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AIDS action  >  Issue  8 - Community-based care
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AIDS action  -  Issue 8 - Community-based care

AIDS home care team at Chikankata Hospital, Zambia

Issue Contents 
 

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AIDS home care team at Chikankata Hospital, Zambia

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Taking counselling and care into the community

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Setting up a team

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Counselling

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Gilbert's story

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Opinion

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Not just a Rabbi's responsibility

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African women against AIDS

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Working in schools

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Join the Club!

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What do the clubs do?

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How are the Zambian clubs organised and funded?

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How successful are the clubs?

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Oral signs of AIDS

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Fungal infections

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Bacterial infections

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Viral infections

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Oral manifestations: prevention and treatment guidelines

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Prevention

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Treatment

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Thrush

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Gum disease

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Letters

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Quality and proper use of condoms

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Resources

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Education in schools

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Manual - A Colour Atlas of AIDS in the Tropics

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Video - AIDS-Wise, No Lies

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Colour slide sets

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WHO Report - AIDS: a worldwide effort will stop it

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The role of non-government organisations (NGOs) in National AIDS Programmes

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What are the major areas for government and NGO co-operation in the ACP?

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How does NGO/government co-operation really work?

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What is the financial relationship between NGOs and the national programme?

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What do you see as the main direction for ACP/NGO co-operation in the future?

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Biomedical update

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HIV infection and drug research

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HIV-I and HIV-2

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Drugs which slow down or block the multiplication of HIV

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Explanation of scientific terms

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'Our lives, our world ...'

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Funding opportunity for NGO projects

 

 

 

AIDS action  Issue 8         Page 1   2  top of page

  Issue 8 September 1989

 

The following story is based on one of the daily activities of the AIDS home care team at Chikankata Hospital, Zambia. 

Doris is working in the maize fields, in rural Zambia, when a yellow van belonging to the AIDS home care team arrives at the farm. Two health workers, Zebron and Christine, are bringing the result of a blood test carried out on Doris' 18-month-old baby daughter.

Doris comes in from the fields, but insists on her mother being present before talking to Zebron and Christine. Gently, Christine tells Doris that the baby is infected with HIV, the virus that causes AIDS, and will need a lot of care because she will often be ill. She may not live long enough to go to school. Zebron explains how this virus is transmitted, and that Doris is probably infected. He suggests she and the child's father should have a blood test for HIV.

The problem is that Doris is not married to the child's father, a worker on the farm who already has one wife. He has promised to marry Doris as well, and has already paid the dowry. Doris says she will try to persuade him to come to the hospital, but she does not seem hopeful. Zebron will return next month and try to speak with the child's father - but only if Doris agrees. Zebron and Christine are members of a mobile hospital team which is providing HIV infected individuals with the medical and psychological support they need. One of the other major successes of the programme (described on pages 2-3) lies in the educational and counselling effect that home based care can have on the wider community. For example, if other villagers become frightened of catching AIDS from Doris' baby and begin to spread false rumours, Doris could ask the hospital team to help, by organising educational meetings with villagers in co-operation with the village Headman. The schools educator in the team could also speak to local schoolchildren and encourage positive educational activities, such as those organised by Zambia's anti-AIDS schools clubs (see page 5). 

Community care programmes, like the one at Chikankata, are based on two fundamental primary health care (PHC) principles. Firstly, co-operation between health and non-health services (for example, a local clinic and school). Secondly, community participation. This does not simply mean getting people to build their own pit latrines. It means the development of ideas and action arising from popular and/or traditional forms of organisation. In the case of Chikankata, the participation of village Headmen like Mr. Handa Bile (pictured here) is vital to the promotion of AIDS awareness in the local community. In any AIDS programme, all relevant forms of community based organisation, such as women's groups, should be encouraged. The Society of Women against AIDS in Africa (see page 4), formed to address the social and economic problems which prevent effective behavioral change among women, is an example. The Society aims to find ways of helping women like Doris, who are frightened of telling their partner 'Your child is dying of AIDS,' or women who, as yet uninfected by HI\/; cannot persuade their unfaithful lover to use a condom, or cannot risk leaving his home, quite simply because there is nowhere else to go.

Mr Handa Bile, pictured here with his youngest children

Mr. Handa Bile, pictured here with his youngest children, is Headman of Chikankata village, Zambia, and a keen AIDS educator. 

He asserts: 'God did not give me riches, but he blessed me with people to lead.' Mr. Bile works in cooperation with the AIDS home care team from the local Salvation Army Hospital. His home is used as a meeting place for discussions on AIDS.

 

In this issue 
 

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Home based care a case study from rural Zambia

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Oral signs of AIDS prevention, treatment and diagnosis 

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Clubbing together organising anti-AIDS clubs in schools

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Opinion from Rabbi Nilton Bonder in Brazil

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WHO Report biomedical update on HIV and drug research



The international newsletter for information exchange on AIDS prevention and control



AIDS action  Issue 8    1   Page 2   3  top of page

  Counselling

Taking counselling and care into the community

How does a hospital cope with the increasing demands of AIDS care and prevention without sacrificing work in other vital areas? Chikankata Hospital, in rural Zambia, may have found an answer.

The Salvation Army Hospital at Chikankata is 130 kilometres from the capital city, Lusaka, serving a mainly rural population of 100,000. It has 240 beds, with special units including leprosy, tuberculosis (TB), ophthalmology and nutrition. By 1987, the hospital was treating increasing numbers of AIDS patients. As the scale of the problem became more apparent, a British funding agency suggested converting buildings formerly used for leprosy patients into a small AIDS hospice. After careful consideration it was agreed that this approach would not be appropriate, particularly because the numbers of AIDS patients expected would far exceed the capacity of the hospice. 

Staff at the hospital eventually decided to try a new concept in the management of AIDS patients - home based care. The family network, not the hospital, would be the main means of caring for people with AIDS. But this would not mean leaving patients and their families to cope alone. The hospital would decentralise its services and visit patients in their own homes, providing medical, psychological and pastoral care through a small, mobile team.

