Harmonized presentation targeting all Medics

1. FUNDAMENTALS OF HIV AND AIDS
By
Apollo Musa
EHS

2. Outline
• Brief History, Epidemiology and Transmission of HIV
• HIV Infection and Disease Progression
• National Policies, Guidelines; Legal and Ethical Issues

3. BRIEF HISTORY, EPIDEMIOLOGY AND
TRANSMISSION OF HIV
• Why? :- to impart knowledge on the natural history, epidemiology,
modes of HIV transmission, impact and legal and ethical
implications of the HIV epidemic

4. Objectives
Be able to:-
•Outline the history of the HIV pandemic since the reported index cases
•Describe the epidemiology of HIV at the global, regional and national
level
•Describe modes of HIV transmission and key risk factors
•Discuss transmission of HIV and the known HIV types and subtypes
•Describe the impact of HIV and AIDS in the community
•Describe the legal and ethical implications of the HIV epidemic and
national response

5. A Brief History of the HIV Pandemic
• In 1981, young doctors in the United States of America recognized a
previously unknown syndrome in a group of men having sex with men
(MSMs).
• The syndrome was characterized by Pneumocystis Carinii pneumonia,
Kaposi’s sarcoma and generalized immune deficiency.
• After two years of painstaking work, in 1983, researchers identified the
cause of the syndrome as a retrovirus, Human immunodeficiency virus.
• Before scientists came to an agreement on this new name, the causative
virus was previously referred to as Lymphadenopathy associated virus
(LAV), AIDS associated retrovirus (ARV) and human T-lymphotrophic virus
III (HTLV-III).
• In 1986, the Human Immunodeficiency Virus (HIV) was accepted as the
international designation for the acquired immunodeficiency syndrome
causing retrovirus.

6. A Brief History of the HIV Pandemic…..
• The origin of HIV has remained steeped in controversy and several
theories have put forward to explain its source.
• It is postulated by some that HIV originated from a mutation of
the simian immunodeficiency virus (SIV) found in primates in the
tropical forests of the Congo in Central Africa.
• This new virus then jumped species into man through unintended
contamination of raw wounds during slaughter of the primates for
food by the local communities.
• This new virus then spread through the exchange of contaminated
body fluids among humans.

7. HIV Epidemiology
• Since the first cases of AIDS were reported in the USA in the
Centres for Disease Control and Prevention (CDC)’s Morbidity and
Mortality Report of 5th
June 1981, HIV spread rapidly throughout
out the world. It has touched countries and populations far and
wide.

8. The Global Picture
• Globally, HIV has left enormous devastation in its wake. AIDS is now
the fourth biggest cause of death worldwide.
• Many countries and communities have suffered untold losses in
human resources and reduced economic productivity as a
consequence.
• It is estimated that there are about 33.2 million people living with
HIV (PLHIV) throughout the world today. Cumulatively about 25
million people have died of AIDS worldwide since 1981, with an
estimated 3.1million deaths occurring in 2010 alone.
• Majority of those infected in the developed world are in the key
populations (especially men having sex with men and intravenous
drug users) and the developing countries mostly individuals in
heterosexual relations.
• Incidence throughout the world is estimated at 5 million.

9. HIV in Sub-Saharan Africa
• The sub-Saharan African region is the hardest hit, with about 70% of
the global number of PHIV living here.
• There are currently about 23 million PLHIV in the region.
• The region contributes nearly the same proportion of the 3.1 million
deaths and 5 million new infections globally.
• There about 12 million children orphaned by AIDS in sub-Saharan
Africa and the number is expected to rise, in the absence of more
accessible care and treatment for the infected, as the pandemic
matures.
• The HIV pandemic in SSA has a feminine character, with about 60% of
all PLHIV being women.
• South Africa has the largest absolute number of PLHIV in SSA, with an
estimated 5 million; and Botswana with the highest HIV prevalence at
38%. Countries in Southern Africa have the highest relative HIV
prevalence in SSA; and Uganda in the East African region has the
highest prevalence at 6.4% (UNGASS, 2010).

