Women and HIV

Women and HIV
Sudha Salhan
Consultant and Head
Department of Obstetrics and Gynaecology
VM Medical College and Safdarjung Hospital
New Delhi
A FOGSI Publication
JAYPEE BROTHERS
MEDICAL PUBLISHERS (P) LTD.
NEW DELHI
Women and HIV
Federation of Obstetric and Gynaecological Societies of India
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
EMCA House, 23/23B Ansari Road, Daryaganj
New Delhi 110 002, India
Phones: 23272143, 23272703, 23282021, 23245672, 23245683
Fax: 011-23276490
e-mail: jpmedpub@del2.vsnl.net.in
Visit our website: http://www.jpbros.20m.com
Branches
202 Batavia Chambers, 8 Kumara Kruppa Road, Kumara Park East
Bangalore 560 001, Phones: 2285971, 2382956 Tele Fax: 2281761
e-mail: jaypeebc@bgl.vsnl.net.in
282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza
Pantheon Road, Chennai 600 008, Phone: 8262665 Fax: 8262331
e-mail: jpmedpub@md3.vsnl.net.in
4-2-1067/1-3, Ist Floor, Balaji Building
Ramkote Cross Road, Hyderabad 500 095
e-mail: jpmedpub@rediffmail.com
1A Indian Mirror Street, Wellington Square
Kolkata 700 013, Phone: 2451926 Fax: 2456075
e-mail: jpbcal@cal.vsnl.net.in
106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital
Parel, Mumbai 400 012, Phones: 24124863, 24104532 Fax: 24160828
e-mail: jpmedpub@bom7.vsnl.net.in
Women and HIV
2003, Federation of Obstetric and Gynaecological Societies of India
All rights reserved. No part of this publication should be reproduced, stored in a
retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of
the editor and the publisher.
This book has been published in good faith that the material provided by
editor is original. Every effort is made to ensure accuracy of material, but the
publisher, printer and editor will not be held responsible for any inadvertent
error(s). In case of any dispute, all legal matters to be settled under Delhi
jurisdiction only.
First Edition : 2003

Publishing Director: RK Yadav
ISBN 81-8061-087-X
Typeset at JPBMP typesetting unit

Printed at
Gopsons Papers Ltd, A-14, Sector 60, Noida
Preface
As HIV infection and AIDS is becoming more visible a need for a
comprehensive book about the subject is being felt. This book is
an attempt to fill that void. What is the load of infection in our
population, how can the disease manifests, how to prevent and
suppress it are some of the questions which come to our mind and
which are answered in this book. The role of reproductive tract
infection and sexually transmitted diseases in enhancing HIV
infection is emphasized Counselling is required before testing and
after disclosing the results to the patient. Even if the result is
negative counseling regarding prevention of the infection is
necessary. This vital topic is dealt with in detail.
The National AIDS Control Organization (NACO) has
published guidelines for the diagnosis of AIDS in different
circumstances. These, too, are highlighted.
The signs and symptoms of HIV/AIDS, including opportunistic infections and their treatment, are elaborated.
The only treatable entity, that is mother-to-child transmission,
is discussed in detail. The circumstantial predisposition of
adolescent girls should be understood. The prevention of infection
in health workers and its immediate treatment, if accidental
infection occurs, is of considerable importance to all of us.
Therefore, chapters dealing exclusively with postexposure
prophylaxis and biosafety measures are included.
Finally, a knowledge of the psychological effects of the disease
is imperative in treating the patient in totality. Due importance
has, therefore, been given to it.
To battle this epidemic obstetricians and gynaecologists,
paediatrician, microbiologists, physicians, epidemiologists and
psychiatrists must act in concert.
I am grateful to Mr. Brijesh Tripathi and my daughters for
helping me with the manuscripts and the computer work. The
publishers, Jaypee Brothers, have been very patient, throughout
and thus I also thank them profusely.
Sudha Salhan
Contributors
Usha K Baveja
Consultant in Microbiology
National Institute of Communicable Disease, New Delhi
M Bhattacharya
Professor
Department of Community Health Administration
National Institute of Health and Family Welfare, New Delhi
Rajesh Rastogi
Consultant in Psychiatry
VM Medical College and Safdarjung Hospital, New Delhi
Krishna Ray
Consultant in Microbiology
Sudha Salhan
Consultant and Head
Department of Obstetrics and Gynaecology
RN Salhan
Department Director General Govt. of India
Nirman Bhawan, New Delhi
Naveet Wig
Assistant Professor
Department of Medicine
AIIMS, New Delhi
Contents
1. Epidemiology of HIV Infection and AIDS
M Bhattacharya
2. HIV: The Virus

Usha K Baveja
19
3. Syndromic Management of Reproductive Tract

Infections and Sexually Transmitted Infections
in Females
Sudha Salhan
33
4. Voluntary Counselling and Testing and its

Rationale for HIV Infection
Sudha Salhan
49
5. Establishing the Diagnosis of the HIV Infection

Usha K Baveja
76
6. Women and HIV Infection including Mother to

Child Transmission
Sudha Salhan
92
7. Management of HIV Infected Individuals

Naveet Wig
118
8. HIV and Adolescent Girl

Sudha Salhan, RN Salhan
142
9. Infection Control and Bio-medical Practices

in Health Care Settings
Krishna Ray
153
10. Postexposure Prophylaxis against HIV

Naveet Wig
178
11. Psychiatric Aspects of HIV/AIDS in Women

Rajesh Rastogi
194
Index
207
READER SUGGESTIONS SHEET

Please help us to improve the quality of our publications by completing and returning
this sheet to us.
Women and HIV by Sudha Salhan
Title/Author:
Your name and address:

Phone and Fax:
e-mail address:
How did you hear about this book? [please tick appropriate box (es)]
#
#
#
Direct mail from publisher

Book review
Other (please specify)
Type of purchase:
#
#
#
Conference
Lecturer recommendation
#
#
Bookshop
Friends
Website
Direct purchase
Bookshop
Friends
Do you have any brief comments on the book?
Please return this sheet to the name and address given below.
JAYPEE BROTHERS
MEDICAL PUBLISHERS (P) LTD
EMCA House, 23/23B Ansari Road, Daryaganj
New Delhi 110 002, India
one
Epidemiology of
HIV Infection and AIDS
M Bhattacharya
INTRODUCTION
AIDS (Acquired Immunodeficiency Syndrome) represents the late
clinical stage of infection with HIV (Human Immunodeficiency
Virus). The AIDS with all manifestations combined, it is called AIDS
syndrome was first recognized in 1981, but probably it had existed
at low endemic level in Central Africa before the epidemic spread
to several areas of the World during 1980s.
The presence of a new type of viral infection that could
progressively destroy the immune system was first suspected in
1981, in USA, when there was sharp increase in the number of
reports of opportunistic illness Pneumocystis carinii pneumonia
(PCP) and Kaposis sarcoma in relatively young, previously healthy
homosexual males and a comparable increase in the number of
cases of PCP in young children of mothers who were injection drug
users (IDUs). In 1983, hemophiliacs who had received transfusions
of factor 8 were identified as a third group in whom incidence of
immunodeficiency and PCP was increasing. Further investigations
led to the discovery and isolation in 1983 of the pathogen
responsible for AIDS, the human immunodeficiency virus (HIV).
Since then, this retrovirus has been detected in more than 99 percent
of patients diagnosed with AIDS.
CHARACTERISTICS OF HIV
HIV attacks the immune system as a lentivirus, a subfamily of the
retroviruses. By definition, retroviruses are RNA viruses that
contain the reverse transcriptase enzyme. Reverse transcriptase
Women and HIV
catalyzes the synthesis of DNA from an RNA template. As its name

implies, reverse transcriptase causes the reverse of the usual
transcription process, which involves the synthesis of RNA from a
DNA template.
Following infection with the HIV virus, the viral reverse
transcriptase produces a haploid double standard DNA provirus.
This provirus gets inserted into the chromosomal DNA of the host
cell. Once it is integrated, the provirus may remain latent, especially
in resting lymphocytes. However, if the cells are activated,
transcription and translation occur, allowing the assembly of viral
proteins necessary for the production of virions that are released
to infect other cells. HIV has a high replication and a high mutation
rate, hence a patient may harbour a number of variants, which
may pose problem for vaccine development and antiretroviral
therapy.
Figure 1.1 shows the organization and structure of the HIV
genome and virion. As with other retroviruses, HIV-1 contains the
three key coding regions pol, gag and env. Pol encodes reverse
transcriptase, integrase and protease, which are necessary for
replication for HIV-1. gag encodes the capsid proteins. Env encodes
for the external glycoprotein that attaches to cell receptors to initiate
infection. Other proteins encoded for by HIV-1 regulate gene
expression, promote propagation of the virus and increase the
complexity of the virus.
Some of the major HIV-1 proteins include gp120, gp41, p16/
p14, p19, p27/p25, and p24. The gp120 and gp41 proteins are
external envelope proteins that bind to the receptors of CD4 cells.
These proteins are found in the plasma membrane and envelope
region of the virus. The p16/p14 Tat proteins, found mostly in
the nucleus and nucleolus of infected cells function as an activator
of viral transcription. The p19 rev protein is responsible for the
transport and stability of viral RNA. This protein travels between
the cytoplasm and the nucleolus of the infected cell. The p27/p25
nef proteins are active in the down-regulation of CD4 cells. They
reside in the plasma membrane as well as the cytoplasm. The p24
gag protein functions in the core capsid and is found in the virion.
Molecular epidemiologic data indicate that there are two subtypes:
HIV type 1 (HIV-1) and type 2 (HIV-2). Both infections were
zoonotic in origin.
Epidemiology of HIV Infection and AIDS 3
Fig. 1.1: (a) Schematic drawing of the HIV life cycle;

(b) Antigenic structure of HIV
Source 1: Guidelines, Govt. of India, Ministry of Health and Family Welfare
Women and HIV
NATURAL HISTORY OF HIV

HIV infection is characterized by 3 phases as given in Figure 1.2:
acute (primary) infection, latency, and chronic infection (including
development of symptomatic disease and, eventually AIDS). Acute
infection (acute seroconversion) occurs soon after a person has been
affected with the virus. During this phase, HIV levels in plasma
are high; immune response is active and usually sufficient to reduce
the amount of virus in the circulation and shift it into the lymphatic
system. Cytotoxic cells, complement, and neutralizing antibodies
are activated in the acute infection phase, although neutralizing
antibodies do not reach detectable levels for 2-3 months after
infection. This period is known as Window period and persons
tests negative by ELISA. Patients frequently (i.e., about 30 percent
of the cases) present with a viral syndrome consisting of fever
(97percent of cases), adenopathy (77 percent), pharyngitis(73
percent), rash( 70 percent), and myalgia or arthralgia (58 percent).
Fig. 1.2: Typical course of HIV infection in persons who receive no treatment.
Following primary infection, a chain of events occurs over the next decade of the
persons life. Widespread dissemination of HIV in peripheral blood accompanied
by an abrupt fall in CD4+ T lymphocytes; a clinical latency period lasting about
5 years; further declines in CD4 cells marked progressively by constitutional
symptoms, opportunistic diseases and death

During the clinical latency phase of HIV infection, outward
clinical signs and symptoms are absent. Nevertheless, viral
replication continues unabated within the lymphatic system. The
patients immune system responds to the virus, resulting in
increased lymphocyte production. However, the immune system
eventually begins to break down, and plasma virus levels rise as a
consequence.
In the chronic infection phase, there is progressive, symptomatic
clinical disease due to severe immune dysfunction, elevated plasma
HIV levels, and decreased CD4 lymphocyte cell counts to below
200/cumm3.
HIV-1 compared to HIV-2 is associated with a higher motherto-child transmission rate (20-35 percent vs 0-4 percent), attacks a
younger age group (peak age 20-34 years vs. 45-55 years), and
produces higher mortality (10-fold vs. twofold). The lower
efficiency of heterosexual transmission of HIV-2 is also believed
to be due to lower concentration of this virus type in cervicovaginal
secretions.
MODES OF TRANSMISSION OF HIV
HIV infection is spread by sexual intercourse, injecting drug use,
prenatal transmission, transfusion of blood and blood products,
organ transplantation, and occupational exposure to HIVcontaminated blood or body fluids. The likelihood of infection after
a single exposure by the various routes is given in Table 1.1 and
the amount of virus isolated from various body fluids, inside the
cells or as cell free virus particles are given in Table 1.2.
Sexual Transmission
Largest number of cases in the world have been observed to be via
the sexual route. Unprotected receptive anal/vaginal intercourse
is the most effective mode of the sexual transmission of HIV.
Among MSM, the biggest HIV risk factor is a combination of
receptive anal intercourse and a high number of male sexual
partners. History of anogenital rectal gonorrhea or other ulcerative
STDs like Hepes simplex, syphilis and rectal trauma enhance the
chances of transmission.
Vaginal penile heterosexual intercourse is not a very efficient
mode of HIV transmission especially from infected women to a
man but the efficiency is higher from male to female by sexual
Women and HIV

Table 1.1: Estimates of risk of HIV transmission and global importance
Type of exposure
Likelihood of infection after a

single exposure ( %)
Sexual intercourse
Receptive vaginal
Receptive anal
0.01-1.0
~ 0.01
~ 1.0
70-80
60-70
5-10
Injecting drug use
0.5-1.0
5-10
Maternal transmission
Pregnancy/delivery a
Breast milk
12-50
12b
5-10
Not quantified
Medical interventions
Blood transfusion
Blood products
Organ transplantation
Artificial insemination
> 90
Not quantified
Not quantified
Not quantified
3-5
Not quantified
Not quantified
Not quantified
0.1-1.0
< 0.01
Health care worker

(needle-stick etc.)
Global total
( %)
a. Rate of infection diminished greatly by antiretroviral therapy during pregnancy
and neonatal period

b. Risk from continuous breastfeeding and not a single exposure
mode. The chances are higher when other well defined risk factors
are also present like multiple sex partners, presence of STDs e.g.
genital ulcers (allowing direct exposure to HIV laden blood),
engaging in receptive anal intercourse and sex with persons from
areas of high HIV infections or high risk behaviors (e.g. IDUs).
Non-ulcerative STDs like gonorrhea and chlamydia also facilitate
transmission nearly 3 times compared to in a woman without these
STDs. Other factors include genital trauma, an exposure to blood
during intercourse (e.g. sex during the time of menses), lack of
male circumcision and the use of IUDs. Sexual transmission is
more likely when partner has clinical manifestation, i.e. AIDS, when
there are high viral loads both in blood and genital fluids.
Behavioral factors such as use of alcohol or other addictive
drugs impair judgment and may lead to risky sexual behavior,
enhancing the probability of transmission. Table 1.3 shows the
factors affecting HIV-1 shedding in the genital tract and Figure 1.2
depict the factors affecting transmission by sexual route.

Table 1.2: Isolation of infectious HIV from body fluids a
Fluid
Cell free fluid
Plasma
Tears
Ear secretions
Saliva
Sweat
Feces
Urine
Vaginal cervical
Semen
Milk
Cerebrosopinal fluid
Virus isolation
Estimated quantity of HIV
33/33
2/5
1/8
3/55
0/2
0/2
1/5
5/16
5/15
1/5
21/40
1-5000b
<1
5-10
<1
<1
<1
10-50
<1
10-10,000
89/92
4/11
3/24
7/16
11/28
0.001 1%b
< 0.0%
ND
ND
0.01 5%
Infected Cells
PBMC
Saliva
Bronchial fluid
Vaginal-cervical fluid
Semen
a
For cell-free fluids, units are infectious particles per milliliter; for infected cells,
percentage of total cells capable of releasing virus. Abbreviation: ND, not determined.
High levels associated with acute infection and advanced disease
None detected.
Use of Condoms and Other Protective Agents

Latex condoms reduce/block the passage of HIV through it.
Consistent and correct use of condoms can reduce the risk of
HIV amongst heterosexual couples, MSMs and prostitutes. Uses
of topical vaginal microbicides are under trial for preventing HIV
transmission.
Transmission among Injecting Drug Users (IDUs)
Injecting drug use is a major risk factor and in many parts of the
developed world it contributes more to the number of cases than
heterosexual or homosexual acts. Drug injection practices, sexual
behavior, presence of STDs, and increase of addictive drugs are
Women and HIV

Table 1.3: Factors affecting HIV-1 shedding in the genital tract
Factors in:
Status
Females
Males
Confirmed
Correlates
Pregnancy
Cervical ectopy
Cervicitis
Potential
Correlates
HIV disease stage

Plasma viremia
CD4+ lymphocyte count
Viral phenotype or subtype
Plasma viremia
Circumcision
Viral phenotype or subtype
Nutritional deficiency status
Antiretroviral therapy
Nongonoccoccal urethritis
Nutritional deficiency status
Mucosal HIV antibodies
Specific cervical or vaginal STD
Lactobacillus and H2O2 production
Mucosal HIV antibodies
HIV disease stage

Leukocytospermia
Gonorrhea
Urethritis
PARTNERS
HIV prevalence in core groups
Number of sexual contacts/time
Number of new partners/time
Social mixing among persons
from areas with different HIV
prevalance
INFECTIOUSNESS
Stage of HIV disease
Immune status
Viral load and phenotype
Sexually transmitted diseases
Genital tract inflammation
SUSCEPTIBILITY
Stage of HIV disease
Immune status
Viral load and phenotype
Sexually transmitted diseases
Genital tract inflammation
Fig. 1.3: Interplay of factors which determine the probability of transmission of

HIV in sexual relationship.

all factors that contribute to HIV transmission amongst IDUs.
IDUs frequently share needles and syringes among themselves as
a routine practice leading to high rate of infection. Among IDUs
HIV infections progresses more rapidly to AIDS with increasing
age.
Perinatal (Vertical) Transmission
HIV can be transmitted from mother to fetus in utero, intrapartum,
or during postpartum by breast-feeding to the infant. Although
the timing of maternal fetal transmission is uncertain HIV has been
isolated in fetal tissue during the early to late stages of pregnancy,
from placental tissue during the first trimester, and from cord blood
of infants at delivery. Usually 65-80 percent of transmission occurs
during intrapartum period. Caesarean section appears to reduce
the risk of HIV transmission significantly. The incidence of HIV
infection among infants varies from 14 percent in Europe to 45
percent in Africa and other developing countries. In mothers who
become infected during late pregnancy or lactation, the risk of HIV
transmission through breast milk may be as high as 50 percent
due to a very high viral load, which occurs at the early stage of
infection. However, the rate of postnatal transmission of HIV-1
from mothers who have been HIIV positive throughout their
pregnancy is lower (5-15 percent).
Transmission by Blood Transfusion, Blood Products and
Organ Transplantation
The risk of HIV transmission from whole organ of an HIV infected
donor is nearly 100 percent. Fresh frozen, unprocessed bone from
an infected donor has a higher risk, if marrow elements or tissues
are not removed. Vascular solid tissues pose a lower risk for HIV
transmission if processed by techniques that might have inactivated
the HIV. Persons may become infected by receipt of blood, organs
and tissues from donors who are in the window period and hence
have tested seronegative by ELISA during the period of donation,
but would become positive later.
Transmission to Health Care Workers
HIV infection is a risk for health care workers and laboratory personnel who handle sharp instruments or body fluids from HIV
10
Women and HIV
infected patients. Needle-stick accidents pose a far greater risk than

does intact skin on mucous membrane exposure to HIV contaminated blood or body fluids. A 0.4 percent HIV seroconversion rate
has been reported in health care workers who have percutaneous
injuries with HIV contaminated surgical instruments.
The risk of HIV infection is greatest when the health care worker
has been exposed to a large quantity of blood from patients with
advanced HIV disease who have very high viral loads. Single
exposure of mucosal and intact skin to HIV contaminated body
fluids accounts for a lower infection risk (less than 0.1 percent)
than does penetrating exposures.
In hospitals in the developing worlds, inadequate infection
control practices of contaminated syringes and needles have
resulted in HIV transmission to patients.
Environmental and Casual Contact Transmission
No one has been infected with HIV due to contact with an
environmental surface because HIV is unable to reproduce, spread
or maintain infectivity outside its living host. There is no evidence
to support the possibility of HIV transmission by insects.
Household transmission of HIV in absence of sexual or
percutaneous exposure is rare. HIV has not been shown to be
transmitted through the sharing of household items, such as towels,
plates, sheets, glasses, toilet or bath or shower facilities that have
been soiled by feces, saliva, urine or tears, as the quantity is very
small or the virus may be absent as observed from Table 1.2.
An Overview of the HIV/AIDS Pandemic
The WHO/UNAIDS have given the following estimates
which depict the problem worldwide and show that it is progressing (Table 1.4).
The countries in the African and the Asian region have the
highest numbers because of the large population base where small
percentages are translated into large number of infected individuals
in the community. In Africa the number is highest because the
prevalence amongst pregnant women is high, nearly 30-45 percent.
As a result more number of children are also affected in the absence
of an antiretroviral therapy to prevent transmission from mother
to child. This phenomenon is observed whenever heterosexual
Epidemiology of HIV Infection and AIDS
11
Table 1.4: Global summary of the HIV/AIDS epidemic,

as of end 2001 (from UNAIDS)
Number of people living with HIV/AIDS Total

Adults
Women
Children under 15 years
40 million
37.1 million
18.5 million
3.0 million
People newly infected with HIV in 2001 Total

Adults
Women
5 million
4.2 million
2.0 million
800, 000
AIDS deaths in 2001
3 million
2.4 million
1.1 million
580, 000
Total
Adults
Women
transmission is the major mode of spread. In countries where the

spread is primarily through homosexuals and injecting drug users
the number in the population rise slowly as observed in the other
regions of the globe. The region wise description as follows.
Sub-Saharan Africa
Africa remains by far the worst affected region in the world: 3.5
million new infections occurred in Africa in 2001, bringing to 28.5
million the total number of people living with HIV/AIDS in the
region (Fig. 1.4). Of the 14 million children orphaned by AIDS
worldwide, 11 million live in sub-Saharan Africa. The highest HIV
prevalence rate worldwide for pregnant women stands at 44.9
percent in Botswana. As the epidemic matures younger women
are affected as observed in Botswana, where among 25-29-YearOld women attending antenatal clinics in urban areas, 55.6 percent
of pregnant women (one out of two) were living with HIV/AIDS.
The prevalence in other African regions are also increasing except
in Uganda where over the past eight years the seroprevalence has
fallen from 29.5 to 11.2 percent among pregnant women in
Kampala. The experience in Uganda and Senegal bring to light
how a rampant HIV/AIDS epidemic can be brought under control
with intensive prevention programs.
Asia and the Pacific
Currently the estimate for this region stands at approximately 6.6
million. India alone has 3.97 million HIV cases in 2001 which is
12
Women and HIV
Fig. 1.4: Adults and children estimated to be living with HIV/AIDS as of End 2001
[From UNAIDS, Report on the Global HIV/AIDS Epidemic, XIV International Conference on AIDS, Barcelona, 7/102:http://www.unaids.org]
highest for any individual country after South Africa. The

epidemics in this region, which were initially localized and hence
reported low prevalence figures for the country suddenly flared
up and engulfed wide regions and large number of persons. This
phenomenon has been observed in Indonesia, India and China due
to high population density coupled with heterosexual mode of
transmission. The low socioeconomic status of the region is the
main impediment to prevention programmes. However Thailand
has demonstrated success in prevention programmes and is
combating the epidemic successfully, throwing a ray of hope for
the region.
Eastern Europe and Central Asia Eastern Europe is experiencing the
fastest growing epidemic in the world (Fig. 1.4). Within three to
four years, the number of HIV infected people rapidly rose from
less than 100,000 to over 1 million, a ten-fold increase. Unfortunately, fewer than 1,000 people (0.1 percent) are estimated to
be receiving antiretroviral therapy.
Latin America and the Caribbean An estimated 1.9 million adults
and children are living with HIV in this region (Fig. 1.4), and an
estimated 170,000 (8-9 percent) people were receiving antiretroviral
treatment. Brazil has a nationalized antiretroviral therapy campaign which provides drugs for all eligible HIV-infected individuals. By reducing HIV/AIDS related morbidity through treatment,
13
Brazils program is estimated to have avoided 234,000 hospitalizations in 1996 to 2000, thereby demonstrating a cost-effective
approach to care. In the Caribbean region, adult HIV prevalence
rates are the second highest in the world after sub-Saharan Africa,
e.g. Haiti 6 percent prevalence.
High Income Countries Western Europe, North America, and
Australia have benefited from broad access to treatment for the
nearly 1.5 million people living in these regions (Fig. 1.1). Approximately 33 percent people are receiving antiretroviral therapy. A
major concern is the high rate of sexually transmitted infections
among men who have sex with men (MSM), signaling a rise in
unsafe sex and highlighting the need for renewed prevention
efforts, especially among young people.
Problem In India
The nationwide surveillance being done since 1998 till date to find
out the HIV positive amongst various groups in the country, have
generated data for the high risk groups like STD patients, IVDUS,
MSM and low risk group as the ANC mothers. It is assumed that
when the prevalence crosses 1 percent amongst the ANC women
in a geographical area, then HIV is a problem for the community.
Based on this prevalence data, the country has been divided into
three regions as given in the map of India (Fig. 1.5).
High prevalence (>5 percent in STD, >1 percent ANC)The states
are Tamil Nadu, Maharastra, Karnataka, Manipur, Andhra Pradesh
and Nagaland. The range of HIV positivity amongst STD patients
is from 9.2-26.6 percent.
Moderate prevalence (>5 percent in STD patients and <1 percent in
ANCS) Gujarat and Goa fall in this category.
Low prevalence (<5 percent in STD patients and <1 percent in
ANCs) Rest of the states and UTs.
The overall prevalence for the country is 0.7 percent(UN AIDS)
These figures do no reflect the intense epidemic in some
regions/groups such as 55 percent HIV positive amongst CSWs
in Goa and Mumbai. 56 percent HIV positive in IVDUs at Manipur,
and more than 3 percent in pregnant women in Mumbai. The major
mode of transmission is heterosexual which leads to infection in
women and children.
14
Women and HIV
Fig. 1.5: Three regions in India
Evolution of HIV Epidemic in India

The first case of HIV positive was detected in 1986 amongst CSWs
in Chennnai and the first AIDS case was detected in 1987 in Mumbai
heralding the arrival of the infection in the country.The epidemic
has spread in three waves. The first is of the Core transmitters
consisting of groups with high risk behavior such as STD patients,
CSWs, MSM and IVDUs (in the northeast region). Then the infection
is carried to the general population through the Bridge
population like the clients of CSWs and IVDUs, etc. The third
wave is in the general population which involves the monogamous
housewife and the transmission to the children. The shift from the
first to the third wave usually occurs when the HIV prevalence
amongst the high risk group crosses 5 percent. The interval for the
shift is nearly 3-5 years. All the moderate and low prevalence state
should use this opportunity to implement the programs for
preventing further spread. The waves are depicted in Figure 1.6.
(First wave)
Core group
CSWs
STD patients
MSM
IVDUs
(Second wave)
Bridge population
CSW clients
Truck/ auto/ taxi drivers
Mobile males
Single male migrants
Fig. 1.6: Flow of epidemic
(Third wave)
General population
Housewives
(without risk behavior)
Children
Other population
15
The various groups and factors determining the spread are

given below.
STD Patients
The median prevalence of HIV infection amongst STD patients is
26.6 percent for AP, 17 percent for Mumbai, 15 percent for Goa
and 13 percent for Tamil Nadu3. It is 6.6 percent for Kerala, a state
also in south. Factors like number of sex partners, lack of condom
use and previous or present STD/s were found to be important
predictors of prevalent and incident HIV infection. Recent use of
condoms reduced the risk of acquiring HIV infection by almost
half. A high HIV prevalence of about 14 percent was found amongst
women attending STD clinic who denied history of sex work.
Bridge Population
A high HIV point prevalence of 20-30 percent was found amongst
truck drivers/helpers, in AP, Karnataka, Maharashtra3 provide
epidemiological support to the findings that the bridge population
plays the role of carrying over the infection to the low risk
group.
Blood Donors and Recipients
HIV prevalence among voluntary/replacement blood donors in
the cities of India during 2000-2001was 0.56 percent5. Mandatory
testing of blood and blood products for HIV antibodies was
initiated in July 1989. Under the Blood Safety Programme all blood
and blood products should be tested before administration.
Pregnant Women
The HIV seroprevalence among the pregnant women primarily
attending the public hospitals has been reported to be between
0.5-3.3 percent in various parts of the country3. The HIV sentinel
surveillance data amongst pregnant women shows that six states
in India; Maharashtra, Tamilnadu. Andhra Pradesh, Karnataka,
Manipur, and Nagaland have a HIV prevalence of more than
1 percent. Majority of them are industrialized or have lot of migrant
population or are on the drug route (like Manipur).
16
Women and HIV
Gender-related Issues
Presence of STDs/HIV infection in low risk women is indicative
of being married as a risk factor. High HIV prevalence and
incidence was noted amongst women attending STD clinics in Pune
who denied history of sex work. Apart from practices like male/
female age differences in sexual relationship and anatomical
peculiarities of genitalia of the females; the fact that a high
proportion of STDs tend to remain asymptomatic in women,
increases the risk of acquiring HIV infection.
Men Who have Sex with Men
In India, HIV transmission among men has been reported from
Mumbai and Chennai, and the HIV prevalence is 23.6 percent and
4 percent respectively. In most of the developing countries
including India, men who have sex with men are far more likely to
do so secretly, and they are less likely to have access to prevention
and information programmes.
Rural/urban differential It has been observed that rural STD
patients and ANCs are testing HIV positive, indicating spread in
the rural area.
Age The surveillance data 2001 indicate that more persons < 20
years getting affected compared to past data, both amongst ANC
and STDs. A wave amongst adolescents has to be avoided with
adequate awareness programmes.
Sex More men than women are affected early in the epidemic, e.g.
the male:female ratio for AIDS patients is 1:4 at present in India.
However as the epidemic progresses the ratio becomes equal,
which has occurred in Africa.
Vulnerability of women to HIV Women are biologically more susceptible to HIV infection than men. Male to female transmission of
HIV is 2-4 times more efficient than female. This is because women
have a larger mucosal surface exposed during sexual intercourse.
Another reason is that semen contains a much higher concentration of HIV than vaginal fluid. Women are also disproportionately
represented among those who receive blood or blood products as
a consequence of their childbearing role, which exposes them to
17
the risk of yet another mode of transmission. The fact that it is the
norm for young women to have sex with, or marry older men, also
increases the risk of infection. Poverty, lack of education and limited
income-earning opportunities often propel women to commercial
sex which significantly increases their risk of infection. Social norms
which accept extra-marital and pre-marital sexual relationships in
men as normal, and womens inability to negotiate safe
sex practices with their partners, are factors that make it difficult
for women to protect themselves from HIV infection. Unwillingness to use condoms further accentuates womens risk.
Infant feeding dilemmas Women breastfeeding infants is the norm
in India. When a woman does not breastfeed and accepts replacement feeding (to avoid transmission) her HIV positive identity may
be disclosed.
Mother to child transmission Since large number of ANCs are
infected and they can pass the infection to their children, mothers
can avail of the NACO programme to prevent MTCT by accepting
voluntary testing and taking a dose of 2 mg tab of Neverapine
during labour and a dose of 2 mg/kg bw to the infant within
72 hours. This programme has been implemented in all Govt.
hospitals of high prevalence states and medical colleges in low
prevalence states.
At present, epidemiologists cannot predict with certainty the
momentum of the epidemic, and when it will peak, although shortterm predictions can be made on the basis of information on risk
behavior and accessibility to health services. There is strong
evidence indicating that the rate of new infections will ultimately
reduce if effective preventive programmes are carried out,
encouraging abstinence, fidelity, safer sex and empowerment of
women.
BIBLIOGRAPHY
1. Bhattacharya M. Annual Sentinel Surveillance for HIV Infection in India, Country
Report, NIHFW 2001.
2. Levy Jay A., HIV and the Pathogenesis of AIDS. ASM Press, Washington D.C.
1998.
3. Nelson Kenrad E., Williams Carolyn Masters, Graham Neil M.H. Infectious
Disease: Epidemiology, Theory and Practice, Published by Aspen Publishers, Inc.,
Maryland 2001.
18
Women and HIV
4. NACO, Combating HIV/AIDS in India 2000-2001. Ministry of Health and Family

Welfare, Government of India.
5. UNAIDS, Report on the Global HIV/AIDS Epidemic, XIV International
Conference on AIDS, Barcelona, 7/02, http://www.unaids.org.
two
HIV: The Virus

Usha K Baveja
HISTORY AND ORIGIN

Acquired Immunodeficiency Syndrome (AIDS) was first reported
in 1981 in San Francisco and New York in USA. on account of
clustering of diseases like Pneumocystis carinii (P. carinii)
pneumonia and Kaposis sarcoma, respectively amongst young,
otherwise healthy adult homosexuals1. Soon AIDS was reported
in other population groups, i.e. intravenous drug users (IVDU),
haemophiliacs and children born to mothers suffering from AIDS
or who were IVDU2-3. Mode of transmission of causative agent of
the AIDS pointed to an infectious aetiology. High on the list of
suspicion were viruses, e.g cytomegalovirus and EB virus already
known to cause infections in immunocompromised hosts. Since,
the hallmark of AIDS was depletion of T helper lymphocytes, it
was postulated that causative agent of AIDS may be HTLV, a
member of Retrovirus and the only virus known to infect human
T lymphocytes. The only controversy was that AIDS agent caused
lysis of infected T cells in vivo and was difficult to replicate
in vitro whereas, HTLV caused leukaemia, i.e. immortalized the
infected T cells and replicated well in vitro. The search for the
identification and nomenclature of the agent went on till in 1986
the International Committee on Taxonomy of Viruses recommended the name Human Immunodeficiency Virus (HIV) to LAV
agent identified and named such by Montagnier and coworkers
(1983)4 and HTLV III isolated and identified by Gallo and associates
(1984) 5 and named as such. Both groups of workers had isolated
the agent from patients suffering from AIDS. So, it was in 1983-84
that the causative virus was isolated from patients of AIDS and
was named HIV in 19866.
20
Women and HIV
June 5, 1981
: CDC sites 5 cases of homosexual men with

P.carinii pneumonia in Los Angeles, USA
July 27, 1982
: CDC names the new disease AIDS-Acquired
Immune Deficiency Syndrome
April, 1984
: Viral aetiology of AIDS identified by two
groups of scientists. Montagnier and Associates in France named it LAV and Gallo and
coworkers in USA. named it HTLV III
March, 1985
: Test kits developed to detect antibodies to
HIV
1986
: International Committee on Taxonomy of
Viruses named the virus as Human Immunodeficiency Virus (HIV)
1987
: Zidovudine marketed under the brand name
of Retrovir.
HIV-1 (1999)
: Probable origin from a progenitor virus isolated from chimpanzees in Africa postulated
1986 HIV-2
: Probable origin: monkeys in West Africa.
HIV-1 (O group) : Probable origin from chimpanzees.
1998 HIV-1 (N group)
Whenever a new infectious disease like AIDS appears the
causative agent though appearing to be new must have already
existed. Then why the epidemic now? May be the agent represents
the mutant more virulent variant or recombinant of the already
existing organism which previously infected the same population
producing a disease with a different profile or pathology or the
organism was circulating in an isolated population of people who
had developed resistance or the organism has been introduced to
humans from another species. The third explanation seems the most
probable for HIV. May be HIV or a virus similar to it existed in
subhuman primates and over the years was introduced in humans
where it produced AIDS. In Africa, many primate species are
hunted and butchered for food and kept as pets. In fact there is
genetic closeness of HIV strains isolated from humans in Africa
with those isolated from chimpanzees. Chimpanzees are also
resistant to infection with HIV-1. A virus that could be a progenitor
of HIV-1 has also been isolated from chimpanzees in Central Africa.
The findings available so far on the origin of HIV-1 are compatible
with a subhuman primate origin for HIV-1 7-9. HIV-2 is genetically
and biologically different from HIV-1 but is closer to simian
HIV: The Virus 21

immunodeficiency viruses (SIVs). HIV-2 was identified in West
Africa in 1986. Viruses similar to HIV-2 have been isolated from
Macaques and Mangabeys monkeys in Africa. So, HIV-2 may have
originated from Mangabey and then spread to other monkeys in
Asia, Africa and humans (Table 2.1).
CLASSIFICATION
HIV belongs to the class Retroviruses and family lentivirinae. Two
types are recognised HIV-1 and HIV-2. Both differ in geographical
distribution, biological and molecular characteristics and extent
of transmissibility though, both produce AIDS. These viruses store
their genetic information as ribonucleic acid (RNA) unlike most
viruses. RNA must be converted to deoxy-ribonucleic acid
(DNA) by a special enzyme reverse transcriptase. HIV-1 has 3
groups HIV-1 major main group, outlier (HIV-1 O) and new group
(HIV-1 N). The strains of HIV-1 isolated from people in U.S.A.
and Europe are genetically diverse from strains isolated in Africa
and Asia. HIV-1 major group can be further classified into subtypes
or clades designated A through K. Such subtypes have envelope
gene sequences that vary by 20 percent or more between subtypes.
Distribution of common subtypes is shown in Table 2.2. The subtypes differ in geographical distribution, biological characteristics,
major mode of transmission, etc. HIV-1 subtype O is more distant
to all other HIV-1 subtypes but less so compared to HIV-2. So it is
classified under HIV-1 only and has limited distribution in West
Africa (Cameroon). HIV-2 has also been reported from other
countries and this also comprises of heterogeneous group of
viruses10. Six subtypes of HIV-2 (A-F) have been reported11.
Table 2.1: Probable origin of HIV
SIV Mangabey Natural host African
monkey. No disease, high transmission
HIV -1 Progenitor
Asian monkey
Some diseases ?
HIV HIV
1-A 1-B
HIV
1-C
HIV
1-D
HIV
1-E
HIV
1-F
HIV HIV
1-0 1-N
SIV Chimpanzee
Natural host African ape
Human
Some disease
Some transmission (HIV-2)
22
Women and HIV

Table 2.2: HIV-1: Major subtypes
Major epidemic pattern
Geographic region
HIV-1 subtype
A
Heterosexual hosts
Sub-Saharan Africa
South East Asia
India
+
+
+
Intravenous drug users

and homosexual hosts
North America
Western Europe
South East Asia
India
+
+
+
+
The genetic studies of the subgroups of HIV-1 suggest separate

introduction of these groups from animal host into the human
population12.
STRUCTURE AND GENETIC MAP WITH FUNCTIONS
HIV comprises of an outer envelope consisting of a lipid bilayer
with uniformly arranged 72 spikes or knobs of gp 120 and gp 41(TM).
Glycoprotein 120 protrudes out on the surface of the virus and gp
41 is embedded in the lipid matrix. Interior to lipid bilayer are the
matrix (MA); internal capsular (CA) and nuclear capsid (NC)
proteins. Core contains two copies of single stranded RNA and
viral enzymes reverse transcriptase, integrase and protease, all
essential for viral replication and maturation. Proteins p7 and p9
are bound to the RNA and are believed to be involved in regulation
of gene expression (Fig. 2.1).
The genetic structure of virus contains both highly conserved
and highly variable regions. The high variability of the virus
accounts for drug resistance and evasion from immune response.
This also poses problems for development of a successful vaccine.
In infected individual quasispecies of a particular viral subtype
may be found on account of constant variability.
HIV has structural and regulatory genes coding for structural
and regulatory products, respectively. Structural genes direct the
synthesis of physical components of the virus and are also
responsible for viral size, shape, structural integrity and its
compartmentalization in host cell. The regulatory genes direct
synthesis of proteins that effect the synthesis of viral components
HIV: The Virus 23
Fig. 2.1: Structure of HIV
and viral replication (Fig. 2.2). pol, env and gag are the structural
genes and others shown in Figure 2.1 are the regulatory genes.
Replication Cycle
Glycoprotein 120 of the infectious virus particle (HIV) binds to a
receptor/receptors on HIV permissive host cell. Predominant
receptor is CD4 though others such as galactosyl ceramide (gal C)
have also been proposed. Entry of virus into the host cell requires
certain cellular coreceptors/factors expressed on cell surface, e.g.
CCR-5, CXCR-4, CCR-2 and CCR3, etc. designated collectively as
cell infectivity factor (CIF). CIF may be a coreceptor or enzyme
helping in virus interaction with host cell. Most convincing
candidate is the chemokine receptor related protein, Fusin
(CXCR- 4). Once the gp41 of the virus undergoes conformational
24
Women and HIV
Fig. 2.2: 9.8 KB HIV-1 genome map
change and fuses with the host cell membrane the capsid is
uncoated and a ribonucleoprotein complex capable of reverse
transcription is formed. During the process of reverse transcription
cDNA is formed under the effect of viral enzyme, the reverse
transcriptase. Reverse transcription is inefficient in quiescent cells
suggesting the involvement of host components in the process. The
nucleoprotein complex formed after transcription comprises of
linear double stranded DNA, the gag matrix (MA) protein, the
accessory vpr protein and the viral integrase (IN) and is called
preintegration complex and is transported into the host cell nucleus.
IN mediates a complex series of enzymatic steps and integration
HIV: The Virus 25

occurs at nuclear loci with open chromatin structure. Integration
probably is an essential step for viral replication. The integrated
virus is called provirus. The virus may not be expressed in many
cells and is considered latent. Virus expression can be stimulated
by many viral, cellular and exogenous factors. Other, co-existent
viral infections, e.g. CMV, herpes virus infection can make the nonpermissive cells permissive. Following integration several viral
factors and host transcriptional factors stimulate the viral
replication. Regulatory proteins such as Tat, Rev and Nef are
produced early in the replication cycle and Tat stimulates the virus
to replicate. From Rev dependent m-RNA unspliced or singly
spliced RNA products are formed and escorted into the cell
cytoplasm. In the cell cytoplasm these RNA are translated into
structural proteins (Gag Pol and Env) and late regulatory proteins
(V.F), which further stimulates the production of structural
proteins. Once the proteins and genomic RNA have been produced,
these aggregate near the cell surface, assemble and an immature
virion buds on the cell membrane. This virion matures under the
effect of the enzyme protease, and so the cycle goes on.
HIV REPLICATION STEPS
gp 120 blinds to host cell receptors
Uncoating
Reverse transcription
Proviral DNA synthesis
Integration with host cell DNA
Viral proteins synthesis (transcription and translation)
Virus assembly and budding.
(Maturation of core-proteins (under effect of viral enzyme protease)
HETEROGENEITY/GENETIC DIVERSITY
Studies conducted on different isolates of HIV revealed that the
HIV was highly heterogeneous in a variety of biological, serological
and molecular features. These include:
Geographical distribution
Transmissibility and routes of transmission
Level of virus production
26
Women and HIV
Replication kinetics in vivo and in vitro

