AIDS action Issue 1 Page 1 2
Issue 1 November 1987
This is the first issue of AIDS Action, an International newsletter about a new disease, Acquired Immune Deficiency Syndrome (AIDS), sometimes called 'Slim disease'.
AIDS is spreading fast and is already a worldwide epidemic. The spread of AIDS threatens all countries and all individuals. It is a complicated and fatal illness normally involving more than one previously rare disease. AIDS develops in people who are infected with a virus called the human immunodeficiency virus, or HIV. Not everyone who is infected with HIV will go on to develop AIDS, but they can unknowingly pass the virus on to others.
Education: a powerful weapon
There is as yet no vaccine against HIV and no cure for AIDS. The most powerful weapon we have in the fight against AIDS is education - empowering people to make life-saving choices by changing their behaviour. AIDS Action aims to provide relevant information about all aspects of prevention and control of AIDS and HIV infection: the nature and epidemiology of the virus; 'risk behaviour' and non-risk behaviour (how you can be exposed to HIV and how you cannot); the care and treatment of patients with AIDS; research updates; social, economic and political impact; and international, national and local campaigns.
AIDS Action is for all those who can contribute towards fighting this disease: community health workers, doctors and nurses, ministries of health, international and local non-government organisations, community groups of all kinds (including youth and women's groups) teachers and those in the media.
The newsletter will build on the existing international readership involved in primary health care (PHC) activities who already receive Dialogue on Diarrhoea and ARI (Acute Respiratory Infections) News. It will be produced four times a year, and distributed to readers in developing countries free of charge. A French edition is planned for 1988.
Following in the traditions of Dialogue on Diarrhoea and ARI News, we hope that readers will write to us about their experiences and problems. AIDS Action is your forum for discussing approaches to prevention, treatment, and health education, and for exchanging information.
The first issue presents a global overview of the disease by Dr Jonathan Mann, Director of the World Health Organization Special Programme on AIDS (WHO/SPA); a question and answer page which covers some of the essential facts about AIDS, AIDS Related Complex (ARC) and HIV; and a resource list which gives an initial selection of internationally produced materials. The WHO/SPA will be contributing material for a regular insert, to keep readers up-to-date on worldwide AIDS prevention and control activities.
AIDS and the developing world
AIDS is a social, economic and political issue, as much as a medical one. For underdeveloped countries in particular, AIDS is one more serious disease to contend with. Other diseases remain major killers, for example, communicable diseases such as malaria, diarrhoea, tuberculosis and respiratory diseases. AIDS is not yet responsible for as many deaths as these diseases, but for this to remain true, action needs to be taken now. Health care resources worldwide - particularly in the developing world - will be drastically overstretched simply coping with the numbers of AIDS cases which will develop, based on estimated figures of individuals already infected with HIV.
An integrated approach
There is a danger that resources will be diverted from vital on-going PHC activities in favour of single focus AIDS campaigns. Existing programmes and curative services should be strengthened and combined with AIDS prevention activities: some PHC programmes have valuable experience to offer in effective community education and self-help activities. Wherever possible, existing channels should be used. AIDS prevention campaigns must be integrated with broader development activities - such as local water, sanitation, income-generating and educational projects.
The basic facts about AIDS are the same for all countries and all individuals. But there are still many questions to be answered. AIDS Action hopes to give voice to some of these questions and, where possible, to their answers.
The international newsletter for information exchange on AIDS prevention and control
Questions and answers
What is AIDS?
AIDS is on abbreviation used for Acquired Immune Deficiency Syndrome (a Syndrome is a set of conditions or illnesses).
What causes AIDS?
AIDS is caused by a virus known as the Human Immunodeficiency Virus (HIV). Once infected, it is probable that a person will be infected for life.
What is a virus?
Viruses are the smallest of all disease-producing organisms - too small to be seen through an ordinary microscope. Examples of other diseases caused by viruses include measles, polio, influenza. Viral diseases cannot be cured by antibiotics. Viruses can only reproduce within a living cell and, once inside may kill the host cell, or affect its ability to function.
How does the body react to viruses?
The body defends itself against viruses with white blood cells - which identify the virus invader and stimulate the body to produce antibodies which neutralise the virus. Each antibody type recognises and acts against only one specific virus. The presence of antibodies in the blood usually means that the body is responding well to a viral attack. Once the individual's immune system has 'conquered' a virus, he or she acquires a natural immunity to the disease. However, with AIDS, there is no natural immunity, and those with antibodies to HIV, usually have too few HIV antibodies, and these antibodies are also ineffective against the virus.
