H

1. HIV / AIDS
BY
DR. MUKESH KUMAR PANTH

2.  http://naco.gov.in/
 https://www.avert.org
 https://aidsinfo.nih.gov/

3. THE GLOBAL AIDS EPIDEMIC 2017
 An estimated 36.9 million people were living
with HIV worldwide in 2017.
 3.0 million were children and adolescents
under 20 years of age
 19.1 million were women and girls.
 Each day, approximately 4,900 people were
newly infected with HIV
 Approximately 2,580 people died from AIDS
related causes, mostly because of
inadequate access to HIV prevention, care
and treatment services.

4. THE GLOBAL AIDS EPIDEMIC 2017
2017
PEOPLE LIVING WITH HIV
(all ages)
36.9 million
Adults (aged 15+) 35.1 million
Women (aged 15+) 18.2 million
Children (aged 0–14) 1.8 million
Adolescents (aged 10–19) 1.8 milllion

5. THE GLOBAL AIDS EPIDEMIC 2017
AIDS-RELATED DEATHS
2017
All ages 940,000
Adults (aged 15+) 830,000
Women (aged 15+) 350,000
Children (aged 0–14) 110,000
Adolescents (aged 10–19) 38,000

6. HIV AND AIDS IN INDIA
 India has the third largest HIV epidemic in the
world.
 In 2017, HIV prevalence among adults (aged 15-
49) was an estimated 0.2%, this equates to 2.1
million people living with HIV.
 Overall, India’s HIV epidemic is slowing down,
Between 2010 and 2017 new infections declined by
27%.
 in 2017, new infections increased to 88,000 from
80,000, and AIDS-related deaths increased to
69,000 from 62,000.

7.  In 2017, 79% of people living with HIV were
aware of their status, of whom 56% were on
antiretroviral treatment (ART).

8. INDIA: HIV INFECTIONS
2005 2010
2017
New HIV infections
(all ages)
130 000 120 000 88 000
New HIV infections
(0–14)
13 000 7700 3700
New HIV infections
(women, 15+)
48 000 45 000 34 000
New HIV infections
(men, 15+)
71 000 67 000 50 000

9. INDIA: AIDS-RELATED DEATHS
2005 2010 2017
AIDS-related
deaths (all ages)
240000
160000 69000
AIDS-related
deaths (0–14)
11000 6800 2600
AIDS-related
deaths (women,
15+)
88000 58000 20000
AIDS-related
deaths (men, 15+)
140000 91000 46000

10. INDIA: PEOPLE LIVING WITH HIV
2005 2010 2017
People living with
HIV (all ages)
2 800 000 2 300 000 2 100 000
People living with
HIV (0–14)
100 000 88 000 61 000
People living with
HIV (women, 15+)
1 100 000 900 000 880 000
People living with
HIV (men, 15+)
1 600 000 1 300 000 1 200 000

11. DR. S.K CHATURVEDI
ADULT HIV PREVALENCE
High Prevalence States:
these are
Tamil Nadu,
Maharastra,
Karnataka,
Andhra Pradesh,
Manipur and Nagaland

12. DR. S.K CHATURVEDI
MODE OF TRANSMISSION OF HIV IN INDIA
5.95
3.45
2.07
2.7
85.83
Sexual IDUs Blood & blood proucts Perinatal Unidentified

13. HIV “HUMAN IMMUNODEFICIENCY VIRUS”
H – Human – This particular virus can only infect human
beings.
I – Immunodeficiency – HIV weakens immune system by
destroying important cells that fight disease and infection. A
"deficient" immune system can't protect you.
V – Virus – A virus can only reproduce itself by taking over a
cell in the body of its host.

14. AIDS : Acquired Immune Deficiency Syndrome
A – Acquired – AIDS is not something that someone inherit
from their parents like other things.
You acquire AIDS.
I – Immuno – Body's immune system includes all the organs
and cells that work to fight off infection or disease.
D – Deficiency – Someone get AIDS when their immune
system is "deficient," or isn't working the way it should.
S – Syndrome – A syndrome is a collection of symptoms and
signs of disease. AIDS is a syndrome, rather than a single
disease. It is a complex illness with a wide range of symptoms.

15. HIV VS. AIDS
 HIV causes AIDS by attacking the immune
system’s CD4 T cells.
 Normal CD4 count is between 500 – 1500
CD4 T cells per ul of blood, while AIDS CD4
count is less than 200 CD4 T cells per ul of
blood.
 AIDS viral load is about 55,000 HIV RNA
copies per ml of blood.
 On average, it takes approximately 10 years
to develop AIDS from initial infection.
 As a person’s CD4 count decreases, he/she
is more prone to opportunistic infections.