10. HIV in Kenya• After index case reported in 1984, Kenya experienced a rapid spread of HIV
throughout the country. The epidemic peaked in (year...) with the prevalence
estimated at 14.7% at the time.
• The policy makers and statisticians in the country back then, did question the
national prevalence data and the methodology used to estimate the numbers.
• The country was at the time using ANC surveillance data to undertake the
estimation and it became abundantly clear that this cohort had a risk of HIV
infection higher than the general population.
• The pregnancy that sent the women in the cohort to the clinics for the ANC
services was an indication they had had unprotected sex, and which
predisposed them to risk of HIV infection.
• This compelling insight did drive the country to, in addition, adopt population
based surveys to estimate the national HIV prevalence. As expected with this
new broadened approach, the first Kenya demographic survey and health
survey (KDHS, 2003), which had an HIV indicator, put the national prevalence
at 6.7%.

11. HIV in Kenya…..
• The 2007 Kenya AIDS Indicator Survey (KAIS, 2007) put the country’s HIV
prevalence at 7.1%; and the KDHS (2008) confirmed this. From this data, it is
estimated that there are about 1.3 million Kenyans in the age bracket 15 – 64 years
old who are PLHIV. Further, there are about 100, 000 Kenyans who get HIV
infected, and half this number of PLHIV who die, every year (UNGASS, 2010).
• The epidemic in Kenya, however, remains heterogeneous in its distribution with
lower rates generally observed in rural communities compared to urban centres,
but this is rising. The Kenyan epidemic has a feminine character with 60% of PLHIV
being women.
• The KAIS report indicated that a higher proportion of those infected in the 15- 64
year age category are women (8.7%Vs 5.6%). There are about 1.6 women infected
for every man.
• And in the age bracket between 15- 24 years, women are four times more likely to
be HIV infected than their male counterparts (6.1% Vs1.5%) due to age-mixing; a
phenomenon driven by the recognized culture of young women who tend to date
older men.

12. HIV in Kenya………
• The young girls’ inability to negotiate for safer sex tends to put them
at greater risk of HIV infection. In the 15 -64 age category, the
female to male HIV prevalence is 8.2% Vs 5.5% in the rural areas,
and 10.8% Vs 6.2% in the urban areas. The HIV prevalence among
men in the rural areas is however increasing (KAIS, 2007).
• Nearly two thirds of the 15 – 64 year olds who are PLHIV are in a
union (married or cohabiting). Further, the KAIS report (2007)
indicates that about ten percent (10%) of the monogamous married
couples and 14% of the polygamous ones have one or more of the
partners infected.
• HIV prevalence among Kenyans who have multiple sexual partners is
higher than for their monogamous counterparts (11% Vs 7%).
Further analysis did show that, the HIV prevalence among the
polygamous males was 15.9% in 2007 (KAIS, 2007), and that among
the divorced and/or widowed women was also high at 17 – 21%.

13. HIV in Kenya…………..
• A higher proportion of Kenyans between 30 – 34 years are
currently infected with HIV than any other age category in the
country.
• The HIV prevalence rates also exhibit significant regional and
rural/urban variations, with the average urban rate at about 9%
and the rural at 7% among those in the15-64 year olds (KAIS,
2007).
• In absolute numbers, nearly 70% of the 1.4 million people living
with HIV are in the rural areas.

14. Modes of HIV transmission
• HIV is transmitted when an uninfected individual comes into
contacted with body fluids and/or tissues of a PLHIV.
• The key modes of HIV transmission include:
– unprotected sexual contact with an infected individual,
– through contact and/or transfusion of contaminated blood to an
uninfected individual and
– from mother to child.

15. Sexual contact
• Sexual transmission of HIV through the sexual route is responsible
for over 80% of those infected in Kenya.
• Any unprotected penetrative sex, be it vaginal or anal, in the
absence of correct and consistent (male or female) condom has
some risk of HIV infection if any of the partners is infected.
• The risk an individual is exposed of getting HIV infected through the
sexual route is largely dependent on their sexual practices and
preferences.
• Penetrative anal sex is associated with a threefold higher risk of HIV
infection for the ‘receiving person’, if the penetrating sexual partner
is infected, than with vaginal sexual intercourse.
• The reason for this is most likely because of the associated breach of
the mucosal barrier of the rectal area due to inherently lower
lubricated related friction during intercourse allowing for easier
transmission of virus, if the sexual partner is infected.

16. Sexual contact…….
• Women are at higher risk of getting if they have unprotected vaginal sexual
intercourse with a male PLHIV; and the converse is not true. A woman is at a
higher risk of HIV infection in this context because of several factors includin
biological, and especially the fact that her vagina has a large surface area for
the virus to gain entry and that she gets highly infectious semen deposited
into her
• A man is less likely to get HIV infected if he has vaginal sexual intercourse
with an infected woman. Unless he has injuries on his penile shaft, as would
be the case in the presence of other sexually transmitted diseases like genita
herpes, or if he is not circumcised. If the skin of the penis is intact, the most
likely route of viral entry is the urethra. The urethra has a relatively smaller
surface area exposed, and when the man has been aroused it is bathed in
seminal fluid conferring some additional protection.

