LESSON 17
Preventing the Spread of HIV/AIDS -General Considerations
Introduction:
There are four major sources of HIV infection:
sexual
transmission,
transfusions of blood or blood products, or transplanted tissue or organs
obtained from HIV-infected donors,
using skin piercing instruments or injecting equipment that is contaminated with
HIV (Fact Sheet 1), and
transmission from mother to child during pregnancy, labour, or following birth
through breast feeding (Fact Sheet 10).
This
Fact Sheet will attend to prevention through sexual transmission, blood
transfusions and injecting drug use.
There is ample evidence globally that well-designed prevention programmes can
reduce the incidence of HIV. In societies where services and programmes were in
place before the epidemic, the creation of new initiatives and the
re-orientation of existing initiatives led to a gradual decline in the incidence
of HIV by the mid-1990's. A similar trend is observed even in resource-poor
settings, in part a result of rigorous prevention efforts.
However, prevention is a very complex challenge. Some prevention strategies need
to be addressed at the greater society (or macro) level, such as strengthening
or changing government policies, modifying laws, and enforcing new laws or human
rights policies. Other prevention strategies must address the behavioural,
social and cultural context (the micro level) of the individual. At both the
macro and micro level, policies, programmes and practices should address both
harm reduction and prevention of HIV.
At the macro level, governments and governing bodies have to be aware of the
magnitude of the HIV epidemic in their country, and be mobilized to face this
challenge. Nurses and midwives can play an important role in promoting such
awareness. However, it is at the micro level, where behavioural, social and
cultural influences have the most affect on communities, families, and
individuals, that nurses and midwives can make the greatest contribution to HIV
prevention. Although HIV prevention and harm reduction have been separated into
challenges at the macro and micro level, in practice, they are interdependent
and closely related.
Sexual transmission
The
most common form of HIV transmission (as well as other STD transmission) is
through sexual intercourse or through sexual contact with infected blood, semen,
or cervical and vaginal fluids transmitted from any infected person to his/her
sexual partner, whether it be man to woman, man to man, or woman to woman,
although the latter is less likely. HIV transmission through sexual contact can
occur vaginally, orally, anally or rectally.
Man to woman transmission, usually from a single partner, is now the most common
form of HIV sexual transmission. Women (and to a lesser extent men) who remain
faithful in their partnership, contract HIV when their partner has sexual
contact with an HIV-infected person outside (or before) their relationship.
Although this is the most common form of transmission, women still suffer more
stigma, discrimination, and isolation than their male partners. As a result
there is often denial or a "conspiracy of silence." Acts of violence
may also be directed toward the woman. In addition, other sexually transmitted
diseases, which often go undiagnosed in women, contribute to a higher rate of
HIV transmission.
Man to man
transmission (Men who have sex with men: MSM)
Unprotected penetrative anal sex carries a high risk of HIV transmission,
especially in the receptive partner. This risk is several times higher than
vaginal intercourse because the lining of the rectum is thin and can easily
tear, and even small lesions can allow the virus easy access. Worldwide, a large
percentage of MSM are married, or have sex with women as well. These men often
do not identify themselves as homosexual or "gay." In addition, MSM is
often stigmatized or criminalized, and therefore there is difficulty in reaching
these men. The results are inadequate or inappropriate health care, and health
promotion/preventive programmes.
Woman to woman
transmission
Transmission of HIV from woman to woman is less common than MSM or heterosexual
contact. However, the risk still remains. HIV transmission can occur through
rough sex play where the mucous membrane of the external genitalia, vagina or
cervix is torn. Also, if the woman has an STD, the likelihood of HIV
transmission is increased.
Male condom (Credit: JHU/CCP)
• Prevention of sexually transmitted HIV
The
safest form of prevention of sexually transmitted HIV is abstinence. However, in
most instances, such practices are neither realistic nor desirable. Barrier
methods that prevent semen and other bodily fluids from passing from one partner
to another are the next most effective preventive methods. These barrier methods
also reduce the risk of STDs, however, they also act as a contraceptive. Such
barrier methods include the male and female condom.
