HIV INITIALLY SEEMED TO BE ISOLATED TO HOMOSEXUAL MEN WAS FIRST CALLED GAY RELATED IMMUNE DEFICIENCY SYNDRO OR GRID. THERE ARE TWO TYPES OF HIV: HIV-1 AND HIV-2. HIV REDOMINANT WORLDWIDE AND MUTATES VERY EASILY. GOO NUTRITION IS AN ESSENTIAL PART OF HIV TREATMENT. WHEN ERSON IS INFECTED WITH HIV, THEIR IMMUNE SYSTEM IS COM ROMISED AND BECOMES INCREASINGLY VULNERABLE TO OP ORTUNISTIC INFECTIONS. CONDOMS WORK BECAUSE DISEA ATHOGENS WHICH ARE TRANSMITTED THROUGH SEXUAL INT COURSE ARE TOO SMALL TO PASS THROUGH LATEX. HIV TESTS NOT ACTUALLY TEST FOR THE VIRUS ITSELF BUT INSTEAD DETEC ANTIBODIES PRODUCED BY IMMUNE SYSTEM CELLS. WHEN TW EOPLE ARE HIV SERODISCORDANT IT MEANS THAT ONE PART S HIV-POSITIVE, WHILE THE OTHER IS HIV-NEGATIVE. SQUASHNG OR ACCIDENTALLY SWALLOWING A MOSQUITO DOES NO UT ONE AT RISK OF CONTRACTING HIV. A NORMAL CD4 COU RANGES FROM 800-1200 CELLS PER CUBIC MILLILITRE OF BLOO HAVING ORAL OR GENITAL HERPES CAN INCREASE THE RISK O HIV INFECTION. WOMEN ARE MORE VULNERABLE TO INFECTIO HAN MEN. OVER CROWDING IS OFTEN ASSOCIATED WITH PO RTY AND DISEASES SUCH AS TB SPREAD EASILY IN SMALL OV OPULATED AREAS, PUTTING THE HIV-POSITIVE PERSON AT GR R RISK. A STIGMA IS A QUALITY OR ATTRIBUTE WHICH SIGNIF CANTLY DISCREDITS AN INDIVIDUAL IN THE EYES OF OTHERS. T ERM HAS REPLACED TERMS SUCH AS “AIDS ORPHAN”, WHICH CAN BE MISLEADING AS IT IMPLIES THAT CHILDREN ORPHANED AIDS ARE THEMSELVES HIV-POSITIVE. PEOPLE TAKING ARV DRU ARE LIKELY TO EXPERIENCE SOME SIDE EFFECTS DURING THEIR REATMENT. THE SA NATIONAL DEPARTMENT OF HEALTH’S EDU ION STRATEGY FOLLOWS AN ABC PREVENTATIVE STRATEGY (A TAIN, BE FAITHFUL, CONDOMISE). A MICROBICIDE HAS THE C ACITY TO KILL, NEUTRALISE OR BLOCK HIV AND STI INFECTIO A PATIENT DOES NOT TAKE THEIR TREATMENT CORRECTLY, THE S A DRUG [ TAKE NOTE OF HIV ] RESISTANCE AS MUTATIONS E ALLOWED TO DEVELOP BETWEEN THEIR INTERMITTENT TREA MENT. HIV-POSITIVE PEOPLE WITH COMPROMISED IMMUNE SY EMS ARE MORE LIKELY TO HAVE EXTRA-PULMONARY OR NON
This notebook was developed by the HIV & AIDS Media Project to ensure
that you always have some basic details about HIV on hand. If you need more information or want to speak to an expert, call the journAIDS helpline at 011 715 5828 or visit www.journAIDS.org. All information in this notebook applies to HIV care in the public sector, unless otherwise stated.
