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AIDS action  >  Issue 23 - Vaccination and risk reduction
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AIDS action  -  Issue 23 - Vaccination and risk reduction

Rights and risk reduction

Issue Contents

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Rights and risk reduction

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Vaccine update

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HIV vaccines on trial?

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Challenging HIV

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Slow steps forward?

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No quick fixes for prevention

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Strategies for development

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Ethics are essential

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Preventing HIV in prisons

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Reaching people behind bars

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Educate for protection

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Concerns for care

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Rope of hope

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Clinical update

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Respiratory diseases and HIV

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Bacterial pneumonias

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Pneumocystis carinii pneumonia (PCP)

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Clinical tuberculosis

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Kaposi sarcoma (KS)

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Fungal infections

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Management approaches

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Prevention measures

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Possible steps in second line management

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Letters

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New resources

 

 

 

AIDS action  Issue 23         Page 1   2  top of page

  Issue 23 December 1993 - February 1994

Rights and risk reduction

Efforts to ensure people's rights to health care, education and freedom from discrimination are widely acknowledged to be essential to HIV control. The people who are at highest risk of HIV through unsafe sex or drug use are often those with the least power to change the situations that involve risk or whose needs are badly neglected. Prisoners are one such group. Their human rights are abused in most countries, and millions are held in overcrowded and dirty conditions. Without knowledge of the risks or access to protection, both male and female prisoners are extremely vulnerable to HIV infection, through forced or consenting high risk activities. As the Brazilian educator featured on page 5 points out, even just a brief period in prison can become a death sentence if a person is infected with HIV. And it is not only inmates who are at risk - after prisoners are released into the wider community, HIV may be spread to others. In view of these issues, WHO has recently announced its strong support for strategies such as condom distribution in prison, because prisoners have the same rights as other citizens to health care, including preventive measures.

No high hopes 
A safe and effective vaccine to prevent HIV infection could be ready for testing with large groups of people within the next five years. Experts are already planning the design of vaccine trials in countries including Rwanda, Thailand, Brazil and Uganda. Making sure that the trials do not abuse people's human rights is as important as overcoming the problems of vaccine development. On pages 2 and 3, AIDS Action explores some of the ethical and technical challenges.

But it is unwise to hope that HIV will be controlled through vaccination. A vaccine would playa role in prevention - immunising against infection with a simple injection or a pill is much easier and quicker than changing sexual behaviours. However, even if an effective and inexpensive vaccine were developed, the hard work of education and counselling about HIV and STDs, and treating curable infections, must always be at the heart of prevention efforts. 

Thousands of people could soon be involved in HIV vaccine trials -but first many ethical and technical challenges must be overcome.

Vaccinating every person would be an enormous task, especially in light of the fact that the most vulnerable people are often the poorest and most difficult to reach. People must consent to be vaccinated, and if they have had no education about HIV, they would be unlikely to come forward for immunisation.

HIV prevention is forcing us to confront many other human rights issues. Not least of these is the need for women to have more control over their lives (including sex), in order to be able to protect themselves and their children from HIV infection. Increasing people's self-esteem and independence goes hand-in-hand with HIV prevention. It would be an immeasurable loss if vaccination programmes were to replace these efforts, because they are achieving much in terms of human rights as well as HIV control.

 

In this Issue
 

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Update to HIV vaccine progress Page 2

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Preventing HIV spread in prison Page 4

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HIV-related respiratory infections Page 6



AIDS action  Issue 23    1   Page 2   3  top of page

  Vaccine update

HIV vaccines on trial?

Research into HIV vaccines continues, but there are still many obstacles to overcome. AIDS Action explains some of this issues.

Since the mid 1980s scientists have been trying to develop vaccines against HIV that can carry out at least one of the functions below.

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‘Preventive’ or ‘prophylactic’ vaccines would protect HIV-negative people from infection and would also reduce rates of transmission, because fewer people would become infected. This type of vaccine is thought to be the least difficult to develop.

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‘Therapeutic’ or ’treatment’ vaccines would slow down or reverse the effect of HIV after infection. However, scientists have not yet succeeded in developing effective therapeutic vaccines for any viral infection, and many believe that there is little hope of  a vaccine for people who are already infected with HIV.