17. Sexual contact……….
• Recent studies in South Africa (2005), in Uganda and Kenya
(2006) have shown that male circumcision is protective.
• It does reduce the risk of HIV infection via the heterosexual
route by about 60%. When a man gets circumcised, the foreskin
is removed leaving the penis exposed and this allows the skin to
get dry and thicken, providing greater protection.
• It is important to remember that circumcision is just one factor,
and that its protection/benefit may be dramatically reduced if
one gets involved in frequent and high risk behavior, or does
not take appropriate precautions such as embracing the correct
and consistent use of condoms.

18. IV Drug Use
• Intravenous drug use is common among some of the key
populations especially in the developed world, accounting for
about 5 – 10% of all HIV infections worldwide.
• The practice is however fast taking root in the developing
countries including among some of groups of people in urban
centres in Kenya.
• Interdiction of drug hauls, including heroin, by the Kenyan
police is on the increase.
• Those who abuse drugs tend to ‘shoot’ in groups and share
needles, increasing significantly their own risk of infection if any
person in the group is a PLHIV.

19. IV Drug Use……
• Data has shown that about 50% of IV drug users in Mombasa
and 53% in Nairobi were HIV infected in 2005.
• This clearly demonstrates that IV drug use is increasingly
becoming an important route of HIV infection in Kenya, and
may increase the risk HIV in the general population.
• Blood-letting procedures, such as traditional male circumcision,
if done with shared and poorly/un-sterilized instruments can
increase the risk of HIV infection among the initiated youth.

20. Occupational Exposure to HIV infected Material/
specimens
• The risk of occupational exposure to HIV infected body fluids is
common particularly for health providers serving in high
prevalence and resource poor settings where protective gear and
infection control procedures are wanting.
• Contamination of the mucous membrane or needle stick injuries
during a procedure on an HIV patient or material can lead to
infection.
• Studies in the USA have put the risk of HIV infection at about 0.1%
for a single mucous membrane exposure and 0.32% in the event
of a needle stick injury.

21. Occupational Exposure to HIV infected
Material/ specimens………….
• The risk of infection is higher for health providers, as stated earlier, are
serving in areas where HIV prevalence is high, there is poor access to
protective clothing and gloves, and where fewer eligible patients are on
treatment.
• Poor access to anti-retrovirals for the eligible patients is associated with
high viral load and therefore accidental exposure of the health
providers to the body fluids of PLHIV could lead to HIV infection.
• Those accidentally exposed to potentially infectious body fluids from
patients they are attending to should go on Post Exposure Prophylaxis
(PEP) immediately or within two hours to ensure they get the full
benefit.

22. Blood Transfusion
• Worldwide, blood transfusion is blamed for about 3 to 5% of all
HIV infections. Any persons who gets transfused with a unit of
HIV contaminated blood will get infected, and especially if the
viral load is high.
• The individuals who infected through blood transfusion have
rapid disease progression and often to AIDS earlier than those
who get HIV through other modes of transmission.
• The risk of HIV infection through this route of transmission has,
especially for individuals getting transfusion in recognized
health facilities, because screening of blood for HIV and
Hepatitis has been scaled up over the last ten years in Kenya.

23. Mother to Child Transmission of HIV
• Worldwide, the risk of HIV transmission from mother to child varies
from 13 to 40%. In 2003, it was estimated that mother to child
transmission of HIV in Kenya was about 30% according to the Kenya
Demographic and Health Survey (KDHS, 2003).
• While the estimated relative risk has declines significantly as more
pregnant women seek antenatal care services and access skilled
delivery, about 22% (or about 22,000 children) of the total incidence
of HIV in Kenya is due to mother to child transmission (UNGASS,
2010).
• The child’s risk of infection varies including with when the mother
got infected (if she got infected before or during pregnancy) and her
general health, and therefore her prevailing viral load; the mode of
delivery; the absence or presence of elongated labour; and whether
or not the child is breast-fed.

