PARTICIPANT

S MANUAL
ADHERENCE IN HIV CARE AND
TREATMENT

MODULE 1
EPIDEMIOLOGY OF HIV

GOAL
The goal of this module is to impart knowledge on the
nature and the scope of HIV and AIDS globally and in
Kenya.

OBJECTIVES
At the end of this unit, participants will be able to;
Define HIV and describe the situation in the world and in
Kenya
Discuss different modes of HIV transmission and factors that
facilitate HIV Transmission and Prevention

UNIT 1
DEFINITION AND PREVALENCE OF HIV

INTRODUCTION
1981-Doctors in US recognized PCP in homosexual males,
a condition previously unreported in healthy adults
Later recognized that patients were immunosuppressed

1983/4- Scientist described the cause of the syndrome as

retrovirus
Lymphodenopathy associated virus (LAV)
AIDs Associated Retrovirus (ARV)
Human T.Lymphotrophic Virus (HTVL-)

In Kenya the first case was described in1984

In 1986-Human immunodeficiency virus (HIV) accepted as
international designation for the Retrovirus in the WHO
consultative meeting

Global picture
UNAIDS 2015 HIV updates
36.7 million living with HIV; 1.8m of these
children <15 years
2.1 million new infections; 150,000 among
children
1.1 million death
66% of new infections are in SSA
About one-third of PLHIV are between 15-24
years.
Young women are more vulnerable
Sub-Saharan Africa home to over two-thirds of

Kenya: Population based

National HIV data (KAIS
2012)
National HIV prevalence:5.6% (15-64
years)
More women are HIV positive than
men (6.9% vs 4.4%)
Age peak of HIV prevalence differs
with sex. Female 25-29yrs, male 3544yrs.
Urban HIV prevalence:6.5%, Rural HIV
prevalence 5.1%
Highest prevalence in
Nyanza:15.1%,followed by Nairobi:9.1%

HIV prevalence among persons aged 15-64 years by

NASCOP region, KAIS 2012

* North Eastern region not surveyed in KAIS 2012.

HIV prevalence among adults aged 15 to 64 years stands at 5.6% in 2012.

HIV prevalence among children aged 18 months to 14 years was 0.9%.

HIV prevalence by age category, KAIS 2007 and

2012

*18 months to 14 year age category not included in KAIS 2007.

Service Coverage

HIV Testing
72% of adults reported that they have ever been tested
compared to 34% in 2007
Only 47% of individuals who were HIV positive correctly
reported their status compared to 16% in 2007

Awareness of HIV status among HIV-infected individuals

aged 15-64 years, KAIS 2007 and 2012

Self-reported HIV status among HIV-infected individuals aged

15-64 years, KAIS 2012

HIV concordance and discordance among married

or cohabiting couples aged 15-64 years, KAIS 2012

Sexual behaviour

National percentage of key populations at high risk for HIV

infection, men and women aged 15-64 years, KAIS 2012

High-risk population

Ever

In the last 12
months

Persons who had ever injected drugs

0.1%

--

Men who have had had sex with men

1%

--

3%

1%

4%

1%

17%

5%

Men who had received money, gifts, or favours

for sex
Women who had received money, gifts, or
favours for sex
Men who had given money, gifts, or favours in
exchange for sex with women

THANK YOU

UNIT 2
TRANSMISSION AND PREVENTION OF HIV

Basic facts about HIV

HIV is a retrovirus from the Lentivirus family
There are two types of HIV
HIV-1
Is found worldwide
It is the main cause of the pandemic

HIV2

Is mainly found in West Africa. Mozambique and

Angola
Causes a similar illness to HIV 1
Less efficiently transmissible rarely causing vertical
transmission
Less aggressive with slower disease progression

How HIV affects immune

system
HIV attaches to cell of the immune
system with special surface markers
called CD4 receptors
The following immune cells have CD4
receptors
T-Lymphocytes- CD4 cells
Macrophages
Monocytes
Dendritic cells

