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AIDS action  >  Issue 21 - Drugs and HIV
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AIDS action  -  Issue 21 - Drugs and HIV

Sex, drugs and HIV control

Issue Contents
 

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Sex, drugs and HIV control

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Outreach guidelines

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Take prevention to the people

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Face-to-face outreach work increases impact

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HIV and injecting drug use

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Clean needles save lives

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Sterile equipment reduces risk of HIV

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Strategies for safer drug use (from most to least safe)

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Clinical update

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Anti-HIV drugs: no magic bullets

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AZT: limited usefulness

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Letter

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Resources

 

 

 

AIDS action  Issue 21         Page 1   2  top of page

  Issue 21 June-August 1993

Sex, drugs and HIV control

At this year's international AIDS conference, great emphasis was placed on the need to take a broader approach if we are to succeed in fighting AIDS. Speakers stressed that individual behaviour is much more than a matter of individual choice - it is affected by social, political and economic forces. Mary Bassett, from the University of Zimbabwe, described how economic pressures have compelled the government to introduce school fees. Enrolment figures for girls now show signs of falling, because families are also short of money, and social attitudes still favour the education of boys. Yet education is key to women's economic independence and ability to negotiate safer sex. Confronting contradictions such as these needs commitment from policy makers at all levels.

Changing policy is essential 

People who are promoting safer behaviours have a vital role to play in influencing both policy makers and public opinion, and in ensuring that those who lack access to health care and education are reached. Lessons learnt from a wide range of projects provide guidelines (on pages 2 and 3 of this issue) for planning and implementing outreach programmes.

This may be a difficult task - especially for people whose activities are disapproved of or illegal, such as injecting drug users or sex workers. But many organisations, including those that have contributed to this issue, find that, while it may not be easy, it is possible, and are convinced that changing policy is essential for the success of their work.

Prevention is also essential, because there is no cure for HIV. But a few drugs, like AZT, are helping some people with AIDS to live longer. These drugs are not generally available or affordable in developing countries. In principle, this situation is unjust. It is another example of how the unequal distribution of the world's resources limits most people's access to health care. Yet are these particular drugs worth having? AIDS Action reports on AZT and other anti-HIV drugs on pages 6 and 7

Reach out and organise: members of a sex workers' association discussing HIV prevention

Another AIDS treatment has been in the press recently. 'Kemron', developed by the Kenyan Medical Research Institute, consists of low oral doses of human interferon (an anti-viral chemical produced by cells in the immune system). In 1990 the institute reported positive results from a small treatment trial without a control group. In June 1993, the results of a larger, longer, controlled trial sponsored by WHO in Uganda were published, showing that people with AIDS symptoms experienced no detectable benefits from treatment. These results should help to resolve the debates about Kemron.

 

New eye-catching design 
AIDS Action has been redesigned in response to a questionnaire and discussions with readers in different countries. 

The new design has been developed in consultation with AHRTAG's publishing partners in Brazil, Mexico, Mozambique and Senegal, and will be used for all five language editions of AIDS Action. 

We hope that readers like the new look and we would welcome your comments.

 

In this Issue
 

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Reaching out: tips for success Page 2

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Injecting drug use and HIV Page 4

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AZT and other anti-HIV drugs Page 6



AIDS action  Issue 21    1   Page 2   3  top of page

  Outreach Guideline

Take prevention to the people

Experience from different outreach projects offers useful lessons for reaching those without access to health care or education.

Outreach aims to reduce the risk of HIV for people who are not reached by existing health or information services. HIV prevention activities are taken directly to people where they are, instead of through a school, clinic or workplace. Through face-to-face, relationships developed over a period of time - usually at least a year - outreach workers learn about people's needs and priorities. They can then find the best ways to develop appropriate information and materials, to improve skills and self-esteem, and to increase access to services. Successful projects have been developed by both non-government organisations and local government health and social services. A successful outreach programme:
  

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is an effective way to reach people who lack access to services, including sex workers and clients, injecting drug users, young women, men who have sex with men, and street children

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is inexpensive and appropriate for poorly resourced settings

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can strengthen the effectiveness of other activities (see diagram on page 3)

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takes time - a few meetings or one-off events will achieve very little

