HIV: BASIC FACTS ABOUT THE DISEASE HIV - Human Immune Deficiency Virus • HIV is a retrovirus.
• HIV attacks the immune system, which helps defend the body against infections.
Over a period of time, the virus overwhelms the immune system. The body is thennot able to successfully defend itself from opportunistic infections.
• The virus targets a cell known as the T4 lymphocyte.
• It can be isolated from blood, semen, and secretions that include cervical and
vaginal, breast milk, saliva, tears and urine. But a certain viral load is necessaryfor the infection to be successfully transmitted. AIDS – Acquired Immune Deficiency Syndrome • It is a life threatening condition and is characterised by the destruction of certain
cells mainly the T4 lymphocytes. This leads to opportunistic infections, which aresevere and ultimately fatal.
• The length of time from when a person is infected with HIV to the development
of AIDS varies from person to person. People can remain healthy for any timefrom a few years to more than ten years before developing any AIDS relatedsymptoms.
• If a blood test shows that a person has HIV it does not necessarily mean that
Modes of Transmission
• Pregnancy-related vertical transmission
• Sharing of infected needles used to inject drugs intravenously. HIV Cannot be Transmitted by:
• Casual everyday contact e.g. shaking hands, hugging, kissing, coughing, sneezing
• Using common swimming pools or public toilet seats
1 A virus containing genetic RNA material rather than DNA. For the virus to replicate itself within an infectedcell its RNA must be converted to DNA. It does this by using an enzyme known as reverse transcriptase. 2 Over the course of a lifetime, starting from infancy, we are all subjected to infections that are held in check byour own immune systems. When HIV suppresses a person’s immune system, these infections can manifestthemselves, e.g. tuberculosis while others may never cause disease unless the immune system is weakened, e.g. CMV retinitis. These infections move a patient from HIV status to AIDS, and are referred to as opportunisticinfections. 3 Viral load is the amount of HIV per milliliter of blood.
• Sharing bed linen, eating utensils, food
• Animals, mosquitoes, and other insects
Origin and History • In the late 70’s doctors began to recognise a new pattern of illnesses.
• In 1981 – AIDS was recognised as a syndrome (a group of symptoms emerging
• In 1984 – HIV was isolated in France and the United States.
• In 1985 – HIV semen antibody test for the diagnosis of HIV became available. Diagnosis • HIV antibodies can be detected through the HIV antibody test about 3-6 months
• The period during which the antibodies are not yet detected is called the window
period. Transmission of infection can take place during this period.
• Screening is done by a test know as the ELISA test – Enzyme Linked Immuno
Sorbent Test Assay. If it is positive it is followed by a confirmatory test which iseither Western Blot or Fluorescent Antibody Technique.
• Incubation period of AIDS is the time between infection and the onset of
symptoms. It varies from person to person. Treatment of HIV Since HIV is a retrovirus, medications are mainly anti-retroviral. Treatment is a three- drug combination therapy. The drugs are:
NRTIs: Nucleoside Reverse Transcriptase Inhibitors
NNRTIs: Non-Nucleoside Reverse Transcriptase Inhibitors
Reverse Transcriptase is an enzyme that changes the HIV in a way that enables it tobecome part of the nucleus of a target cell thereby allowing it to make copies of itself. NRTIs and NNRTIs inhibit (slow down) the action of this enzyme. If this enzymedoes not do its job properly HIV cannot take over and start making new copies ofitself.
4 France – Luc Montaguier et al, 1983. US – Robert Gallo, et al, 1984. 5 NRTI’s : Retrovir (AZT/Zidovudine), Videx (ddi/Didanosine), Zerit (d4T/Stavudine), Hivid (ddC/Aziciabine),Epivir (3TC/Lamivudine)6 NNRTI’s: Delavirdine (Rescriptor), Nevirapine (Viramune)
These slow down the enzyme protease, which works on the HIV virus after it comesout of the nucleus of the cell. Protease acts like a pair of chemical scissors by cuttingup the long chains of HIV proteins into smaller pieces so that it can make active newcopies of itself. Protease Inhibitors gum up (block) the protease scissors.