Male condom
The male condom is placed over the erect penis before penetration occurs. The
condom then remains on the penis until after ejaculation when it should be
immediately removed, knotted and discarded in a safe place such as a toilet,
latrine, or in a safe disposal unit. It is vitally important that people are
given accurate information and an opportunity to practice using condoms.
Information should include:
how
to place the condom on the erect penis, leaving space at the top to receive the
ejaculate,
how to unroll the condom down to the base of the penis,
how to ensure that the condom remains in place throughout intercourse, and
how to remove the condom before the penis loses its erection.
It
is important to emphasize that individuals may practice using condoms on a model
or other object, such as a banana or cucumber. A new condom must be used for
each sexual act. Condoms should be easily accessible for both men and women, and
are best distributed in places where a sense of privacy is increased and
embarrassment is reduced. Wherever possible, free condoms should be available.
Female condom
The female condom is a soft yet strong polyurethane sheath, about the same
length as the male condom, only wider. A plastic ring at the closed end helps
keep the condom fixed within the vagina during sex. A larger ring at the opening
stays outside the vagina, spreading over the woman's external genitalia.
The female condom provides extra protection to men and women because it covers
both the entrance to the vagina and the base of the penis, both of which are
areas where STD sores make it easy for HIV to enter. Female condoms should only
be used once and do not require a prescription. However, they are more expensive
than male condoms and not as easily acceptable or accessible. Because the
external ring is visible outside the vagina, using a female condom might require
the agreement of both partners. However, because it can be inserted hours before
intercourse, it can provide protection in situations where consumption of
alcohol or drugs may reduce the chances that a male condom will be used. Less is
known by the public about the female condom than about the male condom, and use
of the female condom is less widespread. Therefore, there needs to be education
for both health care workers and women in general.
The condom is inserted with the finger, making sure no damage is done to the
polyurethane by finger nails or other sharp objects. The condom should then fit
snugly against the cervix. During intercourse, it is necessary to guide the
penis in or check that the penis has entered the condom and not entered the
vagina outside the condom wall. The condom should be removed as soon possible
after male ejaculation, and disposed of in the same ways as the male condom.
Other barrier methods
Other barrier methods exist to help reduce the sexual transmission of HIV, but
these are less reliable, and often not as readily available. The female
diaphragm prevents semen from entering the cervix. However, it does not protect
the vagina or the external genitalia from exposure to HIV. Special mouth condoms
are available for oral sex. However, these are not readily available and are
rarely used. Scientists are working on a vaginal cream that would kill the HIV
virus, but it is not yet available.
Blood transfusions
There is a 90-95% chance that someone receiving blood from an HIV infected donor will become infected with HIV themselves. Millions of lives are saved each year through blood transfusions, even in countries where a safe blood supply is not guaranteed. However, recipients of blood have an increased risk of HIV-infection. This risk can be virtually prevented by a safe blood supply, and by using blood transfusions appropriately. Difficulties hindering a safe blood supply include:
lack
of national blood policy and plan
lack of an organized blood transfusion service
lack of safe donors or the presence of unsafe donors
lack of blood screening, and
unnecessary or inappropriate use of blood.
Minimizing the risk of HIV infected blood transfusions
In many countries, regulations on blood donations, screening and transfusions exist, but are not adhered to. It is vitally important that regulations be established and rigorously enforced.
Three essential elements must be in place to ensure a safe blood supply:
1.
There must be a national blood transfusion service run on non-profit lines which
is answerable to the Ministry of Health.
2. Wherever possible, there should be a policy of excluding all paid or
professional donors, but at the same time, encouraging voluntary (non-paid)
donors to come back regularly. People are suitable donors only if they are
considered to have a low risk of infection.