Essential Contacts --- medical matters Anova Health Institute www.anovahealth.co.za +27 (0)11 715 5800 HIV Clinicians Society www.sahivsoc.org +27 (0)11 341 0162 National Institute for Communicable Diseases www.nicd.ac.za CHAPS (MMC) +27 (0)11 484 8068 Health4Men (MSM) www.health4men.co.za +27 (0)11 989 9756 +27 (0)21 421 6127 Population Council (PEP) www.popcouncil.org +27 (0)11 781 759 --- gender-issues People Opposing Women Abuse POWA (GBV) www.powa.co.za 011 642 4345/6 Sonke Gender Justice Network www.genderjustice.org.za +27 (0)11 339 3589 Gender Links www.genderlinks.org.za +27 (0)11 622 2877 --- access to treatment TAC (Treatment Action Campaign)
www.tac.org.za +27 (0)21 422 1700
Section 27 www.alp.org.za +27 (0)11 356 4100 Right to Care www.righttocare.org +27 (0)11 276 8850 --- behaviour change communication Scruntinize (MCP) Johns Hopkins Health and Education South Africa (JHHESA) www.scrutinize.org.za + 27 (0)12 366 9300 Brothers for Life JHHESA www.brothersforlife.org +27 (0)12 366 9300 LoveLife www.lovelife.org.za + 27 (0)11 523 1000 Soul City www.soulcity.org.za 0861 768 524 --- children and young adults Childrenâ€™s Institute www.ci.org.za +27 (0)21 689 5404 / 8343 email@example.com
Childrenâ€™s Rights Centre www.crc-sa.co.za +27 (0)31 307 6075 --- people living with HIV HIVSA www.hivsa.com +27 (0)11 494 1900 AIDS Consortium www.aidsconsortium.org.za +27 (0)11 403 0265 --- research and statistics HSRC www.hsrc.ac.za
MRC www.mrc.co.za SA Department of Health www.doh.gov.za
UNICEF South Africa www.unicef.org/southafrica
Whilst all care was taken to ensure that the details in this booklet are correct at the time of print, we cannot accept responsibility for inaccurate information or errors.
Knowing when to use the correct terms when speaking about the epidemic is much easier when you understand the difference between HIV and AIDS.
(Human Immunodeficiency Virus) is the virus responsible for AIDS. A virus is a microscopic infectious agent that needs the cells of other living organisms (hosts) to multiply.
The HI-virus enters the body and uses CD4 positive cells (especially CD4 positive T helper cells, a vital part of a healthy immune system) to make copies of itself. In the process, the cell is destroyed. Over time the CD4+ T helper cells are depleted and the body becomes vulnerable to numerous diseases. This marks the onset of AIDS.
AIDS ---- syndrome
(Acquired Immune Deficiency Syndrome) is the most advanced stage of HIV infection. AIDS is classified as a clinical syndrome.
A syndrome is a collection of physical symptoms / conditions that together indicate the existence of a particular disease.
In the case of AIDS there are more than 20 conditions or AIDS-related illnesses which qualify an HIV+ person as having AIDS. A low CD4 count of 200 is also used to diagnose AIDS.
HIV progression, CD4 count and viral load viral load: concentration of HIV in the
CD4 count: level of immunity
HIV INFECTION Acute Infection Stage: 3-6 weeks after infection the level of HIV in the body (viral load) rises dramatically, increasing the risk of HIV transmission.
HIVPOSITIVE 9-12 weeks later HIV reproduces at a lower
HIV has become a kind of short-hand that implies AIDS, so many people speak simply about HIV. When you want to speak about both, use ‘and’ instead of the slash, e.g. ‘the effects of HIV and AIDS’. This is because the virus, HIV, and the syndrome, AIDS, are two different things (see above). Use ‘HIV infections’ rather than ‘HIV/AIDS infections’. ‘HIV test’ ‘AIDS test’ HIV tests determine the presence of the HI-virus or antibodies produced in response to it. There is no way to test for AIDS itself as it is defined by a number of conditions. But a CD4 count of under 200 (determined by administering a test which ‘counts’ the number of CD4 positive cells) is a means of diagnosing AIDS.
HIV-POSITIVE During the latent (hidden) stage of HIV infection no symptoms are experienced.
HIV-POSITIVE After many years HIV has killed many of the CD4 cells because it uses them to make copies of itself.
AIDS The immune system is weakened and opportunistic diseases can now invade the defenceless body.
‘spread of HIV’ ‘spread of AIDS’ A virus can move from one host to another. A syndrome cannot. ‘orphaned by AIDS’ ‘orphaned by HIV’ The conditions associated with AIDS cause death, not HIV itself. ‘the war/battle against AIDS’ Cliché headlines and combatant language should be avoided. Language can be loaded with stereotypes and stigma so use it carefully. Avoid making up words using HIV or AIDS. So instead of saying ‘HIV-infected’, rather say ‘living with HIV’. It is also better to say ‘orphaned by AIDS’ than to call someone an ‘AIDS orphan’.
Types, strains and subtypes
(TB) is an infectious disease which mainly affects the lungs. In HIV-positive people with low CD4 counts TB often also affects other parts of the body (extra-pulmonary TB).
There are two different types of HIV: HIV-1 and HIV-2.
uncovered HIV can be a very technical topic. As a journalist covering HIV, getting your head around the finer details like the types and strains of the virus is essential.
The two types differ in their effects and require different treatment. Globally, the most predominant is HIV-1.
TB is spread when a person coughs, sneezes or exhales and tiny fluid droplets containing the bacteria are ejected into the air (droplet infection).