What is HIV?
HIV (Human Immunodeficiency Virus) is the virus which infects the body and causes the natural immune system, which usually enables an individual to fight off disease, to break down. When the virus was first identified it was called HTLV in the United States and LAV in France. The internationally recognised name is now HIV. It now seems that there are two types of HIV - the most common HIV1 and a more recently recognised virus (in West Africa) called HIV2.
What is HIV antibody positive?
This is a blood test result showing that a person has been infected with HIV lit does not mean that the person has AIDS. Seropositive means that blood contains a particular antibody. Someone who is HIV Seropositive has antibodies to HIV in his or her blood.
Is there a test for AIDS?
No. There is only a test for HIV infection. AIDS can be diagnosed through recognition of clinical symptoms people with AIDS may have several serious illnesses.
What is ARC?
A person with ARC has illnesses caused by HIV infection damage to the immune system, but without the opportunistic infections and cancers associated with AIDS. Many infections occur, including unexplained diarrhoea lasting longer than a month, fatigue, loss of more than 10 per cent of body weight, fever and night sweats. Other symptoms may also include oral thrush, swollen lymph glands, or enlarged spleen.
What are the symptoms of AIDS?
Symptoms include: Pneumocystis carinii pneumonia (a lung infection), weight loss, skin tumours (Kaposi's sarcoma), candida albicans (a fungus creating scabs and lesions on the lips, mouth and throat), degenerative brain disorders. It is characterised by a combination of diseases known as opportunistic infections. When it becomes apparent that someone is suffering from at least one opportunistic infection this indicates the onset of full blown AIDS. Opportunistic infections vary: in the U.S. and UK for example, pneumonia, and Kaposi's sarcoma are more common, in some parts of Africa, tuberculosis and persistent diarrhoea seem to be more common associated conditions.
What is AIDS dementia?
It seems that HIV can pass through the blood-brain barrier and can then destroy some brain cells, causing symptoms ranging from mild confusion, memory loss and poor thought processes, through to personality changes, premature senility and incontinence.
How is HIV transmitted?
HIV is mainly transmitted through:
sexual contact with an HIV infected person; this can be through sex between men and women, or between two men or two women. Having many sexual partners carries an especially high risk - the more sexual partners a person has the more likely they are to come into sexual contact with a person who is infected with HIV Some groups such as prostitutes and their clients are therefore particularly at risk;
infected blood entering the body, for example through receiving transfusions of blood from an HIV-infected person;
contaminated medical equipment, for example needles, syringes, razor blades used by traditional birth attendants (TBAs) or traditional healers, and any equipment used which comes into contact with blood, which may therefore come into contact with the blood of an HIV infected person. If used for another person such contaminated equipment may spread the virus;
maternal child transmission. It seems that infected mothers can pass the HIV to their unborn children, either during pregnancy (through the placenta), or during birth.
How can AIDS be prevented?
AIDS can be prevented by preventing the spread of HIV by:
preventing sexual spread;
preventing spread through blood contact;
preventing spread from mother to child.
Things which are not true about AIDS
Because AIDS is a new disease, rumours have been spread about it which are not true. For example, it is not possible to become infected with HIV or to catch AIDS from: sharing food, drinks, clothing, toilet seats; shaking hands; touching things that an infected person has used; or any general social contact with people at work, at school, in the home; from water or air; from utensils, e.g. cups, plates, cutlery; from mosquitoes or other insects; from a faithful sexual partner/husband/wife (i.e. those who have not had any other sexual partners) of many years; from donating or giving blood.
AIDS and primary health care
In general, live vaccines are not given to individuals suffering from immunodeficiency. This has implications for unimmunised children who may be immunosuppressed. However, the World Health Forum (vol. 8 1987) stresses that, in developing countries, the high risk to unimmunised infants and children of measles and poliomyelitis and other preventable diseases, far outweighs the risks from live vaccines, even in those who are HIV infected.
Care with BCG
Unimmunised individuals with clinical symptoms of AIDS in countries where target diseases of the Expanded Programme on Immunisation remain serious risks should not receive BCG, but should receive the other vaccines (see table). In countries where HIV infection is considered to be a problem - all infants and children, including those with asymptomatic infection (i.e. not showing any symptoms) - should be immunised with all the EPI vaccines according to the standard schedules.
