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AIDS or The Acquired Immuno Deficiency Syndrome is a cluster of symptoms. It is a condition first described in the early 1980's, caused by a virus, the Human Immunodeficiency Virus (HIV). It is characterized by extreme immuno suppression with diverse clinical features including:
* Opportunistic Infections
* Malignancies
* Central Nervous System (CNS) Degeneration

HIV primarily infects and destroys CD4 expressing T cells, including helper T cells and macrophages, (CD4 stands for "cluster of differentiation" and refers to a specific membrane protein expressed on the cell surface). Since T cells play a vital role in directing the body's immune response, the immune system is disabled, leaving the person vulnerable to various infections and diseases. As AIDS progresses, the body becomes less and less capable of fending off serious diseases that are normally held in check by a healthy immune system, hence they are dubbed opportunistic diseases. AIDS itself does not kill but eventually the person succumbs to one or more of these opportunistic diseases or infections.

1981: Epidemic of Pneumocystis carinii infection In 1981, doctors in Los Angeles (USA) reported a small epidemic of an unusual kind of pneumonia - puenmocystis carinii pneumonia – in apparently healthy young men. Pneumocystis carinii is a protozoon, which does not usually cause disease, but which can be an opportunistic infection.
Before 1981, Pneumocystis carinii infection was seen mainly in patients taking immuno-supressant or cytotoxic drugs. The young men with Pneumocystis carinii infection also suffered from opportunistic infections.

1981: Epidemic of Kaposi’s sarcoma. At the same time, doctors in New York diagnosed severe Koposi’s sarcoma in several young men. Kaposi’s sarcoma is an uncommon vascular neoplasm, which also occurs in people with impaired immunity.

Search for the cause of the decreased immunity. Researchers found that the young men were all homosexuals who had many sexual partners. They had a high incidence of STI’s, including gonorrhoea, cytomegalovirus and herpes virus. Cytomegalovirus and herpes virus infection both depress immunity. Many of them used a volatile drug called amyl nitrate as a stimulant. Amyl nitrate depresses the immune system. Homosexuals with many partners are exposed to an antigen overload from the semen of their partners. At first, researchers thought that a combination of these factors caused the severe decrease in immunity.

Appearance of AIDS in other groups: Next, people who were not homosexuals developed AIDS. Most of them were haemophiliacs and intravenous drug abusers. Epidemiologists realized that an infection agent that spreads in body fluid must cause AIDS.
1982: Case definition In 19982 the US Centre for Disease Control (CDC) established an AIDS case definition, and began formal surveillance of the disease.

1983: Isolation of virus: The virus was first isolated from the blood of AIDS patients in 1983 by Montagnier in France. He called it the Lymphadenopathy Associated Virus, or LAV. In 1984, a virus was isolated by Gallo and colleagues in America. They called the Human T-call Lymphotrophic virus 111, or HTLV 111. We know that LAV and HTLV 111 are the same virus. In May 1986, the International committee on Taxonomy of Viruses renamed the virus Human Immunodeficiency Virus, or HIV. Since the discovery of HIV-2, HIV is often called HIV-1

1985: ELISA Blood Test: In 1985, a blood test to detect antibodies to HIV was developed, called the ELISA (Enzyme-Linked ImmunoSorbent Assay) test. The test is now available commercially.
The first cases of AIDS: To identify AIDS cases retrospectively doctors can examine old medical records and test old frozen blood samples for HIV antibodies. The earliest retrospectively identified cases of AIDS occurred in the 1960s.

History of AIDS in Africa: The first cities in Africa where doctors recognized an epidemic of AIDS were Kigali, in Rwanda and Kinshasha, in DRC (Former Zaire). Cryptococcal meningitis is a common opportunistic infection in patients in DRC. In 1982, in Rikai, South West Uganda, the first patients with enteropathic AIDS or slim disease was diagnosed. In 1983, AIDS appeared as an epidemic in Zambia. The incidence of kaposi’s sarcoma and enteropathic AIDS has increased.

1987: HIV-2 In 1987 French workers identified another retrovirus, HIV-2, in AIDS patients and healthy people in West Africa. Researchers find HIV-2 infection more commonly in west Africa than HIV-1. It is not clear whether HIV-2 is a single virus, or whether there are a number of related retroviruses. A few cases of HIV-2 infection have also been detected in Europe countries and the US. Researchers believe that HIV-2 can also cause AIDS, but that the time from infection to clinical disease is much longer than for HIV-1. Researchers believe that HIV-2 has been present for a long time in West Africa because the prevalence of seropositivity in Guinea Bissau, West Africa is high in older people.

Recent research at the Centres for Disease Control (CDC) in the United States has added weight to the mass evidence that blood-feeding insects do not transmit HIV.

Although scientific and epidemiological evidence has been available for several years, the public still expresses concern that blood-feeding insects could pass the virus from an infected person to an uninfected one. After all, mosquitoes spread other diseases such as yellow fever and malaria, and what about bedbugs? Insects also transmit retroviruses other than HIV, including equine infectious anemia virus and bovine leukemia virus.

Blood-feeding insects can transmit infections by many routes. In the case of malaria, the disease-causing organism, plasmodium, is sucked up in blood by the mosquito, reproduces in the insect’s gut and then migrates from the gut wall into the salivary glands. From there it is passed into another person when the mosquito injects saliva as a prelude to feeding.

HIV has been shown NOT to multiply in mosquito cells. Neither does it pass from the gut to the salivary glands. Without such migration, no exchange of contents can occur between the gut and salivary glands, which are completely separate inside a mosquito’s body. Thus HIV cannot be injected into another person through saliva.

In the case of bed bugs, the bug excretes the organism causing Chagas’ disease, Trypanosoma cruzi, after a blood meal. The parasite infects another person through minute holes in the skin. The CDC researchers examined the potential of bedbugs to transmit HIV. After feeding bedbugs on blood containing very large amounts of HIV, they were able to detect the virus in the blood after three to eight days. However, HIV was never detected in big faeces. Further evidence that insects cannot transmit HIV comes from calculations concerning the amount of infected blood that would have to be transmitted to results in infection. When HIV transmission occurs during sexual intercourse, transfusion of contaminated blood or sharing needles, it does so because a sufficient does of the virus is transmitted. One virus alone would be insufficient to cause infection. Researchers believe that at least 0.1 ml of blood is probably needed to produce infection. Calculations show that even if the entire contents of the bug’s mouth-parts and food channel were transferred to a second person after feeding on a subject with 10 infectious doses of HIV in each millilitre of blood, then about 1,400 infected bugs would have to bite to transfer one infectious does of virus.