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does not involve putting pressure on people to change behaviour (to stop drug use or sex work, for example)


Assess the situation 

A project needs to have an overall picture of the situation before planning outreach activities. Assessment can be carried out by staff, although it may be useful to contact sympathetic researchers for advice. Methods such as observation, group discussions and open-ended interviews help to find out:
 

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where people live, work and socialise

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how people view themselves, their health (including HIV and STDs), and their needs

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sexual behaviours and understanding of risks taken by themselves and partners

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what people do to obtain money, food and shelter, as well as companionship or relaxation

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relationships with others who may have influence: police, religious leaders, sex work clients or managers, drug dealers and sex partners

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what people think of existing services, if and how they use them.


Assessment should enable staff to make links with existing organisations, health workers, police and social workers, and individuals who have a leadership role in the community. It will help in planning: how to promote safer behaviours; when and where to meet people; skills training courses; and whether to set up new services and/or to focus on existing ones.

Find the right workers
The effectiveness of outreach work depends very much on who the workers are, and on how their work is managed. Issues like these are important:

Age, gender and sexuality
Female sex workers may, or may not, find it easier to talk with male outreach workers, rather than with other women. Men who have occasional sex with men may, or may not, relate well with men who identify as gay. Young people may feel more comfortable talking to someone who is nearer their own age.

Social background, class and ethnic origin The best workers are  often recruited from the target group itself, as this can help to generate trust. However, sometimes these workers may set themselves apart from the community they come from.

Education and training Communication skills, life experience and approach can be more valuable than formal education or qualifications.

How to do the work Depending on the circumstances, it may be better to do the work on foot or from a vehicle (such as a mobile clinic); on the street or in bars; in pairs or alone.

Start small
Making contacts and developing relationships with people takes time. In one project two workers spent about four months getting to know people on the streets. After eight months, they had trained 15 'peer communicators' to distribute condoms and talk with people about reducing risk. 

Another project, in Morocco, developed a good relationship with a sex worker who visited the project clinic several times. She invited other women along to discuss AIDS, and through 'friends of friends', information and condoms were distributed.

Involve people
Outreach projects need to be flexible to adjust to changes in people's situations, to take into account their priorities, and to provide appropriate services. Members of the group a project is trying to reach are the only people who can provide information about these issues. Women working in brothels in one Indian city said that, while they already knew about STDs and HIV, most felt unable to insist on condom use. They wanted the project to target safer sex information at clients, but not in the red light district itself. In response, the project reached men by arranging drama shows on the streets leading into the district.

Increase self-esteem and skills 
People whose behaviour is disapproved of by wider society often have low opinions of themselves and little self-confidence about their ability to change their situation. This is reinforced by the fact that often they have had little or no education or training. A project in Ghana provided literacy classes at the request of street youth. Some of the boys who were in contact with the project worked as porters, and they were helped to become a formal organisation. As well as supporting new types of organisation, projects can link people with existing social or political groups. For example, gay organisations can provide a supportive environment for some men in same sex relationships which can help them to sustain safer sexual practices.



AIDS action  Issue 21    2   Page 3   4  top of page

  Outreach Guideline

 

Respond to wants and needs 
People's immediate needs for food, shelter and medical treatment are often more important to them than preventing HIV. The things they do to survive, such as selling sex, may increase vulnerability to HIV. Project workers have to find ways to help people to meet their needs and overcome the problems that may prevent them from practising safer behaviours. Outreach work with boys who had dropped out of school in Zambia included setting up group discussions to learn about their priorities. As a result, the project designed a five-day 'crash course in survival skills', which included discussions on drug use, how to stay within the law, running a business, obtaining health care, and self-esteem exercises, as well as information about HIV and STDs.

Avoid making assumptions
 
Outreach workers need to have a non-judgemental approach - it is important that they do not have prejudices or make assumptions about people's ways of living and behaving. How people define themselves (their identities) may be different from what they actually do (behaviours). And prejudice stops people being open about behaviours which may be putting them at risk but which are stigmatised, such as anal sex, same sex activity, injecting drug use and exchanging sex for money or food. For example, street youth workers in a Tanzanian city found that sex between boys was common, although most people denied its existence. Confidentiality is very important too, to avoid increasing people's vulnerability to violence or repression, especially where their activities, such as prostitution, may be illegal.