3. All donated blood must be screened for HIV, as well as for hepatitis B and
syphilis (and hepatitis C where possible). In addition, both donors and patients
must be aware that blood should be used only for necessary transfusions.
Screening
The majority of tests done for detection of HIV detect the presence of
antibodies to HIV, not the virus (Fact Sheet 1). However, there is a window
period (with the most sensitive tests about 3 weeks, and longer with less
sensitive tests) when the test may provide a false negative result and the blood
be infected with HIV. Tests also exist (called HIV antigen tests), that detect
the virus in the blood, but these are more expensive and of limited value. In
many countries, correct screening of blood is still applied to some but not all
blood donations. For example, in many developing countries, blood is screened in
the capital city, and perhaps in one or two other larger towns, but not screened
in rural districts. Lack of screening is most often due to lack of funding, and
it is expensive to set up a national system to test all donated blood. Good
organization, planning, and management are necessary, as well as trained staff
at all levels and the availability of test kits.
Selecting blood
donors
Paid donors very often come from the poorest sectors of society. They may be in
poor health, undernourished and at risk of having infections that can be passed
on through transfusions. In some places, paid donors sell blood in order to buy
drugs to inject themselves, often using shared, unsterile equipment. In
addition, paid donors are more likely to give blood too frequently, making their
blood substandard, and increasing the possibility of damage to their own health.
The practice of paying donors usually goes hand-in-hand with the practice of
selling blood to people who need it. Under such a system, poor families may not
be able to afford vitally needed blood.
Replacement donors have also been found to be problematic. In the replacement
donor system, families of people needing a transfusion are asked to donate the
same quantity as that given to their relation. This blood may be used directly
for the relative, or placed in the general pool. This practice is strongly
discouraged because the "relation" is often a paid donor, and even if
the person is a relative, there are doubts about the safety of the blood, as
normal criteria for selecting donors cannot be applied.
Therefore, the safest type of blood donor is the voluntary, unpaid donor. Such
donors give their blood for humanitarian reasons and are more likely to meet
national criteria for low-risk donors. Every effort should be made to educate,
motivate, recruit and retain low-risk, unpaid donors.
Avoiding unnecessary
or inappropriate transfusions
Unnecessary transfusions increase the risk of transmitting HIV, especially in
places where there is no adequate screening programme. Additionally, unnecessary
or inappropriate transfusions can create a shortage of the blood supply, which
in turn encourages professional donors to become more active, thus reducing the
safety of the supply.
Doctors and other health care workers should be educated to avoid prescribing
inappropriate transfusions. Blood substitutes should be given where appropriate.
In addition the underlying cause for the blood transfusion should be considered.
For example, blood transfusions are often given for anaemia. Instead, the
underlying cause of the anaemia should be investigated. Anaemia may be due to
malnutrition, slow blood loss, and to infections such as malaria. Blood is often
needed during complications accompanying childbirth. However, providing proper
care for women before, during and after delivery, can decrease the need for
blood transfusions.
Creating a national
blood transfusion service
A national blood transfusion service means making all transfusion centres and
blood banks part of a national network accountable to a government appointed
nonprofit organization. This service must be developed within the framework of
the country's health service, and must have an adequate budget and trained
staff. There must be a national system of regulations, and regular, independent
monitoring of the blood transfusion service. There is no guarantee that blood
can be 100% free of HIV, however, with political commitment, good organization,
sufficient funding and donation of blood from low-risk, voluntary, non-paid
donors, the risks can be reduced to a minimum.
Body organs and
tissue transplantation
HIV transmission can also occur through transplantation of body tissue or organs
from an HIV-infected donor. This body tissue should follow the same screening
programme as blood.
njecting drug users and other skin piercing practices
This
Fact Sheet focuses on HIV prevention in injecting drug users (IDUs). Prevention
of HIV infection through other skin piercing such as accidents at work, surgical
interventions, tattooing, female and male circumcision, and scarification have
been described earlier (see Fact Sheet 11 Universal Precautions).