Cellular tropism (types of cells infected, e.g. T helper cells and
dendritic cells)
Cytopathicity
Syncytium forming ability
Latency and inducibility
Sensitivity to neutralizing/enhancing antibodies
Genetic structure.
There are two main types, HIV-1 and HIV-2. HIV-2 which was
isolated in Protugal from patients with AIDS who had come from
West Africa showed sequence difference of more than 55 percent
from earlier isolated strains of HIV, so was designated a different
type status. HIV-2 sequences are closer to SIV than HIV-1. HIV-1
and to a lesser extent HIV-2 are undergoing mutation during each
replicative cycle (one nucleiotide per genome per replicative cycle).
Accumulated env gene variation is approximately 1 percent per
year. Quasi species are being thrown constantly into circulation of
the infected individual. HIV-1 strains from different geographical
areas are different genetically (>20 percent sequence differences).
Three major groups namely major (M), outlier (O) and new group
(N) have been identified for HIV-1 type. Major group has been
classified into different subtypes/grades A through K on the basis
of geographical, molecular and biological differences as above.
Each subtype again comprises of genetically herterogeneous strains
on account of high rate of variability of the virus even in the same
host. Heterogeneity of virus has implications for development of a
successful vaccine, a therapeutic agent and in diagnosis 11. HIV-2
has six subtypes A through F 11.
Human Cells and Tissues Susceptible to HIV as
Shown by in vitro and in vivo Study11
Haematopoietic system T lymphocytes, B lymphocytes, macrophages, NK cells, mega- karyocytes, dendritic cells, promyelocytes,
stem cells, thymic epithelium, follicular dendritic cells.
Brain Capillary endothelial cells, astrocytes, macrophages
(microglia), oligodendrocytes, choroid plexus, ganglia, neuroblastoma cells, glioma cell lines and neurons (?).
Skin Fibroblasts and Langerhans cells.
HIV: The Virus 27

Bowel Columnar and goblet cells, enterochromaffin cells and
colon carcinoma cells.
Others Myocardium, renal tubular cells, synovial membrane,
hepatic sinusoid epithelium, hepatic carcinoma cells, Kupffer cells,
pulmonary fibroblasts, fetal adrenal cells, adrenal carcinoma cells,
retina, cervix epithelium (?), prostate, testes, osteosarcoma cells,
rhabdomyosarcoma cells, fetal chorionic villi, placental trophoblast
cells.
HIV practically multiplies in all cells but the extent of replication
varies in different cells.
How the Virus Kills the Cells
HIV infected cell may undergo lysis due to virus replication and
budding. If the infected cell does not undergo lysis, other normal
or infected cells can stick to it due to the presence of envelope
proteins. These cells may fuse and form giant cells. The fused cell
may or may not function normally. If the viral genome is not
transcribed in the infected cell it will led to latent infection but, all
cell progeny will carry proviral DNA. Apoptosis is another
mechanism by which infected CD4 cells are killed. Autoimmunity
also plays a role in bringing down the CD4 cell counts.
Viral Dynamics and its Implications
With the availability of techniques which can accurately measure
the HIV-1 RNA in plasma from infected persons it has been possible
to study the dynamics of HIV-1 following entry in the human host.
The studies have shown that continuous, rapid, high-level virus
production and CD4+ lymphocyte destruction occurred at all stages
of infection. The half-life of the plasma virus population was
2 days. The plasma HIV-1 levels fell exponentially by 99 percent
within 1-2 weeks after administering potent antiretroviral agents
indicating that vast majority of plasma HIV-1 originates from
continual de novo infection and replication of virus in CD4+ cells.
The rate of CD4+ cell destruction was 2X109 cells/day in these
studies. Another study reported that average total HIV-1
production was 10.3X109 virions per day. The average life span of
virions was 0.3 days (half life = ~ 6 hrs) and half life span of
productively infected cells was 2.2 days (half-life = ~ 1.6 days).
28
Women and HIV
The average HIV-1 generation time (from release of virion until it

infects another cell and causes the release of a new generation of
viral particles) was 2.6 days suggesting that approximately 140
viral replication cycles occur each year13-14.
Although there is a period of clinical latency in almost all
HIV-1 infected individuals, there is no clean period of virological
or immunological latency. The continuous high production rate of
HIV-1 has profound implications for drug therapy, drug resistance
and development of a successful vaccine. Each day approximately
109-1010 new HIV-1 infection cycles occur in the infected individual.
The mutation rate of retroviruses is approximately 3X10-5/bp/cycle
and the genome of HIV-1 is 104 base pairs, that means that every
possible mutation in HIV-1 is made 104-105 times per day. As a
result drug resistant mutants that encode single or double
mutations are likely to exist before therapy is started. With
institution of single drug therapy these resistant variants quickly
break through and dominate the replicative virus production
leading to viral rebound and drug failure. Resistance to
combination of drugs can also develop through accumulation of
multiple resistance mutations. As a result multidrug resistant
HIV-1 clinical isolates are being reported 13-15.
SUSCEPTIBILITY OF HIV
Fortunately HIV is a very fragile virus. It is susceptible to heat a
temperature of 56C for 30 minutes or boiling for a few seconds
kills the virus. Most of the chemical germicides used in hospital/
laboratories and health care settings kill HIV at much lower
concentrations. Thus 0.2 percent sodium hypochlorite, 70 percent
eltanol, 2 percent glutaraldehyde, acetone, ether, beta propiolactone
(1:400 dilution) and sodium hydroxide (40 m mol/litre) inactivate
the virus.
STERILIZATION
Autoclaving at 121C, 15 lbs pressure for 20 minutes
Dry heat 170C for 2 hours
Boiling for 20-30 minutes.
Chemical Disinfectants which Inactivate the Virus Include
Sodium hypochlorite: 1 gm/litre
HIV: The Virus 29

Calcium hypochlorite: 1.4 gm/litre
Chloramine: 20 gm/litre
(Available chlorine 0.1 percent)
Ethanol: 70 percent
Formalin: 3-4 percent
Glutaraldehyde: 2 percent for 30 minutes
Polyvidone iodine (PVI).
TRANSMISSION
Risk factors for HIV infection include multiple homosexual or
heterosexual partners; failure to use condoms, existing sexually
transmitted disease, cervical ectopy in young women, blood
transfusion; injections with unsterile needles, syringes; infected
mother to fetus/infant before, during or shortly after birth and
breastfeeding. The mode of transmission of HIV is determined by
the amount of infectious virus in a body fluid and the extent of
contact. High concentrations of free infectious virus and virusinfected cells have been reported in blood, genital fluids and
cerebrospinal fluid. Breast milk and saliva yield varying numbers,
whereas, other body fluids have a low viral content. High levels
of virus are always associated with symptoms and advanced
disease12-16.
Saliva in adults contains some non-specific inhibitory
substances like fibronectins and glycoproteins, which could prevent
cell-to-cell transfer of virus. Thus, saliva is not a likely vehicle of
transmission. Urine, sweat, milk, broncho-alveolar lavage fluid,
amniotic fluid, synovial fluid, faeces and tears have been reported
to yield zero or a few HIV virus particles. Hence, these vehicles
also do not appear to be important in virus transmission.
Breast milk at the time of primary infection in a feeding mother
has a high content of virus and may transmit the infection to the
baby. Cerebrospinal fluid (CSF), on the other hand, also has a high
content of virus particularly in individuals with neurological
disease, but, CSF is not a natural source of virus transmission.
The most efficient vehicle of HIV transmission is blood
(Table 2.3). However, the risk of infection via blood transfusion is
now extremely low due to strict HIV screening of donated blood.
The most common route of transmission is unprotected, penetrative
sexual contact. Different forms of sexual practices carry a variable
30
Women and HIV

Table: 2.3: Efficacy of different routes of HIV transmission and
their contribution to total number of cases
S.
no.
1.
2.
3.
4.
5.
6.
Exposure route
Blood transfusion
Perinatal
Sexual intercourse
Vaginal (male to female)
Anal (male to male)
Injecting drugs use
Needle stick exposure
Others
Efficiency
90-95%
20-40%
0.1-1.0% (average)
01-0.2%
0.3-10%
0.5-1.0%
0.5%
% of total
(World over)
5
10
75
60
15
10
0.1
India
5.5
0.7
81
5.2
7.6
(Indian figures from combating HIV/AIDS in India 1999-2000, NACO)
risk gradient of acquiring HIV. Cell associated rather than free virus
is responsible for disease transmission. Anal intercourse carries a
high risk of transmission because of HIV in bowel mucosa, which
act as a portal of entry for virus, and also because of a greater chance
of injury to the mucosa. Risk to insertive partner is through infection
of lymphocytes and macrophages in the foreskin or along the
urethral canal. In females HIV transmission occurs when infected
cells in the semen gain entry into the uterus through the cervical
os, and infect the resident lymphocytes, macrophages and probably
the uterine epithelial cells.
The transmission from infected mother to child appears to occur
in 11-60 percent children born to HIV positive mothers. The source
of virus in the newborn is controversial. HIV infection can occur
via amniotic fluid, genital secretions, maternal blood and rarely
through the breast milk. Transmission to the baby can occur
in utero, and during or after delivery.
Transmission of HIV infection to Health Care Workers (HCW)
is extremely uncommon. Pooled data from 20 prospective studies
suggests that risk associated with needle injury from HIV infected
blood is approximately 0.2 percent. Further, the risk associated with
mucocutaneous contact is too low to be reliably estimated. The
risk from mucosal or non-intact skin is also minimal.
So far, there has been no report of HIV transmission through a
casual contact, by the enteric or respiratory route, and through an
insect, e.g. mosquito bites. Prospective studies offer a conclusive
evidence that family members and close household contacts of HIV
HIV: The Virus 31

infected individuals are not at risk of acquiring HIV infection
through casual human contact (shaking hands, kissing and by
sharing of utensils, toilet, linen, bed, etc.) or by providing routine
nursing care.
REFERENCES
1. Gottlieb, M.S., Schroff, R. Schanker, H.M. et al. Pneumocystis carinii pneumonia
and mucosal candidiasis in previously healthy homosexual men: evidence
of a new acquired cellular immunodeficiency. N. Eng. J. Med. 305: 1425-1430,
1981.
2. Curran, J.W., Lawrence, DN., Jaffe, H. et al. Acquired immunodeficiency
syndrome (AIDS) associated with transfusions. N. Eng. J. Med. 10: 69, 1984.
3. O Leske, J., Minnefor, A., Cooper R. Jr. et al. Immune deficiency syndrome in
children J.A.M.A. 249: 2350, 1983.
4. Montagnier, L., Chermann, J.C., Barre-Sinoussi, F. et al. A new human
T lymphocyte retrovirus: Characterisation and possible role in lymphadenopathy and acquired immune deficiency syndrome. In: Human T cell Leukaemia/
Lymphoma virus. Ed. R.C. Gallo. M.E. Essex and L.Gross. Cold Spring Harbour
Laboratory Cold Spring Harbour. N.Y 363-379, 1984.
5. Gallo, R.C., Salahuddin, S.Z, Popovic, M. et al. Frequent identification and
isolation of cytopathic retroviruses (HTLV III) from patients with AIDS and at
risk for AIDS. Science 224: 500-503, 1984.
6. Coffin, J., Haase, A., Levy J.A. et al. Human Immunodeficiency viruses. Science
232: 697 (Letter), 1986.
7. Mann J.M., Billa, K., Colebunders, R.L. et al. Natural history of human
immunodeficiency virus in Zaire. Lancet 2: 707, 1986.
8. Huet, T., Cheynier R., Meyerhaus, A et al. Genetic organisation of a chimpanzee
lentivirus related to HIV-1. Nature; 345-356, 1990.
9. De-Leys R., Vanderborght, B Haesevelde, M.V. et al. Isolation and partial
characterisation of an unusual human immunodeficiency retrovirus from two
persons of West-Central African origin. J. Virol. 64: 1207, 1990.
10. Korber, bette T.M., Allen E., Ethan, Farmer, A.D. Heterogeneity of HIV-1 and
HIV-2. AIDS (supplement) 9: 55-518, 1995.
11. Hahn BH, Shaw GM, DeCock KM et al. AIDS as a Zoonosis: Scientific and public
health implications. Science 287: 607-614, 2000.
12. Levy, J.A. Pathogenesis of human immunodeficiency virus infection.
Microbiological Reviews 57: 183-289, 1993.
13. Ho, D.D., Neumann, A.U., Perelson, A.S. et al. Rapid turnover of plasma virions
and CD4 lymphocytes in HIV-1 infection. Nature 373: 123-126, 1995.
14. Pereleson, A.S., Neumann, A.U. Markowitz, M. et al. HIV-1 dynamics in-vivo:
virion clearance rate, infected cell life span and viral generation time. Science
271: 1582-1586, 1996.
15. Ratner, Lee. Genetic Organisation of HIV. In Immunology of HIV infection.
Ed. Sudhir Gupta, Plenum Medical Book Company. N.Y. and London. 3-22,
1996.
32
Women and HIV
16. Bowler S, Sheon Ar, D Angelo, L.J and Vermund SH: HIV and AIDS among
adolescents in the United States: increasing risk in the 1990s. J. Adolesc. 15: 345371, 1992.
17. Royce RA, Sena A, Cates W Junior and Cohen MS. Sexual transmission of
HIV. N Eng J Med. 336: 1072-1078, 1997.
Syndromic Management of RTI and STI in Females
33
three
Syndromic Management of
Reproductive Tract
Infections and Sexually
Transmitted Infections
in Females
Sudha Salhan
LEARNING OBJECTIVES
1. To emphasize the importance of RTI/STI in the spread of HIV/AIDS.
2. Know the methods of primary secondary and tertiary prevention of RTI/STI.
3. Understand the effectiveness of Syndrome Management in the Prevention
of HIV/AIDS Epedemic
To implement the recommendations of International Conference

on Population Development in Cairo in 1994 the Reproductive and
Child Health (RCH) Programmewas officially launched in our
country on October 15, 1997. As we all know that one of the
objectives of RCH is prevention and providing treatment for
Reproductive Tract Infection including sexually transmitted
infection and HIV/AIDS.
Table: 3.1: Shows that India has more than 1% prevalence of HIV/AIDS
(Estimated HIV prevalence in adults, 1998)
> 1%
0.1 - 1%
<0.1%
Thailand
Myanmar
India
Nepal
Vietnam
Sri Lanka
Indonesia
Bangladesh
Bhutan
Maldives
34
Women and HIV
Fig. 3.1: Effect on HIV epidemic of curing/preventing

100 STD cases in core and non-core groups
Table 3.2: Gives the routes of HIV transmission in
South-East Asia gives maximum transmission to population by
sexual route (HIV Transmissionin South-East Asia)
Route of transmission
Percentage of total
Sexual intercourse
Blood transfusion
Injecting drug use
Equipment/needles
Perinatal
85-90
3-5
3-5
<0.1
2-5
We have to realise that our country has substantial number of

AIDS cases. Epidemic of HIV/AIDS has brought the RTI/STI,
specially those which cause discharge, e.g., gonorrhoea, chlamydia
and trichomonas etc, and those causing ulcer, e.g., syphilis and
chanchroid etc., increase the risk of HIV infection upto 10 times,
while, if these RTI/STI are treated they are cured in over 95% of
cases as is shown by Table 3.3.
Table 3.3: Increased risk of HIV infection associated
with common STDs and their curability
STD
Gonorrhea
Chlamydia
Chancroid
Trichomoniasis
Increased Risk of HIV
Curability
++
++
+++
+
Over 95%
Over 95%
Over 95%
Over 95%
Relationship of RTI/STI and HIV/AIDS

1. Same risk behaviour. Hence same measures to prevent both.
35
2. Presence of RTI/STI facilitate acquisition and transmission of

HIV/AIDS 10 fold increased risk more irrulent in presence.
3. Treatment and cure of RTI/STI is possible but if they acquire
HIV/AIDS it means sure death.
So our goal is clear, now we must treat RTI/STI earliest
completely and vigorously to prevent development of HIV/AIDS
(which has no treatment, yet) and other complications (Pelvic
inflammatory disease, infertility, cancer of cervix etc.,). The
question of how to go about it in females is not easy to answer. Pot
Fransen model of STD management shows that of the 40 percent
of women having RTI/STI only halt of them are a symptomatic.
Of these only 3.5 percent seek treatment. Thirty percent go to health
units and a mere 6 percent are treated correctly. On the part of the
lady only 4 percent are complying with instructions andC
treatment. Treatment is effective in 3 percent of cases and partner
treated in 1 percent, only. Partner is very important in the effective
treatment of RTI/STI.
All women
with STD/RTI (40%)
100%
50%
Symptomatic
Seek treatment
35%
Go to health unit
30%
Treat correctly
Compliant
Treatment effective
Partner treated
6%
4%
3%
1%
Fig. 3.2: Piot-Fransen model of STD management:

Potential effect syndrome STD treatment
Women report late because as we have seen half of them do

not have any symptoms. Rest are not treated adequately or
incorrectly and hence continue to suffer and also transmit the
illness. They do not get time from their very busy household work
to go for consultation for their symptoms. They also do not know
36
Women and HIV
the consequences of not being treated hence the importance of

showing and getting treated is not known. There is also stigma
attached to the visit of a lady to an STD clinic. All these factors
prevent women getting completely treated.
WOMEN REPORT LATE BECAUSE
50 percent are asymnptomolic

Inadequately or improperly treated by quacks
Lack of time
Lack of awareness of consequences
Fear of stigmatism.
Sequelae and Complications and RTI/STI are

1. As we have leamt, previous RTI/STI increases ten times the risk
of acquiring HTV/AIDS.Hence development of HIV/AIDS can
occur
2. As RTI/STI affect Fallopian tube lining, infertility is a dreaded
complication.
3. Foetal wastage can occur
4. Ectopic pregnancy can occur because of involvement of
Fallopian tubes.
5. Because of repeated RTI/STI (including human papilloma virus)
cancer of cervix can occur.
Death due to any one or all of them may occur

Considering the delay in reporting of female patients of RTI/STI
control programme is early detection and prompt and complete
treatment of the disease at the point of the patients first contact
with the health system.
Women, often seek medical help only when an
illness is well advanced and they must be treated
at once when they must be treated at once
when they contact you
Comprehensive RTI/STI and HIV/AIDS Control Programme
Requires Three Levels of Action
1. Primary prevention of RTI/STI/HIV/AIDS.
37
2. Secondary prevention (Identification and prompt and complete

treatment)
3. Tertiary prevention and minimizing the impact of complication
of infection.
Primary Prevention Emphasizes

Prevention of RTI/STI so that no HIV/AIDS develops. The focus
is on the prevention of causes of RTI/STI. There are three causes
of RTI/STI
1. Endogenous
2. Latrogemic
3. Sexual transmission
Endogenous
Causes can be prevented by improving knowledge of reproductive
physiology as mentioned and personal hygiene in adolescents. In
teenage girls promoting appropriate help-seeking behaviour, if
there is excessive discharge per vaginum or pruritis vulvae, she
should seek medical examination and advise.
Reducing the use of harmful infravaginal substances (i.e.,
douches and dessicants).
Iatrogenic
We must reduce the inappropriate use of systemic antibiotics so
that organisms causing RTI/STI do not become resistant to these
drugs. It is very important that we must provide methods of safe
delivery and abortion services. This will reduce the incidence of
RTI/STI in females to a great extent hence preventing HIV/AIDS.
We must improve infection control in hospital and use safe
practices
Our service delivery must be very good (quality care)
Providing antibiotics judiciously.
Sexual transmission
It is known that immature vaginal epithelium and cervical lining
of teenage girls increase the chances of acquiring RTI/STI and
hence HIV/AIDS very easily. They must be told about safe sexual
practices, delay in sexual initiation, and use of condom, if they
must. By providing more education and making them economically
38
Women and HIV
independent the marriage is delayed and mature vaginal and

cervical linning is resistance to acquiring infection. Reducing
number of sexual partners or rate of partner change is very
important point in prevention. Promoting condom use is essential.
Strategies for Primary Prevention
Type of Prevention Strategy:
Infection sexually
Delaying sexual initiation (coital delay). And, also
Reducing number of sexual partners or rate of partner change
Changing they dynamics of partner selection
Reduding nonconsensual sexual exposure
Encouraging safer sexual practices
Promoting condom use
Providing voluntary counseling and testing
Promoting use of other barrier methods
Encouraging penile hygiene.
Endogenous
Improving knowledge of reproductive physiology and
menstrual and personal hygiene
Promoting appropriate help-seeking behaviour
Reducing the use of harmful intravaginal substances (i.e.
douches and desiccants).
Iatrogenic
Reducing the inappropriate use of systemic antibiotics
Improving access to safe delivery and abortion services
Improving infection control competence
Enhancing the management of service delivery (quality of care)
Providing antibiotic prophylactically.
The main concepts of tertiary prevention are:

Septic abortion must be properly managed so that there is no
residual infection. This is possible only if they report early for
treatment
39
Ectopic pregnancy must be promptly diagnosed and treated

otherwise the patient can die
Infertility causes lot of mental and physical complications. Hence
it must be managed efficiently
Cervical cancer screening causes early detection and prompt
treatment.
Secondary prevention
It includes identification, prompt and complete treatment of RTI/
STI, HIV/AIDS. It can be done by two traditional approaches.
TWO TRADITIONAL APPROACHES TO STD DIAGNOSIS
ETIOLOGICAL DIAGNOSIS
Uses test to identify the causative agent and then treat it.
CLINICAL DIAGNOSIS
Uses clinical experience of the doctor to diagnose RTI/STI by
symptoms typical for a specific RTI/STI eg. candidiasis. But there
are problems with both methods.
PROBLEMS WITH ETIOLOGICAL DIAGNOSIS

Skilled personnel and sophisticated equipment are needed to
identify the causative agent of an STD
Laboratory tests for diagnosis are expansive and timeconsuming
Treatment does not begin until the results are obtained
Testing facilities are not available at the PHC level where many
people with an STD seek care
Laboratory tests for diagnosis are expensive and time consuming
and they are not available universally
As we know ladies report late for treatment and do not have
time to come again for report collection.
PROBLEMS WITH CLINICAL DIAGNOSIS

Clinical diagnosis is only accurate for 50% of STD cases
40
Women and HIV
Mixed infection are usually not considered

Mis-treated or under treated infections can lead to complications
and continued transmission of infection
Therefore treatment does not begin until the results are obtained.
We know that testing facilities are not available at all places
e.g., test for chlamydia is not available at all big hospitals and
medical colleges. What to speak of primary health care level
where many people with RTI/STI seek care.
PROBLEMS
With clinical diagnosis are it is only accurate in 50% of cases of
RTI/STI. Only one aetiology is considered which mostly is mixed
infection.
Mistreated under treatment of infection lead to complications
and continued transmission.
In the light of these difficulties in both aetiological and clinical
approaches, the World Health Organization (WHO) is promoting
the management of RTI/STI on the basis of a set of symptoms and
signs also called syndromes. It provide the most effective therapy
at patients first contact with a health and medical facility. This
approach is popularly known as syndromic management. A
syndrome is identified by a group of symptoms and early
recognised signs associated with a number of well defined
aetiologies.
The main features of syndromic approach are that we group
main infections agents according to the clinical symptoms they
cause. We use flow charts as tools. Hence we treat patient tor all
important causes of a syndrome. Syndromic management also
educates the patients and promoting condom. Most important part
is emphasizing the importance of partner referral and treatment.
THE MAIN FEATURE OF THE SYNDROMIC APPROACH
Grouping the main infectious agents according to the clinical
syndromes they cause
41
Using flow-charts as tools

Treating patients for all the important causes of a syndrome
Educating patients, promoting condoms and emphasizing the
importance of partner referral
Complete RTI/STI management is offered at first visit
The treatment is more widely and rapidly accessible
Patients are treated for possible mixed infection by assessing all
the important causes of a syndrome
Prevention and compliance are addressed through education,
partner referral and condom provision/promotion.
In brief syndromic management of RTI/STI
All patients should be treated
Instruction for medication and follow-up are given
Education and counseling is done
Condom use is promoted.
EDUCATION AND COUNSELLING IS TO INCLUDE
Cure your infection

Do not spread STI
Help your sexual partner/partners to get treatment
Come back to make sure that you are cured
Stay cured with condom use
Keep safety by staying with just one sexual partner
Protect yourself against AIDS as it is not curable
If you are pregnant attend antenatal clinics, so that your delivery
may be safe.
A study conducted in Miranza district of Tanzania established

conclusively the potential role of Syndromic management as an
important advance in RTI/STI control and preventing sexual
transmission of HIV/AIDS. Strengthening the syndromic
management of RTI/STI caused a decline in the prevalence and
incidence of STI a 42 percent reduction of HIV incidence in over a
period of 2 years. This study further recommended the Syndromic
management of RTI/STI as a cost effective tool to back the RTI/
STI/HTV/AIDS problem in resource poor setting including our
42
Women and HIV
country India. Let us see the common RTI/STI causing organisms

in our country.
COMMON STDs IN INDIA
Gonorrhoea
Syphilis
Trychomoniasis
Candidiasis
Herpes progenitalist
Pediculosis pubis
Chlamydia
Chancroid
Bacterial vaginiosis
Granuloma inguinale (Donovanosis)
Genital warts
Molluscum contagiosum
WHAT ARE THE MOST COMMON STD

ASSOCIATED SYNDROMES?
STD syndrome
Possible causes
Neisseria gonorrhoea, Chlamydia

trachomatis
Genital ulcer discharge Treponema pallidum, Haemophilus
ducreyi, C trachomatis,
Calymatobacterium
granulomatis, Herpes simplex virus
Vaginal discharge
N. gonorrhoea, C trachomatis,
Trichomonas vaginalis, Candida
albicans, Gardnerella vaginalis
Lower abdominal plain
N. gonorrhoea, C trachomatis and
anaerobic abacteria
Ophthalmia neonatorum N. gonorrhoea, and C trachomatis
Inguinal bubo (Acute
H. ducreyi and C trachomatis
inguinal lymphadenitis)
Swollen scrotum
N. gonorrhoea, and C trachomatis
(Scrotal swelling)
Viruses and surgical conditions
Urethral discharge
Let us discuss the causes of vaginal discharge.

TRICHOMONIASIS
Trichomoniasis is caused by Trichomonas vaginalis seen as activity
motile flagilleted protozoa on wet mount of vaginal discharge in
sexually active women.
43
RTI-STI VAGINAL DISCHARGE WOMAN COMPLAINS

OF VAGINAL DISCHARGE
Speculum available
Mucopus
from
cervix
Profuse
Clumped
No
discharge discharge discharge
seen
Treat for Treat for Treat for

Counsel
gonorrhea trichomo candidiasis
niasis
+
+
Chlamydia Bacterial
vaginosis
Speculum not available
Treat for candidiasis

trichomoniasis
bacterial vaginosis
Fig. 3.3: Appearance is suggestive of Trichomonas vaginalis infection gonorrhoea
Discharge is complaint in 50% of cases which is cream coloured,

frothy, offensive, of sudden onset during or after menstruation or
exacerbated with menstruation.
Puritis in 75% is severe
There is the H/O dyspareunia and 20% cases complain of
dysuria.
ON EXAMINATION
We see oedema and excoriation of external genitalia

Frothy purulent foul smelling discharge
Gragnualar vaginitis of fornix and cervix
Straberry cervix
Bartholinitis
Urethritis
Rarely abdominal and rectal tenderness.
44
Women and HIV
CANDIDIASIS
Candidiasis is caused buy Candida albicans seen as budding mould
on KOH mount more common in. Oral contraceptive antibiotic
users. During Pregnancy and in cases of diabetes mellitus.
Fig. 3.4: Vaginal infection with Candida albicans

as seen on speculum examination
Diagnosis is by colour of vulva ranging from palid to

erythematous Vulva may be oedematous or have excoriation
Discharge is thick, white, cheesy and adherent to vagina but
atypically it can be white seen on vagine and labia.
BACTERIAL VAGINOSIS
It is caused by Anaerobe, Gardinerella vaginalis and Mycoplasma.
*Diagnosis is by
Vaginal discharge with fishy odour
Gray vaginal secretons coating vaginal wall
pH is more than 4.5
Microscopy on stain smeer shows presence of clue cells
Addition of KOH to vaginal secretions releases a fishy odour.
TREATMENT OF VAGINAL DISCHARGES
For Gonorrhoea and Chlamydia in Non-pregnant Ladies

Ciprofloxacin 500 mg in single oral dose. Doxycycline l00 mg orally
twice daily for 7 days. Alternative regimen- Azithromycin 1gm
single oral dose under supervision (effective both for gonorrhoea
45
and chlamydia). During pregnancy: Inj Ceftriaxone 250mg single

dose Im + Erythromycin Stearat 500mg orally QID 7 Days.
For Trichomoniasis and Candidiasis

Metronidazole 400 mg TDS 7 days PLUS Miconazole or
dotrimazole 200 mg vaginaly 3 days OR Cicatrimazole 500 mg
vaginally once only OR Fluconozole 150 mg orally once During
first trimester pregnancyDo not give Metronidazole treat with
Miconazole only.
LOWER ABDOMINAL PAIN IN THE FEMALE (PID)
Patient complains of lower abdominal pain
Take history and do abdominal and vaginal examination
Missed/ over period
Vaginal bleeding, or
Recent delivery/ abortion, or
Rebound tenderness or guarding,
or pelvic mass
Yes Refer immediately to higher level

facility
No
Pain on moving cervix and

temperature 38 C or higher
No Reassure follow up in 3 days if

pain persists
Yes
Treat of PID
Educate
Counsel
Promote and provide condoms
Partner management/treatment*
Follow up in days or sooner if pain persists or gets worse
Improved
No Refer to higher level facility
Yes
Complete treatment (Return if pain persists)
* Treatment for goncoocal and chlamydial infections
46
Women and HIV
TREATMENT FOR PID

(Gonorrhoea + Chlamydia + Anaerobic infection)
Use this regimen only if patient is well enough to take food and
liquids, walk unassisted, take her medication, and return for followup. Otherwise, refer to higher level care.
SINGLE DOSE TREATMENT FOR GONORROHEA
Ciprofloxacin 500 mg orally as a single dose OR Norfloxadn 800 mg
orally as a single dose OR Ceftriaxone 250 mg IM as a single dose
OR Cefixine 400 mg orally as a single dose OR Kanamycin 2g IM
as a single dose. Alternative treatment if single dose treatment is
not available Trimethoprim 80 mg/Sulphamethoxazole 400 mg
10 tablets once daily for 3 days. Plus Treatment for Chlamydia:
Doxycycline l00 mg orally 2 times daily for 14 days OR Tatracycline
500 mg orally 4 times daily for 14 days. Plus treatment for
Anaerobic infection: Metronidazole 400 mg twice daily for 14 days.
TREATMENT OF GENITAL ULCER
SYPHILIS
Benzathine Penicillin - G 2.4 million units in 2 inj (1.2 m. each)
given as one in each buttock after test dose or aqueous procaine
penicilline 1.2 million units in daily for 10 days.
Fig. 3.5: Primary syphilis
47
GENITAL ULCER
Patient complains of genital sore or ulcer
Examine
Vaginal found or/and
history of
recurrences
Yes
Ulcer present?
Yes
No
Treat for herpes

Educate
Counsel
No
Educate
Counsel
Treat for syphilis and chancroid

Educate
Counsel
Partner management/treatment
Advise to return in 15 days if symptoms persists
Ulcer healed?
Yes
Cured
No
Refer to higher facility
No

Responding to treatment?
Yes
Continue treatment for chancroid advise return in 7 days
Examine
Cured No
Ulcer persists?
Refer to a higher facility
For women sensitive to penicillin (Non-pregnant)Doxycydine

l00 mg orally BDX 15 days. OR Tetracycline 500 mg orally QID
15 days. For pregnant women sensitive to Pencillin: Erythromycin
500mg orally QID 15 days (advise those women to bring the
child within 7 days of birth for screening)
48
Women and HIV
CHANCROID
CHANCROID IN FEMALE
- Haemophilus Ducreyi
Fig. 3.6: Chancroid in female (Haemophilus ducreyi)
Erythromycin 500 mg Orally QID 7 days OR Qprofloxacin 500 mg

orally single dose (not for pregnent patient) OR Trimethoprim
50 mg/Sulfamethoxazole 400 mg 2 tab BD 7 days OR Ceftriaxone
250 mg single dose im.
HERPES
Symptomatic Treatment
Apply topical antibiotic ointment.
Advise patient, to wash genital area regularly with soap and
water
First episode-Acyclovir 200 mg orally 5 times daily for 7 days
Recurrent episodes - Acyclovir 200 mg orally daily for 5 days.
Fig. 3.7: Herpes genitalis
Fig. 3.8: Ulcer on cervix (Herpes cervicitis)
BIBLIOGRAPHY
1. Simplified STI and RTI Treatment guidelines. Prepared by Ministry of
Health and Family Welfare ( Govt of India).
four
Voluntary Counselling and

Testing and Its Rationale
for HIV Infection
Sudha Salhan
WHAT IS COUNSELLING?
Counselling is one person helping another as they talk person-toperson. When you help a person make a decision or solve a
problem, your are counselling. Despite the dramatic advances in
therapy decrease in mortality and hospitalization and overall
improvement in quality of life, HIV remains a life threatening and
often life ending disease with no cure on the horizon. Unlike most
other chronic medical illness, HIV positive individuals remain
infectious for the rest of their lives and must learn about and become
empowered to change behaviors that put themselves and others
at risk. Counselling is an integral part of comprehensive care for
HIV/AIDS. It should aim to correct misconceptions and myths
and should recognize that relapses and atleast episodic problems
are the norms rather than the exception. Peer advocates (HIV
affected persons from similar cultural background) with can be
effective members of the clinical team to help educate patients,
advocate for them and provide counselling as needed.
The counselling that occurs before and after HIV testing has
3 principal goals.
1. To counsel about risk reduction for HIV negative person.
2. To identify HIV infected persons for clinical interventions and
3. To provide counselling to HIV positive persons about potential
transmission.
50
Women and HIV
According to the policy of Government of India all clients who

are getting themselves tested have to undergo pretest counselling.
Then he/she comes to collect the repair and at that time post-test
counselling is done.
Issues related to HIV counselling include
Confidentiality
Empathy
Non judgmental.
INTRODUCTION
HIV voluntary counselling and testing (VCT) has been shown to
have a role in both HIV prevention and as an entry point to care. It
provides people with an opportunity to learn and accept their HIV
serostatus in a confidential environment. VCT has become an
integral part of HIV prevention programs in many countries, as it
is a relatively cost-effective intervention in preventing HIV
transmission.
In India, as HIV testing becomes simpler to perform with the
advent of newer rapid and simple kits, the National AIDS Control
Organisation has plans for the expansion of testing facilities to all
corners of the county in a phased manner. It is envisaged that within
the next few years every district in the country would be equipped
with HIV testing facilities. With easy accessibility and availability
of testing it becomes necessary to improve the services of
counselling and the guidelines clearly states that no HIV testing is
to be undertaken without pretest and post-test counselling. It is,
therefore, important to document the benefits of VCT in order to
promote and expand access to it. Improving Information Education
and Communication (IEC) to advocate the benefits of VCT and
raising community awareness greatly contribute to the success of
this strategy. Integrating VCT into other health and social services
may improve access and effectiveness in some settings.
HIV testing services should be designated to address the
multiple needs and rights of individuals at risk or already infected.
A more humane and person centered approach to HIV testing could
be achieved by moving from HIV testing alone to Voluntary
Counselling and Testing (VCT) where primary emphasis would
be to reach individuals with effective counselling, condom supplies
and peer and community support, rather than focus on HIV testing.
Such efforts to reduce stigma and discrimination, seek to
Voluntary Counselling and Testing and its Rationale
51
normalise community perceptions of HIV infection and AIDS,

and make counselling services available to all who seek them,
regardless of their willingness to be tested.
Voluntary Counselling and Testing
Voluntary HIV counselling and testing is the process by which an
individual undergoes counselling enabling him or her to make an
informed choice about being tested for HIV. This decision must be
the choice of the individual and he or she must be assured that the
process will be confidential. However, in currence with the
Supreme Court decision, partner notification is necessary and this
makes it imperative for the attending physician to disclose the HIV
status to the spouse or sexual partner of the person. Inspite of this
all efforts must be made to counsel the person for disclosure of
HIV status to the spouse or sexual partner.
Benefits of VCT
The potential benefits of VCT are:
Improved health status through good nutritional advice
Earlier access to care and treatment
Prevention of HIV related illness
Emotional support
Better ability to cope with HIV related anxiety
Awareness of safer options for reproduction and infant feeding
Motivation to initiate or maintain safer sexual practices
Motivation for drug related behavior
Safer blood donation.
Voluntary Counselling and Testing Centres (VCTC)
Voluntary counselling and testing centers will be located in the
Blood testing centers in the Microbiology department of all medical
colleges, tertiary care hospitals and the district hospitals where
testing facilities for HIV are available.
However, VCT may be carried out in various other settings
depending on the demand and resources. Different models of VCT
are available for the different settings. The choice of VCT service
will depend on the needs of the community, HIV seroprevalance,
maturity of the epidemic and attitudes towards HIV.
52
Women and HIV
The VCTC can be:

1. Part of the hospital services. The Model Counselling Center
functional at the Safdarjung Hospital, New Delhi and run by
the NGOs is a fine example of integration of services with that
of the medical outpatient services.
2. VCTC can be as an entry into the continuum of care/home-based
care services.
3. Industrial houses may have the option of having these facilities
at the workplace clinics subject to the availability of HIV tests.
4. VCTC may be made available for the following vulnerable
groups:
i.
ii.
iii.
iv.
v.
vi.
STD clinics attendees

Sex workers
Prison population
IUDs (Intravenous drug users)
Men having sex with men (MSM)
Orphans and street children.
Remember
The VCTC should house in a place that is easily accessible to
the general public. It must be adjacent to the testing laboratory.
There should be 2 rooms, one for waiting and one for
counselling. The counselors should have a private chamber
where one-to-one counselling can be done. It should not be in
view of the others who are waiting. The waiting room can
provide information in the form of flip charts, handbills or
booklets on HIV/AIDS and STDs.
HIV TESTING
The diagnosis of HIV testing has traditionally been made by
detecting antibodies against HIV. There has been rapid evolution
in diagnostic technology since the first HIV antibody tests became
commercially available. Besides ELISA, newer rapid and simple
tests are available which are comparable to ELISA on sensitivity
and specificity. In addition they are easy to perform in limited
resources setting like district hospitals and more cost-effective than
ELISA.
53
The success of the voluntary counselling and testing strategy

largely depends on the availability of cheap testing facilities that
give results at the shortest possible time. This makes the rapid test
an attractive option where the client can be subjected to a pretest
counselling, test result and posttest counselling in one session. The
National testing guideline lays down the following strategy to be
adopted for voluntary testing for diagnosis of HIV infection.
Strategy I of the guidelines limits the use of HIV test to blood
banks where the blood units are screened for HIV and this strategy
of 1 ERS (ELISA/rapid/simple) test does not recommend its use
for diagnosis of HIV infection in a person. Strategy II and III of the
guidelines states that the blood must be tested for HIV antibodies
with 2 or 3 tests conducted with ELISA/rapid/simple (ERS) with
different antigen preparations or different principles. The tests may
be 2/3 rapid tests or 2/3 ELISA or a combination of rapid and
simple and ELISA but no two tests should be one kind of antigen
or principle. This ensures a better reliability of the test. Two tests
are undertaken when the person is symptomatic with any one of
the underlying AIDS defining illnesses as laid down in the NACO
guidelines. Three tests (Strategy III) is used for asymptomatic
persons who have a suspicion of HIV infection.
WHEN TO DECLARE HIV POSITIVE?
In voluntary counselling and testing centers the following
procedures should be practiced.
i. The serum sample is first test with one ELISA or simple/
Rapid assay.
ii. Any reactive sample is retested using a different assay.
iii. Serum found reactive on the second assay is repeated for
the third test.
iv. Serum found reactive on all the three tests is considered
HIV antibody positive.
v. Indeterminate resultserum that remains discordant in the
second assay or reactive on the 1st and 2nd test but nonreactive on the 3rd test is considered to be indeterminate.
In such cases, the person must be asked to report for a
re-test after a minimum period of 2 weeks and if still
indeterminate may be subjected to a confirmatory assay
like Western blot or Line immunoassay. In some cases the
person may be followed up for 3, 6 or 9 months.
54
Women and HIV
Counselling Process
The VCT process consists of the following:
a. Pre-test counselling
b. Post-test counselling
c. Follow-up counselling.
Pre-test Counselling
The Aim of pre-test counselling

Counselling before the test should provide individuals who are
considering being tested with the information on the technical
aspects of screening and on the possible personal, medical, social,
psychological, and legal implications of being found either HIVpositive or HIV-negative. The information should be given in a
manner that is easy to understand and should be up to date. Testing
should be seen as a positive act that is linked to changes in risk
behavior.
A decision to be tested should be an informed decision.
Informed consent implies awareness of the possible implications
of a test result. In some countries, the law requires explicit informed
consent before testing can take place; in others, implicit consent is
assumed whenever people seek health care. There must be a clear
understanding of the policy on consent in every instance, and
anyone considering being tested should understand the limits and
potential consequences of testing.
Testing for HIV infection should be organized in such a way
that minimizes the possibility of information disclosure or of
discrimination. In screening, the rights of the individual must also
be recognized and respected. Counselling should actively endorse
and encourage those rights, both for those being tested and for
those with access to records and results. Confidentiality should be
ensured in every instance.
Issues in pre-test counselling

Pre-test counselling should be centered on two main topics: first,
the persons personal history and risk of being or having been
exposed to HIV (Box 4.1); secondly, the clients understanding of
HIV/AIDS and previous experience in dealing with crisis situations
(Box 4.2).
55
In assessing the likelihood that the person has been exposed to