Advocate for people's rights Outreach projects can influence attitudes of police or health workers and lobby for improvements in laws or policy that help people to change their behaviour. For example, an outreach project in one Indian city persuaded local police not to arrest sex workers who distribute condoms.

Based on a report by John Daly and Meurig Horton of a WHO workshop with participants from 17 outreach projects. Other outreach workers also shared their valuable experience with AIDS Action. Contact addresses are available from AHRTAG.

Face-to-face outreach work increases impact

Outreach activities can include and strengthen the effectiveness of:
 

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providing materials to reduce risk, such as condoms or new needles and syringes 

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strategies that encourage people to change behaviour, such as leaflets and posters, counselling, group discussions and special events (e. g. drama or beauty contests) 

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improving access to health services, including STD clinics and antenatal care

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setting up local support services, such as laundry facilities, credit unions and child care

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follow-up with referrals to health and social services, or legal advice centres

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promoting the development of self-help or advocacy organisations

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liaising with local police and authorities, for example, to improve people's legal rights or housing.

Activities that outreach can include and reinforce. They range from those that reach many people, but have less influence on behaviour (e. g. mass media) to those that reach fewer people, but have more influence (e. g. counselling).
 

Activities that outreach can include and reinforce. They range from those that reach many people, but have less influence on behaviour (e. g. mass media) to those that reach fewer people, but have more influence (e. g. counselling).





AIDS action  Issue 21    3   Page 4   5  top of page

  HIV and injecting drug use

Clean needles save lives

Injecting drug use is on the increase worldwide. In some places up to 80 per cent of people who inject are HIV-positive. AIDS Action reports on strategies to prevent HIV transmission.

Injection is one of the most stigmatised methods of taking drugs - injected drugs include cocaine, amphetamines, tranquilisers and opiates. Many of these drugs can also be taken orally (chewed or swallowed) or inhaled (smoked or snorted through the nostrils). Until recently it was thought that injecting drug use was limited to North America, Australia, New Zealand and Europe. Research shows that this is not true. Drug injecting is now reported in over eighty countries in Latin America, eastern Europe, the Middle East, western, central and southern Africa, south-west Asia (the Golden Crescent), and south-east Asia (the Golden Triangle). Numbers of injectors are rising to tens of thousands in cities on drug shipment routes and in drug producing areas. People who inject drugs are often very vulnerable to HIV through sharing needles and syringes. Unprotected sex with sexual partners also poses a high risk of transmission of the virus. For both these reasons it is essential to reach injecting drug users with programmes to prevent HIV transmission. While taking any kind of drug involves a risk to health, it is possible to inject drugs safely, stay relatively healthy and cause minimal harm to self and others. But many users are trapped in a vicious circle of poverty, violence, ill-health and drug dependence, with little access to social and medical services.

Crime and punishment?
Injecting drug use is common in poor urban areas with high unemployment, particularly among young people with low self-esteem and few opportunities for education or paid work. Given these factors, and the high cost of illegal drugs, drug use is often linked with crime and the exchange of sex for drugs by both women and men. Possessing using and selling injected drugs is against the law in most places. In many countries it is also illegal to buy, sell or possess needles and syringes without a prescription. Despite these restrictions, there is little or no evidence that penalising drug distribution or possession prevents injecting. In fact, these policies force prices up, and this may be a factor influencing people to shift from traditional forms of taking drugs, like opium smoking, to injecting which requires less drug for the same effect.

Unsafe drug use 
Sharing needles and syringes (or the contents of syringes) which have traces of infected blood can transmit HIV. All three ways of injecting (into a muscle, vein or just beneath the skin) can be unsafe. Studies show that, although HIV cannot normally survive outside the body, it can survive for more than a week inside a closed syringe or a needle that has not been cleaned. Unclean equipment can also transmit hepatitis B and septicaemia (bacterial infection in the blood), and cause skin infections at the place of injection. 

