1. HIV AND AIDS PREVENTION
DR. DOREEN ASIMBA
CHS,

2. Historical Background
1981 – CDC(USA): Unexplained PCP/KS in previously healthy homosexual men
1984 – HIV virus clearly demonstrated to be the causative agent
1984 – First case of AIDS was described in Kenya
Human Immunodeficiency Virus (HIV) accepted as international designation for the retrovirus in a WHO consultative meeting

3. Modes of Transmission
Sexual contact most important mode of transmission/acquisition of HIV worldwide
Heterosexual
Homosexual
Non-consensual sexual exposure (assault)
Parenteral
Blood or blood products
Infected blood or body fluids through contaminated sharps
IDU through needle-sharing or needle stick accidents
Donated organs
Traditional procedures
Perinatal
Transplacental, during labor/delivery and breastfeeding
HIV is not transmitted by casual contact, surface contact, or from insect bites

4. Percent infection by transmission route….%
Sexual intercourse
70-80
Mother-to-child-transmission
5-10
Blood transfusion
3-5
Injecting drug use
Health care – eg: needle stick injury
<0.01

5. Biological Factors Influencing HIV Transmission
Disease status of source person
Degree of imunosuppression (primary infection , VL ,CD4)
Presence of untreated STIs in source & person at risk
High VL in genital secretions in STIs/disturbance of genital mucosa
A major reason for high prevalence in SSA
Circumcision status
Uncircumcised men 2x as likely to acquire HIV infection than circumcised. Also more likely to acquire STIs
Gender differences in susceptibility
Female genital anatomy presents a larger surface area
(Socio-cultural factors)
Genetic host differences

6. Socio-economic Factors Facilitating HIV Transmission
Social Mobility
Global Economy
HIV/AIDS follows routes of commerce
Partners living apart
Stigma and Denial
Denial and silence is the norm
Stigma prevents acknowledgment of problem and care-seeking
People in Conflict
Context of war and struggle of power spreads AIDS
Cultural Factors
Traditions, beliefs, and practices affect understanding of health and disease and acceptance of conventional medical treatment

7. Socio-economic Factors (cont’d)
Gender
In many cultures it is accepted for men to have many sexual relationships
Women suffer gender inequalities
Many women unable to negotiate condom use
Poverty
Lack of information needed to understand and prevent HIV
Drug Use and Alcohol Consumption
Impaired judgment
Sharing of needles and equipment

8. Behavioral Factors Multiple sexual partners
Unprotected sexual intercourse
Large age difference between sexual partners

9. Natural History and Progression Of HIV Infection

10. HIV AND AIDS
The hallmark of HIV and AIDS is a profound immunodeficiency as a result depletion of CD4+ T lymphocytes.
The CD4+ T cell depletion is two fold
Reduction in numbers
Impairment in function

11. HIV in plasma (copies/mL)
800
10,000,000
1,000,000
500
100,000
Non-progressors: normal CD4 count, low detectable viral load; no need to treat
10,000
1,000
200
100
100 50 10
Months Years
CD4 Count (cells/mL)
HIV in plasma (copies/mL)
HIV in plasma (“viral load”)
CD4 (T Cell) count

12. Natural History of HIV Infection
Rapid Progressors
5– 10%, AIDS 1-2 years
Intermediate Progressors
80-90%, Asymptomatic 5-8 years
Slow Progressors
5-10%,Good immune responses
10-15 years, Rare

13. Symptomatic Disease and AIDS
Viral load continues to rise causing
Increased demands on immune system as production of CD4 cells cannot match destruction
Increased susceptibility to common infections (URTI, pneumonia, skin etc)
Late-stage disease is characterized by a CD4 count <200 cells/mm3 and the development of opportunistic infections, selected tumors, wasting, and neurological complications).