These help prevent opportunistic infections when the immune system becomes weake.g. Foscarnet and Ganciclavin to treat Cytomegalovirus Eye infections, Fluconozoleto treat yeast and other fungal infections, TMP/SMX or Pentamidine to treatPneumocystis Carinii Pneumonia.
7 Protease Inhibitors: Indinavir (Crixivan), Nelfinavir (Viracept), Ritonavir (Norvir), Saquinavir(Invirase/Fortovase)
GLOBAL SUMMARY OF THE HIV/AIDS EPIDEMIC People newly infected with HIV in 2000 5.3 million Number of people living with HIV/AIDS 36.1 million AIDS deaths in 2000 Total number of AIDS deaths since the 21.8 million Beginning of the epidemic
8 AIDS Epidemic Update: December 2000. REGIONAL OVERVIEW OF THE EPIDEMIC Adults & Adults & Percent of Epidemic children children prevalce transmission10 for living with positive adults living with HIV/AIDS infected HIV/AIDS Sub-Saharan North Africa & Middle East South & South-East Asia East Asia & Latin America Caribbean Europe & Central Asia Western North America Australia & New Zealand 5.3 million
9 The proportion of adults (15 to 49 years of age) living with HIV/AIDS in 2000, using 2000 populationnumbers. 10 MSM (sexual transmission among men who have sex with men), IDU (transmission through injecting druguse), Hetero (heterosexual transmission). HIV: A RAPIDLY EXPANDING EPIDEMIC11
• In 1999, there were nearly 33.6 million people living with HIV. By the end of 2000, this
figure rose to approximately 36.1 million.
• The percentage of women infected by HIV in 1997 was 41%, in 2000 this figure had
• Since 1994 in almost every country of Asia there has been a 100 percent increase in the
• In the last three years the prevalence rate in 27 countries has doubled. In Botswana and
Zimbabwe the prevalence rate among adults is 25 percent.
• HIV infections in the former Soviet Union have doubled in just two years.
• The Caribbean is the region hardest hit by HIV/AIDS in the world outside sub-Saharan
• HIV is considered to be among the top ten killers in the world.
• In 1998, there were 2.6 million deaths from HIV/AIDS, as many as from malaria.
• Thirty percent of the AIDS deaths have resulted from tuberculosis (TB).
• Around half of all the people who acquire HIV become infected before they turn 25 and
typically die of the life threatening illnesses called AIDS before their 35th birthday.
• In 1998, Africa witnessed 5,500 funerals per day due to HIV/AIDS related deaths.
• At the end of 1999, there were 11.2 million AIDS orphans around the world.
11 AIDS Epidemic Update: December 1999; AIDS Epidemic Update: December 2000; and the Speech to theHouse Committee on International Relations on 16 September 1998 by Peter Piot M.D., Ph.D. ExecutiveDirector Joint United Nations Program on HIV/AIDS. HARD WON VICTORIES12
There is sound evidence that HIV infection rates are stabilising or decreasing in places wherefocused and sustained prevention programs have resulted in significantly safer behaviour. This is not just the case in the developed countries in Europe and the Americas. It is truearound the world. Widespread access to highly effective antiretroviral therapy hassignificantly prolonged life and improved the quality of life for people living with HIV in thewestern world and has resulted in a dramatic decline in AIDS deaths in these countries.
• In Uganda delayed first sexual intercourse, increased condom use, and fewer sexual
partners have been responsible for a 40 percent drop in HIV prevalence amongpregnant women.
• In Thailand there is comprehensive evidence that prevention campaigns work. Annual
representative surveys in young men showed both substantial reductions in riskbehaviour and decreases in HIV infection levels. Between 1991 and 1995, visits tosex workers reported by these men were cut by almost a half; and those who reportedusing a condom on the last visit increased from nearly 60 percent in 1991 to slightlyunder 95 percent in 1995. HIV prevalence among this group has gone down as aresult from 8 percent in 1992 to less than 3 percent in 1997.
