Frequently Asked Questions

WHAT IS HIV ?

HIV stands for human immunodeficiency virus. It is the virus that can lead to acquired immunodeficiency syndrome or AIDS if not treated. Unlike some other viruses, the human body can’t get rid of HIV completely, even with treatment. So once you get HIV, you have it for life.

HIV attacks the body’s immune system, specifically the CD4 cells (T cells), which help the immune system fight off infections. Untreated, HIV reduces the number of CD4 cells (T cells) in the body, making the person more likely to get other infections or opportunistic infections. Over time, HIV can destroy so many of these cells that the body can’t fight off infections and disease. These opportunistic infections take advantage of a very weak immune system and signal that the person has AIDS, the last stage of HIV infection.

No effective cure currently exists, but with proper medical care, HIV can be controlled. The medicine used to treat HIV is called antiretroviral therapy or ART. If taken the right way, every day, this medicine can dramatically prolong the lives of many people infected with HIV, keep them healthy, and greatly lower their chance of infecting others. Before the introduction of ART in the mid-1990s, people with HIV could progress to AIDS in just a few years. Today, someone diagnosed with HIV and treated before the disease is far advanced can live nearly as long as someone who does not have HIV.

WHAT ARE THE STAGES OF HIV?

When people get HIV and don’t receive treatment, they will typically progress through three stages of disease. Medicine to treat HIV, known as antiretroviral therapy (ART), helps people at all stages of the disease if taken the right way, every day. Treatment can slow or prevent progression from one stage to the next. It can also dramatically reduce the chance of transmitting HIV to someone else.

Stage 1: Acute HIV infection

Within 2 to 4 weeks after infection with HIV, people may experience a flu-like illness, which may last for a few weeks. This is the body’s natural response to infection. When people have acute HIV infection, they have a large amount of virus in their blood and are very contagious. But people with acute infection are often unaware that they’re infected because they may not feel sick right away or at all. To know whether someone has acute infection, either a fourth-generation antibody/antigen test or a nucleic acid (NAT) test is necessary. If you think you have been exposed to HIV through sex or drug use and you have flu-like symptoms, seek medical care and ask for a test to diagnose acute infection.

Stage 2: Clinical latency (HIV inactivity or dormancy)

This period is sometimes called asymptomatic HIV infection or chronic HIV infection. During this phase, HIV is still active but reproduces at very low levels. People may not have any symptoms or get sick during this time. For people who aren’t taking medicine to treat HIV, this period can last a decade or longer, but some may progress through this phase faster. People who are taking medicine to treat HIV (ART) the right way, every day may be in this stage for several decades. It’s important to remember that people can still transmit HIV to others during this phase, although people who are on ART and stay virally suppressed (having a very low level of virus in their blood) are much less likely to transmit HIV than those who are not virally suppressed. At the end of this phase, a person’s viral load starts to go up and the CD4 cell count begins to go down. As this happens, the person may begin to have symptoms as the virus levels increase in the body, and the person moves into Stage 3.

Stage 3: Acquired immunodeficiency syndrome (AIDS)

AIDS is the most severe phase of HIV infection. People with AIDS have such badly damaged immune systems that they get an increasing number of severe illnesses, called opportunistic illnesses.

Without treatment, people with AIDS typically survive about 3 years. Common symptoms of AIDS include chills, fever, sweats, swollen lymph glands, weakness, and weight loss. People are diagnosed with AIDS when their CD4 cell count drops below 200 cells/mm or if they develop certain opportunistic illnesses. People with AIDS can have a high viral load and be very infectious.

For more information go to: https://www.cdc.gov/hiv/basics/whatishiv.html

WHAT IS THE HISTORY OF THE HIV/AIDS EPIDEMIC?

The world first became aware of AIDS in the early 1980s. Growing numbers of gay men in New York and California were developing rare types of pneumonia and cancer, and a wasting disease was spreading in Uganda. Doctors reported AIDS symptoms under different names, including “gay-related immune deficiency” and “slim,” but by 1985, they reported them all over the world.

