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The goals of routine HIV screening are two-fold: improve the quality of life and survival of patients who have HIV infection and decrease the risk of transmission of infection to others. Prompt referral of HIV-infected individuals to HIV care is a critical step in this process. In an effort to increase the likelihood that a person living with HIV infection can benefit from treatment and care plus reduce the chance of spreading the infection to others, CDC, through their revised recommendations, seeks to increase the number of physicians offering routine HIV screening as a standard part of care.
The tile of this presentation is phrase taken from a research study into the impact of stigma conducted by the Panos institute. The phrase Dirty Blood and Worms from the gutter illustrates how language is used to stigmatize people with HIV/AIDS
Then concept has origins in the ancient Greek world. The modern usage draws on the work of Irving Goffman an American sociologist, who developed the concept in relation to his work on mental illness. Stigma builds on and reinforces negative stereotypes. In HIV/AIDS the stigma of the disease emerges from several sources; the fear of plague and epidemic disease, the taboo’s associated with the way the disease is transmitted; the association with death and dying. Certain groups have come to be identified with HIV/AIDS. In the early western epidemic and still in many counties it is seen as a disease of homosexual men. It has also been seen as an African disease and given encouragement to racist views on Africans. In Asia it is mainly associated with sex work and drug use and people identified with these groups bear a double and sometimes triple stigma.
Research into the causes and effects of stigma will reveal what underlying assumptions are driving stigma. Religious groups play an important role in assisting communities and PLWHA to address the beliefs and values that underpin stigma GIPA Positive speakers operate in many countries in the Asia region. Media are also key players, encouraging a more positive approach and representation of PLWHA by the media is an important aspect of changing discriminatory attitudes Involving PLWHA in the response is perhaps the most important aspect of addressing stigma. There are still too few examples of PLWHA who are active.
AIDS IssuesAIDS Issues
Dr Mona AbosereaDr Mona Aboserea
Prof. of Public HealthProf. of Public Health
Zagazig universityZagazig university
Human Immunodeficiency VirusHuman Immunodeficiency Virus
H = Infects onlyH = Infects only HHuman beingsuman beings
I =I = IImmunodeficiency virus weakens themmunodeficiency virus weakens the
immune system and increases the risk ofimmune system and increases the risk of
V =V = VVirus that attacks the bodyirus that attacks the body
AAcquiredcquired IImmunemmune DDeficiencyeficiency SSyndromeyndrome
AA == AAcquired, not inheritedcquired, not inherited
II = Weakens the= Weakens the IImmune systemmmune system
DD = Creates a= Creates a DDeficiency of CD4+ cellseficiency of CD4+ cells
in the immune systemin the immune system
SS == SSyndrome, or a group of illnessesyndrome, or a group of illnesses
taking place at the same timetaking place at the same time
DR. S.K CHATURVEDIDR. S.K CHATURVEDI
Transmission of HIVTransmission of HIV
HIV is not transmitted byHIV is not transmitted by
• Public bathsPublic baths
• Work or school contactWork or school contact
• Using telephonesUsing telephones
• Sharing cups, glasses,Sharing cups, glasses,
plates, or other utensilsplates, or other utensils
• Coughing, sneezingCoughing, sneezing
• Insect bitesInsect bites
• Touching, huggingTouching, hugging
• Water, foodWater, food
HIV infection occurs in 4 stages:HIV infection occurs in 4 stages:
primary infection, clinicallyprimary infection, clinically
asymptomatic stage, symptomatic HIVasymptomatic stage, symptomatic HIV
infection, and progression from HIV toinfection, and progression from HIV to
Case Surveillance DefinitionsCase Surveillance Definitions
The WHO system also is based onThe WHO system also is based on
laboratory confirmation of HIV infection.laboratory confirmation of HIV infection.
However, the WHO surveillance systemHowever, the WHO surveillance system
consists of 4 clinical stages that correspond toconsists of 4 clinical stages that correspond to
WHO antiretroviral treatment guidelines:WHO antiretroviral treatment guidelines:
HIV infection – stage 1, no symptoms.HIV infection – stage 1, no symptoms.