• In Senegal, prevention efforts appear to have reduced rates of sexually transmitted
diseases and stabilised HIV rates at low levels of less than 2 percent among sexuallyactive adults.
• In northern Tanzania the first sign of an HIV turnaround has also been seen among
young people. In areas with active prevention programs, prevalence in young womenfell by 60 percent over a period of six years.
• New research findings from Thailand demonstrate that even a short course of AZT
for HIV-infected pregnant women could reduce by half the risk of HIV transmissionto their new-born.
• It has been confirmed that the usefulness of tuberculosis prophylaxis will now allow
more effective action against this important co-epidemic.
• Brazil and other South American countries have started widening access to treatment,
including access to antiretroviral therapy.
• Significant progress in expanding global capacity to monitor the epidemic has also
been made. There are now country-specific estimates and data for almost everycountry in the world.
12 Speech to the House Committee on International Relations on 16 September 1998 by Peter Piot M.D., Ph.D. Executive Director Joint United Nations Program on HIV/AIDS. UNDERSTANDING GENDER
The word “gender” differentiates the sociologically attributed aspects of an individual’sidentity from the physiological characteristics of men and women. Gender has to do withhow we think, how we feel and what we believe we can and cannot do because of sociallydefined concepts of masculinity and femininity. Gender relates to the position of women andmen in relation to each other. These relationships are based on power. Difference Between Sex and Gender
The word gender is used to describe socially determined characteristics; sex describes those,which are biologically determined. Sex is something one is born with, whereas gender isimbibed through a process of socialisation. Sex does not change and is constant, whereasgender and consequent gender roles change and vary within and between cultures. Implications for HIV/AIDS
• Where sex is biological, gender is socially defined. Gender is what it means to be male
or female in a certain society as opposed to the set of chromosomes one is born with. Gender shapes the opportunities one is offered in life, the roles one may play, and thekinds of relationships one may have – social norms that strongly influence the spread ofHIV.
• For women, risk-taking and vulnerability to infection are increased by norms that make it
inappropriate for women to be knowledgeable about sexuality or to suggest condom use;the common link between substance abuse and the exchange of sex for drugs or money;and by resorting to sex work by migrant and refugee women and others with familydisruption.
• For men, risk and vulnerability are heightened by norms that make it hard for men to
acknowledge gaps in their knowledge about sexuality; by the link between socialisingand alcohol use; by the frequency of drug abuse, including by injection; andpredominantly male occupations (e.g. truck-driving, seafaring, and military) that entailmobility and family disruption.
• In cultures where HIV is seen as a sign of sexual promiscuity, gender norms shape the
way men and women infected with HIV are perceived, in that HIV-positive women facegreater stigmatisation and rejection than men. Gender norms also influence the way inwhich family members experience and cope with HIV and with AIDS deaths. Forexample, the burden of care often falls on females, while orphaned girls are more likelyto be withdrawn from school than their brothers.
• Hence, responses to the epidemic must build on an understanding of gender-related
expectations and needs, and may need to challenge adverse norms.
13 UNAIDS, Gender and HIV/AIDS: Technical Update, September 1998. HIV: A GENDER ISSUE HIV is a gender issue because: Although HIV/AIDS affects both men and women, women are more vulnerable because of biological, epidemiological and social reasons.
• 41 percent of 33.4 million adults living with HIV/AIDS are women.
• 55 percent the 16,000 new infections occurring daily are women.
• 43 percent of pregnant women tested positive in Francistown, Botswana.
• Following a trend observed in some countries the male to female ratio among
HIV infected persons has begun to equalise. In fact in some of the worst affectedcountries, women outnumber men. “I have AIDS…Today it is me, tomorrow it’s someone else. If I am not kind, if I do notsympathise and get involved with my neighbours, what will happen to me when my turncomes?”The epidemic is fuelled by situations where macro policies have led to an increase in gender disparities.
