session at
the time they are given the test results. This session will help both the
health care provider and the client assess the client’s understanding of the
results of this test. Test results should be given as soon as possible so that
the client has time to absorb this information. When giving negative test
results, remind clients that the results may not be accurate if the client has
engaged in behaviors that put him or her at risk during the three months before
testing or since the test was done. If appropriate, clients should be offered a
repeat test at an appropriate time in the future.
When disclosing a negative test result, the
counselor should explain what the test result means, answer any questions,
address the client’s emotional response, and discuss strategies for remaining
HIV-negative. This could include further discussion of the client’s
risk-reduction plan.
Recognizing
Clients’ Anxieties
Most clients who test positive for HIV are likely to have a high degree of
anxiety, even before learning of the diagnosis. Many people at high risk for
infection have friends or acquaintances who are currently living with HIV
infection or who have already died from AIDS, and many may have misperceptions
about the facts of HIV infection. Even clients who already have a good level of
information about HIV infection in general will require personalized
information about the infection regarding the specifics of their own individual
case.
While giving information, health care
providers should be aware that the anxiety and emotion that accompany a positive
result are likely to have a profound effect on the client, and the client may
need some time to come to terms with the results before being able to deal with
more detailed information. For many clients, it might be more appropriate to
wait for a little while to discuss treatment options, perhaps with the
supportive presence of a friend or family member.
Talking
About Clients’ Prognoses
When discussing HIV infection with newly diagnosed clients, health care
providers must walk a very thin line between the clients’ simultaneous needs
for honesty, factual information, practical information, advice, and hope for
the future.
Many clients are likely to ask difficult
questions, such as “How long will I live?” after learning of the diagnosis.
Honesty and realism are essential tools for health care providers when
discussing a client’s prognosis, but a realistic optimism should be applied
whenever appropriate.
While
recognizing the seriousness of the diagnosis, providers should avoid
speculating about a client’s survival time, stressing that each individual case
is different and that strategies to extend survival and new treatment therapies
are being developed and tested at a rapid pace; however, this may offer little
comfort in settings where treatment options are not readily available.
In general, the needs of HIV-infected
clients and their families can be categorized into four overlapping areas:
Because HIV infection is both chronic and
progressive, most medical management is provided by the client’s primary care
physician on an outpatient basis, particularly during the long asymptomatic
stage of the infection.
In addition to any available drug therapies,
clients living with HIV/AIDS need a host of clinical services. For example,
children with HIV/AIDS require routine medical care and immunizations, and
women with HIV/AIDS may require specialized contraceptive and prenatal
counseling and services.
Aside from clinical care, though, health
care workers should be aware that clients living with HIV require a wide range
of services, and that infected clients also often face difficult psychosocial
issues, including a high incidence of depression. Health care providers need an
understanding of the social, economic, psychological, behavioral, and
philosophic factors that affect management of the infection and should consider
all aspects of a client’s life when making management and drug recommendations.
Because clients often need assistance in
terms of housing, food, child care, and other social services, optimal
management of the infection should include thoughtful counseling, close
cooperation with family members and friends, and referral for additional
medical and non-medical services, as available.
The most urgent management goal for health
care providers working with HIV-infected clients is counseling to prevent
further transmission of the infection, treatment of any conditions that require
immediate attention, and the use of a nonjudgmental approach to encourage
clients to remain within the health care system for follow-up.
Clients with HIV infection often experience
shame or social stigma either because of the infection itself or because of risk
behaviors leading to infection. In addition, some clients may have experienced
biases or had negative interactions within the health care system.
Health
care programs need to address such stigma and discrimination against people
with HIV/AIDS. Staff in health care facilities can benefit from training that
addresses the needs and human rights of those affected by HIV and that
emphasizes clients’ rights to privacy, confidentiality, dignity, and services
free of discrimination and judgment. Staff can also have their fears about
occupational exposure to HIV addressed through training in standard
precautions. Procedures can also be put in place to ensure clients’ rights and
confidentiality.
Antiretroviral drugs are the
most effective intervention to date in managing HIV infection. These drugs have
the potential to dramatically improve the health and extend the lives of many
people living with HIV/AIDS.