HIV-1 is divided into groups or strains M, O, N & P. Of these, group M accounts for 90% of global infections. Group M is again divided into sub-types or clades: A,B,C,D,F,G,H,J,K. There are also combinations of these subtypes, known as circulating recombinant forms (CRFs). Each of the subtypes roughly corresponds to a geographical region. Subtype C is most common in subSaharan Africa.
re-infection There are documented
Most people have been exposed to the TB bacteria but because their immune system is strong it stays inactive (latent TB). People with untreated HIV have weakened immune systems and the latent TB eventually becomes active TB.
cases of people being infected with more than one strain of the HI-virus. This is referred to as reinfection and happens when an HIV+ person contracts another strain of HIV from a sexual partner.
HIV tests differ as some determine the presence of antibodies produced in response to HIV whilst others detect the virus itself.
Rapid HIV tests are the standard tests used at HIV counselling and testing (HCT) facilities. They look similar and work in a similar way to home pregnancy test kits. Results are immediate. Two positive rapid tests of different brands confirm an HIV+ status. If one of the two rapid tests is inconclusive or the two results are different, a laboratory test like the ELISA (enzyme-linked immunosorbent assay) test is performed.
Both the rapid HIV and ELISA tests detect antibodies which are the body’s response to HIV infection. But these antibodies take time to appear in the body (6 to 12 weeks after infection). This early phase where antibodies are not detectable by tests is called the window period. It is one of the main reasons why people are encouraged to come back and test again in three months, even if they get a negative result.
TB is the most common opportunistic infection in people with HIV and is the biggest killer of HIV+ people. TB is curable (even among people living with HIV) but treatment must be taken properly to ensure it is effective.
Polymerase Chain Reaction (PCR)
tests do not test for HIV antibodies but for the HI-virus itself, making them less likely to be ‘duped’ by the window period. These viral load tests are most commonly used to monitor HIV progression in people living with HIV. A PCR test can be used either to say whether HIV is in the blood or not (qualitative test) or it can be used to measure the amount of HIV (viral load) in the blood (quantitative test).
CD4 count refers to the amount of CD4
positive cells in a person’s system. CD4 positive T helper cells are destroyed by HIV. A CD4 test helps to determine the state of the immune system of persons living with HIV. A CD4 count of below 350 indicates low immunity. In South Africa the patient can now be entered in the government ART programme for treatment.
HIV life cycle and treatment
HIV is a retrovirus because it has to take a “step back” to infect human cells. Because human cells work in DNA, and HIV consists of RNA and 3 enzymes, HIV must work backwards, converting its RNA into DNA in order to use the hijacked CD4 positive T helper cell to make copies of itself. By blocking this process at various stages, ARVs can prevent HIV replication.
Antiretrovirals or ARVs are drugs which interfere with the proteins that HIV uses to make copies of itself inside the human body.
1. FUSION, PENETRATION & UNCOATING
HIV binds with the CD4 protein on the surface of the T helper cell, depositing its contents (RNA and 3 enzymes - reverse transcriptase, integrase & protease) into the cell. blockers: fusion & entry inhibitors
The reverse transcriptase enzyme uses HIV’s RNA and the host cell’s own tRNA to make DNA. blockers: NRTIs & NNRTIs
HIV uses integrase to bind its DNA with the cell’s DNA in the nucleus. HIV now controls the cell producing viral material. blockers: integrase inhibitors
treatment In SA treatment
is divided into first and second line therapy. There are a number of ARV combinations in each line. HIV+ people start first line treatment when their CD4 count drops below 350 or if they are in the fourth stage of HIV infection.
Side effects are addressed by substituting the drug in question with a different TYPE OF ARV
2 - Nucleoside/ Nucleotide Reverse Transcriptase Inhibitors (NRTIs)
3 - Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs) 4 - Protease Inhibitors (PI)
4. ASSEMBLY & BUDDING
With the help of the enzyme protease, the new viral material is packaged into new HIV molecules which bud from the cell, ready to start the process again. blockers: PIs
ARV. This does not mean the person has been switched to second line therapy. If the virus becomes resistant to the first line regimen the person is switched to second line therapy. Second line therapy in SA involves changing two or even three of the drugs in the regimen. ART in SA does not include use of entry or fusion inhibitors & integrase inhibitors, mentioned in 1 & 3 above.
AZT or ZDV
lopinavir + ritonavir
3TC/FTC + TDF/AZT/ABC/d4T + EFV/NVP
regimens for are different to those for adults and adolescents. First line therapy for children under three involves a combination of two NRTIs and one PI. First line treatment for children over three involves two NRTIs and one NNRTI.