16. HIV MYTHS
• I can get HIV by being around people who are HIV-positive.
• I'm HIV-positive…my life is over.
• I'm straight and don't use IV drugs - I won't become HIV-
positive.
• You can’t get HIV from oral sex.
• My partner and I are both HIV positive, so there is no need
to use a condom.
• I can get HIV from mosquitoes.
• Coughing, sneezing
• Insect bites
• Touching, hugging
• Water, food
• Kissing
• Public baths
• Handshakes
• Work or school contact
• Using telephones
• Sharing cups, glasses,
plates, or other utensils

17. TYPES OF HIV
 HIV-1
 More virulent
 Responsible for
worldwide
epidemic
 Severity of
infection varies
from person to
person
 HIV-2
 Primarily found in
western Africa
 Not transmitted as
efficiently

18. ORIGINS OF HIV
HIV-1 likely descended
from SIVcpz
HIV-2 likely descended
from SIVsm
Pan troglodytes
troglodytes
Sooty Mangabey

19. ZOONOSIS: HOW DID IT HAPPEN?
 Human killing and eating of
chimpanzees
 contact with infected blood
 ingestion of uncooked or undercooked meat

20.  Three earliest know HIV infections
 1959 - serum sample from an adult male living
in what is now the Democratic Republic of
Congo
 1969 - tissue samples from a teenager who
died in St. Louis
 1976 - tissue samples from a Norwegian sailor
 January 2000 - study by Dr. Bette
Korber estimates first case of HIV
infection to be 1930
 Study based on complicated computer model of
HIV’s evolution and has a 20yr error margin

21. HIV
A Brief History of
the modern
epidemic

22. IN THE BEGINNING...
 1675 - Speculation that HIV was first
transmitted from chimpanzees to
humans
 1926-1946 - Scientists believe HIV first
spread from monkeys to humans
 1959 - First proven AIDS death
 1978 - Gay men in US and Sweden
begin showing signs of what is
now known as AIDS

23. THE FIRST INDICATIONS
 1981 - CDC notices increase in cases of
Kaposi’s sarcoma and Pneumocystis
carinii pneumonia

24. DEFINING THE PROBLEM
 1982 - The term AIDS (acquired immune
deficiency syndrome) is used for
the 1st time
 1983 - Institut Pasteur isolates HIV-1
CDC issues warning to blood banks about
potential problem
 1984 - Dr. Robert Gallo claims discovery
of HIV

25. THE START OF THE WAR
 1985 - FDA approves first HIV antibody
diagnostic test
- First International Conference
on AIDS
 1986 - HIV-2 isolated
 1987 - azidothymidine (AZT) approved
by FDA (1st anti- HIV drug)

26. FOUR PHASES OF HIV

27. • The period of time after you may
have been exposed to HIV, but
before a test can detect it (at least
3-6 months)
• Antibody tests cannot accurately
identify infection during this time.
Incubation
period-
Time from
exposure
to HIV to
time when
antibodies
can be
detected
through an
HIV test.

28. PRIMARY HIV INFECTION
 Asymptomatic
 Short, flu-like illness, swollen glands, fatigue,
diarrhea, weight loss, or fevers - occurs one to six
weeks after infection
 no symptoms at all
 Infected person can infect other people
 Lasts for an average of ten years
 HIV antibodies are detectable in the blood
 Acute retroviral syndrome

29. CLINICAL STAGE 1
. Asymptomatic
Short, flu-like illness, swollen glands, fatigue,
diarrhea, weight loss, or fevers - occurs one to six
weeks after infection
 no symptoms at all
 Infected person can infect other people
Lasts for an average of ten years
HIV antibodies are detectable in the blood
. Persistent generalized lymphadenopathy

30. . Moderate unexplained weight loss (<10% of presumed or
measured body weight)
. Recurrent respiratory tract infections
. Herpes zoster Angular cheilitis Recurrent oral ulceration
.
Papular pruritic eruptions Seborrhoeic dermatitis
.
.
.
. Fungal nail infections
CLINICAL STAGE 2

31. CLINICAL STAGE 3
 Unexplained severe weight loss (>10% of presumed
or measured body weight)
 Unexplained chronic diarrhoea for longer than one
month
 Unexplained persistent fever (intermittent or constant
for longer than one month)
 Persistent oral candida
 Oral hairy leukoplakia
 Pulmonary TB
 Severe presumed bacterial infections (e.g.
pneumonia, or joint infection, meningitis)
 Unexplained anaemia (<8 g/dl ),