You need to know that the AIDS virus is present in sexual secretions, including vaginal secretions of a woman and the semen (in both the pre-ejaculation, or “cum”) of a man. This means that taking the partner’s sexual secretions into the mouth can pose a risk of infection. It is strongly advisable to carry out oral sex only with some kind of protection. You should use a condom on the erect penis, and place a thin rubber sheet or “dam” over the woman’s genitals.

The AIDS virus is not found in the saliva of the mouth under normal conditions. So, when two healthy people kiss, or even kiss without touching or inserting the tongue deeply into the other person’s mouth, there should not be any significant risk. However, everyone has times when there is bleeding from the gums or a small ulcer in the mouth. Some people have this almost all the time. If this is true for both individuals who are kissing, and if there is any exchange of blood between the two mouths, there is a potential risk that the virus could pass from one person to the next. Obviously, the risk would be higher in “wet” kissing. It is not possible to know exactly how important this risk is.Q. What is the use of knowing whether or not I am infected?
It may take a great deal of courage to go and get the answer to this question. But it will permit you to get full and proper medical care should you be infected. By taking extra care, people with HIV infection can live for many years. If you are infected, you can find out what to do to stay as healthy as possible for as long as possible. For example, it is very important not to get another Sexually Transmitted Disease (STD), or expose yourself to other types of infection. There are two other reasons why it is important to know if you are infected. First, if you are infected with HIV and have sex with other people, there is a great risk you could transmit the virus to them. In this situation, you need to prevent passing on the virus to others. You need to be sure that the infection stops with you.

Since 1992, scientist has estimated that about half the people with HIV develop AIDS within 10 years after becoming infected. This time varies greatly from person to person and can depend on many factors, including a person’s health status and their health-related behaviours. Today there are medical treatments that can slow down the rate at which HIV weakens the immune system. There are other treatments that can prevent or cure some of the illnesses associated with AIDS, though the treatments do not cure AIDS itself. As with other disease, early detection offers more options for treatment and preventive health care.

The test for HIV is called an HIV antibody test. Antibodies are the body's response to an infection. Antibodies normally begin to appear in your blood a few weeks after you become infected with HIV.

The HIV antibody test detects the presence of antibodies to HIV in the blood or saliva. It is easier and cheaper to detect antibodies to HIV rather than to look for the virus itself.

Even if you're found to be HIV antibody positive, this doesn't predict which HIV–related conditions may or may not develop. All it tells you is whether there are HIV antibodies in your blood. It is not a test for AIDS.

HIV (or Human Immunodeficiency Virus) is the virus that can cause AIDS. But not everyone with HIV infection has developed AIDS. In fact, we know that after being infected for ten years, about one in three people still don't have any symptoms of AIDS.

However, without treatment, two–thirds of adults infected with HIV are likely to develop AIDS within ten years of being exposed to HIV. In countries where people are exposed to tuberculosis and parasitic diseases such as malaria, this period is likely to be shorter. It is also shorter for children born with the virus.

HIV antibodies don't appear the day after you become infected, so it is not possible to find out if you have been infected immediately after a possible risk. Antibodies usually take between two and three months to appear in your blood. The time between infection and the development of antibodies is called the window period.

In the window period people infected with HIV have no antibodies in their blood, but may already have very high levels of HIV in their blood, sexual fluids or breast milk. In fact, people with HIV are most infectious during this window period before their own immune system has tried to control the virus. So you could pass on HIV to another person during this period even though an antibody test shows that you are HIV-negative.

Clinics generally recommend that you wait three months from the time of a possible risk before taking an antibody test, to be sure that a negative result is truly negative. However, if you have been at unusual risk or have reason to believe you may have been infected, you should not delay in seeking advice.

The Red Ribbon is the international symbol of AIDS awareness; a symbol of respect for those who have died of AIDS, of concern for those living with it, and reminder to us all of the constant need to keep up the fight against AIDS.

It's a symbol of how great achievements begin with small actions. The Red Ribbon came into being 9 years ago as the idea of a small HIV charity, Visual AIDS, in New York. Now, it's recognized the world over as the symbol of AIDS awareness.

CD4 cells, also known as helper T-cells, are a type of lymphocyte, which is a white blood cell that plays an important role in the immune system. Lymphocytes control the body's ability to recognize and fight infections and cancers. CD4 lymphocytes help to identify, attack, and destroy specific bacteria, fungi, and other germs that infect the body. In addition, they regulate the production of antibodies (proteins that fight infections) and cytokines (chemicals that regulate other immune functions). CD4 cells are produced in the spleen, lymph nodes, and thymus gland, and they circulate throughout the body in the bloodstream.

CD4 cells are a major target for HIV. HIV binds to the surface of CD4 cells, enters them, and either reproduces immediately, killing them in the process, or remains in a resting state, reproducing when the cell becomes active. Although the body attempts to produce new lymphocytes in order to replace the ones that have been destroyed, the number of CD4 cells in the blood gradually declines as HIV disease progresses.

The CD4 cell ("T-cell") count is a test, which measures the number of CD4 cells in a blood sample. Normal CD4 counts in adults range from 500 to 1200 cells per cubic millimetre (mm3) of volume.

The CD4 cell count is a laboratory marker of the strength of your immune system. It helps to determine how advanced your HIV disease is (staging) and to predict your risk of complications (prognosis). Medical conditions, such as thrush, Pneumocystis carinii pneumonia (PCP), and Mycobacterium avium complex (MAC) disease, occur at particular stages of HIV disease (. The CD4 count is a "quantitative" test--meaning the result is a number that can be compared with the number obtained from an earlier test. The HIV viral load (measurement of level of HIV in the blood) is also important for disease staging and prognosis. Other laboratory studies, including the CD4 percentage, are less commonly used for these purposes.

The CD4 cell count is a marker of the level of your immune function at any given time, while the viral load is a measurement of the level of circulating virus in your blood. As the virus reproduces, it destroys CD4 cells and reduces your count. In general, the higher your viral load, the more quickly your CD4 cells will be destroyed. Both tests are useful in guiding the use of antiretroviral therapy, staging HIV disease, and determining prognosis. The CD4 count is also used to identify problems for which you may be at risk and to determine what medications might be helpful.