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‘Perinatal’ vaccines would be for HIV-positive women who are, or likely to become, pregnant. Ideally a perinatal vaccine would have a therapeutic effect for the woman and prevent infection of the fetus or infant.



Challenging HIV
 

The ideal preventive vaccine must be inexpensive and easy to give by a single injection or oral dose.


A preventive vaccine would work in a similar way to other vaccines. The human immune system produces white blood cells and antibodies to attack disease-causing organisms such as viruses. Viral vaccines contain manufactured or inactivated viral material which stimulates the body to produce a more effective immune response that prevents the virus from causing infection. 

A therapeutic vaccine would need to increase the immune response in an infected person, and prevent the virus from further damaging their immune system.


Research into these vaccines is posing many challenges. Scientists do not yet fully understand why the body’s natural immune response to HIV fails to kill the virus. Unlike many other viruses, HIV attacks the very cells that normally defend against infection, and can also remain inactive in certain cells where it does not stimulate the immune system. It also changes its structure very fast, and so there are many types or strains of HIV which differ in small but significant ways. The immune response triggered by the strains used in the vaccine may not be stimulated by other, possibly newer, strains.

 

No quick fixes for prevention
Even with a highly efficient preventive vaccine, and the best vaccination policy, the number of people with AIDS will continue to grow, because millions of people will have already been infected with HIV.

HIV prevalence will also continue to increase. Vaccinating all adults will be impossible in the short term, if ever, given limited resources. Targeting people at high risk is a possible strategy, but could increase stigmatisation and involve mistaken assumptions about who is at risk and why. However, in communities where many adults are already infected, it may be most important to immunize young people before they are sexually active.

Without universal coverage, it will still be essential to educate people about practising safer sex. A vaccine could give people a false sense of security and reduce efforts to prevent other STDs and promote sexual health.


Slow steps forward?
All possible or candidate vaccines must go through a series of rigorous tests to make sure they are safe and effective for humans. After initial laboratory research, there are three main stages of testing.

Preclinical trials: a large number of experimental HIV vaccines are currently being tested in animals to assess: safety; ability to stimulate immune responses (immunogenicity); and ability to protect against HIV infection or disease progression (protective efficacy). Some have shown limited success, and have entered phase I/II trials.

Phase I/II clinical trials are designed to find out whether vaccines are safe and if they can stimulate an immune response in humans, but not if they protect against infection. They involve a small number of volunteers, without a control group. A number of possible vaccines have been tested with both HIV-negative and HIV-positive volunteers, mostly in the USA. Both groups showed a limited immune response and very minor side effects. But there is no information on clinical benefits for the HIV-positive volunteers or the long-term safety of the vaccines. Trials with HIV-positive women to prevent pregnancy-related transmission have recently started.



AIDS action  Issue 23    2   Page 3   4  top of page

  Vaccine Update

 

Phase III clinical trials are designed to test for a vaccine's ability to protect against HIV infection or slow down disease progression. No phase III trials for either preventive or therapeutic HIV vaccines have taken place yet. The trials will be: 
 

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large scale, involving thousands of people

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controlled (after random division of selected participants into two groups, one group will be given a placebo or non-vaccine substitute and the other will be given the vaccine, but otherwise both groups will be treated in the same way)

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double blinded (neither participants, health workers nor researchers will know who received the vaccine or the placebo).


Strategies for development
WHO is working with four countries - Brazil, Thailand, Rwanda and Uganda - to plan HIV vaccine research and trials. Their national plans include:
 

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studying different virus strains in the country

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carrying out clinical trials, especially

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further phase I/II trials of selected candidate vaccines

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researching patterns of infection and incidence 

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researching the ways in which vaccine trials could affect sexual behaviour and attitudes towards sex

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ensuring that the health care system can provide advice, counselling and treatment. 


These activities are supervised by the health ministry and are guided by a national committee which may include NGOs. WHO provides technical and ethical advice to these committees and co-ordinates liaison with other international institutions, including the pharmaceutical companies which are developing the vaccines. WHO aims to have an advisory role with companies and research institutions that are planning other trials, in China for example.

Thanks to Jorge A Beloqui, Grupo pela VIDDA-SP, CP 08350, 01 065-970 Sao Paulo, Brazil, Stephen K Lwanga, Uganda AIDS Commission (presentation at 8th international AIDS conference) and Dr Jose Esparza, Vaccine Development Unit, GPA/WHO, Geneva, Switzerland.

