1. HIV AND AIDS FACTS

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1 1. HIV AND AIDS FACTS AIDS stands for Acquired Immune Deficiency Syndrome Acquired Something gained as opposed to something we have as part of our nature. Immune The immune system is a complex biological system that fights infections and keeps our bodies healthy. Deficiency A lack of or shortage. Syndrome A collection of symptoms that characterises a condition (not a single illness). HIV stands for Human Immunodeficiency Virus Human This virus can only be transmitted to and from human beings. It cannot be transmitted to or from animals. Immunodeficiency Immunodeficiency means a lack of or deficiency in the immune system. Virus A medical term for a tiny bit of biological matter capable of reproducing itself in living cells. It is the transmitted cause of infection. HIV IS THE VIRUS THAT CAN LEAD TO SOMEONE DEVELOPING AIDS Beware of confusing HIV infection with AIDS and be careful to clarify the issues with anyone who does not understand the difference. 1

2 2. STATISTICS In Namibia, figures for statistics are obtained during sentinel surveys. The Namibian Sentinel Surveys are part of unlinked anonymous testing programmes used widely throughout the world to estimate the spread of HIV infection in population groups. Such surveys use the blood of pregnant women coming for pre-natal care. The women don t know that their blood is being tested for HIV/AIDS and they don t get the results (as the tubes are anonymous it is impossible to trace back their origin). The reason for not telling the mothers is that if told, they could refuse. Such refusal could bias the results and the accuracy of the statistics. Therefore, sentinel surveys are anonymous, samples are taken at random during a sample period for statistical purposes only and individual results are not communicated back. Such surveys allow us to find out the number of infected people per country, region or geographic area. Such sentinel surveys are very different from testing of donated blood or individual testing: When someone donates his/her blood in Namibia, he/she fills in a questionnaire. Only if the person fulfils some requirements is he/she accepted for blood donation. Blood donation is not anonymous. The donated blood is tested for HIV/AIDS antibodies (see 3.4). Results of the test should be communicated back to the donor. However, this is not always done. Such samples cannot be used for statistic purposes, as only people fulfilling certain requirement are selected. Less than 1% of the blood donor population is HIV positive in Namibia. This is far below the national figures. When someone wants to know his/her own HIV/AIDS status, he/she goes for an individual test. A counselling session will be provided prior to the test and after the results have been received. Supportive counselling is possible in case of HIV positive results. Counselling is compulsory in case of individual testing. The HIV/AIDS infection rate is higher in Africa than in any other continent. This is probably due to: The widespread practice of having more than one sexual partner. Cultural practices such as polygamy and sexual initiation ceremonies. Cultural unacceptability of condoms in some population groups. Mobile workers who may have sex with others while away from home and may particularly engage in transactional sex (sex in return for money of gifts). The traditionally low status of women that makes negotiation of safer sex by women difficult. Social factors, such as the high incidence of rape and domestic violence. A high incidence of Sexually Transmitted Diseases (such as gonorrhoea, Chlamydia, Syphilis, etc.) due to all of the above and made worse by inadequately resourced health care resulting in late diagnosis and treatment. Increased vulnerability to disease resulting from poverty, malnutrition and unclean water. Practical difficulties of spreading health messages in populations that use many languages and may have little access to modes of mass communication such as radio and TV. The low standard of education in some population groups hinders the communication of complex health messages. Negative attitudes expressed towards those infected means that many people keep their HIV status secret thus rendering the epidemic and its consequences invisible. Behaviour change is unlikely in populations that do not own the reality of the epidemic. 2

3 Figure 1: AIDS epidemic in Namibia AIDS Epidemic in Namibia Number of cases In-patients adultes In-patients < 12 Deaths Years In Africa, the highest rates are encountered in the Southern part of the continent. In Namibia, the trend is really on the increase, with an average of 4% of HIV positive people out of the population in 1992 and 17,4% in This figure has most probably gone on increasing in the past 2 years. Figure 2: AIDS epidemic in Kunene Region AIDS Epidemic in Kunene Region Number of cases In-patients adultes In-patients < 12 Deaths Years 3

4 Table 1: AIDS National Year TOTAL In-patients adults In-patients < Deaths The figures are on the increase, with more and more cases reported each year. In Kunene Region, figures seem to be much lower than in the rest of the country. However, care must be taken not to reach false conclusions. It is possible that in Kunene Region cases are either not recorded or not recognised. Furthermore, infected people in Kunene Region may go to Oshakati or Windhoek for testing and treatment. Such in-patients will be recorded in the area where they have been admitted. Finally, in Kunene Region, it is known that people go back to die to their place. They do not die in hospitals. All these factors can contribute to the apparent low figures obtained in Kunene Region Table 2: AIDS Kunene Region Year TOTAL In-patients adults In-patients < Deaths In 1999, the number of deaths showed a decrease. This may be due to the fact the persons did not come to die at the hospital. Another possibility is that death are not being attributed to AIDS to avoid problems with insurance companies that currently discriminate on the grounds of HIV and AIDS. Photo 1: Andrew CLOCLOUGH presenting a session in Khorixas Teachers Resource Centre 4