TB treatment Because it is a
for prevention & care
public health care facilities only deal with stable patients on ART or TB treatment. Patients requiring more complex procedures are referred to secondary and tertiary hospitals.
(MMC) is where the foreskin is completely removed by medically trained personnel, according to surgical techniques and standards. The WHO confirms, based on landmark studies, that MMC can reduce a man’s risk of HIV infection by up to 60%. There are several reasons why circumcision reduces the risk of HIV infection: »» The delicate foreskin is more likely to tear during sex, forming pathways through which HIV can enter the body.
»» The foreskin creates a warm and moist environment in which HIV thrives.
»» When the foreskin is removed completely, the soft top of the penis (glans) is exposed. Without the foreskin to protect it, skin on the glans keritinises (hardens), forming a barrier against HIV.
notifiable disease TB is almost always treated at public health facilities so that cases can be monitored and followed-up. The standard government treatment regimen involves taking isoniazid, rifampicin, pyrazinamide and ethambutol for 2 months. This is the initiation phase of treatment. Treatment lasts for 6, 9 or 12 months and can extend for up to two years depending on the severity of the TB. If the patient shows improvement, they are moved on to the continuation phase taking isoniazid and rifampicin, until a healthcare worker determines that the TB is cured and instructs the patient to stop taking the treatment. There has been an increase in cases of drug resistant TB like MDR and XDR TB - multi and extensively drug resistant types that develop when patients do not complete their treatment. These types do not respond to standard treatment and usually require aggressive intervention and specialist attention. Tuberculosis (TB) is one of 33 notifiable diseases. This means healthcare workers must report the case to the local or provincial health department, which enables the DoH to keep track of and control contagious and dangerous diseases.
levels of public health care in South Africa primary health care (PHC) includes clinics and community health centres staffed by nurses who are supported by visiting doctors. PHC facilities are outpatient centres, which means that unlike in hospitals, patients do not stay overnight.
HIV treatment in the SA public sector is largely limited to PHC facilities to ease the burden on hospitals. Clinics offer HCT, PMTCT, follow-up visits and supply ARVs. The SA government provides free ART to HIV-positive people.
secondary health care (SHC) At this
level of care, doctors who are generalists in various medical fields work in district hospitals and nurses provide a support network. People seeking public health care may come to these hospitals if they are their closest port of call. Therefore these facilities might provide the same HIV services as PHC facilities.
tertiary health care (THC)
facilities offer services which require specialist intervention and thus house general practitioners, specialists and sub-specialists. Regional and tertiary hospitals qualify as THC facilities. When HIV-positive patients fail on second line ART they are often referred to HIV specialists for salvage therapy. These specialists are likely to work from a THC facility, but might also visit clinics and district hospitals. Young children failing on second line therapy will either be referred to a specialist or be admitted to a hospital within the THC sector.
prevention of mother to
(PMTCT) of HIV reduces the chance that an HIV+ mother will give HIV to her child.
ARVs are currently the best method for controlling and treating HIV. However, ARVs also have a part to play in the prevention of HIV. PMTCT, PEP and PrEP are all treatments which use ARVs to avoid HIV infection.
Without PMTCT there is up to 35% chance that a mother will pass HIV to her baby. Following a PMTCT regimen reduces this chance to a mere 3.5%. PMTCT treatment involves giving mother and child ARVs. There are two pathways: the mother will either go on lifelong ART if her CD4 count is below 350, or if her CD4 count is above 350 she will be given antiretroviral prophylaxis with AZT (during pregnancy), AZT and NVP (during labour) and one dose of TDF & FTC (post delivery). Babies are given a dose NVP daily until the mother stops breastfeeding.
early initiation of ART
The HPTN 052 (2011) trial showed that starting treatment early reduces an HIV+ person’s chance of infecting their HIV- partner by 96%. The study also showed that early initiation of ART benefits the overall health of the HIV-positive individual.
(pre-exposure prophylaxis) Recent studies have shown that if HIVnegative people take an ARV (tenofovir) or combination of ARVs (tenofovir & emtricitabine) orally, their chances of contracting HIV are reduced. Microbicide gels which are applied to the vagina or rectum, forming a barrier against HIV, are also classed as PrEP because they are ARV-based and meant to prevent HIV infection. Pre-exposure prophylaxis is a relatively new discovery which is not yet widely available to the public because it is still being tested.
feeding South Africa has adopted an exclusive breastfeeding strategy and government has stopped providing free baby formula at clinics and hospitals. Mothers are now encouraged to breastfeed regardless of their HIVstatus. The government advises that all mothers should breastfeed exclusively for six months and then start introducing other foods. However, babies whose mothers are HIV+ should take ARVs while breastfeeding. The infant is also given a daily dose of NVP. It is recommended that HIV+ moms stop breastfeeding at one year. Mixed feeding prior to six months is discouraged as an additional precaution against HIV transmission because it can increase the chance that the baby will become infected with HIV. This is because foods other than the mother’s milk damage the baby’s sensitive gastro-intestinal system (gut) making it vulnerable to the HIV in the breast milk.