HIV, the following aspects of his or her life since about 1980 should
be taken into account:
Box 4.1: Assessment of Risk
Frequency and type of sexual behavior and specific sexual
practices; in particular, high-risk practices, such as vaginal
and anal intercourse without using condoms, unprotected
sexual relations with commercial sex workers, and drug
injecting.
Being part of a group with known high HIV prevalence or with
known high-risk lifestyles, e.g. injecting drug users, male and
female commercial sex workers and their clients, prisoners,
and homosexual and bisexual men.
Exposure to possibly non-sterile invasive procedures, such
as tattooing and scarification.
Box 4.2: Assessment of Psychosocial Factors
and Knowledge
Why is the test being requested?
What particular behaviors or symptoms are of concern to the
client?
What does the client know about the test and its uses?
Has the client considered what to do or how he/she would
react if the result was positive, or if it was negative?
What are the clients beliefs and knowledge about HIV transmission and its relationship to risk behaviors?
Who would provide (and is currently providing) emotional and
social support (family, friends, others)?
Has the client sought testing before and if so, when, from
whom, for what reason, and with what result?
This initial assessment should make it possible to discuss and
assess the likelihood of the clients understanding: (a) the meaning
and potential consequences of a positive or negative result; and
(b) how change in behavior can reduce the risk of infection or
transmission to others.
Pre-test counselling should include a careful consideration of
the persons ability to cope with a diagnosis and the changes that
may need to be made in response to it. It should also encourage
56
Women and HIV
the person being counselled to consider why he or she wishes to

be tested and what purpose the test will serve. When the counsellor
enquires about personal history, it is important to remember that
the client:
May be too anxious to fully absorb what the counsellor say
May have unrealistic expectations about the test
May not realize why questions are being asked about private
Matters and therefore be reluctant to answer and
May not be willing to change behavior irrespective of the result.
During pre-test counselling, it is also important that the client
be told that current testing procedures are not infallible. Both falsepositive and false-negative results occasionally occur, although
supplemental (confirmatory) tests are very reliable if an initial test
is positive. These facts must be clearly explained, together with
information about the window period during which the test may
be unable to assess the true infection status of the person.
In Thailand pretest counselling of antenatal patients is done in
a group in a lecture room. Persons refusing pre-test counselling
should not be prevented from taking a voluntary HIV test. But
informed consent from the person being tested is usually the
minimum requirement before an HIV test.
In summary pre-test counselling should:

Determine what that person understands about HIV and AIDS
Provide latest factual information as needed
Discuss potential implications of a positive and negative test
result
Explain and obtain informed consent
Review the test procedure
Assess the person ability to cope with a positive result and
Establish a relationship as a basis for post-test counselling.
ONCE A DECISION HAS BEEN MADE TO TAKE THE TEST FOR
HIV ANTIBODIES, ARRANGEMENTS SHOULD BE MADE TO
PREPARE FOR POST-TEST COUNSELLING
Post-Test Counselling
Post-test counselling should always be offered. The idea is to help
clients to understand their test results and initiate adaptation to
their seropositive or seronegative status. It is done in most
57
confidential form and one to one only. Only the client and the
counselor is there.
HIV testing can have three possible outcomes:
1. A negative result
2. A positive result
3. An equivocal result.
Counselling after a Negative Result
It is very important to carefully discuss the meaning of a negative
result (whether this was expected or not). The news that the result
was negative is likely to produce a feeling of relief or euphoria,
but the following points must be emphasized.
1. Following possible exposure to HIV the window period must
have clapsed before test results can be considering reliable. This
means that, in most cases, a minimum of at least three months
must have clapsed from the time of possible exposure before a
negative test can be considered to mean that infection did not
occur. A negative test result carries greatest certainty if at least
six months have clapsed since the last possible exposure.
2. Further exposure to HIV infection can be prevented only by
avoiding high-risk behaviors. Safer sex and avoidance of needle
sharing must be fully explained in a way that is understood
and permits appropriate choices to be made.
3. Other information on control and avoidance of HIV infection,
including the development of positive health behaviors, must
be provided. It may be necessary to repeat such explanations
and for the counselor and the person being counseled to practice
together methods of negotiating these with others, in order to
assist the client in introducing and maintaining the new
behavior.
Counselling after a Positive Result
People diagnosed as having HIV infection or disease should be
told as soon as possible. The first discussion should be held in
private and under conditions of confidentiality and the client
should be given time to absorb the news. After a period of
preliminary adjustment, the client should be given a clear factual
explanation of what this news means. This is not a time for
58
Women and HIV
speculation about prognosis or estimates of time left to live, but

for acknowledging the shock of the diagnosis and for offering and
providing support. It is also a time for encouraging hopehope
that achievable solutions can be found to the resulting personal
and practical problems. Where resources are available, it may also
be justifiable to talk about possible treatments for some symptoms
of HIV infection and about the efficacy of new antiviral drugs.
Important practical information for people with HIV infection must
be provided.
After a positive result, the counselling relationship may enter
a new phase. Crisis counselling will always be necessary, and
usually also problem solving counselling. The pre-test assessment
can be used to determine the best way to tell the client about the
test result. How the news is accepted will depend on the persons
personality, psychosocial circumstances, previous knowledge of
HIV, and cultural attitudes towards AIDS. The client must be told
how to contact the counselor during periods of severe stress. There
should be some discussion of what may happen if employers or
others learn that the person is HIV infected. All the information
previously given about safer sex, prevention of transmission, and
maintaining health must be repeated. Follow-up visits must be
arranged, often on a routine basis.
Counselors must always stress the individuals responsibility
for changing behavior to avoid infection or to limit, if not eliminate,
the risk of transmission, and the life-long nature of the infection
and of the risk of infecting others.
How the news of HIV infection is accepted or incorporated often
depends on the following:
1. The persons physical health at the time. People who are ill may
have a delayed reaction. Their true response may appear only
when they have grown physically stronger.
2. How well prepared the person was for the news. People who
are completely unprepared my react very differently from those
who were prepared and perhaps expecting the result. However,
even those who are well prepared may experience the reactions
described herein.
3. How well supported the person is in the community and how
easily he/she can call on friends. Factors such as job satisfaction,
family life and cohesion, and opportunities for recreation and
sexual contact may all make a difference in the way a person
59
responds. The reaction of the news of HIV infection may be much

worse in people who are socially isolated and have little money,
poor work prospects, little family support, and inadequate
housing.
4. The persons pre-test personality and psychological condition.
Where psychological distress existed before the test result was
known, the reactions may be either more or less complicated
and require different management strategies than those found
in persons without such difficulties. Post-result management
should take account of the persons psychological and/or
psychiatric history, particularly as the stress of living with HIV
may act as a catalyst for the re-appearance of earlier disturbance.
In some cases, news of HIV infection can bring out
previously unresolved fears and problems. These can often
complicate the process of acceptance and adjustment and will
need to be handled sensitively, carefully, and as soon as possible.
5. The cultural and spiritual values attached to AIDS, illness, and
death. In some communities with a strong belief in life after
death, or with a fatalistic attitude towards life, personal
knowledge of HIV infection may be received more calmly than
in others. On the other hand, there may be communities in which
AIDS is seen as evidence of antisocial or blasphemous behavior
and is thus associated with feelings of guilt and rejection.
Counselling and support are most needed when reactions to
the news of HIV infection or disease appear. Some reactions may
initially be very intense. It is important to remember that such
responses are usually a normal reaction to life-threatening news
and as such should be anticipated.
The psychological states that develop in most people with HIV
infection or disease revolve around uncertainty and adjustment.
HIV infection gives rise to uncertainty about hopes and
expectations about life in general, but it may be felt mainly about
family and job. An even more fundamental uncertainty may
concern the quality and length of life, the effect of treatment, and
the response of society, all of which are relatively unpredictable in
terms of their long-term outcome. They need to be discussed openly
and frankly but care should always be taken to ensure that hope
and a positive outlook prevail.
In response to uncertainty, the person with HIV must make a
variety of adjustments. Even the apparent absence of response may,
60
Women and HIV
in itself, be an adjustment through denial. People adjust to news of

their infection or disease from the time they are first told. Their
day-to-day lives will reflect the tension between uncertainty and
adjustment. It is this tension that causes other psychological issues
to assume more or less prominence and intensity from time to time.
There is no way of predicting the reaction to news of HIV
infection or disease. Some people will go into shock and a state of
crisis, and then come around to acceptance, with medical care and
counselling. Others will resort to denial, and face up to their
condition only when they become too ill or weak to keep up the
pretence.
Miller, in Living with AIDS and HIV, writes that shock is a
normal response to life-threatening news and has listed the
following common shock reactions to diagnosis or infection:
Numbness/ stunned silence/disbelief;
Confusion/distractibility/uncertainty about present and future
circumstances;
Denial (It cant be true, Dont worry, thing will be fine);
Despair (Oh my God, everything is ruined);
Anger towards health staff, loved ones etc., over the impact on
life and circumstances;
Fear of pain, death, disability, loss of bodily/mental functioning,
loss of confidentiality/privacy;
Guild/self-recrimination over the association of infection or
illness with sexual activity or with being gay or a drug user;
Acute and severe anxiety;
Emotional liability (moving quickly and unpredictably from
tears to laughter and vice versa);
Sadness and morbid concern about the future, work, lover/
spouse, family, health;
Suspicion about the actions and behavior of staff/loved ones/
helpers;
Relief at knowing what causes the recent illness.
In conjunction with these, Miller also cites a number of
behavioral reactions to shock:
Cryingepisodic and often unpredictable:
Anger and irritabilitytowards anybody, often sparked off
by trivial and unimportant event, (may be physical and/or
verbal);
61
Withdrawaldistancing from present issues and circumstances,

reluctance to become involved in conversation, activities or plans
for treatment;
Self-denigration-description of the self as deserving this
plague, worthless, unclean and dirty;
Checking the body for signs of further infection or physical
deterioration;
Questioningfor reassurance, further information.
The following points need to be repeatedly emphasized:
1. HIV infection is not AIDS. Prognosis varies, but every infected
person should be encouraged to life a normal social and
economic life unless AIDS-related symptoms do not permit this.
Since normal living requires the support of others, those
concerned may need regular counselling to anticipate and cope
with new needs.
2. A person who is HIV positive should take care of his/her general
health. The presence of other infectionssuch as other sexually
transmitted diseases or any illness will affect the immune
response and may hasten the development of AIDS. The
counselor must stress the need to avoid exposure to illness as a
measure to prolong life. The counselor must explain how the
risk of infections can be avoided through general home hygiene
and the prevention of other sexually transmitted diseases,
emphasizing the use of condoms and reducing the number of
sexual partners.
3. Spouses and partners will need support; telling them that HIV
infection has been found is difficult, and considerable support
for this may be needed from the counselor. Bringing spouses or
partners in for counselling to prevent transmission and, where
indicated, testing is a frequent counselling goal.
4. Spouses and partners must be protected against infection.
Condoms should be recommended to prevent infection
transmission and re-infection of the patient. The counselor
should stress the need for care in ensuring that the condoms are
of good quality and intact. Latex condoms are much safer that
animal-membrane condoms. The proper and consistent use of
condoms should be stressed. The use of condoms may not be
acceptable in some cultures and countries. Objections to them,
and the consequences of not using them, need to be discussed.
62
Women and HIV
5. Person who is HIV positive should not share their syringes,

needles, or other skin-piercing instruments.
In summary after a positive test result, post-test counselling
should.
Ensure that the person understands what a positive HIV test
result means
Discuss how they feel about being infected
Provide support to help the person deal with these feelings
Discuss their plans for the immediate future
Establish a relationship with the person as a basis for future
counselling
Schedule appointments for medical evaluation and follow-up
counselling
Counsel partner(s) if possible and
Refer the person to local community services if possible.
Guidelines on Prevention of Further Sexual
Transmission of HIV
The following general guidelines are aimed at individuals or
groups directly affected by an HIV-positive result. Counselors can
share them with the clients and their partners or give them as a
hand-out for them to read and keep.
Recommendations to HIV Infected Persons
1. Inform former and current sexual partners about your HIV
infection and recommend that they visit a testing center or
health-care provide for counselling and evaluation (including,
if available, serological testing). If you are unable or unwilling
to notify former and current sexual partners personally, request
health workers or public health agencies to notify or help with
notifying such partners.
2. Inform potential sexual partners of young HIV infection and
either decide to avoid sexual intercourse, rigorously restricting
sexual contract to activities (e.g. hugging, caressing) that do not
involve sharing of semen, vaginal and cervical secretions, or
blood, or discuss the precautions that need to be taken to
minimize the risk of HIV transmission from sexual activity (e.g.
the use of condoms).
63
3. If you both decide to engage in penetrative sexual intercourse,

learn how to use condoms correctly, as consistent correct use
will reduce the risk of HIV transmission.
4. Strictly avoid sexual intercourse when you or your sexual
partner has an infection or lesion in the genital, anal, or oral
area and during menstruation.
5. Avoid pregnancy. HIV infected women who are pregnant
should know about the great health risk to their unborn children
and the potential health hazard to themselves, and be provided
with counselling services. HIV infected men should discuss the
hazard of pregnancy with their partners.
6. Do not share syringes, needles or other skin piercing instruments.
7. Do not donate blood, plasma, body organs, or other tissues.
8. Mothers should continue to breastfeed it does in itself leads to
discussion.
Recommendations to Sexual Partners of
Known HIV Infected Persons
1. Contact a health-care provider for counselling and evaluation
(including, if available, serological testing). If the HIV serological
test is negatived and you are clinically healthy and if the last
unprotected sexual or needle-sharing exposure to your infected
partner was six or more months ago, it can generally be assumed
that you have not acquired HIV infection from the exposure. If
your last exposure was less than six months ago, or if you
continue to have sexual intercourse with your infected partner
repeat tests will be necessary to determine whether infection
has occurred. If you were negative on initial serological testing,
see the recommendations below.
2. Be aware that avoiding sexual intercourse with an HIV-infected
person or rigorously restricting sexual contact to activities that
do not involve sharing of semen, vaginal and cervical secretions,
or blood (e.g. hugging, caressing) is the only way of eliminating
the risk of acquiring HIV infection from that person. If this is
not acceptable, the use of a condom is an alternative. Although
the precise effectiveness of condoms in preventing HIV infection
is unknown, their correct and consistent use will significantly
reduce the risk of transmission.
64
Women and HIV
3. Avoid all sexual intercourse when either you or your sexual

partner has an infection or lesion in the genital, anal, or oral
area and during menstruation.
4. If you are pregnant, find out and seek counselling about HIVantibody testing. If you are tested and found to be seropositive,
find out and seek counselling about the significant health risk
to your unborn child and the potential risk to yourself.
5. Do not donate blood, plasma, semen, breast milk, body organs,
or other tissues.
Counselling after an Equivocal Test Result
A test result may be equivocal for a number of reasons: for instance,
there may have been insufficient time for full seroconversion to
take place since the possible exposure to HIV occurred (the
window period previously mentioned). In such circumstances,
there are two main issues for the counselor to consider.
1. The test used to determine whether the person is infected with
HIV. The first test most commonly used is ELISA, which is
100 percent sensitive with specificity approaching 99.5 percent,
so that a negative result can be regarded as a definite indicator
that the person is not infected, except for tests carried out during
the window period. Correspondingly, a positive result
suggests the possibility of HIV infection or negative, indicating
no infection. In areas with less than 10 percent prevalence of
HIV infection, to diagnose HIV infection, a third ELISA with a
specificity of 100 percent may be carried out on sera positive
with first two ELISA tests. If it is positive, it strongly indicates
HIV infection. If it is negative, it is indeterminate. The reasons
may be as follows:
The person has developed non-clinical signs of HIV infection
more quickly than might normally be expected;
A related HIV virus is present;
A cross-reaction is occurring with a non-viral protein and
the reaction is simulating that associated with HIV p24 core
protein;
The following options are then available:
To use alternative methods with the aim of obtaining a
reliable result, e.g. by using combinations of techniques so
as to exclude false-positive results.
Not to carry out further testing. Where the result is
indeterminate and either the results of further testing are
65
being awaited or further testing is not possible, it is not

possible to say with any degree of assurance that the person
is HIV-infected. The counselor should than advice the person
to present against after three months for repeat testing. It is
important to remember that, in areas with low levels of HIV
infection, the risk of finding a false-postive result is greater
than in those where background rates of HIV infection are
high. thus, where there are many people with AIDS in the
community, it is more likely that a positive ELISA result is
accurate.
2. Prevention and support while waiting for an unequivocal result.
The period of uncertainty following equivocal or indeterminate
test results may be three months or longer after the last instance
of potentially high-risk exposure or the previous test for HIV
infection. It is then important for counselors to emphasize
essential prevention messages regarding sexual and drug-use
activity, body fluid and tissue donation, and breastfeeding. The
person will need to undertake the precautions recommended
for HIV positive persons until proven others. Just as importantly,
however, the uncertainties associated with this period may lead
to acute and severe psychosocial difficulties, and the counselor
must be prepared to assess and manage such issues or to make
appropriate referrals, if necessary, in every case.
Unresolved Issues in HIV-antibody Testing
When someone seeking to be tested gives no history of high-risk
behavior, the counselor should enquire into the reasons why testing
is sought, and offer preventive and supportive counselling. The
counselor may discourage people who do not want to know the
test result from taking it, but should make it quite clear to them
that they must behave as if they were seropositive in order to
prevent infection of themselves or transmission to others.
In some places, there is much concern lest, without compulsory
testing, many people will not admit to risk behavior and infection
will not be detected. This risk must be weighed against the cost to
and consequences for social order and civil rights of compulsory
testing. Counselling should encourage motivation and voluntary
action to bring about behavior change.
66
Women and HIV
Informed consent is another difficult issue. Where health care

workers usually behave in an authoritarian manner, it may be
tempting to order a person to be tested. Counselors know,
however, that people are more likely to respond positively to
information and counselling if they themselves take part in
decision-making. As far as possible, therefore, counselors should
ensure that, before any test, the client understands the procedures,
their limits and the possible psychosocial consequences of being
tested. Whether they are likely to be seropositive or only want to
be reassured, clients must be told what the test involves, to whom
the result may be communicated and the possible repercussions
on themselves.
In some places, the counselor may be required to ensure that a
client gives written informed consent for certain medical
procedures. The counselor should therefore make the following
points very clearly:
No test can tell whether someone has, or will, develop AIDS
The tests available detect antibodies to HIV in the blood
The presence of HIV antibodies (except for passive maternal
antibodies in the case of uninfected infants of HIV-infected
mothers) is proof only of HIV infection; it does not prove that
the person is suffering or will suffer, from HIV-related diseases
It is impossible to tell from a positive HIV test when the person
was infected, or for how long. This point is important and needs
to be discussed with clients so as to make sure that they
understand that HIV infection may have occurred before an
existing relationship began and does not necessarily imply that
the current partner has been unfaithful
Whether the test is positive or negative, behavior must often be
changed, either to remain negative or to protect others against
HIV infection
A negative result does not rule out infection; if there has been
risk behavior, the test should be repeated three months after
exposure has occurred, to allow for the window effect
Some kinds of behaviour and practices are dangerous to the
HIV-infected person, because they lead to exposure to other
infections, including sexually transmitted diseases; safer sex
must become part of the way of life both of the sero-positive
person and the sero-negative person who wants to remain
sero-negative.
67
Trust in terms of confidentiality is one of the most important

factors in the relationship between the counsellor and the person
being counseled. It enhances that relationship and improves the
chances that the person (or even the group) will act decisively on
the information provided. Given the possibility of discrimination,
ostracism, and personal recrimination when an individual is
diagnosed as having HIV infection, it is all the more important
that confidentiality be guaranteed. The counselling relationship
must be based on the understanding that whatever is discussed
will remain confidential until and unless the client decides to share
that information with someone else. A breach of confidentiality is
unethical.
Sometimes, e.g. in a hospital, the counselor may not be in a
position to guarantee confidentiality before a test, for example, and
must tell the client about this and discuss the implications.
Protecting confidentiality may be very difficult in clinics or health
services where there is little privacy, or where offices are kept open
for ventilation purpose.
There may be some instances where the counselor or other
health workers feel that confidentiality may need to be broken,
e.g. a decision made to notify the sex partners of an infected person
even when the client has refused them permission to do so. The
most common conflict for counselors is that between observing
complete confidentiality and informing the family or other
intimates, in their own or the publics interests. Also, what is the
counselor to do when a HIV carrier or AIDS patient conatus to put
other people at risk? Counselor must be aware of, and consider
these difficult issues and be familiar with the legal and ethical rules,
which guide them.
Confidentiality is valued differently in different places. In some
cultures, for example, a person may have a relationship with
someone else who has a culturally assigned role as a caregiver or
confidant. Anyone who fails to reveal something to this person
violates an important cultural norm.
Counselors must be aware of the limits of medical confidentiality in a particular culture. The ideal is total confidentiality of test
results and respect for privacy. Where the rights of individuals are
highly valued, it is easy for counselors to explain the need for
confidentiality. In community to cultural expectations and traditional norms.
68
Women and HIV
In such and similar situations, the health care provider will be

required to make a decision consistent with medical tics and the
relevant law of the country. In general, where confidentiality is
preventing the adoption of appropriate individual measures for
avoiding the spread of HIV, it may be necessary to reconsider
whether it should be maintained in that situation.
The counselor should tell the client about any official policy on
further testing for confirming a positive result. For example, the
general policy is to follow an initial positive ELISA test with a
second one containing a different antigen or principle and, if that
is also positive, to confirm with another ELISA test with 100%
specificity.
Practical Information for People with
HIV Infection or Disease
Counselling for both support and prevention are needed in the
post-test or pre-diagnosis phase. In addition to acknowledging and
working with the psychological issues that appear at this time,
particularly if people are HIV-infected or have HIV disease, the
counselor should emphasize information that provides the frame
work for living with HIV. Similarly, as part of the process, the
following points should be covered repeatedly in all counselling
sessions, whether for HIV-positive or HIV-negative people.
1. HIV infection is not the same as AIDS. People with AIDS have
HIV infection, but only a proportion of those with HIV have
AIDS.
2. Sexual intercourse, whether heterosexual or homosexual, is the
major route of transmission of HIV. The virus can be transmitted
by any penetrative sexual act in which HIV-infected semen,
vaginal/cervical segregation, or blood is exchanged. HIV
infection can be prevented. During each act of sexual intercourse,
men should always use a condom, from start to finish. Women
should make sure that their partners use a new condom for each
act of sexual intercourse.
3. Condoms, when carefully and consistently used, provide
effective protection against HIV transmission. Latex condoms
lubricated with a silicone or water-based lubricant is
recommended. When additional lubrication is desired to reduce
the risk of condom breakage, only water-based not oil-based
4.
5.
6.
7.
69
lubricants should be used. Animal membrane (e.g., lambskin)

condoms are not believed to be as effective as latex condoms, as
a barrier against HIV and are therefore not recommended.
Non-barrier contraceptives such as intrauterine devices (IUDs)
have no protective effect against HIV transmission. It is not clear
whether oral and injectable contraceptives affect the risk of a
HIV transmission. Coordination between AIDS control and
family planning services is clearly essential.
Certain health conditions, especially other sexually transmitted
diseases may accelerate the progression of HIV infection to
AIDS. Guidelines for avoiding sexually transmitted diseases
should be followed by people with HIV as well as by those
without. This type of information must be clearly explained to
the client and, with the explicit agreement of the client, his/her
sex partner, if that person is known and accessible.
It is not yet clear whether pregnancy accelerates the progression
of HIV infection to AIDS. The uncertainties about this must be
carefully explained to infected women of childbearing age. The
risk of transmission to the fetus is 16-39 percent. If a woman has
AIDS she is much more likely to have problems with the
pregnancy. If HIV-infected women want to avoid pregnancy,
advice about contraceptives should be given to them and to their
sex partners. Access to safe and reliable contraceptives methods
must be ensured.
With regard to immunization, studies have demonstrated that
the use of the vaccines is safe in children suspected of being
infected with HIV-1, BCG, DTP, OPV, IPV, measles vaccine and
tetanus toxioid (all the standard vaccines recommended for
children). However, BCG should not be used if a child has
symptoms of HIV-related disease. The safety of other live
vaccines, such as yellow fever vaccine, has not been evaluated.
In general, where there is a high prevalence of HIV infection,
symptomatic persons should continue to be immunized in
accordance with the standard schedules recommended by the
WHO Expanded Programmed on Immunization (EPI). Further
experience continues to support these recommendations,
highlighting the benefits of immunization in protecting HIV-1
infected children, particularly against measles and the
complications of tuberculosis.
70
Women and HIV
8. Persons with HIV infection should never donate body fluids,

such as blood, semen, and breast milk, or body organs.
9. If blood from a person infected with HIV is spilt in the home or
workplace, it should be cleaned up with an absorbent material
(such as a cloth, rag, paper towel, or sawdust). While avoiding
direct skin contact with it. The blood-soaked absorbent material
should then be washed with a disinfectant (preferably sodium
hypochlorite, or household bleach, diluted 1:10 with water) to
clean up any excess blood. Household (rubber) gloves should
be worn, if available, when cleaning up blood spills. If gloves
are not available, another barrier such as a large wad of paper
towels should be used to protect against direct skin contact with
the blood. Hands should always be washed with soap and water
after cleaning up blood or other body fluids.
Clothes or cloths that are visibly contaminated with blood
should be handled as little as possible. Household (rubber)
gloves should be worn, if available, and the clothes or cloths
placed and transported in leak-proof bags. Such items should
be washed with detergent and hot water at least 71C (160F)
for 25 minutes, or if in colder water (less than 70C (160F) with
a detergent suitable for cold-water washing. Disposable sanitary
towels and tampons, on which menstrual blood has been split,
should be disposed of immediately after use. Bandages and
other dressings soiled with HIV-infected blood should be
similarly disposed of. If they cannot be placed in tied plastic
bags, they should be burned or buried. If cloth or material is
used for menstrual blood these should be wrapped in plastic
or paper until laundered as other clothes.
10. People with HIV infection should not share syringes, needles,
or other skin-piercing instruments, e.g., in drug injection as this
adds the risk of transmission of HIV and other pathogens to
the existing risk of such practices. People with HIV should avoid
being tattooed or having any other invasive procedure unless
sterilization of the instruments can be ensured before and after
the procedures.
11. People with HIV infection should not share toothbrushes, blade
razors or other instruments that could become contaminated
with blood (even though the risk of HIV transmission from these
devices is extremely low).
71
12. People with HIV infection or disease usually seeks or request

information about treatment and possible cures. It is therefore
important for counselors to receive regular and reliable updates
as to the progress of research together with information about
the availability and effectiveness of specific drugs or therapies
for HIV-related conditions. While there is as yet no cure for
HIV infection or for AIDS, some therapies have been found to
be effective in treating opportunistic diseases arising from
immunodeficiency. More than 40 different drugs (antiviral and
immunomodulators) are currently being tested separately or
in combination in more than 100 clinical trials, mainly in
industrialized countries.
13. It is also important to recognize that many people may mistake
expensive treatment or care for good treatment. Counselors
should be aware of this and help patients make decisions on
the advantages and disadvantages of different therapies and
interventions.
Counselling should also emphasize socially constructive
behaviors and activities that do not involve a risk of HIV
transmission. Casual social contactsharing crockery and
cutlery being in the same room, sharing swimming pools and
lavatories do not pose a risk to anyone and help to maintain a
feeling of social cohesion.
Drug injectors who are unable to stop using drugs should
be told where they could obtain sterile needles and syringes (if
this is possible) or how to disinfect, with bleach, equipment
used for injection. Some countries or cities have needle and
syringe exchange programmers. drug use is always expensive,
and some drug injectors may engage in prostitution to obtain
the money the need for drugs. Combining drug use with
prostitution is particularly dangerous for both the prostitute
and the client. Special care is needed in counselling those
thought to be doing this, in regularly providing condoms, and
in encouraging them to insist on their use.
Sex partners of drug injectors may be at risk of acquiring
HIV infection and other diseases if sexual intercourse occurs
without the use of condoms. Counselling and information
should always be provided for the sex partners of drug injectors
on how to avoid possible HIV infection by the adoption of safe
sexual practices.
72
Women and HIV
14. Positive health behaviors need to be actively encouraged. The

specific behaviours to be encouraged will vary from one social
group and country to another. The counselor will need to be
specific to meet the needs of individuals and special situations.
It is important to stress to HIV-injected people how they can
live positively with AIDS. In the following section are some
general guidelines for living with AIDS.
LIVING POSITIVELY WITH AIDS
A person with AIDS should try to keep the body strong. This means
they should:
Eat a good diet, whenever possible including food which is rich
in proteins, vitamins, and carbohydrates. Nutritional deficiencies may adversely influence immune function.
Stay as active as possible to keep fit and get regular sleep.
Exercise help prevent depression and anxiety and can add to a
general feeling of well-being and contribute to general health
and stamina.
Continue to work, if possible
Occupy one with meaning full or al least distracting activities
Socialize with friends and family
Talk to someone about the diagnosis and illness
Use a condom during sexual intercourse
Seek medical attention for health problems and follow the advice
for care; including counselling and social services, this includes
preventive services such as immunization of children and infants
with HIV/AIDS. Reduce stress by identifying potential and
actual stress factors.
And they should avoid:
Alcohol and cigarettes
Other infections-including further doses of HIV
Pregnancy because it lowers the bodys immunity and some
report it can hasten the onset of AIDS in an HIV positive woman
Using unperceived drugs
Isolating them.
Follow-up Counselling
Most of the persons may require follow-up counselling
immediately after post-test counselling or anytime between 1 to 5
73
years following post-test counselling. This often coincides with a

crisis or change in personal circumstances. VCT services should
therefore be flexible and either be able to provide ongoing
counselling or have close links with other organizations for referral
like community organizations, spiritual groups or health facilities.
As part of follow-up counselling, the VCT services should offer
the opportunity of ongoing care and support for seropositive cases
and should act as an entry point to medical care. Including home
care and supportive palliative care.
Counselling of women in antenatal settings of MTCT
(Prevention of mother to child transmission) interventions special
consideration should be given to:
Counselling about infant feeding
Counselling about MTCT options
Family planning counselling
Counselling about partner notification
Involvement of partner in decision making
A comprehensive manual on Counselling on HIV/AIDS is
developed by NACO and counselors are required to be in tune
with the procedures as laid down in this manual.
One of the benefits of VCT is that it can help people with HIV
to make plans for their future and the future of their dependants.
For VCT services to be promoted and developed it is important to
document their usefulness in:
Reducing HIV transmission
Improving access to medical and social care
Facilitating MTCT interventions
Improving coping for people with HIV.
Innovative approaches can be devised to help make the
counselling component of VCT less labour-intensive. Group
education prior to pretest counselling can shorten the length and
time required for one to one counselling and hence reduce costs as
is done in Thailand ANC clinic. Promotion of the advantages of
VCT should be an integral part of HIV education programs and
included IEC materials.
Confidentiality
Confidentiality may be defined is as a protection of personal data
and test results to ensure the rights and welfare of the individual
74
Women and HIV
from whom such data are collected. This information is not to be

furnished under any circumstances to any other person without
the individuals explicit consent. However, as stated earlier, this
information should be disclosed to the spouse of the person.
The VCT services should always preserve individuals records
for confidentiality.
The Counsellors
Counsellors must be knowledgeable on the issues concerning HIV/
AIDS. They should be adequately trained on HIV/AIDS pretest and
post-test and follow-up counselling. Establishing good rapport and
showing respect and understanding are necessary credentials for
a sensitive counselor. The success of a VCT largely depends on the
counselor and his/her communication skills. The counselors, as is
seen in all other countries mostly belong to the social sciences.
Besides, psychiatrists and other doctors are also equipped to
counsel on HIV/AIDS.
The counselors must provide services to all persons referred to
them and should include the family members of the persons as
well.
Under the NACP II program, provisions have been made for 2
counselors in each VCTC. These counselors may be provided by
the NGOs and will work under the administrative control of the
Officer-in-charge of the testing laboratory. One of the counselors
should preferably be a female. The State AIDS Control Societies
while appointing counsellors must ensure that they are abreast
with the latest developments in the field of HIV/AIDS and must
also ensure that the counselors are updated in their knowledge
about HIV/AIDS.
EFFECTIVE VCT SERVICES
In order to make the services effective the following points should
be considered.
1. The location and opening hours of the services should reflect
the needs of the community. In practice all VCTCs located in
the blood testing centers should remain open during the
laboratory working hours.
2. Counselling sessions need to be monitored to ensure that they
are of high quality.
75
3. Informed consent must be taken before HIV testing. Here it is

emphasized that counselors should not be rotated from center
to center and from one day to another since the report between
the counselor and client is essential.
4. Counselling should be integrated into other services, including
STI, antenatal and RCH clinics.
5. Adequate supply of condoms must be made available in these
counselling centers. Individuals attending the VCTC should also
be made aware about the outlets from which they can get
condoms under various schemes.
6. Referral system should be developed in consultation with NGOs
community based organizations, hospitals and PLWA networks.
7. Counselors need adequate training and ongoing support and
supervision to ensure that they give good quality counselling
and avoid burnout.
8. Linkages to crisis support, follow-up counselling and care for
those tested seropositive should be developed.
9. Innovative ways of scaling up VCT services and making them
more accessible land available should be explored.
The contents and approach of each type of counselling may
vary and should be adapted to the needs of the clients and may be
different for individuals, couples, families, men, women, etc. Contents and approaches may also reflect the context of intervention,
e.g. counselling associated with specific interventions like MTCT.
Counselling as part of VCT ideally involves at least two sessions
(pretest and post-test counselling). More sessions can be offered
before and after the test or during the time the client is waiting for
the test result.
BIBLIOGRAPHY
1. AIDS Prevention: Guidelines for MCHIFP Programmed Managers AIDS and
Maternal Child Health, WHO, Geneva, May 1990.
2. Draft statement on criteria for screening programmes for Human
Immunodeficiency Virus (HIV), WHO, Geneva, (WHO/SPA/INF 87.4), 1987.
3. Draft statement on screening and testing in AIDS and control Programmes WHO,
Geneva, (WHO/SPA/INF 8.81), 1988.
4. Living with AIDS and HIV Miller D, Macmillan Press, London, 1987.
76
Women and HIV
five
Establishing the Diagnosis

of HIV Infection
Usha K Baveja
INTRODUCTION
Human Immunodeficiency Viruses (HIV) cause AIDS. The
infection is spreading relentlessly in India with grave health and
other consequences. The Global and National figures indicating
the number of HIV infected in the world and in India are staggering.
Prevention of primary and secondary transmission of HIV will go
a long way to contain the epidemic in the absence of successful
drug cure and vaccine.
Primary HIV infection is asymptomatic/silent in majority of
cases. Approximately 50-93 percent cases of primary HIV infection
are symptomatic with a variety of symptoms ranging from
influenza like or mononucleosis like illness to more severe
neurological symptoms which may persist from a few days to as
long as two months. HIV antibodies appear in circulation anywhere
between 2 weeks to 6 weeks after primary HIV infection and persist
at high levels throughout life. Other clinical laboratory
abnormalities may include transient panycytopaenia and elevated
serum transaminases. This stage is followed by a long
asymptomatic phase during which the individual is infectious as
viral replication continues, and can transmit HIV through unsafe
sex and various other routes of transmission. During this phase of
clinical latency there is a gradual decline in CD4+cells. This stage
is followed by early AIDS and late AIDS stages when one or the
other opportunistic infection sets in. Once the level of CD4+ cells
is markedly reduced (<50 cells/cmm) infection with one of the
opportunistic pathogens (Pneumocystis carinii, etc.) proves fatal.
Establishing the Diagnosis of HIV Infection 77

Laboratory testing is the only method for determining the HIV
status of an infected individual. A number of tests and diagnostic
kits are available to assess the HIV status (Table 5.1). Serological
tests to detect viral specific antibodies are most commonly
performed though, HIV infection can also be detected in the
laboratory by detection of viral antigens; detection of viral nucleic
acid; or by culture and isolation of virus in vitro. Detection of viral
specific antigens, viral nucleic acid and viral culture are all
confirmatory tests in that the presence of the virus is detected. But,
they are risky (viral culture), laborious and difficult to perform,
require skilled expertise and hence can be undertaken only by
specified laboratories, mostly at tertiary care level.
HIV testing is an important and integral part of any AIDS
control programme. National AIDS Control Organisation, India
has developed the National policy on HIV testing as part of the
National AIDS Control Programme. The detection of anti-HIV
antibody is the mainstay of diagnosis. Molecular techniques like
PCR, viral load assay and CD4 estimation, etc. are reserved for
certain circumstances. PCR is mainly done to determine vertical
transmission in the baby borne to HIV positive mother and to
determine transmission of HIV infection following accidental
Table 5.1: Tests available for HIV diagnosis
Antibody blood tests

HIV antibody enzyme immunoassays (EIAs)
(ELISA and or rapid)
Immunofluorescent assays (IFA)
Western blot (WB) and immunoblot (IB)
Antibody tests on other fluids
Oral HIV antibody EIA
Urine HIV antibody EIA
Other blood tests
p24 antigen assay
Culture of peripheral blood mononuclear cells (PBMC) for HIV
PBMC HIV DNA detection
Plasma/serum viral load (HIV-1 RNA)
RT-PCR (e.g. monitor)
b-DNA (e.g. quantiplex)
NASBA (e.g. nuclisens)
78
Women and HIV
exposure amongst HCW, etc. CD4 estimation and viral load assay
are undertaken to determine efficacy of anti-retroviral drug therapy
and to monitor progression of HIV disease. p24 antigen assays
based on ELISA system are also available, but sensitivity of these
assays is low as compared to PCR. p24 antigen positive result
confirms HIV infection but a negative result does not rule out HIV
infection. The applications of this assay are similar to PCR.
LABORATORY TESTS USED FOR THE
DIAGNOSIS/DETECTION OF HIV INFECTION
Detection of Specific Antibodies
This is done by performing initial screening tests, which if positive,
are followed up by supplemental tests to confirm the diagnosis.
Most of HIV testing in India is based on detection of anti-HIV
antibodies.
Screening Tests
This is the systematic application of HIV testing to whole
populations; and donors of blood products and cells, tissues or
organs.
ELISA/EIA (Enzyme-linked Immunosorbent
Assay/Enzyme Immunoassay)
EIA is the most commonly performed test to detect HIV antibodies.
There are various kinds of ELISAs based on the principle of
test:
Indirect ELISA
Competitive ELISA
Antigen sandwich ELISA
Antigen and antibody capture ELISA.
ELISA is also classified on the basis of the antigens utilised
into:
1st generation : Infected cell lysate is used as the antigen.
2nd generation : Glycopeptides (recombinant antigens) are used
as the antigen.
3rd generation : Synthetic peptides are used as the antigen.

4th generation
: A mixture of synthetic peptides and recombinant glycopepides is used as antigen. p24

antigen and HIV antibodies can be detected
simultaneously.
Rapid Tests Include
Dot blot assays

Particle agglutination (gelatine, RBC, latex, microbeads)
HIV spot and comb tests, etc.
Fluorometric microparticle technologies.
ELISA can take upto three hours to yield results. It has a major
advantage of being economical. Although rapid tests give result
within minutes these are far more expensive. Commercial kits are
available for ELISA and rapid tests. The recommended first line
tests are ELISA and or rapid.
Simple tests are also based on EIA principle but take a little
longer time (> hr.) compared to rapid tests.
Tests which detect antibody to all subtypes of both HIV 1 and 2
are to be employed
Supplemental Tests
This testing is done on serum sample reactive in screening test to
confirm the result of the screening test.
Second and third
ELISA/rapid/simple
Western blot (WB) and Immunoblot (IB) WB/IFA/IB
Indirect immunofluorescence
employed in case of
Assay (IFA)
discordant results
Radioimmuno precipitation assay
and for research
Second and third E/R/S kits should employ either different

antigens or different technical principle/technology of testing.
WB, IFA, etc. are expensive, time-consuming and require
expertise to perform. They are to be done to confirm the diagnosis
on samples which give discordant results in E/R/S.
The Choice of Test Protocol
The choice of HIV test kit to be used for screening and HIV testing
80
Women and HIV
and which protocol to follow depends upon the parameters detailed

below:
Objective of HIV testing
Sensitivity and specificity of the test used
The prevalence of HIV infection among the population
Resources available
Appropriateness to the strategy of testing being followed
Infrastructural facilities available.
Objectives of HIV Testing
Blood and blood products safety. This is determined by
mandatory screening of all donated blood and blood products
Donors of sperms, organs and tissues are tested for HIV to
prevent HIV transmission to the recipient
Diagnosis of HIV infection in clinically suspected individuals
Voluntary testing: individuals practising high risk behavior seek
HIV testing. This is done after counseling and informed consent
Sentinel surveillance to monitor epidemiological trends
To prevent mother to child transmission of HIV, ANC cases are
tested after counseling and consent
Health care workers after accidental exposure to potentially
infectious fluids to administer PEP
Research.
STRATEGIES OF HIV TESTING
Often the separate objectives mentioned above cannot be met by a
single testing strategy. Different objectives require separate testing
procedures and the choice of tests (discussed in detail above). Based
on relevant consideration different procedures and strategies of
testing are adopted. The various strategies, so designated, involve
the use of categories of tests in various permutations and
combinations.
ELISA/simple/rapid tests: used in strategies I, II and III
Supplemental test: Western blot is used in problem cases
(discordant result).
Strategy I: Serum is subjected to an E/R/S for HIV. If negative,
the serum is to be considered free of HIV antibodies and if positive,
the sample is taken as positive for HIV antibodies and infected for

all practical purposes. This strategy is used for ensuring donation
safety (Blood, organ, tissues, sperms, etc.). Donor is not informed
about the result. Unit of blood testing positive is destroyed as per
the guidelines.
Strategy II: A serum sample is considered negative for HIV
antibodies if the first E/R/S test reports it so, but if reactive, it is
subjected to a second E/R/S which utilises a system different from
the first one, i.e. either antigens employed by the manufacturer
are different or the technology/principle of test is different. The
test is reported reactive only if the second E/R/S confirms the
report of the first. This strategy is used to diagnose HIV infection
in individuals with AIDS indicator symptoms and for sentinel
surveillance (anonymous, unliked testing). Two different kits with
different antigen system or different principle of test are required
to follow this strategy. Testing is done on one sample collected at
one time.
Strategy III: It is similar to strategy II, with the added confirmation by a third E/R/S test. The test to be utilised for the first
E/R/S is one with the highest sensitivity. (this may give a number
of false-positive results). For the second and third E/R/S tests kits
with the higher/highest specificity respectively, are to be used.
This strategy is used for diagnosis of HIV infection in asymptomatic individuals. Counselling and informed consent are a must
in these cases. Three different kits with different antigen and/or
different principles of test are required to follow this strategy. All
testing is done on one sample collected at one time.
Strategies II and III are to be used for diagnosis of HIV infection.
Second and third E/R/S ought to be tests with the highest positive
predictive value (PPV) possible to eliminate any chance of falsepositive results.
Causes of False-positive or False-negative HIV EIA Results
1. Causes of False-positive Results for HIV on EIA
Hematologic malignant disorders

DNA viral infections
Autoimmune disorders
Multiple myeloma
Primary biliary cirrhosis
82
Women and HIV
Alcoholic hepatitis
Influenza vaccination
Hepatitis B vaccination
Passively transferred antibodies
Antibodies to class II leukocytes
Renal transplantation
Chronic renal failure
Stevens Johnson syndrome
Positive rapid plasma reagin test.
2. Causes of False-negative Results for HIV on EIA
Incubation window period before antibody development

Immunosuppressive therapy
Replacement transfusion
Malignant disorders
B cell dysfunction
Bone marrow transplantation
Kits that detect primarily antibody to p24
Starch powder from laboratory gloves.
ANTIBODY TESTS ON OTHER FLUIDS

Oral HIV Testing
Oral fluids contain antibodies, primarily IgG isotype against HIV.
The concentration of antibodies is usually greater than concomitant
serum levels. Commercially available oral tests have been found
to give comparable results with rapid test kits. Recently, Food
and Drug Administration (USA) has approved an oral salivary
test called Orasure (Epitope, Inc.). A cotton swab is inserted into
the mouth for 2 minutes to collect oral mucosal transudate (OMT).
The swab is then placed into a transport container containing an
antibacterial preservative. The sample is tested in the referral
laboratory by standard EIA and confirmatory tests (E/R/S or WB).
Sensitivity of OMT in true HIV positive subjects was 99.99 percent
and specificity was 99.99 percent when compared to standard
Western blot confirmation. Performance of this system during
seroconversion is not clear.