HIV infection – stage 2, mild symptoms.HIV infection – stage 2, mild symptoms.
Advanced HIV disease – stage 3,Advanced HIV disease – stage 3,
advanced symptoms.advanced symptoms.
AIDS – stage 4, severe symptomsAIDS – stage 4, severe symptoms..
In addition, for children aged youngerIn addition, for children aged younger
than 5 years, WHO suggests using thethan 5 years, WHO suggests using the
percentage of total CD4+ Tpercentage of total CD4+ T
lymphocytes rather than the absolutelymphocytes rather than the absolute
CD4 count for accuracy.CD4 count for accuracy.
The WHO staging system is designedThe WHO staging system is designed
to assist in the clinical management ofto assist in the clinical management of
HIV, especially where there are limitedHIV, especially where there are limited
laboratory facilitieslaboratory facilities
What is HIV Incidence SurveillanceWhat is HIV Incidence Surveillance
HIV incidence measures the number of new HIV
infections in a population over a period of time.
HIS estimates are based on data collected through
routine case reporting and a newly developed
HIS is part of a national effort supported by the
Centers for Disease Control and Prevention
(CDC) to fully integrate incidence as a component
of the HIV/AIDS surveillance system and will
help target HIV treatment and prevention efforts.
HIV and AIDSHIV and AIDS
• When the immune system becomesWhen the immune system becomes
weakened by HIV, the illnessweakened by HIV, the illness
progresses to AIDSprogresses to AIDS
• Some blood tests, symptoms orSome blood tests, symptoms or
certain infections indicatecertain infections indicate
progression of HIV to AIDSprogression of HIV to AIDS
Period of communicability:Period of communicability:
So long the infected person is aliveSo long the infected person is alive
Incubation period:Incubation period:
But 50% of those infected develop AIDSBut 50% of those infected develop AIDS
about 10 years after infection.about 10 years after infection.
Clinical picture of AIDS:Clinical picture of AIDS:
11 -- Non-specific manifestations:Non-specific manifestations: e.g.e.g.
lymphadenopathy, anorexia, chronic diarrhea, weightlymphadenopathy, anorexia, chronic diarrhea, weight
loss, fever and fatigue.loss, fever and fatigue.
2 -2 - Specific indicator diseasesSpecific indicator diseases::
(a) Opportunistic infections such as pneumocystitis(a) Opportunistic infections such as pneumocystitis
carenii pneumonia, chronic cryptosporidiosis,carenii pneumonia, chronic cryptosporidiosis,
toxoplasmosis of CNS,etc.toxoplasmosis of CNS,etc.
(b) Neurologic diseases as HIV dementia or sensory(b) Neurologic diseases as HIV dementia or sensory
(c) Cancers as Kaposi sarcoma and Hodgkin's lymphoma.(c) Cancers as Kaposi sarcoma and Hodgkin's lymphoma.
(d) Others e.g. pulmonary or extra-pulmonary T.B.(d) Others e.g. pulmonary or extra-pulmonary T.B.
Diagnosis of AIDS:Diagnosis of AIDS:
1 - Clinical picture.1 - Clinical picture.
2 - Laboratory diagnosis:2 - Laboratory diagnosis:
Serologic tests for HIV antibodiesSerologic tests for HIV antibodies
e.g.e.g. ELISA, Western blot, IndirectELISA, Western blot, Indirect
Immunofluorescence Assay.Immunofluorescence Assay.
PCR test to detect HIV antigen.PCR test to detect HIV antigen.
Desired Outcome of Routine HIVDesired Outcome of Routine HIV
Health Consequences ofHealth Consequences of
AIDS-related StigmaAIDS-related Stigma
What is Stigma?What is Stigma?
1)1) It's a mark of anIt's a mark of an enduringenduring condition orcondition or
2)2) The condition isThe condition is negatively valuednegatively valued byby
As a consequence, those with theAs a consequence, those with the
condition becomecondition become disadvantaged.disadvantaged.