Injecting drug users
HIV can spread very rapidly among IDUs, and from them to their sex partners and
children. However, this spread can be prevented or slowed significantly if
interventions are designed which take into account specific local
characteristics of the IDUs. IDUs are usually a hidden and stigmatized group,
because their drug-usage behaviour is illegal. Often caught in a cycle of
poverty and faced with the cost of the drugs, IDUs often engage in criminal
activities such as theft, and in high risk behaviours for HIV infection such as
commercial sex work and paid blood donation. To date, the only effective
responses to HIV transmission among IDUs to date are those based on the
philosophy of harm reduction. Harm reduction is compatible with proven public
health principles, and need not conflict with demand and supply reduction (law
enforcement) programs. Harm reduction programs approach drug abuse primarily as
a public health rather than a law and order issue. Such programs take into
account:
Promoting use of
sterile equipment
The most common pathway for HIV transmission among IDUs is the sharing of
non-sterile injecting equipment. Scarcity, or lack of access to safe injecting
equipment, and legal sanctions against possessing injecting equipment, are the
two main reasons for reusing or sharing needles and syringes. Other reasons
include ignorance of the risks of HIV infection and prevention methods.
The two strategies that have proven effective are:
the sale of needles and
syringes at minimum prices through pharmacies or other outlets,
needle and syringe exchange programs.
These exchange programs ensure that dirty syringes and needles are exchanged for sterile ones. In addition, if community acceptance of these programs is to occur, then needles and syringes must be safely and discretely disposed of after use, and must not pose a threat to the non-IDU community. Ball (1998) recommends a hierarchy of decision making related to the prevention of HIV through intravenous drug use:
reducing
the frequency of sharing, and the number of sharing partners,
cleaning injecting equipment with bleach,
not sharing injecting equipment,
using sterile needles and syringes, and not sharing other equipment,
changing from the injection of illicit drugs to use of non-injecting drugs,
reducing the frequency of non-injecting drug use, and
abstaining from all drug use.
This
hierarchy of decision-making can be a useful framework to consider HIV
prevention programmes. However, it should be noted that people do not fall
neatly into any one of these categories. For example, a person may regularly
engage in a needle and syringe exchange program, but, because of unforeseen
circumstances, finds him/herself sharing used injecting equipment. This
hierarchy also assumes that there is collaboration between the principles of
public health (i.e.. Safe injection practices) and law enforcement. This is
often not the case. In order for DU HIV prevention programs to be effective,
national and local policies must achieve a balance between their attempts to
reduce the supply and use of illicit drugs and their efforts to decrease unsafe
injection practices.
The principles of harm reduction that have been proven effective in reducing HIV
transmission in IDUs include:
education,
especially peer education (Fact Sheet 9) and consoling (Fact Sheet 7);
promotion of the use of sterile injecting equipment for every injection;
increasing the availability of equipment; removing barriers that prevent access
to the use of sterile equipment (especially policing and legal barriers);
increasing drug treatment availability, accessibility and options;
increasing access to primary health care, particularly through services designed
to be "friendly" to, and appropriate for, the DU community;
research and education performed in collaboration with the affected community.
Other mood altering drugs
It is important to note that although DU carries the greatest risk of HIV transmission, taking other mood altering drugs can also promote at risk behaviours. Alcohol, and other legal and illegal drugs taken orally or as an inhalant can affect a person's decision making abilities. In such circumstances, the use of condoms is less likely, and other behaviours and sexual practices that increase the risk of transmission of HIV/AIDS might occur.
Populations at risk
The
vast majority of people who become infected with HIV are from vulnerable
segments of the population. Children and youth (including street youth), women
(Fact Sheet 10), prisoners, refugees, migrant workers, ethnic minorities, the
military and people who live in poverty are some of the most vulnerable
populations.