From the first days of the AIDS epidemic, the history of HIV has been one of stigma and activism as well as science. The earliest people with AIDS and the health officials advising the public didn’t know what the disease was or how it was transmitted. This uncertainty, and the speed with which the disease spread, led to an “epidemic of fear” and to discrimination against those with HIV and against groups perceived, correctly or not, to be more at risk.

As individuals with AIDS were evicted from housing, barred from attending schools and continuing to die with limited treatment, activists fought for money for AIDS research and an end to discrimination.

We now know that HIV existed long before it was identified as the cause of AIDS in 1984. Blood analysis reveals instances of the virus as early as the 1940s. While researchers aren’t sure exactly when and how HIV developed, the most likely theories posit that HIV-1 – the most common strain of the virus – was transmitted to humans from chimpanzees sometime in the early to mid 20th century.

In 1985, the first blood test for HIV was approved. That same year, the first needle exchange program was started in Amsterdam. In 1986, AZT, a failed cancer drug, was tested as an HIV treatment for the first time. The trial was so successful that researchers stopped the study, not wanting to withhold medication from the placebo group.

AZT was the only AIDS treatment through much of the 90s. In 1996, doctors started to prescribe combinations of medications, including new protease inhibitors, to control HIV. These “cocktails” were a treatment breakthrough, offering much brighter prospects for people living with HIV and AIDS. But the breakthrough only helped those with access to treatment.

Since the development of combination antiretroviral therapy, HIV/AIDS professionals have focused much of their efforts on expanding access to the medications in that treatment. The expansion has largely required funding: more money for national programs to provide medicine to those who couldn’t otherwise afford it and the formation, in 2001, of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

As researchers continue to develop better treatments and more efficient tests, medical professionals, politicians and activists work towards universal access to the condoms, testing and treatment that saves lives.

In 2006, the number of AIDS-related deaths and new HIV infections fell for the first time since the epidemic began 25 years before. According to the most recent estimates, about 33.3 million people are living with HIV today.

HOW IS HIV PASSED FROM ONE PERSON TO ANOTHER?

You can get or transmit HIV only through specific activities. Most commonly, people get or transmit HIV through sexual behaviors and needle or syringe use.

Only certain body fluids—blood, semen (cum), pre-seminal fluid (pre-cum), rectal fluids, vaginal fluids, and breast milk—from a person who has HIV can transmit HIV. These fluids must come in contact with a mucous membrane or damaged tissue or be directly injected into the bloodstream (from a needle or syringe) for transmission to occur. Mucous membranes are found inside the rectum, vagina, penis, and mouth.

HIV is spread mainly by

- - Having anal or vaginal sex with someone who has HIV without using a condom or taking medicines to prevent or treat HIV.
    - Anal sex is the highest-risk sexual behavior. For the HIV-negative partner, receptive anal sex (bottoming) is riskier than insertive anal sex (topping).
  - Vaginal sex is the second-highest-risk sexual behavior.
    - Sharing needles or syringes, rinse water, or other equipment (works) used to prepare drugs for injection with someone who has HIV. HIV can live in a used needle up to 42 days depending on temperature and other factors.

Less commonly, HIV may be spread

- - From mother to child during pregnancy, birth, or breastfeeding. Although the risk can be high if a mother is living with HIV and not taking medicine, recommendations to test all pregnant women for HIV and start HIV treatment immediately have lowered the number of babies who are born with HIV.
  - By being stuck with an HIV-contaminated needle or other sharp object. This is a risk mainly for health care workers.