Care with sterilisation
Since unsterile needles and syringes can transmit not only HIV infection but also other infectious agents, immunisation programmes must ensure that a sterile needle and a sterile syringe are used for each injection. WHO/UNICEF guidelines are as follows:
A single sterile needle and a single sterile syringe should be used for each injection. Disposable needles and syringes should only be used if it is certain that they will be destroyed after a single use Where reusable needles and syringes are recommended for use in developing countries, they should be steam-sterilised between use. Boiling is an acceptable alternative if steam-sterilisation is not available. The number of reusable needles, syringes and sterilisers should be adequate to ensure that operations are not slowed up by sterilisation requirements. The low cost of a new plastic syringes should now make this possible Disposable needles and syringes should only be used if it is certain that they will be destroyed after a single use. Disease transmission through the use of jet injectors is possible. Until the risks associated with different types of jet injectors have been clarified, their use should be restricted to special circumstances where large numbers of persons need to be immunised within a short period of time
Yvonne D. Senturia MD, Clinical Lecturer, Paediatric Epidemiology Department, Institute of Child Health, University of London, 30 Guilford Street, London WC1N 1EH.
Concern has been expressed over the possible role of breastfeeding in the transmission of the human immunodeficiency virus (HIV). However, there is little evidence to support this.
As the number of women of childbearing age infected with HIV increases, it is important to know whether or not concerns over breastmilk transmission of the virus are well founded. Although theoretically there are several ways that a mother could pass HIV to her child, the only certainty - according to current estimates - is that women who are HIV seropositive during pregnancy will, in 20-25 per cent of cases, transmit the infection to their unborn children (through the placenta). It is not known how many of these babies will be expected to develop symptoms of the disease.
There has only been one published report where HIV was recovered from breastmilk. It was this report which raised the possibility that breastmilk might be a source of transmission. To date, however, only three infants might have become infected in this way. All three children had been breastfed by mothers who had received blood transfusions after delivery, and were subsequently found to be infected with HIV. On the other hand, we know infants who have been breastfed by HIV seropositive mothers, but who were not infected with the virus. The evidence available, therefore, suggests that the risk of a mother passing HIV to her child through breastfeeding is very small compared with the risk of infection during pregnancy.
In view of the likelihood that breastfeeding does not appreciably increase the risk of passing HIV from the mother to her child, we must remember the positive impact of breastfeeding on the morbidity and mortality of children in the developing world. Breastfeeding is a safe, hygienic, inexpensive means of nutrition, known to decrease the incidence of respiratory and diarrhoeal infections.
AIDS: a global problem
Jonathan Mann, Director of the World Health Organization's Special Programme on AIDS provides a brief overview of the worldwide AIDS situation.
In 1981 the Acquired Immunodeficiency Syndrome (AIDS) was first recognised. The disease seemed to be limited to one country and to a single group of people. Since then, extensive national and international research has revealed a worldwide epidemic of human immunodeficiency virus (HIV) and related retroviruses*; now recognised as a major international health problem.
The numbers of reported cases of AIDS, and of countries reporting AIDS cases have increased dramatically. By December, 1982, 711 AIDS cases had been reported to WHO from only 16 countries. However, by 9 September 1987, 59,563 AIDS cases had been reported to WHO from 123 countries, representing all continents.
An additional 21 countries have told WHO that so far they have no AIDS cases to report. The number of cases reported to date represents only a fraction of the total cases. This is for various reasons including:
reticence in reporting cases from some areas;
under-recognition of AIDS;
under-reporting to national health authorities.
The total number of AIDS cases worldwide is estimated to be more than 100,000. Therefore the number of countries reporting AIDS cases shows more clearly the geographical extent and is more relevant in assessing the scope of the HIV pandemic than the number of officially reported cases. In addition, there is a long incubation period (up to six years or longer) from HIV infection to the development of AIDS. The number of AIDS cases therefore provides, at best, an inaccurate view, and at worst, an underestimate of the real extent of HIV infection. Worldwide, WHO estimates that between five and ten million people are currently infected with HIV.
Finally, recognition of additional human retroviruses, principally in Africa, suggests that HIV may be only one of a series of retroviruses capable of infecting humans and producing immunosuppression.
So far scientific knowledge about the natural history of HIV infection is limited to the five to seven year observation period since AIDS was first described.