The decision was based on the following assumptions:

 

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in rural Zambia, the family is the most effective means of supporting patients and assisting the hospital in providing clinical care and psychological support 

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as the incidence of HIV infection/AIDS increases, the decentralisation of case management is the most economic and effective way of providing patient care

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taking care into the community has an educational and counselling effect that extends beyond family members

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terminally ill patients prefer to die at home. 


Setting up a team
A small team of health personnel was organised to give the home based care idea a try. The team began by making weekly visits to patients within 20-30 kilometres of the hospital, reaching five to eight patients a day. Soon the team realised that home visits offered an ideal opportunity for 'contact tracing' - that is, asking about the patient's sexual partners (past and present) and trying to contact them for counselling and the possibility of blood testing. In addition, home based care presented new opportunities for educating family members about AIDS, and helping to dispel the many fears and false rumours spreading in communities. 

The pilot project was so successful that, two months later, the funding agency agreed to provide funds for a vehicle and its running costs, blood testing kits, medical supplies and other expenses. The home care team now consists of four people, including a clinical officer, a nurse, a schools educator and a driver. They are often joined by a social worker, a health educator or the project manager. The team travels through rural areas in a yellow van. 

Activities include:
 

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visiting people with HIV infection/AIDS in their homes to assess their physical, psychological and social needs, and to provide for these needs wherever possible

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counselling and education within families and communities, providing personal support and promoting changes in sexual behaviour

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contact-tracing

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evaluating the educational impact of their work on patients, families and communities. 


It may be thought that Patients would prefer not to attract local attention to their illness by having regular visits from the hospital team. So far, this has not been the case and the team is almost always made welcome by patients and their families. From the start of the programme in March 1987; up until the end of 1988, a total of 267 people with HIV infection, from 176 families, were visited in their homes. The team traced 105 contacts of HIV infected patients and took samples of their blood for testing. Among the difficulties faced by the team are the poor state of the roads and the remoteness of villages. Patients are often difficult to find; addresses are vague, and patients may be out working or travelling when the team arrives. In the future it may be possible to work more closely with rural health centres and community health workers and to give patients advance warning of team visits.



AIDS action  Issue 8    2   Page 3   4  top of page

  Counselling

 

Counselling 
Counselling is an essential part of the Chikankata approach to AIDS management. All individuals diagnosed HIV positive by a blood test are informed of the result as soon as possible. With the patient's permission, a close relative responsible for looking after the patient is also informed. The counsellor explains the various stages of HIV infection and the ways in which the virus is transmitted, encouraging the patient and other members of the family (if present) to ask questions. 

Wherever possible, patents are counselled before having a blood test. Usually, however, counselling takes place only after the results of the test have been received, because pre-test counselling is often not possible in a busy hospital where staff already have a very heavy workload. The counsellor also starts the process of contact-tracing; although sexual partners and family members are not told of the patient's diagnosis without the patient's consent. The patient may also ask the counsellor for advice or direct help in dealing with employers, workmates, or neighbors, which opens up the possibility of education and counselling within the wider community: a process which the Chikankata team describe as 'community counselling'.

The experience of Sinadambe community, situated on the northern shores of lake Kariba, is an example of how caring for patients within a family can lead to greater community awareness of AIDS. In December 1987; the Chief of Sinadambe called a meeting of all village Heads in his area to discuss the problem of AIDS. For several months the team had been visiting three AIDS patients in the area. One of them, the son of a village Headman, had died only a few weeks earlier. Surprisingly few people, however, were aware of the seriousness of the AIDS threat to themselves and their families. Some had not even heard about the disease, despite frequent radio broadcasts.

The meeting was held in the local primary school and attended by about 20 village Headmen. The discussion demonstrated how little these community leaders knew about AIDS: most wrongly believed that it was spread by shaking hands, sharing eating utensils, or standing in the shadow of someone with the disease. Few could accept that there was no cure, and felt that the traditional healers probably had a remedy. Finally the father of the young man who had received home based care up until his death, stood up and passionately spoke out, 'You all saw how my son suffered before he died. You all saw how he was. Have you ever seen anything like that before? There is no cure for this disease. It's something completely new. We have to do something now to stop it spreading further.' This meeting marked the start of a gradual process of raising people's awareness of the seriousness of AIDS and for the urgent need for changes in sexual behaviour to reduce further transmission.

As in the counselling of individuals or families, the home care team spend a great deal of time listening and learning about people's attitudes before giving information or trying to guide discussions at public meetings. The emphasis is on helping people develop a sense of collective responsibility for dealing with the threat of AIDS. The team is now involved in community counselling in four different types of communities: traditional villages, commercial farms, periurban farming settlements and one urban area. One common problem is stigmatisation of people suspected of having AIDS.

Rural Zambia -a member of the AIDS home care team takes a blood sample from a patient, inside the hospital van.


Gilbert's story 

Gilbert, for example, worked as a labourer on a commercial farm about 20 kilometres from Chikankata. He had been unwell for several weeks and had sought treatment for a persistent genital ulcer; his workmates suspected he had AIDS and were frightened of catching AIDS from him at work. They insisted that he took an HIV antibody test so they could know the result. The hospital stated that a test could be done but that the result would not be given to anyone without Gilbert's permission. Gilbert was found to be HIV positive. 

At this point the home care team offered to visit the farm and discuss the problem. The meeting created enormous interest, and was attended by over 50 workers and their families. Initially, everybody was very tense, as speaker after speaker got up and expressed fears of catching AIDS from someone at work. Without referring to Gilbert in particular, the team explained that it was impossible to catch AIDS during normal social contact with an infected workmate; the only risk was through having sex with that person or with that person's sexual partners. The most effective way of avoiding exposure to the virus was to have one faithful partner for life. The meeting reduced tension in the community, at least temporarily. Gilbert continued working at the farm for several months before returning to his home village for terminal care. He left behind a farming community better able to discuss and confront the problem of AIDS. As Thebisa Chaava, social worker and head of the counselling team points out: '...the only long term hope for prevention is for communities themselves to feel a sense of responsibility for dealing with AIDS. They are the only ones who can change their behaviour and stop the spread of the virus.'

This article is based on two booklets due to be published in November 1989: 
'AIDS Management - an integrated approach'
by Dr Ian Campbell and Glen Williams. A case study aimed at health practitioners and planners. Includes hospital and home care treatment protocols.

