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HIV/AIDS

 Overview/Lessons Learned | Key Issues | Annotated Bibliography
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Key IssuesSPECIAL REPORT:
Click here for 
information on the
XIII International AIDS
Conference in Durban,
South Africa.

This section provides brief summaries of current research related to care and support for people with HIV/AIDS, particularly in low-resource settings. More detailed discussions of specific key issues are included in the Annotated Bibliography.

Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.

 

HIV counseling and testing

HIV counseling and testing (CT) can be used as a decision-making and intervention tool by both clients and service providers. HIV CT can help uninfected clients to understand their risk for HIV and encourage them to adopt and sustain risk-reducing behaviors; educate infected clients about living with HIV infection and avoiding infecting others; assist infected individuals in obtaining early medical intervention and support services; help discordant couples make decisions about family planning and contraceptive use; and guide health professionals in the management and care of infected pregnant women (Campbell et al., 1997; de Bruyn, 1996). In relation to HIV and pregnancy, VCT provides the opportunity for early access to prevention and care for mothers who know their serostatus, including a number of interventions to prevent mother to child transmission of HIV infection (WHO, 2000; UNAIDS, 2000).

Though HIV CT services have long been an integral component of HIV/AIDS control programs in the industrialized world (Chen et al., 1998; Ades et al, 1999), their role in resource-poor settings is still being debated. Results from research regarding the ability of HIV VCT to motivate risk-reducing and help-seeking behavior are mixed (Wolitski et al., 1997). A Zambian study found that readiness for HIV VCT in the general population to be very low (Fylkesnes et al., 1999). There is concern that HIV CT services may compete with other health and social programs for scarce resources and priorities. Furthermore, there is worry of the potential for human rights abuses such as breaching of confidentiality, discrimination, quarantine, and violence, all of which would lead to a widespread fear of getting HIV testing (Campbell et al., 1997).

Several research studies and ongoing programs in Africa, however, serve as examples that HIV CT services can be feasibly implemented in low-resource settings and can be effective in influencing behavior toward reduction of HIV transmission (Worthington, 1997; Bentley et al., 1998; Kamb et al., 1998; Cartoux et al., 1998; Killewo et al., 1998; Sweat et al., 2000). One strategy that may optimize the effectiveness of HIV CT services in low-resource settings is the use of rapid testing techniques to detect antibody to HIV rather than the widely used but time-consuming enzyme-linked immunosorbent assay (ELISA), which requires trained laboratory technicians and specialized equipment. Field trials in Africa have shown that use of highly sensitive and specific rapid tests can easily be integrated into existing HIV counseling procedures (Downing et al., 1998: McKenna et al., 1997).

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Care and support for people with HIV/AIDS

As the number of people living with HIV/AIDS continues to increase, strategies to control the epidemic need to incorporate a care continuum that includes counseling, clinical care, community- and home-based care, and social support services (Macinnis, 1997; London et al., 1998; MacNeil et al., 1998; Wigersma et al., 1998). People with HIV/AIDS, particularly those in rural settings, face many barriers that prevent them from receiving important life-care services (Heckman et al., 1998). The provision of care and support must extend from the individual/home to the hospital, with the various levels of care linked by referral networks (Osborne, 1996). Furthermore, services must reach as many of those needing the services as possible, allowing them to access the care continuum in any given setting and move freely from one level to another (Drew et al., 1997; Osborne, 1996). Early entry into the continuum assures opportunities for improving quality of life and educating infected individuals about ways to avoid HIV transmission. Children with HIV/AIDS require routine wellchild medical care and immunizations and appropriate management of diseases such as pneumonia, diarrhea, measles, malaria, malnutrition, and other common health problems (Larson and Bechtel, 1995; Lepage et al., 1998). (See the HIV/AIDS Program Examples page for developing-country experiences in providing care and support to people living with HIV/AIDS.)