Ethics are essential

Thousands of people could be taking part in preventive HIV vaccine trials within the next five years. WHO and others are trying to draw up ethical guidelines to ensure that these trials respect people's rights to education, information and health care. But there are many difficulties.

Questions about participation A vaccine's success in protecting against HIV will be tested by seeing how many individuals become newly infected in the vaccinated group compared with the placebo group, over a period of time. Trials can involve fewer people, last for a shorter time and cost less if they take place where there is already a high number of new infections each year. These smaller trials could take place anywhere if they involve people in communities with high HIV incidence. However, worldwide the highest rates of HIV are often among people who are already vulnerable to discrimination, such as sex workers or injecting drug users. In Brazil, where trials are likely to involve men who have sex with men, NGOs and activists are worried that research and participation could expose people to increased prejudice and stigma.

Access to the vaccine WHO-sponsored trials are being planned with governments in some developing countries where HIV incidence is high, such as Uganda. These governments are seeking guarantees that a successful vaccine will be affordable. Some vaccines, against hepatitis B for example, are too expensive for use in the developing countries where they were tested. But even if an inexpensive vaccine is made available, lack of resources means that the need for this must be considered in relation to other budget priorities.

Education for all Involvement in the trial will not mean that participants are safe from infection, and they and their partners will need education about safer behaviour. As a result some, but not all, participants will have safer sex sometimes, but probably not always. Some behaviour will remain unsafe. However, safer behaviour means fewer newly infected people, which means involving more participants to ensure statistically significant results.

Need for informed consent Individuals should be able to freely choose to participate in a trial. Decisions should be based on full knowledge of the implications of taking part, including the fact that being vaccinated may cause an HIV-positive test result, though this will not necessarily mean that someone is HIV-infected. However, if people are not used to Western models of medicine they may find it difficult to understand the trial design, and the risks involved. In certain cultures individual decision making is unfamiliar, and families or community leaders may have to be involved. Pressure on people to participate and use of incentives must be avoided. However, access to health care may encourage many to volunteer in poorer countries.

Providing care Care and education costs will be large. Each possible participant must consent to have an HIV antibody test (with pre-and post-test counselling about the implications). People who test antibody positive will not be able to participate in trials for the preventive vaccine, but they (and their families) will need follow-up care and counselling. Participants will need access to health care during the trial and afterwards, if for example they experience any medical problems caused by the vaccine. 





AIDS action  Issue 23    3   Page 4   5  top of page

  Preventing HIV in prisons

 

Prisoners are at risk from HIV - and efforts to prevent transmission in jails protect people in the wider community too.
Evidence for high HIV infection rates among prisoners is growing. Worldwide, most prisoners are from poorer sections of society with a higher prevalence of HIV/STDs. This means that the proportion of men and women in prison who are HIV-positive may be greater than in the rest of society. Sex workers and drug users may be at particular risk of HIV, and are often imprisoned in places where prostitution and drug use are illegal. Up to 30 per cent of prison inmates in cities in the USA where illegal drug use is common are serving sentences linked with drug use or related crimes. People also risk being infected with HIV during their prison sentence. Both female and male prisoners are vulnerable to sexual assault by prison staff and other prisoners. Surveys show that sex between prisoners happens, in spite of severe penalties. For example, between 2 to 30 per cent of inmates in prisons in the UK, USA, Australia and Brazil reported sex with other inmates, which often involved unprotected anal intercourse for men. In a survey of five prisons in Zambia, over 12 per cent of male prisoners reported sexual experiences - both forced and consensual - with other men during their time in prison. Some prisons allow conjugal visits, when prisoners can have sex with a visiting partner which, if unprotected, could spread HIV. Drugs are often illegally smuggled into prisons, and obtaining clean injecting equipment is very difficult. Sharing needles and syringes is a common high risk activity. Body tattooing, scarring or piercing with shared instruments can also involve risk. Preventing HIV transmission in prisons not only protects prisoners, but others in the wider community too. Most inmates are in prison for brief periods only, and return to their home communities when they are released. If they are infected they could pass the virus to others through unsafe drug use or unprotected sex.

