Question 5 (Practical Tasks) The Concept of the Elisa Test and the implications it has on the window period and the use of vaccinations. The ELISA antibody test, which stands for Enzyme-Linked Immuno-Absorbent is also known as EIA (Enzyme Immuno-Assay) was the first HIV test to be widely used across the world to detect an HIV Infection. The HIV antibody tests are the most appropriate test for routine diagnosis of HIV among adults. The tests are inexpensive and very accurate and is one of the most common tests used to test for HIV in South Africa. When a person is infected with HIV, their body responds by producing special proteins that fight infection, called antibodies. An HIV antibody test looks for these antibodies in blood, saliva, or urine. If antibodies to HIV are detected, it means a person has been infected with HIV. There are only two exceptions that has found to be true facts; Babies born to HIV infected mothers retain their mother's antibodies for up to 18 months, which means they may test positive on an HIV antibody test, even if they are actually HIV negative. Normally babies who are born to HIV positive mothers receive a PCR test after birth; and some people who have taken part in HIV vaccine trials may have HIV antibodies even if they are not infected with the virus. Most people develop detectable HIV antibodies within 6 to 12 weeks of infection. It has been found in some very rare cases, that it can take up to 6 months to be detected and there are nearly always very particular reasons for antibodies developing so late for instance the person might be suffering from other auto-immune disorders. It is exceedingly unlikely that someone would take longer than 6 months to develop antibodies. What is a Window period? The Window Period is a term used to describe the period of time between HIV infection and the production of antibodies. During this time, an antibody test may give a False Negative result, which means the test, will be negative, even though a person is infected with HIV. To avoid false negative results, antibody tests are recommended three months after potential exposure to HIV infection. A negative test at three months will almost always mean a person is not infected with HIV. If an individual’s test is still negative at six months, and they have not been at risk of HIV infection in the meantime, it means they are not infected with HIV. It is very important to note that if a person is infected with HIV, they can still transmit the virus to others during the window period. 1|Page The importance of pre and posttest counselling and the personal implications of HIV testing for an individual It is of utmost importance to conduct Counselling before as well as after an HIV test. The emotional wellbeing of an individual needs to be established and when conducting the counselling such important and critical information about HIV will be provide to the person. The counselling itself should not just be about HIV itself but also about the testing process and what the various outcome implications can be for the person. The counselling services may not be available in all health care facilities, many testing sites do offer these services. If you would like access to pre-test and post-test counselling, be sure to inquire about the availability of these services at your chosen test site. If they do not have them readily available, the staff may be able to direct you to alternate service providers who does offer the services. Pre-HIV test counselling is extremely important. It should not only be seen as a preparation for the HIV test, but as a golden opportunity to educate people about HIV/Aids and safer sex. Remember that this may be the one and only time that you will see the client because he or she might decide not to be tested, or not to come back for the test results after all. The purpose of pre-test counselling is further to find out why you want to be tested, the nature and extent of your previous and present high-risk behaviour, and the steps that need to be taken to prevent you from becoming infected or from transmitting HIV infection. Counselling after testing will depend on the outcome of the test - which may be a negative result, a positive result, or an inconclusive result. The counsellor should always ask the client if he or she is prepared to receive the results. In the case of the rapid HIV antibody test - where the results are available within minutes - ask the client if he/she is ready to receive the results immediately. Some clients need time to prepare for the results. Informed consent The decision to be tested can only be made by the client and their informed consent must be obtained prior to testing. Consenting to medical testing or treatment has two elements: information and permission. Before an HIV test can be done, the client must understand the nature of the test, and he/she must also give verbal or written permission to be tested. A client may never be misled or deceived into consenting to an HIV test. 2|Page According to the law, health care professionals may not do an HIV test on a person unless he or she clearly understands what the purpose of the test is, what advantages or disadvantages testing may hold for him or her as client, why the health care professional wants this information, what influence the result of such a test will have on his or her treatment, and how his or her medical protocol will be altered by this information. The stages of the HIV - from infection with to full-blown AIDS and death. The Four Stages of HIV/AIDS, also be known as: Stage 1: Primary HIV Infection Stage 2: Asymptomatic