Adapted from "Understanding and Avoiding HIV Infection" module, Pre-Service Health Training for Volunteer Binder, Peace Corps Office of Medical Services

BACKGROUND

Human immunodeficiency virus (HIV) causes an infection which, after a varying number of years, usually leads to AIDS (acquired immunodeficiency syndrome). HIV is a global issue, with 80% of reported cases occurring in the developing world. Unlike the U.S., where the vast majority of infected individuals are males, worldwide the ratio of infected men and women approaches 1:1.

Almost all HIV infections progress to AIDS, the final stage of HIV infection. To the best of our knowledge, AIDS universally results in death.

There are two closely related HIV viruses, HIV 1 and HIV 2. HIV 1 is present in all areas and most closely associated with the development of AIDS. HIV 2 is endemic principally in West Africa. Infection with HIV 2 appears to progress more slowly than with HIV 1; however, AIDS and other HIV complications are present with this infection as well.

Students should:

1. Understand the disease caused by HIV, how it is transmitted and diagnosed.
2. Understand what constitutes high-risk behavior for becoming infected with HIV.
3. Develop a realistic view of their own personal risk.
4. Know that they are capable of controlling their risks and developing strategies to reduce them.

STATISTICS

In 1994 there were an estimated 10 million persons infected with HIV. In parts of Africa, as many as one third of the sexually active population may be infected. In 1980, the infection began to spread in Asia, and it is expected that new infections will exceed those in Africa by the late 1990’s.

Students are always anxious to know about the local prevalence of HIV infection. The Administrator should consult local health professionals, health department and blood banks, for information on the seroprevalence of HIV in their country and region.

TRANSMISSION

Transmission of HIV requires contact with body fluids that contain the HIV virus. Transmission has been documented from contact with blood, semen, vaginal secretions, and breast milk.

HIV is most commonly transmitted by:

• Unprotected sex with an infected partner
• • Over 85% of HIV infections are acquired by this route. The risk of transmissions increases when either partner has a STD.
• Inoculation of blood
• • Receiving a blood transfusion (or blood products) from an infected donor.
  • Sharing intravenous drug injection equipment with an infected individual.
  • Using unsterilized needles and /or syringes (including medical and dental injections, tattooing, acupuncture).
  • Needle stick, open wound, and mucus membrane exposure in health workers.
• Mother to child
• • Transplacental transmission from infected mother to unborn child.
  • Intrapartum transmission.
  • Breast feeding.

HIV is NOT transmitted by:

• Casual or close non-sexual contact.
• Saliva or the droplet nuclei produced by coughing or sneezing.
• Mosquitoes.

THE NATURAL HISTORY OF HIV INFECTION

Following infection, an individual usually experiences an acute illness that can cause a spectrum of symptoms from mild non-specific constitutional symptoms to an illness associated with rash, fever, and aseptic meningitis. However, regardless of the signs and symptoms present, there is a high level of viremia at this time associated with a high degree of infectivity. As antibodies develop (and the HIV antibody test becomes positive), a variable period of asymptomatic infection ensues. An infected individual remains capable of transmitting HIV infection during this asymptomatic period. The typical duration of this infection is 10 years. AIDS is diagnosed when an individual develops severe compromise of the immune system with opportunistic infections, malignancies, neurologic dysfunction, a CD4 count of less than 200, or one of several other syndromes.

HIV ANTIBODY TESTING

The two commonly used tests for HIV identify antibodies to the HIV virus in the blood. They do not directly test for presence of the virus. Antibody tests become positive with six months of the initial infection in almost all cases; however during this period the individual is highly infectious and usually unaware of the infection.

Screening test: ELISA (Enzyme –linked Immuno Assay)

Confirmatory Test: Western Blot

• Counseling is always appropriate prior to testing.
• False positive and false negative tests do occur.
• HIV antibody tests are negative for several months after infection.

RISK BEHAVIORS

Students who have become infected with HIV, the consistent risk behavior identified has been unprotected sexual intercourse. Other recognized risks behaviors include:

• STDs which dramatically increase the risk of becoming infected with HIV
• Alcohol use
• Multiple sexual partners

The following may be helpful for placing sexual behavior on a risk continuum:

Safe

• Massage
• Hugging
• Body rubbing
• Kissing (dry)
• Masturbation
• Hand-to-genital touching or mutual masturbation

Possibly Safe

• Kissing (wet)
• Vaginal/rectal intercourse using latex condoms
• Oral sex on a man using a latex condom
• Oral sex on a woman who does not have her period or a vaginal infection with discharge (use a latex barrier such as a dental dam for extra safety)

Unsafe

• Any intercourse without a latex condom
• Oral sex on a man without a latex condom
• Oral sex on a woman during her period or vaginal infection with discharge without a latex barrier such as a dental dam
• Semen in the mouth
• Oral-anal contact
• Sharing sex toys or douching equipment
• Blood contact of any kind, including menstrual blood, sharing needles, and any sex that causes damage and/or bleeding

BARRIERS TO SAFER SEX

A survey of Peace Corps volunteers has identified the following barriers to the implementation of safer sex practices, which are relevant for study abroad students:

• Vulnerability: Volunteers frequently do not personalize risk, i.e., they do not perceive themselves at risk.
• Impaired judgement from alcohol use.
• Volunteers perceived their partners to be "clean," that is, without an STD or HIV.
• Obstacles to condom use, including unavailability, personal or partner dislike for condoms, physical discomfort in using condoms.
• Failure to separate steps taken to prevent pregnancy from those taken to reduce the risk of STDs and HIV infection.
• Awkwardness, lack of skills in talking about sex.
• Desire to trust partner.
• Fear of rejection.
• Poor self-esteem.
• Not knowing the language well enough.

REDUCING RISK

Knowing about HIV and its associated risk behavior frequently does not result in reduced participation in those behaviors. Studies have shown that well-informed individuals are often unable to effectively translate their knowledge into consistent behavior.

• Abstinence and deferral of sexual activity (postponement) should be acknowledged as effective risk-reduction choices. Many who choose abstinence choose to avoid intercourse but engage in other forms of sexual intimacy.
• A mutually faithful relationship with an uninfected partner is an effective risk-reduction strategy. However, it is much easier to become convinced that neither you nor your partner would have sex with another person than to admit that many relationships are not or do not remain monogamous.
• When used consistently and correctly, condoms are the most effective method for preventing HIV in sexually active couples. Consistent use means using the condom every act of intercourse. When a male condom cannot be used, couples should consider using a female condom.
• Students choosing to be sexually active place themselves on a risk continuum based on the level of risk associated with the behaviors they choose. The "safe," "possibly safe," and "unsafe" behaviors described above are useful for discussion.
• Alcohol use is prevalent among students and is implicated in high-risk sexual activity. Decreased substance use is an essential element of risk reduction.

Adapted from "Understanding and Avoiding HIV Infection" module, Pre-Service Health Training for Volunteer Binder, Peace Corps Office of Medical Services