'From Fear to Hope; AIDS care and prevention at Chikankata hospital, Zambia'
by Glen Williams. Describes a home care programme for people with HIV infection/AIDS in a rural area. Aimed at policy makers, health professionals, field workers and community leaders.

These publications are part of 'Strategies for Hope', a new series of printed and audiovisual materials on AIDS control in developing countries, published by Action Aid, AMREF and World in Need. Both booklets are available from: Action Aid, Hamlyn House, Archway, London N19 5PG, UK. Price £1.50 each (includes package and postage worldwide). SPECIAL OFFER Organisations in sub-Saharan Africa may order up to 25 copies of each booklet free of charge, while stocks of the first edition last.

Chikankata Hospital offers free training courses for those working on AIDS prevention and control in Africa. For further information please write to: Captain (Dr.) Ian Campbell, The Salvation Army Hospital, Chikankata, Private Bag 52, Mazabuka, Zambia.





AIDS action  Issue 8    3   Page 4   5  top of page

  Opinion / News

Not just a Rabbi's responsibility

From Rabbi Nilton Bandel;
in Brazil
'Within the Jewish community, AIDS was first seen as the 'Rabbi's problem' - that is, it was the Rabbi who was expected to provide pastoral care when called upon. I am one such Rabbi. While living in the United States in the early 1980s, I found myself working with AIDS patients in a New York hospital, with almost no guidance from state or religious leaders on e building a communal response to the growing crisis.

Rabbi Nilton Bonder 

Since then, things have changed considerably in the United States. AIDS slowly forced religious and lay communities to face particularly controversial issues, such as sexuality and homophobia (hatred or fear of  homosexuality), and theological questions, such as the belief that AIDS is a 'punishment' of the 'guilty'. Many  religious movements have set up special AIDS committees. One of the most effective is the National Committee on  AIDS, formed by the Union of American Hebrew Congregations, which  provides practical and emotional support to those who suffer from AIDS, has developed health education materials and participates in the AIDS Pastoral Care Network.

 
Being a disease that does not stop at religious or geographical boundaries, AIDS has exposed the need for an institutional framework to provide support to Third World prevention and control programmes. This is how the World Jewish Service and the Hessed Institute were started, with the aim of supporting community based health and development programmes. 

However, when I returned to my native country, Brazil, I found a very different situation. Although many Jews are involved individually in fighting AIDS, the community itself has not been active collectively or institutionally. The response has been restricted to pastoral care, carried out by a few Rabbis like myself. My work within the group Religious Action Against AIDS (ARCA) - part of the Religious Studies Institute (ISER) in Rio de Janeiro -  forms the beginning of efforts to inform and organise the Jewish community as a whole.

We are developing a curriculum on AIDS for our Bar and Bat Mitzvah celebrations with young adults. AIDS is now an issue for our sermons. I have also written articles for Jewish-magazines on AIDS and have been interviewed on television. At first, the community was shocked to learn that some of its own members could be, or were, HIV positive; shocked that AIDS is also a 'Jewish' question. A Jewish question which could provide an important link between the Jewish community in Brazil (one of the largest in the Third World) and a wider Brazilian reality. Jews are only now under standing that AIDS must be responded to collectively by working together with other members of the national and international community. In this sense, AIDS has one positive side effect - to open up new areas for human understanding, interreligious  and political debates, and for developing solidarity between religious and lay communities alike.'

Rabbi Bonder was ordained by the Jewish Theological Seminary and is the Rabbi of the Jewish Congregation of Brazil.

Readers are invited to write in with  their contributions to AIDS action 'Opinion' page.

African women against AIDS

A group of African professional women has formed a regional organisation to carry out research, education and development activities aimed at helping women protect themselves and their families from AIDS. 

The Society for Women and AIDS in Africa (SWAA) was formed in June 1988 during the Fourth International Conference on AIDS in Stockholm, Sweden. SWAA's first major event was a four-day international workshop, held in Harare, May 1989. The workshop provided a forum to discuss a range of women's health problems, including prostitution, reproductive health, and hetero-sexual transmission of HIV The event was officially opened by the Zimbabwean Deputy Minister of Health, Dr Swithun Mombeshora, and was the first meeting of its kind, attracting 90 participants from 14 English and French-speaking African countries. 

Speaking about AIDS prevention activities among female prostitutes, the President of SWAA, Dr Fathia Mahmoud, a Sudanese obstetrician and gynecologist, said: 'It's not just a matter of giving out condoms to prostitutes and their clients - we are concerned that the social and health problems of female prostitutes should be addressed.' This message was also stressed in a speech given by the First Lady of Zimbabwe, Sally Mugabe, when she introduced the conference delegates to a group of women who, five years ago, were working as prostitutes. In an attempt to make a better life for themselves, some of the women got together to seek assistance to start an income-generating cooperative. The First Lady donated an initial Z$300, and with additional financial support from other sources, it was possible for the women to rear and sell chickens, and to set up a food bar and nursery school.

In preventing heterosexual HIV transmission by changing their own and their partners' sexual behaviour, women face a number of problems, including: lack of decision-making power over sexual behaviour or traditional practices such as polygamy and widow inheritance; cultural and religious taboos which prevent discussion of sexual practices, AIDS and STDs. 

Workshop recommendations considered cultural, social and economic realities affecting the role of African women in HIV prevention and control, and were aimed at finding practical solutions. Both women and men are welcome to join SWAA. For further information, and membership, please write to: Dr N. P. Luo, Treasurer, SWAA, UTH, Dept. of Pathology and Microbiology, PO Box 50110, Lusaka, Zambia.





AIDS action  Issue 8    4   Page 5   6  top of page

  Working in schools

Join the Club!

In 1987, Dr Kristina Baker visited a secondary school in Lusaka, Zambia, to talk to students about AIDS. They were obviously interested and wanted to do something to help. Dr Baker suggested starting an anti-AIDS club. Students took up the idea, and with Dr Baker's help, they worked out activities and club promises for members. There are now nearly 200 similar clubs in Zambia and more are forming in neighboring countries. Dr Baker explains about their activities and gives advice on setting one up.