32. CLINICAL STAGE 4
 . HIV wasting syndrome :
 The "wasting syndrome" is defined as a weight loss
of at least 10% in the presence of diarrhea or chronic
weakness and documented fever for at least 30 days
that is not attributable to a concurrent condition other
than HIV infection itself.
 Pneumocystis pneumonia
 Chronic herpes simplex infection (orolabial
genital or anorectal of more than one months
duration or visceral at any site)
 Oesophageal candidiasis (or candida of trachea,
bronchi or lungs)Oesophageal candidiasis.jpg
 Extrapulmonary TB

33. CLINICAL STAGE 4
 . Kaposi sarcoma
 . Central nervous system toxoplasmosis
(headache, fever, confusion, muscle
weakness,seizures, abnormal behavior, and coma)
 . HIV encephalopathy (decline in thinking, or "cognitive," functions such
as memory, reasoning, judgment, concentration, and problem solving.)
 . Progressive multifocal leukoencephalopathy (“Progressive” means that
it continues to get worse, often leading to serious brain damage.
“Multifocal” means that it affects several parts of the brain.
“Leukoencephalopathy” means that the disease affects the white matter
of the brain.)
 Chronic cryptosporidiosis
 Chronic isosporiasis
 Disseminated mycosis (extrapulmonary histoplasmosis,
coccidiomycosis, penicilliosis)
 Recurrent septicaemia (including non-typhoidal salmonella)
 Lymphoma (cerebral or B cell non-Hodgkin)
 Invasive cervical carcinoma
 Atypical disseminated leishmaniasis

34. HOW IS HIV SPREAD?
HIV is passed from person to
person through the exchange of
bodily fluids.
4 Main Ways:
1. Unprotected sex with people living with
HIV (vaginal, oral, or anal)
2. Infected syringe
3. Infected blood
4. Exposure to HIV before or during birth
or through breastfeeding

35. WHAT FLUIDS CAN TRANSMIT
HIV?
8

36. THROUGH IV DRUG USE
 Sharing Needles
 Without sterilization
 Increases the chances of contracting HIV

37. THROUGH SEX
 Intercourse (penile penetration into the
vagina)
 Oral
 Anal

38. MOTHER-TO-BABY
 Before Birth
 During Birth
 Postpartum
 After the birth

39. CANNOT GET HIV FROM…
 Tears
 Saliva
 Sweat
 Urine
of an HIV infected person
39

40. WHY HIV RATES NOT GOING
DOWN?
 Sex at an early age
 Little life-skills and sex education
 Little condom use
 Multiple partners
 Stigma and Discrimination
 Sex for money or sex for .....things
 Substance abuse: Ganja, cocaine, alcohol
 Men having sex with men
40

41. TESTING OPTIONS FOR HIV

42. TESTING
1. Enzyme-linked immunosorbent assay (ELISA);
2. Western blot assay; and
3. Rapid tests.

43. TREATMENT OPTIONS

44. ANTIRETROVIRAL DRUGS
 Nucleoside Reverse Transcriptase
inhibitors
 AZT (Zidovudine)
 Non-Nucleoside Transcriptase inhibitors
 Viramune (Nevirapine)
 Protease inhibitors
 Norvir (Ritonavir)

45. FOUR WAYS TO PROTECT
 Practice abstinence
 Avoid multiple partners- Monogamous
Relationship (only one sex partner)
 Protected Sex
 Don’t share needles, syringes, drug injection
equipment, or any item that may put a person
in contact with blood

46. ABSTINENCE
 It is the only 100 % effective method of
not acquiring HIV/AIDS.
 Refraining from sexual contact: oral,
anal, or vaginal.
 Refraining from intravenous drug use

47. MONOGAMOUS RELATIONSHIP
 A mutually monogamous (only one sex
partner) relationship with a person who is not
infected with HIV
 HIV testing before intercourse is necessary to
prove your partner is not infected

48. PROTECTED SEX
 Use condoms (female or male) every time
When Using A Condom Remember To:
•Make sure the package is not expired
•Make sure to check the package for damages
•Do not open the package with your teeth for risk
of tearing
•Never use the condom more than once

49. STERILE NEEDLES
 If a needle/syringe or cooker is shared, it
must be disinfected:
 Fill the syringe with undiluted bleach and wait
at least 30 seconds.
 thoroughly rinse with water
 Do this between each person’s use