Many factors lead to sharing injecting equipment. New needles and syringes are usually very difficult to obtain. In Manipur, a state in northern India, there are over 30,000 people who inject drugs. A survey carried out by the Voluntary Health Association of India among 500 users found that over 70 per cent shared equipment(1). Most knew the risks, and said they would stop sharing if they had access to sterile equipment

Materials to clean equipment are also often in short supply, or people may not know how to sterilise it. There is sometimes pressure to share equipment with a sexual partner, friend or relative because sharing is seen as part of a close relationship. 

Women are particularly vulnerable as they are often dependent on their male partners for supplies of drugs and injecting equipment, and therefore may have less choice about adopting safer behaviours. In prisons, where people continue to obtain drugs despite strict security, sharing is very common.

 

Sterile equipment reduces risk of HIV
 

Sterile equipment reduces risk of HIV

Exchanging used syringes for new ones in New York. In 1988 activist groups began to provide needles and syringes to the city's 200,000 injecting drug users. This was illegal: workers were arrested and programmes closed. 

Then in 1991, a study showed that providing sterile equipment does not increase drug use, but reduces the risk of HIV. With new support from policy makers and community leaders, needle exchange programmes won the right to operate legally. 





AIDS action  Issue 21    4   Page 5   6  top of page

  HIV and injecting drug use

 

Effective prevention strategies
Effective prevention stresses 'harm reduction' or 'harm minimisation'. Harm reduction means strategies to encourage and enable people to adopt safer forms of drug use. Strategies include:
 

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face-to-face outreach programmes involving users or ex-users

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access to sterile equipment, cleaning materials and information about safer drug use (and safer sex)

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counselling, support groups, health care, and methadone (heroin substitute) treatment and maintenance programmes 

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care and support for users, partners and children living with HIV/AIDS

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advocating policy changes, such as legalising provision and possession of needles and syringes

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supporting users' self-help organisations and involving them in policy development and programme design.


Research suggests that harm reduction programmes and policies do not increase drug use, and in fact may help some people to stop using drugs altogether. Programmes are effective in slowing down the transmission of HIV. In cities such as Glasgow in Scotland and Sydney in Australia, the number of HIV-positive drug users has remained below 5 per cent. Key factors in these success stories include developing out-reach programmes that involve users themselves and providing new injecting equipment and cleaning materials(2). 

People who use drugs are showing that, given the means to prevent HIV infection, and access to education and health care, they have the ability to change unsafe injecting practices. Policy makers and politicians need to aim to remove obstacles that contribute to a worsening HIV epidemic among people using drugs, their sexual partners and children.

Barbara James, Institute for the Study of Drug Dependence, I Hatton Place, London EC1 8ND, UK.

1. KABP study related to AIDS in Manipur State and intervention strategies, VHAI/MVHA, 1992. 
2. Characteristics of prevented HIV epidemics. Paper WS-C1 5-6, Des Jarlais et al, International AIDS Conference 1993.

Source: HIV prevention charter for injecting drug users, Third international conference on the reduction of drug-related harm, 1992.

Contact: International Drug Users Network, do Deutsch AIDS Hilfe, Diffenbachstrasse 33, W-1000 Berlin 61, Germany.

Strategies for sager drug use (from most to least safe)

Stopping injecting - using other methods
 

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Increasing access to voluntary treatment programmes and support services 

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Suggesting alternatives to injecting, such as smoking, swallowing or inhaling


Using new needles and syringes, and disposing of them safely
 

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Advising people not to share, borrow or lend needles and syringes, or other materials used to prepare drugs

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Setting up needle exchange services (where used equipment can be exchanged for new) run by outreach projects, pharmacists or doctors


Cleaning used needles and syringes 
 

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If equipment has to be used again, it can be cleaned to make re-use safer.


How to clean used equipment 
 

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If bleach is available 

1 a Immediately after being used, the needle and syringe should be washed thoroughly with cold water to remove all visible blood before it clots.
1 b Empty the syringe into a sink, drain or different container. Repeat the process.
2 a Fill the syringe with undiluted household bleach drawn up through the needle from a cup or other container. Leave for at least half a minute.
2 b Empty the syringe as above. Repeat the process.
3 a To rinse, fill the syringe with cold water. 
3 b Empty the syringe as above. Do this at least twice. 