Three major HIV-associated out-comes have already been identified:
HIV neurological disease
During a five-year period from the time of infection, 10-30 per cent of HIV-infected persons can be expected to develop AIDS. An additional 20-50 per cent are likely to develop AIDS-related illnesses. The proportion of infected persons who will have HIV neurological (to do with the nervous system) disease (particularly dementia) is unknown, but a large number of cases of progressive neurological disease among HIV-infected persons must be considered a possibility. Ultimately, the majority of infected persons may suffer from severe illness associated with HIV infection, or death.
Social and economic impact
The personal, social and economic costs of the HIV epidemic are enormous. Not knowing about the outcome of the disease and, in some places, rejection by the family and the community can cause great stress in those infected with HIV. Family structure is threatened both by the infection and by the loss of mothers and fathers. Social structure and economic activities will be greatly affected by a disease which mainly kills those aged between 20 and 40 years. This age group is most affected in every country where AIDS is a problem. The costs of AIDS are also enormous. In the United States, for example, it is estimated that the total cost of medical care for AIDS patients in 1991 will be 16 billion dollars. In some African hospitals, where between 20 and 50 per cent of adult patients on medical wards have AIDS or other HIV-related conditions, this places an additional burden upon health workers and limited resources.
The impact of the pandemic on health care, insurance and legal systems, economic and social development and entire cultures and populations is already enormous and will become more so. Health care workers are at the frontline of caring for AIDS patients and of preventing further spread of HIV infection. Many are trying to cope with the extra demands on their time and on resources caused by the AIDS problem on top of an already full primary health care workload.
AIDS: a global problem
The HIV infection appears to be spreading geographically as well as increasing in intensity in areas already affected. However, it is difficult to predict future trends. Further spread of HIV will occur, for several reasons:
Persons with HIV are likely to be infected for life; most will not develop any symptoms or show any evidence of illness for at least several years, during which time they may transmit HIV to others.
HIV is already a problem throughout the world, although current regional differences in levels of infection are quite significant.
WHO: a global response
After several years of preliminary activity, the WHO Special Programme on AIDS (SPA) was created on 1 February 1987. The Special Programme has put together, and raised funds to implement, a global AIDS strategy, with the support of every country in the world.
At the global level, SPA's role includes providing strategic leadership, facilitating information exchange, providing mechanisms for achieving consensus and coordination for scientific and educational research and development, and resource mobilisation and coordination.
The objectives of the WHO/SPA global strategy are:
to prevent HIV transmission;
to take care of HIV infected persons;
to unify national and international AIDS control efforts.
The principal components of global AIDS prevention and control are:
strong national AIDS prevention and control programmes;
international leadership, coordination and cooperation.
The Key components of national AIDS prevention and control programmes include:
political willingness to confront the HIV problem;
creation of a National AIDS Committee, representing the health and broad social interests involved in the HIV problem;
initial epidemiological and resource assessments;
establishment of a surveillance sys-tem for AIDS, and particularly for HIV infection;
development of in-country laboratory capabilities;
educational programmes for health workers at all levels;
prevention programmes directed to the general public and to specific groups in the population;
programmes for the care and management of HIV-infected persons, their sexual partners, families and other groups;
evaluation mechanisms based, as
far as possible, on indicators of HIV
WHO's work at the national level is
well underway. National AIDS Committees
have been established in over
100 countries. In 1987 91 countries,
including 40 in Africa, 30 in the Middle
East, Asia and Oceania, 15 in the
Americas and six in Europe have
requested collaboration with WHO to
develop, support and strengthen their
national AIDS programmes. Already
WHO has provided over 250 technical
support missions by health professionals,
and 50 countries have prepared
written plans for national AIDS prevention
and control. Uganda, Kenya,
Tanzania, Rwanda and Ethiopia have
put together medium-term (three to five year) plans and, in collaboration
with WHO, have received pledges of
funding from aid agencies to implement
these plans. In addition, 15
laboratory workshops have trained
approximately 300 laboratory workers from 90 countries; these workers will
then train others in their countries in
the latest HIV diagnostic methods.
The HIV epidemic affects both industrialised and developing countries. It represents an urgent and unprecedented threat to world health, the eventual magnitude of which cannot be predicted. Action taken now will have greater impact than action taken later. It must also be integrated carefully to fit in with existing primary health care priorities and to support existing primary health care strategies. AIDS prevention will strengthen primary health care efforts to provide sterile needles, to reduce the spread of all sexually-transmitted diseases, to improve the training of health care workers and to improve health promotion and education outreach systems. It is clear that the health care worker will have a central role to play. WHO will make every effort to support this role.