5 3. HOW HIV/AIDS MAKES PEOPLE SICK The Human Immunodeficiency Virus or HIV makes people sick by attacking the Immune System of the infected person THE FUNCTIONING OF THE IMMUNE SYSTEM The function of the Human Immune System is to eradicate invading infectious agents such as viruses, bacteria, fungi, protozoa and parasites. It is the system in the body responsible to protect any individual from most infections. The Human Immune System is a complex system of cells with specific functions. These cells do not work in isolation, they work together like the regiments of an army or the instruments played by a group of musicians. Of central importance to the co-ordination of the immune system is a particular kind of white blood cells called CD4 T Lymphocytes, often abbreviated to just CD4 cells. CD4 cells are like the sergeants of an army or the leaders of a group of musicians. They play a central role in organising the other cells and co-ordinating their activities. White Blood Cells have got the characteristic to possess specific tiny receptors on their surface. White Blood Cells, as any other cells, possess a nucleus, DNA material and proteins. Figure 3: a White Blood Cell (scheme) In the presence of a virus, for instance the virus of the flu, White Blood Cells produce antibodies. Antibodies are very tiny proteins, able to fight against the virus. The antibodies are virus-specific. It means that the antibodies against the virus of the flu are different than the antibodies against the measles virus or the antibodies against the virus of polio. 5

6 Figure 4: production and role of antibodies 3.2. THE EFFECT OF HIV ON THE IMMUNE SYSTEM General presentation In the case of the HIV, the following will happen: Once HIV enters the blood of a person, it is recognised by the White Blood Cells as a virus. The White Blood Cells will start producing antibodies. Although the antibodies will kill a large quantity of HIV, HIV is able to mutate in ways that enable it to avoid the antibodies and so not all of the HIV will be killed. Meanwhile, the virus will attach itself to the CD4 White Blood Cells by using a molecule that is the exact match for the CD4 receptor. It is useful to consider the CD4 receptors as locks for which HIV has a matching key. Once it has attached itself, the viral membrane will merge with the membrane of the White Blood Cell and the genetic content of the virus will pass inside the White Blood Cell. The genetic content of the virus will use the genetic content of the White Blood Cells and proteins present to replicate itself. It will produce a lot of new viruses. Once the genetic material has been replicated, new viral particles bud from the surface of the infected cell and look for new White Blood Cells to infect. The infected White Blood Cells will eventually die. It therefore takes time before the virus has infected and destroyed enough White Blood Cells for the Immune System to start being deficient. 6

7 Figure 5: attack of the White Blood Cell by the HIV The stages of the infection The progress of the HIV infection can be classified into the following stages: Seroconversion Asymptomatic Symptomatic AIDS Initial infection When a sufficient quantity of live HIV enters the body via a susceptible route, the person becomes infected with HIV. Initially, the levels of virus in the blood will be very low. After a few days the levels of virus in the blood will begin to increase at a dramatic rate. The Body s Immune System will try to fight the infection by producing antibodies which bind to virus particles, attracting the attention of other Immune System cells which will then kill them. Most people start producing antibodies after about six to eight weeks (sometimes it can take up to three months, very exceptionally six months or longer). The point at which the person begins producing antibodies is called Seroconversion. There may be fever, swollen glands and occasionally a rash at the time of Seroconversion. More serious illnesses are rare. Some people experience no symptoms at this point and those that do are unlikely to suspect that HIV is the cause. 7

8 Asymptomatic period Following seroconverion, most people will remain well for several years. They have no symptoms and are therefore described as asymptomatic. During that period, the virus replicates millions of particles every day, which are destroyed by the Immune System. During that period, the Immune System is still strong enough to protect the individual. People are infectious to others during the asymptomatic period Symptomatic period Early symptomatic HIV infection is characterised by minor ailments of the skin, mouth, gut and respiratory system and other HIV related conditions, such as Persistent Generalised Lymphadenopathy, Hairy Oral Leukoplakia and night sweats AIDS The diagnosis of AIDS is based on a complex list compiled by the Centre for Disease Control in the USA. Doctors look at a range of symptoms and test results before making an AIDS diagnosis. The diagnosis is made on the basis of matching a number of criteria on the list. Different people match the list in different ways. The World Health Organisation has developed specific definitions of AIDS for developing countries where the progress of infection and standards of medical care are different. The conditions for an AIDS diagnosis therefore vary in different parts of the world. It is important to remember that symptoms and infections are often successfully treated, many infections can be prevented and there is no inevitable progression THE PRODUCTION OF ANTIBODIES AND ITS IMPORTANCE Just after infection, there is a huge replication of the virus inside the body, for about 4 weeks. It takes time for the Immune System to start fighting against this new disease. Therefore, the number of White Blood Cells decreases. After about 4 to 12 weeks, the White Blood Cells start to produce antibodies. As a result, the number of viruses in the blood decreases. It gives time to the White Blood Cells stock to re-organise itself. For several weeks, or months or years the level of virus will be low, the level of White Blood Cells will be normal and the level of antibodies will be high. However, the viruses keep on multiplying themselves and killing the White Blood Cells. Therefore, step by step, the number of viruses increases and the number of White Blood Cells decreases. The number of antibodies remain pretty high during that time. When the number of White Blood Cells is below 200/mm 3, the person becomes vulnerable to any germs (even bacteria or viruses that are usually harmless to the body can attack it and develop unusual diseases). This is usually the stage around which an AIDS diagnosis is likely. When the number of 8

9 White Blood Cells is becoming very low, then the number of antibodies also starts to decrease. In the latest stage of the disease, when the person is almost dying, the production of antibodies can even stop. Figure 6: evolution of the number of viruses, white blood cells and antibodies in an infected person 3.4. THE HIV TEST The antibodies are very important as: They contribute to the fight against the virus They are used for diagnosis purposes. To measure the number of White Blood Cells is not accurate, as other diseases can also affect this factor. It is possible to measure directly the number of viruses in the blood, but it is a very complicated and expensive test. Therefore, the easiest and most cost effective technique is to test antibodies. It is therefore important to understand the following: The virus is present in the body immediately following infection and it can be passed to other people. However, antibodies will not be produced for a while, typically 4 to 12 weeks after infection, but exceptionally six month or longer. During this period,. the infected person will test HIV negative. This is the window period. Such a person looks perfectly healthy, tests HIV negative but is highly infectious. After the window period, the virus is still present, as well as the antibodies. The infected person tests HIV positive. At the very late stage of the disease, it can happen that the production of antibodies stops. Then, the infected person may test HIV negative. However, it is easy, at that stage, to have a clinical diagnosis, as the person looks very sick. 9