StigmaStigma , prejudice, prejudice &&
Related but not synonymous:Related but not synonymous:
PrejudicePrejudice: An attitude. An: An attitude. An individualindividual
evaluation or judgment of a groupevaluation or judgment of a group
DiscriminationDiscrimination:: AA behaviorbehavior. Refers to. Refers to
treatment of individuals based on theirtreatment of individuals based on their
membership in a group.membership in a group.
Why is AIDS so highlyWhy is AIDS so highly
Stigma is more intense when the conditionStigma is more intense when the condition
1) Perceived as lethal and incurable1) Perceived as lethal and incurable
2) Perceived to be the responsibility of the2) Perceived to be the responsibility of the
Effects of stigmaEffects of stigma
Social isolationSocial isolation
Limited rights and reduced access toLimited rights and reduced access to
HIV/AIDS related stigma fuels new HIVHIV/AIDS related stigma fuels new HIV
Secondary stigmaSecondary stigma (stigma by association)(stigma by association)
Consequences of AIDS-relatedConsequences of AIDS-related
stigma and discriminationstigma and discrimination
It causes human suffering due to:It causes human suffering due to:
Loss of employmentLoss of employment
Loss of housingLoss of housing
Rejection by familyRejection by family
Rejected by communityRejected by community
Denied schoolingDenied schooling
Denied marriageDenied marriage
Restrictions on movement -> QuarantineRestrictions on movement -> Quarantine
Physical and verbal abuse and threatsPhysical and verbal abuse and threats
Interferes with AIDS prevention and treatmentInterferes with AIDS prevention and treatment
Stigma in service deliveryStigma in service delivery
• Discourages access to ANC servicesDiscourages access to ANC services
• Prevents access to counselling , HIV testingPrevents access to counselling , HIV testing
• Discourages disclosure of HIV test results toDiscourages disclosure of HIV test results to
• Discourages acceptance of any health careDiscourages acceptance of any health care
• Inhibits use of safer infant-feeding practicesInhibits use of safer infant-feeding practices
• Confers secondary stigmatisation on the childConfers secondary stigmatisation on the child
Health Consequences of AIDS StigmaHealth Consequences of AIDS Stigma
PreventionPrevention - afraid to access prevention services and- afraid to access prevention services and
be identified as member of "at risk" group.be identified as member of "at risk" group.
- afraid to disclose positive sero status to sex partner- afraid to disclose positive sero status to sex partner
Treatment -Treatment - afraid to disclose status to health careafraid to disclose status to health care
staff and not wanting to be seen at "AIDS clinic"staff and not wanting to be seen at "AIDS clinic"
ResearchResearch - not wanting to identify as member of- not wanting to identify as member of
stigmatized group. Concerns of loss of confidentialitystigmatized group. Concerns of loss of confidentiality
CareCare - unwilling to provide care for sick family- unwilling to provide care for sick family
member. Unwilling to go into AIDS treatment fieldmember. Unwilling to go into AIDS treatment field
Mental healthMental health consequences for PWAs: High rates ofconsequences for PWAs: High rates of
depression and suicide.depression and suicide.
Addressing stigmaAddressing stigma
• Interventions addressing HIV-relatedInterventions addressing HIV-related
stigma can take place at all levels:stigma can take place at all levels:
Community and social/culturalCommunity and social/cultural
Health care site/facilityHealth care site/facility
Stigma avoidance strategies included:Stigma avoidance strategies included:
1) stating or implying that they had a1) stating or implying that they had a
different disease, such as TB;different disease, such as TB;
2) adopting a “don’t ask, don’t tell” status;2) adopting a “don’t ask, don’t tell” status;
3) lying outright about their HIV status;3) lying outright about their HIV status;
4) seeking treatment at a hospital far away4) seeking treatment at a hospital far away
from home; andfrom home; and
5) refusing to explain written medical5) refusing to explain written medical
documents to illiterate family members.documents to illiterate family members.
Interviewed at baseline, six-Interviewed at baseline, six-
month follow-up, and twelve-month follow-up, and twelve-
month follow-up visits aboutmonth follow-up visits about
their experiences withtheir experiences with
medication and living with HIVmedication and living with HIV
So what can we do to reduceSo what can we do to reduce
AIDS-related stigma?AIDS-related stigma?