Antiretroviral drugs work by interfering
with HIV’s life cycle and its ability to reproduce. This group of drugs
includes reverse
transcriptase inhibitors, which work by neutralizing an enzyme HIV needs
at the beginning of its life cycle, and protease inhibitors, which
neutralize an enzyme HIV needs near the end of its life cycle.
The goals of antiretroviral drugs are to
prolong the health and life of HIV-infected clients, improve the symptoms of
HIV infection, improve immune function, and suppress the replication and
mutation of HIV.
In developed countries, combination
therapy, in which several antiretroviral drugs (usually
three or more) are used together, has been credited with the decline in the
number of HIV infections that progress to AIDS and the number of AIDS-related
deaths. Studies have shown a dramatic reduction in the viral load (level of
virus in the blood) through combining various antiretroviral drugs.
Protease inhibitors may eventually prove to
be more effective than reverse transcriptase inhibitors, or the two together
may prove to fight HIV in ways that either alone does not. The protease inhibitors seem less toxic than
reverse transcriptase inhibitors and reduce the level of HIV in the blood to a
greater degree than reverse transcriptase inhibitors.
Both
the client and the provider should agree on an approach to drug therapy, and
health providers should discuss the risks and benefits of any available
treatment options.
Treatment regimens may be difficult for
clients to follow. Antiretroviral drugs can cause a number of side effects that
clients need to learn to deal with or can require clients to switch to other
drugs if the side effects are too severe. In addition, combination therapy
requires taking a large number of pills on a complicated schedule.
Different clients may have
widely different views about taking these drugs. For example, some clients may
be skeptical about taking drugs with potentially significant side effects,
while others may request the most aggressive therapies possible. In addition,
it is difficult to predict whether clients will be willing or able to adhere to
a complicated schedule of medication.
Adherence to a drug regimen—taking every
dose of the prescribed drug(s) when and how it is prescribed—is critical to the
success of treatment; missing even a single dose can compromise suppression
efforts or contribute to the development of resistant strains of HIV. Effective
treatment requires health care providers to design therapy with individual
adherence in mind.
Because
of the long-term consequences of the development of drug-resistant HIV strains,
the initial therapy tried should be considered “the best shot” at the virus. To
maximize the possibility of success, clients should undertake a treatment
regimen only after they are fully committed to it and ready for treatment and
are assured adequate supplies of medication.
Where available, preventive therapies and
treatment of opportunistic infections can help prevent opportunistic
infections, reduce mortality, slow the progress of HIV infection, and ease
painful symptoms.
Therapies to prevent some of the most common
opportunistic infections are shown in the following table:
|
Opportunistic Infection |
Preventive therapy |
|
Pneumocystic carinii
pneumonia |
Trimethoprim-sulfamethoxazole
(Co-trimoxazole) |
|
Tuberculosis (TB) |
Isoniazid |
|
Toxoplasmosis |
Trimethoprim-sulfamethoxazole
(Co-trimoxazole) |
|
Mycobacterium avium
complex ( |
Azithromycin |
Unfortunately,
in many low-resource settings facilities for diagnosis are inadequate and drug
supplies are erratic, even for those opportunistic infections that are easy to
diagnose and less costly to treat. Access to treatment for clients in these
settings will remain compromised until drugs and diagnostic equipment are
accessible and countries can afford to equip their health systems with the
necessary infrastructure and well-trained
staff.
Nutrition is an important issue for
HIV-infected persons, who are particularly vulnerable to malnutrition and
weight loss. Infected individuals may require an extremely high caloric intake
to maintain weight, and drugs and conditions affecting the gastrointestinal
tract can result in severe weight loss due to nausea, vomiting, or
malabsorption. In addition, HIV-infected clients may experience loss of
appetite or may be too sick or lack adequate income or resources to obtain
food.
Those at risk for opportunistic infections
should avoid eating raw foods, which might contain bacteria or other microbes
that could make them sick. However, there is little evidence that highly
specialized diets, such as a macrobiotic diet, have any beneficial effect.
Many people with HIV use some kind of
alternative or complementary therapy, such as herbs, acupuncture, megavitamins,
or other therapies that are purported to strengthen the immune system. Some
alternative therapies may be beneficial, some can be dangerous, and others may
be safe but ineffective.