24. Mother to Child Transmission of HIV
• About 60% of the children currently living with the virus got it
from their mothers during delivery. A child’s risk of HIV infection
is increased by presence of extended labor which often results
in membrane rapture and release of the amniotic fluid.
• This rapture of the protective membrane allows direct contact
of the baby with its mother’s potentially highly infectious blood
and vaginal secretions.
• Any injuries the child may suffer during its forced exit may
results in contamination of the wounds with potentially
infectious blood and vaginal secretions, significantly increasing
their risk of infection.

25. Risk Factors that Increase an Individual’s vulnerability to
HIV infection and/or transmission
Biological Factors
•Biological factors can increase an individual’s risk of HIV infection
and/or transmission. These include infectiousness of the host of the
virus, susceptibility of the potential recipient, and viral properties.
Infectiousness of host
•High viral load during the initial stage of infection and at the stages of
the disease increase the risk of HIV transmission. High levels of virus in
semen and genital secretions, as well as genital ulcers, menstruation,
and trauma during sexual contact increase the risk of transmission.
Breastfeeding by a HIV-positive mother increases their risk of passing
on the virus to their young children through vertical transmission.

26. Risk Factors that Increase an Individual’s vulnerability
to HIV infection and/or transmission…
Susceptibility of recipient
•Inflammation or disruption of the genital or rectal mucosa increases the
risk of HIV infection if sexual partners engage in unprotected intercourse.
Lack of circumcision in men having unprotected penetrative sexual
intercourse with PLHIV female partners increase s his risk of HIV
acquisition.
•Male circumcision reduces risk of HIV infection from heterosexual
encounter if other factors are held constant). Unprotected heterosexual
intercourse during menstruation increases a woman’s risk of infection,
and so does the presence of an ulcerative or non-ulcerative sexually
transmitted disease around her genitals.

27. Risk Factors that Increase an Individual’s
vulnerability to HIV infection and/or
transmission…Viral properties
•A mutant virus and/or resistant strain resulting from either the
prevailing environmental conditions and/or sub-optimal exposure to
antiretrovirals may be more virulent.
Socioeconomic factors
•Some of the socioeconomic factors known to heighten the risk of
infection include social mobility that is accelerating with increasing
globalization. More people are travelling and working away from home.
•The HIV pandemic and epidemic do follow the routes of trade and
commerce. For example, truck drivers who follow these trade routes may
get infected after having unprotected sexual intercourse with sex
workers, and transmit the virus to their wives, who in turn pass it along
to their infants in utero- or through breast milk.

28. HIV subtypes
• There are two types of HIV, namely HIV-1 and HIV-2.
Worldwide, the predominant virus is HIV-1, and which is both
more infectious than HIV-2 and those that it infects succumb to
AIDS in about 12 years unless they are put on effective
treatment.
• Transmission of both types of virus is the same: via unprotected
sexual contact with an infected individual, through contact
and/or transfusion of contaminated blood, and from mother to
child.
• They both appear to cause clinically indistinguishable syndrome
as the diseases progresses after infection However, HIV-2 is
transmitted less easily, and the period between initial infection
and illness is longer than the cases is for HIV-1.

29. HIV subtypes……
• Because of its high rate of replication, HIV-1 mutates rapidly,
and therefore there are about 10 known genetically distinct
subtypes (mutants) of HIV-1 within the major group (Group M).
• The known subtypes are alphabetically named - A to J. In
addition, Group O (the Outliers) has a distinct group of very
heterogeneous viruses.

30. HIV subtypes……
• These subtypes are unevenly distributed throughout the world as highlighted
below:
• Subtype B: is found mostly in the Americas, Japan, Australia, the Caribbean,
and Europe
• Subtypes A and D: predominantly found in sub-Saharan Africa
• Subtype C: largely found in South Africa and India
• Subtype E: more common in the Central African Republic, Thailand, and
other countries of Southeast Asia
• Subtypes F (Brazil and Romania), G, and H (Russia and Central Africa), I
(Cyprus), and O (Cameroon) and are associated with very low prevalence
• All the subtypes are present in Africa, but with subtype B being less
prevalent.

31. Case Study # 1 - Impact of the HIV Epidemic on the Health Sector in
Kenya
• It is a known fact that HIV has had a significant impact on the
Health Sector in Kenya.
• As part of group work, seek out relevant sources of information
(national reports, policies and strategic plans)

32. Assignment
• Write a short essay on Legal and ethical Issues associated with
HIV epidemic and the National HIV response.
• This assignment is to be handed in during the next session.

33. HIV INFECTION AND DISEASE PROGRESSION
• Why?
• To enable students to learn and understand the effects of HIV at
different stages post infection.