In extremely rare cases, HIV has been transmitted by

- - Oral sex—putting the mouth on the penis (fellatio), vagina (cunnilingus), or anus (rimming). In general, there’s little to no risk of getting HIV from oral sex. But transmission of HIV, though extremely rare, is theoretically possible if an HIV-positive man ejaculates in his partner’s mouth during oral sex.
  - Receiving blood transfusions, blood products, or organ/tissue transplants that are contaminated with HIV. This was more common in the early years of HIV, but now the risk is extremely small because of rigorous testing of the US blood supply and donated organs and tissues.
  - Eating food that has been pre-chewed by an HIV-infected person. The contamination occurs when infected blood from a caregiver’s mouth mixes with food while chewing. The only known cases are among infants.
  - Being bitten by a person with HIV. Each of the very small number of documented cases has involved severe trauma with extensive tissue damage and the presence of blood. There is no risk of transmission if the skin is not broken.
  - Contact between broken skin, wounds, or mucous membranes and HIV-infected blood or blood-contaminated body fluids.
  - Deep, open-mouth kissing if both partners have sores or bleeding gums and blood from the HIV-positive partner gets into the bloodstream of the HIV-negative partner. HIV is not spread through saliva.

HOW WELL DOES HIV SURVIVE OUTSIDE OF THE BODY?

HIV does not survive long outside the human body (such as on surfaces), and it cannot reproduce outside a human host. It is not spread by

- - Mosquitoes, ticks, or other insects.
  - Saliva, tears, or sweat that is not mixed with the blood of an HIV-positive person.
  - Hugging, shaking hands, sharing toilets, sharing dishes, or closed-mouth or “social” kissing with someone who is HIV-positive.
  - Other sexual activities that don’t involve the exchange of body fluids (for example, touching).

For more information go to: https://www.cdc.gov/hiv/basics/whatishiv.html

CAN I GET HIV FROM ANAL SEX?

Yes. In fact, anal sex is the riskiest type of sex for getting or transmitting HIV.

HIV can be found in certain body fluids—blood, semen (cum), pre-seminal fluid (pre-cum), or rectal fluids—of a person who has HIV. Although receptive anal sex (bottoming) is much riskier for getting HIV than insertive anal sex (topping), it’s possible for either partner—the top or the bottom—to get HIV. The bottom’s risk is very high because the lining of the rectum is thin and may allow HIV to enter the body during anal sex. The top is also at risk because HIV can enter the body through the opening at the tip of the penis (or urethra); the foreskin if the penis isn’t circumcised; or small cuts, scratches, or open sores anywhere on the penis.

CAN I GET HIV FROM VAGINAL SEX?

Yes. Vaginal sex is the sexual behavior with the second-highest risk for getting or transmitting HIV.

It is possible for either partner to get HIV from vaginal sex.

When a woman has vaginal sex with a partner who’s HIV-positive, HIV can enter her body through the mucous membranes that line the vagina and cervix. Most women who get HIV get it from vaginal sex.

Men can also get HIV from having vaginal sex with a woman who’s HIV-positive. This is because vaginal fluid and blood can carry HIV. Men get HIV through the opening at the tip of the penis (or urethra); the foreskin if they’re not circumcised; or small cuts, scratches, or open sores anywhere on the penis.

CAN I GET HIV FROM ORAL SEX?

The chance that an HIV-negative person will get HIV from oral sex with an HIV-positive partner is extremely low.

Oral sex involves putting the mouth on the penis (fellatio), vagina (cunnilingus), or anus (anilingus). In general, there’s little to no risk of getting or transmitting HIV through oral sex.

Factors that may increase the risk of transmitting HIV through oral sex are ejaculation in the mouth with oral ulcers, bleeding gums, genital sores, and the presence of other sexually transmitted diseases (STIs), which may or may not be visible.

You can get other STIs from oral sex. And, if you get feces in your mouth during anilingus, you can get hepatitis A and B, parasites like Giardia, and bacteria like Shigella, Salmonella, Campylobacter, and E. coli.

IS THERE A CONNECTION BETWEEN HIV AND OTHER SEXUALLY TRANSMITTED INFECTIONS?