10 Therefore, the diagnostic test detects the antibodies produced by the White Blood Cells. A person who is HIV positive always has the HIV virus in his/her body and can transmit it to other people for the whole duration of his/her life. A person HIV negative however is not always free of the HIV virus. He/she can have been recently contaminated and still be in the window period. This is the reason why a person at risk should always be tested twice, the second time after 3 months. There are advantages to knowing whether you have HIV or not: If you have HIV, you can look after yourself to stay healthy longer. If both you and your partner don t have HIV, and you are faithful to each other, you may decide to give up using condoms. It becomes especially important if you wish to make children. When someone is infected with HIV it takes up to three months before the signs of HIV can be detected in their blood by a test. During this period the person can still infect other people even though their test result will be negative. You may need two tests three months apart to be sure you don t have HIV. If your results after three months are still negative and you haven t taken any risks in the meantime, then it is unlikely that you have HIV. Having a negative test result does not protect you in the future; you must still follow the advice given to protect yourself. Everyone has a right to voluntary and confidential HIV/AIDS testing and counselling, as well as the right to information to make fully informed decisions. You can get HIV counselling and an HIV test at your nearest hospital. 10

11 4. GAME ONE: A DEMONSTRATION OF HOW HIV MAKES PEOPLE ILL No materials needed This demonstration will work best after the group has already received some information on: The difference between HIV and AIDS The function of the immune system How HIV attacks the immune system leading to a range of symptoms, illnesses and diseases 4.1. PREPARATION OF THE GROUP Ask for (or choose) one volunteer. Divide the remainder of the group into three and call them: White Blood Cells HIV viruses Diseases and illnesses. Give these people names such as TB, Diarrhoea, Pneumonia and Skin Rash Use terms suitable for the knowledge level of the learners group RUNNING THE DEMONSTRATION Ask the volunteer to stand in the middle of the room. He or she is the body Ask the people playing immune system cells to stand around this person quite close for them to protect the body. Ask the diseases and illnesses to try to grab and hold onto the person standing in the middle while the immune system cells protect him/her. Moderate this to ensure it doesn t become too rough. The point is to graphically demonstrate how the immune system is able to protect the person most of the time and even when the person is grabbed (made ill) the immune system cells can pull the disease or illness off again. Ask people to stop for a moment. Now ask the HIV viruses to come and hold on to the immune system cells to make it as difficult as possible for them to protect against diseases. Bring in the diseases again who should now be able to get through the defences of the immune system cells and grab and hold on to the person in the middle. 11

12 Photo 2: Explanation of the game to the group. The teachers playing White Blood Cells surround the teacher playing the body. Photo 3: Process: teachers playing diseases trying to attack the body while the ones playing White Blood Cells try to protect her. 12

13 4.3. PROCESSING Ask for questions and continue playing out the demonstration in different forms to explain the subject material in a depth appropriate to the group. Examples: Explain that even healthy people can get TB. Ask all the people playing diseases and HIV viruses to change role for a moment and all play TB. Ask this large group of TB to try and get past the immune system cells to grab the person in the middle. As there will be a lot of TB attacking they should succeed. Explain that for a person with a damaged immune system they will get TB more easily and it may be more severe. Remind people of the previous demonstration in which HIV compromised the immune cells letting the diseases through more easily. Replay the original scenario but send in the HIV viruses one at a time to show how HIV reproduces itself over time the person becomes more susceptible to illness. Use this to illustrate how people remain healthy for a long time then experience deterioration in health due to increasing immune damage. 13

14 5. HOW IS HIV PASSED FROM ONE PERSON TO ANOTHER? For HIV transmission to take place there must be: 1. PRESENCE of live HIV 2. In a sufficient QUANTITY to be infectious 3. Entering the body by a ROUTE vulnerable to infection 5.1. INFECTIOUS FLUIDS Body fluids that contain a sufficient quantity of HIV to be infectious to others are typically those that contain a significant quantity of White Blood Cells. In other words, in an HIV infected person, where there are White Blood Cells there will be HIV Body fluids that can be infectious Blood: this is the fluid that contains most of the White Blood Cells. It is therefore highly infectious. However, only fresh blood is infectious. Once in contact with the air and the light, the blood dries up quickly. Dry blood is not infectious (the virus cannot survive in the dry blood). Cleaning dry blood is not dangerous. It is advised however not to come into direct contact with dried blood as it can transmit other diseases because stronger viruses can still be infectious (for instance the virus responsible for Hepatitis B). Male sexual fluids (semen): the semen is highly infectious, not the sperm. The semen is the fluid that surrounds the sperm to allow it to survive and move inside the female genital organs. A lot of viruses concentrate in the semen, making it highly infectious. The presence of the virus in the semen is not linked to the presence of White Blood Cells (there are in a very small amount in the testicles) but to the presence of Langerhans cells (particular cells of the immune systems acting as messengers and sending messages to the ganglions in case of an infection). Female sexual fluids (vaginal fluids or juices): the vaginal fluids are extremely infectious. The vaginal mucous is very sensitive and very often irritated. There are always numerous White Blood Cells in this area. The amount of White Blood Cells is increased at the time of the menstruation, when there is also presence of blood. Pus: it is the result of the reaction of the body when attacked by some germs. It can be described as a whitish or yellowish liquid that issues from sites on the body being invaded by germs. Typically, these sites of infection are blister like pustules or abscesses. Being the answer of the body to an aggression, there is a huge amount of White Blood Cells present in the abscesses. Pus is a highly 14