34. Objectives
• Describe the normal immune system.
• Describe major components, the HIV life cycle and Immunology
• Outline the WHO and CDC classification of HIV infection
• Outline the phases of HIV infection
• Discuss the effects of HIV on the immune system.

35. Introduction to the Immune System
• The immune system protects the body by recognizing antigens
or invading bacteria and viruses; and mounting a reaction
towards them to protect the body from danger.
• When the immune system is weakened or destroyed by a virus
such as HIV, the body is vulnerable to opportunistic infections.
• The immune system consists of lymphoid organs and tissues,
including the bone marrow, thymus gland, lymph nodes, spleen,
tonsils, adenoids, appendix, blood and lymphatic vessels

36. The HIV Lifecycle and Immunology
• The Human Immunodeficiency Virus (HIV) is a retrovirus
belonging to the family of lentiviruses.
• Retroviruses have the ability to use their RNA and host DNA to
make viral DNA and are known for their long incubation periods.
• Like other retroviruses, HIV infects the human body, has a long
incubation period (clinical latency), and ultimately causes the
signs and symptoms of AIDS.
• HIV causes severe damage to the immune system and
eventually destroys it.
• It accomplishes this by utilizing the DNA of CD4+ cell to replicate
itself. In that process, the virus destroys the CD4+ cell.

37. The HIV Life Cycle
The HIV lifecycle can be divided into six phases: binding and entry, reverse transcription,
integration, replication, viral assembly, and budding as elaborated below:
Binding (attachment) and entry
•The HIV envelope proteins, gp120 and gp41, bind to receptors and co-receptors on the outside
of the CD4+ cell.
•The joining of the proteins and the receptors results in the fusion of the HIV membrane with
the CD4+ cell membrane thereby allowing viral penetration of the CD4+ cell to occur.
•During this process, CD4+ cell enzymes interact with the core of the HIV and stimulate the
release of viral RNA into the cytoplasm of the CD4+ cell as well as the release of the viral
enzymes, namely the i) reverse transcriptase, ii) integrase, and iii) protease.
Reverse transcription
•The HIV- RNA must be converted to a viral DNA strand before it can be incorporated into the
DNA of the CD4+ cell.
•This incorporation is required for the virus to multiply.
•The conversion of HIV- RNA to viral DNA is known as the process of reverse transcription and is
mediated by the HIV enzyme, reverse transcriptase.
•The result is the production of a single strand of DNA from the viral RNA.
•The single strand of this new DNA then undergoes replication into double-stranded HIV-DNA.

38. The HIV Life Cycle…………..
Integration
•Once reverse transcription has occurred, the viral DNA can now enter
the nucleus of the CD4+ cell. The viral enzyme, integrase, then inserts
the viral DNA into the CD4+ cell’s DNA. This process is known as
integration. The CD4+ cell has now been changed into a “machine” used
to produce more HIV.
Replication
•After successful integration of the viral DNA (called a provirus), the host
cell is now latently infected with HIV. When the immune cell becomes
activated, the provirus instructs the cellular machinery to produce the
necessary components of HIV.
•From the viral DNA, two strands of RNA are constructed: i) one strand is
translated into HIV subunits such as protease, reverse transcriptase,
integrase and structural proteins; and ii) the second strand becomes the
genetic material for the new viral particles.

39. The HIV Life Cycle…………..
Viral Assembly
•All the components, or subunits, necessary to infect other CD4+ cells are
available, but cannot do so until they have been assembled into new viruses.
•During this process, the HIV protease enzyme cuts the produced long HIV
proteins into smaller functional units which then get reassembled to form new
virions.
•The virions are now ready to infect other human cells.
Budding
•The HIV proteins, viral RNA, and all other components needed to make a new
virus, are pushed close to the CD4+ cell membrane where they are assembled
into new viruses.
•The new virus particles push through the cell wall by budding. Many viruses
can push through the wall of one CD4+ cell.
•These new viruses leave the CD4+ cell and enter into circulation ready to infect
other CD4+ cells.