Urine HIV Testing
It is known that urine contains antibodies against HIV and has
been studied for diagnosis of HIV. Tests which have been used are
IgG antibody capture particle adherence tests (e.g. GACPAT, GAC
ELISA, SUDS and standard commercially available EIA tests).
Various studies reported that performance of urine-based antibody
screening was comparable to that of serum tests. Urine may
therefore, provide alternative medium in patients unwilling to
provide serum. However, further evaluation and discussions on
ethical issues are required to avoid random involuntary testing.
Home HIV Testing
Home Access System has been approved by FDA. The system
utilises standard EIA and confirmatory WB technology from blood
collected by a person at home. From the preliminary studies it is
apparent that home collection of HIV antibody screening along
with pre and post-test telephone counseling is a viable alternative
to conventional venous antibody testing in clinics.
After the pre-test counseling on telephone the individual
collects blood at home with a lancet, places it on the test card and
mails the card to the testing centre. Testing is done at the centre
and results are obtained by the client telephonically with post-test
counseling. The clients identification number is the number
assigned to specific test kit. Post-test counseling of negative test is
given through pre-recorded matter whereas in case of positive tests
result the client is referred to the counselor.
However, the anonymity of the test makes the partner
notification problematic.
OTHER BLOOD TESTS
Detection of p24 antigen
Detection of p24 viral antigen is expensive. The sensitivity of the
test is also limited. Though, a positive test confirms HIV infection,
a negative test does not rule out HIV infection. It is undertaken in
the following situations:
i. To detect infection in the newborn
ii. To resolve equivocal Western blot results
84
Women and HIV
iii. To detect infection during early window phase

iv. To diagnose CNS disease
v. Late stage of disease (immune collapse where antibody tests
may be negative)
vi. To monitor response to anti-retroviral therapy
vii. For research.
EIA for HIV-1 antigen detects primarily uncomplexed p24
antigen, in serum, plasma, CSF or cell culture. It indicates active
infection, allows diagnosis before seroconversion, can predict
prognosis and is useful for monitoring response to therapy.
Disadvantages of antigen detection assays include: poor sensitivity
(only 69 percent in patients with AIDS and low in neonates <1
month old); detection is not possible in patients with high titers of
p24 antibody (which complexes with the antigen); and failure to
detect HIV-2 antigen.
Polymerase Chain Reaction (PCR)
PCR can detect proviral DNA during window period, can
differentiate latent HIV infection from active viral transcription
and can quantitate the copy number of HIV DNA when used with
external standards (e.g. viral load assays). PCR can successfully
differentiate between HIV-1 and HIV-2 infections. Proviral DNA
can be detected in peripheral blood mononuclear cells before
seroconversion. Limitation to the diagnostic use of PCR are rare
false-negatives, some of which can be avoided by the use of
multiple primer pairs and primers from conserved regions of the
genome and false-positives due to cross-contamination of the PCR
reaction mixture.
HIV-1 can be detected by PCR in the CSF of HIV-infected
patients independent of disease stage; spread of HIV-1 to the brain
represents an early event during infection which occurs in most
asymptomatic individuals. PCR can also be used to detect HIV
infection in neonates borne to HIV infected mothers.
Virus Culture
Virus culture is another method for identifying HIV infection.
Positive culture rates of up to 98 percent are reported in confirmed
seropositive individuals. The culture method, however, is

expensive, labour-intensive, can take weeks for complete results
and potentially exposes laboratory workers to high concentrations
of HIV. Virus culture is used for research (drug sensitivity, vaccine
studies, etc.).
Viral Load Assay
Quantitation of HIV RNA in plasma is useful for determining free
viral load, assessing the efficacy of antiviral therapy, predicting
progression of HIV disease and clinical outcome. Because baseline
HIV viral load is predictive of survival at 10 years in patients with
nearly identical CD4 counts (70 percent survival with low viral
load versus > 70 percent mortality with high viral load), assessment
of baseline viraemia prior to initiation of therapy is useful in patient
management.
The various tests which are used for viral load assay are:
RT PCR
b DNA
NASBA.
RT-PCR has higher analytical sensitivity (100 copies/mL
plasma) than branched-chain DNA detection (5,000-10,000 copies/
mL plasma).
Surrogate Markers
Prognostic factors for progression to AIDS requiring further study
include elevated serum prolactin concentrations, decreased
dehydroepiandrosterone concentrations, the presence of antibodies
of HIV-1 virion infectivity factor protein, and elevated serum IgE
concentrations. The role of cytokines and cytokine receptors and
their potential prognostic value in HIV infection also require further
investigation in addition to the other well known prognostic factors.
Indirect Predictors of HIV Infection
Decreased CD4 cells

Increased b2 microglobulin
Increased serum neopterin
Increased IL2 receptors
Indicator diseases for AIDS
86
Women and HIV
DIFFERENT PROCEDURES FOR TESTING

Unlinked anonymous testing Such type of screening or testing is not
directed to the individual, but has as its objective, the public health
surveillance of HIV infection. It is a method for measuring HIV
prevalence in a selected population with the minimum of
participation bias. Unlinked anonymous screening offers a distinct
advantage over mandatory or voluntary testing. Unlinked
anonymous testing involves use of blood already collected for other
purposes; therefore, the effect of selection bias will remain though
minimal and will depend upon time, location and other details of
blood collection.
Voluntary confidential testing This testing is often done for
diagnostic purposes. Here it is important that the issues related to
counseling, informed consent and confidentiality receive due
attention. Since this method is based on voluntary HIV testing or
testing for diagnosis of HIV/AIDS cases, it is imperative to respect
the individuals need to maintain confidentiality. By maintaining
confidentiality, it will not only instill faith in the individual about
the health care system in the community but also encourage more
and more people practicing risk behavior to come forward for an
HIV test.
Mandatory testing When testing is done without the consent of the
patient and the result is/could be linked to identify the person it is
called mandatory testing. Mandatory testing is recommended
for ensuring blood safety and screening donors of semen, organs
or tissues in order to prevent transmission of HIV to the recipient
of the biological products.
Compulsory testing This is the process of determining HIV
antibody status without the individuals consent and with legal
sanctions to enforce compliance (e.g. rape cases on courts orders).
The fear and apprehension that exists among health care
workers in managing HIV infected individuals and AIDS patients
is largely due to the risk, though minimal, that exists of HIV
transmission due to a needle stick or other sharp injury. Thus the
demand for mandatory HIV testing of patients admitted in
hospitals or undergoing surgery, etc. This demand is neither
rational nor appropriate. A mandatory HIV test is no substitute
for Standard Work Precautions that need to be adopted for every

patient in a hospital or any other health care setting. On the other
hand testing without explicit consent of the patient has proven to
be counterproductive in the long run. In the control of the HIV
epidemic such testing can drive the target people underground
and make it more difficult for launching interventions.
ISSUES RELATED TO HIV TESTING
Technical Considerations
How useful an assay will be depends upon the sensitivity,
specificity and predictive values of the test used. Sensitivity is the
ability of a test to detect the condition of interest in those individuals who truly have the condition. Specificity reflects the ability of a
test to exclude those who do not have the condition. The predictive value of a test reflects false-positive and false-negative results.
The positive predictive value (PPV) of a test is the probability that
an individual testing positive is really infected. The negative predictive value (NPV) of the test is the probability that an individual
testing negative is really negative. The predictive value of a test
varies according to the prevalence of the condition (HIV infection)
in the population being studied. The positive predictive value is
higher if prevalence of the condition is high (>10 percent).
Currently used p24 antigen detection assays lack specificity and
sensitivity and are therefore not recommended for screening and
testing purposes.
A variety of antibody testing assays are available. Different
strategies involving repeat testing with different test kits are used
to reduce the false-positives.
Whom to Test ?
The decision as to whom to test for HIV rests with the doctor.
Doctors usually elicit history of high risk behavior (unsafe sex,
substance abuse, profession, etc.) from their patients and correctly
identify individuals to be tested. Alternately all ANC may be given
information on risk behaviors and then invited to undergo testing
voluntarily. HIV testing of ANC cases must be promoted in high
prevalence areas. Particularly pregnant women, women
contemplating pregnancy, commercial sex workers, drug users and
rape victims should be counseled to undergo HIV testing.
88
Women and HIV
Ethical and Legal Considerations

The screening and testing programmes should be designed to
comply with ethical and legal guidelines of the Nation. Two central
issues involving HIV testing are consent and confidentiality.
Confidentiality requires the doctor to preserve secrecy on all that
he knows, with few exceptions where breach of confidentiality is
permissible : when patients gives consent for the breach ; on medical
grounds for the benefit of the patient; when the duty of doctor to
society overrides his duty to the patient; for medical research after
approval of the ethical committee and when information is required
by due legal process. Most difficult is to draw a clear line between
doctors duty to the patient and to the society (e.g. disclosing result
to sexual partner). In case of conflict this can be resolved by open
discussions with the patient.
Confidentiality
Important to safeguard the rights of HIV infected
To prevent victimisation, ostracisation, discrimination, etc
The Medical Officer Incharge of the case has to be prudent
(whom to tell) and motivate the client to confide in a friend,
parents, spouse, etc.
Some kind of code should be devised to indicate the HIV positive
statusrather than writing on the case sheet/OPD cards in
Hospitals.
Issue of consent/informed consent must be resolved while
designing testing and screening programmes. Consent is only valid
when it is freely given by a patient who understands the nature
and consequences of the proposed tests. This requires adequate
pretest discussions of these issues (counseling). Assumed consent
and consent obtained by undue influence is valueless. Consent is
particularly important for HIV testing because of the possible
serious social, financial and personal consequences.
Informed consent
The client is given knowledge about :
HIV transmission
Implication of a HIV positive result
Implications of a HIV negative result (window period, repeat
testing)

Emphasis given on cost of antiretroviral drugs and nonavailability of cure and vaccine
Client is empowered to make an informed decision and to
accept the result
Counseling (Fig. 5.1)
Counseling is an important prerequisite whenever the result of
HIV testing is going to be linked to an individual.
Pretest counseling Knowledge about HIV is imparted to the
client/patient so that the client may make an informed decision
and is emotionally/psychologically prepared to accept the HIV
test result.
Post-test counseling The HIV test result is communicated to the right
person, in the right way in the right circumstances (one to one
interaction). Mainly aimed at reiterating the uptodate knowledge
Take lifestyle history
Risk behavior absent
Risk behavior present

(asymptomatic)
Give IEC on HIV/AIDS
Risk behavior present

(symptomatic)
Pretest counseling
Informed consent
HIV testing (Strategy II and / or III depending on whether

symptomatic or asymptomatic)
Detected negative
Detected positive
Risk reduction counseling
Infection confirmed
Post-test counseling
Counseling for lifestyle
Counseling for self care
Regular follow-up through continuum
of counseling and care
Family counseling if required
with clients consent
Fig. 5.1: Steps in HIV testing and counseling
90
Women and HIV
about HIV/AIDS to empower the client to make decisions on

management/behavior modification issues.
Continuum of counseling and support Essential for HIV positive
clients.
The Indian National Testing Policy Reiterates the Following:
No individual should be made to undergo a mandatory testing
for HIV
No mandatory HIV testing should be imposed as a precondition
for employment or for providing health care services and
facilities
Any HIV testing where an individual is going to be informed
about the result must be accompanied by a pretest and post-test
counseling services
Informed consent and confidentiality are important issues to be
considered when HIV testing is undertaken for diagnostic
purposes
HIV testing protocol should be commensurate with the objective
of testing and the appropriate strategy should be followed to
achieve the said objective
Testing is part of the overall comprehensive and preventive
programme
Testing should be technically sound and appropriate
Test procedure must be appropriate to the field situation
Testing procedure must be cost effective.
Laboratory procedure must be monitored for ensuring quality
Quality assurance should be practiced to avoid false-positive
and false-negative results.
BIBLIOGRAPHY
1. AIDS HIV: Reference Guide for Medical Professional. 4th ed. Ed. Fahey, John L,
and Flemming, D.S. CIRID, UCLA Williams and Wilkins, London, 1996.
2. AIDS Etiology Diagnosis Treatment and Prevention 4th Ed Ed. Curran, J. Essex,
M and Fauci, A.S. Lippincott- Raven, 1997.
3. AIDS Therapy ed. Ralph Dalin, Henry Masur and Micheal S. Saag. Publishers.
Churchil Livingstone, 1999.
4. British Medical Association. The handbook of Medical Ethics. 1984. BMA London
Gallo D, George JR., Fitchen JH, et. al for the USA Orasure HIV Clinical Trials
5.
6.
7.
8.
9.
Group : Evaluation of a system using oral mucosal transudate for HIV-1

antibody screening and confirmatory testing JAMA, 277: 254, 1997.
HIV testing policies and guidelines. W.H.O. 1994.
HIV Testing Manual: Laboratory Diagnosis, Biosafety and Quality Control. NICD
and NACO document , 1999.
Mortimer PP. Screening for HIV. New Egnl J. Med, 318:379, 1998a.
Retroviral testing: Essentials for Quality Control and Laboratory Diagnosis, Ed.
Constantine, N.T. Callahan, J.D. Watts, D.M. CRC Press, London, 1992.
Sterne JA, turner AC, Connel JA et al. Human immunodeficiency virus: GACPAT
and GACELISA as diagnostic tests for antibodies in urine. Trans. R. Soc. Trop.
Med. Hyg. 87:181, 1993.
92
Women and HIV
six
Women and HIV Infection

including Mother to Child
Transmission
Sudha Salhan
INTRODUCTION
In 1981 the first Human Immunodeficiency Virus infected case was
seen in USA. At that time it was considered a disease of males.
Now 21 years later the rapid increase in the number of women
infected with HIV worldwide forecasts an inevitably greater
number of women who will develop and die from acquired
immunodeficiency syndrome. Currently, almost half of new HIV
infections in the reproductive age group are women1,2. Hence,
worldwide the HIV risk for women is rising. And 9 out of 10
Table 6.1: AIDS and HIV infections in South-East Asia as of 1st March, 1999
Country
Bangladesh
Bhutan
DPR Korea
India
Indonesia
Maldives
Myanmar
Nepal
Srilanka
Thailand
Total
Reported
AIDS cases
10
1
0
6,252
230
5
2,312
183
77
83,357
92,427
Date of
last report
3/97
8/98
11/96
3/98
2/99
3/98
3/98
1/98
3/98
3/98
Estimated HIV
infections
21,000
< 100
< 100
4,000,000
25,000
< 100
440,000
25,000
6,000
950,000
5,600,000
Rate per
1,00,000
Population
16
< 16
<1
418
12
< 25
760
66
32
1,345
>358
Women and HIV Infection including Mother to Child
93
infected women live in a developing country. Black3,4 women have

a disparately increased infection rate.
From exclusive male disease HIV/AIDS
is now almost equally distributed in both sex
(#) 1996 population estimates for all countries except Bhutan are
based on UN population figures for mid 1994, with annual growth
rates applied.
As we see in Table 6.2, India has the maximum number of
estimated HIV infected cases as on 1st March 1999. It is estimated
that two adults get infected every minute and 0.5 million young
people, 230,000 women and 30,000 children get infected every year.
Though the country is vast the number is also substantial and must
alert us. In Mumbai, HIV seroprevalence doubled from 20 to 40
percent between 1992 and 1994 among male commercial sex works.
As in Africa, evidence suggests that the epidemic is spreading
rurally in India along commercial truck-routes5.
Table 6.2
AIDS cases in India (1986-30-4-2002)
Males
Females
Total
26473
6655
35128
Source: NACO
Because of the underecognition of HIV in women the actual

epidemic burden is probably greater that reported.
Factors Increasing Vulnerability of Females
Throughout the world unprotected heterosexual exposure is the
primary risk factor for HIV infection in adolescent and adult
females. More than four-fifth of all infected women get the virus
from a male sex partner; the reminder become infected from a blood
transfusion or from injecting drugs with contaminated needles.
More and more adolescent and younger females are becoming
victims of HIV.
94
Women and HIV

Table 6.3: Risk/transmission categories in India
No. of cases
Percentage
Sexual
Perintal transmission
Blood and blood products
Injecting drug users
Others (Not specified)
29666
838
1118
1124
2382
84.45
2.39
3.18
3.20
6.78
Total
35128
100.00
Source: NACO
Sexual Relationship
Sexual relationships of women are often with older men, who are
more likely to be HIV infected and at an advance stage of the
disease. This increases the risk of transmission6.
Male to Female Transmission of HIV
It is 2 to 17 times higher as reported by different workers than vice
versa. Padian et al 7 1995 reported a 17 times higher risk for females
while Nicolosi et al8 1994 reported a two fold increase in the
efficiency of male to female transmission when compared to female
to male transmission.
The Social Factor
In our country the custom of selecting significantly younger woman
as wives makes them culturally vulnerable to HIV infection at an
early age. Table 6.4 shows that women are infected with HIV even
at a very young age.
Table 6.4: Age group of HIV infected
Age Group
Male
Female
Total
0-15 years
15-29 years
30-44 years
> 45 years
825
8895
14556
2197
523
4071
3499
562
1348
12966
18055
2759
TOTAL
26473
8655
35168
Source: NACO
95
Biological Factor
As we see girls are married off at a younger age in our country.
Before 18-20 years of age the vagina is lined by a single columnar
layer, which offers only minimal protection against HIV infection
compared with multilayered stratified squamous epithelium lining
the vagina in females of 20 years or more in age. Younger womens
immature cervix (cervical ectopy) and relatively low vaginal mucus
production presents less of a barrier to HIV, making them
biologically more susceptible to infection. The same is true in
younger age of sexual abuse and child prostitutes. As a consequence
women are increasingly becoming infected with HIV at a younger
age than men. More girls are becoming infected in their teens and
early twenties than women of any other age group.
As compared to men, females have a large surface area of
mucosa exposed during intercourse to their partners sexual
secretions, which also stay there for a long time. Semen infected
with HIV typically contains a higher concentration of the virus
than womens sexual secretions. This makes male to female
transmission more effective than female to male. Sex during
menstruation and anal sex also favour male to female transmission.
Previous RTI/STI
As is well established, STD and RTI causing ulcers and discharge
increase the chances of HIV transmission9,10. Female patients with
STD present few symptoms and often go unnoticed and untreated.
Also, the chance of women reaching a health facility, where proper
treatment is available, is low. All these contribute to increasing the
number of HIV infected females.
Economic Factor
Women are economically dependent on men. Hence they cannot
insist on safe sexual practices, like the use of condoms, by males.
Urbanization, male migration, changing social structure, poverty
and gender inequality influence the risk of HIV infection among
women.
Blood
There is increased vulnerability to HIV transmission through
untested infected blood in women. Women receive blood
96
Women and HIV
transfusions more often than men because of anaemia and

complications of pregnancy and childbirth (including unsafe
abortions).
Marriage with an older man who is more likely to have HIV/
AIDS
Economic dependence on men
More efficient (2-17 percent) male to female transmission
than vice versa
Bigger surface area to acquire infection in women
RTI/STI goes unrecognized in women making them more
susceptible to HIV/AIDS
More blood transfusion in women
Adolescents are the biggest segment indulging in unsafe
sex practices.
To reduce the vulnerability of women to HIV infection it is
important to ensure support from men at all levels. Educational
programmes must focus on the media and other means of
dissemination of knowledge about how HIV spreads and how it
can be prevented. The responsibility of men and women in
preventing transmission by engaging in safer sex practices should
be given wide coverage. Increasing the age of marriage,
and providing economic independence to woman are important
steps.
Issues Concerning Pregnancy
HIV-1 is expected to infect 10 million children worldwide by the
year 2000 and a majority of these children have acquired their
infection as a result of mother-to-child transmission (MTCT)11.
Moreover over 5,90,000 children are infected with HIV each year
by vertical transmission12. Since women infected with HIV are the
major source of infection for infants, trends in HIV infection among
women forecast the impact of HIV in children.
Determinants of Vertical Transmission
The rate of vertical transmission of HIV from the mother to the
foetus varies between 15 to 45 percent13,14. The determinants of
transmission seem to be multifactorial and include maternal viral
97
load, viral prototype, obstetrical factors and maternal immune

response15.
Viral Load
Viral load in the mother is maximal immediately after infection
and in the advanced stage of the disease. Measurement of plasma
HIV-1 RNA and quantitative culture, especially the former, is a
better predictor of vertical transmissions. Data from studies shows
that neonatal infection of HIV is below 5 percent with less than
1000 copies/ml of plasma viralRNA burden and over 40 percent
with levels greater than 100,000 copies/ml. In the current era of
potent antiviral therapy these studies provide a scientific rationale
for measuring viral load in pregnant women both to predict risk
of transmission and to monitor antiviral therapy16.
Concurrent STI
This is also strongly associated with vertical perinatal HIV
transmission, e.g. Syphilis infection17.
Unprotected Sexual Intercourse
A high frequency of unprotected intercourse during pregnancy
was associated with an increased risk of transmission even after
the adjustment of multiple potent confounding variables18.
Maternal CD-4 and Lymphocyte Count
It is known that is an independent predictor of prenatal
transmission risk.
Mothers Neutralizing Antibody Monoclonal HIV-3
This may be a protective association.
Nutritional Status
Inadequate nutrition may increase the risk of vertical HIV
transmission by influencing maternal and child factors for
transmission. Micronutrient deficiencies are prevalent in many HIV
infected populations and it is reported that they impair systemic
98
Women and HIV
immune response, weaken epithelial integrity of the placenta and

the genital tract and are associated with accelerated HIV disease
progression. A number of trace elements including zinc are
involved in many immunologic impairments. Zinc deficiency is
also evident in HIV disease, most notably by a reduction in the
number of circulating T-lymphocytes. It causes an increased risk
of low birth weight and preterm births and impaired gastrointestinal immune function and integrity of foetuses and children.
More studies are underway to define the role of zinc in the vertical
transmission of HIV from mother to child19.
Low vitamin A levels during pregnancy were associated with
an increased transmission of HIV in a cohort of infected women in
Malawi. A 4.4 fold increase in transmission was seen if vitamin. A
level was less than 0.7 g/1(normal>1.4g/1); this was
independent of the CD4 count and the duration of membrane
rupture.20
Membranes
A correlation between the time elapsed from rupture of membranes
to actual delivery and an increased risk of transmission is known21.
Landersmen and associates (1996) reported that HIV-1 transmission
at birth was increased from 14-25 percent in women whose
membranes were ruptured for more than 4 hours22.
Type of Virus
The viral biological phenotype may influence the transmission risk.
Monocyte-macrophage tropic (M-tropic) maternal virus isolates
are reported to be more likely to be transmitted than maternal
isolates of T-cell tropic phenotype23.
Placental Barrier
Breaches in the placental barrier could lead to a mixing of maternal
and foetal cells. Conditions like chorioamnionitis, cigarette smoking
and illicit drug use are known to be associated with placental
disruption and hence cause an increased transmission risk24.
Presence and Amount of Virus in the Genital Tract
This may affect the transmission risk. HIV-1 DNA was detected in
32 percent of cervical and 10 percent of vaginal samples25.
99
Foetal Factor
Genetic differences in host cell susceptibility to HIV infection of
foetal cells have been reported. The susceptibility to infection could
vary with gestational age possibly because of development of CD4+
expression26. It has been reported that there is a 3.7 times relative
risk for intrapartum HIV transmission during preterm delivery,
perhaps because the newborns immune mechanism is immature.
Intensive exposure of the infants thin skin and mucosal surfaces
to maternal blood and secretions during the birth process could
provide a significant route for viral transmission.
Consistent with a possible route of HIV-1 transmission by oral
exposure, in one study HIV-1 was detected in the gastric aspirate
form 2 of 4 newborns who were subsequently shown to be
infected27.
Invasive procedures that breach the infants skin barriers could
provide another mechanism for viral entry (e.g. foetal scalp
electrode, scalp blood sampling, chorionic villus sampling
amniocentesis, cordocentesis) External cephalic version, episiotomy
and operative vaginal delivery also increase intrapartum
transmission to the foetus.
It is observed that there is a more than two-fold risk of infection
of the first-born twin as compared to second (26 percent versus 13
percent respectively) 28. These data suggest that the greater risk of
infection in the first born may be related to more prolonged
exposure of the presenting twin to infectious secretions in the
genital tract during the later stages of pregnancy and delivery.
Breastfeeding
Transmission via breast milk is supported by known transmission
of other retroviruses by milk, the detection of HIV-1 in the cellular
and acellular compartments of breast milk and reports of
transmission from mothers infected during the postpartum period29
or from an infected wet nurse.
There is evidence that breast-feeding increases postnatal
HIV-1 transmission by 10-20 percent31. Breast-feeding transmission
appears to result from the coexistence of HIV-1 and an inadequate
humoral response in milk. Hence complete avoidance of breastfeeding is the surest way to avoid MTCT of HIV through breastfeeding. Despite this, in underdeveloped countries, formula feeding
100 Women and HIV

may be impractical and associated with increased mortality from
diarrhoea and respiratory infection33. WHO has reported a six-fold
increase in the risk of mortality from diarrhoea in children of the
developing world who are not breast-fed in the first 6 months of
life and around a two-fold increased risk of mortality from
respiratory diseases. WHO and UNICEF (1998) 33 have
recommended exclusive breastfeeding, as malnutrition is the
primary cause of infant death in many developing countries. Infants
who are not exclusively breastfed appear to have a less chance of
HIV infection than those who are34.
The risk of transmission varies with the period of breastfeeding,
amount of exposure, infectivity of milk and specific susceptibility
of the infant. It was found that breast-feeding beyond 15 months
was associated with a 1.9 fold increased risk of infection. 32 percent
of HIV infection was attributed to breast-feeding beyond 15
months. It was calculated that the risk of HIV-1 transmission
exceeded the potential benefits of breast-feeding after 3-7 months
of age35. It is recommended to exclusively breast-feed the baby for
4-6 months only.
The newborns immature gastrointestinal tract may facilitate
transmission; gastric acidity is diminished in the newborn and the
mucosa and microvilli are thin with a deficiency in IgA secreting
cells. However an immature GIT is not a requirement, because
transmission has been reported in infants beginning breast-feeding
after the neonatal period.
The potential value of nevirapine used for a longer duration in
the breast-feeding population is under trial to further reduce the
risk of MTCT of HIV, particularly if combined with early weaning.
Caesarean Delivery
In 1994 the European collaborative study group reported that
elective caesarean delivery decreased the rate of MTCT of HIV
by approximately 50 percent. In the European mode of delivery
collaboration36 MTCT by caesarean section was not statistically
significant in pregnant women on antiretroviral therapy (vaginal
vs. caesarean is 2.1versus 3.3 percent). American college of
Obstetrician and Gynecologists conclude that scheduled caesarean
delivery should be discussed and recommended for HIV-infected
women with an HIV-1 RNA load of greater than 1000 copies/ml.
101
Scheduled delivery may be done as early as 38 weeks to lessen the

chance of membrane rupture37.
Some obstetricians38 concluded that combined antiretroviral
therapy (ART) may reduce the risk of vertical transmission to as
low as 2 percent or less. According to them prophylactic caesarean
delivery would be of benefit for only a small number ART treated
women and it will increase morbidity and mortality of the operative
procedures. It is also not possible in developing countries because
of the cost factor and significant increase in morbidity.
Newborn Immune Response
Reports of transient HIV-1 infection have suggested that the
newborn immune response to HIV-1 exposure may have a role in
averting MTCT of HIV. Several researchers have reported finding
a transient HIV-1 specific immune response in 18 to 40 percent
RATE OF VERTICAL TRANSMISSION 15-48 percent
Determinants
A. Maternal
Viral load
Biological prototype of virus
Unprotected sex during pregnancy
Smoking and illicit drug use in mother
Maternal level of CD4 and lymphocyte count
Low maternal zinc, vitamin A level
Presence of RTI/STI in mother
Time of rupture of membranes and chorioamnionitis more
than 4 hours
Episiotomy and operative vaginal delivery
Presence and amount of virus in genital tract
B. Foetal
Preterm foetus
Foetal ingestion of the virus.
Foetal scalp electrode, scalp blood sampling and umbilical blood sampling.
Duration of exposure to maternal secretions (first twin)
Via breast milk depending on the immune response of
the newborn and period of breast-feeding and infectivity
of mother.
102 Women and HIV

uninfected infants born to infected women. These data suggest that
cell-mediated immunity in the foetus or newborn may have a
crucial role in protection or clearance of infection39.
TIMING OF VERTICAL TRANSMISSION
The exact timing of HIV transmission from the mother to the foetus
or infant is not known with certainty. Some foetuses are infected
in utero, others in late gestation or during delivery or during
puerperium via breast milk in lactating mothers. However, the
relative proportion of transmission that occurs intra-partum versus
intra-uterine remains controversial. The current hypothesis is based
on experimental and clinical observations that support these three
different periods of transmission.40. Transplacental transmission
can occur early and the virus has been identified in early
pregnancies terminated by elective abortion41.
Fig. 6.1: Possible Routes of

Transmission
Intrauterine transmission is documented by HIV identified in placental

tissue, foetal blood samples and amniotic fluid, positive viral studies in
20-60 percent of infected infants at birth
and bimodal onset of symptoms with
early onset (<12 months) in > 30 percent.
In most cases however transmission
occurs during birth. Intrapartum transmission is inferred by HIV isolation
from cervicovaginal secretions, intrapartum exposure to blood, increased
infection rate in the first born twin,
virology and immunologic pattern,
negative viral studies at birth followed
by positive studies in the 1st month of
life in 40 to 80 percent of infected
infants, bimodal onset of symptoms
with late onset (>12 months) in 70 percent, HIV P24 antigen in cervicovaginal
secretions associated with increased
risk of infection, and association of
duration of membrane rupture with
risk of infection.
103
EFFECT OF PREGNANCY ON HIV DISEASE

According to CDC42 maternal morbidity and mortality are not
increased by pregnancy in seropositive but otherwise asymptomatic women.
The vast majority of HIV infected women are in their
childbearing years and fertility does not seem to be impaired except
in the end-stage severe immunodeficiency state. Minkoff and
co-workers43 studied HIV positive pregnant women and HIVnegative controls. Serious infections were found significantly more
often in the HIV positive group only if CD4 counts were lower
than 300 cells/mm3. No difference was noted with higher counts.
To date, the majority of data are unable to support the notion that
pregnancy enhances HIV diseases progression.
EFFECT OF HIV ON PREGNANCY
A high rate of preterm delivery was noted in women with CD4
cell count below 30 percent44. Stratton and colleagues reported that
adverse pregnancy outcome is common in HIV-infected women
and is associated with CD4 proportion of less than 14 percent. The
rate of preterm births was 20 percent and foetal growth restriction
was identified in 24 percent. Langston and associates45 reported
increased stillbirths with maternal HIV infection. Spontaneous
abortions and ectopic pregnancies are also reported more often. A
higher rate of genital ulcer disease, genital warts, syphilis serology
and post-partum endometritis was noted. Low CD4 counts
correlated with postpartum endometritis.
MANAGEMENT OF HIV POSITIVE PREGNANT WOMEN
Obstetricians are becoming increasingly involved in prenatal care
of HIVpositive women. Appropriate care of HIV infected women
depends on knowing their serostatus.
All pregnant women should receive HIV education and
counseling and be offered HIV testing as part of their regular
prenatal care so that all pregnant women learn their HIV status.
This is the national policy in Thailand. The HIV infected pregnant
woman should be provided with the appropriate background for
an informed reproductive choice. If she chooses MTP, safe MTP
services must be provided to her. If she prefers to continue her
104 Women and HIV

pregnancy, she should be told about the risk of vertical transmission
and her antepartum care should be tailored to her specific needs
preferably with ample psychological support. The knowledge of
their HIV infection will increase the opportunities for HIV infected
pregnant woman to prevent transmission to their children. Ideally,
counseling and testing should precede pregnancy so that
appropriate contraceptive advice can be given. Unfortunately,
many infected women do not seek or get prenatal care until the
3rd trimester. Of those who are tested positive in early pregnancy
and who choose to continue it, prenatal care will be somewhat
altered by serostatus. The clinician will also be watchful for the
early symptoms of HIV disease. The key to the appropriate care of
the HIV infected woman during pregnancy is optimal care of the
pregnancy and optimal care of the HIV infection.
General measures of proper diet, hygiene, rest, etc. are to be
strictly followed. Nutritional counseling should be instituted if
difficulty is encountered in maintaining appropriate weight gain.
She must have enough sleep and must avoid stress and fatigue.
Alcohol, smoking, and illicit drugs should be prohibited. Prevention of opportunistic infections is also a critical goal for the
obstetrician. As CD4 counts decline and viral load climbs, the
patient becomes susceptible to an array of infections. At the
current time, critical landmarks for the introduction of prophylaxis include CD4 count of <=200 cells per mm3 when Pneumocystis
carinii pneumonia may occur. Obstetricians must be vigilant for
the signs and symptoms of opportunistic infection (as CD4 count
is a costly affair in underdeveloped countries) and must initiate
appropriate prophylactic therapies (trimethoprim sulphamethoxazole or pentamidine). CD4 counts<=100/mm3 may invite
Toxoplasma gondii infection and at counts <=50/mm 3 MAC
(Mycobacterium avium complex) and perhaps CMV (Cytomegalovirus) conjunctivitis can occur46. Screening for tuberculosis is to
be done. Appropriate prophylaxis should be started and may need
modification.
Obstetric management (i.e. decisions regarding monitoring
obstetric problems and choosing candidates for timing of induced
delivery) is uninfluenced by a womans serostatus.
Controversy exists regarding vaccination because the associated
viraemia during pregnancy poses the theoretical risk of increasing
the rate of antepartum transmission of HIV.
105
INTERVENTIONS AIMED AT DECREASING THE

RISK OF MOTHER TO CHILD TRANSMISSION (MTCT)
OF HIV INFECTION
The prevention of the vertical transmission of HIV from mother to
child can be done by following the broad principles given below.
Counseling
Counseling is mandatory for the HIV-positive woman. This is
preferable early in pregnancy and if she chooses to continue
pregnancy, ongoing counseling for psychological support is
important. Because of the devastating consequences of this
infection, if untreated, a shift has occurred from exclusive
protection of the foetus to mother and foetus protection from HIV
infection.
General Measures
The mother should be kept in good health. Treating malnutrition
in pregnant mothers helps in reducing MTCT47. Testing for other
sexually transmitted diseases and for tuberculosis is carried out. If
detected they are to be treated vigorously.
Obstetric Measures
Obstetric measures are of considerable importance. Prevention and
treatment of chorioamnionitis and discontinuation of cigarette
smoking and illicit drug use during pregnancy could have
important roles in reducing the transmission. Rupture of
membranes should not be carried out. Mwanyumba and associates
(2002)48 have seen that acute chorioamnionitis is independently
associated with peripartum HIV-1 transmission. They concluded
that approximately 3 percent of MTCT could be prevented if acute
chorioamnionitis is eliminated by antimicrobial treatment.
Systematic birth canal cleaning has been attempted49. As a large
proportion of mother-to-child transmission is thought to occur at
the time of delivery, it is suggested that a low cost, low-tech
approach, which could be adopted in many developing countries,
is to disinfect the vagina prior to and during labour. Several agents
have been suggested as potential candidates because of their
in vitro activity against HIV, e.g. Benzalkonium chloride, chlorhexidine, nonoxynol 9, betadiene, chlorine bleach, etc.
106 Women and HIV

Invasive procedures on the foetus like foetal scalp electrode or
foetal scalp blood sampling, umbilical cord blood sampling, etc.
are to be avoided during labour. Also avoid episiotomy and vaginal
operative delivery, if possible.
Giving a bath to the baby immediately after birth is useful to
wash off the HIV virus on the foetal body as it might get a foothold
on the skin of the newborn. Mild disinfectants or baby soap and
plain running water can be used. In fact, mechanical cleaning may
play an important role.
Immunological
Immunological approaches are based on the assumption that more
transmission occurs at or around the time of delivery and that a
combination of passive and active immunization will be effective
in the transmission. At this stage, however vaccine is a concept
rather than a reality. Passive protection using HIV IgG is presently
under investigation (ATGT, 185). Use of hyperimmune anti-HIV
immunoglobulin given I.V. to the baby alone or also to the mother
may reduce perinatal HIV transmission. Protocols to test
neutralizing monoclonal antibodies are in the developmental stage.
Early umbilical cord clamping is thought to decrease the chance
of maternal blood containing HIV crossing over to the foetus. Close
ANC CARE
Counseling and knowing HIV status (Preferably before
pregnancy)
Choice of MTP or continuation of pregnancy
Correct diet and anaemia
Discontinue smoking and illicit drugs
Regular check-up
Treat RTI/STI
Detect and treat opportunistic infection
Delivery in hospital
Do not do amniotomy, foetal scalp electrode monitoring,
foetal scalp blood sample or umbilical blood sampling.
Avoid Episiotom y and Vaginal Operative Delivery (If
possible)
Systematic cleaning of birth canal Immunotherapy
Immediate bath to baby and antiretroviral therapy.
107
monitoring of CD4 cell count should be a routine. If possible

Pneumocystis carinii pneumonia prophylaxis should be started for
women with CD4 count below 200/mm3 with trimethoprimsulphamethoxazole or, if resistant, with pentamidine.
Antiretroviral Drugs
Use of antiretroviral drugs among HIV-infected pregnant women
in many developed countries has significantly reduced rates of
MTCT of HIV, demonstrating that this route of transmission is amenable
to intervention.
ZIDOVUDINE
In trial ACTG 076 HIV transmission rate was reduced by
approximately 2/3rd. At 14 weeks of gestations zidovudine 100
mg 5 times a day is given until labour. During labour a loading
dose of 2 mg/kg over the first hour is given followed by a
maintenance dose of 1 mg/kg/hr until delivery. In the neonatal
period oral zidovudine syrup 2 mg/kg orally four times a day for
6 weeks is given. Monitoring of the mother while she is on the
regimen include complete blood count every 2 weeks(on two
occasions) and then every month, liver function test every month
and serum creatinine level every month. Therapy is discontinued
if the haemoglobin is < 9 mg/dl, platelet count < 100,000 cu/mm3
granulocytes are < 1000 cu/mm3 , SGPT and SGPT are greater than
two times normal or there are serious cardiac, respiratory,
neurologic or gastro-intestinal problems50.
In a more recent trial conducted in Thailand, a short course
of Zidovudine regimen given from 36 weeks of pregnancy and
during labour is compared with no treatment 35 . 300mg of
zidovudine is given orally twice a day from 3 weeks of gestation
until onset of labour. Then 300 mg is given every 3 hours from
onset of labour to delivery. The newborn is given zidovudine
syrup 2 mg./Kg for one week. All women are provided with
infant formula and are counseled against breast-feeding. There
are four types of courses of Zidovudine therapy practised at
present
1. Short-Short Zidovudine coursefrom 35 weeks in pregnancy for the mother and for the baby until three days old.
108 Women and HIV

2. Long-Long Zidovudine coursefrom 28 weeks in pregnancy
for the mother and for the baby until 6 week old.
3. Long-Short Zidovudine coursefrom 28 weeks in pregnancy
for the mother and for the baby until 3 days old.
4. Short-long Zidovudine coursefrom 35 weeks in pregnancy
for the mother and for the baby until 6 weeks old.
Long-Long, long-short and short-long Zidovudine courses did
not differ much in efficiency. But the rate of transmission using a
short-short course of Zidovudine was found to be higher52.
NEVIRAPINE(HIV/NET 0/2)
It is given to pregnant women as a single dose (200 mg tablets) at
the onset of labour, within 4 hours of delivery and to the baby
(2 mg/kg) as a single dose within 72 hours of birth. This has been
shown to be more effective than an intrapartum and postpartum
regimen of Zidovudine.
But when nevirapine is given to mothers already receiving
standard antiretroviral therapy (for their HIV infection), there
appears to be no additional advantage, possibly because the risk
of transmission in this group of women has already been reduced
to less than 1.5 percent. Development of nevirapine resistance by
the HIV virus is sometimes reported. Nowadays Nevirapine is the
drug of choice for MTCT as it is cheap, easy to administer and
highly effective even following a single dose.
At present the most promising avenue of approach is through
the use of ART and this option should be discussed with the HIV
infected pregnant women. The long-term effect of this therapy is
unknown.
COMBINED THERAPY
Preliminary findings of the effect of combined therapy using
Zidovudineand Lamivudine (3TC) suggest a decrease in the risk
of MTCT when the combination is given during the antenatal and
intrapartum period compared with placebo.
Results indicate a significant decrease in the transmission risk
of the neonate. The reduction rate is similar to the long course
treatment trial.
109
Trials on different combinations of anti-HIV drugs and

hydroxyurea and are ongoing and their effects on mother to child
transmission are not available yet.
For successful prevention of mother to child transmission of
HIV, family planning does play an important role.
There is no evidence that intrapartum Zidovudine or
Lamivudine alone are sufficient to decrease the risk of transmission
compared with placebo.
PRECAUTIONS TAKEN
Precautions Taken During MTP or
Delivery of HIV Positive Women
Stringently following universal precautions in the labour room and
delivery area is essential to prevent infection of the conducting
doctor and those who clean the area after delivery.
Fig. 6.2: Equipments to be used in labour room

as a precautionery measure
Fig. 6.3: Shows a well

covered person
Barrier
The most convenient and practical procedure is disposable gloving,
hand washing, special gown or suit, mask, boot, eyeglass, eye-shield,
110 Women and HIV

automatic water tap. The mucous trap is attached to ward suction.
The pressure should be less than 140 mm Hg to prevent theoretical
damage to neonatal gut. Once the child is born universal precautions
should be exercised by the Pediatric care provider. Gloves should
be worn until all secretions have been removed from the skin.
Disinfectant Solution
0.5 percent Sodium hypochlorite or household bleach for
cleaning.
10 percent Lysol for cleaning metallic table and chairs.
Dip all linen in household bleach (1 percent) for half an hour
before sending to laundry.
Put placenta in a bag with bleaching powder and either burn or
bury with bleaching powder in the soil.
Precaution during Operation
Double gloving (Special punctureresistant gloves if available)
Untouched technique
Using eyeglasses, shield, special gowns and boots.
DURING DELIVERY
*Precautions by Obstetrician
Universal Precaution
Gloves
Gown
Mask
Boots
Eyeglasses
Mucous Trap
Eye Protection Shield
Automatic Water Tap
HIV-EXPOSED NEWBORN
The actual HIV status of the newborn cannot be obtained up to
18 months of delivery, as the mothers antibodies are present in
the neonate till 18 months of age. Polymerase chain reaction (PCR)
and p24 antigen analysis, which are very costly and not available
at all places, give the true picture of HIV status of the newborn
111
before 18 months of age. So the HIV exposed newborn must be

followed for 18 months of age and the mother should be counseled
about the merits and demerits of breast-feeding.
GYNAECOLOGICAL CARE
Health care practitioners fail to consider an underlying HIV
infection when a woman is admitted with viral infection. There
are gender differences in the relative distribution of the cytochrome
P450 enzyme. This is important as p450 enzymes metabolize 2 of
the 3 major classes of antiretrovirals in use. Treatment strategy
paradigms developed for men may not be optimal strategies for
women, e.g. the viral load is lower in women earlier in the disease
process but the mechanism and clinical implications are still
unknown.
Preliminary data from womens Interagency HIV study
(WIHS) 53 suggest that HIV infection with a CD4 count less than
200/mm 3 is associated with an increase in the prevalence of
amenorrhoea. Oesophageal candidiasis occurs 30 to 50 percent
more commonly in women54. Chronic Herpes simplex infections
may be more likely to develop in women than in men. The most
common conditions that manifest differently in HIV infected
women are gynecological infection, including vaginal infections
of candidiasis, trichomoniasis and bacterial vaginosis. The WIHS
reports a 10-fold increase in genital warts in HIV infected women.
HIV infected women have a higher prevalence of CIN and higher
rate of human papilloma virus infection than non-HIV infected
women55. Hence pap screening can be incorporated into HIV
infected womens care.
Women infected with HIV may have more frequent and severe
episodes of PID (pelvic inflammatory disease)56.
GYNAELOGICAL DISEASES IN HIV/AIDS INFECTED
WOMEN
More Oesophageal Candidiasis
More Trichomoniasis
More PID
More CIN & Human Papilloma Virus Infection
112 Women and HIV