Yes. Having another sexually transmitted infections (STIs) can increase the risk of getting or transmitting HIV.

If you have another STI, you’re more likely to get or transmit HIV to others. Some of the most common STIs include gonorrhea, chlamydia, syphilis, trichomoniasis, human papillomavirus (HPV), genital herpes, and hepatitis. The only way to know for sure if you have an STI is to get tested. If you’re sexually active, you and your partners should get tested for STIs (including HIV if you’re HIV-negative) regularly, even if you don’t have symptoms.

If you are HIV-negative but have an STI, you are about 3 times as likely to get HIV if you have unprotected sex with someone who has HIV. There are two ways that having an STI can increase the likelihood of getting HIV. If the STI causes irritation of the skin (for example, from syphilis, herpes, or human papillomavirus), breaks or sores may make it easier for HIV to enter the body during sexual contact. Even STIs that cause no breaks or open sores (for example, chlamydia, gonorrhea, trichomoniasis) can increase your risk by causing inflammation that increases the number of cells that can serve as targets for HIV.

If you are HIV-positive and also infected with another STI, you are about 3 times as likely as other HIV-infected people to spread HIV through sexual contact. This appears to happen because there is an increased concentration of HIV in the semen and genital fluids of HIV-positive people who also are infected with another STI.

For more information go to: https://www.cdc.gov/hiv/basics/whatishiv.html

DOES MY HIV-POSITIVE PARTNER’S VIRAL LOAD AFFECT MY RISK OF GETTING HIV?

Yes, as an HIV-positive person’s viral load goes down, the chance of transmitting HIV goes down.

Viral load is the amount of HIV in the blood of someone who is HIV-positive. When the viral load is very low, it is called viral suppression. Undetectable viral load is when the amount of HIV in the blood is so low that it can’t be measured.

In general, the higher someone’s viral load, the more likely that person is to transmit HIV. People who have HIV but are in care, taking HIV medicines, and have a very low or undetectable viral load are much less likely to transmit HIV than people who have HIV and do not have a low viral load.

However, a person with HIV can still potentially transmit HIV to a partner even if they have an undetectable viral load, because

- - HIV may still be found in genital fluids (semen, vaginal fluids). The viral load test only measures virus in the blood.
  - A person’s viral load may go up between tests. When this happens, they may be more likely to transmit HIV to partners.
  - Sexually transmitted diseases increase viral load in genital fluids.

If you’re HIV-positive, getting into care and taking HIV medicines (called antiretroviral therapy or ART) the right way, every day will give you the greatest chance to get and stay virally suppressed, live a longer, healthier life, and reduce the chance of transmitting HIV to your partners.

If you’re HIV-negative and have an HIV-positive partner, encourage your partner to get into care and take HIV treatment medicines.

Taking other actions, like using a condom the right way every time you have sex or taking daily medicine to prevent HIV (called pre-exposure prophylaxis or PrEP) if you’re HIV-negative, can lower your chances of transmitting or getting HIV even more.

CAN I GET HIV FROM INJECTING DRUGS?

Yes. Your risk for getting HIV is very high if you use needles or works (such as cookers, cotton, or water) after someone with HIV has used them.

People who inject drugs, hormones, steroids, or silicone can get HIV by sharing needles or syringes and other injection equipment. The needles and equipment may have someone else’s blood in them, and blood can transmit HIV. Likewise, you’re at risk for getting hepatitis B and C if you share needles and works because these infections are also transmitted through blood.

Another reason people who inject drugs can get HIV (and other sexually transmitted diseases) is that when people are high, they’re more likely to have risky sex.

Stopping injection and other drug use can lower your chances of getting HIV a lot. You may need help to stop or cut down using drugs, but many resources are available.

If you keep injecting drugs, you can lower your risk for getting HIV by using only new, sterile needles and works each time you inject. Never share needles or works.

CAN I GET HIV FROM USING OTHER KINDS OF DRUGS?