There are three main aims to anti-AIDS clubs, reflected in the club promises each member has to make (in other countries, different promises may be considered more suitable)
 

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I will avoid HIV infection/AIDS by avoiding sex before marriage, and outside marriage

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I will help my friends and relatives to protect themselves by telling them about HIV infection and AIDS 

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I will help people with HIV infection/AIDS as much as possible.


Each school club has an adult 'patron' usually a teacher at the school, who helps students run the club.

What do the clubs do? 
Each club develops its own organisation, rules and activities, so each is slightly different. Some clubs are very active; others less so. After getting permission from the head teacher or community leader, a committee of interested members can be formed to plan future activities and to write the membership rules. 

Firstly, all committee members should carefully read and discuss information on AIDS with an adult who is well informed (for example, a nurse or doctor from the local hospital or clinic). Why not order back issues of 'AIDS action' and select articles for discussion?


Club activities could include: 

doing a local survey
to find out what school students and members of the public believe, or know, about AIDS. Use the results of this to plan information campaigns.

making and circulating membership cards, which members can sign and keep, and which have club promises written clearly on them.

offering help to people with AIDS
such as doing the gardening, carrying water, helping with the children, taking messages, and to act as an example to others in the community.

organising fundraising activities
for printing educational materials, a club magazine (see below) and posters, providing support to patients and their families. It is also worth approaching the parent-teacher association, local health workers and the Notional AIDS Committees for club funds.

organising educational activities for example, using the subject of AIDS and other sexually transmitted diseases (STD) as the base for school projects in science or English; organising school quizzes and debates; inviting outside speakers from the local hospital or clinic where AIDS patients are being treated; writing and rehearsing plays or songs about HIV infection; organising a 'design a poster' competition with prizes for winning posters; practising writing and giving talks on AIDS. Talks must be short, accurate and interesting. If you have access to a slide projector, low-cost, colour slide sets on AIDS/HIV infection are now available (see page 8).

Try producing a short, local club magazine in duplicated form. The magazine could include: poems, stories, cartoons, and a section for readers' letters and questions (these should be answered anonymously where requested). Why not provide a special club mail box in school for people to put their written questions about AIDS and other STDs? Correct answers should be published in the club magazine.

How are the Zambian clubs organised and funded?
After the first few school talks were given, the project was offered financial support from NORAD (the Norwegian Agency for International Development) to help run an AIDS education campaign and expand and co-ordinate clubs nationwide. The anti-AIDS club project now has an office and a widely publicised postal address. 

People write to us for information about AIDS and also for educational materials - such as booklets, posters, a club Resource Pack including samples of club badges and membership cards - which we were able to develop and print with NORAD funds. We send out a leaflet called 'Information about anti-AIDS clubs' with ideas about starting up clubs, and the office keeps a record of established clubs and their addresses. This regular contact is important, to keep clubs active and interested. However, clubs do not need external funding to be effective, nor do they need a central office. It costs nothing for a school student to talk to his friends about AIDS!

How successful are the clubs? 
When lots of students are members of anti-AIDS clubs, it is tempting to feel satisfied that many young people are hearing about AIDS. But will the sexual behaviour of these students actually change? We cannot tell the success of the project by looking to see if numbers of AIDS patients are going down, since people who become ill now were often infected years ago. Perhaps the best way to measure sexual activity in schools is to look at the number of schoolgirl pregnancies and STD rates among students. 

Schoolchildren are an essential target group for AIDS education, and everyone involved in health education should try their best to reach this group. The anti-AIDS clubs are one idea among many others.

For further information, and addressees of existing school clubs, write to: The anti-AIDS project, P/Bag RW 75X, Lusaka, Zambia, Central Africa.



AIDS action  Issue 8    5   Page 6   7  top of page

  Oral signs of AIDS

Oral signs of AIDS

Diseases of the mouth can often be the first indication of HIV infection. Dr Jens Pindborg, from the WHO Collaborating Centre on Oral Manifestations of HIV, describes the most common symptoms.

Oral diseases are found in people infected with HIV both during the early and final stages of infection, as well as in sick and/or malnourished individuals not infected with HIV. Many of the oral signs of AIDS are the same common diseases which occur in people without HIV infection/AIDS, for example, oral candidiasis (thrush) which commonly affects malnourished babies, and the elderly. A diagnosis of AIDS, therefore, cannot be made on oral signs alone. 

However, people with HIV infection often develop diseases of the mouth before any other visible sign develops. Because of this, dentists are likely to be the first health workers to recognise these symptoms and are best placed to provide treatment and to refer patients where necessary for full medical examination and counselling. For this reason, dentists should be encouraged to participate more fully in the diagnosis and management of AIDS patients.

In 1986, the European Economic Community classified over 40 different oral diseases associated with HIV infection (1). This classification is used to help dentists, dental hygienists and physicians to diagnose infections associated with HIV infection/AIDS. The most common of these are out-lined below.

Fungal infections

The most common oral infection associated with HIV infection is candidiasis (thrush), a pseudomembranous type which looks like large white patches on the palate (roof of the mouth and the buccal mucosa (inside cheeks) and which can be scraped off (see photo). The majority of epidemiological surveys in the developed world indicate over 40 per cent of HIV infected individuals develop candidiasis. There are fewer surveys available from developing countries. Another less common type of candidiasis, erythematous, has also been associated with HIV infection, where the palate and upper surface of the tongue look very red. Several patients have been observed where the erythematous type developed into the pseudomembranous type, indicating a progression from early HIV infection to AIDS. Oral candidiasis can be effectively treated (see page 7).

Bacterial infections
So-called gum disease is caused by a variety of bacterial infections. Gum disease is very common in developing countries, and people with HIV infection are at particularly high risk of developing common bacterial infections.

The early signs of gum disease are swollen areas of the gingiva (gums) and an increased tendency to bleed when pressed, or when food is scraped from under them. Gums look red instead of pink, and are loose instead of tight against the tooth. The patient has bad breath, and a bad taste inside the mouth.

Necrotising gingivitis, now a rare condition in Europe, has reappeared over recent years in some HIV positive patients. The condition (also known as trench mouth) is where the gum tissue dies, becomes grey, and pus and old blood collect around the teeth. In the developing world, Necrotising gingivitis is more common, particularly in malnourished children recovering from measles; however, in Zaire and Zambia, an even more serious form of Necrotising stomatitis (cancrum oris) has been reported amongst infants of HIV positive mothers. In its worst form, this disease can eat a hole through the cheek of a weak child. Fortunately, effective treatment is available for gum disease. However, prevention is very important, especially in HIV positive patients (see page 7).