HIV Stage 3: Symptomatic HIV Stage 4: Acquired Immune Deficiency Syndrome (AIDS) Stage 1: Infected: The period following the initial HIV infection is called the window period. This is the period between infection with the virus and when HIV antibodies develop in the bloodstream. At this stage there is no way of detecting HIV infection in the body. Seroconversion refers to the period of time during which the body is producing HIV antibodies, trying to protect itself against the virus. Many people experience flu-like symptoms and swollen lymph nodes – this is a highly infectious stage. Stage 2: HIV Well: After sero-converting, many people usually experience a symptom-free period or asymptomatic period. For many years, people with HIV look and feel well. Although the person with HIV is experiencing no symptoms, the virus is still replicating inside the body and weakening the immune system. This stage can last anything from three to twelve years. The average time is six years. During this stage, infected people need counselling, support and a healthy lifestyle. This is the most dangerous stage because unless they have an HIV test, they will not know that they are infected. In this way they can spread the virus without knowing it. Stage 3: HIV ill: HIV slowly weakens the immune system. Between five and eight years after infection, people start getting sick. They usually begin to lose weight and their bodies become weak. The early signs of HIV related illnesses are: Weight loss Swelling in the neck, behind the ear, under the arm and in the groin Sores on the lips or genitals which do not heal 3|Page A white rash inside the mouth or on the genitals Signs of TB – coughing, sweating, and losing weight Painful sores or rashes Fevers and sweating at night Diarrhea that does not stop Stage 4: AIDS: After this period, severe immune cell loss leads to the symptomatic period, in which the body experiences the symptoms associated with AIDS. This is the final stage and is referred to as AIDS sickness. On average it takes a person 18 months between getting very ill with AIDS and dying. People with AIDS need special care and medicine. There is often a need to go to the hospital. People with AIDS usually suffer from serious diseases like TB, pneumonia, or certain types of cancer. They become very ill with these diseases, and they eventually die. It usually takes about eight years between the times people are first infected with the HI Virus to when they die of AIDS (www.unaids.org). Later signs of AIDS are: TB and pneumonia Thrush (a fungal infection of the mouth or vagina) Re-occurring shingles and skin rashes and lesions Various cancers Meningitis Weight loss of more than 10% What are the chances of a person surviving with AIDS - latest views on medication and the cost of Drugs To be infected with HIV is in some instance a lifelong disease, these days it is considered that people with HIV and AIDS are living longer, if they conduct a healthier lifestyle and with the new and effective treatments available the disease is treated and managed more like a Chronic illness as to a death sentence. Since the introduction of the newly developed HIV medications treatment regiments, statistics have shown that fewer people are dying of AIDS and people are now living long, productive lives despite their HIV infection. Unfortunately, what has become a challenge and especially with African countries is the cost of HIV medications, it is sometimes seen as the only obstacle for people to step forward in getting therapy. While this hurdle has been negotiated in the western world, some of the world's hardest 4|Page hit areas still can't afford to properly treat their citizens with HIV medications. As of late, governments, advocacy groups and even drug manufacturers are making HIV medications more affordable for those who can't afford them. The government is spending billions and billions of Rands to provide medication to people living with HIV/AIDS. South Africa has the largest Antiretroviral therapy programme in the world, but it also has the world’s largest epidemic, and access to treatment is low. According to the latest World Health Organisations guidelines of 2010, an estimated 55 percent of people who needed ARVS was receiving treatment for HIV, at the end of 2010. Over the last 10 years, the country has been making progress towards its goal of 80 percent coverage. By mid-2011, it was announced that the number of people on antiretroviral treatment had increased significantly from 923,000 in February 2010 to 1.4 million in May 2011. The state of HIV treatment in South Africa can only be seen in the context of years of doubting the effectiveness of treatment at the highest levels of government, and the initial delay and slow pace of delivering a public ARV programme. The initial cost the government spend on tender prices during 2010 stood at a cost more than R8.8 billion to treat people with antiretroviral. Following this massive reduction in the price of antiretroviral drugs, the government can now treat twice as many people as before. Understanding HIV/AIDS and behaviour that carry a risk of contracting HIV/AIDS A person that contracts an HIV infection can at most relay it to the result of human behavior, and at best to ensure that rate of infections grows less. Such has been the aim of awareness campaigns and educational life skills programmes have inevitably been to broadcast that change in behaviour. As this change in lifestyle has long been understood as essential to curbing the spread of infection. In all cases where national epidemics have been reversed, broad-based