(PEP) is when an HIVnegative person is given ARVs after they might have been exposed to HIV. PEP can prevent HIV from taking root in a person’s system. PEP courses are similar to ART regimens, with patients taking a combination of two or three different ARVs within 72 hours of potential HIV exposure. A course of PEP lasts for 28 days. It is vital that people taking PEP take the medication as instructed. Otherwise, like HIVpositive people on ART, they could develop drug resistance. This is why people on PEP require counselling as well as support for side-effects.
In SA free PEP treatment is given to people who might be exposed to HIV (it could be through their jobs, e.g. doctors or nurses, as a result of rape, a burst condom or risky unprotected sex. PEP must be taken within 72 hours of possible HIV exposure in order to be effective.
safe sex & prevention HIV is spread predominantly through risky sexual behaviour. By using condoms and reducing the number of sexual partners, it is possible to significantly minimise the risk of contracting the HI-virus.
Condoms are strongly associated with avoiding pregnancy and are not always considered necessary for anal sex - an act both heterosexual and same-sex couples engage in. The risk of contracting HIV during anal sex is actually much higher than vaginal sex, making condoms and lubrication essential for anal sex.
currently the best and most easily accessible method of preventing HIV, provided they are used consistently and correctly. They come in a variety of colours, shapes, sizes and there are male and female variants. Condoms work because the HIV molecules are too big to pass through these materials. They are classified under the broad term contraceptives because they are effective at preventing pregnancy. However, most other contraceptives (such as ‘the pill’) only help to prevent pregnancy and do not provide any protection from HIV. Condoms prevent pregnancy AND protect from HIV.
The condoms people are most familiar with are the ones men wear during sex. These sheaths cover the entire shaft of the penis and act as a barrier method of protection, preventing contact between each partner’s bodily fluids.
lubricants that are
oil-based destroy natural latex, increasing the risk of the condom breaking or tearing. Always use water or silicone-based lubrication as most condoms are made out of latex. Cooking or baby oil, vaseline and body lotion will destroy most condoms.
Condoms made out of polyurethane or nitrile can be used with either oil, water or silicone-based lubricants.
the female condom was
developed in the 1980s. It is a flexible and soft tube with one open end. It is also suitable for anal sex for men and women. The closed end is inserted into the vagina or anus. The “femidom” has been praised for being the only form of female-initiated HIV prevention currently available. Female condoms have the potential to empower women in situations where their male partners refuse to wear a condom. But it is more expensive than the male condom, is not widely used and is often hard to source.
conception It is possible to conceive a child when one or
both partners are HIV-positive. To protect both partners and the unborn baby, a medical professional must be consulted on conceiving safely. A PMTCT regimen is an additional and necessary protective measure.
HIV+ woman & HIV- man Artificial insemination: Semen is deposited into
the vagina artificially and fertilisation happens inside the uterus (intrauterine fertilisation). This can be done at home with a syringe, at minimal cost. In vitro insemination (IVF): The woman’s egg cells are “harvested” and fertilised by the sperm outside of the body. The resulting embryo is then placed back inside the uterus.
HIV+ man & HIV- woman In this case a doctor would recommend that the male partner be on ART for some time to ensure his viral load is low (see ART section) and advise the couple to time intercourse to the woman’s ovulation.
If both partners are HIV+ A doctor will advise that both partners are on
treatment to ensure they have low viral loads and is likely to recommend one of the above procedures in addition. PMTCT is vital.
gender based violence (GBV)
HIV risk & behaviour
can take many forms but includes emotional, mental and physical abuse and can affect males and females. Women and children are most vulnerable because they are seen as occupying inferior positions to men. While women are already biologically more vulnerable to HIV infection, it has been found that women who are exposed to GBV are also more likely to be HIVpositive, because: »» sexual violence may cause small tears in the
Certain practices and behaviours can put people at increased risk of HIV infection. Some of these risky behaviours go beyond personal choice and are influenced by broader social, political and economic factors.
vagina which allow HIV to enter the body easier
»» condom use is not always easily negotiated »» abuse may lead to low self esteem and depression which can lead to higher sexual risk-taking
the role of men is receiving
increasing attention in addressing the HIV epidemic. Organisations have come to realise that prevailing conditions of gender inequality and corresponding constructions of masculinity contribute to the soaring HIV prevalence among SA women.