Counseling is an important component of HIV/AIDS care; counseling can help infected individuals better cope with their disease, assist individuals to obtain early medical intervention, and help them to make decisions about family planning and contraceptive use (Branson et al., 1998). Counseling can be clinic-based, school-based, and/or community-based, and can involve doctors, nurses, support groups, and home-care workers, as well as church leaders (Balmer et al., 1996; Campell et al., 1997; Kaleeba, 1997; Krabbendam et al., 1998). An evaluation of the counseling, social, and medical services provided by a Ugandan NGO known as TASO (The AIDS Support Organization) has shown that these care and support services were able to bring about positive behavior change and family and community support (Kaleeba, 1997). This study also suggested that ongoing group counseling may assist clients to better deal with their situation and help families and the community to better accept and care for people with HIV/AIDS. Social support from peers, family members and relatives also can be important to helping clients, particularly women, seek early medical care and cope with their disease Williams et al., 1997).

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Reducing maternal-fetal HIV transmission

While the specific risk factors of HIV in pregnant women vary depending on region and population, research consistently has shown that, in developing countries, that the chances of contracting HIV increase with multiple sex partners (or a partner with multiple sex partners), a history of sexually transmitted disease (STD), positive syphilis serology, and sex work (Smith and Hwang, 1996). Maternal-fetal (also called vertical or perinatal) transmission of HIV can occur transplacentally, at delivery, or postpartum as a result of breastfeeding. The majority of cases of vertical transmission occur during labor and delivery. Possible mechanisms include transfusion of the mother's blood to the fetus during labor contractions, infection after the rupture of membranes, and direct contact of the fetus with infected secretions or blood from maternal genital tract (The International Perinatal HIV Group, 1999). In order to optimize the health and well-being of the mother and child, ideally the management of HIV-positive pregnant women should include routine care and lab monitoring; administration of antiretroviral therapy during pregnancy and postpartum for the infant; and prophylactic therapy to protect against opportunistic infections (McIntyre 1999). With the advent of new HIV tests, it is possible to identify infants infected with HIV and thus coordinate timely and appropriate care (Andiman, 1998). Knowledge of the mother's HIV-positive status during pregnancy is integral to employing these strategies to reduce the risk of HIV transmission to the child. Strategies for reducing maternal-fetal transmission of HIV have been developed and studied.

The 1999 WHO Reproductive Health Library includes a review of interventions aimed at reducing the risk of mother-to-child HIV transmission, which found that provision of zidovudine to HIV-infected women during pregnancy and at delivery, in addition to treatment of the neonate with zidovudine until six weeks of age, appears to substantially reduce the risk of mother-to-child HIV transmission. Three recent studies from Thailand, Côte d'Ivoire, and Burkina Faso showed that short-term administration of zidovudine during late pregnancy and delivery reduced the risk of perinatal HIV transmission (Dabis et al., 1999; Wiktor et al., 1999). In the Thailand study, for example, vertical transmission was reduced from 18.6 percent to 9.2 percent (Shaffer et al., 1999). Utilized singularly or in combination, the administration of zidovudine during pregnancy, the use of elective Cesarean sections instead of vaginal childbirth, and bottle feeding instead of breast feeding have been shown to reduce the likelihood of an infant contracting HIV from an infected mother (The European Collaborative Study, 1994; Simonds et al., 1998; Kind et al., 1998; Mandelbrot et al., 1998). Additional research suggests that less costly alternatives such as a single dose of nevirapine may be useful in resource-limited regions (Marseille et al., 1999). Other potential approaches to reducing the risk of vertical HIV transmission include cleansing the birth canal, immunotherapy, and supplementation with vitamin A (see Vitamin A and vertical HIV transmission below) (Newell, 1999; Mofenson and McIntyre, 2000). Studies have found that antiretroviral interventions are probably cost-effective across a wide range of settings, with or without formula feeding interventions (Soderland et al., 1999). A recent meta-analysis by the International Perinatal HIV Group (1999) found that elective Cesarean section delivery reduced the risk of perinatal transmission independently from the effects of treatment of zidovudine. Because there is still insufficient evidence from randomized controlled studies, it is premature to recommend routine elective Cesarean section for all HIV-infected women. The procedure may be recommended for some women, however. The Perinatal Group emphasized that the benefits of elective Cesarean delivery must be weighed against the risks of the procedure.