behavior changes were central to success. For example, Acts such as sexual behaviour can range between more, or less risky Low Risk or No Risk Behaviors: Kissing, dancing, hugging, body rubbing (outer course) and massage are no-risk behaviors for contracting HIV; mutual masturbation if there are no cuts on the hand, penis or vagina is very low risk. But individuals should at all times not just be guarded against HIV but should be aware that STIs (Sexually Transmitted Infections) such as Herpes or Genital Warts can be transmitted by body-to-body contact, without intercourse. Moderate Risk Behaviors 5|Page Oral sex on a man is a higher risk than oral on a woman which is considered as moderately risky behavior. The risk is increased when there are open sores in the mouth, on the penis or vagina. Flossing and rigorous brushing before oral sex can cause small cuts in the gums, increasing the risk; mouthwash is an alternative. If there is body fluids present, oral sex is high risk behavior. Using condoms on penis or dental dam on vagina can make oral sex a safe behavior. Oral sex on anus is very low risk for HIV, but like all unprotected oral sex, has some risk for STIs; using a dental dam reduces this risk. High Risk Behaviors Unprotected vaginal and anal sex and oral sex with ejaculate (cum) or vaginal blood are high risk behaviors as is using and sharing un-sterilized injection drug needles. HIV infected mother breast feeding is also high-risk behavior for mother to child transmission. Other factors that can influence your behaviour Having a perception that you can't get HIV or that your partner does not look like someone who can have HIV can increase your likelihood of participating in unprotected sex. Being high on drugs and alcohol can increase the chance that you will do something that you would not do sober and increase the incidence of unprotected and unplanned intercourse. Avoid contracting or spreading HIV/AIDS and how behaviour can reduce the risk of infection. Always using condoms for vaginal intercourse also prevents unplanned pregnancy. Make use of PReP if you and your partner has not undergone testing before your first time of having planned intercourse. Be Proud that you take control of decision regarding your body and your safety. Taking responsibility for your own actions can decrease your chance of becoming infected with HIV or an STD. Becoming educated about HIV and understanding how it is transmitted is the most important way to prevent the spread of HIV. It is essential to make informed decisions about the level of risk they are willing to take, based on what is realistic for them. Using a Condom and not sharing needles is one of the most effective ways for people to protect themselves from HIV and other Sexually Transmitted Diseases (STDs). Even though abstinence is not a realistic option for everyone, it should be practiced at best possible in situation where you do not know the person. When abstinence is not an option, the proper use of barrier protection such as latex or 6|Page polyurethane condom (male or female) with a water-based lubricant is the next best thing for vaginal or anal sex. When working within a health care environment or coming across an incident where blood or body fluids are exposed, be stringent about taking all necessary precautions.; Although this is a rare way of contracting HIV, avoid coming into contact with other people's blood. Your health comes first. If you ever need a transplant, know where organs come from. whether it be organs or other body parts, like cells, it would be safer to know where they come from. Try to get organs, such as kidneys, from a family member. Other transplants, such as cell transplants, can also be taken from willing family and friends. Know that there is no way to avoid it entirely and there is no cure. So the only way is to not have sex at all unless you are positive the significant other does not have this STD or any other STD of the sort. Prevention is always better than cure. This principle holds a phenomenal significance when it comes to HIV/AIDS. AIDS is one such disease that does not have any permanent cure. Available PReP treatment options are only effective in reducing the symptoms associated with the disease. In such scenario, it is important to have adequate protection so that you do not get the infection. Situations that have a potential to spread HIV/AIDS in the workplace HIV infections is mostly contracted through the blood of an infected person into another person's bloodstream. HIV has been found in several body fluids, including blood, semen and vaginal secretions. Small amounts of the virus have been detected in saliva, tears and breast milk. HIV is also acquired through vaginal or anal intercourse, direct injection of contaminated blood or blood products, or by using contaminated needles. HIV is not spread through the air like cold or covid viruses. You cannot "catch" HIV like the common cold or flu. The virus is not transmitted in social situations, such as at work or by sharing food or water, through contact with saliva or tears or using the same utensils and toilet as an HIV Infected person. No evidence exists that HIV can be transmitted through insects, such as mosquitoes. It's important to keep in mind that there is no medical evidence that HIV can be spread by casual contact with someone with HIV infection. Low Risk Situations: Most occupational groups are not at risk of becoming infected with HIV through exposures at work. There is no evidence that HIV is transmitted through touching or caring for patients or clients (unless direct contact with blood or body fluids is involved); from cutlery, glasses, food, or dishes, swimming pools, drinking fountains, coughing or sneezing, or toilet seats. 