Table 1 outlines specific ways in which CD4 count results may guide your medical care. If your CD4 count declines over a period of several months, your doctor may recommend: 1) beginning or changing antiretroviral (anti-HIV) therapy; and/or 2) starting preventive treatment (prophylaxis) for opportunistic infections like PCP. Your CD4 count should increase or stabilize in response to effective combination antiretroviral therapy.

Because of variations in procedure, the CD4 cell count is not a precise test. Results may vary between laboratories, so your test should always be performed at the same site. In addition, other situations may have an impact on your CD4 results. The CD4 count tends to be a little lower in the morning and higher in the evening. Acute illnesses, such as pneumonia, influenza, or herpes simplex virus infection, can cause the CD4 count to decline temporarily. Cancer chemotherapy can dramatically lower the CD4 count.

In general, the CD4 count goes down as HIV disease progresses. Any single CD4 count value may be different from the last one even though your health status has not changed. You should not place too much importance on any one result; what is more important than any single value is the trend of CD4 counts over time.

The CD4 count does not always reflect how someone with HIV disease feels and functions. For example, some people with higher CD4 counts are ill and have frequent complications, and some people with low CD4 counts have few medical complications and function well. HIV-infected persons with CD4 counts below 200/mm3 are considered to have AIDS, regardless of whether they are sick or well, according to criteria established by the Centres for Disease Control and Prevention.

A CD4 cell count and viral load are obtained as part of a baseline laboratory panel when you are initially diagnosed with HIV infection. Both tests should be repeated about four weeks after starting antiretroviral therapy. If your regimen is maintained, the tests for CD4 count and viral load should be performed every three months thereafter, along with other laboratory studies.

There is evidence that PCP prophylaxis can be safely discontinued in patients who are on antiviral therapy, if their viral load is well suppressed and if they maintain a CD4 cell count of over 200/mm3 for 3 - 6 months. There is evidence that MAC prophylaxis can be safely discontinued in patients who are on antiviral therapy, if their viral load is well suppressed and if they maintain a CD4 cell count of over 100/mm3 for 3 - 6 months.

Table 1.

CD4 count above 500/mm3

· No unusual conditions expected
· Emphasis on good health habits (nutrition, sleep, exercise) and health care maintenance issues (vaccinations) · Combination antiretroviral therapy recommendations are individualized

CD4 count 200 to 500/mm3

· Increased risk for shingles, thrush, skin infections, bacterial sinus and lung infections, and tuberculosis
· Opportunistic infections, such as PCP, MAC, and cytomegalovirus (CMV), are very rare
· Combination antiretroviral therapy generally recommended for CD4 count < 350/mm3

CD4 count 50 to 200/mm3

· Increased risk for PCP and other opportunistic infections
· Combination antiretroviral therapy recommended
· Prophylaxis for PCP (TMP-SMX, dapsone, or aerosol pentamidine) necessary
· Consider prophylaxis for toxoplasmosis (TMP-SMX or dapsone/pyrimethamine) for CD4 count < 100/mm3

CD4 count below 50/mm3

· Increased risk for opportunistic infections, including MAC and CMV
· Combination antiretroviral therapy recommended · Prophylaxis for MAC (azithromycin, clarithromycin, or rifabutin) necessary

Figure 1

Relationship between CD4 Cell Count and Opportunistic Diseases

Background Briefing

Currently, there are almost 14 million women of childbearing age throughout the world who are HIV positive. Among those women who are pregnant, the highest rates of infection have been reported from sub-Saharan Africa. In urban centres in southern Africa, for example, HIV rates of 20-30% among pregnant women tested anonymously at antenatal clinics are common. And rates above 40% of 59% and even 70% have been recorded in Botswana and parts of Zimbabwe, and 43% in Botswana. According to data from UNAIDS, there are very few places outside
sub-Saharan Africa in which the prevalence of HIV infection among pregnant women has reached 10%, let alone the extremely high figures seen in this region. However, this is partly because the epidemic in other badly affected countries is younger and less advanced than in sub-Saharan Africa, so there is no room for complacency.

Figures from UNAIDS show that the risk of infection is increasing for women everywhere -- in developed and developing countries alike. In France, women’s share of reported AIDS cases increased from 12% in 1985 to 20% ten years later. In Spain female AIDS cases rose from 7% to 19% of all AIDS cases during the same period. And in Brazil the proportion rose from just 1% in 1984 to 25% ten years later.

Furthermore, in the worst affected countries, the virus is spreading fastest among young people below the age of 24 years -- at the peak of fertility. And in places where the virus is spread predominantly through heterosexual intercourse -- notably sub-Saharan Africa -- young women outnumber young men among those becoming infected. Studies sponsored by UNAIDS show that in western Kenya nearly one girl in four between the ages of 15 and 19 years is living with HIV compared with one in 25 boys in the same age group. In Zambia in this age range, sixteen times as many girls as boys are infected. And in rural Uganda among 20-24 year olds, there are six young women who are HIV positive for every infected young man. It is these high rates of infection, coupled with high rates of pregnancy among women, that explain why, at the present time, Africa is also home to the vast majority of
HIV-positive children. (The 7th Sentinel Surveillance; Swaziland 2000)

The virus may be transmitted during pregnancy, childbirth, or breastfeeding. Where no preventive measures are taken, the risk of a baby acquiring the virus from an infected mother ranges from 15% to 25% in industrialized countries (most estimates are below 20%), and from 25% to 45% in developing countries (most estimates are between 30% and 35%). Evidence suggests that the risk of transmission is increased when the mother has a higher viral load (this is the case when a person is newly infected with HIV or is in an advanced stage of disease), or if the baby is highly exposed to the mother's infected body fluids during birth.

The difference in risk between developing and developed countries is due largely to feeding practices: breastfeeding is more common and usually practiced for a longer period in developing countries than in the industrialized world. It is estimated that a child born uninfected to an HIV-positive mother has a one in five chance of acquiring the virus from her milk if it is breastfed. In places where breastfeeding is the norm, this route may account for more than one-third of mother-to-child transmissions of the virus.