Where antiviral or surgical interventions not possible, bottle feeding may offer the greatest reduction in viral transmission (Ratcliffe et al., 1998). In developing countries, the risk of infection through breastfeeding must be weighed against the health benefits of breastfeeding and the potential dangers posed by artificial feeding (i.e., bottle feeding). In settings where sanitation is inadequate and where families cannot afford to buy sufficient formula, bottle feeding may present serious threats to a child's health and survival from diarrhea and respiratory infections (See Outlook, Volume 15, Number 3). Research findings presented at the XIII International AIDS Conference suggest that breastfeeding may increase maternal mortaility, further complicating the management of maternal-fetal HIV transmission in developing countries.

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Drugs and treatment for HIV/AIDS and opportunistic illnesses

In developed countries, drug treatment for HIV is evolving from single to combination therapies. With combination therapy, several antiretroviral drugs (usually three or more) such as saquinivir, ritonavir, lamivudine, zalcitabine, indinavir, or zidovudine are used together. (See detailed list of available antiretroviral agents at http://hopkins-aids.edu/publications/book/ch4_main.html.) Increased access to new and effective antiretroviral combination therapies is mainly responsible for the decline in the number of AIDS cases and AIDS-related deaths observed in developed countries (Detels et al., 1998). For example, in the US, AIDS deaths declined by nearly 50 percent in 1997 from over 31,000 deaths in 1996. (Click here for more information on antiretroviral treatment www.worldbank.org/aids-econ/arv/index.htm.) There also is evidence that primary prophylaxis of opportunistic infections can help extend the life of those infected with HIV/AIDS (Chaisson et al., 1998). For example, the 1999 WHO Reproductive Health Library includes a summary of a meta-analysis of the effectiveness of preventive therapy with anti-tuberculosis drugs in HIV-infected patients. The review found that preventive therapy with anti-tuberculosis drugs appears to benefit HIV-infected patients with positive tuberculosis skin tests by reducing the incidence of active TB. Though the use of drugs to treat HIV and opportunistic infections has become relatively common in the developed world, this is not so in low-resource settings, where the issues of access to and affordability of medical care and pharmaceuticals remain a challenge. The question most commonly raised is whether drug treatment is cost-effective given a developing country's scarce resources. Cost-effectiveness may be measured in terms of cost per year of healthy life gained with the treatment; or the reduction in the incidence of HIV-infected children in the context of maternal-child transmission (Floyd et al., 1998). Although the cost of HIV drug therapies may be prohibitive, it has been suggested that antiretroviral therapy may be cost-effective if HIV prevalence is high, the therapies are proven effective, and drug prices are reduced (Marseille et al., 1998). In the near future, antiretroviral therapy may become more affordable as bulk-purchase arrangements become commonplace; partnerships between international agencies, countries, and drug companies are established; and lower drug dosages may be proven to be effective (Floyd et al., 1998). Where drugs are available, appropriate monitoring of the administration of these drugs by trained health care workers is essential (Lepage et al., 1998).

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Vitamin A and vertical HIV transmission

Vitamin A is an essential micronutrient for normal immune function. Among women, the highest risk of vitamin A deficiency occurs during pregnancy, when there are increased demands for vitamin A because of the growing fetus. In developing countries, vitamin A deficiency is common among HIV-infected pregnant women, and its association with increased infant and maternal mortality, low birth weight, impaired antibody responses is well documented. In addition, a growing body of data suggests that vitamin A deficiency also is associated with increased vertical HIV transmission (Semba et al., 1994; Greenberg et al., 1997; Semba 1997; Fawzi et al., 1998). A study from Malawi found that vitamin A deficiency among pregnant women was associated with a fourfold increased risk of vertical HIV transmission (Semba et al., 1994). A study from Kenya found that HIV-infected women with vitamin A deficiency had a greatly increased (20-fold) risk of HIV viral load in their breast milk, suggesting a possible mechanism for increased vertical transmission through breastfeeding (Nduati et al., 1995).