40. WHO Classification System for HIV-Infected Adults and
Adolescents
• The WHO has provided specific criteria for the classification of
manifestations of HIV infection. This classification has been used to
grade the disease progression and inform the time to start ART.
Clinical stage 1
Asymptomatic
Persistent generalized lymphadenopathy
Clinical stage 2
Moderate unexplained weight loss (under 10% of presumed or measured body weight)
Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis)
Herpes zoster
Angular cheilitis
Recurrent oral ulcerations
Papular pruritic eruptions
Seborrhoeic dermatitis
Fungal nail infections

41. Clinical stage 3
Unexplained severe weight loss (over 10% of presumed or measured body weight)
Unexplained chronic diarrhoea for longer than 1 month
Unexplained persistent fever (intermittent or constant for longer than 1 month)
Persistent oral candidiasis
Oral hairy leukoplakia
Pulmonary tuberculosis
Severe bacterial infections (e.g. pneumonia, empyema, meningitis, pyomyositis, bone or joint infection,
bacteraemia, severe pelvic inflammatory disease)
Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
Unexplained anaemia (below 8 g/dl ), neutropenia (below 0.5 x 109/l) and/or chronic thrombocytopenia
(below 50 x 109/l)
Antiretroviral therapy for HIV infection in adults and adolescents
Recommendations for a public health approach

42. Clinical stage 4
HIV wasting syndrome
Pneumocystis jiroveci pneumonia
Recurrent severe bacterial pneumonia
Chronic herpes simplex infection (orolabial, genital or anorectal of more than 1 month’s duration or
visceral at any site)
Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
Extrapulmonary tuberculosis
Kaposi sarcoma
Cytomegalovirus disease (retinitis or infection of other organs, excluding liver, spleen and lymph
nodes)
Central nervous system toxoplasmosis
HIV encephalopathy
Extrapulmonary cryptococcosis including meningitis
Disseminated nontuberculous mycobacteria infection
Progressive multifocal leukoencephalopathy
Chronic cryptosporidiosis
Chronic isosporiasis
Disseminated mycosis (histoplasmosis, coccidiomycosis)
Recurrent septicaemia (including nontyphoidal Salmonella)
Lymphoma (cerebral or B cell non-Hodgkin)
Invasive cervical carcinoma

43. The Phases of HIV Disease Progression
Generally, four phases of HIV disease are recognized. These are i) the acu
phase, ii) the asymptomatic phase, iii) the symptomatic phase, and iv) the
late symptomatic phase.
Acute phase (initial infection)
•As soon as HIV enters the body, it replicates rapidly.
•This rapid replication requires energy from the host’s body.
•The virus relies entirely on the host for survival and will access from the
host whatever is required for its multiplication and survival.
•The HIV infection may have a rapid onset, leading to hypermetabolism
with catabolism.
•Although some PLHIV may not have any symptoms at this stage, the host
energy and nutrient requirements increase significantly, and therefore th
food intake ideally should increase accordingly.
•This period varies from 1 to 6 weeks.

44. Acute phase (initial infection)…………..
• After the first six (sometimes up to 12) weeks, levels of the virus
decrease, as the body produces antibodies to fight it (sero-
conversion).
• The body needs additional energy to cope with the infection and
begins to hydrolyse its fat stores and muscle.
• The hydrolysed muscle is used to repair the cellular and damaged
tissue.
• If the additional energy and nutrients needed are not provided to
the body in earnest, the host loses weight and gradually develops
malnutrition that weakens the immune system making the host
vulnerable to opportunistic infections.
• Without symptoms, as often is the case, the stage of initial infection
with HIV goes un recognized and diagnosed.

45. Asymptomatic phase
• The length of the asymptomatic phase of the HIV disease varies
and may reach several years, depending on the health and
nutritional status of the host prior to infection.
• The asymptomatic phase is marked by hyper-metabolism and
increased energy needs.

46. Symptomatic phase
• Initial symptoms associated with HIV disease start at the onset of opportunistic
infections.
• The PLHIV presents with common symptoms such as fever, night sweats, tuberculosis,
and fungal infection of the mouth, chronic diarrhea, and weight loss.
• The onset of opportunistic infections is a sign of a weakened immune system.
• Negative nitrogen balance occurs early in acute infections because of decreased food
intake and increased urinary protein loss.
• Immunologic response to HIV infection activates cytokines, which causes fever and
anorexia, thereby leading to increased energy expenditure and decreased caloric
intake. The opportunistic infections further increase the nutritional needs of the host
and continue to weaken the immune system, speeding up the progression of the HIV
disease.
• Early immune failure occurs when the persistence of symptoms and opportunistic
infections lead to increased energy needs, reduced food intake, malabsorption of
nutrients, weight loss, and wasting. The increased incidence of and sustained presence
of these conditions are AIDS defining.