Collective response: in 1991 inmates of Santo Boma prison, in Paramaribo (in Surinam, Latin America) were invited by prison authorities to form the 'Boma Education Collective' after a survey showed that unprotected anal sex was common. After training in peer education, they developed and tested posters and leaflets and organised an HIV/STD awareness week. Prison warders also received training and a confidential counselling service was set up.

Collective response: in 1991 inmates of Santo Boma prison, in Paramaribo (in Surinam, Latin America) were invited by prison authorities to form the 'Boma Education Collective' after a survey showed that unprotected anal sex was common. After training in peer education, they developed and tested posters and leaflets and organised an HIV/STD awareness week. Prison warders also received training and a confidential counselling service was set up.


Christel Antonius, NAP Surinam, c/o 4205 NW 36th Ave, Miami, FL 33142-4217, USA.


Educate for protection
Increasingly prisons are introducing measures to reduce the spread of HIV. Both staff and inmates should be involved in developing a programme and putting it into action. Education about HIV/STDs, safer sex and injecting drug use is an essential part of programmes. Staff need training to help them deal with their own and inmates' fears of infection and prejudices about AIDS, and how to protect themselves from, for example, contamination with blood.

In some prisons, AIDS committees with staff and inmate representatives co-ordinate training, materials production and special events, such as drama. Peer education is useful since most practices involving risk are illegal, and prisoners themselves are more likely to be trusted by other inmates.

Distributing condoms in prisons is another important strategy for reducing prisoners' risk. Some prison authorities accept that they cannot prevent all sexual activity. They feel that providing condoms strengthens education efforts, enables prisoners to take care of themselves, and is likely to reduce the spread of HIV/STDs. A recent WHO-sponsored report showed that condoms are now available in prisons in over half of the countries surveyed, including Brazil, Canada, Costa Rica and many European countries(1). Some prison services, such as in Botswana and Cuba, distribute condoms only before parole periods and on release. Prisons in, for example, Australia, Spain, Mauritius, Tanzania and Costa Rica, provide disinfectant or bleach, and encourage inmates to sterilise needles and syringes and cutting instruments. By 1993, needles and syringes themselves had not been made legally available in any prison, although one women's prison in Switzerland had begun a small needle exchange scheme.





AIDS action  Issue 23    4   Page 5   6  top of page

  Preventing HIV in prisons

 

Concerns for care 
Women have particular needs for education on health, pregnancy-related transmission and safer sex. More than 10 per cent may be pregnant on admission, and they need counselling and pre/ante-natal care, access to voluntary abortion services or child care in or outside prison. In many prisons, HIV-positive prisoners are housed in separate units or cells and are not allowed to work or have social contact with other in-mates. This is not justified, as HIV is not transmitted through casual contact. Separate housing is only justified if behaviour is aggressive or violent (whether or not it involves a risk of HIV). However, sometimes separate housing is offered to HIV-positive prisoners who are experiencing prejudice from other inmates. Some prisons want to know whether inmates are HIV-infected or not and test for HIV antibodies without their consent, often in order to house them separately. This is not necessary or justified. Ideally counselling and voluntary testing should be available to all prisoners. However it should not be offered unless follow-up care and support are possible. Prisoners who are ill should be transferred to a public hospital if there are no adequate prison facilities for caring for AIDS patients. Many prisons now have a policy of releasing people who develop AIDS. HIV-related TB is also a risk for inmates and staff, particularly in over-crowded prisons. Regular TB screening (involving voluntary TB testing) is an important preventive measure, and treatment should be available.

1. HIV/AIDS and prisons: a survey of 55 prison systems in 31 countries, University Institute of Legal Medicine, Geneva for WHO/GPA, 1992.

WHO guidelines on HIV infection and AIDS in prisons, 1993. Single copies are available from DS1; GPA/WHO, 1211 Geneva 27, Switzerland.

See AIDS Action Issue 21 for more information on HIV infection and injecting drug use.

Role of Hope
Prison conditions in Brazil, as in many countries, are poor and contribute to the spread of HIV. In some prisons, as many as 40 men or women may be crowded into each small and dirty cell, designed for only half the number. The conditions cause stress and violence, and sexual assault and rape are often reported. Consenting sex between prisoners is common too, and includes unprotected anal sex between men. Sharing contaminated needles and syringes for injecting drug use also puts people at risk. 