There are many reasons why such advice may not necessarily be appropriate -- and might, indeed, be dangerous. The cost of infant formula is often beyond the means of poor families in developing countries, even when it is widely available. Besides, many lack easy access to the knowledge, safe clean water and fuel needed to prepare replacement feeds safely, or simply have no time to prepare them. If used incorrectly -- mixed with dirty unsafe unboiled water, for example, or over-diluted -- a breast milk substitute can cause infections, malnutrition and even death. But even if a mother has the means to feed her baby safely with a breast milk substitute, she may face other dilemmas. In cultures where breastfeeding is the norm, the very fact that she chooses not to breastfeed may draw attention to her HIV status and invite discrimination or even violence and abandonment by her family and community.

A further consideration is that breastfeeding suppresses ovulation and delays the return of a woman's fertility. A mother who does not breastfeed loses the natural contraceptive effect of the practice and is at increased risk of getting pregnant again too soon.

In August 1997, WHO, UNICEF and UNAIDS issued a joint Policy Statement on HIV and infant feeding. They subsequently prepared guidelines to help national authorities to implement the policy. These documents emphasize that it is the individual mother's right to decide how she will feed her child; any attempt to influence her decision, no matter what the circumstances or motives, is an abuse of her human rights and freedom of choice. The responsibility of health or social work professionals who counsel HIV-positive women about infant feeding is to give them the fullest available information on the risks associated with breastfeeding, to discuss the feasibility and pros and cons of this and alternative feeding methods in the light of personal circumstances, and to give them appropriate support for the course of action they choose. And women should have easy access to voluntary and confidential counselling and testing for HIV. Since the majority of pregnant and lactating women attending clinics are likely to be HIV negative, information on how to protect themselves from infection is also a vital component of routine care.

Breastfeeding has been the cornerstone of child health and survival strategies for the past two decades and has played a pivotal role in reducing infant mortality in many countries. Even in the era of AIDS, breastfeeding remains the best possible nutrition for the great majority of babies and it is important that the practice by women who are
HIV-negative or whose HIV status is unknown continues actively to be promoted, protected and supported.

As with the issue of infant feeding, it is every woman's fundamental right -- as enshrined in human rights conventions -- to decide for herself, without coercion, whether or not to have children. The responsibility of the government and health services is to provide HIV-positive women and their partners with comprehensive information and education about the risks associated with childbearing as part of routine public information about HIV/AIDS, to ensure they have real choices of action, and to respect and support the decisions they reach. This means providing good quality, user-friendly and easily accessible family planning services so that HIV-positive women can avoid pregnancy if they choose, and similarly acceptable and accessible abortion services, where the procedure is legal, so that they can terminate pregnancy if desired.

For women to make informed decisions about childbearing in the AIDS era, they need to know and understand the implications of their HIV status. It is important, therefore, that voluntary and confidential counselling and HIV testing be widely available, and that its use by women, and their partners if desired, be promoted.

It should be recognized, however, that no matter how good the information, counselling and services a woman has access to, the decision about whether or not to have a child may still present her with agonizing dilemmas. In many parts of the world bearing children is of paramount importance, and may be a woman's only path to social status and self-fulfilment. Failure to get pregnant, especially if she has no children already, will be noticed and commented on and may even be reason for abandonment by her partner. And if prejudice against people with HIV/AIDS is strong -- as it still is in many societies -- she may also risk her personal safety by raising suspicion that she is infected.

There are three complementary strategies for preventing mother-to-child transmission of HIV. They are:

o The protection of girls and women from HIV infection. This will minimize the risk that women of childbearing age are carrying the virus in the first place. The strategy is sometimes referred to as "primary prevention". It involves promoting safe and responsible sexual behaviour in couples, providing them with knowledge about HIV/AIDS and how to prevent infection, and ensuring that they have the necessary personal skills and access to condoms so that they can act on their knowledge. It also means providing good quality, user-friendly prevention and treatment programmes for other sexually transmitted diseases (STDs), the presence of which increases the risk of HIV transmission as much as 6-10 fold. And, crucially, it means taking steps to deal with the cultural, legal and economic factors that make girls and women specially vulnerable to HIV infection by limiting their autonomy and power to protect themselves.

o The provision of efficient and accessible family planning services -- and abortion where this is legal -- to enable women to avoid unwanted pregnancies and births. The aim is to ensure informed reproductive choice.

o An integrated package of measures consisting of voluntary HIV counselling and testing (VCT), the provision of antiretroviral drugs for HIV-positive pregnant women (and sometimes their babies), counselling on infant feeding, and support for the feeding method(s) chosen by the mother. This package is often referred to as the antiretroviral drug strategy.

In cases where a mother knows she is HIV positive and gives birth without the benefit of antiretroviral drugs during pregnancy or delivery, she can still refrain from breastfeeding, counting on the two-to-one chance that her baby has avoided infection in the womb or during childbirth. But if she chooses this course of action she should be made aware of the fact that she will lose the natural contraceptive effect of breastfeeding and be at increased risk of becoming pregnant again unless she takes alternative precautions.

Until recently primary prevention measures and the provision of family planning were virtually the only options for limiting the number of HIV-infected children. However, in 1994, researchers in France and the United States reported the results of a major collaborative study, code-named ACTG 076, on mother-to-child transmission of HIV that offers a complementary strategy for HIV-positive women who want to give birth. The scientists found that when the antiretroviral drug zidovudine (AZT, or ZDV) is given to HIV-positive women orally five times daily from the 14th week of pregnancy onwards, and intravenously during labour, and administered to their infants for six weeks after birth, the risk of transmitting HIV from mother to child is reduced by over two-thirds if breastfeeding is strictly avoided. The ACTG 076 regimen is now offered routinely to HIV-positive women in the industrialized world and rates of MTCT below 5% are now common. However, the regimen is costly (approximately US$ 1000 per mother and child pair), long and complicated to administer, which means it is unsuitable for widespread use in developing countries.

Early in 1998, trials in Thailand sponsored by the country's Ministry of Public Health and the US Centres for Disease Control and Prevention showed that a shorter and simpler course of AZT is able to cut the rate of mother-to-child transmission of HIV by at least half if the baby is not breastfed. The infection rate was just above 9%, compared with a rate of 19% for babies of infected mothers who did not take antiretroviral, but who also avoided breastfeeding. In this regimen, the drug is given to the mother only and consists of 300 mg of AZT taken by mouth twice daily from the 36th week of pregnancy and during labour.