Dr Jonathan M Mann, Director, Special Programme on AIDS, World Health Organization, 1211 Geneva 27, Switzerland.
* The name 'human immunodeficiency virus' has replaced the earlier names for the AIDS virus (LAV and HTLV). Related retroviruses include LAV-2, HTLV-4 and other recently recognised retroviruses which are related to HIV with or without evidence of immunosuppression or clinical disease. In this article, 'HIV' stands for all of these viruses.
Uganda: an AIDS control programme
The government of Uganda has recognised that the AIDS epidemic is a serious threat to economic and social development. The Ministry of Health has therefore given AIDS control high priority and has initiated a comprehensive health education programme.
In October 1986 the National Committee for the prevention of AIDS was appointed to advise the Ministry of Health and coordinate related technical and operational activities. To strengthen the Committee, an AIDS Control Programme (ACP) was developed which includes a Health Education component (known as the National Health Education Programme on AIDS). The ACP has three main objectives:
to provide information to the population about how AIDS is transmitted;
to assist individuals to change risk behaviour;
to promote non-risk sexual behaviour.
Programme activities concentrate on the development of educational material, including:
information material for seminar, participants;
communication through radio and television;
brochures and posters, and the communication of health education messages through a number of channels;
special campaigns addressing target groups; a campaign for training trainers;
seminars for parents, teachers, religious and political leaders;
seminars for modem and traditional health workers in all districts, including private practitioners and midwives;
in-service training of staff.
Thirty-three health inspectors, based at district level, will be seconded to be in charge of health education, surveillance and staff administration, as well as promoting community organisation and participation. They will be in charge of between six and ten male and female health assistants, whose activities will be coordinated with other services such as environmental improvements, nutrition education and home visits.
Reaching target groups
The primary audience are members of high risk groups, mainly prostitutes and their customers. Special educational efforts are being targeted at these groups and messages are delivered in bars and hotels. There is also free distribution of condoms in all hotels.
It is estimated that 60 per cent of all children aged 6-13 years and approximately 10 per cent of all adolescents in Uganda attend school (a total of 2-3 million). Special efforts through school health education are being targeted at these groups using information materials produced by the Ministries of Education and Health. UNICEF is also preparing AIDS school health kits. Teaching about sexually transmitted diseases and AIDS will be included in schools' ongoing family life classes. Suitable channels for communicating with children and adolescents not attending school are being explored, for example through the resistance committees and the child-to-child programmes. The feasibility of revitalising tribal customs, linked to initiation of the young, including sex education, is being looked at through discussion with local chiefs, traditional healers, resistance committees and church leaders.
Health education activities targeted at adolescent girls and women of child-bearing age are approached through women's organisations, traditional midwives and other formal women's networks and church organisations.
Messages and media
The messages in the programme include 'Zero Grazing' which means keeping strictly to monogamous behaviour (one sexual partner) and requiring the same from husband, wife or sexual partner - and the slogan 'Love Carefully'. The fact that infected mothers can pass HIV on to their unborn children is an important message.
There are about three million radio sets and about half a million TV sets in Uganda. Much of the AIDS educational programme is being carried out on the radio. Programmes are translated into all (about 20) Ugandan languages.
Mrs. Faith Elangot, Deputy Chief Nursing Officer, Ministry of Health, PO Box 8, Entebbe, Uganda.
The following resource list is the first of an occasional series, covering new sources of information on AIDS and its prevention, from both developed and developing countries. The list is based on relevant materials we know to be currently available. Readers are encouraged to send in examples of additional resources relating to AIDS and its prevention, published in their own countries. In this way we hope future resource lists will most usefully reflect the activities and campaigns of our readers.
Academy of Educational Development (AED)
1255 Twenty-third St, N. W, Washington D. C. 20037; U.S.A.
Activities: USAID has granted $15.5m for a five-year contract to assist developing countries in implementing their AIDS education programmes. The project will work closely with WHO in supporting national programmes.
AIDS and Development Information Unit
8 Alfred Place,
London WC1E 7EB, UK
Activities: The Unit is establishing an AIDS Response Monitoring Network of Third World journalists to provide a better understanding of the social and political dimensions of the AIDS pandemic (see also books/manuals). In 1988 Panos will be collaborating with the Bureau of Hygiene and Tropical Diseases (see below) on a monthly newsletter World AIDS.
Bureau of Hygiene and Tropical Diseases
Keppel Street, Gower Street,
London WC1E 7HT UK
Activities: An information clearing-house, covering tropical and communicable diseases worldwide. The Bureau produces AIDS Newsletter (see below), disseminates information on current AIDS literature, and has an electronic AIDS database.