In 1991, 'Projeto Tereza' was started by a non-government organisation which was already working voluntarily in prisons. A 'tereza' is a rope made out of towels and sheets used to escape from the prison. The project offers a way to escape the isolation and depression caused by prison life, as well as helping both male and female prisoners to protect themselves against HIV and STDs. 

The prison authorities support the project's work and permit the distribution of condoms during health education sessions. When first going into a prison, the project's educators start by giving a talk to as many inmates as possible to advertise the project's activities. The educators then make regular visits and arrange to meet individuals for counselling sessions and to give talks to small groups.

Through developing long term, one-to-one relationships, they aim to build up prisoners' self-esteem and increase their motivation to take care of themselves and others. People volunteer for these regular sessions, and are encouraged to share what they learn with other inmates and visitors. The response has been very positive. As one prisoner said to an educator: 'I have been here for six years, and the best thing that has happened to me is to meet you.' At the biggest prison a group formed to do a drama about AIDS for their families during Easter celebrations. Another group wrote a song about the importance of taking care of yourself.

During the one-to-one sessions, the educators discuss general health care and hygiene as well as HIV/STDs. Individuals are referred to the prison clinic if they think they have an STD or other illness. Although many of the men do not want to discuss having same sex relationships, they often accept condoms for their family members or friends, and educators believe they use these with other prisoners. Prison authorities do not allow the distribution of new syringes or bleach, but the educators give advice about the dangers of dirty needles. Inmates also talk about a wide range of issues, from human rights to sexuality, and the educators support them in campaigning for better living conditions and health care.

Health care provided by the prisons is poor, and although the project offers AIDS awareness training to staff, it is not compulsory and generally only non-medical staff come to the courses. HIV testing is provided by an external agency and the educators fear that prisoners are being encouraged to have the test for research purposes. Once someone has tested positive, opportunities for follow-up and care are very limited. 

The project's approach seems to be working - since it started in 1991, the number of STD cases treated in the prison clinics every month has dropped from 850 to 80. The number of prisoners asking for sessions with educators increases every week, as does their demand for condoms.

Sylvia de Oliveira, Projeto Tereza, Rua Visconde de Piraja 127, 22410-001 Ipanema, Rio de Janeiro, Brazil.



AIDS action  Issue 23    5   Page 6   7  top of page

  Clinical update

Respiratory diseases and HIV

AIDS Action provides an overview of diagnosis and treatment for adults with respiratory problems.

People with HIV often suffer from respiratory problems, such as bacterial pneumonias, TB or Pneumocystis carinii pneumonia (PCP). The pattern of respiratory disease varies from region to region.

Bacterial pneumonias
Occurrence These pneumonias occur in all regions and are much more frequent in adults with HIV than in those not infected with HIV, and attacks are often recurrent. The most common organism is Streptococcus pneumoniae, also known as pneumococcus.

Bacterial pneumonias often develop before other conditions related to HIV-infection. The risk of pneumonia is increased by smoking, excess alcohol, drugs made from opium and poor nutrition.
 
Diagnosis Patients may have fever, a cough with green or yellow sputum, breathlessness, and chest pain which worsens on taking a deep breath. A typical chest X-ray shows marked shadowing limited to a single lobe of one or other lung (lobar pneumonia). In patients without HIV infection pneumonia is usually limited to the lungs, although in some circumstances it can invade other parts of the body to cause bacteraemia (infection of the blood) and empyema (infection in the space between the lungs and the chest wall). These complications are much more common in people with HIV infection. Fortunately, many HIV-positive individuals respond well to treatment with an antibiotic. 

Other less common forms of bacterial pneumonia include infections caused by Staphylococcus and Klebsiella. Patients become rapidly unwell, and present in a 'toxic' state, with low blood pressure, high fever, fast pulse and they may be confused. A chest X-ray may show cavities or abscesses. These infections are best treated with cloxacillin and chloramphenicol, or clindamycin.

Pneumocystis carinii pneumonia (PCP) 
Occurrence
PCP is caused by a yeast-like organism which is less common in tropical climates than in the USA or Europe. People in the later stages of HIV infection are more vulnerable to PCP. In poorer communities, people with HIV probably die before their immune systems become suppressed enough to be vulnerable to PCP. While PCP is said to be uncommon in Africa, it certainly does exist. In a hospital-based study involving HIV-infected adults in Harare, Zimbabwe, about 25 per cent of severe pneumonias were diagnosed as PCP. PCP is more common in countries in Latin America, the Caribbean and Asia. In one Mexican study, about a quarter of AIDS-related deaths were linked to PCP, and a similar proportion to TB. 