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If bleach is not available, use cold soapy water or water mixed with some detergent, and rinse at least twice with clean water. If bleach, detergent or soap is not available, flush out with clean water three or four times, shaking vigorously.

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If the syringe is glass, sterilise it and the needle by placing it in cold water, bringing the water to the boil and boiling for 15 minutes. Most plastic syringes will not withstand boiling.

 

How to clean used equipment



AIDS action  Issue 21    5   Page 6   7  top of page

  Clinical update

Anti-HIV drugs: no magic bullets

AIDS Action describes the benefits and limitations of anti-HIV drugs and explains why AZT may not be worth the cost
 

Anti-HIV drugs: no magic bullets         

The most prescribed drug for people with AIDS-related illnesses in industrialised countries is AZT (zidovudine), although other anti-HIV drugs are becoming more widely used. AZT was the first drug approved for treating people with AIDS, in the USA in 1987. It is manufactured by Burroughs Wellcome, under the brand name of Retrovir, and is now licensed for use in 150 countries worldwide.


How do anti HIV drugs work? 
AZT and other anti-HIV drugs (such as ddl and ddC) do not cure HIV infection, but only slow the worsening of disease in most people with AIDS-related illnesses. The drugs are called 'nucleoside analogues', because they have a similar (or analogous) structure to chemicals called 'nucleosides', which are part of DNA. DNA is the genetic building block material found in all human cells, and is essential for cell growth and reproduction. During the process of reproducing itself, HIV forces human DNA to produce more virus. Nucleoside analogue drugs interfere with, and slow down, this process.

Value for people with AIDS 
AZT can benefit people with AIDS. The first AZT trial in 1986 involved 282 people with AIDS symptoms. After 24 weeks the trial was stopped for ethical reasons, because the results showed that AZT was helping people to live longer. One person had died in the group receiving AZT, compared with 19 people in the control group who were taking a placebo (a harmless inactive substitute for AZT).

Although this has been the only controlled study, other types of trials in the USA and Europe found that AZT improves survival in people with AIDS, and that new infections are less likely to develop in the first year of treatment. Increases in CD4 cell levels* and weight gains have been reported. AZT is also considered to be an effective treatment for dementia caused by HIV. 

Very few women with AIDS have been involved in the trials, so there is little data on the drug's specific effects for them. One small study explored the effect of AZT when taken by women with AIDS during pregnancy. AZT appears to have no influence on pregnancy outcome, nor to affect the infant. However it is not known whether AZT can improve the health of pregnant women with AIDS. A trial to test whether AZT affects mother-to-child transmission is underway in the USA. 

After studies showing that most children with AIDS can tolerate the drug, the USA government approved the use of low doses of AZT for children aged over three months.

Problems with AZT
Despite its widespread prescription for people with AIDS in industrialised countries, AZT is not a miracle drug. Some people choose not to take it, or combine it with other types of treatment such as herbal medicine, and a healthier lifestyle.

Limited benefits AZT does not significantly reduce the amount of HIV in the body. While patients taking AZT may show improvements at first, benefits often cease after a few months or years of treatment. CD4 cell counts often return to pre-treatment levels. It is thought that development of viral resistance may be a reason for decreasing effectiveness of AZT.

Side effects While most people can take AZT without any serious side effects, the drug can cause headaches, muscle aches and nausea. For most, these problems cease after a few weeks. AZT can inhibit human cell reproduction. For example, production of red blood cells can be reduced, resulting in anaemia. Muscle damage with pain, wasting and weakness can occur after some months or years of taking AZT. The current dosage is usually 500-600mg per day. Higher dosages tend to produce more side effects. People who are very ill are also more likely to experience more serious side effects.

No symptoms, no proven benefits 
It is not clear that AZT benefits asymptomatic people (those who are HIV-positive but have no opportunistic infections). In the late 1980s, a controlled study involving people with no symptoms reported that AZT appeared to prevent the development of serious opportunistic infections. However, this trial was stopped after a year, and provided no information about longer term effects. The results of the Concorde study, the largest and longest trial involving symptom-free people, were published in mid-1993. After three years, survival rates in both the group taking AZT, and in the control group (who did not take AZT unless they developed AIDS symptoms), were very similar. Equivalent numbers also developed serious opportunistic infections or died. The results of this study showed that in healthy HIV-positive people, AZT does not increase the time before AIDS-related symptoms develop. In addition, HIV-positive people who take AZT while still healthy do not live for any longer than those who start taking AZT after they develop AIDS symptoms. Of the people taking AZT from the beginning of the trial, 9 per cent developed anaemia.