There are compelling theoretical and physiological mechanisms to support the view that vitamin A protects against perinatal HIV transmission (Fawzi et al., 1998). Clinical trials are currently in progress in sub-Saharan Africa to determine whether micronutrient supplementation (vitamin A or other micronutrients) during pregnancy can reduce vertical HIV transmission. A study in South Africa found that vitamin A supplementation was associated with decreased incidence of pre-term births and reduced perinatal transmission of HIV in pre-term babies, but was not associated with a reduction in HIV transmission overall (Coutsoudis et al., 1999).

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Gynecological complaints common in HIV-infected women

Gynecological infections are common in women with HIV infection. While the types of gynecological infections are not significantly different for infected and uninfected women, in the presence of HIV they may be more severe and more difficult to treat. Among the gynecological manifestations that frequently occur in the presence of HIV infection is recurrent candidiasis (Williams et al., 1998). (See the Candidiasis Fact Sheet at www.natip.org/candi.html for more information on candidiasis and its relationship with HIV. Also available in Spanish at www.natip.org/spanish/CANDIDIAsp.html.) Other infections commonly seen in women with HIV include trichomoniasis, bacterial vaginosis, cervicitis, genital ulcer disease (e.g., herpes, syphilis, chancroid), and human papillomavirus (HPV) (Levine, 1998; ARHP, 1998). (Untreated reproductive tract infections including STDs can greatly enhance the risk of HIV acquisition and transmission. See RHO Reproductive Tract Infections for more information.)

Research has suggested that prior infections by certain types of human papillomavirus increase the risk of sexual transmission of HIV, and are also strongly associated with cervical cancer and its precursor lesions (dysplasia) (Pisani et al., 1997; Levine, 1998). Cervical dysplasia is more common in women with HIV and may progress more rapidly in infected women. (Also see the RHO Cervical Cancer section for more information on cervical cancer and prevention strategies in low-resource settings.) Menstrual abnormalities such as spotting and irregular menstrual cycles are also common in women with HIV infection. Amenorrhea is three times more common in HIV-infected women (ARHP, 1998). Because HIV-infected women often present with reproductive tract infections, cervical dysplasia, and other relatively common gynecological complaints when seeking medical services, they are not diagnosed of HIV infection, resulting in missed opportunities for early testing and diagnosis (Minkoff et al., 1998; MacDonald et al., 1998; Capps et al., 1998).

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Male circumcision and HIV

There is a growing consensus among researchers that male circumcision provides a protective effect on heterosexual acquisition of HIV (Kelly et al., 1999; Urassa et al., 1997; Lavreys et al., 1999). A recent study in rural Uganda found that men who were circumcised before puberty had a much lower risk of HIV infection than men who were uncircumcised (Kelly et al., 1999). Circumcision after the age of 20 was not shown to be significantly protective against HIV infection. The protective effect of prepubertal circumcision may be explained by several biological mechanisms: the exposed glans penis may develop a protective layer of keratin (sometimes referred to as a "natural condom"); the foreskin may be especially susceptible to inflammation and trauma during intercourse; the warm, moist environment under the foreskin may facilitate growth of microorganisms, thereby increasing exposure to potential infections and possibly leading to a higher concentration of HIV target cells in the foreskin; and lack of circumcision may predispose men to a coinfection with other STDs (such as genital ulcers) that are known to facilitate heterosexual transmission of HIV (Lavreys et al., 1999; UNAIDS, 2000).

While some researchers have proposed that male circumcision should be considered a preventive intervention for reducing HIV transmission, the implementation of population-based circumcision programs, particularly in adult men, remains a critical question. Researchers caution that many of the practitioners performing circumcision in developing countries lack adequate medical training. Unsafe clinical practices (such as use of dirty instruments) and mass ritual events, including mass circumcision, may expose men to harm and infection. In some developing countries, the risks of tetanus, iinfection, and death from circumcision may outweigh the benefit of preventing a small number of HIV infections (Van Howe, 1999). Moreover, researchers caution that promoting circumcision as protection against HIV infection instead of condoms may create a false perception that a circumcised penis is adequate protection against HIV (Van Howe, 1999).

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