Diagnosis Symptoms can include a dry non-productive cough, breathless-ness and fever. A typical chest X-ray shows widespread, regular (diffuse) shadowing in both lungs. Even in countries where PCP is less common, treatment for PCP should be an option for patients whose suspected bacterial pneumonia does not improve with a penicillin. PCP is treated with a high dosage of cotrimoxazole.

Clinical tuberculosis
Occurrence
TB is epidemic world-wide in poor communities where HIV is common. People with HIV in these communities are vulnerable to developing TB. because their weakened immune systems cannot protect them against the disease.

Diagnosis TB may be difficult to diagnose in people with HIV. HIV-positive patients are more likely to have TB in unusual sites such as the lymph nodes, the pleura and the pericardium (the membrane sacs enclosing the lungs and heart); to have a negative sputum smear and a negative tuberculin test; and to have an X-ray showing disease in the lower part of the lungs, without cavities. (See AIDS Action 18 for more information on TB and HIV.)

Kaposi sarcoma (KS) 
Occurrence
KS is a common HIV-related cancer in many regions. The skin, the mucosa (such as the lining of the mouth), the lymph glands and viscera (surface of gut and lungs) are all possible sites.

Diagnosis Symptoms of pulmonary KS (in the lungs) are similar to TB and PCP, although fever is unusual. Breathlessness on exertion may be the only symptom at first and the patient may have haemoptysis (blood in the sputum). Pulmonary KS is also associated with recurrent bacterial pneumonias. There may be characteristic purple or darkened patches of KS on the skin or in the mouth. A chest X-ray may show very coarse patchy shadowing with nodules often greater than 1-2mm in diameter. Unfortunately, the outcome is poor despite treatment with radiotherapy or chemotherapy.

Fungal infections
Occurrence
Cryptococcus neoformans usually causes meningitis, but cryptococcal infection can affect the lungs of HIV-infected people in all regions. Two other fungal infections - histoplasmosis and coccidiomycosis - are common in north, central and south America and the Caribbean. Penicilliosis is now common in south-east Asia and China. 

Diagnosis
All fungal infections may resemble TB. Clues to their diagnosis are failure to improve with TB treatment and whether or not they occur in the country. Cryptococcal infections should be suspected in sick patients where trials of treatment for common conditions have failed, especially if the patient has symptoms of meningitis such as a headache, neck stiffness or drowsiness. A lumbar puncture and examination of the cerebrospinal fluid using India ink may show typical cryptococci. Fungal infections should be treated with amphotericin or fluconazole.



AIDS action  Issue 23    6   Page 7   8  top of page

  Clinical update

Management approaches

A rational approach to diagnosis and management of respiratory infections is based on knowing which ones are common in a particular region, and on available diagnostic facilities. A diagram (algorithm) showing the different steps to take according to the results of diagnosis and treatment may help health workers. The example shown below was developed for a hospital in Zimbabwe.

First line management 
If a history and a physical examination indicate bacterial pneumonia and the patient is not in respiratory distress, the infection should be treated with a penicillin. The signs of respiratory distress are a respiratory rate of over 24 per minute, intercostal muscle indrawing, use of neck muscles during breathing and central cyanosis (blue tongue and lips).

Second line management If the patient is in respiratory distress; or if there is no response after three days of treatment with a penicillin; or if the patient's condition worsens, these steps should be taken. 

If facilities are available, a sputum smear for acid fast bacilli for TB, a gram stain (for bacteria) and a chest X-ray should be carried out, and the patient treated accordingly (see diagram).

If facilities are not available, and it is impossible to refer the patient, a second antibiotic such as normal dose cotrimoxazole will cover many resistant pneumonias, and improvements should be seen within three days. Alternatively, extremely breathless patients should be given high dose cotrimoxazole for possible PCP as well as resistant pneumonias. This should be prescribed with caution, as it can cause side effects such as severe rashes (Stevens-Johnson syndrome). If the patient does not improve after 7-10 days of high dose cotrimoxazole treatment then smear-negative TB may be the diagnosis.