CONTRACEPTION AND HIV
In HIV infected women there is dual risk of STDs (including HIV/
AIDS) and unwanted pregnancy. These women may face a
heightened risk of HIV transmission depending upon their choice
of contraceptive method.
Intrauterine Contraceptive Devices
The intrauterine contraceptive devices (IUCD) may cause increased
bleeding and thus an increased number of infected cells in the lower
genital tract. IUCDs have been associated with an increased risk
of pelvic inflammatory disease (PID) and may increase the risk of
HIV transmission.
Barrier and Spermicide
On the other hand, condoms (and to a lesser extent) spermicidal
and cervical caps may lower the risk of HIV transmission but are
not excellent contraceptive measure. Female condoms, when freely
available, will become a better contraceptive choice (as its use will
be under the control of the woman). Spermicidal drugs are used in
the absence of vaginal inflammatory reaction to them. In some
women using nonoxynol-9 spermicidal impregnated vaginal
sponge (Today) there was an increased frequency of genital ulcer,
vulvitis and HIV57.
Oral Contraception
Oral contraception is a very efficient contraception method. But
cervical ectopy, which can result from them, may increase HIV
transmission and acquisition. Oestrogen may impair cell-mediated
immunity suppressing mucosal plasma cells, by decreasing level
of secretory IgA or by altering T-lymphocyte function58.
Drug interactions have been reported with the use of oral
contraceptive and antitubercular drugs, e.g. rifampicin has been
shown to increase the metabolism of oral contraceptives. In a
preliminary study ritonavir was found to decrease ethinyl
oestradiol concentrations in 23 women59. These interactions are
expected to lead to a decrease in contraceptive efficiency.
Thus we see that no single agent provides ideal contraceptive
efficiency and good protection against STD acquisition for women
with HIV.
113
If the family is complete, in an HIV positive women, tubal

sterilization /vasectomy and the use of condoms will be ideal. But
it is difficult to insist on condom use within marriage. The
advantages of the use of two methods at the same time must be
made clearer in public campaigns. This may increase their use.
Norplant with condom use may be considered for spacing but
if there is more bleeding during periods the method is to be
discontinued.
NATURAL HISTORY OF HIV DISEASE IN WOMEN
The overall differences between the natural history of HIV disease
in females and males are minimum, the exception being that there
is more oesophageal candidiasis and genito-urinary cancers and
infections in women. Hence the management is to be similar to
that of males as given in other chapters of the book.
ETHICS AND HIV DISEASE IN WOMEN
Before testing for HIV their pretest counseling must be carried out,
after taking an informed written consent and ensuring complete
confidentiality. A pregnant woman is concerned about her unborn
child. Hence while framing the HIV testing policy of a country we
must keep HIV positive pregnant women in mind. She has the
right to information as to her HIV status and the effect on her
unborn child, influence of breast-feeding and even the effect of
antiretroviral therapy. She must know the side effects of these
drugs.
CONCLUSIONS
Each country needs to take into account the features of the HIV
and AIDS epidemic that are peculiar to it, its infrastructure use
and the resources that are available.
Obstetrician and Gynaecologists have to consistently fulfill the
obligation to advocate the health of women. For this to keep abreast
with the most recent developments in HIV/AIDS is essential.
Keeping utmost secrecy and non-insistent (but gentle) persuasion
to bring her partner along will bear better fruits as otherwise she
will disappear from your care and will report only when she is in
a very advanced stage of the disease and has spread it without any
114 Women and HIV

knowledge. Reaching the adolescents and giving them knowledge
of safer sex practices is the need of the hour; the most unfortunate
part of this epidemic of HIV is that theirs is the most affected group.
Reaching adolescent girls is difficult as in India most of them are
out of school by this age. Extensive dissemination of health
information through the media is essential to prevent the HIV
epidemic from spreading.
REFERENCES
1. AIDSCAD, Family Health International, Harvard School of Public Health
USAIDS, the Status and Trends of the Global HIV/AIDS Pandemic Symposium,
Final Report Vancouver July 6-7, 1996.
2. Tarantola DJ, Mann JM: Global expansion of HIV infection and AIDS. Hosp.
Pract: 31:63, 1996.
3. Centres for disease control and prevention: MMWR 47/RR-2: 1, 1998.
4. Haverkos HW, Tumer and F Jr.Moodchan ET, Cadet JL: Relative rates of AIDS
among racial/ethnic groups by exposure categories. J.Natl Med Association 91:17,
1999.
5. USAIDS Fact Sheet: HIV/AIDS, The Global Epidemic, December 1996.
6. European Study Group on heterosexual transmission of HIV: Comparison of
female to male and male to female transmission of HIV in 563 stable couples.
BMJ 304:809-813, 1992.
7. Padian NS, Shibiski SC, Jewell NP: Female to male transmission of HIV. JAMA
266:1664, 1991.
8. Nicolosi A, Correa Leite ML, Musicco M et al: The efficiency of male to female
and female to male sexual transmission of the HIVA study of 730 stable
couples: Epidemiology, 5:570, 1994.
9. Lage M, Nzila N, Manoka AT et al: Non ulcerative sexually transmitted diseases
as risk factors for HIV transmission in women: Result from a cohort study.
AIDS 7: 95, 1993.
10. Tumweisigye E. Loue S, Mortimer EA Jr et al: Changing prevalence of HIV
infection and the clinical findings in women attending a Ugandan STD clinic:
In programs and Abstracts of the 4th conference on Retrovirus and
Opportunistic infection. Washington DC, 98, 1997.
11. Chin J: Global estimates of HIV infection and AIDS cases 1991. AIDS:5
(suppl. 2): S57-S61, 1991.
12. UNAIDS: Report of a global HIV/AIDS epidemic. December 1997.
13. Anastos K, Devenbarg R, Soloman L, HIV infection in women, Medical clinics
of North America: 10(2): 533-537, 1997.
14. European Collaborative Study, Risk factors for mother to child transmission of
HIV, 339:1007-1012, 1992.
15. Scarlatti G: Paediatric HIV infection. Lancet, 348: 863-868, 1996.
16. Dickover RE, Garrathy EM, Herman SA et al: Identification of levels of maternal
HIV-1, RNA associated with risk of perinatal transmission JAMA 275: 599-605,
1996.
115
17. Lee MJ, Hallmark RJ, Frenkal LM et al: Maternal syphilis and vertical perinatal
transmission of HIV type 1 infection. Int J. Gynaecol Obstet 63:247, 1998.
18. Matheson PB, Thomas PA., Abrams EJ et al: Heterosexual behaviour during
pregnancy and perinatal transmission of HIV-1 AIDS 10:1049-1056, 1996.
19. Kupka R, Fawzi W: Zinc Nutrition and HIV infection. Nutr. Rev 60(3) 69-79
2002.
20. Semba RD, Miotti PG, Chiphangwi JD et al: Maternal vitamin A deficiency and
mother to child transmission of HIV-1. Lance 343:1593-1597, 1994.
21. Minolf H, Burns ON, Lendesmen S, et al: The relationship of the duration of
ruptured membrane to vertical transmission of HIV-1. Amer J. Obst. Gynaecol.
173: 585-589, 1995.
22. Landesman SH, Kalish LA, BurnDN, Minkoff H et al: Obstetric factors and
the transmission of HIV type from mother to child N ENGL J Med 334:1617,
1996
23. Reinhardt, PP Reinhardt B, Lathey JL et al: Human cord blood mononuclear
cells are preferentially infected by non-syncytium-including macrophage-tropic
HIV-I isolates, J.Clin Microbiol, 33: 292-297, 1995.
24. St. Louis ME, Kemenga M, Bandayo J et al: Risk for perinatal HIV-1 transmission
according to maternal immunologic, virologic and placental factors, JAMA 269:
2853-59, 1993.
25. Jenkins M, Landers D, Williamens-Herman, D, et al: Association between
HIV-1 antibody dependent cellular cytotoxicity antibody titres at birth and
vertical transmission of HIV-1. J. Infect. Disease. 70:308-312, 1994.
26. Just JJ, Abrams E, Louie CG, et al: Influence of host genotype on progression to
AID syndrome among children infected with HIV-1. Paediatrics, 127:544-549,
1995.
27. Nielsen K, Boyer P, Dillon M, et al: Presence of HIV-1 and HIV-1 specific
antibodies in cervico-vaginal secretions of the infected mother and the gastric
aspirates of their infants. J Infect disease 173: 1001-104, 1996.
28 Landesmen, SH, Kailash, LA Burns DN et al: Obstetrical factors and the
transmission of HIV-1, from mother-to-child. The women and infants
transmission study, N.Engl. J.Med. 334: 1617-1623, 1996.
29. Nicoll A, Nawell M.L, Van Praag E, et al: Infant feeding policy and practice in
the presence of HIV-1 infection. AIDS, 9: 107-119, 1995.
30. Dunn Dt, Newell ML Ades AE, Peckham CS: Risk of HIV-1 Transmission
through breast-feeding, Lancet 340:585, 1992.
31. Nduali R, John G, MboriNgacha D et al: Effect of breast feeding and formula
feeding on transmission of HIV-1.A randomized clinical trial JAMA 283:1197,
2000.
32. DeCook KM, Folwer MG, Mercier E et al: Prevention of mother to child HIV
transmission in resource-poor countries JAMA 283:1175,2000.
33. United Nations Children Fund: The State of Worlds childrenBreast milk and
transmission of HIVPanel 6-UNICEF home information participation
organization activities, 1998.
34. Kunn L, Peterson I: Options for Prevention of HIV transmission from mother
to child with a Focus on developing countries. Paediatra. Drug. 4(3) 191-203,
2002.
116 Women and HIV

35. Minkoff HL: Preface HIV disease in pregnancy. Obstt and Gynae, Clinic of North
AM.24: 4:1977.
36. European Collaborative Study: Maternal viral load and vertical transmission
of HIV-1: An important factor but not the only one AIDS 13:1377,1999.
37. Gracial PM, Kalish LA, Pitt J, et al: Maternal levels of plasma HIV Gynae, RNA
and the risk of perinatal transmission N.Engl. J Med 341:394, 1999.
38. Striger JSA, Rouse DJ, Goldenberg RL: Prophylactic Caesarean delivery for the
prevention of perinatal HIV Transmission JAMA 281:1946,1999.
39. Clerici M, Sison AV, Berzofsky IA, et al: Cellular immune factors associated
with mother-to-infant transmission of HIV AIDS 7: 1427-1433, 1993.
40. Mofenson LM: Epidemiology and determinants of Vertical HIV transmission,
Semin Pediatr Infect Dis. 5: 252-256, 1994.
41. Lewish SH, ReynoldsKohler C, FOXHE and Nelson JA: HIV-1 in trophoblastic
and villain Hofbaucer Cells and haematological precursors in 8-week fetuses.
Lancet 335:565, 1990.
42. Centers for Disease Control and Prevention: 1998 Guidelines for treatment of
Sexually Transmitted diseases. MMWR 47:1, 1998 b.
43. Minkoff HL, Henderson C, Mendes H, et al: Pregnancy outcome among mothers
infected with HIV and uninfected control subjects, Amer J. Obst Gynaecol. 163:
1598-1609, 1990.
44. Stratton P, Tuomala RE, Abbound R et al: Obstetrics and new born outcomes in
a cohort of HIVinfected pregnant woman: J Acquired Immune Deficiency
Syndrome Retroviral 20:179, 1999.
45. Langston C, Lewis DE, Hammill HA et al: Excess Intrauterine fetal demise
associated with maternal HIV infection. J.Infect. Dis. 172:1451, 1995.
46. Minkoff HL: Preface HIV disease in pregnancy. Obst and Gynae, Clinic of North
Am. 24:4:1977.
47. Andimen WA: Transmission of HIV-1 from mother to infants Curr Opin Pediatr
14(1) 78-85, 2002.
48. Mwanyumba F, Gaillard P, Inion I: Placental Inflammation and Perinatal
Transmission of HIV-1 J.Acquired Immuno Deficiency Syndrome. 29 (3) 26269, 2002.
49. Biygar RS, Miotti, PGTahe, T.E et al: Perinatal intervention trial on Africa: effect
of birth canal cleaning intervention to prevent HIV transmission. Lancet, 347:
1647-1650, 1996.
50. Connor EM, Sperling, RS, Gelber R, et al: Reduction of Maternal-infant
Transmission of HIV-1 with Zidovudine treatment. New Engl J. of Med: 331:
1173-1180, 1994.
51. Vuthipongse P, Bhadrakom, C, Chisilwattana, P, et al: Administration of
Zidovudine during late pregnancy and delivery to prevent perinatal
transmissionThailand 1996-1998. Morbidity and Martality weekly report
(MMWR): 47: 151-154, 1998.
52. Brochlehurst P, Volmink J.Antiretrovirals for reducing the risk of mother to
child transmission of HIV infection. The Cochrena Library Issue), (Update
Software), 2002.
53. Grant I, Anastok K, Ernst J: Gender differences on AIDS defined illness
presented at 7th International Conference an AIDS, Florance, 1991.
117
54. Delepene R, Greenblatt RM, Barkan S, et al: The womens inter-agency HIV
study (WIHS) 11th International Conference on AIDS, Vancouver, 1996.
55. Vermund SH, Kalley KF, Klein RS, et al: High risk of HIV infection and CIN
Lesions among women with symptomatic HIV infection. Amer J. Obstet-Gynaecol,
165: 392-400, 1991.
56. Kimani J, Maclean IW, Bwaya JJ, et al: Risk factors for Chlamydia trachomatis
pelvic inflammatory disease among sex workers in Nairobi, KenyaJ. Infect
Dis 173: 1437-1444, 1996.
57. Kreiss J, Ngngi E, Holmes K et al: Efficiency of Nonoxynol 9 contraceptive
sponge use in preventing Heterosexual acquisition of HIV in Nairobi Prostitutes
JAMA 268:477-482, 1992.
58. Mostad S, Welch M, Chohan B, et al: Cervical and Vaginal HIV-1, DNA
Shedding in female STD clinic attenders. Abstract Wec 333 presented at the XI
International Conference on AIDS, Vancouver, 1996.
59. Ouellet D, Hsu A, Qian J, et al: Effect of ritonavir on the pharmacokinetics of
ethinyl oestradiol in healthy female volunteers. Abstract, M.O.B. 1198, presented
at the XI International Conference on AIDS. Vancouver, 1996.
118 Women and HIV
seven
Management of HIV
Infected Individuals
Naveet Wig
ABSTRACT
Equality of the sex is prime objective, which the world desires to achieve. HIV
infected women in the world are increasing fast. Women at peak reproductive
age group are getting infected silently particularly in developing countries and in
areas where awareness of HIV is negligible. The high incidence of STDs and
lack of safe sex practices make situation even worse. Unwillingness to use
condoms by both partners adds to the problem. Further number of women
participating in HIV clinical trials worldwide is very low. More aggressive
combination drug regimens that maximally suppress viral replication is
recommended. Commonest presenting clinical features include fever, weight
loss, loss of appetite, cough, diarrhea, oral ulcers, cachexia, oropharyngeal
candidiasis and lymphadenopathy. Tuberculosis is the commonest infection.
Oral candidiasis, persistent diarrhea, PCP, oesophageal candidiasis, recurrent
pneumonia and cryptococcal meningitis are other common opportunistic
infections. Motherhood is the immense desire of all women and hence cannot
be denied. Proper counseling should be available for HIV-infected women so
that they can make informed choice. Although considerations associated with
pregnancy may affect decisions regarding timing and choice of therapy,
pregnancy is not a reason to defer standard therapy. Standard antiretroviral
therapy should be discussed with and offered to HIV- infected pregnant women,
though for poor patients high cost of such therapy makes it difficult to afford.
Short course oral ZDV and nevirapine is the minimum, which should be offered
to all HIV-infected pregnant women. It is the responsibility of the Government
and non-governmental organizations (NGOs) to help of HIV- infected
pregnant women. Immediate availability of Post-exposure prophylaxis drugs to
prevent the occupational exposure to HIV is must for the safety of healthcare
workers.
Management of HIV Infected Individuals
119
INTRODUCTION
Human immunodeficiency virus (HIV) has achieved epidemic
proportions. The burden of HIV disease is greater in developing
world. It is particularly important since most of infected women
are in peak reproductive age group and, coupled with their lower
socio-economic and educational levels, it is going to become
impossible to control this epidemic. Just use of antiretroviral
therapy, particularly for the prevention of perinatal transmission
of HIV will prevent many new infections in the newborns.
Clinical Management of HIV-infected Women
People with HIV/AIDS experience a variety of health care and
social support needs during the course of their illness. Continuum
of care is haunts these individuals. The benefits of investing on
care are many folds. The suffering is reduced and quality of life
improves. Economic and socially productive activity is also
prolonged.
A major drawback is the persistence of stigmatization and
discrimination. Worldwide people living with HIV/AIDS (PLWAs)
have become open about their illness and face the challenges of
this infection. This helps to reduce the stress and the burden of the
disease on the communities. Inappropriate negative attitude must
be dispelled. As soon as the infection is identified, not only the
person concerned but also the entire family is subjected to
innumerable problems ranging from harassment to total isolation
in the community.
Numbers of women in HIV clinical trials worldwide have been
low. Reasons for low numbers need to be looked into. There are
small studies available, which have shown comparable results in
both men and women on antiretroviral therapy. There has been no
gender-specific analysis in trials of prophylactic therapies.
At present treatment of opportunistic infections, care and social
support remains the mainstay of management in India.
Antiretroviral therapy to all HIV infected pregnant women is of
great importance in preventing mother to child transmission and
many trials have been conducted around the world including
India1. Trial of cocktail therapy has shown lots of hope for these
individuals. I shall be discussing the clinical spectrum of HIV
infection and antiretroviral therapy.
120 Women and HIV

Clinical Spectrum of HIV/AIDS
The clinical consequences of HIV infection encompass a spectrum
ranging from an acute syndrome associated with primary infection
to a prolonged asymptomatic state to advanced disease. HIV
disease begins at the time of primary infection and progressing
through various stages. Virus replication and progressive
immunologic impairment occur throughout the course of HIV
infection in most patients. With the exception of long-term
nonprogressors, HIV disease progresses even during the clinically
latent stage. HIV disease can be divided empirically on the basis
of the degree of immunodeficiency into an early stage (CD4+ T
cell count >500/uL), an intermediate stage (CD4+ T cell count 200
to 500/uL), and an advanced stage (CD4+ T cell count <200/uL).
Most AIDS-defining opportunistic infections and true malignancies
occur in the advanced stage of disease, while neurologic disease
and Kaposis sarcoma are not as strictly related to the degree of
immunodeficiency. The US Centers for Disease Control (CDC)
Classification System for staging HIV disease is given in Table 7.1
and this relies on clinical conditions. This is to be distinguished
from the CDC case definition for AIDS2. (Tables 7.2 to 7.4) and
Indian case definition1 for AIDS (Table 7.5) which are used for
surveillance purposes.
While the definition of AIDS is complex and comprehensive,
the clinician should not focus on whether AIDS is present but
should view HIV disease as a spectrum ranging from primary
infection, with or without the acute syndrome, to the asymptomatic
stage, to advanced disease. I shall discuss the clinical syndromes
like the acute syndrome, the asymptomatic stage, early
symptomatic disease, neurologic disease, secondary infections,
neoplasms, organ-specific syndromes seen in patients with HIV
disease and our own experience.
Group I: Acute Retroviral Syndrome
Acute retroviral syndrome or primary HIV infection occurs in
50 to 70 percent of infected patients following infection with HIV.
The diagnosis is often missed, as symptoms are nonspecific and
there is lack of awareness. Onset of symptoms is with in 2 to 4
weeks. Typical symptoms include fever, lymphadenopathy, pharyngitis, erythematous maculopapular rash, and myalgias or
121
Table 7.1: Centers for Disease Control Classification

System of HIV disease
Group I
Group II
Group III
Group IV
Subgroup A
Subgroup B
Subgroup C
Subgroup D
Subgrop E
Acute Primary Syndrome

Asymptomatic disease
Persistent generaized lymphadenopathy
Other diseases
Constitutional Disease
Neurologic disease
Secondary Infectious diseases
Secondary Neoplasms
Other conditions
Source: Modified form Centers for Disease Control and Prevention (USPHS)
1986 and 1987
Table 7.2: 1993 Revision of the CDCs AIDS surveillance
case definition for adolescents and adults
According to this system, individuals are assigned a stage according to three
CD4+ cell count categories and three clinical categories.
CD4+ cell count categories are as follows:
Category 1: CD4+ count greater than or equal to 500 cells/mm3 or 29%

Category 2: CD4+ count equal to 200-499 cells/mm3 or 14-28%
Category 3: CD4+ count less than 200 cells/mm3 or less than 14%
Clinical categories are as follows: documented HIV infection and
Category A: Asymptomatic, including PGL; or acute HIV infection.
Category B: Symptomatic disease, conditions not listed in clinical Category C,
including conditions such as: bacillary angiomatosis; persistent or
recurrent thrush; poorly responsive vulvovaginal candidiasis; moderate
to severe cervical dysplasia; constitutional symptoms such as fever
(38.5° C) or diarrhea greater than one month; oral hairy
leukoplakia; herpes zoster (greater than 1 episode or greater than
one dermatome); ITP; listeriosis; PID; and peripheral neuropathy.
Category C: AIDS indicator condition, once a Category C condition has occurred
the individual remains in Category C (Table 1 -AIDS Indicator
Conditions).
According to the 1993 Case Definition for AIDS, individuals with stage A3, B3,
C1, C2, or C3 infection have CDC-defined AIDS. Specifically, any individual with
either an AIDS indicator condition or a CD4+ count less than 200 cells/mm3 has
AIDS.
arthralgias. Primary HIV infection should always be considered

in patients presenting with febrile illnesses resembling mononucleosis or other nonspecific viral syndromes. The HIV serology
is usually negative in patients with primary infection. The diagnosis
122 Women and HIV

Table 7.3: 1993 AIDS surveillance case definition for
adolescents and adults
CD4+ Cell
Categories
Clinical Categories
A. Asymptomatic, PGL, B. Symptomatic
or acute HIV infection
1. > 500/mm3
(>/= 29%)
2. 200-499/mm3
(14%-28%)
3. < 200/mm3
(< 14%)
C. AIDS indicator
condition
A1
B1
C1
A2
B2
C2
A3
B3
C3
Key Point: The 1993 CDC Case Definition for AIDS includes all patients with CD4+
count less than 200 cells/mm3, and all those individuals with an AIDS indicator
condition.
Table 7.4: AIDS indicator conditions in the 1993
CDC case definition for AIDS (Adults)
Candidiasis, of esophagus, trachea, bronchi or lungs

Cervical cancer, invasive*
Coccidioidomycosis, extrapulmonary*
Cryptococcosis, extrapulmonary
Cryptosporidiosis with diarrhea greater than 1 month
Cytomegalovirus of any organ other than liver, spleen, or lymph nodes
Herpes simplex with mucocutaneous ulcer greater than 1 month or bronchitis,
pneumonitis,esophagitis
Histoplasmosis, extrapulmonary*
HIV-associated dementia: disabling cognitive and/or motor dysfunction interfering
with activities of daily living*
HIV-associated wasting: involuntary weight loss >10% of baseline plus chronic
diarrhea (2 loose stools/day 30 days) or chronic weakness and documented
enigmatic fever 30 days*
Isosporiasis with diarrhea greater than 1 month*
Kaposis sarcoma in patient under 60 years (or over 60 years*)
Lymphoma of brain in patient under 60 years (or over 60 years*)
Lymphoma, non-Hodgkins of B-cell or unknown immunologic phenotype and
histology showing small, noncleaved lymphoma or immunoblastic sarcoma
Mycobacterium avium complex or M. kansasii, disseminated
Tuberculosis*
Nocardiosis*
Pneumocystis carinii pneumonia
Pneumonia, recurrent-bacterial (2 episodes in 12 months)*
Progressive multifocal leukoencephalopathy
Salmonella septicemia (non-typhoid), recurrent*
Strongyloidiasis, extraintestinal
Toxoplasmosis of internal organ
* Requires positive HIV serology
123
Table 7.5: Case definition for AIDS in India

(for persons above 12 years of age)
Case definition for AIDS in India was revised in October, 1999. The new case
definition is as follows:
1. Two positive tests for HIV infection by ERS test (ELISA/RAPID/SIMPLE) AND
2. Any one of the following criteria:a. Significant weight loss (> 10% of body weight) within last one month/Cachexia
(not known to be due to a condition other than HIV infection) AND
Chronic diarrhea (intermittent or continuous) > 1 month duration or prolonged
fever (intermittent or continuous) > 1 month duration
b. Tuberculosis: Extensive pulmonary, disseminated, miliary, extra-pulmonary
tuberculosis
c. Neurological impairment preventing independent daily activities, not known
to be due to the conditions unrelated to HIV infection (e.g. trauma)
d. Candidasis of the oesophagus (diagnosable by oral candidiasis with
odynophagia)
e. Clinically diagnosed life -threatening or recurrent episodes of pneumonia,
with or without etiological confirmation
f. Kaposi sarcoma
g. Other conditions:
Cryptococcal meningitis
Neurotoxoplasmasis
CMV retinitis
Pencillium marneffei
Recurrent herpes zoster or multi-dermatomal herpes infection
Disseminated molluscum
is best established with the quantitative plasma HIV RNA assay

(the standard viral load test) or the qualitative HIV DNA assay.
These patients experiencing primary infection are highly infectious
because of high-level viremia and should be counseled about risk
reduction.
Group II: The Asymptomatic Diseas-Clinical Latency
Time from initial infection to clinical disease varies. The median
time is approximately 8-10 years and may be shorter in developing
countries. Virus replication progresses during this asymptomatic
period. Course is variable during this period. In most of patients
CD4+ T cell counts fall progressively. When the CD4+ cell count
falls below 200/uL, the immunodeficiency is severe enough to place
the patient at high risk for opportunistic infections and neoplasms,
and hence for clinically apparent disease.
124 Women and HIV

Group III: Persistent Generalized Lymphadenopathy (PGL)
PGL is defined as the presence of enlarged, discrete and freely
movable lymph nodes (>1 cm) in two or more extrainguinal sites
for more than 3 months without an obvious cause. It may be the
earliest symptom of HIV infection after primary infection. In the
early and intermediate stages of HIV infection (CD4+ T cell counts
>200/L), the main differential diagnosis is mycobacterial
infection. Lymph node biopsy is not indicated in patients with
early-stage disease unless there are signs and symptoms of systemic
illness, such as fever and weight loss, or unless the nodes begin to
enlarge, become fixed, or coalesce.
Group IV: Other Diseases
Subgroup A: Early Symptomatic Disease
After the CD4+ T cell count has fallen below 500/L, patients begin
to develop signs and symptoms of clinical illness (Table 7.2). Many
of these are minor opportunistic infections, not sufficiently
indicative of a defect in cell-mediated immunity to be considered
AIDS-indictor illnesses, while some of them appear to be direct
effects of long-standing HIV infection.
Subgroup B: Neurologic Disease
The neurologic problems that occur in HIV-infected individuals
may be either primary to the pathogenic processes of HIV infection or secondary to opportunistic infections or neoplasms. Neurologic problems occur throughout the course of disease and may
be inflammatory, demyelinating, or degenerative in nature. While
only one of these, the AIDS dementia complex, or HIV encephalopathy, is considered an AIDS-defining illness. Among the opportunistic infections and neoplasms that involve the central nervous
system (CNS) are Mycobacterium tuberculosis, toxoplasmosis,
cryptococcosis, progressive multifocal leukoencephalopathy,
infection with cytomegalovirus, syphilis and primary CNS
lymphoma3.
HIV ENCEPHALOPATHY
HIV encephalopathy, also called HIV-associated dementia or AIDS
dementia complex, consists of a constellation of signs and
125
symptoms of CNS disease that generally occurs late in the course

of HIV infection. A major feature of this entity is the development
of dementia, which is defined as a decline in cognitive ability from
a previous level. It may present as impaired ability to concentrate,
increased forgetfulness, difficulty reading, or increased difficulty
performing complex tasks. Initially these symptoms may be
indistinguishable from findings of situational depression or fatigue.
In addition to dementia, patients with HIV encephalopathy also
may have motor and behavioral abnormalities.
Subgroup C: Opportunistic Infections
Opportunistic infections are late complications of HIV infection,
for the most part occurring in patients with less than 200 CD4+ T
cells per microliter4. The clinical spectrum of important and
common selected protozoal, bacterial, fungal and viral illness which
are AIDS-defining illness according to revised 1993 CDC
Classification System are being reviewed. Treatment and
prophylaxis of opportunistic infections is discussed in Table 7.6.
1. Bacterial Infections
Tuberculosis
TB is one of the commonest infections in our patients. The diagnosis
of TB in patients with HIV is more difficult than in those without
HIV. In early HIV disease when TB presents with he typical signs
and symptoms of pulmonary TB i.e. cough with or without fever,
night sweats, weight loss, and upper-lobe infiltrates with or without
cavitation on chest x-rays5. The diagnosis of TB for advanced HIV
disease (AIDS) patients might be difficult because TB in an
immunocompromised host can be associated with atypical
symptoms, a lack of typical symptoms, and a paucity of findings
in chest x-rays6. Among persons with AIDS, the diagnosis of TB
also can be complicated by the presence of other pulmonary
infections such as pneumocystis carinii pneumonia and by the
occurrence of TB in extrapulmonary sites.
Disseminated infection with Mycobacterium avium complex

MAC infection is uncommon in our AIDS patients in tropics,
probably because such patients dont survive long enough to be
126 Women and HIV

Table 7.6: Treatment and prophylaxis of opportunistic infections
Opportunistic infection
Treatment
Prophylaxis
Pneumocystis carinii
pneumonia
TMP-SMZ 15-20 mg/kg/

day x 21d
(corticosteroid if
paO2<70 mm Hg).
Sulfadiazine
Pyrimethamine
Azithromycin
TMP-SMZ
Amphotericin B
Flucytocine
Then Fluconazole
TMP-SMZ 1 DS qd
Toxoplasmosis
Cryptosporidiosis
Isospora
Cryptococcal meningitis
Candida esophagitis
Cytomegalovirus
Ganciclovir
Herpes zoster
Tuberculosis
Fluconazole
Ganciclovir 5 mg/
kg q12 h then
5 mg/kg 3 to 5 d/wk
Acyclovir 800 mg
po 5 x /d x 7-10 d
Rifampicin, INH, PZA,
Ethambutol 2 months
then Rifampicin,
INH X 4 months
TMP-SMZ
Food and water sanitation
TMP-SMZ
Fluconazole
None
None (Debatable)
severely immunosupressed. The symptoms of fever, night sweats,

weight loss, those of anemia and general malaise are rather nonspecific and may be caused by other AIDS related infections.
Involvement of the intestines may lead to malabrsoption and
chronic diarrhea. Physical findings include hepatosplenomegaly
and generalized lymphadenitis. The diagnosis of disseminated
AIDS related MAC disease is made from culture of organism from
blood, bonemarrow and feces.
2. Fungal Infections
Pneumocystis carinii pneumonia (PCP)

Pneumocystis carinii remains as one of the most important
opportunistic infection which needs early suspicion and urgent
aggressive management. Classically patients with PCP presents
with fever, dry cough and dyspnea. A clinical presentation varies
from fulminant to chronic course7. Diffuse alveolar or interstitial
127
pulmonary infiltrates are the classic radiological findings of PCP,

but patchy, asymmetric infiltrates have been reported. Normal
chest films, nodular infiltrates, parenchymal cavitation, blebs and
bullae have also been described. Clinical features and classical
X-ray finding are sufficient to start patient on treatment.
Cryptococcosis
CNS involvement is seen in 70-90 percent patients with cryptococcal disease. The commonest mode of presentation is sub-acute
meningoencephalitis. Acute fulminent onset is rare. The common
clinical features include fever and headache 65-90 percent, neck
stiffness 30 percent, altered sensorium 20 percent and seizure/
focal deficit in less than 10 percent of patients. The diagnosis is
made by positive CSF India Ink stain (yeast cells with capsules
without buds or single bud), CSF cryptococcal antigen titer > 1:8
and positive CSF culture8. CT/MRI are done to rule out space
occupying lesion.
Candidiasis
Candidiasis is the one of the commonest infection observed in
HIV-infected patients. Oral candidiasis may occur in 46-70 percent
of patients as one of the initial manifestations of HIV disease.
Candida thrush generally presents as a white cheesy exudate on
the posterior oropharyngeal wall. Early lesions also may be
detected along gingival and labial margins. The 1993 centers for
disease control (CDC) classifications system for HIV infections
classified oral candidiasis as indicative of HIV infection but not
AIDS. Esophageal candidiasis is an AIDS defining illness according
to 1993 CDC classification system. There is also increased incidence
of vaginal candidiasis in HIV-infected women.
3. Protozoal Infections
Toxoplasmic Encephalitis (TE)

The commonest CNS manifestation of toxoplasma is Toxoplasma
encephalitis. TE presents as focal narcotizing encephalitis with one
or more intracerebral mass lesions. It can also present as diffuse
encephalitis or meningoencephalitis. The common presenting
128 Women and HIV

clinical features include focal neurological signs, headache,
confusion and seizures. The diagnosis is made by positive antitoxoplasma antibodies, CSF antibody to toxoplasma, multiple
lesions in multiple locations or single ring enhancing lesion on MRI
or double dose contrast CT9. Empirically treated patients should
have clear clinical response in 2 weeks and clear radiographic
response in 3 weeks. In case of treatment failure, brain biopsy is
resorted to after 3 weeks to confirm the diagnosis.
Cryptosporidiosis
The clinical spectrum varies from asymptomatic to severe life
threatening enteritis complicated by biliary tract involvement.
Diarrhea presents as frequent voluminous, watery, non-bloody
bowel movements associated with abdominal cramps and malaise.
The diagnosis is made by microscopic identification using modified
acid-fast stain, immuno-flourescent assay and by polymerase chain
reaction (PCR).
4. Viral Infections
Cytomegalovirus disease
Because CMV disease in HIV infected individuals almost always
represents a reactivation of latent virus. CMV retinitis is the most
devastating and common manifestation. It presents as low grade,
painless, unilateral visual blurring, scotoma, or subtle decrements
in acuity. There is progressive loss of vision. If left untreated, it
will lead to blindness over several months. On fundoscopy there
are peripheral focal white necrotic patches and flame shaped
retinal hemorrhages. Other manifestations of CMV disease
include encephalitis, neuropathy-polyradicular/multifocal. Gastrointestinal involvement includes oesophagitis, gastritis, colitis,
pancreatitis, cholangiopathy and hepatitis.
Subgroup D: Neoplastic Diseases
A variety of neoplastic and premalignant diseases occur in HIVinfected individuals. These include Kaposis sarcoma, lymphoma,
and intraepithelial dysplasia of the cervix and anus. These diseases
are significant contributors to the morbidity and mortality of
patients with HIV infection. These are uncommon in our country.
129
Subgroup E: Generalized Wasting

Generalized wasting, defined as involuntary weight loss of greater
than 10 percent associated with intermittent or constant fever and
chronic diarrhea or fatigue lasting more than 30 days in the absence
of a defined cause other than HIV infection, is an AIDS-indicator
condition (Table 7.2). It is one of important initial clinical indication
of AIDS. A constant feature of this syndrome is major muscle
wasting.
Organ-specific Syndromes
Managing organ-specific syndromes is a therapeutic challenge.
Virtually every organ in the body is vulnerable to disease. It is
either as a direct consequence of HIV infection or secondary to
other infectious or neoplastic conditions. Multiple organisms are
common in advanced disease. These could be common pathogens
or opportunistic infections. Hence high index of suspicion and good
clinical sense is required in managing these patients. While most
of these diseases are due to opportunistic infections or, there are
also a variety of clinical problems for which no specific pathogens
are clearly identified.
Clinical Spectrum of HIV Infected Patients at All India
Institute of Medical Sciences
Of 158 HIV individuals seen the common presenting clinical
features were fever (83%), weight loss (61%), loss of appetite (47%),
cough (49%), diarrhea (35%), oral ulcers (25%), shortness of breath
(12%), painful swallowing (10%), and visual loss (3%). Important
clinical findings included cachexia (46%), oropharyngeal candidiasis (40%), lymphadenopathy (51%), pulmonary findings (30%)
and alteration of sensorium (6%). The laboratory findings included
mean hemoglobin of 9.4 2.6 gm%, ESR 5221 mm/1st hr, lymphocyte count 2050 1299/ cubic mm, CD4 T cell count 133 97/
cubic mm. Important HIV related illnesses included tuberculosis
56 percent (PTB [30%], EXPTB [36%]), oral candidiasis 46 percent,
persistent diarrhea 10 percent, PCP 9 percent, oesophageal candidiasis 8 percent, recurrent pneumonia 6 percent, cryptococcal
meningitis 5%, toxoplasmosis 1 percent and PML 1 percent10.
130 Women and HIV

Evaluation before Initiating Therapy in HIV Infection
In all patients with HIV infection, the following evaluation should
be performed:
Complete history and physical examination
Complete blood count, chemistry profile
CD4+ T lymphocyte counts
Plasma HIV RNA measurement.
Additional evaluation should include routine tests pertinent to the
prevention of opportunistic infections, if not already performed
(chest X-ray, VDRL, tuberculin skin test, toxoplasma IgG serology,
and gynecologic exam with Pap smear), and other tests as clinically
indicated hepatitis B virus (HBV) serology, hepatitis C virus (HCV)
serology, CMV serology and ophthalmologic examination may be
useful in identifying HIV related complications in certain
individuals4.
Viral Load Assays and CD4 T Cell Counts
Plasma HIV RNA (viral load) and CD4 T cell count gives the
physician important information about the virologic and immunologic status of the patient and the risk of disease progression to
AIDS (11,12). Data suggest that patient with low viral loads
(i.e., <2500 copies of HIV RNA/ml) are at lower risk of disease
progression than those with higher (2500 to 20,000 copies of HIV
RNA/ml) or very high (>20,000 copies of HIV RNA/ml) viral loads.
Measurement of plasma HIV RNA levels (viral load), using
quantitative methods should be performed at the time of diagnosis
and every 3-4 months thereafter in the untreated patient [Difficult
in present circumstances in India]. CD4+ T cell counts should be
measured at the time of diagnosis and generally every 3-6 months
thereafter12,13.
The speed of viral load decline and the movement toward
undetectable are affected by the baseline CD4+ T cell count, the
initial viral load, potency of the regimen, adherence, prior exposure
to antiretroviral agents, and the presence of any opportunistic
infections.
These intervals between tests are merely recommendations and
flexibility should be exercised according to the circumstances of
131
the individual case. If patient cant afford ART there is no need to

do viral load.
CD4 T cell counts are available at few centers and cost varies
from 500- 1500 rupees. It is recommended that all patients should
have CD4 count done to stage the disease. One viral load test costs
3500-6000 rupees. It is beyond the reach of common man in India.
It is recommended that those who can afford and are willing to
have triple drug therapy should have their base line viral load done.
Routine use of viral load in patients who cant afford ART may not
be of great help.
Antiretroviral Therapy
Many advances have been made in the understanding of the
pathogenesis of HIV infection, its treatment and monitoring of HIV
disease. The rapidity and magnitude of viral turnover during all
stages of HIV infection are greater than previously recognized;
plasma virions are expected to have a mean half-life of only 6 hours.
Thus current therapeutic interventions focus on aggressive
antiretroviral regimens to maximally suppress viral replication,
preserve immune function and reduce development of resistance.
Goals of Antiretroviral Therapy

Virological
Ultimate Goal
- Complete suppression
of replication
- Preventing the emergence
of resistance
Immunological
- CD4 >300
- Improve immune functions
Patient
- No opportunistic infections
- Improve survival
- Improve QOL
132 Women and HIV

Now with the availability of potent ART, HIV RNA levels may be
reduced for prolonged periods to levels that are undetectable using
current assays. Improved clinical outcome and survival have been
observed in adults receiving such regimens. Thus two important
separate but related issues which must be taken into account by
health care providers are:
a. Antiretroviral treatment of womens HIV infection and
b. Antiretroviral chemoprophylaxis to reduce the risk for
perinatal transmission (discussed separately).
Consensus guidelines have been developed for the use of highly
active antiretroviral therapy (HAART) in adults and adolescents,
as well as in children and in HIV-infected pregnant women15. In
general, any patient with less than 200 CD4+ T cells/mm3 or greater
than 50,000 (RT-PCR) copies of HIV RNA/ml of plasma should be
offered therapy. The decision to begin therapy is complex and must
be made in the setting of careful patient counseling and education.
National Guidelines in India
Now 11 antiretroviral drugs are available in India. Still for common
Indian they are difficult to afford for a long time despite of cost
reduction of few drugs. Government of India is not in a position to
provide these drugs free of cost except for mother to child
transmission and post-exposure prophylaxis. Further ideal
monitoring of HAART, which includes viral load estimation, is
again costly and quality control is almost impossible in present
setup. These factors are the main obstacles in forming national
guidelines on use of ART in India.
Antiretroviral Drugs Available in India
Till date there are 16 US Food and Drug Administration (FDA)
drugs for the use in HIV infected adults: seven reverse transcriptase
inhibitors (RTIs) and four protease inhibitors (PIs). Of 9 RTIs, 6 are
nucleoside RTIs i.e., zidovudine (ZDV), didanosine (ddI), zalcitabine
(ddC), stavudine (d4T), lamivudine (3TC) and abacavir (ABC). The
3 non-nucleoside RTIs are nevirapine, delavirdine, and efavirnez.
The 6 PIs are saquinavir, ritonavir, indinavir, nelfinavir, amprenavir
and loprinavir. (Drugs in italics are available in India).
133
Timing to start treatment?