Clearinghouse on Infant Feeding and Maternal Nutrition
American Public Health Association, International Health Programs,
1015 Fifteenth Street, NW,
Washington DC 20005, U.S.A.
Activities: Resource centre with a collection of material (mainly North American and Western European publications) about HIV and AIDS.
International Planned Parenthood Federation (IPPF)
PO Box 759, Inner Circle,
London NW1 4LQ, UK
Activities: An AIDS resource unit has been set up to coordinate AIDS prevention activities within the IPPF's international, regional and national networks. Activities will include assessment of how AIDS affects on-going work; new activities relating to the prevention of AIDS including providing relevant training for FPA staff and consultants. The AIDS unit will produce a booklet giving the facts about AIDS using clear language and illustrations. A video is also planned, and FPAs will be provided with audio-visual equipment.
Teaching Aids at Low Cost (TALC)
PO Box 49, St. Albans AL1 4AX, UK
Activities: A flannelgraph will be produced early next year. Price: £17.00 plus postage and packing. A set of 24 slides relating to the AIDS epidemic will also be available in early 1988. Prices start from £2.50 (surface mail) or £3.10 (airmail) far 24 unmounted slides.
Tropical Child Health Unit (TCHU)
Institute of Child Health (ICH), 30 Guilford Street, London WC1N 1EH, UK
Activities: The TCHU is focusing on AIDS in children including producing low cost training materials, and supporting small scale local research.
World Health Organization Special Programme on AIDS (WHO/SPA)
1211 Geneva 27;
The Progress Report, number 1, April 1987 outlines WHO activities from June 1986-April 1987; including support to national AIDS programmes, and international activities.
Strategies and Structure: Projected Needs, March 1987 outlines WHO programme goals, strategies, organisations and projected development needs from 1987-1991. An annex contains an overview of the AIDS pandemic.
Equipment for Charity Hospitals Overseas (ECHO)
Coulsdon, Surrey, UK
Activities: Provides blood testing kits, low cost disposable needles, syringes, gloves, vehicles for AIDS outreach programmes, information on safe re-sterilisation of equipment. Relevant interests also include supply of generic pharmaceuticals, and maintenance of clinic and hospital equipment in developing countries.
AIDS and the Third World
Blaming Others: Racial and Ethnic
Aspects of AIDS
What is AIDS? A Manual for
AIDS: Questions and Answers
Preventing a crisis: How the problems
of AIDS affect Family Planning Associations
AIDS Nursing Guidelines
ABC of AIDS
AIDS in Africa: A Challenge to
People and AIDS
AIDS and You: Some Facts about the Acquired Immune Deficiency
AIDS: Facing the Worldwide
Threat. Network, Special Issue,
AIDS: The virus, its clinical features,
transmission and prevention
AIDS Resource Pack
WHO Report - Special Programme on Aids
WHO Report - Special Programme on AIDS
Health care workers are the main line of defence against the spread of AIDS and against the hysteria that fear of AIDS can cause
The WHO Special Programme on AIDS (SPA) is pleased to collaborate with AHRTAG on this newsletter for health core workers. The WHO REPORT will be a regular feature of each issue. It will provide an update of worldwide AIDS data reported to WHO, along with information from national AIDS programmes, of particular relevance to health care workers. Summaries of WHO scientific meetings and WHO guidelines will be included from time to time.
WHO's Special Programme on AIDS
AIDS cannot be stopped until it is stopped in every country. Thus, controlling the disease means attacking every method of HIV spread, in every country, using every scientific and educational tool. Health care workers are central to AIDS control both in treating AIDS and in preventing the further spread of infection. They face an enormous challenge; actions taken against AIDS must be integrated carefully within existing primary health care strategies. Health care workers must know thoroughly, and put into practice, measures for preventing the transmission of AIDS to themselves and to others. At the same time, they have a commitment to treat patients with dignity and respect and according to the highest professional standards, without prejudice or stigmatisation. To help them, WHO/SPA is developing guidelines.
This issue includes a summary of WHO recommendations for health care workers for preventing transmission of infectious disease through blood and blood products.
Preventing transmission through blood and blood products: recommendations for health workers.
has been documented from patient to Health Care Worker (HCW) (for example, through needlestick injury);
is suspected to occur from patient to patient (for example, through reuse of improperly sterilised needles);
is theoretically possible from HCW to patient (for example, HCW with draining lesion).