• In Sub-Saharan Africa, policies leading to internal and external conflicts have
resulted in mass population displacements. This has created unequal sex ratiosamong refugees, internally displaced and those remaining in the areas of conflictexacerbating gender disparities. As a result six women for every five men inconflict situations are HIV positive.
• UNDP estimates over 85 percent of the cases of paediatric infection in Africa
have resulted from perinatal transmission. The infant mortality rate in this regionis expected to increase by up to 30 percent.
• In the Asia-Pacific region, the exclusion of women from the emerging market
economies led to an increase in existing gender disparities. Out of the 2.7 millionestimated new HIV cases in the world in 1996, 1 million were in South andSoutheast Asia.
• In Latin America and the Caribbean, policies promoting high urbanisation have
pushed women into a low productivity informal sector, where they have to clusterfor survival. In Sao Paolo, HIV/AIDS was the leading cause of death amongstwomen in the age group of 20-34 years. “To be alone and dying, yet to care for one’s own HIV infected child is tragedy, thedimension of which few of us can truly comprehend.”“Like every other epidemic, AIDS develops in the cracks and crevices of society’sinequalities….”
14 All the quotes in italics are voices of women living with HIV/AIDS. The rapidity of the spread of HIV/AIDS among women can be slowed only if concrete changes are brought about in the sexual behaviour of men.
• A study of female youth in South Africa showed that 71 percent of the girls had
• A behaviour survey financed by USAID in Tamil Nadu in India shows that 82
percent of the male STD patients had sexual intercourse with multiple partnerswithin the last 12 months and only 12 percent had used a condom. “ The women tell us they see their husbands with the wives of men who have died of AIDS. And they ask what can we do? If we say no, they’ll say: pack and go. If we do, where do wego to?”The feminisation of poverty is a key characteristic of the socio-economic impact of HIV/AIDS
The burden of care of the infected and sick invariably falls on women in the family. In households where women are responsible for subsistence farming this leads to:• Reduction of productive time on farms.
• Threat to the food security of the family.
• Withdrawal of the girl child from school to bridge the demand for additional
• Increase in households headed by women, at times by girl children with little
access to productive resources, often driving them into sex work for survival. “The children are lonely and sad without any family…I do not know how to comfort them. Itell them they cannot even rely on me, as I fear I am infected. I know I am asking them togrow up before their time, but I see no other alternative, if they are to survive.”“It is as if we are beginning a new life. Our past is so sad. We are not understood bysociety…we are not protected against anything. Widows are without families, without houses,without money. We become crazy. We aggravate people with our problems. We are the livingdead.”Existing legal and policy frameworks need to be reviewed with a gender sensitive lens to ensure positive and sustainable changes.
The laws that need to be reviewed include:• The laws relating to the prevention and suppression of commercial sex work.
• The laws relating to homosexuality. (Homosexuality is an act categorised under
• The laws both federal and personal that reduce women’s access to productive
assets like laws on inheritance, marriage, divorce, and cultural sexual practices.
• Policies regulating sex education in schools.
• Rules relating to ethical and professional orientation of service providers. “Sometimes sex work is a form of self-defence: We are going to sell what they want to take by force or by chance.” “Through my and others personal experience I have learnt that many women suffer insilence…Now HIV has changed many aspects of our lives and humanity is facing a plaguewhich requires that we reassess and reform some of our cultural and traditional values.”Gender inequality is a key variable in the incidence of HIV/AIDS. As gender disparities increase, the epidemic is affecting more and more women who bear the negative consequences of the gender imbalances. And as the epidemic is maturing, it is drawing in women who have had only one sex partner. A decade ago women seemed to be on the periphery of the epidemic. Today they are at the centre of concern. HIV/AIDS: MEN MAKE A DIFFERENCE15
All over the world, women find themselves at special risk of HIV infection because of theirlack of power to determine where, when and how sex takes place. What is less recognised,however, is that the cultural beliefs and expectations that make this the case also heightenmen’s own vulnerability. HIV infections and AIDS deaths in men outnumber those inwomen on every continent except sub-Saharan Africa. Young men are more at risk thanolder ones: about one in four people with HIV are young men under the age of 25.