Research is being conducted at present to test the effectiveness of an even shorter antiretroviral regimen, using two drugs -- AZT and lamivudine (3TC) in combination. The PETRA trial, as it is known, is coordinated by the UNAIDS Secretariat and is being conducted in five urban settings in South Africa, Tanzania and Uganda. It is the largest ever clinical trial to examine this issue. According to preliminary findings announced in February 1999, when an HIV-positive mother starts taking the drugs at the time of delivery, and when she and her newborn baby continue on the drug regimen for just one week following birth, the risk of the baby becoming infected is reduced to about 11% at 6 weeks of age.

UNAIDS stresses that an antiretroviral drug programme for the prevention of MTCT should never be adopted as an alternative to the other two strategies for protecting children from HIV, but as an addition. Everywhere, protecting girls and women from HIV infection and ensuring informed reproductive choice through good-quality and accessible family planning services, and abortion where legal, should remain high priorities.

This is a critically important question since the majority of HIV-positive women who risk transmitting the virus to their infants come from cultures where breastfeeding is the norm, and where artificial feeding often presents great difficulties.

The majority of women taking part in the PETRA trial have chosen to breastfeed their babies. All mothers and babies involved in the trial will be followed for 18 months (to about the middle of the year 2000), after which the risks associated with breastfeeding under these circumstances will become clearer. Results from other studies -- notably one in Abidjan, Côte d'Ivoire, and Bobo-Dioulasso, Burkina Faso, conducted between 1995 and 1998 -- found that the rate of HIV infection among babies who were breastfed by mothers given a short course of AZT was 18%, measured at 6 months after birth, compared with 27.5% among the breastfed babies of HIV-positive mothers who took no antiretrovirals. Whether the preventive effects of the antiretroviral drugs persist to any significant degree if babies continue to breastfeed beyond six months is still a matter of concern and the subject of ongoing research.

Preliminary results from a number of ongoing studies in breastfeeding populations indicate that a short course of antiretrovirals can still reduce the transmission of HIV from the mother to the baby, though not as well as when mothers do not breastfeed as earlier stated. One of these studies is the PETRA trial, which is testing the effectiveness of a number of antiretroviral regimens using two drugs – AZT and lamivudine (3TC) – in combination. Coordinated by the UNAIDS Secretariat, this trial is being conducted in five urban settings in South Africa, Tanzania and Uganda. It is the largest-ever clinical trial to examine this issue. According to preliminary findings announced in February 1999, when an HIV-positive mother starts taking the two drugs at the time of delivery, and she and her newborn baby continue on the drug regimen for just one week following birth, the risk of the baby becoming infected is reduced to about 11% when measured at 6 weeks of age, as compared with a 17% risk when no antiretroviral drugs at all are given. An even bigger reduction – to 9% -- is seen when the drug regimen is started at 36 weeks of pregnancy, around a month before delivery. All mothers and babies involved in the trial will be followed for 18 months (to the middle of the year 2000), by which time the risks associated with breastfeeding under these conditions will be clearer.

Results from two other studies, conducted between 1995 and 1998 in Abidjan, Côte d’Ivoire, and Bobo-Dioulasso, Burkina Faso, were released in March 1999. It was found that the rate of HIV infection among breastfed babies whose HIV-infected mothers had a one-month course of AZT was about 18% at age 6 months (16% at age 3 months), compared with 27.5% (25% at 3 months) among babies whose mothers received no antiretroviral. Again, research is being pursued to see whether the preventive effects of the antiretroviral will be maintained to any significant degree if the babies continue to breastfeed beyond the age of 6 months.

In July 1999, the US National Institutes of Health released the results of a joint Uganda-US study comparing the preventive efficacy of a single dose of the antiretroviral drug nevirapine, given to the mother during labour and to the baby within the first three days of life, with that of AZT given during labour to the mother and administered to the baby for one week after delivery. Measured at around 3 months of age, HIV infection was found in 25% of the infants who received AZT, compared with 13% in those receiving nevirapine. Again, the infants will be followed up until they are 18 months old to understand the impact of breastfeeding on this reduced transmission rate.

In the meantime, it is a point of principle that an HIV-positive woman's ability and willingness to give her child a breast milk substitute should not be a precondition for offering her antiretroviral drugs for the prevention of MTCT if they are available in the health system. HIV-positive mothers who choose to breastfeed should be supported in their decision, and they should be advised that giving breast milk exclusively for the duration of breastfeeding, stopping the practice as early as possible, and taking care to avoid cracked nipples and breast abscesses will all help to reduce and minimize the risk of transmitting the virus.

To clarify what has become a rather confusing picture in summary, the rates of mother-to-child transmission of HIV under the different regimens and circumstances are as follows:

* Where no drugs are administered and the baby is breastfed by its HIV-positive mother, the risk of infection is generally around 30-35%.

* Where no drugs are administered and the baby is not breastfed by its HIV-positive mother, the risk of infection is around 20%.

* Where a one-month course of AZT is administered and the baby is not breastfed, the risk of infection is around 10%.

* Where a one-month short course of AZT is administered, and the baby is breastfed by its HIV-positive mother for up to 6 months, the risk of infection is about 18% at that age6 months of life, according to preliminary data.

* Preliminary results from the PETRA study show that where two antiretroviral, AZT and 3TC, drugs are administered at the time of labour, and to mother and baby for one week following delivery, the risk of infection that the baby will be HIV infected at 6 weeks of life, with breastfeeding if it is being breastfed by its mother, is around 11%. If the drugs are given for approximately one month -- from the 36th week of pregnancy, continued in labour and given for a further week after delivery, -- the chances of the baby being infected risk of infection at 6 weeks of life, when the baby is being breastfed, is around 9%. The rates of infection with continued breastfeeding further follow-up will show what the respective rates of infection are at 6, 12 and 18 months, if breastfeeding is maintained. Will only be known when the data from follow-up of the PETRA trial are complete.

* Where one oral dose of nevirapine is given to the mother in labour and to the baby within three days of birth, the risk of infection at 3 months of life is about 13%, with breastfeeding. The risk at later ages, in infants that continue to breastfeed, will be determined through follow-up.