When you’re drunk or high, you’re more likely to make decisions that put you at risk for HIV, such as having sex without a condom.

Drinking alcohol, particularly binge drinking, and using “club drugs” like Ecstasy, ketamine, GHB, and poppers can alter your judgment, lower your inhibitions, and impair your decisions about sex or other drug use. You may be more likely to have unplanned and unprotected sex, have a harder time using a condom the right way every time you have sex, have more sexual partners, or use other drugs, including injection drugs or meth. Those behaviours can increase your risk of exposure to HIV. If you have HIV, they can also increase your risk of spreading HIV to others. Being drunk or high affects your ability to make safe choices.

If you’re going to a party or another place where you know you’ll be drinking or using drugs, you can bring a condom so that you can reduce your risk if you have vaginal or anal sex.

Therapy, medicines, and other methods are available to help you stop or cut down on drinking or using drugs. Talk with a counselor, doctor, or other health care provider about options that might be right for you.

IF I ALREADY HAVE HIV, CAN I GET ANOTHER KIND OF HIV?

Yes. This is called HIV superinfection.

HIV superinfection is when a person with HIV gets infected with another strain of the virus. The new strain of HIV can replace the original strain or remain along with the original strain.

The effects of superinfection differ from person to person. Superinfection may cause some people to get sicker faster because they become infected with a new strain of the virus that is resistant to the medicine (antiretroviral therapy or ART) they’re taking to treat their original infection.

Research suggests that a hard-to-treat superinfection is rare. Taking medicine to treat HIV (ART) may reduce someone’s chance of getting a superinfection.

ARE HEALTHCARE WORKERS AT RISK OF GETTING HIV ON THE JOB?

The risk of health care workers being exposed to HIV on the job (occupational exposure) is very low, especially if they use protective practices and personal protective equipment to prevent HIV and other blood-borne infections. For health care workers on the job, the main risk of HIV transmission is from being stuck with an HIV-contaminated needle or other sharp objects. However, even this risk is small. Scientists estimate that the risk of HIV infection from being stuck with a needle used on an HIV-infected person is less than 1%.

CAN I GET HIV FROM CASUAL CONTACT (“SOCIAL KISSING”, SHAKING HANDS, HUGGING, USING A TOILET, DRINKING FROM THE SAME GLASS, OR SNEEZING AND COUGHING ON AN INFECTED PERSON)?

No. HIV isn’t transmitted

- - By hugging, shaking hands, sharing toilets, sharing dishes, or closed-mouth or “social” kissing with someone who is HIV-positive.
  - Through saliva, tears, or sweat that is not mixed with the blood of an HIV-positive person.
  - By mosquitoes, ticks or other blood-sucking insects.
  - Through the air.

Only certain body fluids—blood, semen (cum), pre-seminal fluid (pre-cum), rectal fluids, vaginal fluids, and breast milk—from an HIV-infected person can transmit HIV. Most commonly, people get or transmit HIV through sexual behaviors and needle or syringe use. Babies can also get HIV from an HIV-positive mother during pregnancy, birth, or breastfeeding.

For more information go to: https://www.cdc.gov/hiv/basics/whatishiv.html

CAN I GET HIV FROM TATTOO OR BODY PIERCING?

It is possible to get HIV from a reused or not properly sterilized tattoo or piercing needle or other equipment, or from contaminated ink.

It’s possible to get HIV from tattooing or body piercing if the equipment used for these procedures has someone else’s blood in it or if the ink is shared. The risk of getting HIV this way is very low, but the risk increases when the person doing the procedure is unlicensed, because of the potential for unsanitary practices such as sharing needles or ink. If you get a tattoo or a body piercing, be sure that the person doing the procedure is properly licensed and that they use only new or sterilized needles, ink, and other supplies.

CAN I GET HIV FROM BEING SPIT ON OR SCRATCHED BY AN HIV-INFECTED PERSON?