There are sound reasons why men should be more fully involved in the fight against AIDS. All over the world, men tend to have more sex partners than women, including moreextramarital partners, thereby increasing their own and their primary partners’ risk ofcontracting HIV, a risk compounded by the secrecy, stigma and shame surrounding HIV. This stigma may keep men and women from acknowledging that they have become infected.
Men need to be encouraged to adopt positive behaviours, and, for example to play a muchgreater part in caring for their partners and families. Numerous studies world-wide show thatmen generally participate less than women in caring for their children. This has a directbearing on the AIDS epidemic, which has now left over 11 million children orphaned and inneed of adult help to grow up clothed, housed and educated.
15 Excerpts have been taken from a press release (6 March 2000) from UNAIDS about the UNAIDS Campaign2000 to target men. HIV: A HUMAN RIGHTS ISSUE
The WHO Constitution has defined health as “a state of complete physical, mental and socialwell being, not merely the absence of disease and infirmity.” This state of human well beinghas been guaranteed as a human right through a number of international human rightstreaties. Although health was first articulated as a human right in the Universal Declarationof Human Rights, a more detailed articulation of this right was set forth in Article 12 of theCovenant on Economic, Social and Cultural Rights and the Convention on the Elimination ofAll Forms of Discrimination Against Women reaffirmed these rights further.
The rapid spread of the HIV/AIDS epidemic has led to an infringement of the human rightsof men, women and children affected by the epidemic in various ways. According to theWorld Development Report of 1993, half of the world’s burden of disease is attributable tocommunicable diseases, to maternal and perinatal causes and to nutritional disorders. However women, particularly women in low-income nations, bear a large proportion of thisdisease burden. The overall morbidity and mortality for women from sexually transmitteddiseases excluding HIV/AIDS is over 4.5 times that of men. The onset of the HIV/AIDSepidemic has exacerbated this situation in no small way. It has opened up a whole new areaof human rights violations as the epidemic depicts a congruence of two most insidious formsof human oppression – gender and sexuality.
In response to this state of affairs the Second International Consultation on HIV/AIDS andHuman Rights concluded that: the protection of human rights is essential to safeguard humandignity in the context of HIV/AIDS and to ensure an effective rights based response to theepidemic. This conclusion was based on the recognition that when human rights areprotected, less people become infected and those living with HIV/AIDS and their familiescan better cope with the disease.
Prevention and care for women are often undermined by pervasive misconceptions aboutHIV transmission and epidemiology. There is a tendency to stigmatise women as “vectors ofdisease,” irrespective of the source of infection. As a consequence, women who are or areperceived to be HIV-positive face violence and discrimination in public and in private life. Sex workers often face violence and discrimination in public and in private life. Sex workersoften face mandatory testing with no support for prevention activities to encourage or requiretheir clients to wear condoms and with no access to health-care service. Many HIV/AIDSprograms targeting women are focused on pregnant women but these programmes oftenemphasise coercive measures directed towards the risk of transmitting HIV to the foetus,such as mandatory pre- and post-natal testing followed by coerced abortion or sterilisation.
The protection of the sexual and reproductive rights of women and girls is, therefore, critical. This includes the rights of women to have control over and to decide freely and responsiblyon matters related to their sexuality. States should thus ensure women’s rights are upheld inmatters relating to property, employment, divorce, access to economic resources so thatwomen can leave abusive relationships which threaten them with HIV infection. This will
also enable them to cope with the burden of caring for people living with HIV/AIDS in theirhouseholds. An engendered human rights approach to the epidemic is therefore imperative.
1. NIDA CTN 0051: A Multi-site Randomized Controlled Evaluation of Extended-Release Naltrexone vs. Buprenorphine for Opioid Treatment (X:BOT). (LIs Rotrosen & Nunes). This study will assess the comparative effectiveness of extended release injectable naltrexone (XR-NTX, Vivitrol®) versus buprenorphine naloxone (BUP-NX, Suboxone®) as pharmacotherapeutic aids to recovery amongst treatment-
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