15 infectious fluid. Great care must be taken when caring for abscesses on HIV positive persons. Furthermore, it has to be noticed that with some STDs there is production of pus in the genital organs. This is one of the reason why STDs increase the risk of transmission of HIV. Blisters: it is also the result of the reaction of the body when attacked by some germs, in case of burns and important skin frictions. Inside the blister is a thick liquid that contains a huge amount of White Blood Cells. This liquid is therefore highly infectious. Great care must be taken when caring for blisters of an HIV positive person. Again with some STDs there is presence of blisters on the genital organs. This is another reason why STDs increase the risk of transmission of HIV. Breast milk: it can be infectious. The milk is produced inside the mammary gland. There are no White Blood Cells inside the glands. However, at the time of the breast-feeding, the breast is full of milk. It is an inflammatory situation. Because of this situation, the number of White Blood Cells increases in this part of the body. As a result, White Blood Cells can go inside the mammary gland, into the milk Body fluids that can become infectious when mixed with blood Several of the body fluids do not in themselves contain HIV but they could contain HIV infected blood. It is the blood that is infectious and not the body fluid. This applies to: Urine: not infectious on its own, especially since it is acid. Small amount of sperm can be encountered in the man s urethra, but the virus will quickly be destroyed by the acids. However, blood may be present if there is an infection of the urinary tract. In this case, the urine may become infectious. Faeces / Diarrhoea: not infectious on its own but blood may be present Vomit: not infectious on itself but blood may be present. Acids from the stomach will quickly destroy HIV so this is an extremely unlikely method of infection Body fluids and other elements that cannot become infectious Other body fluids are not infectious at all: tears and saliva contain very tiny quantities of HIV (as they contain White Blood Cells) but never have enough HIV to infect someone else (one would need to drink 5 litres of saliva to get infected). Sweat contains absolutely no HIV. So HIV is NOT spread by sitting next to someone, using the same washing place, using the same toilet, swimming in the same pool, sharing bedding or towels, donating blood or having a blood test, sharing cups, plates, glasses, spoons or forks or living or working with someone who is HIV positive. Mosquitoes cannot transmit HIV. When the mosquito is sucking the blood, this one goes into the mosquito s stomach. In the stomach of the mosquito, the blood is digested (presence of enzymes and acids). Such digestion kills the HIV. Note that it is different from the transmission of Malaria. Malaria is a parasite that lives in both mosquitoes and human beings. Part of the life cycle of the malaria involves it living in the saliva of the mosquito. The mosquito injects saliva when it bites as an anaesthetic so that the victim does not feel the mosquito s presence. This is how malaria is transmitted to humans. On the other hand, HIV is not present in the mosquito s saliva and cannot survive inside a mosquito. 15

16 Note: alcohol and drugs weaken the Immune System. They cannot transmit HIV/AIDS one their own, but weakening the body they can easily contribute to the rapid development of the disease into AIDS. They also decrease the usual mind control of the person, inducing risky behaviours ROUTES OF TRANSMISSION Sexual intercourse Routes of transmission during sexual intercourse The most common way of getting HIV in Namibia is through having sex with an infected person. Infection occurs: During unprotected sexual intercourse (from the vagina to the penis or the penis to the vagina) During anal sex. It has to be pointed out that the skin around the anus is very thin and sensitive. It can easily be broken, especially during penetration, and bleed. It is therefore an open door for the virus to come in (contaminate the person that is penetrated) or go out (contaminate the person that is penetrating). Anal sex is practised between two men or between a man and a woman (used at times to avoid pregnancy, for fun or because the woman has got a STD and her vagina is sore). During oral sex. It is a less common route of infection, as the virus cannot survive in the mouth for long and, if swallowed, cannot survive in the stomach. It is only possible if there is a sore or blisters in the mouth or the lips. Table 3: possible routes of transmission during sexual intercourse Body fluid Route of transmission Activity Importance of the risk infected From To Penis Vagina Vaginal penetration Very high Semen Penis Anus Anal sex Very high Penis Month Oral sex High if ejaculation, rare without ejaculation Vaginal fluid Vagina Penis Vaginal penetration High Vagina Mouth Oral sex Rare Mouth Penis Oral sex Very rare Other Mouth Vagina Oral sex Very rare Anus Penis Anal sex High 16

17 Therefore the HIV can be transmitted through: The vagina: the wall of the vagina is made of a special, very soft and sensitive skin of the type known as a mucous membrane. HIV can easily pass through this type of skin.. Furthermore, sexual activity can produce small abrasion allowing blood to blood contact. The vagina is very sensitive to HIV infection. The penis: the HIV can go through the urethra or the soft skin at the end of the penis. Men who were circumcised at an early age will have harder skin on the head of their penis and may be less likely to get HIV. The anus: the wall of the anus is made of a very sensitive skin that can easily be broken in case of penetration. The mouth: it is difficult for the HIV to enter the body through the mouth (presence of saliva, that is not environmentally friendly to the virus and, if swallowed, of gastric fluids that will destroy the virus). However, in case of pus, blisters or sores on the lips or in the mouth, the possibility for the virus to enter the body cannot be excluded Importance of Sexually Transmitted Diseases People who have a Sexually Transmitted Disease (STD), particularly ulcers on the genitals, are at high risk of being infected with HIV/AIDS. Immediate treatment will reduce this risk. Some Sexually Transmitted Diseases produce pus, which contains large quantities of HIV. The risk of becoming infected with HIV/AIDS increases by almost 20 times if one of the partners has an STD. If one partner has genital sores, ulcers, inflammation or a discharge from the vagina or penis, he/she is at very high risk of becoming infected with HIV/AIDS and of passing it on to others. It is very important to get any genital infection treated immediately. All partners should be treated together and simultaneously. It is advisable to avoid sexual intercourse until the health worker advises that you are cured of the STD Direct blood contact Through direct blood contact: in case of an open wound, the sharing of blades or needles (body piercing or drug injection) and at birth (blood contact between the mother s blood and the baby see 5.2.3), transmission of the HIV can occur. In medical situations, blades used by doctors are sterilised after each use so that germs are not passed on. Table 4: possible routes of transmission during direct blood contact Body fluid Route of transmission Activity Importance of the risk infected From To Blade skin Blades used in High Blood traditional medicine Blade skin Sharing razors Rare Needle Piercing the skin Sharing needles or syringes High 17