Youth
Over 50% of new infections with HIV are now occurring in young people ages
10-24. That is, 7,000 young people are infected with HIV every day with young
women being infected and affected more frequently than young men (Fact Sheet
10).
The reasons for these alarming figures are very complex. The life situations of
many young people may contribute to infection. They may be gay or bisexual
youth, use alcohol or drugs, have been sexually abused, or live on the margins
of society. Many live on the streets, where violence, abuse, and drug use
(particularly intravenous drug use) are common. In addition, young people often
feel invincible, and do not consider themselves to be at risk for HIV or any
other life threatening situations.
Women
Women are particularly vulnerable to HIV because of their status in many
societies. Poverty, lack of education, poor access to health care and jobs, and
social and cultural practices all contribute to women's lack of power and
control over decision making (see Fact Sheet 10).
Infants
Mother to child transmission accounts for most HIV infections in infants (Fact
Sheet 10).
Prisoners
Prisoners are often injecting drug users before they enter prison. They continue
(or begin) this practice while in prison, often with shared, unsterilized
needles and syringes. In addition, they may have unprotected penetrative sex
with other men, and may be tattooed with shared, unsterilized equipment.
Refugees and migrant
workers
Poverty, drought, flood, earthquakes, and war or civil strife cause many people
to leave their homes and communities. These people end up in special camps where
there is increased danger of HIV transmission. Blood transfusions are often
required in large numbers, especially during times of war. Social systems and
ties disintegrate and unprotected sexual contact and prostitution is common.
Refugees, particularly women and children, are highly vulnerable to sexual
violence, rape and drug trafficking. Where drug injecting occurred before the
emergency, it is likely to continue in the camps where the sharing of injecting
equipment increases the risk of HIV infection.
Military personnel
People in the military (mostly men) are separated from their homes, communities
and social support networks and are often placed in positions where they can
exert considerable control over others. This situation often leads to violence
and abuse (physical and sexual) of the people they are charged with protecting.
In such circumstances, HIV transmission is common.
Ethnic minorities
Like women, youth and children, people who are part of a visible minority are
particularly at risk of HIV infection. These people often have limited social
support, live on the margins of society, are poor, less educated, with little or
no political representation. Such people have limited power or control, and are
vulnerable to abuse, violence, and sexual exploitation. In addition, injecting
drug use is common, often involving the use of unsterile, shared equipment.
Poverty
Poverty is the single common factor related to the transmission of HIV. People
who are economically deprived usually have little access to education, social
and health care services, and other forms of social and financial support. As a
result, these people are often forced into becoming sex workers or in exchanging
sex for food and supplies. Drug trafficking and injecting drugs with shared,
unsterile equipment is also common. Also, poverty often leads people to sell
their blood for transfusion, blood which can be infected with HIV.
• Principles and strategies for prevention
Prevention
programs have to take into account strategies that must be addressed at the
macro (national/regional) level, and those requiring change at the micro
(community) level. At the macro level, public health policies and law
enforcement must focus on harm reduction. National and local policies must be
developed and enforced that promote the reduction in HIV transmission. Where
there is potential for law enforcement and public health policy to conflict (for
example, prevention programs for IDUs), then partnerships must be forged to
overcome these difficulties. At the micro level, the behavioural, social and
cultural context within which people live must be taken into account. Strategies
to promote the prevention of HIV transmission include:
Peer support and
education
It has been widely documented that behavioural change is most likely to occur if
peers educate and support each other (see Fact Sheet 9). Youth programs that are
run by youth, women's collectives, groups involving street children, refugees,
and IDUs, are all effective in promoting practices and behaviours that lead to
reduction in HIV transmission. Frank discussions about sexual practices, drug
taking, and other at risk behaviours are more likely to be explored and
understood within these safe environments. It is important to note that these
groups should be run by and for their particular populations. There are many
powerful examples throughout the world of peer involvement in prevention
strategies. Nurses and midwives can play an important role in facilitating the
formation of these groups and providing expert knowledge where necessary. See
fact sheet 9 for effective educational strategies.