The risk to HCWs of acquiring HIV from infected patients is low. Where health care workers have acquired HIV infection in the work place, the route of infection has been through parenteral, mucous membrane or skin-lesion exposure to HIV-infected blood.
Parenteral exposure occurs when a HCW sustains a needlestick injury, scalpel cut or other sharp injury which introduces blood from an HIV-infected patient. Several prospective studies have shown that the risk of acquiring HIV infection after needlestick injury or other parenteral exposure to HIV is less than 1 per cent.
The risk of acquiring HIV infection after mucous membrane or skin-lesion exposure to infected blood is very low, but more difficult to assess. Individual case reports, however, document that there is a risk when health care workers contaminate open cuts or abrasions or mucous membranes (e. g. mouth, lips or conjunctivae - surfaces of the eyelid and eyeball) with HIV-infected blood.
There are three basic principles to follow to prevent transmission in health care settings:
universal blood and body fluid precautions;
use of alternatives to parenteral diagnostic or therapeutic procedures;
proper use of sterilisation and disinfection (to be described in detail in a future issue of AIDS Action).
Considerations for health care settings in developing countries
In developing countries, and in countries with under resourced health care systems, it may not be possible to follow all the recommendations described. Disposable gloves, for example, may not be available. When limited resources make it difficult to follow recommendations, other strategies which reduce needlestick and other sharp injuries, and avoid exposure of mucous membranes or open skin lesions to patient blood, need to be considered, including alternatives to parenteral diagnostic or therapeutic interventions for patients.
At a national level, AIDS programmes must be developed and strengthened through support for the education of health workers at all levels.
AIDS: a worldwide effort will stop it
WHO Report - Special Programme on Aids
Basic prevention: universal blood and body fluid precautions
Since blood and other body fluids are capable of transmitting HIV, Hepatitis B Virus and other infectious agents, HCWs should treat all blood and body fluids as if they were infectious. This approach, called 'universal precautions', should be used in the care of all patients, and is described below.
HCWs should wash their hands and other parts of their body which have been contaminated with patient blood or body fluids carefully with soap and water. Hands should also be washed immediately after removing protective gloves.
Gloves and other protective clothing
HCWs should wear gloves for all contact with blood and body fluids. When gloves are not available, another barrier should be used to prevent direct contact with blood (for example using a towel or thick piece of gauze to hold a blood-stained needle or syringe). Gloves should either be changed for new ones, or washed and disinfected after contact with each patient. When injuries from sharp instruments are possible (e. g. when cleaning instruments) wearing heavy autopsy gloves is recommended.
During procedures which are likely to produce blood splashing or aerosolisation of blood (spraying droplets in the air), the eyes, nose and mouth should be protected with a face shield or mask and protective eyewear. In situations where splashes of blood are likely (for example during birth) gowns or aprons should also be worn.
Needlesticks and other sharp injuries
Steps should be taken to reduce the risk of needlestick and other sharp injuries. Needles and other sharp instruments should always be handled with extreme care and stored in puncture proof containers.
Although HIV has been found in saliva, there is no conclusive evidence that this particular body fluid is involved in transmission. Nevertheless, to reduce exposure to HI\/; mouth pieces, resuscitation bags, or other ventilation devices should be available for use in areas where resuscitation may be necessary. Mouth-to-mouth resuscitation should continue to be used when other resuscitation methods are not available or possible.
With the use of the universal precautions described above no additional routine isolation is necessary for HIV infected patients. However, associated infectious conditions may require the use of additional measures, for example, enteric precautions for infectious diarrhoea, AFB (acid fast bacillus) precautions for active tuberculosis.
reducing parenteral and other invasive procedures
For protection of patients and HCWs, alternatives to parenteral and other invasive procedures or treatments should always be considered. Medical indications for giving parenteral (by injection) drugs should be reviewed carefully, and drugs should be given orally (by mouth), where possible. Similarly, medical indications for invasive diagnostic procedures including biopsy should also be carefully reviewed. Where adequate sterilisation of instruments after use for each patient cannot be assured, alternatives to invasive procedures should be considered (e. g. clinical diagnosis, empiric therapy).
AIDS: a worldwide effort will stop it
WHO Report - Special Programme on Aids
Open skin lesions
Precautions for HCWs providing home care to HIV-infected patients
Most persons infected with not requiring hospitalisation can be safely cared for at home. HCWs providing home health care have the same low risk of infection as HCWs in hospitals and other health care settings. They should follow the universal precautions outlined above, including use of gloves for contact with blood or body fluids, and disinfection of blood spills.