18 Don t share anything that cuts or pierces the skin in the community. Note: blood may also be passed on during sexual intercourse, especially if: either partner has a Sexually Transmitted Disease or there are genital ulcers or the vagina is very dry The HIV CANNOT be transmitted through unbroken skin. It can only be transmitted through broken skin, meaning in case of an open wound or piercing, blisters or abscesses. The HIV cannot be transmitted through the nose or the ears. However, it has to be pointed out that the virus can be transmitted through the eyes. The eyes are enclosed in sockets lined with a special membrane that is extremely sensitive. Such cases have been recorded with medical surgeons accidentally receiving infected blood in the eyes while performing operations on HIV infected patients From the mother to the child A pregnant mother with HIV has a one in four chance of passing the disease to her child during pregnancy or, more frequently, at birth. There is a much smaller risk that a baby could be infected by breastfeeding after birth. In Namibia, most women don t have access to good alternatives to breastfeeding and if the baby is not properly nourished it will get other diseases. Mothers in Namibia should continue breastfeeding unless told otherwise by a health worker. Table 5: possible routes of transmission from mother to child Body fluid Route of transmission Activity Importance of the risk infected From To Blood Mother Child Problem with the (Pregnancy) placenta High (25%) Blood (at birth) Mother Child Direct blood contact Breast milk Mother (breast) Baby (mouth) Breastfeeding Limited (10-15%) It has to be pointed out that the mouth of a baby is still developing and is therefore more vulnerable than the mouth of an adult. Note: see chapter 7 for more details 18

19 Conclusion The only main ways in which HIV is spread are: Through having unprotected sex with an infected person By sharing anything that cuts or pierces the skin And from infected mothers to babies during pregnancy, birth or breastfeeding. HIV is transmitted much more easily if either partner has a Sexually Transmitted Disease. Photo 4: Dr Gérard BRULE explaining the routes of transmission in Opuwo, Teachers Resource Centre 19

20 6. GAME TWO: HIV TRANSMISSION GAME 6.1. MATERIALS Printed Cards: Header Cards Body Fluids That Can Transmit HIV and How HIV Can Get Into Someone s Body Set of cards printed with body fluids Set of cards printed with routes Flip chart and pens 6.2. STEP 1 Remind participants that for HIV transmission to take place there must be presence of the virus in a sufficient quantity to be infectious entering the body by a route vulnerable to infection STEP 2 Put the Body Fluids That Can Transmit HIV heading card down Place the body fluid cards face down and give one to each member of the group Ask each member of the group to take a turn and decide whether the fluid named on their card could carry an infectious quantity of HIV. The person with the card can ask the rest of the group for help if they get stuck. The trainer should make corrections if the group comes up with the wrong answer. If the fluid named can contain infectious quantities of HIV, place it in a column under the heading card. If it cannot contain infectious quantities of HIV, place it on one side. If it is not infectious on its own but might become infectious when mixed with blood (such as urine, faeces and vomit), place it next to the blood card STEP 3 Place the How HIV Can Get Into Someone s Body heading card down 20

21 Place the route cards face down and give one to each member of the group Ask each member of the group to take a turn and decide whether it is possible for HIV to infect someone by the route on their card. The person with the card can ask the rest of the group for help if they get stuck. The trainer should make corrections if the group comes up with the wrong answer. If HIV can infect someone by the route named, place the card in a column under the heading card. If HIV cannot infect someone by the route named, place it on one side STEP 4 Ask the group to consider each of the identified infectious body fluids one at a time by asking for each fluid, how might this fluid get in through the routes identified. Let the group discuss this and make any corrections necessary. Note the answers on a flipchart ensuring the main routes of infection are covered SOME KEY POINTS The group will likely get caught up in debates about small theoretical risks and far fetched what if. scenarios. The facilitator should ensure that the group makes a clear distinction between what is theoretically possible and what we know are the main routes of HIV transmission. The main route of HIV transmission in Namibia is sex. The main risk is through penis to vagina and penis to anus penetration. During penetrative sex HIV can pass from Man to Woman, Woman to Man and Man to Man. There is a lesser risk of transmission from penis to mouth. There are almost no recorded cases of transmission from vagina to mouth. There are no recorded cases of transmission from mouth to vagina or mouth to penis. Some Examples of Theoretical Routes of Transmission Sharing toothbrushes: no recorded cases world-wide but the possibility of blood to blood contact cannot be ruled out completely Sex between women where vaginal fluids are transferred from vagina to vagina on sex toys or fingers (there are only a few debatable recorded cases world-wide) Occupational accidents: if people are injured at the same time blood to blood contact can take place. This is an extremely rare occurrence. 21