It is important to take a nonjudgmental
approach to the use of these types of treatments, so long as they are not
harmful to clients. Knowing about nonprescription treatments enables providers
to assess the possibility of side effects from these treatments and potential
drug interactions.
Clients often wish to discuss issues
regarding death and dying after diagnosis with HIV infection or during
management and treatment. Although these topics might be difficult for health
care providers to discuss, it is important to listen and respond to clients
honestly.
Because of the progressive and terminal
nature of HIV infection, clients should be encouraged to consider issues
regarding loss of income, the likelihood of increased incapacitation, care of
children and other dependents, and decisions regarding the level of care they
would want to receive in case of terminal illness or respiratory arrest.
Although health care providers should be
realistic and not overly optimistic when discussing a client’s probable life
span, it is equally important and reasonable to hope that research findings,
new developments, improved access to treatment, and other factors will enable
some currently infected people to live out their normal life spans.
The majority of cases of mother-to-child
transmission, (also called vertical transmission or maternal-fetal transmission and, more
recently, parent-to-child
transmission) appear to occur during labor and delivery. This may take
place, for example, during contact with infected secretions, including blood
from the mother’s genital tract during labor and delivery.
It is important to know the mother’s HIV
status during pregnancy in order to begin employing risk-reduction therapies as
quickly as possible. These include prophylactic treatment of opportunistic
infections and antiretroviral therapy both for the mother during pregnancy and
for the child postpartum in settings where these treatments are available.
Since
the presence of other STIs can increase susceptibility to HIV infection, as
well as hasten the development of AIDS, efforts to diagnose and treat curable
STIs have become a major strategy in combating the HIV epidemic. Although
ulcerative STIs (e.g., syphilis, herpes) can most readily facilitate HIV
transmission, other STIs have been shown to do so as well.
Behavior change communication involves
efforts to assist individuals to change high-risk behaviors and to educate
communities to support long-term change.
Voluntary counseling and testing (VCT) is a
combination of two activities — counseling and testing—into a single service
that can amplify the benefits of both. In its ideal form, VCT can be used as a
form of prevention rather than strictly for diagnostic purposes, or to
facilitate entry into HIV care services.
The “gold standard” for VCT incorporates
pretest counseling and posttest counseling. Helping clients understand and
perceive their own risk (and the risks that their behavior may pose to others)
and reduce that risk, are integral components of VCT counseling.
VCT is an important entry point to other
HIV/AIDS services, which can benefit clients with positive or negative results.
When it is well implemented, VCT services offer the possibility of benefiting
the community by “normalizing” the existence of HIV/AIDS, thereby reducing
stigma and promoting awareness..
VCT
is an essential component of prevention of
There has been debate concerning the
effectiveness of voluntary counseling and testing (VCT) as a strategy for HIV
prevention. In theory, if a person tests negative, an opportunity exists to
counsel him or her about primary prevention (how he or she can remain
uninfected). If a person tests positive, an opportunity exists for secondary
prevention (how he or she can prevent transmission to others). The relationship
between knowledge of HIV status and changes in risk behaviors—in particular
decreases in such behaviors by people who know they are infected with HIV—is
unclear. Study results vary, with some finding significant decreases in risk
behaviors in those who knew they were HIV-positive, and others not. While it is
clear that some individuals do reduce risks after knowledge of a positive HIV
test, it is also clear that others do not. Similar results have been seen in people
who tested negative. Ongoing counseling and testing (in other words, repeatedly
over time) appears to have a greater impact on reduction of risk behaviors than
one-time counseling and testing.
Access to affordable treatment is an
important ethical and programmatic concern that must be taken into account when
testing services are established. Testing is now being actively encouraged in
the developed world, where effective medications for the treatment of HIV and
opportunistic infections are more readily available and early treatment is
often feasible.
In developing countries, despite lower
levels of access to treatment, VCT is receiving increasing support since it can
be an important entry point for accessing care as well as prevention. On the
community level, when prevention and care are offered together as a part of a
“prevention-to-care continuum,” they work synergistically. They improve
community acceptance, reduce the stigma of HIV/AIDS, and encourage HIV-infected
people to practice preventive behaviors and seek care and support.