* HIV attacks and destroys a certain type of white blood cell in the human immune system called a T4 or T-helper cell. HIV targets these cells because it is able to attach itself to a particular molecule called CD4 on the cell surface. The impact of HIV infection on the immune system can be measured by recording the level of these cells using a blood test called a CD4 cell or T cell count A low count can indicate that a person has symptomatic HIV infection or AIDS. CD4 cell counts are used to monitor the effects of anti-HIV drugs.



AIDS action  Issue 21    6   Page 7   8  top of page

  Clinical update

 

Barriers to wider use for people with AIDS 
Cost AZT is very expensive. A world-wide survey in 1991 found that the estimated annual cost of AZT ranges from US$2,000 to US$4,000 per patient. Current prices still exclude people unable to afford health care in richer countries, as well as most people in developing countries. However, AZT is becoming a little more widely available. Until very recently, Wellcome was the only company producing AZT. Now a leading pharmaceutical company in India has started manufacturing zidovudine under the brand name Zidovir-100, which is sold for about a third of the cost of Wellcome's Retrovir(2). There are reports that companies in Brazil and Thailand will also be making zidovudine.

Technology Although AZT can be prescribed on the basis of AIDS symptoms alone, the effect of the drug should be monitored using CD4 cell counts. Few health workers in developing countries have access to the laboratory facilities required for these tests. Where available, the test costs from US$20 in Thailand to US$150 in the USA. Blood tests are also needed to find out whether AZT is causing side effects such as anaemia.

Training AZT should only be taken when prescribed by a health worker who has the necessary training. In many countries where AZT is used, doctors must attend a special training course before they are permitted to prescribe it.

New drugs on trial 
Two other nucleoside analogues are being more widely prescribed for people with AIDS in some industrialised countries. Their cost is similar to that of AZT. The drug ddl (didanosine), manufactured by Bristol Meyers-Squibb, is now approved in over twenty countries, including Argentina, Brazil, Chile, Colombia, Mexico, Peru, South Africa and Thailand. The drug works in a similar way to AZT, but has been found to be less effective as a first-line treatment. Neuropathy (nerve damage in the hands and feet) and diarrhoea are common. More seriously, ddl can sometimes cause inflammation of the pancreas which can be fatal. Another drug, ddC (zalcitabine) is made by Hoffman-LaRoche and has been approved in several countries. It is not as effective as AZT. Side effects include neuropathy, nausea and mouth sores. Prescribing combinations of AZT, with either ddC or ddl, could benefit people with AIDS. Trials evaluating the relative safety and effectiveness of combination therapies are still continuing. Other new drugs are also in development.

Summary 
AZT has limited value for people with AIDS. It should be recommended and used with caution. The Concorde study suggests that AZT does not seem to benefit healthy HIV-positive people.* It is also not yet clear whether other drugs being developed will be any more effective. 

While increased availability could benefit some people with AIDS, there remain the problems of quality control, and limited access to required technologies and health worker training. Anecdotal reports indicate that more people in developing countries are obtaining and taking AZT. Many are not aware that taking the drug without proper medical supervision can do more harm than good.

Appropriate prophylaxis, early diagnosis and treatment for opportunistic infections, with supportive health care and 'positive living', are still the most important ways to improve quality of life for people with HIV or AIDS.

Nancy Solomon, AIDS Treatment News International, PO Box 411256, San Francisco, CA 94141, USA.

1. Letters, Lancet, vol 341: April 3, 1993. 
2. Bhupesh Mangla, Lancet, vol 341, Feb 20, 1993.

* Further references available from AHRTAG. Results of another study have just been published in the New England Journal of Medicine. AIDS Action will report on this and other drug trials in future issues.