50. Clinical risk assessment and
HIV pre-test counselling

51. SESSION OBJECTIVES
Integrate clinical risk assessment, HIV
prevention education and counselling into
HIV pre-test counselling
Conduct a clinical risk assessment and
facilitate the development of a plan for risk
reduction
Assess risks within the HIV test window
period
Apply basic counselling micro-skills to HIV
pre-test counselling
Assess client’s coping strategies and

52. RISK ASSESSMENT IN HIV/AIDS
A major component of test HIV pre-
counselling is the completion of risk
assessment
Assesses actual against perceived level of
risk
Requires the counsellor to ask explicit
questions about various practices of an
individual including:
—Sexual practices,
—Drug-using practices,

53. NEED FOR DETAILED CLINICAL RISK
ASSESSMENT
Promote greater awareness and concern
about STIs and HIV
Prevention counselling and education
Determination of necessary health
investigations
Feedback to the client regarding levels of
risk associated with various practices
Implications for treatment

54. REASONS FOR DETAILED ASSESSMENT
Consideration of the window period
Consideration of pregnancy and
prophylaxis
One-to-one education and clarification
Clinical decision-making—early versus
late infection management
Other medical investigations

55. REMEMBER, HOWEVER…
Privacy and confidentiality
Explanation of the four principles of HIV
transmission (ESES) when asking for
sensitive information
Educate first then question about risk
Start with the least controversial area or
the area of least concern for the client
Use open-ended questions
Be non-judgemental

56. GUIDELINES FOR CONDUCTING RISK
ASSESSMENT
Provide space to maintain privacy
Assure confidentiality
See each individual separately
Assume that the client will be
embarrassed
Ensure client understands the terms used:
—clear and simple language
—use models or drawings if needed
Use neutral language, do not use
colloquial, offensive or technical terms

57. GUIDELINES FOR CONDUCTING RISK
ASSESSMENT (CONTD)
Begin with less controversial issues to put
the client at ease
Obtain detailed information
Discuss all practices with all clients
Remember your foundation skills in
communication:
—listening
—questioning
—non-verbal skills or body language
Do not allow your personal values or
beliefs to influence the history-taking

58. AIMS OF PRE-TEST COUNSELLING
To ensure that any decision to take the test
is fully informed and voluntary
To prepare the client for any type of result,
whether negative, positive or indeterminate
To provide information on risk reduction
To provide options for PPTCT
To provide an entry point to treatment and
care

59. AIMS OF PRE-TEST COUNSELLING
(CONTD)
Develop an individualized risk-reduction
plan
Facilitate the enactment of the client’s plan
Facilitate the acquisition of coping skills
Facilitate the use of social support
systems and improved support
mechanisms (interpersonal and familiar)
Focus on issues regarding the test

60. PROCESS OF PRE-TEST COUNSELLING
 Establish a rapport with the client
 Determine the purpose of the client’s
visit to the centre (information,
counselling and testing)
 Give information on HIV
1. Discuss HIV transmission including the
4 principles—ESES
2. Correct any misconceptions—give simple,
factual information

61. PROCESS OF PRE-TEST COUNSELLING
(CONTD)
 Explain the HIV test
 Obtain informed consent
 Reaffirm the right to decline testing
 Discuss the advantages and
disadvantages of the test for the
individual
 Help clients assess their own level of
risk and draw up an individualized risk-
reduction plan

62. PROCESS OF PRE-TEST COUNSELLING
(CONTD)
Discuss the importance of disclosure of
test results to spouse or partner
Summarize the session for the client
Demonstrate the use of condoms to
ensure that the client knows how to use
them

63. PROCESS OF PRE-TEST COUNSELLING
(CONTD)
If the client decides to undergo the test:
 Inform the client about the procedure for
the test
 Length of time for results—
immediate/delayed
 Amount of and manner in which blood
(venepuncture, finger prick, etc.) will be
taken
 Remember to show the client blood

64. PROCESS OF PRE-TEST COUNSELLING
(CONTD)
Some flexibility is required, e.g. if the
client is distressed at initial
presentation, you will need to address
this first

65. SUMMARY OF PROCEDURE OF PRE-TEST
COUNSELLING
Cross-check the personal identification
number and other identification data
against the client’s details
Introduction and orientation
Collection of demographic data and filling
of the pre-test form
Basic facts about HIV/AIDS

66. HIV post-test counselling

67. SESSION OBJECTIVES
Apply knowledge of basic counselling
techniques for post-test counselling
Understand the basic requirements for
the provision of HIV results
Conduct a HIV post-test counselling
session for a negative result
Conduct a HIV post-test counselling
session for a positive result