VCT is also recognized as an essential
component of care for pregnant women in order to determine options for
prevention of mother-to-child transmission (
Although the term “community interventions”
can include many different types of approaches, interventions that seek to
shift social norms or mobilize communities for action are recognized as key
strategies in confronting the HIV epidemic. For example, such efforts might
include reaching out to individuals in their homes or gathering places with
information and education; organizing community educational events (through,
for example, theater or sporting events); working with religious organizations
and leaders, as well as with traditional healers; working with young people in
schools, as well as with out-of-school youth; or integrating
It is important that people already infected
with HIV help prevent the spread of the infection through such practices as
safer sex and safer drug use. Not only do infected people run the risk for
infecting others, but they are also at risk for contracting other, and possibly
more virulent, strains of the virus, as well as other illnesses which are
transmitted sexually (i.e., syphilis) or through shared drug equipment (i.e.,
hepatitis B and C).
Because
no cure for HIV/AIDS is available, the only way to prevent HIV infection is to
avoid behaviors that put a person at risk. Many people infected with HIV have
no symptoms, and, therefore, there is no way of knowing with certainty whether
a sexual partner is not infected unless he or she has repeatedly tested
negative for the virus—and has not engaged in any risky behavior between tests.
A variety of related and overlapping
behavior change theories and paradigms have been used to inform the development
of prevention programs and interventions. In general, these theories and
paradigms recognize the complexity of human behavior and the myriad
psychological, sociocultural, and structural factors that play a role. More
recently, increased attention has been given to the idea of looking beyond
individual behaviors to the contextual factors that make people vulnerable to
In
Sexual behavior, however, is not easy to
change. Simply telling clients that certain behaviors put them at risk for STIs
or HIV is generally insufficient. For example, a person must know which
practices can put an individual at risk (knowledge), must believe that “people
like him or her” can be at risk (attitude), and must believe that he or she is
at risk (attitude) before that person can take action to change his or her own
behavior (practice). Interventions must be in place to address all three
levels, and people must know what to do to protect themselves, must feel that
they have the ability to effect change, and must have the skills and resources
to do so. Most important, people must have willing partners and a supportive
environment.
A variety of theoretical models examine the
factors that contribute to behavior change. One such model is the “stages of
change” model.
This model suggests that individuals or
groups pass through six stages when changing behavior: pre-contemplation,
contemplation, preparation, action, maintenance, and relapse. For example, when
people change their behavior, the stages they pass through could be described
as:
These stages are not linear; people tend to
move back and forth fluidly between stages, and relapse to a prior stage is
always possible. In fact, people can relapse to any stage, but a return to pre-contemplation
is least likely. It is important to remember that changing behaviors,
especially intimate and private behaviors, is a complex process.
Risk
Assessment
Risk assessment is a strategy used within
individual counseling as part of the behavior change process. During risk assessment, health care workers
use a client’s responses to questions about the client’s behaviors and partners
in order to gauge the client’s risk for HIV infection.
Questions about risk often focus on, for
example:
Risk assessment is sometimes done using a
brief checklist, which is more appropriate for screening purposes than behavior
change purposes. It can also be done by providing the client with information
about risks in general, and asking the client to self-assess whether or not he
or she is at risk without revealing specific information. This approach is
often used where it is deemed culturally inappropriate to probe for more
specific information about sexual practices and partnerships. Another approach
is for a counselor or provider to encourage a client to discuss his or her
specific practices and circumstances as part of an interactive, exploratory
counseling process. This approach is likely to be more effective in assisting a
client to perceive his or her risk for infection than the former.
Many people have
difficulty perceiving their own risk for infection, even if they know, in
general, what places a person at risk. When a counselor or provider understands
the individual risks of a client, he or she can apply information to that
client’s particular circumstances, which makes the risks more apparent and
assists in improving risk perception.
Since many women’s risk derives primarily
from their partners’ behaviors rather than their own, and the fact that the
major current strategies for HIV prevention—partner reduction, monogamy, condom
use, and treatment of STIs—are not feasible for many women, there has been a
growing call for the development of a means of protection against HIV that
women can control.
In response to this need, research is currently being conducted into the development of microbicides, products that can be used vaginally (and possibly rectally) to prevent transmission of HIV and, potentially, other STIs, by blocking transmission or killing the pathogen. Over the past 10 years, significant