Campaigns like Brothers for Life and One Man Can aim to redress the gender imbalance in SA society through encouraging men to adopt responsible and respectful behaviours towards women and children.
there are multiple connections between HIV and excessive alcohol consumption.
HIV infection: Excessive alcohol consumption impairs the ability to make decisions and think rationally, which might result in unprotected or otherwise risky sex.
HIV progression: In people living with HIV, studies have shown that excessive alcohol consumption can speed up disease progression by damaging the already compromised immune system.
HIV treatment: Someone consuming lots of alcohol
may forget to take their ARVs and this can lead to drug resistance. Alcohol can also cause vomiting which could mean that any ARVs that were taken within an hour of vomiting are purged from the system and not absorbed.
undercover lovers multiple and
concurrent partnerships (MCP) are defined as having more than one sexual partner at the same time. MCP leads to increased risk of HIV infection as it forms a large network of intersecting sexual encounters. That the encounters are happening simultaneously also increases the risk of transmission as newly HIVinfected people will still have high initial viral loads. HIV can spread quickly and risk escalates as one partner exposes his/her partners who in turn expose their partners. While MCP has been considered one of the main factors contributing to the spread of HIV, new research suggests that it is the overall numbers of partners a person has that ups their HIV risk and it matters less whether these partnerships are concurrent or not.
Why do people still become HIV+ when so many risk reduction methods are available? Access to prevention methods, like condoms, is often limited. But safe sex and HIV prevention is not only about giving people condoms and ARVs. Other social, cultural and political factors affect people’s behaviour and determine how they respond to HIV-prevention methods and messages. Recent campaigns have recognised the need to try and change risky behaviours which potentially expose people to HIV. Scruntinize is an example of a campaign which aims to change people’s behaviour through alerting them to the risks of MCP.
Over arching social and cultural factors in South African society also affect who is exposed to HIV and why.
race & HIV
% of people from each racial group in SA who are HIV-positive: Africans 13.6 | Coloured 1.7 | Indian 0.3 | White 0.3 People often judge these figures as proof that HIV is a ‘black disease.’ This is untrue. Biologically, members of all racial groups in South Africa are at equal risk of HIV infection.
social, political and economic inequality make certain groups of
people more vulnerable to HIV infection. Due to problems associated with poverty, like little or no access to HIV education, limited health care, migrant labour and transactional sex, people in poorer communities are not always able to take the necessary steps to lower their risk of HIV infection. In South Africa, this economic inequality is still largely racialised. HIV progression can also be sped up by poor environmental conditions stemming from poverty, such as poor hygiene, overcrowding and inadequate nutrition.
(TMC) is practiced by many ethnic groups including the Xhosa. The procedure is performed by a traditional nurse or surgeon with no formal training. How much of the foreskin is removed varies between the different groups which practice TMC. This makes it difficult to say to what degree TMC might offer protection from HIV. For many cultures TMC is a small but integral part of the larger initiation ritual during which the initiate makes the transition from boy to man. South Africa’s winter months are labelled the ‘circumcision season’ because thousands of young Xhosa boys ‘go to the mountain’ to be initiated.
terms in statistics
In research and writing on health and disease, the terms incidence and prevalence are often used:
Incidence is the number of new cases of a condition over a certain period of time. Prevalence is the number of people already living with the condition in a given population. In the case of HIV, where there is no cure, the ratio of infected people (prevalence) is unlikely to decline dramatically. Reduced incidence rates (new infections) indicate that prevention efforts are working.
orphans and vulnerable children
& at-risk groups
Most at risk populations (MARPs) are more likely to be exposed to HIV. Vulnerable groups are individuals who are susceptible to other risks because they are living with or have been affected by HIV.
(OVC) is a broad term used to describe children who are more exposed to risks than their peers. It includes children affected by or infected with HIV. HIV can make children emotionally and financially insecure when their caregivers are HIV+ or die from AIDSrelated illnesses. UNAIDS recommends that children orphaned through the passing of their caregiver(s) due to an AIDS-related illness, be referred to as ‘children orphaned by AIDS’. When referring to children who might be affected by HIV and AIDS more generally it is best to use the phrase ‘orphans and other children made vulnerable by HIV.’ MARPS in South Africa include African females (20-34), African males (25-49), men who have sex with men (MSM), high risk drinkers, recreational drug users, people with disabilities, commercial sex workers (CSW) and certain prison populations.