A short course of AZT antiretroviral drugs during pregnancy and delivery (and possibly the early post-partum period), while dramatically increasing the chance that she will give birth to an uninfected baby, does no harm to the health of an HIV-positive woman. The only possible risk is anemia. But any pregnant woman taking antiretroviral for HIV will be doing so under the supervision of the maternal health services, where screening for anemia and treatment for the condition if necessary should be routine procedures.

Taking AZT alone, a single antiretroviral drug on its own, which is the currently recommended regimen for MTCT prevention, is now recognized to offer no intrinsic long-term therapeutic benefits for HIV-infected people who have not yet developed symptoms of HIV-related illness. Only HIV-positive women who have progressed to the end-stage of illness called AIDS could hope to improve their quality of life and extend it by a few months by pursuing monotherapy with AZT.

However, all women, whether or not infected with HIV, stand to benefit considerably from the high quality of maternity care and other services that are the necessary foundation for the introduction of such an antiretroviral drug programme.

The risk of developing drug-resistant strains of HIV is considered to be minimal when antiretroviral are used for a short period of time. Research and extensive experience with AZT, which has been in clinical use since 1987, indicates that the virus takes at least three months to develop resistance to the drug when used as monotherapy. On the other hand, HIV has been shown to develop resistance to nevirapine monotherapy very quickly. Since only a single dose of nevirapine has been given to mother and baby in the study of MTCT prevention, resistance is not expected to be a problem, but no data are yet available to confirm this.

If antiretroviral drugs are used in combination, resistance is even slower to develop than with monotherapy as they offer the virus a more complex challenge. At present, however, the risk of developing drug resistance if a woman is treated with the same drug over several pregnancies is not known.

Two French infants born to mothers who had taken antiretroviral during pregnancy died in 1998 from a rare neurological condition caused by mitochondria disease (mitochondria, found in all cells, are essential for normal cell function). This prompted a search of the records of around 5000 other children born to HIV-infected mothers in France. No deaths were found, although six living children showed signs that could be caused by mitochondria disease. Elsewhere in the industrialized world, no causal relationship has been identified between infant or child death and antiretroviral drugs given during pregnancy. Nor has any evidence of mitochondria disease been found among the 1800 mother-child pairs recruited for the PETRA trial. This issue will continue to be looked at carefully during follow-up in both developing and developed countries.

Overall, the consensus is that the beneficial effect of antiretroviral given for MTCT prevention in utero - a significant reduction in the baby's risk of infection with a fatal virus -- far outweighs any risk to the infant.

For women to take advantage of measures to protect their offspring from infection they need to know and accept their HIV status. Voluntary and confidential counselling and testing services therefore need to be widely available and acceptable before the drug strategy is introduced. All pregnant women must have ready access to antenatal and postnatal care and be able to give birth in a maternity ward or clinic with professional assistance, since skilled supervision of the drug regimen is necessary. In addition, expert counselling on infant nutrition and safe alternatives to breastfeeding must be available to all. Other health system prerequisites for introducing the strategy are efficient systems of quality control, supply and distribution of antiretroviral drugs and HIV test kits, and laboratory facilities with adequate capacity and skills.

In addition, women's personal safety must be assured. The administration of drugs and avoidance of breastfeeding make it virtually impossible for HIV-positive women to keep their infection secret from their families and people in the wider community. Thus, if there is prejudice in society against people with AIDS that might put women identified as HIV positive at risk of rejection or violence, this must be overcome before the drug strategy is widely introduced.

Overcoming the shame and rejection associated with AIDS is an enormous challenge. Stigma remains widespread, even in communities where a tenth or more of the adult population is HIV infected. The health-service challenges are equally daunting. At present, some 40% of the world's women lack access to adequate antenatal care. In
sub-Saharan Africa, professional health staff attends to less than half of all births, with proportions well below this being reported from individual African countries as well as from parts of Asia. The proportion of people without access to health care at all ranges from over 40% in some parts of Latin America and Asia, to nearly 80% in the poorest parts of Africa. Moreover, for huge numbers of mothers in the developing world, there is no truly safe alternative to breastfeeding even if infant formula is available, for they lack access to the clean water, fuel and knowledge needed to prepare it properly.

The affordability of an antiretroviral drug programme for preventing MTCT will depend a great deal on the condition of the health infrastructure within a country or district, and how much strengthening or expansion of services is needed before the strategy can be introduced. Generally speaking, antiretroviral drugs for mothers known to be HIV-positive and breast milk substitutes for their babies are affordable in most countries, or districts within countries, where there are already well-functioning health care systems.

In Thailand, where the effectiveness of a one-month course of AZT together with replacement feeding was first demonstrated, the cost of antiretroviral drugs was US$ 50 per woman. Taking this as the baseline cost for drugs, and a realistic estimate of US$ 50 per child for a six-month supply of infant formula, the cost of the strategy for one mother-and-child pair would be approximately US$ 130, including the costs of counselling and other inputs.
But what does this figure mean from the point of view of the national health budget? If one takes a hypothetical country with a birth rate of 40 per 1000 and a 15% HIV prevalence rate among pregnant women, and one assumes that all women who know they are seropositive (typically around 10% of those infected) accept the intervention, the cost per capita would amount to around US$ 0.08. This calculation does not take into account savings of medical and other expenditures to care for HIV-positive infants -- which, though admittedly very low in some countries, can be substantial in others.

The much shorter antiretroviral regimens being tested in the ongoing PETRA and Uganda nevirapine trials are likely to be even cheaper than the currently recommended one-month course of AZT. As a result the total cost of providing antiretroviral may be reduced, and it may become more cost-effective to introduce the intervention in very-low-income countries.

Voluntary counselling and testing also needs to be taken into consideration. If the cost of this service is to be borne exclusively by MTCT prevention programmes, the cost-effectiveness of the strategy will depend on the HIV prevalence in the area: the higher the prevalence, the less it will cost to identify each HIV-positive pregnant woman.

Where HIV prevalence is high, the cost of a programme of voluntary counselling and testing, AZT antiretroviral drugs and replacement feeding compares well with the cost of interventions for other health problems. It is estimated, for example, that at HIV prevalence rates of 5% and above, this strategy costs around US$ 35 per Disability-Adjusted Life Year (DALY), compared with US$ 20-40 per DALY for polio and diphtheria vaccination, and US$ 200-400 per DALY for river blindness prevention. However, where HIV prevalence is low in the general population, the
cost-effectiveness of the intervention is also lower. Under these circumstances, it may be better to focus only on population groups with particularly high prevalence rates, offering HIV testing to the women who are pregnant or planning a pregnancy.