Reducing AIDS stigmaReducing AIDS stigma
Targeting at multiple levelsTargeting at multiple levels
PolicyPolicy:: Law and policy reforms neededLaw and policy reforms needed
globally to prohibit discrimination of PWAs andglobally to prohibit discrimination of PWAs and
to protect those who are most vulnerable (e.g.to protect those who are most vulnerable (e.g.
sexual partners, substance abusers, ethnic andsexual partners, substance abusers, ethnic and
racial minorities).racial minorities).
SocialSocial: Community-based programs, including: Community-based programs, including
media (as appropriate in each setting). Workmedia (as appropriate in each setting). Work
through local NGOsthrough local NGOs
InstitutionalInstitutional: Military, schools, prisons,: Military, schools, prisons,
hospitals, and religious institutions and leaders.hospitals, and religious institutions and leaders.
FamiliesFamilies - provide support and education in whatever- provide support and education in whatever
venue that is possiblevenue that is possible
Mobilize and supportMobilize and support positive peoplepositive people and encourageand encourage
their involvement in activities and advocacytheir involvement in activities and advocacy
CouplesCouples - in whatever setting that couples can be- in whatever setting that couples can be
reached, including testing and counselingreached, including testing and counseling
IndividualsIndividuals - during healthcare visits, testing and- during healthcare visits, testing and
counseling and other appropriate venuescounseling and other appropriate venues
RecruitRecruit Opinion LeadersOpinion Leaders - educate and involve them- educate and involve them
Reducing AIDS stigmaReducing AIDS stigma
Reducing stigmaReducing stigma
Content of messagesContent of messages
Content needs to be tailored, based on:Content needs to be tailored, based on:
– Cultural context and normsCultural context and norms
– Prevalent health beliefsPrevalent health beliefs
– Local lawsLocal laws
– Setting-specific stigma dynamicsSetting-specific stigma dynamics
Specific infection fearsSpecific infection fears
Pre-existing prejudices toward marginalized groupsPre-existing prejudices toward marginalized groups
Multiple stigmas?Multiple stigmas?
Look for strengths as well as for challengesLook for strengths as well as for challenges
in each cultural settingin each cultural setting
Prevention of HIV TransmissionPrevention of HIV Transmission
Strategies to prevent HIV transmissionStrategies to prevent HIV transmission
Personal strategiesPersonal strategies
Public health strategiesPublic health strategies
Safe practices: no risk of HIV transmissionSafe practices: no risk of HIV transmission
Risk reduction: reduces but does notRisk reduction: reduces but does not
eliminate riskeliminate risk
a) Measures for casesa) Measures for cases
1 -1 - Case findingCase finding: screening of high risk: screening of high risk
groups e.g. male homosexuals, i.v. druggroups e.g. male homosexuals, i.v. drug
abusers, sexual partners of infectedabusers, sexual partners of infected
persons, patients taking repeated bloodpersons, patients taking repeated blood
transfusion as haemophilics.transfusion as haemophilics.
2 -2 - NotificationNotification: is obligatory to local health: is obligatory to local health
authority and WHO.authority and WHO.
3 -3 - Isolation:Isolation: Isolation of the HIV-positiveIsolation of the HIV-positive
person isperson is unnecessary, ineffective andunnecessary, ineffective and
44 - Concurrent disinfection- Concurrent disinfection: of equipment: of equipment
contaminated with blood or body fluids and withcontaminated with blood or body fluids and with
excretions and secretions visibly contaminatedexcretions and secretions visibly contaminated
with blood and body fluids.with blood and body fluids.
5 -5 - Treatment:Treatment:
Treatment of opportunistic diseases thatTreatment of opportunistic diseases that
complicated HIV infection.complicated HIV infection.
Antiretroviral treatment: it is complex, involvingAntiretroviral treatment: it is complex, involving
a combination of drugs as resistance willa combination of drugs as resistance will
rapidly appear if a single drug is used. Therapidly appear if a single drug is used. The
drugs are toxic and treatment must be lifelong.drugs are toxic and treatment must be lifelong.