thanks to developments in HIV treatment and care, children born with HIV are living long and healthy lives. As a result, organisations working with HIV have had to rethink care strategies to accommodate this new generation of young adults who were born HIV-positive. Particular thought has had to be given to coaching young teens through puberty and explaining sex and sexuality to them while keeping their status in mind.
men who have sex with men
(MSM) is a category created to describe all men who have sex with men. This includes, but is not limited to gay men. This is because many men, whilst having sex with men, do not identify as homosexual or gay. Biologically, MSM face increased risk of HIV as the virus is easily passed on during unprotected anal sex. The receptive partner is at even higher risk of HIV infection than the insertive partner. MSM are also more vulnerable to HIV because of social factors like discrimination. Negative attitudes towards people who engage in same-sex behaviour, force MSM ‘into hiding.’ This makes them reluctant to seek out sexual healthcare. This is why MSM are often described as ‘a hidden group’ in the epidemic. Treatment and prevention messaging tailored for gay men often does not reach all MSM or they may feel it does not apply to them. »» Organisations like Health4Men, the
Triangle Project and OUT provide sexual health care for all men who have sex with men (including gay- and straight-identifying men) and produce messaging for both groups.
Transactional sex is when sexual acts are performed in exchange for goods or money. It is often linked to inter-generational sex, where one person is ten or more years older than the other. This is often an older man and younger woman as men tend to be more secure financially due to prevailing gender inequality.
commercial sex work
(CSW) is transactional sex which is entered into as a job. Transactional sex, intergenerational sex and CSW all carry an increased risk of HIV infection as there is low condom use due to the limited bargaining power of the dependent party. Commercial sex workers are put at further risk because they are stigmatised, unprotected by the law (sex work is illegal) and have no recourse to report rape or access PEP. It is no longer acceptable to talk about prostitution or prostitutes. “Sex work” is a more acceptable term which considers that for many people sex work is the only way they can make a living, whilst some actively choose to engage in sex work.
Research and the statistics it produces are important to gauge the effectiveness of any prevention interventions. Research is constantly evolving. This section outlines the latest developments.
HIV-related research have been happening at an unprecedented rate recently. As a result, today’s HIV research news quickly becomes old news.
searching for a vaccine
The RV 144 or ‘Thai trial’ is the largest randomised controlled trial involving an HIV vaccine. It is also the first trial to indicate that a vaccine could reduce the risk of HIV infection.
Writing accurately about HIV involves keeping your ear to the ground and staying up to date with the everchanging world of HIV-research.
Participants in the experimental group were given two vaccines; one to prime (ALVAC HIV) the body to identify HIV and one to boost (AIDSVAX B/E) the immune system to fight the virus.
AVAC.org lists all the latest and most prominent HIV-related trials and research.
The study revealed that the vaccine provided 31 percent protection against acquiring HIV.
Clinical trials A drug goes through vigorous testing before
it can be made available to the public. There are four stages in total that a potential treatment must pass before it is considered safe and effective.
Pre-clinical development The
treatment is subjected to testing in a laboratory. The drug is tested on animals to see if it causes death. If the drug is non-lethal a safe starting dose for human subjects is established through further testing.
3rd & final phase Now an even
larger sample is involved and the study is conducted at multiple sites. If this trial yields positive results the drug will be made available to the public.
microbicides are compounds that are
applied inside the vagina or rectum forming a barrier against HIV. Although many microbicide trials have been conducted, many had to be discontinued following doubts around their efficacy. The most successful trial to date involves a microbicide containing the ARV tenofovir. The 2nd phase of the trial (CAPRISA 004) was conducted in SA and results revealed in 2010 showed that the tenofovir microbicide provided 39% protection from HIV. The 3rd phase of the trial (FACTS 001) was scheduled to begin in mid 2011.
1st phase Human subjects are involved in this stage of the trial. This phase of the drug trial involves a small (20-100) sample (group) of participants and is conducted at one site.
2nd phase The drug continues to be
tested for dosage and safety (this time on a larger sample) and the researchers begin to focus on whether or not the drug works as predicted. Many clinical trials are terminated at this stage because they are found to be ineffective.
Studies have shown that ARVs can be used as HIV prevention. An international phase 3 clinical trial known as the iPrEX study (2010), which involved MSM and female to male (F2M) transgender people, showed that when two ARVs (TDF/FTC) are taken daily as a single pill (Truvada) it provides 44% protection from HIV infection. Another study, TDF 2 (2011) involved serodiscordant couples (one partner HIV+ and one HIV-) and found that the same combination of ARVs used above was up to 77% effective at preventing HIV infection among heterosexual couples. An ongoing Partners PrEP study is comparing the efficacy of tenofovir (TDF) against Truvada, and involves serodiscordant heterosexual couples in Kenya and Uganda.