47. Symptomatic phase…….
• Immunologic response to HIV infection activates cytokines, which
causes fever and anorexia, thereby leading to increased energy
expenditure and decreased caloric intake.
• The opportunistic infections further increase the nutritional needs of
the host and continue to weaken the immune system, speeding up the
progression of the HIV disease.
• Early immune failure occurs when the persistence of symptoms and
opportunistic infections lead to increased energy needs, reduced food
intake, mal-absorption of nutrients, weight loss, and wasting.
• The increased incidence of and sustained presence of these conditions
are AIDS defining.

48. Late symptomatic phase (full-blown AIDS)
• The late phase of the HIV disease progression is marked by
metabolic alteration, significant weight loss, and wasting.
• Other characteristics include fast rising viral load, a decreased
CD4+ count, pneumonia, Kaposi’s sarcoma, systemic fungal
infection, bacterial infections, and cancer.
• At this stage the HIV infected individual is classified as having
full blown AIDS. Unless the PLHIV is started on ART, death may
occur at any time during this state of the HIV disease.
• During the late stage, the common signs and symptoms include
the development of life threatening infections and malignancies
such as pneumonia, systemic fungal infection, bacterial
infection and Kaposi’ sarcoma.

49. Effects of HIV on the immune system
Primary Infection or Acute Retroviral Syndrome (Clinical Category)
•Primary infection refers to the period of time when HIV first enters the body. At the time
of primary infection with HIV, a person’s blood has a very high viral load.
• The number of copies of virus per millilitre of plasma or blood can exceed 1,000,000.
•The newly infected adult often experiences an acute retroviral syndrome.
•Signs and symptoms of acute retroviral syndrome include fever, myalgia (muscle pain),
headache, nausea, vomiting, diarrhoea, night sweats, weight loss, and rash.
•These signs and symptoms usually occur two to four weeks after infection, subside after a
few days, and often are misdiagnosed as influenza or infectious mononucleosis.
•During primary infection, the CD4+ count in the blood decreases remarkably.
•The virus largely targets the CD4+ cells in the lymph nodes and the thymus during this
time, making the HIV-infected person vulnerable to opportunistic infections and limiting
the thymus’s ability to produce T-lymphocytes.
•HIV antibody testing using an enzyme-linked immunosorbent assay (ELISA) or enzyme
immunoassay (EIA) may yield positive results.

50. Effects of HIV on the immune system……….
Seroconversion with relative recovery
•Sero-conversion refers to the period or time at which the body of the newly infected
individual has produced enough antibodies in response to this external challenge to test
HIV positive using ELISA (or any antibody) screening method.
•After infection, the body tries to mount an immune response to beat the virus and the
expressed antibodies are a consequence of this attempt by the individual’s immune
system to fight.
•Different individuals produce antibodies at varying rates depending on the character of
their immune system and perceived risk of the antigen it is exposed to.
•Some individuals will sero-convert within two weeks of exposure but the majority will
have done so by the end of six weeks.
•With the current anti-body based HIV test kits, the window period has been stated as six
week. It therefore takes about six weeks to identify those who HIV infected using the
antibody test in six weeks.
•This phase of the HIV disease progression is characterized by development of some
immunity against HIV, followed by a rapid decline in viremia and slowing down of CD4 cell
loss.

51. Effects of HIV on the immune system……….
Asymptomatic chronic HIV infection
•This phase of the HIV disease progression starts after sero-
conversion and is characterized by increased and sustained CD4
loss depends on plasma viral load. This may take anything from six
weeks to eight years.
Symptomatic phase of HIV disease
•This stage starts anywhere from six to twelve and is characterized
by increasing viremia and accelerated rate of CD4 decline.
•Opportunistic infections (OIs) set in and unless the PLHIV is
started on effective treatment, the PLHIV eventually progresses to
full blown AIDS and dies.

52. LEGAL AND ETHICAL ISSUES AND GOVERNMENT POLICIES AND
GUIDELINES
• Why?
• To learn and understand the legal and ethical issues and
government policies and guidelines related to the HIV epidemic in
the country.