No. HIV isn’t spread through saliva, and there is no risk of transmission from scratching because no body fluids are transferred between people.

CAN I GET HIV FROM MOSQUITOES?

No. HIV is not transmitted by mosquitoes, ticks, or any other insects.

CAN I GET HIV FROM FOOD?

You can’t get HIV from consuming food handled by an HIV-infected person. Even if the food contained small amounts of HIV-infected blood or semen, exposure to the air, heat from cooking, and stomach acid would destroy the virus.

Though it is very rare, HIV can be spread by eating food that has been pre-chewed by an HIV-infected person. The contamination occurs when infected blood from a caregiver’s mouth mixes with food while chewing. The only known cases are among infants.

ARE LESBIANS OR WOMEN WHO HAVE SEX WITH WOMEN AT RISK FOR HIV?

Case reports of female-to-female transmission of HIV are rare. The well-documented risk of female-to-male transmission shows that vaginal fluids and menstrual blood may contain the virus and that exposure to these fluids through mucous membranes (in the vagina or mouth) could potentially lead to HIV infection.

IS THE RISK OF HIV DIFFERENT FOR DIFFERENT PEOPLE?

Some groups of people are more likely to get HIV than others because of many factors, including the status of their sex partners, their risk behaviours, and where they live.

When you live in a community where many people have HIV infection, the chances of having sex or sharing needles or other injection equipment with someone who has HIV are higher. Within any community, the prevalence of HIV can vary among different populations.

Gay and bisexual men have the largest number of new diagnoses in some countries. Blacks are in a minority group that is disproportionately affected by HIV compared to other racial and ethnic groups. Also, transgender women who have sex with men are among the groups at highest risk for HIV infection, and injection drug users remain at significant risk for getting HIV.

Risky behaviours, like having anal or vaginal sex without using a condom or taking medicines to prevent or treat HIV, and sharing needles or syringes play a big role in HIV transmission. Anal sex is the highest-risk sexual behaviour. If you don’t have HIV, being a receptive partner (or bottom) for anal sex is the highest-risk sexual activity for getting HIV. If you do have HIV, being the insertive partner (or top) for anal sex is the highest-risk sexual activity for transmitting HIV.

But there are more tools available today to prevent HIV than ever before. Choosing less risky sexual behaviours, taking medicines to prevent and treat HIV, and using condoms with lubricants are all highly effective ways to reduce the risk of getting or transmitting HIV.

For more information go to: https://www.cdc.gov/hiv/basics/whatishiv.html

WHAT ARE THE HIV MYTHS VS. HIV FACTS?

- HIV is a death sentence
  - In the 1970s and 80s, people with HIV had extremely limited treatment options, and often died quickly after they first got sick. Since then, advances in medical treatment have made it possible to live long and well with HIV. Research into still better treatment is ongoing.
- HIV only affects gay men or drug users

- - HIV is an equal opportunity virus. Newborn babies, women, seniors, teens and people of all races or nationalities can have HIV. The prevalence of the virus in different groups varies (as it does for other diseases), but it can affect anyone. Of HIV positive people worldwide, slightly more than half are women. Find out how HIV is transmitted.
- HIV can be cured

Beliefs that HIV can be cured – through specific sex acts or by new medicines – are unfounded. There is no cure for HIV. Antiretroviral therapy can reduce the presence of the virus in the body, but not eliminate it. Learn more about current treatments.

HIV can be spread through casual contact, through kissing or by mosquitoes

Contact with the blood, semen, vaginal fluid or breast milk of someone with HIV is necessary to get the virus. HIV is not airborne and cannot be caught by touching skin, sweat or saliva. This means that holding hands, sharing drinking glasses and other casual contact can’t spread HIV. Open-mouthed kissing is likewise extremely low risk – open sores or blood would need to be present for transmission. Mosquitos do not inject other people’s blood when they bite, and so can’t spread HIV. Find out how HIV is transmitted.