A successful treatment is not a cure, although itA successful treatment is not a cure, although it
results in suppression of viral replication.results in suppression of viral replication.
b) Measures for contacts:b) Measures for contacts:
1 - Notification of contacts and source1 - Notification of contacts and source
of infection:of infection: The infected patientThe infected patient
should ensure notification of sexual andshould ensure notification of sexual and
needle sharing partners wheneverneedle sharing partners whenever
2 -2 - Screening of contactsScreening of contacts for HIVfor HIV
3 - Health education.3 - Health education.
4 - No vaccination or4 - No vaccination or
Prevention of HIV TransmissionPrevention of HIV Transmission
Public health strategies to prevent HIVPublic health strategies to prevent HIV
Screen all blood and blood productsScreen all blood and blood products
Follow universal precautionsFollow universal precautions
Educate in safer sex practicesEducate in safer sex practices
Identify and treat STIs/other infectionsIdentify and treat STIs/other infections
Provide referral for treatment of drugProvide referral for treatment of drug
Apply the comprehensive care approach toApply the comprehensive care approach to
prevent vertical transmission of HIVprevent vertical transmission of HIV
HIV patients Health care providers
Improve their awareness &
KNOWELEDGE about AIDS
WITH these patients:
Good doctor patient
Change their negative attitude
Fair & justice in dealing with
Especially early seeking
And avoid reluctance or delay
when feeling any sign or
symptoms regarding HIV
And proper health education
To minimize stigma & shyness
Proper counselling &
Vaccine DevelopmentVaccine Development
Developing a vaccine for HIV infection is a globalDeveloping a vaccine for HIV infection is a global
priority because of the vast public health need and thepriority because of the vast public health need and the
lack of an alternative approach to prevent or controllack of an alternative approach to prevent or control
infection adequately.infection adequately.
Development of any vaccine requires a careful,Development of any vaccine requires a careful,
systematic approach from basic scientific testingsystematic approach from basic scientific testing
through definitive clinical trials with human participants.through definitive clinical trials with human participants.
HIV is a global epidemic with staggering economic andHIV is a global epidemic with staggering economic and
social costs, and vaccine trials are among the mostsocial costs, and vaccine trials are among the most
challenging research to date.challenging research to date.
Given the number of people infected, increasing healthGiven the number of people infected, increasing health
care costs, and the increasing prevalence of AIDScare costs, and the increasing prevalence of AIDS
among people in third-world countries, it is critical that aamong people in third-world countries, it is critical that a
vaccine be developed.vaccine be developed.
Challenges and RisksChallenges and Risks
Although the effort to develop an effectiveAlthough the effort to develop an effective
vaccine against HIV has been unprecedentedvaccine against HIV has been unprecedented
in modern science, there have beenin modern science, there have been
formidable challenges with respect toformidable challenges with respect to
the diversity and complexity of viral antigens.the diversity and complexity of viral antigens.
The long incubation period between infectionThe long incubation period between infection
and disease symptoms andand disease symptoms and
an incomplete understanding of the immunean incomplete understanding of the immune
response to the virus are only a fewresponse to the virus are only a few
challenges that plague researchers.challenges that plague researchers.
HIV-related stigma is increasinglyHIV-related stigma is increasingly
recognized as the single greatestrecognized as the single greatest
challenge to slowing the spread ofchallenge to slowing the spread of
HIV/AIDSHIV/AIDS –– a threefold epidemica threefold epidemic
• Stigma, discrimination, and denialStigma, discrimination, and denial
Human rightsHuman rights
• Freedom from discrimination is aFreedom from discrimination is a
fundamental human rightfundamental human right
• Discrimination on the basis of HIV/AIDSDiscrimination on the basis of HIV/AIDS
status, actual or presumed, is prohibitedstatus, actual or presumed, is prohibited
by existing human rights standardsby existing human rights standards
• Discrimination against persons living withDiscrimination against persons living with
HIV/AIDS, or those thought to be infected,HIV/AIDS, or those thought to be infected,
is a clear human rights violationis a clear human rights violation