Prevention of transmission from HIV-infected HCWs to patients
In general, HCWs known to be infected with HIV pose no risk to patients and can continue work. However, HCWs with weeping or pus-producing skin lesions should not have direct contact with patients until the condition has healed completely. HCWs with HIV infection and immunosuppression may be at increased risk of infection, and, consequently of illness and death, from infectious diseases. Their personal health care provider and employer need to determine on an individual basis how safe it is for a HIV-infected HCW to care for patients and if it is necessary to change their work assignment.
All HCWs should be educated about the epidemiology and prevention of HIV infection and the principles of universal blood and body fluid precautions for use with all patients. Continuing education sessions should be held on a regular basis.
CDC Recommendations for prevention of HIV transmission in health settings. MMWR 1987; 36: IS-18S.
WHO/SPA. Guidelines for the Prevention and Control of Infection with LAV/HTLVIII. May 1986.
Gerberding J L, Bryant-LeBlanc C E, Nelson K et al. Risk of transmitting the human immunodeficiency virus, cytomegalovirus and hepatitis B virus to health care workers exposed to patients with AIDS and AIDS-related conditions. J Infect Dis 1987; 156; 1-8.
CDC Update: Human immunodeficiency virus infections in health care workers exposed to blood of infected patients. MMWR 1987; 36; 285-289.
McEvoy M, Porter K, Mortimer P et al. Prospective study of clinical laboratory; and ancillary staff with accidental exposures to blood or body fluid from patients infected with HIV. Brit Med J 1987; 294: 1595-1597.
HIV and AIDS: a worldwide effort will stop it
AIDS action Issue 1 11 Page 12
WHO Report - Special Programme on Aids
Provisional WHO Clinical Case Definition for Adult AIDS
Adult AIDS is defined by the existence of at least two major signs (see below) associated with at least one minor sign (see below), in the absence of other known causes of immunosuppression such as cancer or severe malnutrition or other recognised aetiologies.
Weight loss (10 per cent of body weight)
Chronic diarrhoea for longer than one month
Prolonged fever for longer than one month (intermittent or constant)
Persistent cough for longer than one month
Generalised pruritic dermatitis (itching and inflamed skin)
Recurrent herpes zoster (also sometimes called shingles)
Oropharyngeal candidiasis (yeasty fungus infection of the mouth and pharynx)
Chronic progressive and disseminated herpes simplex (blisters on skin, mouth and lips)
Generalised lymphadenopathy (abnormal enlargement of the lymph nodes)
The presence of generalised Kaposi's sarcoma (a cancer of the skin) or cryptococcal meningitis are sufficient by themselves for the diagnosis of AIDS.
This definition was developed during a WHO Workshop on AIDS in Central Africa, Bangui (October 1985) for use in areas where diagnostic resources are limited.
Other SPA publications of interest
Guidelines for Health Care Workers
This document is being revised for release in late 1987. The summary included in this issue us taken from the revised document
AIDS Technical Literature Update
This monthly publication includes brief summaries of approximately six important scientific articles about AIDS, short abstracts of approximately 10 additional articles and a selected bibliography of recent scientific publications about AIDS.
AIDS Health Promotion Exchange
This quarterly publication is addressed to those planning and implementing health education and communication programmes for AIDS prevention. It will feature articles about health promotion programmes, their strategies and evaluation.
If you are interested in receiving any of these publications free of charge, please fill out the order form below and send to WHO/SPA. Please ask only for those items you need and will use so that funds are not wasted.
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WHO/SPA/HPR, 20 Avenue Appia, 1211 Geneva 27, Switzerland.
AIDS: a worldwide effort will stop it
Managing editor: Kathy Attawell
Deputy editor: Hilary Hughes
Editorial advisory group (as of November 1987): Dr L Guerra de Maceda Rodrigues (Brazil), Dr K Fleischer (FRG), Professor K McAdam (UK), Professor L Mata (Costa Rica), Dr A Meyer (WHO), Dr D Nabarro (UK), Dr A Pinching (UK), Dr P Poore (SCF), Dr M Wolff (FRG).
Views expressed by the authors do not necessarily reflect those of AHRTAG or the editors.
AIDS Action is produced with support from Memisa Medicus Mundi, MISEREOR, Oxfam, Save the Children Fund and WHO/SPA.
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