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ASymptomatic stage
Voluntary counselling and testing
Food and Nutrition
Prevention of onward HIV transmission
Adult transmission of HIV
Mother to child transmission of HIV
Follow-up Counselling
Stigma and discrimination
Spiritual support
Sexually transmitted infections (STIs)
Provision of HIV/AIDS Antiretroviral Drugs
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Voluntary HIV counselling and testing (VCT) plays a
key part in HIV-related prevention and care. It is particularly
important as a starting point for the access of other
HIV/AIDS-related services. If a person does not know they are
infected, they cannot get any treatment or care. It is widely
recognised that knowledge of their HIV infection can help a person
to stay healthy for longer as well as preventing new infections. In
too many places people are diagnosed with HIV when they are
seriously ill. At this point, there are fewer opportunities for
cost-effective interventions, which can improve their quality of
life. VCT also provides benefit for those who test negative. For
those people who learn that they are negative, it may result in a
change of behaviour.
The provision of VCT has become easier, cheaper and
more effective as a result of the availability of rapid HIV testing.
The advantages of rapid testing are:
• The personnel involved with rapid testing do not
have to be fully qualified health care workers. Rapid testing can be
performed by someone with basic health care training (e.g. knowing
how to draw blood and how to use the testing kit).
• There are no complicated storage requirements for
some of the rapid tests and this has expanded the sites where they
can be used. For example, rapid testing can be provided in a
building without electricity.
• Before rapid testing was available people had to
visit a testing site and then wait, often for several days, before
coming back for their test result. With rapid testing people can
wait and have their test result within an hour, and this removes the
problem of people not returning to get their test result.
• Basic counselling services can be offered by
training 'lay counsellors' from the community.
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Nutrition is an essential part of any HIV care
package. Nutritional care and support includes many components, and
particularly when a person is asymptomatic, it must include an
adequate quantity and quality of food. But improved nutrition is not
enough in itself to permanently keep people healthy. History
provides evidence of this, as in the late 1980s many people with HIV
in the United States and other countries, developed opportunistic
infections, progressed to AIDS and died, even though they had an
excellent diet. However, good nutrition may help prolong the period
of time between HIV infection and the onset of OIs.
In some communities affordable food supplementation
may be feasible and it can have a positive impact on both body
composition and weight. For example, The AIDS Support Organisation (TASO)
has been distributing food to clients for 10 years as part of an
overall community outreach response in Uganda.
With regard to vitamins and minerals, it is unclear
to what extent these are helpful in the early stages of HIV
infection. Several studies have been published on the role of
vitamins and mineral in HIV disease progression and mortality.
Primary associations were initially promising and micronutrient
supplementation has the potential in a resource poor country to be
an affordable and relatively easy to deliver public health measure.
But the findings from micronutrient supplementation trials have
however been mixed.
Nutrition also plays an important role in regard to
the provision of antiretroviral drugs. The effects of ARVs are less
known in people with poor nutritional diets than in people with good
nutritional diets. What also needs to be considered is the
interactions that can occur between poor nutrition or food
restriction and some drugs, particularly protease inhibitors.
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When educating people about onward transmission of
HIV, two modes of transmission need to be considered:
• Transmission of HIV from one adult to another
• Mother to child transmission of HIV (MTCT)
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People who are HIV positive should receive
counselling to help prevent them from transmitting HIV to another
adult. Sexual behaviour counselling should include information about
safer sexual behaviour through condom use, fidelity and voluntary
abstinence. Counselling can be provided by lay counsellors from the
community, and should also challenge cultural barriers that may
otherwise prevent condom use.
Condoms are important in preventing the onward
spread of HIV, and they must be readily available to those who need
them. But providing condoms to people must not be seen just as the
provision of a commodity. Providing condoms must also involve
informed choice and empowerment as well as a supportive environment.
If people are to use condoms effectively in order to prevent further
transmission of HIV, they must know how and why they should use
them.
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Mother to child transmission (MTCT) of HIV can occur
during pregnancy, at the time of delivery, and after birth through
breastfeeding. An important part of the prevention of further
transmission of HIV is the education of a mother to be, about the
different options she has, and what implications the options have
for her health and her baby's health.
In general HIV positive women should avoid any
unnecessary invasive procedures during labour and delivery. There is
also some evidence that women who are seriously ill with AIDS are
more likely to pass HIV to their baby. So caring for the health of
the mother not only helps the HIV positive woman, but may also help
to prevent her child from becoming infected.
Transmission through breastfeeding is a significant
route of transmission of HIV, and the UN Task Team on MCTC
recommends that when replacement feeding is acceptable, feasible,
affordable, sustainable and safe, HIV positive mothers should avoid
all breastfeeding. But the vast majority of women breastfeed their
babies because they have no safe, acceptable or feasible
alternative. Even when breast-milk substitutes are provided free of
charge, serious obstacles may be present such as a lack of water and
sanitary conditions, confusion as to appropriate use, cultural
beliefs about what babies should ingest and stigma from family or
community.
If a woman is going to breastfeed, exclusive
breastfeeding is now recommended during the newborn's first months
of life, as some studies have found that non-excusive breastfeeding
may be an additional risk factor in transmitting HIV through breast
milk. WHO describes exclusive breastfeeding as the infant only
receiving 'breast milk from his/her mother or a wet nurse, or
expressed breast milk and no other liquids, or solids with the
exception of drops or syrups consisting of vitamins and mineral
supplements or medicines'. If a woman is going to exclusively
breastfeed then significant counselling and support will need to be
provided.