Any symptomatic patient or person with less than 200 CD4+ T
cells/mm3 or more than 50,000 (RT-PCR) copies of HIV RNA/ml
of plasma should be offered therapy14. Benefits and risks of starting
treatment between CD4 T cell counts between 200-350 and > 350
CD4+ T cells/mm3 should be explained to patients. The decision
to begin therapy is complex and must be made in the setting of
careful patient counseling and education. The factors that must be
considered in this decision are:
The willingness of the individual to begin therapy.
The degree of existing immunodeficiency as determined by the
CD4+ T cell count.
The risk of disease progression as determined by the level of
plasma HIV RNA.
The potential benefits and risks of initiating therapy in
individuals.
The likelihood, after counseling and education, of adherence to
the prescribed treatment regimen.
HIV Replication Cycle and Sites of Drug Activity

NRTIs
AZT (Zidovudine-Retrovir)
ddI (Didanosine-Videx)
ddC (Zalcitabine-Hivid)
d4T (Stavudine-Zerit)
3TC (Lamivudine-Epivir)
ABC(Abacavir-Ziagen)
NNRTIs
Efavirenz (Sustiva)
Delavirdine (Rescriptor)
Nevirapine (Viramune)
Cellular DNA
Protease Inhibitors
Indinavir (Crixivan)
Ritonavir (Norvir)
Saquinavir (Fortovase)
Nelfinavir (Viracept)
Amprenavir (Angenerase)
Lopinavir/ritonavir (Kaletra)
Nucleus
New HIV
particles
HIV Virions
Reverse
Integrase
Transcriptase
Protease
Capsid
proteins
and viral
RNA
CD4
Receptor
Viral RNA
Unintegrated
double stranded
Viral DNA
Integrated
viral DNA
CCR5
or
CXCR4
co-receptor
1
Attachment
2
Uncoating
Reverse
Transcription
Viral
mRNA
Integration Transcription
gag-pol
polyprotein
5
Translation
6
Assembly and
Release
134 Women and HIV
Recommended ART
Preferred
Cost/month
1 Pl
Indinavir
Ritonavir
Ritonavir + Saquinavir
Saquinavir SGC
Nelfinavir
2 NRTI ~ Rs 8000
ZDV + 3TC
ZDV + ddC
d4T + 3TC
ZDV + ddl
d4T + ddl
1NNRTI
2 NRTI ~ Rs 1600
What drugs to start with?

When initiating therapy in the patient naive to antiretroviral
therapy, one should begin with a regimen that is expected to
reduce viral replication to undetectable levels i.e. highly active
antiretroviral therapy (HAART). Based on the weight of experience, the preferred regimen to accomplish this is 2 nucleoside
analogues (NRTIs) and one potent protease inhibitor or non-nucleoside RTI 14,15,16. Triple drug therapy in India at present costs
1500-8000 rupees. Further this therapy has to be continued life long.
Guidelines for optimal antiretroviral therapy and for initiation
of therapy in pregnant HIV-infected women should be the
same as those delineated for non-pregnant adults. The womans
clinical, virologic and immunologic status should be of primary
importance in guiding treatment decisions. The decision to use
any antiretoviral drug during pregnancy should be made by the
woman following discussion with her health care provider
regarding the known and unknown benefits and risks to her and
her fetus.
Problems during antiretroviral regimens

Current antiretroviral regimens are fraught with a number of
problems. The problems of polypharmacy include pill burden, drug
interactions, side effects, food effects, and adherence issues.
135
Adherence
These drugs are to be continued life long and they are expensive.
Hence, good communication with the patient is essential. Education about the disease and the drugs and clarification of the
regimen is must. Patients need to understand the importance of
strict adherence. The regimen should be constructed based on the
patients schedule and lifestyle. Involvement of family is also
important to improve adherence. Poor adherence with antiretrovirals rapidly leads to the development of drug-resistant
strains and rebound of virus. There is significant cross-resistance
within each of the three available drug classes. After the first breakthrough of virus, the likelihood of finding an active regimen
decreases dramatically.
Pill burden
For 3-drug regimens, the number of pills may range from 2 per
day to 24 per day. Patients receiving drugs for opportunistic
infections will require additional agents, as will those who require
supportive medications for depression, nausea, pain, and other
HIV-related complications. Combined, the total pill burden is often
substantial and a hindrance to optimal care.
Drug interactions
It is important to note that drug interactions can be either
detrimental or beneficial to the patient. Many antiretroviral
combinations allow for a reduced dose or an increased dosing
interval due to an inhibition of drug metabolism. In these cases, a
drug interaction can be used to construct a regimen that is less
complex and easier to take on a chronic basis17. All protease
inhibitors are substrates and inhibitors of the hepatic cytochrome
p450 enzyme system. Examples of drug interactions arising from
inhibition of cytochrome p450 include the increases in rifampin
and rifabutin levels with ritonavir, and to a lesser degree, with the
other protease inhibitors. Some protease inhibitors are also inducers
of cytochrome p450.
Dual protease inhibitor regimens make use of drug interactions
to increase drug levels and/or prolong half-lives. Ritonavir
increases saquinavir levels by more than ten-fold, allowing
136 Women and HIV

saquinavir to be given at a reduced dose twice daily. Nelfinavir
also increases saquinavir levels, but the effect is less dramatic and
does not allow dose reduction. Ritonavir also increases drug levels
of nelfinavir and indinavir.
Side Effects
HIV-infected patients have higher incidence of adverse effects to
medications. HIV disease or concomitant opportunistic infections
can cause complications which can become additive with medication side effects. For example, infections with Mycobacterium avium
complex, cytomegalovirus, and histoplasma can cause bone
marrow suppression. When combined with myelosuppressive
drugs such as zidovudine, ganciclovir, TMP/SMX or hydroxyurea,
there can be significant problems with anemia and neutropenia. It
can be difficult to distinguish between an adverse drug effect and
an HIV disease effect. Many HIV-related medications have overlapping toxicities. Nevirapine, delavirdine, abacavir and TMP/
SMX can cause skin rash. Adefovir, cidofovir, foscarnet and amphotericin B may cause nephrotoxicity.
Food Effects
Many antiretrovirals, especially the protease inhibitors, have
certain food restrictions that may complicate a patients daily
schedule. Often, the choice of protease inhibitor with which to
initiate therapy may depend heavily on the patients eating
schedule and dietary habits. The evaluation of an antiretroviral
regimen should include questions regarding when the patient eats
his/her meals and what constitutes a typical meal (high-fat vs lowfat foods).
When to Change Treatment?

This is difficult in our country because of high cost involved and
lack of many alternative treatment options. However, it is generally
recommended that plasma viral load and CD4+ cell count be
measured four to six weeks after initiating or changing therapy.
The maximal response may take longer, however, reflecting
the slower rate of decay resulting from the loss of infected
macrophages18.
137
It is crucial distinguish between virologic failure and immunologic or clinical failure. In fact, there is evidence that patients
experiencing virologic failure may continue to do well, both clinically and immunologically, long after the viral load has begun to
rise. It has been postulated that this discrepancy between virologic,
immunologic, and clinical outcomes may be due in part to
decreased viral fitness resulting from the maintenance of multiple
resistance mutations. This hypothesis would suggest that judicious
use of failing antiretroviral agents might still be beneficial.
What to Change Treatment with?

Antiretroviral regimens may be changed because of intolerance or
failure. Not all antiretroviral failure is due to resistance, nor is
resistance always present to each drug in a failing regimen. There
is now evidence that some patients with detectable virus on a
regimen of two NRTIs plus a PI may have resistance only to one of
the NRTIs (usually 3TC). In such cases, it may be more appropriate
to intensify the regimen with additional agents rather than to
change it completely.
Such a decision would require the use of resistance testing,
however, and currently available assays are insensitive to resistant
strains present at low levels. Further, these resistance assays are
not available in India.
Lacking genotypic or phenotypic resistance data, changes in
therapy due to drug resistance should involve a change at least
two and preferably all of the drugs in the regimen, using new drugs
to which no cross-resistance is expected19,20. Thus, it is crucial that
the clinician must know the patients entire treatment history. When
therapy is effective but must be changed because of side effects or
tolerability, the same rule does not apply.
Prevention of Perinatal/Vertical Transmission in India
Womens hopes and desires for sexual bonding, intimacy and
childbearing are not erased in HIV infection. Women of
childbearing age are disproportionately represented in the HIV
epidemic and face obstacles in their reproductive decision making.
The transmission of HIV from mother to child appears to occur
in 10-50 percent. Possible factors associated with increased mother
to child transmission include low CD4 T cell count in the mother,
138 Women and HIV

high HIV RNA (viral load) in mother at time of delivery, ,
enhancing antibodies in the maternal sera, , syncytium-inducing
virus in the maternal blood, prolonged delivery time, early rupture
of membranes and mode of delivery, high replicating21,22. A
randomized, double blind, pediatric ACTG 076 clinical trial proved
that ZDV reduce the risk of perinatal HIV transmission is ZDV.
This chemoprophylactic regimen reduced the risk of perinatal
transmission by 66 percent23.
Currently available regimens are:
1. Pediatric ACTG 076 Clinical Trial
Antenatal: Zidovudine orally (100 mg five times a day) from
14 weeks gestation and continued throughout pregnancy,
Intrapartum: Intravenously (2 mg/kg loading dose over one
hour, then a continuous infusion of 1 mg/kg/h until
delivery),
Postpartum: To the newborn (2 mg/kg orally every 6 hours),
begun 6 to 12 hours after birth for the first 6 weeks of life.
2. Short Course
Thai regimen which includes:
Oral zidovudine 300 mg twice a day given to women late in
last 4 weeks of pregnancy and,
300mg every 3 hours during labor.
This regimen is effective for preventing perinatal (mother-tochild) transmission of HIV where 076 regimen is unaffordable. This
regimen is estimated to cost roughly 1000 rupees. This is the
minimum which should be offered to all pregnant HIV+ve
pregnant women.
3. Nevirapine
There has been a major break through in prevention of mother to
child transmission of HIV. An interim analysis of a study in Uganda
indicates that two doses of nevirapine
One given to the mother at the onset of labor and
One given to the infant within 72 hours after birth.
These 2 doses of nevirapine can markedly reduce the incidence
139
of perinatal transmission of HIV24. One dose of nevirapine costs

110 rupees. (However nevirapine is not effective against HIV-2)
In era of combination therapy of HIV disease the time-limited
use of ZDV alone during pregnancy for chemoprophylaxis of
perinatal transmission is controversial. The potential benefits of
standard combination antiretroviral regimens for treatment of HIV
infection should be discussed with and offered to all pregnant
HIV-infected women24,15. The benefits of dual drug therapy and
triple drug therapy should be explained to the patients. Further,
the issue of giving new born antiretrovirals is also important as
studies have shown the beneficial effects.
In addition, HIV can be transmitted from a mother to her baby
through breast milk. This isnt a problem in developed nations,
where HIV-infected women can use formula for their infants. But
alternatives to breast-feeding arent easily available in developing
countries and breast-feeding protects infants from other potential
infections.
CONCLUSIONS
In an era of HIV epidemic, counseling of women for the prevention
of HIV infection along with early suspicion and detection of HIVinfected women is of paramount importance. Motherhood is a bless
and womens immense desire. HIV infected mothers have risk of
perinatal transmission of HIV to new born and pregnancy also
affects their own health especially in advanced disease.
Antiretroviral drugs have been very effective in reducing perinatal
transmission and this therapy should be offered to all HIV-infected
women who wish to continue their pregnancy. Hence all out efforts
should be made to prevent perinatal transmission which could help
in bringing down number of HIV cases. Women in whom
antiretroviral therapy is indicated and who can afford it should be
aggressively treated with triple drug therapy. It is mandatory to
provide PEP to all healthcare workers whenever they require it.
REFERENCES
1. www.nic.in/naco.
2. Centers for Disease Control and Prevention. 1993 revised classification.
system for HIV infection and expanded surveillance case definition for AIDS
among adolescents and adults. MMWR RR-17;41:1-5, 1992.
140 Women and HIV

3. Simpson DM, Tagliati M. Neurologic manifestations of HIV infection. Ann
Intern Med 121: 769-85, 1994.
4. USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in
Persons Infected With Human Immunodeficiency Virus. MMWR 48:1-67, 1999.
5. Hira SK, Dupont HL, Lanjewar DN, Dholakia YN. Severe weight loss: the
predominant clinical presentation of tuberculosis in patients with HIV infection in India. Natl Med J India 1998 Nov-Dec;11(6):256-8.
6. Perlman DC, El-Sadr WM, Nelson Eta, et al: Variation of chest radiographic
patterns in pulmonary tuberculosis by degree of human immunodeficiency
virus-related immuno-suppression. Clin Infect Dis 25:2426, 1997.
7. Hoores DR, Saah AJ, Bacellar H et al: Clinical manifestations of AIDS in the era
of Pneumocystis prophylaxis. N Engl J Med 1993; 329: 1992-1926.
8. Nelson MR, Bower M, Smith D, et al: The value of serum cryptococcal antigen
in the diagnosis of cryptococcal infection in patients infected with the human
immunodeficiency virus. J Infect 21:175-181, 1990.
9. Walot I, Miller BL, Chang L, et al: Neuroimaging findings in patients with AIDS.
Clin Infect Dis 22:906-919, 1996.
10. Wig N. Clinical Spectrum of HIV/AIDS in India. JIMI 2001; 4:32-40.
11. Saag MS, et al: HIV viral load markers in clinical practice. Nature Medicine 2:6259, 1996.
12. Turner BJ, Hecht FM, Ismail RB. CD4+ T-lymphocyte measures in the treatment
of individuals infected with human immunodeficiency virus type 1: a review
for clinical practitioners. Arch Intern Med 154:1561-73, 1994.
13. Fessel WJ. Human immunodeficiency virus (HIV) RNA in plasma as the
preferred target for therapy in patients with HIV infection: a critique. Clin Infect
Dis 24:116-22, 1997.
14. Antiretroviral Therapy for adult HIV Infection in 2002: Updated
Recommendations of the International AIDS Society USA Panel. JAMA
288:222-35, 2002.
15. Merrill DP, Moonis M, Chou TC and Hirsch MS. Lamivudine or stavudine in
two- and three-drug combination against human immunodeficiency virus type
1 replication in vitro. J Infect Dis 173:355-64, 1996.
16. Morales-Ramirez J, Tashima K, Hardy D, et al: A phase II, multi-center
randomized, open label study to compare the antiretroviral activity and
tolerability of efavirenz (EFV) + indinavir (IDV), versus EFV + zidovudine
(ZDV) + lamivudine (3TC), versus IDV + 3TC at > 36 weeks [DMP 266-006]
[Abstract I-103]. 38th Interscience Conference on Antimicrobial Agents and
Chemotherapy. San Diego, 7. Hammer, 1998.
17. Piscitelli, S.C, Flexner, C., Minor, J.R., Polis, M.A., and Masur, H. Drug
interactions in HIV-infected patients (review).Clin. Infect. Dis. 23:
685-693, 1996.
18. Kempf DJ, Rode RA, Xu Y, et al: The duration of viral suppression during
protease inhibitor therapy for HIV-1 infection is predicted by plasma HIV-1
RNA at the nadir. AIDS 12:F9-F14, 1998.
19. Deeks SG, Grant RM, Beatty GW, et al: Activity of a ritonavir plus saquinavircontaining regimen in patients with virologic evidence of indinavir or ritonavir
failure. AIDS. 12:F97-F102, 1998.
20. Gulick RM, Mellors JW, Havlir D, et al: Simultaneous vs sequential initiation of
21.
22.
23.
24.
25.
141
therapy with indinavir, zidovudine, and lamivudine for HIV-1 infection: 100week follow-up. JAMA 280:35-41, 1998.
Public Health Service Task Force Recommendations for the Use of Antiretroviral
Drugs in Pregnant HIV-1 Infected Women for Maternal Health and
Interventions to Reduce Perinatal HIV-1 Transmission in the United States.
1-50, 2002.
Minkoff H, Augenbraun M: Antiretroviral therapy for pregnant women. Am J
Obstet Gynecol 176:478- 489, 1997.
Sperling R, Shapiro D, Coombs R, et al: Maternal viral load, zidovudine
treatment, and the risk of transmission of human immunodeficiency virus from
mother to infant. N Engl J Med 335:1621-1629, 1996.
Guay LA, Musoke P, Fleming T, et al: Intrapartum and neonatal single-dose
nevirapine compared with zidovudine for prevention of mother-to-child
transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial.
Lancet 354:795-802, 1999.
Bell DM, Gerberding JL, eds. Human immunodeficiency virus (HIV)
postexposure management of healthcare workers. Am J Med 102(suppl 5B):,
1997.
142 Women and HIV
eight
HIV and Adolescent Girl

Sudha Salhan, RN Salhan
INTRODUCTION
Adolescence is the stage of transition from childhood to adulthood
WHO defines adolescence as the period between 10-19 years which
corresponds to the onset of puberty. During these formative years
the maximum amount of physical (accelerated growth occur in
this period) psychological and behavioral changes takes place. In
additions if she is a student the burden of studies is enormous
with the pressure for choosing a career. Poor health and social status
of adolescent girls is a matter of serious concern. The WHO statistics
line show that fifty percent if worlds populations are below the 25
years of age and one fifth of the worlds population are adolescents1.
MODE OF ACQUIRING HIV
Adolescents are at a high risk for HIV infection: It is estimated by
the Centre for Disease Control (CDC) USA that half the new HIV
infections occurred in youth aged 15-24 years. In developing
countries, women are becoming infected at a significantly younger
age than men, with more women in their teens and early twenties
becoming infected than women in any other age group. Given a
ten years period on average from initial infection to clinical
manifestation of AIDS, most of these young people were likely
infected during their teens. Modes of transmission are varied in
adolescents. Adolescents explore intimacy and sexuality. Hence,
it is a time of hightened vulnerability including the risk for HIV
infection. The majority of adolescent females with HIV get infected
through the hetrosexual route (52-72%) of while others contract
the disease by intravenous drug use (13%). There are some who
acquire the disease by blood transfusion in childhood especially
HIV and Adolescent Girl 143

hemophiliacs2. As the disease is now increasingly affecting nonhigh risk women, the number of young people infected due to
vertical transmission is on the rise (mother to new born) They are
partial slow progressors 345. This category is growing because
more females are infected. Twenty percent of sexually infected HIV
positive youths have a parent who was also HIV positive6.
In girls with HIV, there is widespread lack of awarness about
their partners risk factors7. Further girls are quite likely to have
been sexually abused during their childhood.
To understand the increased vulnerability to HIV in adolescent
girls the following factors should be understood.
1. Sexual risk
2. Sexually transmitted disease and pregnancy
3. Behavioral risk
4. Biological risk
5. Socio-economic risk.
1. Sexual risk: Fifty two percent of adolescent females with AIDS,
were infected hetrosexual route. With an additional 15 to 20
percent presumed to be infected heterosexually but called no
identified risk because they unable to name their partnerss risk
factors8.
A significant proportion of adolescent girls with HIV have
experienced childhood sexual abuse. Twenty five to forty percent
report having been sexually abused. Childhood sexual abuse
has been associated with feeling of powerlessness in sexual
situations later in life an increased risk for unsafe sexual
activity8,9.
2. Sexually Transmitted diseases (STD) and pregnancy: Sexually active
adolescent girls are also at risk of acquiring STDS and becoming
pregnant. About one million teens become pregnant each year,
mostly unintentionally. The study by Miller et al (1999) showed
that girls who had their first sexual intercourse before 15 years
of age were nearly four times more likely to report STDS as
were girls with their first sexual experience after 18 years10. The
inability to understand the risk of STDS, lack of access to
contraceptives, early marriage and child-birth are all recognized
predisposing factors for adolescents STDS. Same unsafe sexual
practices and high-risk behaviors are making the adolescents
girls acquire HIV and STD.
3. Behavioral risk: As is well known, adolescents want to trend the
144 Women and HIV

forbidden path and take uncalculated risks. Sexual activity is
one of these behaviors. Now-a-days adolescent girls experience
sex early and they indulge in unsafe sexual activities. Nearly
half of 9-12 grade girls did not insist on the use of condoms.
About 1 in 5 (19%) used alcohol or drugs; this can impair
judgement and increase the potential for high-risk behavior.
More than 25 percent smoked or used I.V. drugs11,12.
A sub-population of youth use at a high risk: These are the homeless, rune the a way and the IV drug users13. Adolescents are
less likely to recognize the need of medical check up and drug
treatment on their own. In a study in Delhi and Lucknow, it
was revealed that students of public schools are more sexually
active than those of Government schools. In Delhi 21.9 percent
girls start sexual activity at the age of 13 years or earlier compared to Lucknow (Average 17.85 years in Delhi and 20.01 years
Lucknow) In them 20 percent always used condom 31 percent
sometimes 48.6 percent never used. 14 Adolescent girls sexual
practices is also reported by Jejcebtory and Watza 15-16.
4. Biological risk: These are many biological factors which increase
the risk of HIV in adolescent females. In adolescent girls, the
menstrual pattern is not mature and vaginal, ovarian and
cervical functions are incompletely developed which may
account for a higher incidence of HIV infection. In these girls
the cervix is lined by a single layer of columnar cells which is
more susceptible to infection (especially Gonococcus, Chlamydia
and other STDS) easily injured by the sexual act and is less
protective. In adult females this single layer of columnar cells is
replaced by multilayered squamous epithelium which is a very
strong barrier to infection.
It is known that male to female transmission of HIV is much
more than female to male transmission. This is because of trauma
of the female genital tract during the ac. Furthermore, these is a
larger surface area of the vaginae and cervix exposed to infected
semen for a long time. In addition, STDS are more often
17,18
asymptometic in women facilating HIV transmission .
5. Social and economic risk: As noted by Chabon6 one fifth of HIV
infected adolescent have an HIV positive parent. Children of
parents with HIV generally live in the same high prevalence
surroundings as their parents. Thus they face on increased risk
as a sequad of parental illness or substance abuse. In the Indian

society sex is not talked about. Hence girls do not get a proper
knowledge and only acquire incorrect and incomplete facts from
their peers . Sexual violence and exploration, abandonment and
economic deprivation are other factors which increase
vulnerability of girls or adolescents married women to HIV.
Girls are less cared for in India especially in the poor strata of
society. So anemia and malnourishment is often associated.
Increased vulnerability to HIV is associated with poverty, lack of
access to healthcare, education and prevention skilled. Mis-trust
for the health systems, fear of inappropriate disclosure, lack of the
knowledge of their right to confidentiality in the provider patient
relationship are forever present.
The custom of choosing a wife who is much younger, especially
in her teens, make young women culturally vulnerable. Economic
needs or the lure of promises of good clothes, jewellary, or
pornography or idleness, curiosity, peer pressure etc are other
factors for a higher prevalence of HIV infection in adolescent girls.
Parental guidance is mostly lacking in girls in adolescent years.
OBSTACLES TO CARE OF
HIV POSITIVE ADOLESCENTS
It is important to discuss significantly barrier to medical care that
many adolescents encounter. These barriers also exist in the health
care of HIV positive adolescents, which need to be leveled by
delicately devised approaches matching the sensitivity of the
problem. Some invisible barriers are likely to be more common in
girls as they are mostly shy and less communicating.
Have inadequate or inappropriate knowledge about
reproduction.
They are unaware of their infection because they have not
been tested for it.
Even when they know that they are HIV positve, may
adolescents do not take it seriously.
Lack of knowledge and the impression that AIDS cannot
happen to them a feeling that they are young and in the
prime of health and they are immune, invulnerable, and
immortal and will not die20-21.
In some places, adolescents may not be able, by law, to
consent to avail medical services on their own.
146 Women and HIV

Many or them show denial about their HIV disease as a
coping machanism. Over-whelmed with the demands of
school work, chaotic home lives, depression, substance use
(illicit drug use) or homelessness, young people may decide
that they cannot focus on their HIV disease until some points
in the future, e.g. when school is over, or after they move
away from home or after they find a home.
Most of the clinics are not always youth-friendly. Adolescents
typically are inexperienced and unfamiliar with the medical
system, often have difficulty in negotiating the tedious
systems of care associated with HIV. In addition to lack of
skill, a significant fear and a mistrust of the medical system
prevent many adolescents from seeking care.
To provide care to adolescents with HIV, the barriers that
separate them from medical services must be overcome. Individual
clinics and providers can make a difference by offering care that is
as youth sensitive as possible, assuring confidentiality and trust
through counseling.
Involvement of parents in the treatment of HIV positive
adolescent girl. Although parental counset is not needed to be taken
to provide an HIV test or HIV related care doctors should carefully assess an adolescents congnitive capacity to understand the
consequences of having HIV disease. They should also be encouraged to involve a supportive adult in their case.
Counseling and Testing
Usually two short counseling sessions, instead of one (as in adults),
is needed prior to testing. The knowledge of appropriate condom
use is essential for them. With the availability of female condom
now we visualize less HIV infection in adolescent girls in the near
future.
Details of counseling are available in chapter on counseling.
Common indications for doing HIV serology in adolescent girls
include:
High risk categories:
Injection drug users; sexual partners of hemophiliacs,
Prostitutes and persons who received blood and blood
products during the years 1977-85.
Adolescent with sexually transmitted disease, active
tuberculosis and opportunistic infections.

Voluntary testing for pregnant adolescent women after
counseling.
Blood and organ donors.
Persons requesting the test.
Laboratory tests recommended for initial evaluation are same
in adolescents as in any other individual.
Testing strategies are the same as in adults and are provided in
this book.
HIV Disease course in adolescent: The natural history of HIV
infection in adolescence is still being defined. The course of disease appears to follow that of adults. But distinctive features are
found by the REACH study. (Reaching for excellence in adolescent case and health)22. Adolescents acquiring infection sexually
have low CD4 count when they first resist the clinic23.
In contrast adolescent with perinatal acquired HIV have a
different, clinical course reflecting long term infection24.
Immune response in adolescent: Findings show that because of residual thymic function adolescents may have a greater potential
for immune reconstitution than adults25 Research reveals that in
humans, the thymus becomes smaller with age, beginning in the
teenage year. This provide a compelling rationale for early effective treatment.
Clinical Case
Adolescents prefer healthcare settings oriented to their age group
and doctors attended to their many needs26. It is the one-stop
shopping model of multi-disciplinary care with integrated primary
care, including gynaecologic services with HIV-specific care,
mental health care services, prevention and case management27
that is most likely to be successful. Availability of flexible
appointments that do not conflict with school or work and attention
to barriers is essential. The adolescent should have the freedom to
walk in at any time and receive attention.
Physical Examination
Privacy is an important feature of adolescent physical examinations because adolescents often have a high level of modesty. Tanner staging system is essential as it also helps in dosage schedules.
The rest of the physical examination follows the same guidelines
as for adults.
148 Women and HIV

Being a good listeners, not down playing the patients fears,
being professional, holding a non- judgmental stance on the life
style of adolescents are the qualities, that doctors dealing with these
girls must possess.
There is need for routine screening for human papillome virus,
chlamydia, gonorrhoea, syphilis, herpes simplex and hepatitis.
Screening for Tuberculosis There is need for human papillome
virus, chlemydis, gonorrhoea, syphilis, herpes simplex and
hepatitis. Screening tuberulosis is also needed.
Adolescent Girl and HIV Treatment
Although the pharmacokinetics of some medications change
during adolescence especially hepatic enzymens inducers or
inhibitors and protein-bound medications no special clinical effect
has yet been noted.
Although adolescents may be regarded as falling into a gray
area between child and adult, the use of the sexual maturity
ratings (SMRs) of Marshall and Tanners Scale provides a clear
method for evaluating individuals regardless of chronological age28.
For females, Tanners stages evaluate breast and public hair development. Each variable is rated on a scale of 1 to 5 stage 1 representing prepubertal development and stage 5 representing an adult
level of development29.
The dosage guidelines for anti-HIV and anti-OI (opportunistic
infection) medication follow a paediatric schedule for persons in
Tanner stage 1 and 2 and adult schedules for those in stage 3
through 5 with particularly close monitoring for those in stage 30-31.
The difference in the course and response to treatment in
adolescents has not been extensively studied. It is generally
believed that adolescents who are infected through sexual
behaviour or needle sharing have a course of disease which is
similar to that of adults. The girl who have acquired HIV parentally
have a course reflecting long-term infection. But it is important to
know the effect of the HIV disease on medication in adolescent
development. The long term consequences of the newer drugs on
this period of pronounced growth and sexual development are
unknown. Research in this field will give us insight in this aspect.
Initiating HIV therapy in adolescents must be done by including
the individual in the decision making process. Drug regimens

should be simple; in general twice daily regimens are likely to work
better.
Leading information may be given, as they may not ask
questions themselves. They must be informed in simple language
and may be given written information after making them
understand. Tailoring a regimen to the individual and encouraging
adherence is important in adolescence. Counseling pays dividends.
As adolescents are more likely to discontinue a regimen on their
own if they encounter any difficulties, especially unexpected ones,
an adolescent must be explained what is expected while on therapy
and how to manage side-effects.
Causes of not starting therapy include stable health, an unstable
living situation, a lack of support, heavy drug use, a fatalistic
attitude, mental health issues, a lack of readiness and simple refusal.
Prevention
Reducing the risk of HIV infection among teenage girls is important
not only for their well-being but also for the children they might
give birth to. Despite intensive research efforts, prevention is the
only effective AIDS-control strategy at present32. A comprehensive
preventive strategy requires multiple levels that target young
psychological and healthcare needs to protect as many of them as
possible from HIV and other STIs. These levels include primary
care encounters, education in school, open discussions in religious
and community organizations and public services announcements
that educate these girls about risks and encourage them to seek
care early. Those out of school are taken care of by NGOs by
outreach methods.
Primary prevention efforts that combine STI treatment, barrier
methods (male and female condoms) and microbicide-approach
specific to adolescent need to be explored. Additional work is
needed on understanding the malnutrition of the mucosal
immunity response in adolescents to boost mucosal vaccine
development and to provide young ladies with information, social
support and services they need to protect themselves from sexual
and reproductive health problems. Development of school policies
on AIDS education can be an important step in developing an
AIDS education programme. A team of representatives including
the local school boards, parent teacher associations, school
150 Women and HIV

administration, school physicians, teachers and school counselors
should be given training about the AIDS epidemic and how to get
protected. They in turn enlighten adolescents. As we know, the
main purpose of AIDS education is to prevent HIV infection. Teach
them to abstain from sexual intercourse until they are ready to
establish a mutually monogamous relation within the context of
marriage, use condom and refrain from using or injecting illicit
drugs. In addition to medical and social service, peer counseling is
an important weapon in prevention. Increasing the age of marriage
and training adolescent girls, making them economically
independent will go a long way in preventing HIV/AIDS in these
girls since it is observed that young girls with a high sense of self
esteem and direction are less likely to be involved in sexual
experimentation.
Secondary prevention: The prevention of transmission and reinfection in HIV infectied girls receiving care- use of condoms and the
supply of sterilized syringes and needles is giving good results. A
multidisciplinary or holistic approach in addition to providing
medical treatment is essential. This includes addressing the emotional and social needs of these girls. Some of them besides having
HIV infection are also drug addicts or mentally sick. So peer counseling by other HIV positive adolescent can give practical and
emotional support.
Recent trends in adolescent health especially of girls and their
sexual activity, particularly the HIV/AIDS pandemic, calls for
urgent attention on public discussion and policy action.
REFERENCES
1. Jean Anderson, A guide to the clinical case of women with HIV. HRSA HIV
AIDS Bureau, 2000:p.329,.
2. Futterman, D, Chabon B, Hoffman ND. HIV and AIDS in Adolescents. The
pediatrics clinics of North America, 2000:171, 47,1.
3. Joyce W, Happy. Institute of Medicine the Hidden Epidemic Confronting
Sexually Transmitted Disease, Washington DC: National Academy Press, 1997.
4. National Research Council: Risking the Future Adolescent Sexuality Pregnancy
and Child Bearing (Vol.1) Washington DC: National Academy Press, 1987.
5. Population Reference Bureau: Data Sheet of the Worlds Youth 2000 (USAID).
6. Chabon B, Hoffman N, Hesshy B et al. High Prevalence of HIV among patients
of HIV and youth presented at meeting of society of adolescent medicine. San
Francisco, 1997.

7. Singh BM, Vashist S. Knowledge and attitude of adolescent girls towards AIDS
in a resettlement area in Delhi. J Prep Sec Med 1996: 27, 3-4.
8. Sorensen RC: Adolescent Sexuality in contemporary. America, New York:
World Publishing 1973.
9. Futterman D, Hein K, Rauben N et al. Human Immunodeficiency Virus-infected
adolescents: The first 50 patients in a New York City Program. Pediatrics 1993.
91:730-35.
10. Miller HG, Cain VS, Rogers SM et al. Family Planning Perspective, 1999, 31:4.
11. Centres for Disease Control and Prevention: Youth Risk behaviour surveillanceUnited States, 1997. MMWR Marb Mortality weekly Report 1998:47.
12. Mc Kenzie TD, Steinor JF, Daidson AJ: Prev. Med: 1998, 27:792.
13. DAngelo LJ, Ggestoson PR, Luban NLC et al. HIV in adolescents: Can we
predict who is at risk: Pediatrics 1991:88;982.
14. Tiwari VK, Khan AM, Kumar Anil et al. Pre-marital sexuality and unmet need
of contraception in two cites of India-Delhi and Lucknow: National Institute of
Health and Family Welfare, New Delhi, 2000.
15. Jejcebhoy SJ. Adolescent sexual and reproductive behaviour: A review of the
evidence from India: Social Science and Medicine 1998, 46(10): 1275-90.
16. Watza MC: Premarital sexual behaviour of Urban educated youths in India
paper presented at the workshop on sexual aspects of AIDS/STD in India,
Bombay, 1993.
17. Nicolosia A, Correa, Laite ML et al. The efficacy of male to female and female
to male sexual transmission of HIV. A study of 730 couples: Epidemiology,
1994, 5:570.
18. Padian NS, Shiboski SC, Jewell NP. Female to male transmission of HIV, JAMA
1991, 266:1660.
19. Balmer DH: The phenomenon of adolescents. An ethnographic injury NARSEA
monogram 4, Nairobi 1994.
20. Stranin L, Hingson R. AIDS and Adolescent: Knowledge, beliefs, attitudes and
behaviour: Peadiatrics 1987, 79:825.
21. Diclemente RJ, Zkorn J, Jemoshok L. Adolescents and AIDS: A survey of
knowledge, attitudes and beliefs about AIDS in San Francisco. Am J Public
Health 1986, 76:1443.
22. Rogers AS, Futterman DC, Mosciki AB et al. The REACH Project of the
Adolescent Medicine HIV/AIDS Research Network: J Adolesc Health 1998;
22:300.
23. Rogers AS, Futterman D, Levin L et al. A Profile of HIV-infected adolescents
receiving health care services at select sites in the United States. J Adolesc Health
1996; 19:401.
24. Grubamen S, Gron E, Lernor -Weiss N et al. Older children and Adolescents
living with perinatally acquired HIV: Pediatrics 1995; 95:657.
25. Dougles SD, Rudy B, Nuenz L et al. Peripheral blood mononuclear cell markers
in ART-nave HIV infected and High-risk seronegative adolescents: AIDS 1999;
13:1629.
26. Resnick MD, Blum RW, Hedin D. The appropriateness of health services for
adolescents. J. Adolescent Health Care 1980;1:137.
27. Kunins H, Hein K, Futterman D et al. Guide to adolescent HIV/AID program
development: J. Adolesc Health 1993; 14 (suppl) : 36.
152 Women and HIV

28. Marshall W, Tanner JM. Variation in the pattern of pubertal changes in girls:
Arch Dis Chil 1969; 44:291.
29. Hoffman ND: Treatment issues for HIV positive adolescents. AIDS Clinical
Case, 1999;11(3):1.
30. US department of Health and Human Services Guidelines for use of
antiretroviral agents in HIV infected adults and adolescents: Morbidity and
Mortality Weekly Report 1998; 47(RR-5): 1-41.
31. United States conference of Mayors Local School districts activity in AIDS
education. AIDS information exchange 1987;4:1-10.
32. Kolbe LJ, Iversin DC: Integrating school and community efforts to provide
health strategies, policies and methods: J Educ 1983;2:40-47.
33. K.Park. AIDS In K Park (Ed): Parks Textbook of Preventive and Social Medicine.
Bhanot, India: Barkar Sidas, 2000:16; 264-65.
Infection Control and Bio-safety Practices
153
nine
Infection Control and

Bio-safety Practices in
Health Care Settings
Krishna Ray
Health care settings pose high risk of transmitting infections to

patients as well as to the Health-Care Workers (HCW). Many of
these infections, particularly, those transmitted through blood or air,
are of special concern in health care (HC) settings. Infection control
(IC) is a quality standard of patientcare and is essential for the well
being of the patients and the safety of both patients and staff. To
accomplish a reduction in infection rates in HC settings, an effective
infection control programme has to be implemented
LEARNING OBJECTIVES
1.
2.
3.
4.
5.
6.
Nosocomial infections and the different modes of its acquisition.

Bio safety in health care set-ups.
Standard precautions and their importance.
Components of standard precautions.
Ideal sterilisation and disinfection practices in the hospital.
Hospital high risk procedures and prevention of occupational
exposure.
7. Biomedical waste, importance, principle and ideal methods for
their disposal in health care settings.
Infections Acquired in the Health Care
Settings (Nosocomial Infections)
Definition
Infections acquired in the healthcare settings are defined as those
which patients acquire from health facilities and were not
154 Women and HIV

incubating at the time of admission. Infections in HCWs and visitors
following exposure in the health-care settings are also included.
Mode of infection
Infections are transmitted from patients to HCWs or vice-versa by
four main routes:
1. Contact (touching): Hands contaminated from patients infected
body fluids, secretions, excretions or from contaminated items
and brought into contact with skin lesions or mucous
membranes of staff. Large droplets from respiratory tract often
contaminate the environment close to the patient and infection
is transmitted by contact.
2. Faeco-oral route (eating and drinking): Hands, food or water,
contaminated with the patients faecal flora.
3. Air borne: (inhalation). Droplet nuclei dispersed into the air and
inhaled.
4. Blood borne: Blood from the patient reaching the blood of HCW
via cuts or sharp injuries through percutaneous or mucocutaneous route.
Risk factors
The risk factors for acquiring infection in the health care setting
are as follows:
Patient:
Extremes of age, malnutrition, immune deficiency,
injuries, etc.
Microbial:
Load of microbe, high virulence of organisms .and
presence of new organisms.
Environmental: A highly contaminated environment or high risk
procedures, eg, surgery, invasive diagnostic or
therapeutic procedures.
Diagnosis
Diagnosis of nosocomial infections is usually based on methods
common to other infections, i.e. clinical evidence of the disease
along with laboratory evidence (culture, serology, etc.). It is
important to prove that the infection(s) is/are acquired in the
health care settings.
155
Surveillance of Nosocomial Infections

In order to ensure that control measures are effective, surveillance
of nosocomial infection is essential. Surveillance involves the
routine collection of data on infection, analysis of the data and
feedback to the hospital staff. As it is not possible to carry out
surveillance in all the areas, high-risk areas like OTs, labour
rooms, nurseries, etc. can be selected. Surveillance data are essential for developing and revising infection control policies and
procedures.
Principles of Infection Control
Patients
Should be admitted only when absolutely necessary.