Whatever the circumstances, the cost of antiretroviral programmes is a major consideration in developing countries, and UNAIDS and its partners regularly engage in negotiations with industry to try to secure more affordable prices for drugs as well as HIV test kits and infant formula. In March 1998, Glaxo Wellcome announced preferential prices for AZT for the prevention of mother-to-child transmission in developing countries. HIV test kits can be purchased at low prices through the supply division of WHO, and low-cost generic infant formula through UNICEF's supply division. In addition, UNAIDS is collaborating with various partners to document case studies and draw lessons from countries which have managed to provide antiretroviral drugs for MTCT despite scarce resources.

Providing voluntary counselling and testing, antiretroviral drugs and replacement feeding for the reduction of MTCT has benefits that extend way beyond the direct benefits to the health and survival of infants. All pregnant women, mothers and infants will benefit from the expanded provision and improved quality of health care, especially mother-and-child health, antenatal, delivery and postnatal services. And the population as a whole will benefit from general strengthening of the health infrastructure, as well as from the increased understanding and acceptance of the AIDS epidemic and those affected that develop as a consequence of counselling and testing and measures taken to combat stigmatization. A decision to introduce the strategy can, in the first place, be a force for social change, providing the opportunity and impetus needed to tackle often long-standing problems of inadequate services and oppressive attitudes.

For pregnant women to take advantage of measures to protect their offspring from HIV infection they need to know whether or not they are infected. So voluntary counselling and testing services are an essential part of any programme for the prevention of mother-to-child transmission of HIV. Ideally, however, everyone should have access to such services since there are clear advantages to knowing one's serostatus. People who know they are HIV infected are likely to be motivated to look after their health, perhaps with behaviour and lifestyle changes, and to seek early medical attention for problems. They can make informed decisions about sexual practices, childbearing, and infant feeding, and take steps to protect partners who may still be uninfected. And those whose test results are negative can be counseled about how to protect themselves, their partners and their children from infection.

Furthermore, voluntary counselling and testing has an important role to play in unmasking the silent epidemic and reducing the hysteria and fear surrounding AIDS. At present, UNAIDS estimates that around 90% of people with HIV are unaware of their status. Efficient, widely accessible and user-friendly testing services can help societies recognize and come to terms with the fact that there are many people living with HIV who show no outward signs. This in turn encourages commitment to prevention.

It is still common for women to be blamed for spreading sexually transmitted diseases, including HIV, despite the fact that very often the husband or partner to whom they are entirely faithful infects them. Voluntary counselling and testing that involves the partners of pregnant women, where this is feasible and desired, can play a vital part in challenging this pervasive prejudice.

In 1997 UNAIDS issued a policy statement on HIV counselling and testing which endorses the value of this service as a critical part of an effective response to HIV/AIDS, and sets down the guiding principles. UNAIDS promotes the establishment of voluntary counselling and testing services, offers technical assistance, and is currently supporting pilot projects in selected countries to find out how such services can be made as effective, efficient and acceptable as possible to those who wish to know their status.

The ethical implications of the strategy are given very serious consideration. A guiding principle, whenever these measures are made available to reduce MTCT, is that it is the pregnant woman's absolute right to choose, on the basis of full information, whether or not to take advantage of the intervention. Coercion is not justified under any circumstances, even if it seems to be in the best interests of the woman or her child, and her choice should always be accepted and respected. Thus, where it is available, an antiretroviral drug programme will give HIV-positive mothers the possibility, at their own discretion, of protecting their babies from infection -- a chance they would otherwise not have.

However, introducing antiretroviral drug programmes for the prevention of mother-to-child transmission in countries where antiretroviral are not available for the treatment of HIV-positive people more generally has raised sometimes-heated debate. The question is asked: If a mother's access to antiretroviral drugs is limited to the period of pregnancy and labour, does this amount to treating the mother for the sake of her baby alone? In fact, the question is based on an erroneous perception, for an antiretroviral drug used for this purpose is not really a treatment, but a "vaccine" for the infant. A useful analogy is the rubella vaccine given to pregnant women to protect their offspring from the ill effects of maternal infection. Rubella vaccination does not meet with ethical objections, despite the fact that it, too, could be seen as treating the mother for the sake of the baby.

The fact that antiretrovirals can serve two separate purposes -- as vaccine for infants against mother-to-child transmission of HIV, and treatment for HIV-infected individuals -- is, of course, very significant. But the issue of antiretroviral treatment for infected people must be considered separately from the issue of antiretroviral drugs used for the prevention of mother-to-child transmission. It requires debate and policy decisions outside the scope of MTCT policy-making.

It is important also to remember that a short course of antiretrovirals during pregnancy, while increasing the chance that she will give birth to an uninfected baby, does no harm to the health of an HIV-positive woman. Moreover, it is a point of principle when adopting a strategy of antiretroviral drug use that HIV-positive pregnant women must be assured of the best possible care available in their countries. In some places antiretroviral drugs will be available for therapy, too; in others, such treatment will simply not be feasible.

The idea that introducing the antiretroviral drug strategy for the prevention of MTCT might exacerbate the problem of orphaned children and increase the burden on families and societies is based largely on the assumption that children born to HIV-infected mothers infants do not survive long enough to become orphans. But this is a misconception. In the absence of preventive measures for pregnant HIV-infected women, around 65% of the children born to them will escape infection but face orphan hood; of those who are infected (35%), many will likewise survive longer than their mother. With the prevention strategy, the percentage of uninfected prospective orphans will rise to almost 90% but in parallel there will be a significant decrease – two- to three-fold – in the number of infected orphans. In the best scenario, where good health care is available, many such children will survive their infected mothers. The most likely effect of introducing the strategy, therefore, will be to alter the proportion of orphans who are HIV infected compared with those who are uninfected.