14. Common Opportunistic Infections
Tuberculosis
Bacterial infections
Pneumonia
Gram negative sepsis
Pneumocystis pneumonia -PCP (now Pneumocystis jiroveci previously carinii)
Cryptococcal meningitis
Toxoplasmosis
Candidiasis
Infective diarrhoea
Herpes Zoster
Infective Dermatoses

15. Opportunistic Infections
The infections are an indication of how advance the HIV disease is 
Hence an indication of when to start ARVs 
A major cause of stigmatization
Prevention of OIs with ARVs

16. Important Messages about OIs
Opportunistic infections cause the vast majority of the morbidity and mortality associated with HIV
Most are readily treatable and/or preventable
Most of these treatments are simple, available and affordable

17. TB and HIV TB is the major opportunistic infection in Kenya
Since the onset of the HIV epidemic in the early eighties in Kenya, the prevalence of TB stopped falling and over the past 2 decades has risen sharply
HIV fuels the TB epidemic
HIV is the single most important risk factor for TB
>50% TB patients are HIV co-infected

19. TB and HIV TB occurs by reactivation of latent infection
newly acquired infection
HIV increases the risk of TB progression
HIV increases the rate of TB progression
TB may speed the progression of HIV disease
ART reduces the incidence of TB in PLHA
Annual risk of TB in the HIV-infected adults is about 10% (50% lifetime risk for HIV infected compared to HIV negative individuals)
Patients on ART remain at a higher risk of developing TB than HIV negative individuals

20. TB/HIV: Conclusion
TB a major cause of morbidity and mortality in HIV patients
TB occurs at any stage of HIV infection
EPTB/atypical presentations of TB more common in severe HIV disease
All co-infected patients should be started on cotrimoxazole prophylaxis as it reduces mortality
HIV patients on ART remain at risk of developing TB; active case detection important

21. TB Preventive Strategies
Routine neonatal BCG in all children except for those with AIDS/severe immunosuppression
Effective case finding and treatment of infected and infectious people
Treatment of latent tuberculosis infection (LTBI) = INH prophylaxis
Reduces the risk of
progression of recently acquired TB
reactivation of latent TB infection
Particularly in individuals with a positive Mantoux test
Benefits last up to 2.5 years
BCG vaccination prevents against severe forms of TB in children; it has little or no effect in reducing incidence of adult TB.
Transmission of TB in our hospitals not defined. The risk is real especially since most of the wards are not designed for TB treatment (poor ventilation and sun lighting). Known HIV positive staff should not work in designated TB wards (difficult where TB patients admitted into general wards. Isolation of infectious patients should be attempted where possible). TB patients/suspects should cover mouth when coughing particularly in crowded areas, using sputum pots with lids

22. ART is recommended for prevention:
“ART also is recommended for HIV-infected individuals for the prevention of transmission of HIV.”
HIV viral load directly related to probability of HIV transmission; increased ART use and lower community viral load associated with lower HIV incidence
May 2014

23. Post-Exposure Prophylaxis (PEP)
ARV prophylaxis is recommended for occupational and non-occupational high risk exposure.

24. Risk assessment after exposure to body fluids

25. Summary of medical management of medical PEP

26. Summary of medical management of medical PEP

27. PRE-EXPOSURE PROPHYLAXIS (PrEP)

28. Pre-Exposure Prophylaxis (PrEP)

29. GOALS OF PrEP THERAPY
To reduce the acquisition of HIV infection with its resulting morbidity, mortality, and cost to individuals and society
MSM, heterosexually active men and women, and IDU who meet recommended criteria

30. Recommended Oral PrEP Medications

31. STRATEGIES FOR PREVENTION OF HIV INFECTION: HIV NEGATIVE
Know your HIV status : HCT (testing & counseling)
BEHAVIOUR CHANGE & RISK REDUCTION : ABC,
PMTCT: -ve children
VMMC
POST EXPOSURE PROPHYLAXIS
PRE EXPOSURE PROPHYLAXIS
CULTURAL PRACTICES (FGM, wife inheritance)
EDUCATION/INFO (TBA, Public)
EMPOWER THE GIRL CHILD (education)
Commandment: DO NOT COMMIT ADULTERY

32. STRATEGIES FOR PREVENTION OF HIV TRANSMISSION : HIV POSITIVE
Behaviour change (consistent condom usage,
safer sexual and drug-use practices)
Early diagnosis : HCT (testing & counseling)
Antiretroviral treatment(prevents OIs, ↓incidence of Tb, ↓ risk sexual transmission)
Detection and treatment of STIs
Early diagnosis & treatment of OIs
Stigma reduction

33. SUMMARY: PREVENTION STRATEGIES
BEHAVIOUR CHANGE & RISK REDUCTION
ANTIRETROVIRAL THERAPY
HCT: Early diagnosis, Early Rx
POST EXPOSURE PROPHYLAXIS
PMTCT
VMMC

34. THANK YOU