22 Common Anxieties: Blood in food: an extremely unlikely route of transmission. If the food is hot the virus will not survive. Saliva produced in eating will inhibit HIV. When the food is swallowed the virus will be destroyed in the stomach. There are no recorded case of transmission through food. Living with someone who has open sores or wounds. Basic standards of cleanliness will provide protection. Blood from the wounds cannot get in to other people through healthy unbroken skin. Mosquitoes: Malaria is transmitted by the Mosquito s saliva which is injected into a bite as an anaesthetic so that the bitten person will be unaware of the mosquito s presence. HIV is not present in Mosquito saliva and HIV cannot live inside the Mosquito s stomach. It is not possible to get HIV/AIDS from being near or touching those who are infected with the virus. Hugging, shaking hands, coughing and sneezing will not spread the disease. HIV/AIDS cannot be transmitted by toilet seats, telephones, plates, glasses, spoons, towels, bed linen, swimming pools or public baths. HIV is not spread in any of those ways. We have no reason to fear those who are infected. In fact we should respond to them with kindness and love, they will need our support. 22

23 7. TRANSMISSION FROM MOTHER TO CHILD Pregnancy occurs when a male sperm meets with a female egg. The fertilised ovum first divides into two cells. Each of them then divides again, etc. The cells continue to divide in this way to produce a solid ball of cells, called sometimes early embryo. This early embryo travels down the oviduct to the uterus. Here it sinks into the lining of the uterus (this is the implantation of the embryo). The embryo continues to grow and produces new cells which form tissues and organs. After eight weeks, when all the organs are formed, the embryo is called a foetus. 1 Soon after the early embryo reaches the uterus, some of the cells, instead of forming the organs of the embryo, grow into a disc-like structure, the placenta. The placenta becomes closely attached to the lining of the uterus. It is attached to the embryo by a tube called the umbilical cord. 1 Figure 7: growth and development in the uterus (not to scale) WHY ARE ALL EMBRYO INITIALLY HIV NEGATIVE It is important, at that stage, to remember that the HIV can penetrate only the White Blood Cells, not any other type of cells. It can, however, be transported through the blood, the semen and the vaginal fluids. In the semen, the HIV is in the fluid, never in the sperm. Sperms are a special type of cells (called reproductive cells). They are very different from White Blood Cells. They do not have the same receptors on their membranes (see figure 3). The HIV cannot attach itself on the sperm. Therefore, all sperms are HIV free. The same applies to the female egg or ovum. The HIV is in the vaginal fluids, not in the ovum. Ovum are also special types of cells and do not have the same receptors as the White Blood Cells in their membranes. They are also HIV free. 1 Adapted from D.G MACKEAN (1986), GCSE Biology, editor John MURRAY, London 23

24 Therefore, when fertilisation occurs, it occurs between two cells that are HIV free. The HIV cannot be present in the fertilised egg. After fertilisation, all cells in the early embryo are HIV negative THE PLACENTA AND ITS FUNCTION It is not possible to understand the transmission of HIV from mother to child without understanding what the placenta is and how it works. The placenta is like a filter, allowing exchange of very tiny substances from the mother to the child. There in no direct communication between the mother s blood system and the embryo s blood system. The exchange of substances takes place across the thin walls of the blood vessels. Figure 8: the placenta The blood vessels in the placenta are very close to the blood vessels in the uterus, so that oxygen, glucose, amino acids and salts can pass from the mother s blood to the embryo s blood. In a similar way, the carbon dioxide and urea in the embryo s blood escape from the vessels in the placenta and are carried away by the mother s blood in the uterus WHY ARE ALL NEW BORNE BABIES HIV POSITIVE It has been said in 7.1. that all fertilised eggs from HIV positive mothers are HIV negative. They do not contain the HIV inside their membranes. However, all babies from HIV positive mothers are, at birth, HIV positive. It is important, at that stage, to remember that the HIV test is looking for antibodies, not directly for the virus. The infected mother has got antibodies against HIV. Antibodies are very tiny particles. Such as 24

25 the oxygen, glucose or amino acids, antibodies can pass through the placenta filter, from the mother s blood to the embryo s blood. Unlike the antibodies, both the viruses and the White Blood Cells are too big and cannot pass from the mother s blood to the embryo s blood through the placental filter. Therefore, even if the virus does not pass through the placenta, the baby will test HIV positive at birth because it has got the maternal antibodies. However, after 6 to 18 months, when the maternal antibodies will have disappeared, the baby will test HIV negative. All babies borne from HIV positive mothers test HIV positive at birth. However, only 25% are really infected and will remain HIV positive after 18 months. 75% will become HIV negative after 18 months. Figure 9: how are the maternal antibodies passing from the mother s blood to the embryo s blood 7.4. HOW CAN THE EMBRYO GET INFECTED BY HIV? During pregnancy During pregnancy, the embryo can get infected only if there is an inflammation of the placenta. If the placenta gets sick or damaged, then the filter does not work properly anymore and bigger particles can pass from the mother s blood to the embryo s blood. In such case, the HIV and White Blood Cells containing the HIV can pass from the mother s blood to the embryo s blood. This case is relatively rare. 25

26 Figure 10: infection in case of damaged placenta In this case, both the maternal antibodies and the virus are present in the embryo s blood. At birth, the baby will test HIV positive (because of the maternal antibodies). After 18 months, the baby will still test HIV positive (because of the baby s antibodies). The virus will develop in the blood of the baby. Such a baby is likely to get sick soon after birth and to develop an HIV-related illness in the two first years of his/her age At birth This is the most common case. At birth the mother is loosing a lot of blood. If she is HIV positive, the virus will be present in this blood. The blood will come into contact with the baby. It has to be pointed out that the eyes and the mouth of the baby are extremely vulnerable. Therefore, if infected blood from the mother comes into contact with the eyes or the mouth, then the virus can be passed to the baby. This is the most common route of infection from mother to child (rate of occurrence: 25%). Such a baby is likely to get sick soon after birth and to develop an HIV-related illness in the two first years of his/her age During breast-feeding It has been explained that the HIV is normally not present in the mammary glands. However, if the breast is in an inflammatory state, then White Blood Cells can be present and can pass into the milk. The mouth of the baby being sensitive, infection can then occur. This route of transmission is more seldom (rate of occurrence: 10 to 15%) and viruses are not that many (the quantity is rather small). Such a child is likely to live for a longer period and it is not rare to wait 10 years before the first HIV-related illness. 26