68. RECAP ON PRE-TEST COUNSELLING
 Reason for testing
 Knowledge of HIV/AIDS
 Level of understanding of the client
 Correction on misconceptions
 Assessment of personal risk
 Information on HIV test
 Discussion of possible results
 Capacity of the client to cope
 Potential needs and support

69. Taking informed consent from the client
Making arrangements for follow-up
Recap on pre-test counselling
(contd)

70. OBJECTIVES OF POST-HIV TEST COUNSELLING
To prepare the client for the result
To help the client understand and cope
with the result
To provide further information to the client
To refer the client to other services
To counsel for risk reduction

71. KEY CONSIDERATIONS FOR HIV
POST-TEST COUNSELLING
• Cross-check the report with the client’s personal
identification digit (PID), identification marks,
age and sex
• Provide results only ‘face-to-face’
• Be aware of the manner in which you call clients
from the waiting area
• As advised by NACO, all results, whether positive
or negative, are to be provided in writing
• Provide results as per the format provided by the
the State AIDS Control Society (SACS)

72. GENERAL PRINCIPLES FOR HIV POST-TEST
COUNSELLING
Be calm when you call the client in for
their result
Be direct in giving the result
Give an explanation of their result
Allow enough time for results to sink in

73. GENERAL PRINCIPLES FOR HIV POST-TEST
COUNSELLING (CONTD)
Build up a relationship by including a
greeting/ small talk
Confirm that the client is ready to collect
the test result:
Psychosocial condition: Check what was
going on in the client’s mind before coming to
the centre and while waiting for the test
result?
Comprehension: Ask if the client would like
to summarize what was discussed last time.

74. GENERAL PRINCIPLES FOR HIV POST-TEST
COUNSELLING (CONTD)
 Coping strategies: Ask what would they do if
the result is negative? What would they do if it
is positive?
Provide the client space and time to react
Help manage emotional response

75. GUIDELINES FOR THE PROVISION OF
NEGATIVE TEST RESULTS
Check for possible exposure in the window
period including any since pre-test
counselling
Reinforce information on transmission,
safe sex/drug use
Exploration of constraints to practise of
such behaviour
Encourage spouse testing
Refer to appropriate source for help

76. COUNSELLING ISSUES RELATED TO NEGATIVE
RESULTS
Clients may worry that others will know
they have undergone the test and pass
judgements about their behaviour
Clients fear that employers may consider
them ‘risky’
Clients may understand that they need to
modify their behaviour but may worry that
their partners will not want to change
Clients who report HRB but are uninfected
may believe they are immune from HIV

77. FREQUENT HIV-NEGATIVE TESTERS
Often engage in high-risk behaviours
Have deep-seated anxiety and belief that
they are HIV-positive
Should be reassured; if they do not respond
then refer to specialist for psychological
/psychiatric / mental health follow-up

78. POSITIVE RESULT PROVISION
Provide a safe, empathetic and accepting
environment
Allow sufficient time
Avoid giving false reassurance
Clarify misinformation about the meaning
of the result and its implications
Assess coping strategies
Assess short-term arrangements for
leaving the clinic, getting home, etc.
Assess support available to the client and

79. POSITIVE RESULT PROVISION (CONTD)
Discuss partner disclosure and spouse
testing
Provide information on:
health, rest, exercise, diet, risk reduction,
home-based care, infection-control issues
Ask the client if they have any questions
Offer follow-up session
Provide written information to read later

80. MANAGING EMOTIONAL RESPONSES
Crying: Let the client cry; this allows them
to vent their feelings
Anger: Stay calm, let the client express
their feelings, acknowledge that these
feelings are normal
No response: Due to shock, denial or
helplessness
Denial: Client has difficulty in accepting
the result

81. MANAGING EMOTIONAL RESPONSES
(CONTD)
For all responses, encourage the client to
talk about their feelings.
Encourage the client to ask questions.

82. FOLLOW-UP COUNSELLING
HIV tests identify not only infected persons
but also several affected ones close to
them
Important issues need to be addressed
Counselling micro-skills and techniques to
be used.

83. ACTIVITY 3
Role-play

84. HIV tests identify not only infected persons
but also several affected ones close to
them
Important issues need to be addressed
Counselling micro-skills and techniques to
be used.

85. HIV tests identify not only infected persons
but also several affected ones close to
them
Important issues need to be addressed
Counselling micro-skills and techniques to
be used.

86. HIV tests identify not only infected persons
but also several affected ones close to
them
Important issues need to be addressed
Counselling micro-skills and techniques to
be used.