HIV infection of CD4 cells causes cell

dysfunction and death

Effects of HIV on the immune

system
Reduction in the CD4 cells number and
the effects on their function reduces the
capacity of the body to fight the
infectious diseases
Individuals with HIV infections are
therefore increasingly susceptible to
many infections especially at later stages
of HIV infection

Modes of transmission
Sexual contact most important mode of
transmission/acquisition of HIV worldwide
In Africa mainly heterosexual (males-female)
Include homosexual (men having sex with men) as well
Non consensual sexual exposures (assault)

Parenteral
Transfusion of infected blood or blood products
Exposure to infected blood or body fluids through
contaminated sharps- IDU through needle sharing or
need stick accidents
Donated organs
Traditional procedure

Perinatal/Vertical
Transplacental, during labor/delivery and
breastfeeding
HIV is not transmitted by casual contact,
surface contact, or from insect bites

Biological factors influencing

HIV transmission
Disease status of source patient
Related to degree of immunosuppression and viral load.
High risk during primary infection and late disease when viral load is
very high
Also higher the lower the CD4 count independent of viral load

Presence of untreated STI in source and person at risk.

Both ulcerative and non ulcerative STIs important cofactors
Related to high viral load in genital secretions during STIs and the
disturbance of genital mucosa

A major reason for high prevalence in SSA

Circumcision status
Uncircumcised men two times as likely to acquire HIV infection than
circumcised

Biological factors influencing

HIV transmission
Gender differences in susceptibility
Female genital anatomy presents a
larger surface area with more of the
target cells that HIV require to gain
entry

Socio-economic factors
facilitating HIV Transmission
Social Mobility
Global economy
HIV/AIDS follows route of commerce
Partners living apart

Stigma and denial

Denial and silence is the norm
Stigma prevents acknowledgement and care seeking

People in conflict
Context of war and struggle for power spreads HIV

Cultural factors
Traditions, beliefs, and practices affect understanding of health
and disease and acceptance of conventional medical treatment

Socio-economic factors
facilitating HIV Transmission
contd
Gender
In many cultures it is accepted for men to have many
sexual relationships
Women suffer gender inequalities
Many women unable to negotiate condom use

Poverty
Lack of information needed to understand and prevent
HIV

Drug use and alcohol consumption

Impaired judgment
Sharing of needles and equipment

Behavioral factors
Multiple sexual partners
Unprotected sexual intercourse
Large age difference

Factors not associated with

risk of transmission
Insect bites
Saliva (kissing)
Sneezing or coughing
Skin contact (e.g. hugging)
Shared use of facilities (e.g. toilets)

HIV prevention
This includes measures of prevention that stops occurrence of
infection
Active promotion and support for delayed sexual debut
Provide young people with the correct information on sexuality
and sex issues
Friendly Counseling and Testing services to know ones status
Promote safer sex practices

Be faithful to one HIV negative partner

Correct and consistent use of male and female condom
Discourage intergenerational sex
Prevention, early diagnosis and treatment of sexually transmitted
diseases
Male circumcision

Primary prevention
Abstinence
Ensuring blood safety
Screening blood before transfusion
Blood safety education and promotion.
Education on prevention of sharing
needles and syringes and clean needle
exchange programmes in those using
intravenous drugs

Sexual behaviour among respondents by age group, KAIS

2012
12-14
years

Ever had sex

Median age at first sex,
years (interquartile range)
Sexually-active in the past
12 months among those
who have ever had sex
Reported two or more sex
partners in the past 12
months
Aware of HIV status of sex
partners in the past 12
months
Consistent condom use with
partners of discordant or
unknown HIV serostatus in
the past 12 months

15-24 years

25-64 years

Women

Men

Women

Men

7%
10 (912)
--

66%
17 (15-18)

99%
18 (15-20)

85%

59%
16 (1418)
74%

78%

99%
18 (1620)
89%

--

4%

30%

3%

17%

--

57%

38%

48%

61%

--

11%

43%

5%

14%

VMMC (KAIS 2012)

Prevalence of HIV higher in
uncircumcised men than in those
circumcised
The proportion of men who were
circumcised increased nationally from
85% in 2007 to 91% in 2012.
Nyanza region observed the highest
increase in male circumcision rates, from
48% in 2007 to 66% in 2012.