27 7.5. CONCLUSION At birth, 100% of the babies from infected mothers are HIV positive, because all of them have got maternal antibodies. It does NOT mean that all of them ARE actually infected. Summary Infection can occur during pregnancy (if the placenta gets damaged) or, more commonly, at birth. 25% of the babies from infected mothers (one in every four babies) will receive the virus in these ways mostly through transmission during delivery of the baby. 75% (three in every four) of the babies will never get into contact with the virus and will therefore not be infected. Table 6: testing of babies borne from infected mothers Infected mother Presence of virus HIV test at birth All infected mothers 25% of the babies have the virus into their HIV positive have got the HIV into blood system (infection during pregnancy or their blood at birth) 75% of the babies have not been into contact HIV positive with the virus HIV test after 18 months HIV positive HIV negative After birth, there is still a risk for the baby to get infected during breast-feeding (10 to 15% risk). In Namibia, most women don t have access to good alternatives to breastfeeding and if the baby is not properly nourished it will get other diseases. Mothers in Namibia should continue breastfeeding unless told otherwise by a health worker. Photo 5: Participants in Opuwo taking note on the transmission from mother to child. 27

28 8. YOU CANNOT TELL WHO IS INFECTED You cannot tell which people are infected with HIV, the virus that causes AIDS. People infected with HIV usually live for many years without any signs of disease. They may look and feel perfectly normal and healthy. But anybody infected with HIV can infect others. Nice good looking people are just as likely to already be infected as anyone else. Most people in Namibia have not yet taken an HIV test, which means that most people with HIV do not yet even know they have it themselves. You should assume anyone could be infected unless they have been tested and found to be free of HIV. Always remember the figure 7 chapter 3.3. For a long period, the infected person still has got enough healthy White Blood Cells to fight opportunistic diseases. This person will be like anybody else: mostly healthy and occasionally sick but getting better. It is only at the late stage of HIV infection, during the AIDS stage, that the person becomes really sick. Photo 6: Mr Andrew COLCLOUGH explaining to teachers in Khorixas that it is impossible to identify with naked eyes who is infected and who is not. 28

29 9. GAME FOUR: DEMONSTRATING HOW HIV CAN QUICKLY SPREAD IN THE COMMUNITY This can be a fast warm up exercise or a longer session that explores different scenarios. It is a simple demonstration of how HIV can be transmitted through a community from just a small number of people. The exercise will work best in medium to large groups and is not suitable for small groups MATERIALS One small slip of paper for each member of the group PREPARATION Count the number of people in the group and ensure you have the right number of slips of paper. On one fifth of the slips of paper (rounded up if necessary) draw a + symbol (representing HIV positive status). On another one fifth of the slips of paper (rounded down if necessary) draw a letter C (for condom). Leave the remaining slips blank. Fold all the slips of paper so that the writing is not visible 9.3. RUNNING THE EXERCISE For maximum impact do not explain what the exercise is about; ask everyone to stand up. Explain that you will give each person a slip of paper THEY MUST NOT LOOK AT IT! Tell participants to put it in their pocket or somewhere safe for the time being. Now ask everyone to shake hands with two other people. Tell them to stand at the edge of the room as soon as they have shaken hands with two people so that you can see when everyone has finished. Ask people to look at their slips of paper. Ask people with a + to stand at the front of the room. Carefully and sensitively explain that for the purpose of this exercise the group will pretend that the people with the + sign are HIV positive. Now ask the group to imagine that instead of shaking hands with each other, they have just had sex with each other. Ask the people who shook hands with the people with a + to come and stand at the front with them. Explain that you have had sex with someone with HIV and could now be infected. 29

30 Photo 7: at the beginning of the game, only Four members of the community are HIV positive Photo 8: by having each only 2 to 3 sexual partners, 13 people are now infected. 30

31 Ask if anyone who has come to the front has a C on their slip. If so, explain you used a condom and were protected you can go back to where you were. Ask anyone who shook hands with any of the people now standing at the front to come forward. Again explain that you have had sex with someone with HIV and could now be infected Ask if anyone who has come to the front has a C on their slip. If so, explain you used a condom and were protected you can go back to where you were. Repeat the above until nobody else comes forward. You will finish with: a group of people at the front who have been infected with HIV the people who used condoms standing where they were some people who were lucky enough not to get infected despite not using condoms 9.4. PROCESSING Explain that the number of people who had a cross at the start of the exercise was roughly equivalent to the average rate of HIV infection in the Namibian population (in the four Os regions it is already higher than this!) Explain that each person had sex with just two other people and ask the group to reflect on how far HIV has spread in their community Ask the group for comments 9.5. VARIATIONS If you have a fairly equal gender balance within the group, at the handshaking stage you can ask the men to shake hands with two women and the women to shake hands with two men. This may feel like a more realistic scenario for participants when you explain that they must imagine that they have had sex with the people they shook hands with. If time and group enthusiasm permits you can repeat the exercise using different scenarios Mix up and redistribute the slips again then ask people to shake hands with three other people. (this can be particularly useful if a lot of people were lucky enough not to get infected the first time you ran the exercise). It will show how for people who don t use condoms increasing the number of partners will increase the risk. Mix up and redistribute the slips again then ask people to choose just one partner and stand with them. This can be used to promote a discussion about faithfulness. It will also show that someone can be infected in a faithful partnership if their partner had HIV before the relationship started. This can be used to promote a discussion around HIV testing in relationships. You can also discuss what may happen if someone s partner dies or if a relationship breaks up. Increase the number of slips that have a C to half the group. This will demonstrate how when more people use condoms in the community HIV will spread less. 31