“HIV can’t be spread if you’re taking antiretroviral medicine, or if you use birth control.”-

Safer sex and, if you inject drugs, clean works are necessary to keep from spreading HIV. Antiretroviral therapy will control HIV symptoms and progression, but it won’t prevent infection by itself. Birth control methods like the pill, sponges, diaphragms and spermicides are designed to prevent pregnancy, not infection. None of these methods protect against HIV or other STIs.

WHAT IS AN HIV REGIMEN?
- An HIV regimen is a combination of HIV medicines used to treat HIV infection. HIV treatment (also called antiretroviral therapy or ART) begins with choosing an HIV regimen. People on ART take the HIV medicines in their HIV regimens every day. ART helps people with HIV live longer, healthier lives and reduces the risk of HIV transmission.

WHAT ARE THE HIV DRUG CLASSES?

HIV medicines are grouped into six drug classes according to how they fight HIV. The six drug classes are:

- - Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
  - Nucleoside reverse transcriptase inhibitors (NRTIs)
  - Protease inhibitors (PIs)
  - Fusion inhibitors
  - CCR5 antagonists (CCR5s) (also called entry inhibitors)
  - Integrase strand transfer inhibitors (INSTIs)

WHAT FACTORS ARE CONSIDERED WHEN CHOOSING AN HIV REGIMEN?

The choice of HIV medicines to include in an HIV regimen depends on a person’s individual needs. When choosing an HIV regimen, people with HIV and their health care providers consider the following factors:

- - - Other diseases or conditions that the person with HIV may have
    - Possible side effects of HIV medicines
    - Potential interactions between HIV medicines or between HIV medicines and other medicines the person with HIV is taking
    - Results of drug-resistance testing (and other tests). Drug-resistance testing identifies which, if any, HIV medicines won’t be effective against a person’s HIV.
    - Convenience of the regimen. For example, a regimen that includes two or more HIV medicines combined in one pill is convenient to follow.
    - Any issues that can make it difficult to follow an HIV regimen. For example, a busy schedule can make it hard to take HIV medicines consistently.
    - Cost of HIV medicines

Some guidelines on the use of HIV medicines in adults and adolescents recommend several regimens for people starting ART. The best regimen for a person depends on their individual needs.

HOW LONG DOES IT TAKE FOR ART TO WORK?

Viral load is the amount of HIV in a person’s blood. A main goal of ART is to reduce a person’s viral load to an undetectable level. An undetectable viral load means that the level of HIV in the blood is too low to be detected by a viral load test.

Once a person starts taking HIV medicines, it’s possible to have an undetectable viral load within 3 to 6 months. Having an undetectable viral load doesn’t mean a person’s HIV is cured. But even though there is still some HIV in the person’s body, an undetectable viral load shows that ART is working effectively. Effective ART helps people with HIV live longer, healthier lives and reduces the risk of HIV transmission.

Source: https://aidsinfo.nih.gov/education-materials/fact-sheets/21/53/what-to-start–choosing-an-hiv-regimen

What is HIV drug resistance (HIV-DR)?

Once a person becomes infected with HIV, the virus begins to multiply (make copies of itself) in the body. As HIV multiplies, it sometimes mutates (changes form) and produces variations of itself. Variations of HIV that develop while a person is taking HIV medicines can lead to drug-resistant strains of HIV.

HIV medicines that previously controlled the person’s HIV are not effective against the new, drug-resistant HIV. In other words, the HIV medicines can’t prevent the drug-resistant HIV from multiplying. Drug resistance can cause HIV treatment to fail.

Drug-resistant HIV can spread from person to person. People initially infected with drug-resistant HIV have drug resistance to one or more HIV medicines even before they start taking HIV medicines.

How does poor medication adherence increase the risk of drug resistance?

Medication adherence means taking HIV medicines every day and exactly as prescribed. HIV medicines prevent HIV from multiplying. Skipping HIV medicines allows HIV to multiply, which increases the risk that the virus will mutate and produce drug-resistant HIV.