7|Page Medium Risk Situations: The risk associated with broken skin or mucous membrane transmission is believed to be lower than that associated with needle-sticks. Workers who have contact with blood and body fluids are potentially at risk and should take the same type of precautions as are used for other blood borne pathogens, such as Hepatitis B or C. Workers at risk of exposure in their field of work include: Health care workers, including those involved in patient care and support services such as laundry, housekeeping, and materials handling Laboratory workers Emergency response personnel, including paramedics, ambulance attendants, police, and firefighters Institutional workers in group homes and psychiatric facilities Correctional officers Morgue attendants Dental workers. High Risk Situations: Occupational transmission of HIV can happen in several ways. The most effective way for HIV to enter the body is through a needle-stick if that needle has been used by someone with HIV infection. Studies indicate that the risk of developing HIV infection is about 0.4 per cent (or about one chance in 250) after a needle-stick with a needle from a known HIV-infected person. An open wound, cut or skin that is not intact, such as skin that is chapped, weeping or skin that has rashes, can allow infected fluid to enter the body. Finally, if infected fluids touch mucous membranes such as the eyes, nose or mouth, these surfaces can absorb the fluid and transmit the virus. Behaviour and activities that carry a low risk of infection HIV is NOT spread through the environment; it is a very fragile blood-borne virus. HIV-infected persons do not pose a threat to coworkers or clients during casual, day-to-day activities and contacts. So, you cannot be infected with HIV through: Handshakes Hugs or casual touching Close working conditions Telephones, office equipment, or furniture Sinks, toilets, or showers Dishes, utensils, or food 8|Page Sneezing or coughing Air Water Insects Most of the behaviors that pass HIV from one person to another do not occur in the workplace. The only way that most people in the average workplace could be exposed to HIV would be if they had an open wound and someone else’s infected blood entered their body through that broken skin. It is vital that workers recognize that all blood and body fluids they come in contact with are potentially infectious, and not just with HIV! Treatment options available to a person with HIV/AIDS locally in South Africa Antiretroviral drugs (ARVs) are currently the primary method for treating HIV. These drugs inhibit either of the two enzymes that are essential for HIV replication, namely, reverse transcriptase and protease. Newer drugs target other areas of the virus' lifecycle but are not yet readily available in our region. Although antiretroviral treatment is not a cure for HIV/AIDS, it can significantly prolong and improve the lives of HIV-infected people. ARVs slow down the production of HIV and give the body a chance to build up its CD4 cell count which, in turn, helps the body fight against opportunistic infections. Types of Antiretrovirals There are more than 20 approved antiretroviral drugs but not all are licensed or available in every country. Antiretroviral treatment is usually prescribed as a combination of two or three different types of drugs to combat different processes during HIV replication. Taking two or more antiretroviral drugs at a time is called combination therapy. Taking a combination of three or more anti-HIV drugs is sometimes referred to as Highly Active Antiretroviral Therapy (HAART). If only one drug was taken, HIV would quickly become resistant to it and the drug would stop working. Taking two or more antiretrovirals at the same time vastly reduces the rate at which resistance would develop, making treatment more effective in the long term. The three main types of drugs available are listed below: Antiretroviral Drug Action Generic Examples (abbr) 9|Page Nucleoside Prevents healthy T-cells from becoming zidovudine (AZT) Analogue Reverse infected with HIV by preventing the lamivudine (3TC) Transcriptase conversion of viral RNA into viral DNA. stavudine (d4T) Non-nucleoside Prevents healthy T-cells from becoming nevirapine (NVP) Reverse infected with HIV by interfering with the efavirenz (EFV) Transcriptase reverse transcriptase enzyme which the HIV delavirdine Inhibitors (NNRTI) uses to convert viral RNA to viral DNA. (DLV) Protease Inhibitor Prevents infected T-cells from producing new ritonavir (RTV) copies of the virus by blocking the protease indinavir (IDV) enzyme which helps produce new copies of lopinavir the virus. (LPV) Inhibitor (NRTI) There are two groups of HAART ARV drugs that the government uses in South Africa. Health workers call these groups ‘regimens”. These are the names of the drugs in the two regimens: Group 1 or Regimen 1 Group 2 or Regimen 2 (for those whose HIV resists Regimen 1) 3TC or Lamivudine AZT or Zidovudine d4T or Stavudine ddl or Didanosine Efavirenz (or Nevirapine, which is safe for Lopinavir with Rittonavir women who may want to fall pregnant) ARVs have different names, depending on which Drug Company makes them. The names given on this page are the generic names of the contents of the drugs. Other kinds of drugs also use different names for the same thing. For example, paracetamol is sold by different drug companies as Panado, Painamol, Tylenol, or Dolorol. 10 | P a g e