32 10. HOW TO PROTECT YOURSELF PROTECT YOURSELF FROM GETTING HIV THROUGH SEX The ABCD rule: A: Abstain from sex. Abstaining from sex altogether will protect you from being infected through sex. Young people in particular may want to protect themselves by not having sex so early on and then only later with a mutually faithful uninfected partner. It is also possible to abstain from vaginal or anal penetrative sex while still engaging in safer forms of sexual play such as mutual masturbation B: Be faithful to a faithful partner. Mutual faithfulness between two uninfected partners protects both people from HIV. The more sex partners you have, the greater the risk that one of them will have the infection and pass it on to you. The more partners your partner has, the greater the risk that he or she will be infected and can infect you. C: use a Condom. Using a condom is the easiest way to protect against HIV and many other Sexually Transmitted Diseases. Unless you and your partner have sex only with each other, and are sure you are both uninfected, you should reduce the risk of getting HIV by practising safer sex. Safer sex means non-penetrative sex (where the penis does not enter the mouth, vagina or anus), or using a condom (a sheath or rubber) every time you have intercourse. Even if a condom is used, anal intercourse (in which the penis enters the rectum or back passage) is much more risky than vaginal or oral penetration. D: face Death. If you do not chose any of the three above-mentioned option and have unsafe sexual intercourse, then face the risk of getting infected by HIV and die. We can remember the way to protect ourselves from HIV being passed on through sex by thinking of ABCD: A means abstain from sex B means be faithful mutual faithfulness between two uninfected partners protects both people from HIV C means use a condom every time you have sex D means face death, which is what people risk when they do not practise the above. 32

33 Note: unlike what is sometimes believed, people won t become crazy or mentally ill if they abstain. Some people choose to abstain from sex for their whole life for religious purposes (priest) but still live a normal and healthy life. A common fear among teachers and principals is whether talking about condoms in class would not encourage learners to use them and therefore initiate sexual relationships prematurely. It is important to note at this point that the last concern is only theoretical. Most research carried out in different countries has shown that the more you talk about sex, sexual related matters, sexually transmitted diseases and HIV/AIDS with learners, the later they start with sex (the longer they abstain). This can be illustrated by the following quotes: "Studies have shown that sex and AIDS education may lead to a delay in the onset of sexual activity, and to the use of safer sex practices among students who are sexually active" (School Health Education to Prevent AIDS and STD, Handbook for Curriculum Planners, WHO/UNESCO 1994) "Education about sex and AIDS does not encourage young people to have sexual intercourse: on the contrary, it helps them realise the consequences of sexual experimentation and avoid early pregnancies and STD, including AIDS" (School Health Education to Prevent AIDS and STD, Teachers' Guide, WHO/UNESCO 1994) It is also important to consider that realistically, in the modern world, people are likely to have sex before wedding. This is especially true in a school context, where boys and girls are both present and where peer pressure is important. For a lot of young people, condoms will be the only real option How to Use a Male Condom When demonstrating how to use a condom, ensure you make the following points Check the expiry date on the packaging. The expiry date is the date by which the condom must be used. Do not use the condom after this date as it may have become weakened. When there is no expiry date but a manufacture date, you can consider that the condom is valid for 4 years after the date of manufacture. Squeeze the condom down into the packet out of the way and tear the packet open carefully with your fingers. Do not use your teeth or anything sharp like a blade or scissors. The man s penis must be erect (hard). Remove the condom and check you have it the right way up. Squeeze the air out of the tip by holding the tip gently between your fingers. While still squeezing the tip, place the condom on the end of the penis. Using your other hand, roll the condom down the full length of the penis. The tip of the condom should not be pulled over the penis as it is there to catch the man s sexual fluid during sex. The man should pull out soon after sex is finished. Carefully slide the condom off the penis without spilling the fluid. Tie a knot in the condom and dispose of it carefully (burn it, throw it in a pit latrine, bury it). Don t put condoms down flushing toilets, they may cause blockages. Don t throw it away where small children can find it. 33

34 Figure 11: how to use a male condom (extract from safer sex saves lives ) How to use a female condom There is also an alternative to the male condom called a female condom or femidom, which is used by inserting it into the vagina. Female condoms are not yet widely available in Namibia but may be distributed in the near future. It has to be noticed that the female condom can be put in place before sexual intercourse and removed at a later stage. It allows more flexibility in terms of timing than the male condom. Check as well the expiry date. Squeeze the condom down into the packet out of the way and tear the packet open carefully with your fingers. Do not use your teeth or anything sharp like a blade or scissors. You will notice two rings: an inner ring and an outer ring. Squeeze the inner ring, and with your finger gently insert it into your vagina. When the man is about to penetrate, direct the penis in such a way that it will go inside the condom. After sex (but not necessarily just after the man has ejaculated), carefully pull the condom out the vagina without spilling the fluid. Twist the end of the femidom, wrap it in a tissue or piece of waste paper and dispose of it carefully (burn it, throw it in a pit latrine, bury it). Don t put condoms down flushing toilets, they may cause blockages. Don t throw it away where small children can find it Do not use more than one condom at a time It is very important not to use both a male and female condom at the same time. The friction generated between the two condoms may cause both to break. Likewise, it is not a good idea for a man to use two male condoms at the same time (one on top of the other), as friction between the two condoms moving over each other could cause both condoms to break. 34

35 Photo 9 and 10: teachers learning to demonstrate the use of male condoms Opuwo TRC 35

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