For example, it is estimated that, of 100 babies born to HIV-positive mothers in the absence of intervention, roughly 66 will be uninfected, 17 will be infected and die before the age of five years and 17 will be infected but still alive at their fifth birthdays. With the intervention, roughly 90 will be uninfected, five of the remaining ten who are infected will die rapidly and five will survive longer-term. Thus, with or without the intervention, the great majority more than 80% of the babies born to HIV-infected mothers will be exposed to the risk of being orphaned by the age of five years.

The intervention does not therefore affect in any significant way the need for societies to make provision for their orphaned children. However, from the point of view of planning for care and allocating resources, it is important to recognize that, in the absence of measures to reduce mother-to-child transmission, many more orphaned children will be HIV infected and will require medical care as well as support, many of them long-term. It is also worth noting that the strategy is likely to spare many HIV-positive mothers who may be struggling with their own ill health the stress and misery of caring for sickly infants.

Understanding HIV Prevention: Preventing the transmission is often seen from both ends of a board spectrum –from a simple solution of “abstain or the continuous and proper use of a condom” to the understanding of a more complex interplay among health, well-being and the prevention of disease. Health is seen as more than just the absence of disease or even a state of total physical and mental well being, the capacity for human development, and the quality of life. The concepts “health” and “well-being” are reciprocal and potentially mutually reinforcing.

Making and keeping populations healthy is often dependent on factors, which are traditionally outside the definition and concept of health. These factors, which have been shown to influence health, are known as the “determinants of health”.

They include;

Income and social status
Social support networks
Education
Employment and working conditions
Social environments
Physical environments
Personal health practices and coping skills
Healthy child development
Biology and genetic endowment
Health services
Gender
Culture

Through prevention efforts, many of the potential harms of disease can be avoided or diminished
Definitions: The prevention of health problems, such as HIV and AIDS, occurs at three levels:

Primary prevention; involves activities aimed at reducing factors leading to health problems (e.g., awareness and education campaigns on HIV/AIDS)
Secondary prevention: activities involve early detection of, and intervention in, the potential development or occurrence of a health problem. (e.g., HIV testing and individual counselling; outbreak studies – surveillance
Tertiary prevention; is focused on treatment of a health problem to lessen its effects and to prevent further deterioration and recurrence. (e.g., treatment, care and support for People Living With HIV/ADIS

Clinical Features: Signs And Symptoms

HIV follows a relatively slow but inevitable course once it enters the body. Many adults are free of symptoms for years. The mean time from exposure to the clinical manifestations of the disease is 8 to 10 years. For children, the mean time is only 17 months. Most people infected with HIV feel pretty well and are not under constant physician's care.

Shortly after infection, an individual may experience mild flu-like symptoms i.e.:
Fatigue, fever, headaches, muscle pain, lack of appetite, nausea, swollen glands and possibly a rash. These symptoms disappear within a few weeks.

A person may either:
1. Remain symptom-free for months or years. People who enter this a symptomatic or carrier state may appear and act well, not even aware that they are infectious.

2. Enter the symptomatic state known as AIDS-wasting syndrome or AIDS related complex (ARC). Symptoms include: extreme fatigue, intermittent fever, malaise (a vague feeling of bodily weakness or discomfort, frequently marking the onset of disease), night sweats, chills, lymphadenopathy, enlarged spleen, anorexia and consequent weight loss, severe diarrhea, apathy, depression, oral thrush and other immunologic abnormalities characteristic of AIDS.

As the disease progresses further symptoms include: general failure to thrive, anergy (lack or diminished reaction to an antigen or group of antigens), and vulnerability to various opportunistic infections. These include: Pneumocystis carinii pneumonia, meningitis or encephalitis caused by aspergillosis, candidiasis, cytomegalovirus, toxoplasmosis or herpes simplex. In addition patients demonstrate susceptibility to malignant neoplasms, especially: Kaposi's sarcoma, Burkitts lymphoma and non-Hodgkin's lymphoma.

The terminal stage of full-blown HIV infection is commonly designated as AIDS.

The course of the disease roughly corresponds to rapidly falling T-helper cell counts from the normal 1000 T-cells per cubic millimetre of blood. HIV-infected persons usually lose about 40 to 80 T-cells per cubic millimetre per year.

At T-cell counts of between 200 to 500 per cubic millimetre, tuberculosis and Kaposi's sarcoma, (malignant, rapidly growing tumors of the skin and mucous lining of the gastrointestinal and respiratory tracts) occur.

At T-cell counts of below 200 per cubic millimetre, protozoan parasites appear and infect several body organs.
At T-cell counts below 50 per cubic millimetre, cytomegalovirus (CMV, a herpes virus), or lymphoma, (any cancer of the lymphoid tissue) can flourish. Once sufficient T-cells have been destroyed, immune system resistance is overwhelmed and death shortly follows. (Williams, 1995)

SYSTEM SPECIFIC SIGNS AND SYMPTOMS

* Pulmonary symptoms include shortness of breath, dyspnea (difficult breathing), coughing, chest pain and fever. These are caused by a variety of opportunistic diseases the most common of which is Pneumocystis carinii pneumonia having a mortality rate of 60 percent. There is also a greater incidence of tuberculosis (see Section 10).

* Gastrointestinal symptoms may include loss of appetite, nausea, vomiting, candidiasis and chronic diarrhea. Diarrhea is very prevalent, occurring in over half of all AIDS patients.

*Neurological symptoms may include memory loss, headache, fever, confusion and visual disturbances. Dementia and depression may also be seen. (Tamparo and Lewis 1995).

Services Provided by TASC:

Education:

HIV/AIDS education for community groups, organizations and industries.

Videos in siswati and English for the general public (Write down the list we have)

An extensive library for research and general information

Production and distribution of education materials, posters, brochures and flyers

HIV/AIDS Programme Support:

Training and capacity building for diverse organizations/entities working in the area of HIV/AIDS prevention and counselling as well as care.Positive Living Support Groups:

Group support for persons who have tested positive for HIV/AIDS.

Supportive counselling for friends, relatives and significant others of persons who have HIV/AIDS

counselling:

Pre and post-test and on-going counselling

Individual and group support counselling for HIV infected persons and their families

Prevention counselling for individuals and community groups, focus on risk reduction

Telephone hot-line (505-3910)

Testing:

HIV antibody testing is encouraged

Rural communities and HIV/AIDS:

Empowerment of group dynamics at community level

Mainstreaming gender approaches in reproductive health promotion

Condoms:

Female and male condoms available for the general public