Viral infections
Many HIV positive people are at increased risk from all common viral infections. Of interest to the dentist is herpetic stomatitis (which affects about ten per cent of AIDS patients) and hairy leukoplakia. The signs of herpetic stomatitis are bright red blisters which develop either on the gums (but not between the teeth) or outside the mouth on the lips, painful swelling under the jaw, fever and sore throat. (See treatment guidelines).

Hairy leukoplakia is more commonly found among AIDS patients in Europe/North America than in developing countries. It is characterised by a white lesion with vertical folds situated on the edges of the tongue. The folds look like corrugated lines of hairs. Since hairy leukoplakia can mimic a number of white lesions, a biopsy (where tissue and/or surface cells are removed for laboratory examination) is necessary for its diagnosis. There is no successful treatment.

Professor J J Pindborg, The Royal Dental College, Copenhagen, Department of Oral Pathology, 20 Norre Aile, DK-2200 Copenhagen, Denmark.


References/further reading 

(1) Pindborg J J. Classification of oral lesions associated with HIV infection. Oral Surg 1989; 67: 292-5. This is a revised edition of the 1986 EEC classification. Copies are available from AHRTAG.

A more detailed discussion of the less frequent oral manifestations of AIDS can be found in 'AIDS and the Dental Team' Greenspan et al., Copenhagen, Munksgaard, 1986.

Guidelines on cross-infection control in the dental surgery will be published in the December issue of AIDS action.



AIDS action  Issue 8    6   Page 7   8  top of page

  Oral signs of AIDS

Oral manifestations: prevention and treatment guidelines

Prevention
 

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Show the patient how to clean teeth better near the gums. Teeth should be cleaned after every meal, either with a tooth brush, or local chewing stick. Advise the patient to visit a dentist more often to have tartar removed.

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Tell the patient to rinse his/her mouth regularly with water - preferably warm, salt water.

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Advise the patient to eat fresh vegetables and fruit daily to improve nutritional status.



Treatment

Thrush

Thrush can often appear in babies, in people who are weak, poorly nourished and sick, taking antibiotic medicines, or in adults wearing dentures. Thrush can also be indicative of HIV infection/AIDS. Treat as follows:

Thrush in the mouth: people with HIV infection/ AIDS are particularly at risk from this common oral infection.

 

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Check to see if there is some other, underlying cause of thrush which is not HIV infection. For example, treat malnutrition where possible. Stop antibiotic treatment of other infections if possible (antibiotics can make thrush worse).

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Wipe nystatin cream on the white patches with a bit of cotton (adults four times a day, children three times a day, children under five years twice a day.) If there is no nystatin, gentian violet should be painted on the white areas twice a day. Local application of a number of other fungicidal drugs gives good results within one or two weeks, but these may not be available in many developing countries e.g. miconazole, amphotericin B, clotrimazole and chlorhexidine. In general, drugs in tablet form should be sucked three times a day, or gel should be applied three times a day.

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If no improvement is noted after three or four weeks, the patient should be referred to a local doctor for a fuller medical examination.

 


Gum disease
Refer to prevention guidelines above, but note that for treatment, salt water mouth washes should be given four times a day until the bleeding stops and then once a day. Rinse regularly with chlorhexidine where this is available.

Necrotising stomatitis (cancrum oris) This is a very serious form of gum disease. You should refer the patient to the nearest hospital/medical centre. However, begin treatment straight away. Give penicillin for three days, according to the dosage in figure one.

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Tell the patient to rinse his/her mouth with water. Wipe the gums with cotton soaked in five per cent solution of hydrogen peroxide. Rinse with warm water. For a child, use a weaker solution of one part hydrogen peroxide with five parts water.

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Dry the gums with cotton and apply topical anaesthetic if you have some. Remove some of the tartar.

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Give vitamin C (ascorbic acid), two tablets a day for seven days, where one tablet = 500mg.

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Teach the patient (or parents if it is a child) how to care for the gums at home. Rinse at home for three days, every hour, with a weak solution of hydrogen peroxide. The patient should try to keep the solution in the mouth for several minutes: the longer the better. For a child, gums should be wiped with the solution four times a day. After three days change to salt water, four cups a day. If you have no hydrogen peroxide, rinse with salt water from the beginning. Teeth should be cleaned regularly with a soft brush even if the gums bleed. 


Herpetic stomatitis (fever blisters/mouth sores) Medicine cannot kill the herpes virus. The blisters will go away by themselves in about ten days. Treat as follows:
  

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Give aspirin or acetaminophen for fever.

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Advise the patient to wipe milk or yoghurt over the sores to protect them before eating.

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Paint sores on the lips with gentian violet, tincture of benzoin or petroleum jelly to prevent them becoming infected.


Adapted from Where there is no dentist by Murray Dickson, published by the Hesperian Foundation, Mexico





AIDS action  Issue 8    7   Page 8   9  top of page

  Letters / Resources

Letters

Quality and proper use of condoms

In response to a short article that appeared in issue five, under 'Counselling Hints: Using Condoms' I would like to add a few guidelines an this important subject:
 

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Always check the 'sell by' date on the condom packet. Store condoms in a cool, dry place.

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After you open the packet, check for the following: a strong rubbery smell, condom sticky to the touch and tiny bits of loose rubber which separate out. If you find any of the above, the condom is old and damaged - IT IS NOT SAFE TO USE. Ask the distributors (e. g. your local clinic or store) to investigate their supplies.


After use, the condom should be tied in a knot at the open end (making sure that no air is trapped) so that the semen does not leak out after disposal. Remember that condoms are the only method of contraception that provides protection against HIV and the germs that cause other sexually transmitted diseases. 

Dr Chandra Mouli, Copperbelt Health Education Project, Zambia.



I am a Medical Assistant at the Kuhalanga Medical Centre. I totally agree that condoms used in a proper way are really helpful, but from my own experience, condoms, if not used in the right way, are another problem area in the transmission of sexually transmitted diseases like gonorrhoea and syphilis. On this issue a pertinent question is, 'Is it safe to use one condom with two partners if it is washed?' 