In many resource limited countries the
antiretroviral drug Nevirapine is now available free of charge from
the manufacturer. More generally when antiretrovirals do become
available they are often first made available as a part of MTCT
programmes. Antiretroviral drugs such as Nevirapine have the
potential of cutting HIV transmission by up to 50%, although they
will not eliminate HIV transmission if breastfeeding takes place.
Antiretroviral drugs are usually given to the mother during labour
and to the child within 72 hours of birth.
The provision of Nevaripine is to be greatly
welcomed, as it will prevent many children from being born HIV
positive. But the failure to provide antiretrovirals for the mother
at the same time has serious consequences. The child itself may
become orphaned when its mother dies of AIDS, and the woman may feel
that others only care about her child and not about her own well
being. And without the availability of antiretrovirals, a woman's
higher viral load may increase transmission through breastfeeding.
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Follow-up counselling can help an HIV positive
person to understand, cope with, and accept their HIV positive
status. HIV infection affects all dimensions of a person's life:
physical, psychological, social and spiritual. And counselling
should consider both the physical and mental well being of a person.
Counselling should inform people about the facts of
HIV infection. Correct information helps to dispel myths about HIV
and AIDS. In some counties many myths about HIV exists such as the
'virgin cure'. The 'HIV/AIDS virgin cure', sometimes known as the
'Virgin Cleansing Myth', is the mistaken belief that having sex with
a virgin will cure and/or prevent a person from developing AIDS.
Support is also crucial to the success of any
medical treatment. It is important that the person understands why
and how illnesses related to HIV should be treated. The person
should also be informed what treatment and care are available
locally and how they can access them. Even in very resource poor
countries with minimum infrastructure, some treatment can be made
available.
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Stigma and discrimination associated with HIV and
AIDS are one of the greatest barriers to preventing further
infections, providing adequate care, support and treatment and
alleviating the impact of HIV/AIDS. Stigma and discrimination are
triggered by many factors, including lack of understanding of the
disease, myths about how HIV is transmitted, prejudice, lack of
treatment and social fears. Stigma and discrimination can deter
people from getting tested, contribute to them infecting others and
prevent people who are infected from receiving adequate care and
treatment'.
Myths fuel stigma, discrimination and risky
behaviour. It is often believed that members of the community who
lead 'normal lives' cannot become infected with HIV and only those
who are immoral and promiscuous get infected. HIV/AIDS related
stigma and discrimination also make people afraid to find out
whether or not they are infected because of the fear of the
reactions of others.
Wider access to VCT can lead to greater openness
about HIV/AIDS and to less stigma and discrimination. Seeing other
people speaking out about their infection status can then encourage
other people to come forward for testing. If people get tested and
speak out when they are not seriously ill, this can change the image
of HIV/AIDS from illness, suffering and death to living positively
with HIV. If this is to happen, it is essential that people who
speak out be provided with adequate support. There are some examples
where adequate support has not been provided and people speaking out
have faced verbal and physical abuse.
The involvement of people living with HIV/AIDS in
activities for reducing stigma and discrimination is essential.
People speaking out about their HIV status is one of the first steps
to be taken in tackling stigma and discrimination. This can make
people to realise that HIV is part of their community and not just
'other people's problem'. The role of people who are HIV negative
should also not be underestimated. For example, HIV- negative people
speaking out about HIV/AIDS shows wider support for those who are
infected.
There is no single answer for overcoming stigma and
discrimination but there are many things that can be done to help
overcome them. No policy or law can alone combat HIV/AIDS related
discrimination. The fear and prejudice that lies at the core of the
HIV/AIDS discrimination needs to be tackled at the community and
national levels. A more enabling environment needs to be created to
increase the visibility of people with HIV/AIDS as a 'normal' part
of any society.
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Even if people have not been actively involved with
a church or religious group, many people find great comfort from
priests or other spiritual leaders during chronic illness. Others
however may feel pressurised into talking about spiritual issues by
loved ones, when they would prefer not to.
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Sexually transmitted infections (STIs) sometimes
known as sexually transmitted diseases (STDs) are a major health
concern in resource poor countries. Data from large number of
studies conducted in four continents provide evidence that an STI is
a co-factor for HIV transmission. An untreated STI can increase both
the acquisition and transmission of HIV by up to tenfold. This
suggests that STI control has the potential to play an important
role in the reduction of sexually acquired HIV transmission.
If an HIV positive person has an untreated STI, the
potential to spread their infection grows. A person who is HIV
positive and also has an STI may also progress to AIDS quicker.
Therefore, treating an STI during the asymptomatic stage of HIV is
important, since this can keep the person healthy for longer.
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The provision of antiretroviral drugs, sometimes
called antiretroviral therapy (ARV), is just one part of the
treatment and care that needs to be provided for HIV positive
people. Although great efforts are being made to provide ARVs for
resource poor communities, the reality is that for many communities
it will be some time before ARVs are available. In the meantime
there are many other things that can be provided, as described in
this document, and these will not exclude the provision of ARVs when
they are available. Indeed, when ARVs do become available the
availability of these other services will make the provision of ARVs
both easier and quicker.
When ARVs do become available, whether they are made
available for asymptomatic people will depend on a number of
different factors, and in particular the availability of CD4 tests.
If CD4 tests are available, then WHO recommends that ARVs should be
made available to an asymptomatic person if they have a CD4 count of
less than 200. If CD4s are not available then WHO recommends that
ARVs are not provided for people who are asymptomatic.
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