Dr Adam Malin, Nuffield Dept of Clinical Medicine, Oxford University, UK (formerly at the Dept of Clinical Pharmacology, University of Zimbabwe).

References are available from AHRTAG. WHO's guidelines for the clinical management of HIV infection in adults cover respiratory infections, and are available from DST/GPA, WHO, CH-1211 Geneva 27, Switzerland.


Prevention measures
 

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Smoking can hasten the onset of AIDS and increase the risk of bacterial pneumonias in HIV-positive people.

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TB screening should be carried out if a person with HIV has had contact with someone with TB, and TB treated if necessary.

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Prevention of some respiratory infections with drugs is possible.
 

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Penicillin prophylaxis may prevent pneumococcal infections, and be valuable for people who have had severe recurrent attacks

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PCP can be prevented with a daily 960mg dose of cotrimoxazole, and can be considered if the infection is common. 

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Prophylaxis with isoniazid may prevent clinical TB from developing, and the effectiveness of this is still being studied. 

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The existing pneumococcal vaccine is of limited value for people with HIV because it produces a very low immune response.

 

Possible steps in second line management






AIDS action  Issue 23    7   Page 8       top of page

  Letters / New Resources

Letters

I would like to share my experience of using sexual language in workshops for women (issue 22). AIDS educators often emphasise the importance of calling a spade a spade. But in many cultures it is very difficult for women to talk about sex and sexuality with either women or men. In rural South Africa, for example, women use the term 'to meet with' for having sex, and phrases for a man's genitals are rarely used.

During workshops I speak in the women's first language, and acknowledge that these things are difficult to talk about. I ask them to suggest and agree on words for different sex organs and sexual activities. This exercise is enjoyable and acceptable to them. Then, throughout the workshop I use the women's own words and ideas. I also ask the women to talk about whether and how they could raise issues about HIV or STDs with their partners. At one workshop it was suggested that women first talk about aspects of their relationships that keep them together, and start talking about sex only when they feel comfortable. Women wanted to discuss personal experiences, such as what they could say to a partner who works away from home for long periods.

Workshops like these need follow-up sessions, and are best run as part of literacy or income-generating schemes that women are already involved in.

Emelda Boikanyo, Women's Health Project, University of Witwaterstrand Medical School, Johannesburg, South Africa.

Unanswered questions 
The questions and answers section in issue 20 dealt with many common queries. We would like to know the answer to another question which often worries midwives. What is the risk of HIV infecting someone via contact with the eyes, nose or mouth?

Etildah Mwale, Hwange, Zimbabwe.

Editor's note: There is some evidence that HIV infection can occur through contact with the lining of the eye (conjunctiva). There is less evidence for infection of health workers via the mouth or nose. Ideally protective glasses should be worn during surgical operations or deliveries. However, if a health worker's face or eyes are splashed by amniotic fluids (from the womb) during delivery or by blood from any patient, the risk of infection can be greatly reduced by washing at once with soap and water. If possible wash out the eyes and mouth using saline (sterile salt solution) as well.

New Resources

Window of Hope
This new video from Zambia features members of PALS (Positive and Living Squad) working as AIDS educators with young people in Lusaka. Winstone Zulu, who co-ordinates the group, emphasises the important role for people who are HIV-positive and in control of their lives (see issues 20 and 21).
Available in VHF/PAL format from M. Kelly, 114 Mount St, London W1Y 6AH, UK, for £15.00, with a cheque payable to Kara Counselling, Zambia.

Work Against AIDS
No 8 in the Strategies for Hope series by Glen Williams and Sunanda Ray describes several workplace-based HIV/STD prevention initiatives in Zimbabwe that have successfully reduced STD rates among employees.

Available from TALC, PO Box 49, St Albans, Herts, AL1 4AX, UK for £2.75 per copy, with a cheque or IMO made payable to TALC.  Limited numbers of booklets 1-7 may be provided to organisations in sub-Saharan Africa who are unable to purchase them - please include details of how you will use them. 

 

Executive editor Nel Druce
Managing editor Kathy Attawell
Design and production Ingrid Emsden
 
Editorial advisory group Calle Almedal, Nina Castillo, Professor E M Essien, Dr Sam Kalibala, Ashok Row Kavi, Dr Ute Küpper, Professor Keith MacAdam, 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, 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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