Name withheld, Kuhalanga Medical Centre, Magoche, Malawi.



Editor
: No it is not safe! Washing condoms weakens the condom rubber. Condoms are very fragile and should not be used more than once.

Resources

Education in School

An excellent pack for use in schools has been developed by the AIDS Control Programme in Uganda, and is now available for wider distribution, suitable for all English and French speaking African countries. The pack contains: seven colour posters printed' on indestructable, water-resistant 'paper' (with titles including: How is AIDS spread? What does a person with AIDS look like? etc.,); flip-charts which tell the story of four friends (two of whom become infected with HIV); definition cards to explain the meaning of AIDS; teachers' guide to using the materials, as well as a teachers' booklet on human reproduction and sexual responsibility. Packs available in English and French free of charge from: the Medical Missions Institute, Salvator Str. 7, Postfach D-8700 Wurzurg, West Germany.

Manual

A Colour Atlas of AIDS in the Tropics 
Describes diseases associated with AIDS, including colour illustrations of the many clinical manifestations observed among patients in the tropics. Written by four Zambian doctors, it will be of value to a wide range of health practitioners. M A Ansary et al, A Colour Atlas of AIDS in the Tropics, 126 pp, price £8.00, Available from: Tropical Health Technology, 14 Bevills Close, Doddington, March, Cambridge shire PE15 0TT, UK.

Video

AIDS-Wise, No Lies 
Suitable for use with adolescents. Made in the United States of America with fast-moving visuals and popular music. Consists of a series of emotionally powerful interviews with a variety of young people (not actors), some of whom are suffering from AIDS. The interviews successfully convince the audience that AIDS can affect anyone, but that each one of us has the power to avoid it. The audience should be aware of the facts about AIDS/HIV infection before seeing the video. Comes with an excellent viewers' guide, which includes ideas for discussion., Produced by Rutledge Ltd. 22 minutes. US$250 per copy, plus $10 postage and packing. Discounts available for non-profit organisations.
Available from: New Day Films, 853 Broadway, Suite 1210, New York NY 10003, USA. Indicate format required (VHS, Beta, 3/4").

Colour Slide Sets

'Three sets of 24 colour slides are available from Teaching Aids at Low Cost (TALC). Suitable for a range of health workers/educators in Africa. Each set includes teaching notes and subjects for discussion. The first in the series, Virology and Transmission, should be used before the other two sets, Clinical Manifestations and Prevention and Counselling.
PLEASE NOTE price of sets is £2.75 EACH for self-mount sets with instructions. Seamail to developing countries or £0.60 extra for airmail. From: TALC, PO Box 49, St Albans, Hertfordshire, AL1 4AX, UK



AIDS action  Issue 8    8   Page 9  10  top of page

  WHO Report - Global Programme on AIDS


WHO Report - Special Programme on AIDS

The role of non-governmental organisations (NGOs) in National AIDS Programme

The Ugandan AIDS Control Programme (ACP) provides a leading example in the development of effective working relations with non-government organisations and community groups. Bob Grose, External Relations Officer for NGOs at the Global Programme on AIDS, interviews Dr Samuel Okware, Director of the Ugandan ACP.

What are the major areas for government and NGO co-operation in the ACP?
Nearly thirty hospitals and about 100 large health centres (a major part of the existing health structure in Uganda) are run by two coalition Christian organisations, the Catholic Medical Bureau and the Protestant Medical Bureau. These religious groups also run AIDS health promotion in their churches and schools, alongside the government education programmes, especially in the rural areas. 

Much of the care and counselling activities, including training and home visiting, have been carried out by these, and other, NGOs, such as The AIDS Support Organisation (TASO - see AIDS Action issue 7), the Ugandan Red Cross Society and the Moslem Supreme Council. The Federation of Ugandan Employers has been running a project on worker education. Another NGO has produced over two million leaflets in more than 20 local languages.

How does NGO/government co-operation really work?
We have now asked all NGOs interested in working on AIDS to register with the ACP, which makes it much easier to review their proposals and approve activities. 

When an NGO brings a proposal to the ACP we approve it or we suggest small changes. Once agreement has been reached, NGOs usually carry out their project independently. Our approval simply indicates that it is a useful part of the medium term plan. By coordinating in this way, we are able to share available resources in the most effective way and avoid needless duplication of work. For NGO training activities, we ask for the participation of a member of the ACP, in this way, both the national programme and the NGO can contribute and benefit.

What is the financial relationship between NGOs and the national programme?
Many NGOs have their own source of funding, sometimes raised through other NGOs or government agencies. However, for NGOs who do not have resources available for their programmes, the ACP can provide grants through the WHO Trust Fund. These funds are normally used for individual events such as seminars, training sessions, or contracts for specific services, though it can also be used for activities in the medium term plan. When funding is granted to an NGO, a contract is set up through the exchange of letters. 

We are now trying a new mechanism to ensure that money is available for practical, community-based NGO projects within the framework of the medium term plan (see also article on back page WHO Report). First the NGO drafts a proposal for its activities, setting out objectives, work plan and budget. After approval from the ACP, the NGO requests funds from WHO's Global Programme on AIDS (GPA) to cover the total budget or to contribute to joint funding. If both the ACP and GPA agree, funds can be transferred from Geneva through NGO headquarters or through the ACP in Uganda, whichever is preferred.

What do you see as the main direction for ACP/NGO co-operation in the future?
About half of all AIDS patients in our country are treated through NGO facilities. We are now finding that NGOs, as well as the government programme, need drugs and medical supplies. Information on AIDS care and prevention needs to be adequately distributed and care-givers need to be trained in both government and non-government sectors. Supporting regional meetings between NGOs and ACPs may be a way forward: we have found that work-shops are useful for exchanging information and ideas.

Consultation between the ACP and NGOs is improving. NGO involvement is vital to the success of the programme, especially since their existing structures allow for effective out-reach in counselling and home care.