Involving PLHA
People living with HIV/AIDS (PLHA) are often the best advocates and activists
for social and behavioural change. The personal story of someone living with HIV
presents a powerful message. These messages can mobilize people and resources,
and thus initiate successful prevention programmes. In addition, involving PLHAs
in various prevention programs helps to ensure that they are relevant and
meaningful to the different population groups.
Combining resources
The combination of counselling, education, support, care services, and resources
is necessary to provide a holistic continuum of prevention and care (Fact Sheet
3). For example, STD, antenatal, family planning, home care, hospital care, and
community care, as well as other resources and services, can be combined to
provide a comprehensive programme. In this way, programmes and services can be
combined that address the various modes of HIV transmission without the stigma
and discrimination often associated with HIV specific programs.
Forging partnerships
Governments, policy makers, law enforcement agencies, health and social service
agency personnel, non-governmental organizations (NGOs), religious leaders and
religious groups should join together in preventing HIV transmission. Nurses and
midwives can play a central role in advocating for, and creating and
participating in, such partnerships.
Cultural/religious/social
sensitivity
There is no one programme that will be relevant, meaningful, and effective for
all people. Prevention programmes must be sensitive to the local customs,
cultural practices, religious beliefs and values, as well as to other
traditional norms and practices. However, where such beliefs, values and
practices conflict with the prevention of HIV (eg. circumcision, scarification,
sexual abuse of children), then these must be challenged. Nurses/midwives can
play an important role in supporting local practices and traditions while also
challenging those practices that cause HIV transmission.
Facilitating
empowerment
Involving individuals, groups, and communities in addressing their own health
concerns and finding solutions to their problems promotes empowerment. People
who are empowered are more likely to implement effective HIV prevention
programs.
Challenging denial
HIV is surrounded by a conspiracy of silence and denial. People are afraid to be
tested for HIV or admit their HIV status because they fear discrimination,
violence, stigma and isolation (Fact Sheet 6). Nurses and midwives can help
support and counsel people to be HIV tested (Fact Sheet 7) and to be open about
their HIV status. Only when HIV becomes a public concern can prevention
strategies that address the complex and diverse issues related to HIV
transmission be addressed.
Combating stigma,
isolation and marginalization
Nurses and midwives have a responsibility to care for all people, regardless of
their health or social status (Fact Sheet 6). They can act as role models to
others in helping combat stigma, discrimination and isolation of PLHA.
Prevention strategies will be more successful if HIV is treated like any other
chronic illness.
Ensuring the use of
Universal Precautions
Nurses and midwives should play a central role in monitoring and ensuring that
universal precautions are practiced in their workplace (Fact Sheet 11).
Maintaining quality assurance programs and ensuring the availability of adequate
supplies and human resources help promote a safe work environment. In addition,
adequate care for the care provider is an important consideration.
Building on success
Many groups, communities and individuals have been successful in improving their
quality of life. The strategies they developed for this improvement can also be
applied to prevention programs. For example, if communities have been successful
in lobbying for improved housing, these same lobbying tactics can be applied to
HIV prevention programs. In addition, people can learn from one another. Stories
of successful HIV prevention programs throughout the world should be shared with
others so that they too may initiate similar programs.
Respect for human
rights
Nurses/midwives should advocate for vulnerable populations to ensure that their
human rights are respected and not violated (Fact Sheet 6). Prevention programs
will only succeed where human rights are respected and maintained.
Questions for reflection and discussion
What
are the most common ways that HIV is transmitted?
Which populations are most at risk for HIV transmission? Why is this the case?
What role could you play in HIV prevention within your local community?
What role might you play in promoting larger societal change?
What strategies and policies do you consider to be essential before effective
HIV prevention programs could be implemented?
What role might you play in ensuring these strategies and policies are
considered?