Should be discharged as soon as possible.
Special nursing care for patients with low immunity.
Isolation of patients with communicable diseases eg cholera,
tuberculosis etc.
Microbe
Identification of source of infection.
Specific measures to contain their spread.
Environment
Design of health care facilities -good ventilation.
Scrupulous cleaning.
Positive and negative pressure ventilation in certain areas
like OTs.
Proper waste disposal, water treatment, disinfection and
sterilization of equipments.
Infection Control Programme
The primary goal of infection control (IC) programme is to prevent
the spread of infection from patients to Health Care Workers
(HCW), from HCW to patients and from one patient to another.
There should be an infection control team with an infection
control officer, an infection control nurse and an infection control
committee.
156 Women and HIV

The aim of the committee should be
To improve hospital IC practices and recommend
appropriate policies which should be subject to frequent
review in order to make it practical and feasible.
To institute investigation of outbreaks for containing a
particular type of infection occurring in a cluster in a
particular area. Prompt intervention measures should be
instituted to control such outbreaks and for prevention of
future occurrences.
The committee requires information on
Occupational exposure.
The prevalence of infections etc. obtained through regular
surveillance.
Laboratory studies form an important component of the IC
programme . The head of the institution should be responsible for
ensuring proper planning, implementation, monitoring and
evaluation of the programme for effective infection control.
(This chapter has main focus on the prevention of transmission
of blood borne infections in health care settings).
Transmission of Blood Borne Infections in
Health Care Set-ups
Since the advent of the Acquired Immune-Deficiency Syndrome
(AIDS) epidemic, extraordinary efforts all over the world have been
made to prevent occupationally acquired infections with Human
Immune-Deficiency Virus (HIV) and other blood borne infections.
HIV is transmitted from one person to the other in ways very similar
to Hepatitis B andC, although the infectivity of HIV is 100 times
less.
HCWs at risk are physicians, surgeons, dentists, nurses, laboratory
and blood bank staff, paramedicos, housekeepers, laundryworkers, morticians, others in contact with blood, body fluids,
patients, corpses and biomedical wastes
Common microorganisms transmitted through blood/body fluids
Hepatitis B virus , Hepatitis Delta and Hepatitis C viruses,
HIV l and 2, HTLV I and II, HCMV,
Viral Haemorrhagic fever, EB Virus, Brucella, Salmonella,
Malaria parasites.
157
Risk of Transmission of Blood Borne

Infections in Health Care Settings
Patient to HCW Transmission

Transmission of blood borne infections from patients to HCW can
occur when HCW is exposed to infected blood eg.,
a. Parenteral exposure, such as needle stick injury, cuts from
broken blood collection tubes.
b. Through mucous membrane contact, such as a splash of blood
into the HCWs eye or mouth.
c. Non intact skin contact such as splash of blood on to open
wounds or broken skin due to dermatitis, acne or cuts or
abrasions of skin not protected by barriers eg. gloves
The most common way in which HCWs are exposed to HJV and other
blood borne infections is through accidental exposure to sharp objects.
The recent statistics published by CDC relative to transmission
risks for HIV and Hepatitis B virus (HBV) are that the risk for
acquiring HIV following needle stick prick (per-cutaneous
exposure) from a source patient with HIV is very low (0.25-0.3%)
and through muco-cutaneous exposure is 0.05 percent. This is
because the virus generally circulates at a much lower concentration
(10-100 infectious doses/mL) and it is not able to survive as well
in the environment outside the body. In contrast, acquiring HBV
infection following needle stick prick from a HBV carrier ranges
from 9-30 percent as HBV is found in very high litres (> 10,000,000
infectious doses/mL) in the blood of many acutely and chronically
infected individuals and can survive for long periods in dried blood
at room temperature. The chance of acquiring Hepatitis C virus
(HCV) is 3-10 percent. The risk of transmission of HIV through
muco-cutaneous exposure is 0.05 percent. In different studies
carried out in the U.S., there were 24,473 adult AIDS cases reported
who are employed in health care (5.1% of total). Out of them, 57
documented sero-conversions in the context of occupational
exposure up to June 2001 (Of these, 26 developed AIDS). The route
of exposure in 48 were per-cutaneous, in 5 were muco-cutaneous,
2 had both and 1 had unknown type of exposure. There were 49
exposures to blood, 1 to body fluid, 4 with unspecified fluid and
three involved viral cultures in the laboratory. In all, 19 laboratory
158 Women and HIV

technicians, 24 nurses, 6 physicians, 2 surgical technicians,
2 housekeepers and 4 others had got occupationally acquired HIV.
Nearly all cases of HIV transmission to HCWs have occurred
through preventable accidents.
Survival of HIV in the Environment
HIV is heat sensitive:
On drying 90-99 percent of virus die immediately.
At room temperature the virus dies in 15 days.
At 37C HIV dies in 11 days.
56C for 30 minutes reduces the infectivity by hundred fold.
Boiling inactivates the virus and it dies in 1 sec.
The Risk of Occupational HIV Transmission Depends on
Prevalence of infected individuals in the population.

Frequency of exposure to contaminated medical instrument.
Relative infectivity and concentration of the virus.
Exposure to a large quantity of blood.
Deep needle stick injury.
Injury with hollow bore needles and.
Source patient who died within 60 days as a result of AIDS.
In India, there are only meagre data available on HIV

transmission due to needle stick injury/muco-cutaneous exposure
in health care setting. The lack of proper infrastructure, low levels
of awareness about safety precautions and a certain degree of
complacency amongst HCWs are some of the concerns of public
health managers.
Patient to patient transmission

Patient to patient spread of HIV and other blood borne infection is
usually by an indirect route and occurs in countries with limited
supplies and equipments. This can occur through blood-contaminated needles, syringes or other surgical and dental equipments
which have not been properly sterilized or disinfected between
use. Patients can also get infected by receiving transfusion of
contaminated blood/blood products.
159
How to patient transmission

Although risk exists for transmission of infection from HCWs who
are carriers of HBsAg/HIV to patients, it is the least common
pathway of transmission in the HCsetting. All six patients of a
Florida dentist with HIV infection got infected.
Importance of Bio-safety Practices for Prevention of
Transmission of Blood Borne Infections
There is no vaccine for prevention of HIV/AIDS, treatment is
expensive and is not easily available. Hence prevention of infection
is the cornerstone of control of this epidemic. In the health care
settings also, prevention is considered most important. The
irrational fear of accidental infection from HIV/AIDS patients
invariably influences the behaviour of the Health Care Workers
(specially those who routinely handle blood and body fluids)
towards their patients and their specimens.Therefore, on the one
hand, it is extremely important that the HCW.s should be aware of
the risks involved in their day to day work and apply effective
infection control practices to reduce the possibility of transmission
of these fatal infections to a minimum. On the other hand, they
should not be prejudiced and should not show discrimination
towards patients of HIV/AIDS. Table 9.1 shows the different high
risk procedures for the health care workers (H.C.W) and the various
modes of acquiring infection.
Blood Borne Infection Control in
This may be discussed under the following headings:
History
In early days, there was the concept of quarantine. The traditional
system of isolation with use of barrier equipment. The latest
information on transmission of infection in hospitals is provided
by CDC.
1. Precautions in relation to blood and body fluidsstandard
precautions.
2. Effective use of sterilization and disinfection.
160 Women and HIV

Table 9.1: High-Risk Procedures in Health Care Settings Facilitating Parenteral
Infection Transmission and their Prevention
Procedure
Occupational Risk
1. Injections
(TV, IM, IC, SC)
2. Surgical and
Dental
procedures
Needle prick
proper reusable
syringes and needles
Exposure to infected
blood
Spill of blood
Injury with sharps
Contact with tissue, organ,
part of body removed
Prevention
Care during procedure,
disposal disposable/
Barrier protection,
washing of hands
Proper disinfection
Care during procedure,
proper disposal
Proper disposal after
prior disinfection
3. Dressings of Contact with dressing
Consider as potentially
woundsmaterials
infectious
Disposable instruments
Proper disposal after
disinfection
Sterilization after
Reusable instruments
disinfection
4. Management Exposure to splashes
Use of waterproof aprons/
of delivery
of blood and
gowns ,shoes, masks,
amniotic fluid
gloves, hand washing
Spill of blood on surface
Decontamination
Cuts
Care during procedure
Contact with placenta
Placenta incinerated/
Infected secretions during
buried deep with
bleaching powder/
neonatal resuscitation
Instruments and equipments
lime all around
exposed to blood/
Proper disinfection
body fluids
followed by sterilization
5. Investigations Contamination of
Proper disinfection
Invasive
Instruments and
followed by sterilization
procedures
equipments exposed
Care during procedure
Endoscopy,
to blood/body fluids
Barrier protection,
LP, cardiac
Injury with sharps
washing of hands
catheterisation,
objects
Standard precautions
PV.P.R., prostate
for blood/ body
massage,
fluids in collection,
transportation,
speculum
examination
processing,
blood spill and disposal
of laboratory waste
3. Safe disposal of hospital waste.

4. Immunization of HCW eg. HBV.
161
Standard Blood and Body Fluid

Precautions for Laboratory Workers
(Recommended by CDC Guidelines)
Although the risk of transmission of infection due to blood borne
pathogens in the health care settings cannot be eliminated
altogether because chances of accidents are there, application of
standard precautions minimises these to a large extent. Standard
precautions realize that the spread of infection in the health care
setting can be prevented by taking a consistent approach for all
patients regardless of their blood borne infection status as most of
the individuals with HIV/HbsAg/HCV etc. are asymptomatic.
Majority of them may not even belong to recognised high risk
groups. Standard precautions include universal precautions + Body
substance isolation. Under universal precautions, blood and body
fluids of all patients are considered potentially infectious for HIV,
HBV, HCV and other blood borne pathogens. Similarly, all
instruments and other equipments that have come into contact with
blood are assumed to be potentially contaminated with blood borne
pathogens and must be properly handled, cleaned and sterilized/
disinfected or safely disposed of. Universal precautions are
intended to prevent accidental parenteral, mucous membrane and
nonintact skin exposures of health care workers to the above blood
borne pathogens in patients. Routine and/or mandatory testing
of patients for HIV antibody or HBsAg is not an effective strategy
for controlling the transmission of these infections in health care
settings.
Body Fluids to which Standard
Precautions Apply
Blood is the single most important source of HTV, HBV and
other blood borne pathogens in the occupational setting.
All other body fluids containing visible blood.
Semen and vaginal secretions.
Cerebrospinal fluid.
Synovial fluid.
Pleural fluid.
Peritonial fluid.
Pericardial fluid.
Amniotic fluid.
162 Women and HIV

Body Fluids to which Standard Precautions do not Apply
The risk of HIV transmission is extremely low or negligible unless
these contain visible blood. These include faeces, nasal secretions,
sputum, sweat, tears, urine, vomitus.
Standard precautions include:
Hand washing.
Barrier protection.
Safe handling of sharp items or morbid specimens.
Safe handling of spill of blood/body fluid.
Patient placement/transport.
Housekeeping.
Waste disposal.
Use of disposable or sterile items.
Food and nutrition.
Patient visitor exposure.
Immunization with hepatitis B vaccine.
Use of safe techniques, eg, mechanical pipetting device.
Use of mouth pieces and resuscitation bags rather than direct
mouth to mouth resuscitation during medical emergencies.
Linen and laundry services.
Barrier protection
Protective barriers reduce the risk of exposure of the HCWs skin
or mucous membrane to potentially infective
materials including blood and body fluids.
Gloves can reduce the incidence of contamination of hands but
cannot prevent penetrating injuries by needles andother sharp
instruments. Gloves should be worn while,
Carrying out rectal, vaginal, oral, throat or nose examination,
Carrying out delivery of child ,
Handling blood/blood soiled items,
Whenever there is a possibility of exposure to blood or body
fluids containing blood,
Performing invasive procedures like giving injections,
collecting or handling blood specimens for laboratory
investigations/blood transfusion or performing surgical
operations
Disposing biomedical waste.
163
Gloves should be well fitting, disposable, vinyl or multiple use

and must be changed if visibly contaminated with blood/breached.
Heavy duty general purpose rubber gloves for washing infected
glassware/sharps. These utility gloves maybe decontaminated and
reused but should be discarded if they are peeling, cracked or
discoloured or if they have punctures, tears etc.
Gloves should be removed before handling door knobs, telephones, pens, performing office work and leaving the workplace.
Gloved hands should not touch eyes, nose or other exposed membranes or skin.
Gowns
Gowns or uniforms (preferably wrap-around gowns) should
be worn during patient care and removed before leaving the
workplace.
Should be made of water resistant material like rubber,
plastic, water resistant paper or cloth
Should be used when splashing of blood/body fluids are
anticipated eg., in surgical operations, vaginal deliveries,
handling of bleeding patients and handling of an accident
victim and while working in laboratories. These should also
be used while cleaning infected re-usables/during disposing
wastes.
Facial Protection
Simple and cheap deflector masks and protective glasses
without power, goggles or eye covers may be worn if splashing or
spraying of blood/body fluids is expected. Situations are surgical
operations, vaginal deliveries, suction, attending to wound,
accident patients, working in the laboratory and other similar
situations. Eye covers are necessary since HIV can pass through
intact conjunctiva and no disinfectant can be used after exposure
of the eye.
Occlusive Bandage
All skin defects eg., cuts, scratches or other breaks must be covered
with water-proof dressing before patient care.
164 Women and HIV
Hand Washing
The hands of HCWs are many times responsible for the
transmission of various infections. Hand washing is an ideal
safety precaution and is one of the most important in preventing
transmission of infections in HC settings.
Hands should be washed thoroughly in running water with soap
without missing any area with soap for atleast 30 seconds with
thorough rubbing and dried by wiping with paper towels. If
reusable towels are to be used then regular supply of clean
towels should be ensured.
Washing of hands is mandatory,
Before and after direct patient care
Immediately after contamination with blood/body fluids
After removing gowns/coats and gloves
Before eating/drinking and leaving the workplace
(Gloves should not be regarded as a substitute for hand
washing)
Handling Sharp Objects

Extreme care should be used to avoid auto-inoculation.
All chipped or cracked glassware should be discarded in
appropriate containers.
Broken glass should be picked up with a brush and pan. Hands
must never be used.
The disposable needles should never be manipulated, bent,
broken, recapped/removed from syringes.
The used sharps should never be passed directly from one
person to another.
Always one should dispose of his/her own sharps.
Used needles should be discarded in puncture-proof rigid
containers (plastic or cardboard boxes) after disinfection in
0.5-1 percent freshly prepared sodium hypochlorite solution/
common bleach solution kept in a bowl with a strainer and never
in other waste containers. If a needle shredder is available, only
the needles or the needles along with syringe nozzles may be
shredded depending upon the type of the shredder.
Sharp disposable containers should be located close to the point
of use.
Sharp disposal containers should be sent for disposal when
three-fourth full.
165
HANDLING SPECIMENS OF BLOOD/BODY FLUIDS

Specimens, specially blood and body fluids should be collected
in pre-sterilized screw-capped plastic containers, properly
sealed to prevent spillage or leakage. Autoclaved/pre-sterilized
disposable syringes and needles for vene-puncture or lancets/
cutting needles for finger prick should be used.
Cuts in hands should be properly covered with water-proof
adhesive bandages.
Disposable gloves should be worn while collecting blood /body
fluids and proper asepsis should be maintained.
If a sample shows evidence of breakage (in case not collected in
the above container), leakage or soiling, it should be transferred
with a gloved hand into a second sterile container.
Any pertinent information should be rewritten from the old to
the new container.
If the requisition slip is contaminated with blood, it should be
rejected. In case of emergency, the contaminated slip may be
handled using gloves.
Blood and other specimen containers should be labelled with a
special warning sign Biohazard precaution.
If the outside of the container is visibly contaminated with blood,
it should be cleaned with disinfectant.
The blood specimens should be placed in small leak-proof
impervious plastic tubes for transportation to the laboratory.
Hands should be thoroughly washed with soap and water
particularly after handling specimens.
HANDLING BLOOD/BODY FLUID SPILLS
In case of a spill of blood/body fluid in the workplace, first the
area should be covered with paper towels/dry mop or gauze
sponges to absorb the liquid, followed by flooding of the area
with a disinfectant solution, eg. freshly prepared 1 percent
Sodium hypochlorite solution and left for 30 minutes.
After wearing gloves, the paper towels/mop or gauze sponges
are removed followed by a thorough wash with soap and water.
All contaminated materials should be disposed of as infectious
waste.
166 Women and HIV
Protection of Cuts/Abrasions in the Skin

Intact skin without abrasions or cuts is a natural barrier against
infection.
The skin integrity should be checked by rubbing alcohol/spirit
( Methylated/rectified) before starting the duty each day. Cuts
may be visible but abrasions need to be checked by alcoholic
rub.
Cuts and abrasions must be covered with water-proof dressings.
Hepatitis B Vaccine
Appropriate use of HBV vaccine plays a key role in prevention of
transmission of HBV from patient to health care worker. Therefore
it is important that all the HCWs should be immunized as
recommended by WHO.
Patient Placement
Private room necessary when,
Patient has infection that transmits by air borne/droplet nuclei.
Micro-organisms that can be transmitted by contact.
Large amounts of body fluids/discharges.
Poor hygiene.
High Risk Procedures in the Health Care Set-Ups

Special attention should be paid to provision of adequate number
of gloves, protective aprons, sufficient instruments and autoclaving
facilities in the above situations. Infection control in a few areas
are discussed as follows:
Laundry and Linen
Although soiled linen has been identified as a source of large
numbers of certain pathogenic organisms, the risk of actual disease
transmission is negligible.
Soiled linen may be handled as little as possible and with
minimum agitation to prevent gross microbial contaminationof
the air and of persons handling the linen.
All soiled linen must be handled with gloved hands and if
feasible, decontaminated in 0.5-1 percent sodium hypochlorite
in the laboratory before sending to the laundry.
167
Soiled linen after decontamination, should be put in heavy

plastic bags which are tied and sent to the laundry. In the
laundry, decontamination in bleach is recommended in case not
done earlier. This should be followed by washing in hot water
(> 70C ) with detergent. Usual wash cycles in washing machines
kill HIV
Blankets
Synthetic blankets are better than woollens for washing/
disinfection purpose.
Woollen blankets are to be disinfected by formaldehyde vapours
or autoclaving.
Dry cleaning does not inactivate HIV.
Mattresses
Should be ideally autoclaved. In absence of autoclave, manual
washing is advisable.
Water proof synthetic cover (rexine/plastic) for the mattresses
is recommended.
Mortuary
All dead bodies should be handled carefully.
For transportation and storage of dead bodies, wearing of aprons
and gloves by HCW is adequate.
Double gloves, masks, protective eye wears, gowns/water-proof
aprons and shoe coverings should be worn, while performing
autopsy involving invasive procedures like evisceration, cutting
bones and tissues, when splashing of blood/body fluids may
occur.
The dead bodies, after autopsy, should be stitched properly so
that no body fluid comes out. The orifices should be plugged
with cotton swab soaked with disinfectant.
Instruments and surfaces contaminated during autopsy should
be considered as potentially infected and sterilized before
re-use.
In HIV infected cases, specific procedures for providing
morticiary care like use of formalin for embalming should be
made mandatory and parenteral/mucous membrane exposure
prevented. The relatives should be advised to wear gloves.
168 Women and HIV

MANAGEMENT OF ACCIDENTAL EXPOSURE TO
HIV IN THE WORK PLACE
(Post-exposure anti-retroviral prophylaxis is discussed in
Chapter 10 )
Effective Use of Sterilization and Disinfection
Definitions
Cleaning is a process which removes foreign material (e.g. soil,
organic material, micro-organisms) from an object.
Disinfection is a process which reduces the number of
pathogenic micro-organisms, but not necessarily bacterial spores
from inanimate objects or skin, to a level which is not harmful to
health.
High level disinfection is often used for a process which kills
mycobacterium tuberculosis and enteroviruses in addition to other
vegetative bacteria, fungi and more sensitive viruses.
Sterilization is a process which destroys all micro-organisms
including bacterial spores.
(The level of decontamination should be such that there is no risk for
infection when using the equipment).
Classification of Infection Risk from Equipment or
Environment into Three Categories and
Suggested Levels of Decontamination
Low Risk
Items in contact with normal and intact skin, or the inanimate
environment not in contact with the patient (e.g. walls, floors,
ceilings, furniture, sinks and drains). Cleaning and drying is usually
adequate except when there is spill of blood/body fluids.
Intermediate Risk
Equipments which do not penetrate the skin or enter sterile areas
of the body but are in contact with mucous membranes or nonintact skin, or other items contaminated with virulent or transmissible organisms (e.g. respiratory equipment, gastrointesiinal
endoscopes, vaginal instruments, thermometers). High level
disinfection is usually adequate.
169
High Risk
Any other equipment which penetrate the skin and/or enter sterile
areas of the body (eg. Operations), should be thoroughly cleaned
and sterilised. High level disinfection may sometimes be
appropriate, if sterilization is not possible.
Methods
Cleaning of Equipments/Glassware
Thorough cleaning and drying with detergents and water remove
most organisms from an object/surface and should be carried out
meticulously before sterilization. All contaminated items after prior
disinfection should be dismantled before cleaning. Cold water is
preferred as it will remove most of the protein materials (blood,
sputum, etc.). The most simple, cost effective method is to
thoroughly brush the item, keeping the brush below the surface of
the water, to prevent the release of aerosols. The items should be
rinsed finally in clean, warm water and dried. Items are then ready
for use for sterilisation. Personnel handling contaminated items
should wear good quality gloves for personal protection.
Environmental Cleaning
Floors, surfaces, sinks and drains should be cleaned with
warm water and detergent. Routine use ofdisinfectants is
unnecessary.
If there is spillage of blood, body fluids or sputum,
disinfection before cleaning is recommended asdescribed
earlier. Release of chlorine gas from disinfection of large
spillage can be hazardous to staff. If spillage is immediately
removed, general disinfection of the room is not necessary.
Thorough cleaning will suffice.
Disinfection
Most of the disinfectants used in health care settings in this country,

if used in proper concentration and for suitable period of time are
effective against HIV Either thermal or chemical processes are used
for disinfection.
170 Women and HIV

Thermal disinfection is preferred whenever possible. It is
generally more reliable, leaves no residue, is more easily controlled
and is non-toxic. Organic matter (serum, blood, pus or faecal
matter) interferes with the antimicrobial efficiency of either method.
The larger the number of microbes present, the longer it takes to
disinfect. Boiling (100C) for 20-30 minutes is a very simple and
reliable method for the inactivation of all micro-organisms
including hepatitis B virus, HIV and mycobacteria. Carefully done,
it is a high-level disinfection procedure. For used disposable syringes
and needles, the best practice is to use Needle Destroyers, which cut the
nozzle of the syringes.
The main use of chemical disinfectants is for heat labile
equipments where single use is not cost effective.
HIV CAN BE DISINFECTED BY

Sodium hypochlorite
Ethanol
Glutaraldehyde
Hydrogen peroxide
Lysol
0.5-1.0%
70%
2.0%
3.0%
0.5%
Decontamination/Disinfection of used Needles and

Syringes prior to Sterilization/Disposal
The disinfectant is aspirated into the syringe.
The needles and syringes are immersed with disinfectant.
horizontally in a flat tray for 30 minutes.
The disinfectant solution is discharged from the syringe and
needle and rinsed with disinfectant by filling and emptying a
number of times.
The disposable syringes and needles are disposed as described
earlier.
The reusable syringes and needles are autoclaved/boiled for 30
minutes.
Chemical disinfection should never be used as a method of
sterilization particularly for syringes and needles.
Sterilization
HIV is a fragile virus and is adequately inactivated by Standard
sterilisation procedures like autoclaving at 15 pounds pressure
171
for 20 minutes at 121C or hot air oven at 160- 180C for 1 hour
(holding time).
The choice of the methods like autoclaving, use of hot air oven
etc. depends on a number of factors including typeof material
of the object, number and types of organisms involved and risk
of infection to patients or staff.
Pressure cooker (household pressure cooker or WHO/UNICEF
modification) may be used in small settings.
Any sterilization procedure should be monitored routinely by
mechanical, chemical and biological techniques.
Sterile items should be protected against recontamination.
Contact with saliva may have ?HIV transmission risk .

Therefore, mouth pieces, resuscitation bags, ventilation devices
should be either for single use or must be thoroughly cleaned and
disinfected. Use of electric suction machines is advised.
Setting up of Biomedical Waste Facility

Every hospital, nursing home, veterinary institution, animal-house,
blood banks, research institutes generating biomedical wastes
should install an appropriate biomedical waste facility in the
premises or should set up a common facility, in accordance with
the directions given by the appropriate authority. Biomedical waste
should not be generated without authorization. Every hospital
should have a waste management programme Waste survey is an
Table 9.2: Classification of Biomedical Wastes
Non infectious (90%.)
Paper, Cardboard, Thermocol box,
Plastic/ PVC, Discarded reagents
Infectious (10%)(Bio-hazardous)
|
Non sharps
Solids
Human waste, blood/blood
products,body fluids,
animal waste microbiological/
biotechnological
waste, soiled linen/ gauze/ cotton
Liquids
Sharps
______________
______________
Needles, Syringes,
Blades, Scalpels,
Glassware
172 Women and HIV

important part of the waste management programme and helps
in determining both the type and quantity of waste being generated
in the hospital and determine the feasible methods of disposal.
Containing Waste at Generation Point

At the generation point like OPD, OT, laboratory, labour rooms
etc. waste is managed in the following way:
1.
2.
3.
7.
Collection
Segregation
Disinfection
Final Disposal.
4. Weighing
5. Storage
6. Transport
Waste segregation is the key to any waste management scheme.

It consists of placing different types of waste in different containers
or colour-coded-bags at the site of generation. This helps in
reducing the bulk of infectious waste and contains spread of
infection to general waste. This practice reduces the total treatment
cost, the impact of waste in the community and the risk of infecting
workers. Proper segregation should identify waste according to
source and type of disposal/disinfection.Waste should be
segregated into different categories at the site of generation and
weighed separately at the time the waste is being disposed.
Solid non infectious waste is collected in black bags and
disposed as household waste. Infectious waste must be separated
at the point of generation itself and should be decontaminated prior
to its storage, transport and disposal. Solid infectious waste are
disposed as follows:
Sharps
a. Needles and syringe nozzle- shredded in needle-destroyer, if
available, otherwise, decontaminate as described under
b. Disposable scalpel blades/ lancets/broken glass-should be put
in separate container with bleach, transferred to puncture proof
cardboard boxes, and sealed to prevent spillage and transported
to incinerator
Glass Wares
These should be disinfected, cleaned, sterilised and reused.
173
Culture Plates with Viable Culture

These should be autoclaved in plastic autoclavable bags, media
are removed and collected in yellow bags and disposed of by
incineration/micro-waving/ hot air oven. The plates can be reused
after sterilization or disposed by shredding if single use.
Swabs
These should be incinerated.
Disposable Items
These include single use products (syringes, gloves, sharps,
transfusion sets etc.). As these items are often recycled and have
the risk of being reused illegally, these should be disinfected by
dipping in freshly prepared 1 percent Sodium hypochlorite for 30
minutes to 1 hour. Bins /containers which can be used for this
purpose are a set of twin bins, one inside the other with the inner
one being perforated and easily extractable. This minimizes contact
when the contents are being removed. Disposable items like the
gloves, syringes etc. should be shredded cut or mutilated before
disposal, followed by deep burial or properly accounted before
disposal. Extreme care should be taken while handling the needles.
Liquid Wastes
Generated in the health care settings are either pathological or or
chemical in nature and are disposed of as follows:
Non-infectious chemical waste should first be neutralised with
chemicals and then flushed into conventional sewer system.
The liquid infectious waste should be treated with a chemical
disinfectant for decontaminaiion then neutralized and flushed
into the sewer.
Collection Bags
Solid wastes are collected in leak-resistant single heavy duty bags
or double bags may be used. Waste collection bags for waste types
needing incineration should not be made of chlorinated plastics.
Bags having different colour codes with red labels, mentioning date
and details of waste are recommended. The labels should be non
174 Women and HIV

washable and prominently visible. The bags are tied tightly after
they are three-fourths full.
Packing, Storage and Transport

All segregated and disinfected waste should be packed in proper
containers containing colour-coded bags with red labels
mentioning details of biomedical waste and biohazard signs All
containers used for storage of such waste shall be provided with
a properly covered lid.
Such containers should be inaccessible to scavengers and
protected against insects, birds, animals and rain. There
should not be any spillage during handling and transit of such
waste.
The waste sharps, after pre-treatment should be broken before
packing in the container.
The waste should be transported in covered vehicles authorised
for this purpose only.
No such waste should be stored in the place where it is
generated, for a period of more than two days.
Treatment and Disposal
Disposal may be done by either of the following methods:
Municipal Corporation
Sanitary landfill
If incinerator is not available, deep burial in controlled landfill sites
is recommended. Decontamination should be carried out before
burial.
Incineration (Temp.750C)
Incinerator burns/reduces the infectious waste to ashes and
therefore favoured by hospitals. It may be of two types-common
or individual. There are some disadvantages like pollution/
incomplete melting of needles. Hospitals with more than 30 beds
or > 1000 patients per month should have an incinerator. Plastics
cannot be incinerated.
175
Guidelines for Waste Disposal

All biomedical wastes should be treated and disposed of strictly
in accordance with the options mentioned in the Table 9.3.
Waste which cannot be incinerated, (plastics) should be pretreated by disinfection and disposed of in an environmentally
sound manner.
Table 9.3: Container and colour coding for disposal of bio-medical wastes
Sr.
No.
WasteClass/
Category
1. Human anatomical
waste, blood and
body fluids
2. Microbiology and
bio-technology
waste
3. Waste sharps
4. Discarded
medicines
5. Soiled wastes
(Items contaminated
with blood and body
fluids eg. cotton
dressing, soiled
plaster casts,
linens, beddings etc.
6. Disposables (other
than sharps eg.
tubings, gloves
catheters and IV
sets etc.
7. Liquid wastes from
laboratories and
washing, cleaning,
house keeping and
disinfection
8. Noninfectious solid
waste
Type of Container
Color
coding
Treatment/Disposal
option
Single-use containers Yellow

/Plasic holding bags
Incineration/Deep
Burial
Single-use containers Yellow

/Plastic holding bags
Local autoclaving/
Microwaving and
Incineration
Shredding followed
by Landfill
Re-usable/single-use
sturdy containers of
plastic, glass,
cardboard/ metal
Re-usable/single-use
sturdy containers of
plastic/metal
Blue
Black
Incineration/
destruction and
drug disposal in
secured landfills
Incineration/Deep
Burial
Plastic bags/
sacs/container
Yellow
Re-usable/
sturdy containers/
plastic holding bags
Blue
Disinfection
(chemical
treatment)/
and mutilation/
shredding followed
by deep burial
Disinfection by
and discharge
into drains
Black
Municipal
Corporation
NA
Plastic holding bags
176 Women and HIV

Waste should not be dumped, discharged or disposed in any
place other than a site identified for the purpose.
All precautions and personal safety measures should be taken
(including provision of protective clothing, masks,gloves,
gumboots, goggles, etc. as may be necessary). Hepatitis B
vaccination is recommended for affording protection to all
personnel engaged in handling biomedical waste, or being
exposed to such wastes against infection from handling or
exposure.
All treatment and disposal facilities should be located at a
specified area away from the general service area of the hospital,
public places and residential areas.
When the treatment option is burial, the pits should be located
at sites away from agricultural land, residential areas, groundand safe water sources. There should be no leakage from the
pits in to surrounding areas.
All plastics should be disinfected and shredded and disposed
of in an environmentally friendly manner. Recycling of
disposable, should be prevented.
All liquid waste should be disinfected and flushed in the sinks
at the point of generation. Untreated liquid waste should not be
let into sewers.
Biomedical waste should not be disposed of in open land and
municipal dustbins.
Maintenance of Records
Separate records for classification of waste and their regular
disposal should be maintained in the laboratory. The waste
disposal programme should be supervised and monitored
regularly.
Training
Training regarding need of biosafety practices and national
guidelines is extremely important and should be provided at
regular intervals for different levels of health care workers.
Guidelines for biosafety should be provided which may be
modified from time to time according to requirement.
177
IMPLEMENTATION OF BIO-SAFETY PRACTICES

IN HEALTH CARE SETTINGS
In India, sub optimal infection control measures, lack of adequate
infection control programme, surveillance and non reporting of
infection in health care settings has given rise to lack of national
data regarding incidence of nosocomial infection. There is
negligible occupational health risk assessment as there is no
separate department to record the health and immunization status
of the HCWs. In addition, there is indiscriminate use of
antimicrobials by patients as well as HCWs giving rise to multidrug resistant organisms prevalent in the hospital environment.
Although guidelines regarding standard precautions and other
biosafety practices are available since long, strict implementation
is not in practice in healthcare settings in India even in the capital
city. In many areas, the HCWs are not adequately trained in safe
practices resulting in inadequate cleaning, sterilization and
disinfection procedures and unsafe disposal of hospital waste. With
increase in the prevalence of HIV infection, there is a definite need
that the HCWs follow bio-safety practices seriously. For effective
compliance, the national authorities should strengthen national
infection control committees, develop effective infection control
policies and establish training programmes in the control of blood
borne infections including the concept of standard precautions and
safe waste disposal. The authorities should ensure adequate supply
of personal protecive equipments, availability of materials for handwashing, disinfectants and set up an effective programme for
disposal of biomedical wastes.
178 Women and HIV
ten
Post-exposure
Prophylaxis against HIV
Naveet Wig
ABSTRACT
India is estimated to have highest number of HIV infected individuals. There is
alleged discrimination by discrimination by Health Care Workers (HCWs) against
AIDS patients. However, there is also a need of safe working environment and
an excellent system for occupational health for Health Care Workers (HCWs) in
all private and government hospitals across poor, developing and developed
countries. Drugs for post-exposure prophylaxis (PEP) should be available
24 hours. HIV testing should be available 24 hours in case of needle prick injuries
to allay fears in minds of HCWs and to take care of their concerns. Universal
precautions should be met at all costs. Even though the risk of occupational
exposure to HIV is low, but who wants to get HIV?
INTRODUCTION
There is need for safe working environment in both government
and private hospitals. This has become necessary in view of
HIV\AIDS pandemic in the world. In India there are estimated
~3.9 million HIV positive people. However proved HIV+ve are
only ~0.1 million. Hence there are hidden 3.8 million HIV+ve
people1. Therefore, for the safety of Health Care Workers (HCWs),
it is important that universal precautions are adhered to in all
hospitals of India and appropriate post-exposure management is
available 24 hours. It will go a long way in ameliorating the
fears in the mind of HCWs who work day and night for the
benefit of patients. Although preventing blood exposures is the
primary means of preventing occupationally acquired human
immunodeficiency virus (HIV) infection, appropriate immediate
Post-exposure Prophylaxis against HIV 179

post-exposure management is an important element of work place
safety.
Important Definitions
HCW is defined as any person (e.g., doctor, nurses, student,
laboratory worker, ward boys, public-safety worker, or volunteer)
whose activities involve contact with patients or with blood or other
body fluids from patients in a health care or laboratory setting.
An exposure that may place an HCW at risk for HIV infection and
therefore requires consideration of post-exposure prophylaxis
(PEP) is defined as a percutaneous injury (e.g., a needlestick or cut
with a sharp object), contact of mucous membrane or non-intact
skin with blood or body fluids.
Body fluids include
a. Semen, vaginal secretions, or other body fluids contaminated
with visible blood that have been implicated in the transmission
2,3
of HIV infection ; and b. cerebrospinal, synovial, pleural,
peritoneal, pericardial, and amniotic fluids, which have an
2
undetermined risk for transmitting HIV . In addition, any direct
contact (i.e., without barrier protection) to concentrated HIV in a
research laboratory or production facility is considered an
exposure that requires clinical evaluation and consideration of
the need for PEP.
Risk in HCWs
Prospective studies of HCWs in US have estimated that the average
risk for HIV transmission after a percutaneous exposure to HIVinfected blood is approximately 0.3 and after a mucous membrane
exposure is 0.09 percent4-8. This risk is quite low. However, working
conditions and adherence to universal precautions in India are not
similar to US. Hence risk might be substantially high in India. As
of June 1998 52 U.S. HCWs with documented HIV seroconversion
have been temporally associated with an occupational HIV
exposure. An additional 114 episodes in HCWs are considered
possible occupational HIV transmissions; these workers reported
that their infection was occupationally acquired and no other risk
for HIV infection was identified, but transmission of infection after
180 Women and HIV

a specific exposure was not documented. There is no Indian data
on this. However needlestick injuries and percutaneous exposures
keep on occurring daily.
Among the HCWs with documented seroconversions reported
to CDC for whom data are available, 81 percent experienced a
syndrome compatible with primary HIV infection a median of 25
days after exposure (CDC, unpublished data, 1998). In a recent
analysis of 51 seroconversions in HCWs, the estimated median
interval from exposure to seroconversion was 46 days (mean: 65
days); an estimated 95 percent seroconverted within 6 months after
the exposure9. These data suggest that the time course of HIV
seroconversion in HCWs is similar to that in other persons who
have acquired HIV through nonoccupational modes of
transmission10.
Rationale for Post-exposure Prophylaxis (PEP) for HIV
After occupational exposure to HIV, PEP is recommended.
Rationale of PEP is that HIV infection can be prevented or
ameliorated by using antiretroviral drugs. Studies in animals and
humans provide direct and indirect evidence of the efficacy of
antiretroviral drugs as agents for PEP 5,11,12. It is the moral
responsibility of all hospital administrations (both government and
private) in India to provide excellent system for the management
of occupational exposures. It includes written protocols for prompt
reporting, evaluation, counseling, treatment, and follow-up of
occupational exposures that may place HCWs at risk for acquiring
any blood-borne infection, including HIV.
Access to clinicians and laboratory that can provide postexposure care should be available during all working hours,
including nights and weekends. Antiretroviral agents for PEP
should be available for timely administration. HCWs should be
educated to report occupational exposures immediately after they
occur, particularly because PEP is most likely to be effective if
implemented as soon after the exposure as possible. There should
be detailed exposure report which should include date and time
of exposure, details of the procedure being performed, details of
the exposure, including the type and amount of fluid or material
and the severity of the exposure, details about the exposure
source (i.e., whether the source material contained HIV or other

blood-borne pathogen{s}), and if the source is an HIV-infected
person, the stage of disease, history of antiretroviral therapy, and
viral load, if known; and details about counseling, post-exposure
management, and follow-up.
RECOMMENDATIONS FOR THE MANAGEMENT OF
POTENTIALLY EXPOSED HCWS (ANNEXURE-1, 2)13
Written protocols
Prompt reporting
Evaluation
Treatment
Follow-up of HCWs
Counseling.
Written Protocols (Most Valuable)

Each hospital should make its own team of doctors and nurses of
different specialties. They should frame hospital infection control
guide lines according to their own setup. Written protocol for
universal precautions, hospital infection control and management
of exposure to blood-borne pathogens should be available to all
doctors, nurses and para-medical staff. These written protocols
should be available freely.
Prompt Exposure Report (Is Must)
There should be detailed confidential exposure report which should
include following:
Date and time of exposure,
Details of the procedure being performed, including how and
where the exposure occurred, if the exposure was related to a
sharp device and how and when in the course of handling the
device exposure occurred.
Details of the exposure, including the type and amount of fluid
or material and the severity of the exposure, details about the
exposure source (i.e., whether the source material contained HIV
or other blood-borne pathogen{s}), and if the source is an HIVinfected person, the stage of disease, history of antiretroviral
182 Women and HIV

therapy, and viral load, if known; and details about counseling,
post-exposure management, and follow-up.
Evaluation of Exposure (Both Source Patient and HCW are
Evaluated)
Exposure Management
Wounds and skin sites that have been in contact with blood or
body fluids should be washed immediately with soap and water;
mucous membranes should be flushed with water.
Clinical Evaluation and Base-line Testing of Source-person and

Exposed HCWs (Assessment of Infection Risk)
Source-person and the exposed HCW should be evaluated to determine
the need for HIV PEP for HCW. Base-line HIV, HBV (HBsAg), HCV
(anti-HCV) in both source-person and the exposed HCW and antiHBsAg titers in HCW should be determined. Follow-up for HIV,
hepatitis B virus and hepatitis C virus infections also should be
conducted.
If source person is HIV positive, if possible viral load and CD4
T cell count should be done in source patient to know the stage of
disease (early or advanced).
For purposes of considering HIV PEP, the evaluation also
should include information about medications the HCW may be
taking and any current or underlying medical conditions or
circumstances (i.e., pregnancy, breast feeding, or renal or hepatic
disease) that may influence drug selection. Pregnancy testing
should be offered to all non-pregnant women of childbearing age
whose pregnancy status is unknown.
Treatment (HIV PEP) (Immediate)
Explaining PEP to HCWs

Recommendations for chemoprophylaxis should be explained to
HCWs who have sustained occupational HIV exposures14,15,16. For
exposures for which PEP is considered appropriate, HCWs should
be informed that knowledge about the efficacy and toxicity of drugs
used for PEP are limited and only ZDV has been shown to prevent
HIV transmission in humans. There are no data to address whether

adding other antiretroviral drugs provides any additional benefit
for PEP, but experts recommend combination drug regimens
because of increased potency and concerns about drug-resistant
virus. Data regarding toxicity of antiretroviral drugs in persons
without HIV infection or in pregnant women are limited for ZDV
and not known regarding other antiretroviral drugs. Any or all
drugs for PEP may be declined by the HCW. HCWs who have
HIV occupational exposures for which PEP is not recommended
should be informed that the potential side effects and toxicity of
taking PEP outweigh the negligible risk of transmission posed by
the type of exposure.
Factors in Selection of a PEP Regimen

1. Timing of PEP Initiation
PEP should be initiated as soon as possible
2. Recommendations for the Selection of Drugs for PEP
There are three steps to be taken before recommending PEP13
Step I: Determine Exposure Code [ EC ] (Table 10.1)
Step II: Determine HIV Status Code [HIV SC] (Table 10.2)
Step III: Recommendations based on EC and HIV RNA
(Table 10.3) either Basic or Expanded regimen.
Therefore, two regimens for PEP are provided. A basic
two-drug regimen that should be appropriate for most HIV
exposures and an expanded three-drug regimen that should be
used for exposures that pose an increased risk for transmission or
where resistance to one or more antiretroviral agents is known or
suspected. When possible, the regimens should be implemented
in consultation with persons having expertise in antiretroviral
treatment and HIV transmission. PEP for Pregnant HCWs.
2a. Known or Suspected Pregnancy in the HCW
Pregnancy should not preclude the use of optimal PEP regimens,
and PEP should not be denied to an HCW solely on the basis of
pregnancy 17,18,19 . However, as discussed previously, an
occupationally exposed pregnant HCW must be provided with full
information about what is known and not known regarding the
184 Women and HIV

potential benefits and risks associated with use of the antiretroviral
drugs to her and her fetus for her to make an informed decision
regarding the use of PEP.
3. Monitoring and Management of PEP Toxicity
Complete blood count and renal and hepatic function tests should
be performed at base-line and again 2 weeks after starting PEP.
Follow-up of HCWs Exposed to HIV (Post-Exposure Testing)

(At 6 weeks, 12 weeks, and 6 months).
Counselling and Education

There is great effect on the quality of life after exposure. Although
there is a low risk for HIV transmission, drug regimen and
behavioral measures (i.e., sexual abstinence or condom use) to
prevent secondary transmission, their lives for several weeks to
months 20 . Hence immediate access to persons who are
knowledgeable about occupational HIV transmission and who can
deal with the concerns of the HCWs is an important element of
post-exposure management.
HCWs are advised to take measures to prevent secondary
transmission during the follow-up period, especially during the
first 6-12 weeks after the exposure when most HIV-infected persons
are expected to seroconvert. They are told to seek medical
evaluation for any acute illness that occurs during the follow-up
period. Such an illness may be indicative of acute HIV infection
but also may be due to a drug reaction or another medical condition.
They are given information about potential drug interactions. The
importance of completing the prescribed regimen is provided.
However there is no need to modify an HCWs patient-care
responsibilities to prevent transmission to patients based solely
on an HIV exposure.
Why is PEP and Universal Precautions Must?

The emotional trauma following exposure often is very high. This
is compounded by lack of knowledge in handling such situation.
They run here and there for advice and get conflicting information.