AIDS action  Issue 8    9   Page 10  11  top of page

  WHO Report - Biomedical update

HIV infection and drug

Dr Jose Esparza, from the Biomedical Research Unit, Global Programme on AIDS, describes current scientific knowledge about HIV (the virus that causes AIDS) and the development of drugs for the treatment of HIV infection

The Acquired Immune Deficiency Syndrome (AIDS) is a disease characterised by progressive damage to the body's immune system(1) which results in the development of a number of 'opportunistic infections' which are eventually fatal. 

AIDS is caused by the Human Immunodeficiency Virus (HIV), which is a member of the retrovirus family. Viruses are intracellular parasites (very small organisms that exist and multiply inside living cells). Different viruses are attracted to different types of cells, and the destruction of these cells (caused by the multiplication of the viruses inside the cell) results in different types of disease. For example, polioviruses multiply in cells in the spinal cord, causing paralysis and muscle wasting, whereas hepatitis viruses multiply in, and damage, liver cells.  
 
When a person is infected with HIV there is an initial period when the virus multiplies rapidly (reproducing or replicating itself). The body's immune system then produces antibodies specific to the virus (known as seroconversion) - often within the first three months of infection. This initial period is usually without symptoms of illness although some people may develop mild symptoms for a few days or weeks, such as a fever, or a rash.

HIV (the virus that causes AIDS) budding from the surface of a human cell. Magnified 100nm

After infection, individuals generally remain fit and healthy for a number of years. During this period, HIV keeps a low level of multiplication, with a slow, but progressive, destruction of certain cells in the immune system.

This destruction makes infected people progressively more susceptible to infections which would not normally cause disease in people with undamaged immune systems. The occurrence of the most serious of these opportunistic infections defines what we call AIDS, which is considered to be the final stage of HIV infection/disease. The average time between initial HIV infection and the onset of AIDS is estimated to be around eight years.



HIV-1 and HIV-2 
Most cases of AIDS worldwide are produced by a type of virus currently known as HIV-1. A second virus that causes AIDS has also been identified, called HIV-2, which is notably more prevalent in certain areas in West Africa. Like HIV-1, HIV-2 is also a retrovirus, but it more closely resembles the structure of some simian (monkey) immunodeficiency viruses (SIV) than HIV-1. Most scientists believe that HIV-2 causes AIDS in the same way as HIV-1, but possibly with a lower pathogenicity (smaller capacity to cause disease) and a longer period between initial infection and the onset of AIDS.

Drugs which slow down or block the multiplication of HIV
The more the virus multiplies, the more cells become infected and damaged, eventually leading to the destruction of the immune system and the onset of AIDS. Drugs which slow down, or block, the multiplication of the virus are currently being researched and developed. There has been extraordinary progress in scientific understanding of the molecular biology of the virus, enabling drugs to be designed which interfere with one or more steps essential for the multiplication of the virus. These drugs include zidovudine (AZT - see below) and soluble CD4. At present, AZT is the only licensed anti-retroviral drug.

Soluble CD4 
The first step in viral multiplication is the attachment of the virus to the surface of the target cells. In the case of HIV the targets are specialised cells of the immune system known as helper T (T4 or CD4+) lymphocytes and macrophages. The infection and destruction of these key elements of the immune system is the underlying cause of AIDS. In general, HIV can only infect CD4+ lymphocytes and macrophages because they carry the appropriate 'receptor' for the virus on their surface. This receptor is the CD4 protein, onto which the surface proteins of the virus attach themselves. This knowledge has allowed the development of large quantities of genetically engineered (made in the laboratory) CD4 molecules - known as 'soluble' CD4 - which can be used to link onto viruses just like the CD4 molecules attached to cells of the immune system. It has been shown that soluble CD4 molecules can block viral receptors and in theory could make the virus less capable of linking or binding with a human cell. In this way, the capacity of HIV to infect increasing numbers of human cells (and thus progressively to destroy the immune system) may be reduced. However, the therapeutic effects of soluble CD4 have yet to be evaluated. Other drugs which act by interfering with the attachment of the virus to target cells are also being tested.



AIDS action  Issue 8    10  Page 11  12  top of page

  WHO Report - AIDS: a worldwide effort will stop it 

 

AZT 
Another way of interfering with the multiplication of the virus is to stop the virus reproducing itself after it has got inside the target cell. One such drug is zidovudine or AIDS. This is the only drug which has been shown to have a beneficial effect on AIDS patients. It works in the following way: 

Once the virus has entered the target cell, it uses the cell to reproduce itself. Retroviruses, such as HIV; carry an enzyme called 'reverse transcriptase' which copies the viral RNA (genetic information) to make viral DNA, which is then integrated into the host cell genetic material. The viral DNA (now part of the human cell) instructs the cell to make multiple copies of viral RNA. A new generation of viruses then emerges from the cell (see figure one). AZT acts by interfering with this process of reverse transcription.
 
There are a large number of similar drugs being tested as new products, such as DDC (dideoxycytidine) and DDI (dideoxyinosine), but well controlled clinical trials are needed to assess their effectiveness against the virus, and to look at any negative side-effects on the patient. DDI is a more recent development and, so far, seems to be more potent against the virus and may be less toxic than AZT.

None of the drugs mentioned above are cures for AIDS/HIV infection. This is because the drugs do not rid the body completely of the virus, but may only inhibit or slow down its multiplication. After initial infection, when the virus has entered a human cell, it is very difficult to eliminate it, because it becomes part of the cell's genetic material and is passed on to new cells which are formed. Once a patient is infected, they are infected for life, and need life-long therapeutic management. This is one of the major problems we have to confront in the development of anti-retroviral drugs.

The treatment of HIV infection and AIDS should include not only specific anti-retroviral drugs (where available) but also the careful prevention, diagnosis and treatment of opportunistic infections and associated cancers. 



The next edition of WHO Report will include on update on vaccine development.

(1) Terms in bold are explained further in the below box.

 

Explanation of scientific terms

Immune system
This is the body's defence system against attack from viruses, bacteria and other organisms that cause disease or are harmful. The function of the immune system is to recognise and eliminate these organisms. A key element in this response is the production of antibodies; these recognise, and link onto, specific antigens (a protein or carbohydrate substance belonging to an organism that produces an immune response). The combined antibody/antigen can then be engulfed, or eaten up, by macrophages - other cell. s of the immune system. The helper T lymphocytes are a type of white blood cell, which have a very important role in the immune system. These cells carry CD4 receptors, and are the main type of cell. which HIV infects; thereby critically 'injuring' the body's ability to fight off infection.