53. Objectives
• Be able to:
• Identify special features of the HIV epidemic which raise legal
and ethical issues
• Identify statutes and key legal documents that address legal and
ethical issues related to the HIV epidemic
• Outline Kenya‘s legal and ethical guidelines as regards to HIV
• Outline HIV related issues addressed in selected government
policies and guidelines
• Describe the linkage between human rights and HIV.
• Explain the importance of laws and ethical principles in HIV
programming
• Outline the legal and ethical obligations and responsibilities of
the health providers involved in the national HIV response

54. Special features of the HIV epidemic
which raise legal and ethical issues
Feature Consequences
1
.
New epidemic/infection o Fear, misunderstanding and denial
2
.
Long asymptomatic period and life o Infected often unaware.
3
.
Long infectivity o No action taken until people become ill
4
.
No cure, limited expensive treatment&
death inevitable
o Intensifies fear over testing, burden on family and health services
o Demands exceptionally high standard of laboratory services because
of possible false HIV positive and false HIV negative results
5
.
STI o Associated with guilt and shame
o A neglected area of health services
o High stigma

55. STI which can be vertically transmitted o Diagnosis in child implies a diagnosis in the mother and often the father
Initial spread associated with “deviant”
behaviour and
marginalised groups
o Core groups neglected by health services/hard to reach
Associated with stigma and many myths o PLHIV reluctant to come forward for testing/care
o Health workers reluctant/afraid to provide services
Affects young adults o Severe secondary costs due to loss of productive years of life and places
enormous burden on the family
Multi-system disease o Multiple medical problems
o Multiple drugs needed
o Unpredictable
o Needs very active palliative care and diagnosis of opportunistic infections

56. Statutes and Documents that Address Legal and Ethical Issues
related to the national HIV Epidemic
• The following presents a summary of the Kenyan Legal and Ethical Guidelines and
context:
• With the exception of surveillance testing, HIV testing should only be performed with
the specific informed consent of the individual.
• To maximize prevention and care, pre- and post-test counselling should be provided in
all cases.
• HIV infected people should not be subjected to coercive measures such as isolation,
detention or quarantine, based on their HIV status.
• HIV related cases reported to public health authorities for epidemiological purposes are
subject to strict rules of data protection and confidentiality.
• Information related to the HIV status of an individual is protected from unauthorized
collection, use or disclosure and that use of such information requires informed consent.
• Legislation authorizes but does not require that healthcare professionals to inform their
client’s partners of the HIV serostatus of the patient. Health professionals must decide,
on a case by case basis, whether to inform their patients’ sexual partners of the HIV
status or not based on the perceived risk to these partners. Such a decision should only
be made in accordance with the following criteria:

57. Statutes and Documents that Address Legal and Ethical
Issues related to the national HIV Epidemic…..
• The HIV-positive person in question has been thoroughly counselled
• Counselling of the HIV-positive person has failed to achieve appropriate behavioural
changes
• The HIV-positive person has refused to notify, or consent to the notification of his/her
partner(s).
• A real risk of HIV transmission to the partner(s) exists
• The HIV-positive person is given reasonable advance notice
• The identity of the HIV-positive person is concealed from the partner(s), if this is
possible
• Follow up is provided to ensure support to those involved
• Guidelines to ensure that the blood/tissue/organ supply is free of HIV and other blood-
borne diseases
• Implementation of universal infection control precautions in healthcare and other
settings where there is a high risk of exposure to blood and other bodily fluids
• Criminal law does not impede provision of HIV prevention and care services to sex
workers and their clients.

58. Statutes and Documents that Address Legal and Ethical Issues
related to the national HIV Epidemic…..
• Accurate information on the HIV epidemic should be available through
the mass media.
• Quality HIV tests and counselling should be made widely available to
all.
• Quality control of condoms should be enforced.
• All HIV testing be performed with the informed consent of the patient:
– Consent must be given voluntarily.
– Consent must be given by an individual with the capacity and competence to
understand, as appropriate.
– The client must be given enough information to be the ultimate decision
maker.
– The PLHIV have the right to the utmost confidentiality of their test results.
– In certain exceptional circumstances, it may be justifiable for a health care
professional to breach a patient’s confidentiality in order to protect the
health of another person.

59. Kenya Government Policy and Guidelines Related to the
HIV Epidemic
• The main areas addressed in these documents include:
• Behaviour Change Communication (BCC)
• Condom promotion and provision
• Voluntary Counselling and Testing (VCT)
• Home based care (HBC)
• Blood safety
• Orphans and Vulnerable Children (OVC)
• Antiretroviral Therapy (ART)
• Prevention of Mother to Child Transmission (PMTCT)
• Gender mainstreaming

60. Kenya Government Policy and Guidelines Related to the
HIV Epidemic
• Most of the technical documents and guidelines are from National
AIDS and STD Control Programme (NASCOP)
• The policy documents are from National AIDS Control Council
(NACC) and Ministry of Health (MOH).