There is great effect on the quality of life after exposure. Although
there is a low risk for HIV transmission, drug regimen and
behavioral measures (i.e., sexual abstinence or condom use) to
prevent secondary transmission, their lives for several weeks to
months. Hence immediate access to persons who are knowledgeable about occupational HIV transmission and who can deal with
the concerns of the HCWs is an important element of postexposure
management21.
Government of India Policy

National AIDS Control Organization (NACO) has issued
instructions to all government hospitals in the country to provide
these drugs free of cost to HCWs and to keep them available. Money
will be reimbursed by NACO if required. Hence it is now the
responsibility of each hospital to make local arrangements and even
provide rapid HIV tests available in blood banks round the clock.
After Supreme Court judgement all hospitals are to make their
hospital waste disposal systems most efficient.
CONCLUSIONS
Barriers to effective PEP are deficient knowledge, fear and denial
among HCWs, diverse risks with different exposures. It is
recommended standardized procedures should be there for all
hospitals. PEP should be available 24 hours a day, 7 days a week
in pharmacy dose packs. There should be confidential follow ups,
counseling and serology. There should be continuous education
of HCWs. Team of experts should handle this. These simple
measures will go a long way in decreasing fears in minds of HCWs.
It needs a big dedication from HCWs, hospital administration and
government. Because health is wealth and prevention is better than
cure.
186 Women and HIV

ANNEXURE-1
MANAGEMENT OF OCCUPATIONAL EXPOSURE OF HIV TO
HCWS (EACH HOSPITAL TO HAVE ITS OWN PLAN)
Immediate Treatment
1. Needle sticks and cuts washed with soap and water
2. Water-proof band-aid applied
3. Splashes to eyes irrigated with clean water.
Prompt Reporting
Each hospital to have team of 5-7 doctors and nurses (Addresses

and phone numbers to be available round the clock).
1.
2.
3.
4.
5.
6.
7.
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Evaluation
Baseline assessment of patient and HCW:
HIV, HBV (HBsAg), HCV (anti-HCV) in both and anti-HBsAg
titers in HCW.
[Tests will be done in blood bank]
Treatment
Post-Exposure Prophylaxis (PEP) Recommendations:

Step I : Determine Exposure Code ( EC )
Step II : Determine HIV Status Code (HIV SC)
Step III : Recommendations based on EC and HIV RNA
either
Basic or Expanded regimen
[Drugs are available in casuality and hospital store round the
clock]
Monitoring of PEP Toxicity

Blood count, LFT and RFT at base-line and again 2 weeks after
starting PEP.
Counseling and Education

Measures to prevent secondary transmission (i.e., sexual
abstinence or condom use) during the first 6-12 weeks.
To seek medical evaluation for any acute illness during the
follow-up period.
Importance of completing the prescribed regimen.
There is no need to modify an HCWs patient-care responsibilities.
Follow up of HCWs
Monitoring HIV status: Baseline, 6 weeks, 3 months, 6 months
Follow up HBsAg and anti-HCV at 6 months
188 Women and HIV

ANNEXURE-2
CHECK LIST FOR UNIVERSAL PRECAUTIONS
Hands are Appropriately Washed to Prevent Cross Infection
1. Soap and water available.
2. Clean towels/tissue paper available.
3. Random check of the staff to observe hand-washing practices
(After contact with body fluid, removal of gloves and contact
with patients).
A Protective Barrier is Worn to Prevent Exposure to Blood
The following barriers are available for use by staff depending on
the clinical area and risk of exposure
1. Disposable gloves for every procedure.
2. Heavy duty gloves for handling sharps and wastes.
3. Masks.
4. Gowns and plastic aprons.
5. Protective eye wears (goggles).
6. Water-proof band-aid.
7. Gum boots.
Sharps are Handled Safely to Minimize the
Risk of Sharp Injury
1.
2.
3.
4.
5.
6.
Appropriate puncture-proof container.

Container less than three quarters full.
Sharps are not protruding from container.
No recapping or one hand recapping of needle and syringe.
No bending or breaking of needles.
Needles destroyed by the concerned person after use in needle
destroyer.
7. Sodium hypochloride solution.
Instruments Decontaminated Fully
1. Sterilizer available and in good working order (CSSD).
2. Equipment thoroughly cleaned, disinfected and sterilized after
use.
3. Sterile instruments are stored in cupboards (up to 72 hours).

Waste Disposal Safety
1. Proper segregation of waste (YELLOW-infected, BLUE-plastic,
BLACK-general waste).
2. Thorough supervision of waste segregation by Sister incharge,
ANS.
3. Evidence of incineration regularly.
4. No contaminated waste visible.
5. Periodic check up by Hospital Infection Control Team.
190 Women and HIV

ANNEXURE-3
Table 10.1: Determining the need for HIV post-exposure prophylaxis (PEP)
after an occupational exposure
STEP 1: Determine the Exposure Code (EC)
No
Yes
OPIMs
Is the source material blood, bloody fluid, other potentially infectious material
(OPIM) for an instrument contaminated with one of these substances?
Blood or bloody fluid
What type of exposure has occurred?

Mucous membrane
Intact skin
skin, (integrity
only
compromised)
No PEP Needed
Volume
Small
(e.g., few
drops,
short
duration)
EC 1
No PEP needed
Large
(e.g., several
drops, major
blood splash
and/or longer
duration (i.e.,
several minutes
or more)
EC 2
Less Severe
(e.g., solid
needle, superficial
scratch
EC 2
Percutaneous
exposure
Severity
More Severe
(e.g., large-bore
hollow needle, deep
puncture, visible
blood on device,
or needle used in
source pataients
artery or vein)
EC 3

ANNEXURE-4
Table 10.2: Determining the need for HIV post-exposure prophylaxis (PEP)
after an occupational exposure
STEP 2: Determine the HIV Status Code (HIV SC)
What is the HIV status of the exposure source?
HIV negative
HIV positive
No PEP needed
Lower titer exposure

(e.g., asympto matic
and high CD4 count)
HIV SC 1
Status
unknown
Source
unknown
Higher titer exposure

(e.g., advanced AIDS, primary
HIV infection, high or increasing
viral load or low CD4 count)
HIV SC 2
HIV SC Unknown
Table 10.3: Determine the PEP recommendation
EC
HIV SC
1
1
1
2
2
3
2
1 or 2
---Unknown---
PEP recommendation
PEP may not be warranted.
Consider basic regimen.
Exposure type poses a negligible risk for HIV transmission.
Recommend basic regimen.
Most HIV exposure are in this category; no increased risk
for HIV transmission has been observed but use of PEP is
appropriate.
Recommend expanded regimen.
Recommended expanded regimen.
Exposure type represents an increased HIV transmission
risk.
If the source, (in the case of an unknown source), the
setting where the exposure occurred suggests a possible
risk for HIV exposure and the EC is 2 or 3, consider PEP
basic regimen.
192 Women and HIV

REFERENCES
1. www.nic.in/naco
2. CDC. Recommendations for prevention of HIV transmission in health-care
settings. MMWR 1987;36(suppl no. 2S).
3. CDC. Update: Universal precautions for prevention of transmission of human
immunodeficiency virus, hepatitis B virus, and other blood-borne pathogens
in health-care settings. MMWR 37:377-82,3878, 1988.
4. Black RJ. Animal studies of prophylaxis. Am J Med 102(suppl 5B):39-44, 1997.
5. Bell DM, Gerberding JL, eds. Human immunodeficiency virus (HIV)
postexposure management of health-care workers. Am J Med 102 (suppl 5B),
1997.
6. CDC. Update: provisional public health service recommendations for
chemoprophylaxis after occupational exposure to HIV. MMWR 45:
468-72, 1996.
7. Bell DM. Occupational risk of human immunodeficiency virus infection in
health-care workers: an overview. Am J Med 102(suppl 5B):9-15, 1997.
8. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV
seroconversion in health-care workers after percutaneous exposure. N Engl J
Med 337:1485-90, 1997.
9. Busch MP, Satten GA. Time course of viremia and antibody seroconversion
following human immunodeficiency virus exposure. Am J Med 102(suppl
5B):117-24, 1997.
10. Saag MS. Clinical spectrum of human immunodeficiency virus diseases. In:
DeVita VT Jr, Hellman S, Rosenberg SA, eds. AIDS: biology, diagnosis, treatment
and prevention. 4th ed. Philadelphia, PA: Lippincott-Raven Publishers,
203-13, 1997.
11. Shih C-C, Kaneshima H, Rabin L, et al. Post-exposure prophylaxis with
zidovudine suppresses human immunodeficiency virus type 1 infection in
SCID-hu mice in a time-dependent manner. J Infect Dis 163:625-7, 1991.
12. Martin LN, Murphey-Corb M, Soike KF, Davison-Fairburn B, Baskin GB. Effects
of initiation of 3-azido,3-deoxythymidine (zidovudine) treatment at different
times after infection of rhesus monkeys with simian immunodeficiency virus.
J Infect Dis 168:825-35, 1993.
13. Updated U.S. Public Health Service Guidelines for the Management of
Occupational Exposures to HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR June 29, 2001/50(RR11);1-42.
14.CDC. Guidelines for the use of antiretroviral agents in HIV-infected adults and
adolescents. MMWR 51(no. RR-5):1-82, 2002.
15.Katlama C, Ingrand D, Loveday C, et al. Safety and efficacy of lamivudinezidovudine combination therapy in antiretroviral naive patients: a randomized
controlled comparison with zidovudine monotherapy. JAMA 276:118-25, 1996.
16.Larder BA. Viral resistance and the selection of antiretroviral combinations.
J AIDS 10(suppl 1):528-S33, 1995.
17.OSullivan MJ, Boyer PJJ, Scott GB, et al. The pharmacokinetics and safety of
zidovudine in the third trimester of pregnancy for women infected with human
immunodeficiency virus and their infants: Phase I Acquired Immunodeficiency

Syndrome Clinical Trials Group Study (protocol 082). Am J Obstet Gynecol
168:1510-6, 1993.
18.CDC. Birth outcomes following zidovudine therapy in pregnant women. MMWR
43: 409,415-6, 1994.
19.White A, Eldridge R, Andrews E, The Antiretroviral Pregnancy Registry Advisory
Committee. Birth outcomes following zidovudine exposure in pregnant women:
the Antiretroviral Pregnancy Registry. Acta Paediatr Suppl 42:86-8, 1997.
20.Armstrong K, Gorden R, Santorella G. Occupational exposure of health-care
workers (HCWs) to human immunodeficiency virus (HIV): stress reactions and
counseling interventions. Social Work in Health-Care 21(3):61-80, 1995.
21.Emergency department management of blood and body fluid exposures.
Ann Emerg Med. 2000 Jan;35(1):47-62.
194 Women and HIV
eleven
Psychiatric Aspect of HIV/

AIDS in Women
Rajesh Rastogi
INTRODUCTION
HIV/AIDS is a rapidly growing public health problem among
women. Acquired Immune Deficiency Syndrome (AIDS) is a lethal
disorder caused by infection with human immunodeficiency
viruses (HIV). The appearance of AIDS on the medical and social
scene in the early 1980s has been followed by worldwide spread
of the disease and escalating numbers of persons affected. Women
accounts for 47% of the people living with HIV at present1. Women
in general and globally are the most disadvantaged, are valued
less than men, have less access to a range of resources and have
less capacity to realize their potential for health. Womens
vulnerability to HIV/AIDS is primarily because of lack of
knowledge, access to information, economic dependence, forced
sex, rapes and violence on women2, 3. The increase in the number
of HIV-positive women reflects their greater biological vulnerability to the disease. In addition, it is also a result of the extreme
disparities, which continue to characterize many heterosexual
unions4.
Although advances in antiretroviral therapies have decreased
morbidity and mortality rates in the Western world5, many of
the issues that people with HIV face today are similar to those
that were on the pre-HAART agenda. First of all, medication can
never take away the traumatic element of HIV diagnosis and its
attack on the individuals self. The traumatic experience is also
reinforced by the societal oppression of people living with HIV
infection.
Psychiatric Aspect of HIV/AIDS in Women
195
Second, people living with HIV still face the prospect of

physical, social and sexual threats although their gestalt of content
has partly changed.
As to social threats, the stigma of HIV and discrimination of
people with HIV has not disappeared. Subsequently, people with
HIV may still fear aloneness in terms of being abandoned and
isolated, thereby creating a sense of being invisible. These emotions
all have an existential quality in that they represent a sense of being
no one, i.e. to experience psychological death6. Today, there is also
the reverse stigma, i.e. the expectation that people with HIV
should get on with life, since HIV is only a chronic illness7.
Psychological Issues Associated with HIV Disease
A diagnosis of an HIV related condition presents an individual
with numerous psychological stresses. All these stressors represent
potential threats to the individuals psychological well-being and
quality of life.
Although these may recur and overlap throughout the illness
many issues occur at characteristics times. The clinicians must
assess, which issues are of paramount importance to the patient.
Numerous authors have identified psychosocial issues
associated with being HIV positive8. Some of these issues overlap
with the stages of death and dying that have been described by
Kubler-Ross9.
Kubler-Ross staged model of responses to death and dying is a
good starting point to think about some of the emotions
experienced by persons who are living with HIV. She identified
five progressive phases: denial, anger, bargaining, depression and
acceptance. Several authors have extrapolated from her model to
describe emotions reported by persons with HIV disease10.
HIV-infected individuals may present with a variety of mental
health concerns and providers need to be aware of common
conditions as well as special HIV related issues in differential
diagnosis and pharmacological interventions.
Wolcott et al11 outlined five general principles of assessment of
suspected neuropsychiatric disorders in patients with HIV disease
All new psychiatric disorder should be considered secondary
to a neuropsychiatric complication of HIV disease until thorough
evaluation indicates otherwise
196 Women and HIV

Table 11.1: Common psychological issues by stages of HIV infection
Stages of HIV infection

Pre-HIVantibody testing
Confirmation of positive serostatus
Asymptomatic period
Symptomatic period (Early)
Symptomatic period (Advanced)
Death
Psychological Issues
Anxiety
Guilt
Shock
Denial
Depression
Suicide potential
Anxiety
Depression
Anger
Relationship conflicts
Fear
Enhanced anxiety
Depression
Suicide potential
Neuropsychological symptoms
Death anxiety
Body image changes
Self-concept changes
Dependency/independency
Relationship conflicts
Cognitive decline
Acceptance by patient
Loss
Anger
Mourning
Acceptance by survivors
Table 11.2: Psychiatric conditions that occur in HIV/AIDS patients
Anxiety disorder
Depression
Suicide
Mania
Sleep disorder
Neurocognitive disorders
Delirium
HIV and drug Abuse
Postpartum psychosis
Psychotic disorders
Organic mental disorder may appear weeks to months before

an underlying primary central nervous system (CNS) disease
becomes apparent.
Neurodiagnostic tests may be normal or non-diagnostic in
patients with HIV-related organic mental disease or both.
Careful preventive screening is crucial to the early diagnosis of
organic mental disease because mental status changes are often
the first clinical sign of primary CNS changes, many of which
are treatable.
197
Primary care physicians and practitioners should consider early

patient referral when HIV-related neuropsychiatric disorder is
suspected.
Anxiety Disorders
Anxiety and depression are the most common reasons for patients
with HIV to seek mental health consultation. In assessing the HIVinfected patient for treatable anxiety disorders and/or depression,
the clinician needs to be aware of the difference between symptoms
and illness or disease itself, and of the potential of many illnesses
to be disguised, hidden, or mimicked by other conditions and
symptoms.
Anxiety may be both a symptom and a psychiatric illness.
Anxiety, both obvious to the observer and reported by the patient,
may be a manifestation of a chronic or acute pain situation and
undiagnosed agitated depression; substance abuse or use; side
effects of prescribed or over-the-counter medications; a psychotic
or manic disorder; undetected infections; a reaction to bad news;
or stress in waiting for the results of HIV test and so on. Anxiety,
as a symptom of a psychiatric disorder, may range from a mild
sense of dread or unease to full-blown panic attacks with sweating,
palpitations, dizziness, fear of dying, extreme agitation, or fear of
leaving a safe place.
Table 11.3: Sign and symptoms of anxiety
Motor symptoms
Autonomic symptoms
Mental symptoms
Vigilance symptoms
Shakiness, jumpiness, increased muscle tone,

excessive fidgeting
Palpitation, diaphoresis, tachycardia, hyperventilation,
diarrhoea, flushing
Apprehension, worry, fear of losing control
Hypervigilance, decreased sleep, irritability,
distractibility
Treatment
The decision to treat episodes of acute anxiety rests on whether it
appears to interfere with daily functioning or quality of life.
Restlessness, anxiousness, or inability to concentrate that impair
ones usual social relationships or functioning for a week or more
may indicate a need for psychological or pharmacological therapy.
198 Women and HIV

Nonpharmalogical treatments may be tried first, including
supportive psychotherapy or the use of stress and anxiety
management approaches, such as relaxation training, education,
and assisting in accessing various social services.
Psychopharmacological treatments is usually brief, lasting no
more than 2 to 6 weeks, based on the view that most episodes of
anxiety will remit within time. For physically asymptomatic
seropositive patients, the usual choice is an intermediate or longacting benzodiazepine (e.g. diazepam at 20 to 40 mg per day, or
lorazepam at 0.5 mg every 8 hours). For individuals with more
physically symptomatic disease, many clinicians recommend
the use of agents with short to intermediate half-lives and no
active metabolites, such as oxazepam at 10 mg every 6 hours, or
lorazepam at 0.5 mg every 8 hours.
In general, evidence of a therapeutic effect should be expected
within 1 week of starting treatment. Failure to improve means that
the diagnosis should be reconsidered and that major depressive
disorder or substance-related disorder should be included in the
different diagnosis.
For patients with recent histories of alcohol or nonalcohol
substance-related disorders, the use of benzodiazepines may not
be desirable. Buspirone or hydroxyzine are safe and effective, with
low initial starting dosages and slow increases for individuals who
are physically sicker.
Depression
Depression may be a symptom or an illness in itself.
Episodes of major depression are twice as common in HIV
patients as they are in the general population and can approach
40 percent in hospitalized HIV patients12. Recognizing major
depression in the HIV patient poses difficulty, since important
criteria associated with depression- neurovegetative signs (chronic
fatigue, sleep disturbance, appetite loss) as well as cognitive symptoms (disturbance of short-term memory, concentration difficulties)are also likely to be present in patients who are chronically
ill. From a clinical, diagnostic perspective, it is frequently helpful
to focus on the critical psychological characteristics of clinical
depression . Depressed individuals report pervasive sad mood that
rarely fluctuates and a loss of interest in activities that normally
199
are perceived as pleasurable. They may feel helpless to change how

they feel and experience intense guilt and worry. Recurrent
thoughts of death and hopelessness correlate highly with those
who commit suicide.
Many of the symptoms of anxiety and depression may be
manifestations of the HIV infection or illness itself or may be side
effects of the very medications and treatment interventions used
to treat the patients medical symptom.
Treatment
Early detection and treatment of mood disorder would greatly
improve patients quality of life, aid in patient treatment decision
and participation. Although major depression can be successfully
treated in HIV patients, caution must be exercised when using
psychoactive drugs. Antidepressants with a low incidence of anticholinergic side effects are preferred; among them such selective
serotonin reuptake inhibitor (SSRI) antidepressants as sertraline
50 mg po daily or fluoxetine 20 mg po daily have been recommended13. In HIV-infected patients who are on polypharmacy,
sertraline is recommended because, as compared to fluoxetine and
paroxetine, there is a significantly lower risk of producing druginteractions. Bupropion is another newer antidepressant that is nonsedating and may be especially helpful in fatigued patients.
Bupropion is contraindicated in patients with unstable seizure
disorders. Seizures have been noted in patients receiving over
400 mg/day of medication. Venlafaxine is a novel antidepressant
that inhibits reuptake of both serotonin and norepinephrine.
Among the newer antidepressants it is one of the least likely to
have interactions with HIV antivirals. Nefazodone is reported to
be especially useful in anxious depressed patients and is a good
choice for patients with severe insomnia.
Once an antidepressant is chosen, antidepressant therapy
should be continued for 6 to 8 weeks to assess the patients response
to a specific dose. Once an effective dosage is found it should be
continued for 6 to 12 months unless the patient develops a
medication side effect or requires a dosage increase because of
intercurrent stressors or drug malabsorbption.
Psychotherapy and psychopharmacology play complementary
roles in the treatment of HIV associated depression14.
200 Women and HIV

Suicide
Studies suggest that the patients with advanced HIV diseases have
a thirty-fold risk of committing suicide compared to seronegative
persons matched for age and social position. It is important to note
that psychiatric disorder is strongly implicated in suicides,
attempted suicides, and suicidal ideation. Suicide rates in women
are not noted to be elevated, but the epidemic is now just starting
to affect large numbers of women, and their greater vulnerability
to major depressive disorder may mean that women are at risk.
More recent studies has shown a risk for suicide in patient with
HIV disease at all phases of HIV infection15, 16. Advances in therapy
may heighten hope and reduce the risk of suicide.
Mania
Mania is characterized by persistently elevated expansive or or
irritable mood associated with less need for sleep. Pressured speech,
distractibility, flight of ideas, psychomotor agitation or increase in
goal-directed activity, inflated self-esteem or grandiosity, and
excessive involvement in pleasurable activities that have a high
potential for painful consequences. Mania may occur as an initial
manifestation of HIV disease; as a mood disorder superimposed
on previously known advanced HIV disease. As hypomania, as a
complication of corticosteroids, narcotics, or other medications; or
as a first manifestation of an opportunistic or systemic illness. In
most cases mania seems to be a complication of HIV related organic
brain disorder because it tends to occur late in the course of disease
and to be commonly correlated with cognitive defects that often
may not resolve when the manic episode recedes17, 18.
Treatment
Although patients with HIV disease are generally responsive to
standard antimania medicines19. For immediate control of manic
excitement up to 10 mg of clonazepam daily is effective in many
instances. If psychotic features are present, low doses of
antipsychotic agents, such as risperidone at 0.5 to 2 mg daily,
olanzapine up to 10 mg daily, chlorpromazine at 25 to 150 mg daily,
or haloperidol at 0.5 to 5 mg daily, may be employed . For longerterm management lithium is effective but may not be as well
tolerated as is carbamazepine and valproate.
201
Sleep Disorder
Decreased sleep quality, difficulty falling asleep, fragmented nighttime sleep, and early-morning awakenings seem to increase as
immune function and CD4+ lymphocyte counts diminish, and they
may affect a substantial proportion of persons with AIDS. The
therapeutic approaches has generally been limited to symptomatic
treatment with nonbenzodiazepine agents used as hypnotics, such
as trazodone or cautious use of benzodiazepines in severe sleep
disorders.
HIV Associated Neurocognitive Disorders
One of the earliest term used for these disorders was HIV
encephalopathy, a term derived from early pathological studies
that noted the presence of encephalitic features in the brains of
many patients dying with AIDS . Another term was AIDS dementia
complex which suggested a constellation of cognitive , motor, and
affective-behaviour complications . Presently , the neurocognitive
complications can be classified as two syndromes differing in level
of severity:
1. HIV associated dementia and
2. HIV associated mild neurocognitive disorder (MND)
The principal differentiating point between dementia and mild
neurocognitive disorder is the extent to which the cognitive disorder interferes with a persons day to day functioning . Thus a
diagnosis of dementia is reserved for severe cognitive disorders
that interfere substantially with work, home life, and social activities. On the other hand, mild neurocognitive disorder can be diagnosed if cognitive deficits that do not interfere in a major way with
life functioning are reliably identified. Some people manifest mild
neuropsychological deficits that are entirely subclinical (i.e. there
is no documented interference in day-to-day functioning). Because
such deficits do not reach the threshold for being termed a disorder, the term asymptomatic neurocognitive impatient may be used.
Mild Neurocognitive Disorder (MND)
Sign and Symptoms

A person presents with some difficulty in concentrating may
experience unusual fatigability when engaged in demanding
202 Women and HIV

mental tasks, may feel subjectively slowed down, and may notice
difficulty in remembering. Such persons may say that they are not
as sharp or as quick as they once were. Such a set of presenting
complaints, especially in younger individuals who may be
struggling to accept their seropositive status, may lead the clinician
to conclude that anxiety, depression or hypochondriasis are
responsible. It is important to note that these mild neurocognitive
deficits occur independently of depression, anxiety, and other non
HIV sources of cognitive deficit.
HIV Associated Dementia
Sign and Symptoms

The cognitive abnormalities in persons with dementia are more
profound and more generalized than in patients with mild
neruocognitive disorder. Patients report severe forgetfulness,
difficulty concentrating, problems with naming and word finding,
marked mental slowness and disorientation. As the dementia
progresses, the patient may become more apathetic, severely
disoriented, and frankly confused and may have difficulty with
independent living.
Treatment
Clearly dementia is one of the most heartbreaking and medically
challenging complication of HIV disease. Effective disease
recognition by the clinicians requires a high index of suspicion of
dementia whenever the patient manifest neurocognitive symptoms.
Effective treatment of dementia in the AIDS setting requires a
thorough understanding of the patients medical status as well as
his or her home situation and support network.
Clinicians treating HIV-associated dementia need to consider
aggressive antiretroviral therapy for potential reversal or slowing
of the dementia process. Antiretrovirals treatment are the drug of
choice for HIV-associated cognitive impairment. Providing optimal
milieumanagment for the patients, and providing appropriate
practical and psychosocial support for the patients loved ones.
The treatment of neurocognitive impairment in HIV should
ideally be both psychological and pharmacological. The patient
should be informed of the strengths and the liabilities detected on
203
neuropsychological testing and be advised of simple coping

measures, such as keeping to a routine, doing one thing at a time
and reducing external stimuli. The patients safety is a priority,
and friends, family, and service organizations should be listed to
assist with care taking.
Delirium
Delirium is a serious complication of any illness and HIV disease
is no exception. The causes of delirium can include primary
CNS opportunistic infections, drug side effects, systemic illness,
and primary functional disease related to disorientation and
confusion.
Treatment
The general principles of treating delirium in HIVpositive patients are the same as those of patients in general11, 20. General treatment measures include providing orienting information, minimizing disruption of the sleep\wake cycle, avoiding medications with
CNS side effects and treating agitation with appropriate pharmacological intervention11.
HIV and Drug Abuse
Injecting drug use results in 5% of the HIV infections found would
wide. Intravenous drug use is often associated with unsafe sexual
activity which could result in transmission of HIV infection. It is
estimated that there are 6 to 7 millions HIV infected individuals in
the world of whom around 20% are females. In India , most HIV
seropositive intravenous drug users defected are in the state of
Manipur in north eastern India21, 22,23.
Postpartum Psychosis
Postpartum psychosis occurs in women who have recently
delivered a baby; the syndrome is most often characterized by the
mothers depression, delusions and thoughts of harming either
her infant or herself. Such ideation of suicide or infanticide
must be carefully monitored; some mothers have acted on these
ideas.
204 Women and HIV
Clinical Features
The symptoms of postpartum psychosis can often begin within
days of the delivery, although the mean time to onset is 2 to 3
weeks and almost always to complain of fatigue, insomnia, and
restlessness and may have episodes of tearfulness and emotional
lability. Later, suspiciousness, confusion, incoherence, irrational
statements, and obsessive concerns about the babys health and
welfare may be present. Delusions may be present in 50 percent of
all patients and hallucinations in about 25 percent.
Treatment
Postpartum psychosis is a psychiatric emergency. Antidepressants
and lithium, sometimes in combination with an antipsychotic, are
the treatments of choice.
Psychotic Disorders
Psychotic symptoms are usually later stage complications of HIV
infection. Clinician should be aware that medications may cause
psychosis and hallucinations include anabolic steroids, amphotericin, anticonvulsants, ciprofloxacin , buspirone, corticosteroids,
dapsone, ganciclovir, H-receptor antagonists, interferon-,
isoniazed, ketoconazole, nonsteroidal anti-inflammatory agents,
metronidazole, salicylates, sulfonamides, and zidovudine24.
Treatment
Such patients require immediate medical and neurological
evaluation and often require management with antipsychotic
medications. Newer medications, i.e atypical antipsychotic
medications (e.g. risperidone, olanzapine) should be drugs of first
choice because of low adverse effects profiles. Dosing for atypical
antipsychotic drugs can be at one half (or less) the dosages used
for acute psychoses in psychiatric patients.
CONCLUSION
HIV disease represents a continuum ranging from the initial
detection of infection, through a long incubatory and a symptomatic
period, to symptomatic states and diagnosis of AIDS and its
205
complications. Women living with HIV need to adapt to HIVrelated threats various psychological issues, to restore a more or
less shattered self image, and to integrate HIV infection into ones
daily life and create conditions conducive to experiencing quality
of life is an ongoing process and will not change or disappear
because of antiretroviral therapies. The therapist have to pursue
their therapeutic efforts to guide and to support their patients in
the fight for re-capturing their quality of life, autonomy, self worth,
self esteem and human dignity.
Assessment approaches used to evaluate neuropsychiatric
complications of HIV/AIDS should incorporate a high index of
suspicion for more serious complications and cautious dosing of
psychotropic medications to prevent worsening of psychiatric
symptoms. Early detection of psychiatric problems and their
management would greatly improve patients quality of life.
As HIV-infected individuals live longer and more functional
lives, medical practioners in all types of settings will be increasingly
called upon to provide mental health care or consider referrals to
mental health professionals.
REFERENCES
1. UNAIDS (2000). http:www.unaids.org/wac/2000/wad00/files/WAD
epidemic report.htm
2. GARCIA-MORENO C. Presentation on womens health and development.
Report of the Second Meeting of Interested Parties, 17-18 June (unpublished
paper available on request from Womens Health and Development , WHO,
Geneva), 1996.
3. GAVEY N. Technologies and effects of heterosexual coercion. In: S.
WILKINSON and KRIZINGER(Eds), Heterosexuality: a feminism and
psychology reader. London: Sage, 1993.
4. ZIERLER S and KRIEGER, N. Reframing womens risk: social inequalities and
HIV infection. Annual Reviews of Public Health, 18: 401-436, 1997.
5. KLEEBERGER CA., PHAIR JP STRATHDEE, S.A. ET AI. Determinants of
heterogeneous adherence to HIV-antiretroviral therapies in the multicenter
AIDS cohort study. Journal of Acquired Immune Deficiency Syndromes , 26: 82-92,
2000.
6. NILSSON SCHONNESSON, I. Life at focus. A study on quality of life among
gay men and heterosexual women with HIV infection. Gothenberg University,
Department of social work . Report 1999:3 (only in Swedish), 1999.
7. CATALAN J, GREEN L and THORLEY, F. The changing picture of
HIV: a chronic illness, again? FocusA Guide to AIDS Research and Counselling,
16(3): 1-4, 2001.
206 Women and HIV

8. OBrien ME. Living with HIV: experiment in courage. New York: Auburn House,
1992.
9. Kubler-Ross E. On death and Dying. New York, Macmillan, 1969.
10. Kathleen Sheriden Psychosocial services for persons HIV disease in hand
book of clinical psychology in medical settings, 587-599.
11. Wolcott D, Fawzy F. Namir S: Clinical management of psychiatric disorders in
HIV spectrum disease. Psychiatr Med 7:107, 1989.
12. Atkinson JH, Grant I. Natural history of neuropsychiatric manifestations of
HIV disease. Psychiatr Clin North Am 17:7-33, 1994.
13. Atkinson JH, Grant I, Kenned CJ, et al: Prevalence of psychiatric disorders among
men infected with human immunodeficiency virus. Arch Gen Psychiatry 45:
859-864, 1988.
14. Markowitz JC, Rabkin JG. Perry SW: Treating depression in HIV-positive
patients. AIDS 8:403, 1994.
15. Dannenberg A. McNeil J. Brundage J.et al: Suicide and HIV infection. JAMA
276:1734, 1996.
16. Marzuk P. Tardiff K. Leon A,. et al: HIV seroprevalence among suicide victims
in New York City. 1991-1993. Am J Psychiatry 154:1720. 1997.
17. Elliot A. Uldall K. Bergam K. et al: Randomized. Placebo-controlled trial of
paroxetine versus imipramine in depressed HIV-positive patients. Psychiatry
155:367, 1988.
18. Keiburtz K. Zettelmaier A. Ketonen L: Manie syndrome in AIDS. Am J Psychiarty
148:1068. 1991.
19. Gerner R: Treatment of acute mainia. Psychiatr Clin North Am 16:443, 1993.
20. Adams F: Emergency intravenous sedation of the delirious medically ill patient.
J Clin Psychiatry 49(Suppl):22, 1988.
21. Sarkar. S., Das, N., Panda, S., Naik, T.N., Sarkar, K., Singh B.C., Ralte, J.M.,
Aier, S.M. and Tripathy, S.P. Rapid spread of HIV among injecting drug users
in north-eastern states of India. Bull Narc 45:91, 1993.
22. Naik, T.N., Sarjar, S., Singh, H.L., Bhunia, S.C., Singh, Y.I., Singh, P.K. and Pal
S.C. Intravenous grug users-A new High risk group for HIV infection in
India(letter). AIDS 5:117, 1991.
23. Singh, N.B., Panda, S., Naik, T.N., Agarwal. A., Singh. H.L., Singh, Y.I. and
Deb. B.C. HIV-2 strikes injecting drug users (IDUs) in India. J Infect 31:49, 1995.
24. Drugs that cause psychiatric symptoms. Med Lett 35:65, 1993.
Index
Acquired immunodeficiency
syndrome 19
classification 21
genetic map with functions 22
heterogeneity/genetic diversity 25
history and origin 19
human cells and tissues susceptible
26
replication cycle 23
replication steps 25
sterilization 28
chemical disinfectants 28
structure 22
susceptibility of HIV 28
transmission 29
viral dynamics and its
implications 27
Adolescence 142
Antiretroviral drugs 107
combined therapy 108
nevirapine 108
zidovudine 107
Anxiety disorders 197
Bacterial vaginosis 44
Barrier protection
barrier protection 162
facial protection 163
gowns 163
hand washing 164
handling sharp objects 164
occlusive bandage 163
Biomedical waste facility 171
Bio-safety practices 159
in health care settings 177
Blood borne infection control 159
Blood/body fluid spills
handling specimens of 165
Body fluids 179
Candidiasis 44, 127
CD4 T cell counts 130
Chancroid 48
Cleaning 168
Collection bags 173
Common STDs in India 42
Confidentially 73
Contraception and HIV
barrier and spermicide 112
intrauterine contraceptive devices
112
oral contraception 112
Counselling 49, 57, 64
Counselling process 54
after a negative result 57
after a positive result 57
after an equivocal test result 64
HIV infected persons 62
post-test 56
pre-test 54
to sexual partners of known HIV
infected persons 63
Counsellors 74
Cryptococcosis 127
Cryptosporidiosis 128
Cytomegalovirus disease 128
Decontamination 168
Decontamination/disinfection 170
Delirium 203
Dementia 202
Depression 198
Disinfection 168, 169
high level 168
Disinfection 169
Environmental cleaning 169
Exposure 179
Genital ulcer 46, 47
Glass wares 172
Gonorrohea 46
infections acquired 153
diagnosis 154
mode of infection 154
risk factors 154
208 Women and HIV

Herpres 48
HIV and adolescent girl 142
clinical case 147
mode of acquiring HIV 142
sexual risk 143
sexually transmitted disease
and pregnancy 143
behavioral risk 143
biological risk 144
social and economic risk 144
obstacles to care of HIV positive
adolescents 145
counselling and testing 146
to care of HIV positive
adolescents 145
physical examination 147
prevention 149
treatment 148
HIV and drug abuse 203
HIV disease
psychological issues 195
HIV disease in women
ethics 113
natural history of 113
HIV encephalopathy 124
HIV testing 52
HIV-antibody testing 65
HIV-exposed newborn 110
HIV-infected women
clinical management 119
clinical spectrum of
acute retroviral syndrome 120
asymptomatic disease 123
at All India Institute of
Medical Sciences 129
bacterial infections 125
early symptomatic disease 124
fungal infections 126
generalized wasting 129
neoplastic diseases 128
neurologic disease 124
opportunistic infections 125
organ-specific syndromes
persistent generalized
lymphadenopathy 124
protozoal infections 127
viral infections 128
currently available regimens
nevirapine 138
pediatric ACTG 076 clinical
trial 138
short course 138
prevention of perinatal/vertical
transmission in India 137
antiretroviral drugs available in
India 132
adherence 135
drug interactions 135
food effects 136
pill burden 135
problems during
antiretroviral regimens 134
side effects 136
timing to start treatment? 133
antiretroviral therapy 131
evaluation before initiating
therapy 130
national guidelines in India 132
Human immunodeficiency virus 1, 76
antibody tests on other fluids 82
oral HIV testing 82
urine HIV testing 83
home HIV testing 83
characteristics 1
different procedures for testing
compulsory testing 86
mandatory testing 86
unlinked anonymous testing
86
voluntary confidential testing
86
issues related to HIV testing 87
confidentiality 88
counseling 89
ethical and legal 88
informed consent 88
technical 87
life cycle 3
modes of transmission 5
natural history 4
blood products 9
blood transfusion 9
environmental and casual
contact 10
injecting drug use 7
mother to child 17
Index 209
organ transplantation 9
perinatal (Vertical) 9
sexual 5
transmission to health care
workers 9
evolution in India 14
other blood tests 83
detection of p24 antigen 83
indirect predictors 85
polymerase chain reaction
(PCR) 84
surrogate markers 85
viral load assay 85
virus culture 84
overview of the HIV/AIDS
pandemic 10
problem in India 13
blood donors and recipients 15
bridge population 15
gender-related issues 16
pregnant women 15
STD patients 15
vulnerability of women 16
strategies of testing 80
tests available for diagnosis 77
choice of test protocol 79
detection of specific
antibodies 78
ELISA/EIA 78
rapid tests 79
screening tests 78
supplemental tests 79
Incineration 174
Infection risk 168
Laundry and linen 166
Living positively with AIDS 72
Lower abdominal pain in the female 45
Maintenance of records 176
Mania 200
Mild neurocognitive disorder 201
Mortuary 167
Mother to child transmission
counseling 105
general measures 105
immunological 106
obstetric measures 105
Mycobacterium avium complex 125
Neurocognitive disorders 201
Nosocomial infections 153, 155

infection control programme 155
principles of infection control 155
risk of occupational HIV
transmission
patient to patient 158
risk of transmission 157
surveillance 155
survival of HIV in the
environment 158
transmission of blood borne
infections 156
Occupational exposure of HIV to
HCWS 186
Packing 174
Pneumocystis carinii pneumonia 126
Polymerase chain reaction 84
Post-exposure prophylaxis 180
Postpartum psychosis 203
Potentially exposed HCWS 181
counselling and education 184
evaluation of exposure 182
government of India policy 185
prompt exposure report 181
treatment 182
written protocols 181
Practical information for people with
HIV infection 68
Psychotic disorders 204
Recommendations 62
Risk in HCWs 179
RTI/STI 34
education and counseling is 41
feature of the syndromic
approach 41
problems 40
relationship with HIV/AIDS 34
sequelae and complications 36
strategies for primary
prevention 38
traditional approaches to STD
diagnosis 39
RTI/STI and HIV/AIDS control
programme 36
Sharps 172
Sleep disorder 201
Standard precautions 162
Sterilization 170
210 Women and HIV

Storage and transport 174
Surrogate markers 85
Syphilis 46
Thermal disinfection 170
Toxoplasmic encephalitis 127
Trichomoniasis 42
Tuberculosis 125
Universal precautions 188
Vaginal discharges 44
VCT Services 74
Viral load assay 85
Viral load assays 130
Virus culture 84
Voluntary counselling and testing 50, 51
Waste disposal 175
Women and HIV infection 92
determinants of vertical
transmission 96
amount of virus in the genital
tract 98
breast-feeding 99
caesarean delivery 100
foetal factor 99
maternal CD-4 and
lymphocyte count 97
membranes 98
newborn immune response 101
nutritional status 97
placental barrier 98
types of virus 98
unprotected sexual intercourse
97
viral load 97
effect of HIV on pregnancy 103
effect of pregnancy on HIV disease
103
factors increasing vulnerability 93
biological factor 95
blood 95
economic factor 95
issues concerning
pregnancy 96
male to female transmission 94
previous RTI/STI 95
sexual relationship 94
social factor 94
management of HIV positive
pregnant women 103
timing of vertical transmission
102

Women and HIV

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Women and HIV

Caricato da

Copyright:

Formati disponibili

Women and HIV

Women and HIV

Federation of Obstetric and Gynaecological Societies of India

First Edition : 2003

Typeset at JPBMP typesetting unit

2. HIV: The Virus

3. Syndromic Management of Reproductive Tract

4. Voluntary Counselling and Testing and its

5. Establishing the Diagnosis of the HIV Infection

6. Women and HIV Infection including Mother to

7. Management of HIV Infected Individuals

8. HIV and Adolescent Girl

9. Infection Control and Bio-medical Practices

10. Postexposure Prophylaxis against HIV

11. Psychiatric Aspects of HIV/AIDS in Women

READER SUGGESTIONS SHEET

Your name and address:

Direct mail from publisher

Do you have any brief comments on the book?

Women and HIV

catalyzes the synthesis of DNA from an RNA template. As its name

Epidemiology of HIV Infection and AIDS 3

Fig. 1.1: (a) Schematic drawing of the HIV life cycle;

Women and HIV

NATURAL HISTORY OF HIV

Source 1: Guidelines, Govt. of India, Ministry of Health and Family Welfare

Epidemiology of HIV Infection and AIDS 5

Women and HIV

Likelihood of infection after a

Injecting drug use

Health care worker

a. Rate of infection diminished greatly by antiretroviral therapy during pregnancy

and neonatal period

Source 2: Guidelines, Govt. of India, Ministry of Health and Family Welfare

Epidemiology of HIV Infection and AIDS 7

Estimated quantity of HIV

High levels associated with acute infection and advanced disease

Source 2: Guidelines, Govt. of India, Ministry of Health and Family Welfare

Use of Condoms and Other Protective Agents

Women and HIV

HIV disease stage

HIV disease stage

Source 2: Guidelines, Govt. of India, Ministry of Health and Family Welfare

Fig. 1.3: Interplay of factors which determine the probability of transmission of

Source 2: Guidelines, Govt. of India, Ministry of Health and Family Welfare

Epidemiology of HIV Infection and AIDS 9

Women and HIV

infected patients. Needle-stick accidents pose a far greater risk than

Epidemiology of HIV Infection and AIDS

Table 1.4: Global summary of the HIV/AIDS epidemic,

Number of people living with HIV/AIDS Total

People newly infected with HIV in 2001 Total

AIDS deaths in 2001

transmission is the major mode of spread. In countries where the

Women and HIV

highest for any individual country after South Africa. The

Epidemiology of HIV Infection and AIDS

Women and HIV

Fig. 1.5: Three regions in India

Evolution of HIV Epidemic in India

Fig. 1.6: Flow of epidemic

Epidemiology of HIV Infection and AIDS

The various groups and factors determining the spread are

Women and HIV