RNA and DNA Ribonucleic acid (RNA) and deoxyribonucleic acid (DNA) store the genetic information of an organism i.e. the instructions for its growth and reproduction, in every living cell. Most cells carry their genetic information in the form of DNA, which then makes a mirror-image copy of itself, RNA, which is used to make proteins - a vital component of living organisms.

Virus Probably the simplest of all. known organisms. Different viruses cause different diseases. A virus is not a complete cell, and only contains some genetic information (usually DNA) and a coat of protein. It is not 'alive' in the scientific sense, because it needs other organisms to reproduce, which it does by invading other cells.

Retrovirus HIV is a retrovirus. This is a type of virus which stores its genetic material as RNA, not DNA. 'Retro' means 'backwards' or 'in reverse', so-called because the virus persuades the invaded cell to convert viral RNA into DNA, which is 'in reverse' to the cell 's normal operation - which is to convert DNA into RNA, to make proteins or to reproduce itself.



AIDS action  Issue 8    11  Page 12       top of page

  WHO Report - AIDS: a worldwide effort will stop it

Our lives, our world

World AIDS Day, 1 December 1989

AIDS and Youth will be focus of events for the forthcoming World AIDS Day - the biggest single annual day of information and action against AIDS worldwide.


Preparations for the event, to be held on 1 December 1989, are being made at WHO Headquarters in Geneva, six regional WHO offices (Africa, the Americas, the Eastern Mediterranean, Europe, SE Asia and the Western Pacific) as well as thousands of government and non-government organisations and community groups worldwide.

World AIDS Day 1989 aims to increase awareness of the risk of HIV infection/AIDS; strengthen AIDS prevention activities and programmes; promote respect and care for those with HIV infection/AIDS and provide a foundation for continuing activities into the 1990s. The theme 'Our Lives, Our World - let's take care of each other' has been chosen to stress the need for compassion, respect and care in meeting the challenge AIDS poses to us all.

The first event of this kind, held on 1 December 1988, focused on global mobilisation against AIDS. The theme for 1989 stresses the need for individuals to make sure they understand the facts about HIV infection and to help others to do the same. The Director of the Global Programme on AIDS, Dr Jonathan Mann, sums up the significance of this year's event: 'It means that taking care of each other, and supporting each other, is essential to preventing HIV infection and to reducing the impact of AIDS on already infected people and their families.'

Care for your friend with AIDS: a poster produced in Rwanda, during World AIDS Day activities, 1988. 


Write in for your Action Kit
Information about World AIDS Day is being circulated through a central World AIDS Day mailing list, which already includes over 1,700 individuals, organisations and other interested groups. Two newsletters on the event have already been distributed and a poster entitled 'Ten points on AIDS' and a brochure are also available. Further newsletters will be mailed out nearer the time, as well as a twenty-page Action Kit with 101 ideas for activities and a guide to organising events and working with the media (including press kits). William Mwanza, field officer of the Planned Parenthood Association in Chadiza, Zambia, is one of many who has written to WHO for educational materials to support activities planned for 1 December: 'I work in a remote rural area where facilities to mount a meaningful campaign against AIDS do not exist. I am therefore appealing to you to send me as much support material as possible...'

Thomas W Netter, Public Information Unit/GPA


Are you involved?
If you or your Organisation are not already on the WHO World AIDS Day Mailing list, please write to: Global Programme on AIDS, WHO, 1211 Geneva 27, Switzerland, for further information and ideas for action.

Funding opportunity for NGO projects

For a trial period, the Global Programme on AIDS will consider providing funds to a wider range of AIDS projects initiated by non-government organisations.

There are a number of ways that non-government organisations (NGOs) fund their activities in support of the national AIDS programmes: 
 

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In some instances, NGOs have contributed their own funds to national programmes.

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NGOs can obtain funds for specific projects from external donors, including other larger, international NGOs or government development agencies.

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NGOs can submit proposals to their national AIDS Programmes which may agree to provide funding on a contract basis, through the exchange of letters. Funds are provided from the WHO Trust Fund (i.e. the national programme budget). The contract is agreed between the NGO and the in-country representative of the WHO/Global Programme on AIDS, who is authorised to disburse Programme funds if national programme approval has been given. 

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A further funding system is now being developed. For a trial period, GPA is able to provide funds for a wide range of NGO in-country projects designed to strengthen the national AIDS programmes. This system allows NGOs to apply for funds outside the country in which they are working, so long as they have national approval for the activities which they plan. For example, if an NGO in a particular country seeks funds for a project, WHO will now consider contributing all or part of the budget, administered through the NGO headquarters (if these are outside the country) or through a supporting international NGO. The proposal would be assessed according to the usual criteria: including clear objectives, practical activities, availability of key resources such as personnel, management skills, and equipment. The project would also be evaluated according to the same criteria, such as ability to reach targets and effectiveness.


The programme is in a trial phase. NGOs seeking further information are invited to contact Mr. Bob Grose at WHO/GPA (address below).

Any questions about the content of the WHO Report should be sent to WHO/GPA/HPR, 20 Avenue Appia, 1211 Geneva 27; Switzerland.

 

Managing editor: Kathy Attawell
Executive editor: Hilary Hughes
Production: Katherine Miles 
 
Editorial advisory group: Professor E M Essien (Nigeria), Dr K Fleischer (FRG), J Hayman (WHO), Dr P Kataaha (Uganda), Professor K McAdam (UK), Professor L Mata (Costa Rica), Dr D Nabarro (Kenya), Dr P Nunn (Kenya), Dr A Pinching (UK), Dr P Poore (UK), Dr W Almeida (Brazil), Dr T K Sinyangwe (Zambia), Dr M Wolff (FRG).

Produced and distributed (free of charge to developing countries) 

With support from Misereor, ODA, Oxfam, Save the Children Fund, SIDA and WHO/GPA.

 

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AIDS Action
The International Newsletter on AIDS Prevention and Care


This English edition of AIDS action was produced and distributed by Healthlink Worldwide.

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