Male circumcision among men aged 15-64 years by region,

KAIS 2007 and 2012

*North Eastern region not surveyed in KAIS 2012.

Prevention of mother to child

(Vertical) transmission
setting
Prevention of unwanted pregnancy in HIV
positive women
Voluntary prevention of unintended pregnancies
Integration of PMTCT/HIV and family planning
services
Use effective family planning methodspromotion of dual protection especially the use of
condoms to protect against pregnancy and STIs
Integration of STI/FP into CCC

Prevention of mother to child

(vertical) transmission
settings.
Provision of adequate antenatal care of
positive women
Identify pregnant women and refer for
ANC
Offering of HIV counseling & testing in
antenatal clinics as part of routine care

Prevention of mother to child

transmission settings
Routine HIV Counseling and Testing Services in
Antenatal Clinic
Use of prophylactic ARV drugs to reduce MTCT
HAART to mothers when they are indicated
Safer delivery Practices
Infant feeding counseling and support
Supportive psychosocial counseling for
mothers who enroll into PMTCT programme

PMTCT (KAIS 2012

Reports)
92% of women who gave birth between
2007 and 2012 and attended antenatal
care (ANC) for those pregnancies had
been tested for HIV infection at ANC
Of those who were diagnosed with HIV
at ANC, 90% received either maternal or
infant antiretroviral prophylaxis to
prevent mother-to-child transmission of
HIV (PMTCT).

Prevention of Occupational
Exposure in health care
settings
Health care workers are at risk for
exposure to HIV through contact with
blood and other body fluid containing HIV
through
Needle stick injuries
Sharp instruments
Mucous membrane exposure

Measures to minimize
occupational exposure to HIV
include
Use universal precaution
All blood should be treated as if it carries
HIV
Use appropriate barriers such as
Gloves
Gowns
Goggles

Measures to minimize
occupational exposure to HIV
include
Handle sharps with care
Minimize blind surgical procedures
Avoid recapping needles
Use of antiretroviral drugs following
exposures
Other circumstances include use of post
exposures prophylaxis with antiretroviral
drugs in cases of sexual exposure

ART for Prevention

Several studies have shown that HIV transmission from infected to
uninfected can be reduced significantly with initiation of ART
HPTN 052 study showed 96% reduction in HIV transmission among HIVinfected individuals with CD4+ count of 350-500 who were initiated on
ART.
Initiation of ART results in immune reconstitution and subsequent
reduction in viral load

Use of ART among high risk HIV-negative populations has been

shown to reduce the acquisition of HIV
Postexposure prophylaxis is recommended after accidental occupational
exposure and rape in Kenya
Pre-exposure is now recommended for people in high risky behaviours of
HIV acquisition.
Examples of populations: risky sexual behaviours (multiple partners of
unknown HIV status), sex workers, MSMs, HIV discordant relationships)

UNAIDS 2014: 90-90-90

An ambitious testing target to help end the AIDS
Epidemic
90% HIV
positive
know
status

90% on
Treatme
nt

90% Viral
Suppressi
on

Epidemiologi
c Control

Summary
HIV has become a pandemic since the
first cases were identified 2 decades ago
It is a major cause of morbidity and
mortality in many countries particularly
SSA
Many factors contribute to HIV
Transmission in a society
Many are modifiable allowing for prevention
strategies
Knowledge of this factors can be used to
design control strategies

Thank You