--- global 1970 Doctors in Zaire (later DRC) and
timeline HIV is a pressing problem in South Africa more so than in the rest of the world. Comparing the HIV response of other countries to SA’s, reveals that the country’s political history has much to do with the current HIV burden.
Burundi see a rise in certain infections like cryptococcal meningitis and PCP (a type of pneumonia), as well as diarrhoea and severe wasting. The condition is labelled “slims disease”.
1981 First AIDS-related deaths are
recorded among gay men in New York. Links are made between what is first called GRID - Gay Related Immune Deficiency Syndrome, and “slims disease”.
1984 Scientists identify HTLV-III or LAV
--- south africa 1982 Two air stewards die from AIDSrelated illnesses in Johannesburg
1988 There are 1,857 recorded HIVinfections in SA
1993 The recorded number of HIV
infections in South Africa grows by 60% in two years
1995 The South African Ministry of Health announce that some 850,000 people are believed to be HIV+.
(later renamed HIV in 1986) as the cause of what is now called AIDS.
1999 South African President Thabo
1987 AZT is the first drug approved
2000 A letter from President Mbeki to
for the treatment of HIV but is largely unavailable in Africa. The first HIV case is recorded in the Soviet Union, and a massive HIV testing programme is launched.
1987 Australia launches controversial AIDS awareness campaign.
1988 The American government
Mbeki suggests that AZT is “toxic.”
world leaders voices views which seem to agree with those of AIDS denialists and dissident scientists.
2000 HIV among pregnant South African women reaches 30 percent, compared to 0.8% recorded in 1990.
2001 The Constitutional Court orders
conducts a national AIDS education campaign.
the SA government to make nevirapine available to HIV+ pregnant women in the public sector.
1991 Thailand launches Asia’s most
2003 Health Minister Tshabalala-
extensive HIV prevention programme.
1994 AZT is shown to reduce the risk
of mother to child transmission of HIV. HIV infections in infants begin to fall in developed countries, due to use of AZT.
1996 Many HIV+ people in developing countries have access to ART; AIDSrelated deaths begin to decline.
1997 Brazil is the first developing country to begin providing free combination treatment.
2002 Botswana begins Africa’s first
national AIDS treatment programme Global HIV prevalence (the number of people already living with HIV worldwide) 0.8 % of the world’s population has HIV.
Msimang incorrectly claims that good nutrition is a substitute for ART. A study later estimates that the delay in treatment roll-out caused more than 350, 000 South Africans to lose their lives.
2004 South Africa begins to provide free ARVs.
2010 SA institutes new HIV treatment
guidelines which specify earlier initiation of ART for HIV+ pregnant women and people with HIV and TB co-infection.
2011 In August of the same year the
CD4 count criteria for starting ART is increased from 200 to 350 for all HIV+ people. National HIV prevalence: 17.8% of
South Africans over the age of 15 are HIV-positive.
Hold all decision makers to account. Engage with, but do not be held captive by any one interest group.
HIV can be a socially complex and technically loaded topic. These guiding principles will ensure that media practitioners address HIV in an accurate and sensitive manner.
Balance means giving due weight
to the story and highlighting the complexity of HIV. Consider and cover all aspects, including medical, social, political, economic and other issues. Highlight positive stories but avoid down playing the seriousness of HIV.
Ensure that the voices and images of people living with and affected by the virus are heard and seen. Take care that these voices are diverse. Respect the rights of people living with and affected by HIV. Informed consent means that everyone truly, fully understands the implications of appearing in the media. If in doubt, do not identify the person. Particular care should be taken in dealing with children. No images or information which could identify minors (under 18) should ever be published. But children do have the
--- www.journAIDS.org ---
right to be heard, so ensure that the particular concerns they face are covered, but do so in a sensitive manner.
Avoid fuelling discrimination,
prejudice and stigma. Particular care should be taken not to use language, or images that reinforce stereotypes.
Accuracy is critical. Be particularly careful to get scientific and statistical information right. This involves factchecking and the use of multiple sources.
Misconceptions should be debunked. Never report a myth or misconception in a way that could perpetuate it.
Clarity means being prepared to talk
openly about sensitive issues, including sex. Cultural practices and other sensitive issues should be understood and addressed respectfully but openly. These guidelines are based on a set of guiding principals developed by Franz Kr端ger. For more, visit the media toolkit on journAIDS.org.
The HIV & AIDS Media Project is a partnership between the Wits Journalism Programme and the Anova Health Institute, and is funded by USAID/PEPFAR through Johns Hopkins Health and Education South Africa. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID or PEPFAR.