 

AZT: limited usefulness

For people with AIDS symptoms
 

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AZT can increase survival time 

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it can mean fewer infections in the first few months or year of treatment


  but

 

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improvements often cease in the longer term

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there are possible side effects

 

For HIV-positive people without symptoms
 

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no clear benefits have been proved

Best strategies (plus or minus anti-HIV drugs)
 

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prevent symptoms developing/prophylaxis 

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treat opportunistic illnesses: TB, diarrhoea, skin infections

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provide supportive care 

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promote positive living and healthy lifestyle



AIDS action  Issue 21    7   Page 8      top of page

  Letters / Resources

Letter

'Positive and Living' in Zambia
In issue 20, we were encouraged to read about people living with HIV or AIDS taking control over their own lives. We belong to a support group in Lusaka called The PALS (Positive and Living Squad). 

At first we met to discuss our hopes and fears, and strengthen each other emotionally. But we realised that this was not enough. Members wanted to do something about their human rights, and about AIDS. We set up an education programme - training HIV-positive members to run AIDS workshops, particularly in workplaces. PALS also liaises closely with AIDS support organisations, helping with their outreach programmes, and meeting their clients.

Some members are also involved in income-generating activities - usually the ones who decide not be trained as educators. But we find that many members find it difficult to set up their own businesses, even with loans and training. They are used to being paid employees, and find it hard to work without a boss! 

The biggest difficulty for a self-help group like The PALS is this. Of the seven people who were very active in 1992, three have died and two are very ill. As a result it is hard to keep on working - morale drops and anxiety levels increase. 

Despite these issues, The PALS is demonstrating every day what the power of positive living can achieve. You cannot talk about AIDS prevention and care, and empowering people with HIV/AIDS without promoting self-help groups. Yes, we have problems, but these are not all because of our HIV status. Most of them are just due to human nature. So, to everyone trying to set up or support the work of self-help groups, we wish you luck and strength - and 'more grease to your elbow'!

In solidarity, Winstone Zulu, The PALS, PO Box 37559, Lusaka, Zambia.

 

Resources

Praise for 'Women and HIV/AIDS'!

Women and HIV/AIDS: an international resource book, by Marge Berer with Sunanda Ray. Pandora Press/HarperCollins, pp383, ISBN 0-04-440-876-5.
This new book from AHRTAG and Pandora Press covers practical issues concerning women, their reproductive health, HIV/STDs and sexual relationships, as well as including detailed resource and contact lists. 
'The authors have put together a powerful mix of global statistics, biological fact and hypothesis, sexual politics and personal testimony.' The Lancet, June 5, 1993

Readers in developing countries:
£7.50 per copy (surface mail) or £9.00 per copy (airmail), payment by international money order to TALC. PO Box 49, St Albans, Herts AL1 4AX, UK. Contact TALC to order multiple copies.

Other readers: £14.99 per copy from bookshops, HarperCollins Mail Order, Westerhill Rd, Bishopbriggs, Glasgow G64 2QT, UK, or HarperCollins distributors elsewhere.

For information about French and Spanish editions, please contact AHRTAG.


Resource Pack on Sexual Health and AIDS Prevention for Socially Apart Youth 

From SOS Crianca and AHRTAG, this 64-page publication provides resources and contacts for networking, planning activities and materials.

Groups working with youth in developing countries:
One copy free from SOS Crianca, CP 4884, Ag. Central, CEP 20 100, RJ, Brazil, or from AHRTAG.

Other groups: To order, send £5/$10.00 to AHRTAG.

 

Managing editor Kathy Attawell
Executive editor Nel Druce
Production Celia Till
 
Editorial advisory group Calle Almedal, Nina Castillo, Professor E M Essien, Dr Sam Kalibala, Ashok Row Kavi, Dr Ute Küpper, Dr Tuti Parwati Merati, Dr Claudia Garcia Moreno, Dr Chandra Mouli, Dr Anthony Pinching, Dr Peter Poore, Barbara Wallace, Dr Michael Wolff
 
Publishing partners ABIA (Brazil) Colectivo Sol (Mexico) ENDA (Senegal) Consultants based at University Eduardo Mondlane (Mozambique)
 
AHRTAG's AIDS programme is supported by FINNIDA, HIVOS, ICCO, Memisa Medicus Mundi, Misereor, Norwegian Red Cross, Oak Foundation, 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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ISSN 0953-0096
 
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