As a result of drug resistance, one or more HIV medicines in a person’s HIV regimen may no longer be effective.

What is cross resistance?

Cross resistance is when resistance to one HIV medicine causes resistance to other medicines in the same HIV drug class. (HIV medicines are grouped into drug classes according to how they fight HIV.) As a result of cross resistance, a person’s HIV may be resistant even to HIV medicines that the person has never taken. Cross resistance limits the number of HIV medicines available to include in an HIV regimen.

What is drug-resistance testing?

Drug-resistance testing is done to identify which, if any, HIV medicines won’t be effective against a person’s strain of HIV. Drug-resistance testing is done using a sample of blood.

Drug-resistance testing is done when a person first begins receiving care for HIV infection. Resistance testing should be done whether the person decides to start taking HIV medicines immediately or to delay treatment. If treatment is delayed, resistance testing should be repeated when HIV medicines are started.

Drug-resistance testing done before a person starts HIV medicines for the first time can show whether the person was initially infected with a drug-resistant strain of HIV. Drug-resistance testing results are used to decide which HIV medicines to include in a person’s first HIV regimen.

After treatment is started, drug-resistance testing is repeated if viral load testing indicates that a person’s HIV regimen isn’t controlling the virus. (In other words, results of viral load tests may indicate consistent high viral load readings, despite the client taking his/her medication which may be a sign of HIV-DR). If drug-resistance testing shows that the HIV regimen isn’t effective because of drug resistance, the test results can be used to select a new HIV regimen.

Drug-resistance testing is also recommended for all HIV-infected pregnant women before starting HIV medicines and also in some pregnant women already taking HIV medicines. Pregnant women will work with their health care providers to decide if drug-resistance testing is needed.

How can a person taking HIV medicines reduce the risk of drug resistance?

Adherence to an effective HIV treatment regimen reduces the risk of drug resistance.

Here are some tips on medication adherence for people living with HIV:

- - Once you decide to start treatment, work closely with your health care provider to choose an HIV regimen that suits your needs. A regimen that meets your needs will make adherence easier. Tell your health care provider about any issues that can make adherence difficult. For example, tell your health care provider if you have a busy schedule that makes it hard to take medicines on time or lack health insurance to cover the cost of HIV medicines. Your health care provider can recommend resources to help you address any issues before you start taking HIV medicines.
  - When you start treatment, closely follow your HIV regimen. Take your HIV medicines every day and exactly as prescribed. Use medication aids such as a 7-day pill box or pill diary to stay on track. Set daily pill reminders.
  - Keep your medical appointments so that your health care provider can monitor your HIV treatment. Appointments are a good time to ask questions and ask for help to manage problems that make it hard to follow an HIV regimen.

Key Points

- - As HIV multiplies in the body, the virus sometimes mutates (changes form) and produces variations of itself. Variations of HIV that develop while a person is taking HIV medicines can lead to drug-resistant strains of HIV.
  - HIV medicines that previously controlled a person’s HIV are not effective against new, drug-resistant HIV. In other words, the HIV medicines can’t prevent the drug-resistant HIV from multiplying. Drug resistance can cause HIV treatment to fail.
  - A person can initially be infected with drug-resistant HIV or develop drug-resistant HIV after starting HIV medicines.
  - Drug-resistance testing identifies which, if any, HIV medicines won’t be effective against a person’s HIV. Drug-resistance testing results help determine which HIV medicines to include in an HIV treatment regimen.
  - Medication adherence—taking HIV medicines every day and exactly as prescribed—reduces the risk of drug resistance.
  - However, there may be instances where one or more HIV medicines in a person’s HIV regimen, may no longer be effective. Therefore, it is important to monitor consistently client’ dockets and viral load readings to observe signs of HIV-DR and discuss with the sessional doctors any suspected cases.

Source: https://aidsinfo.nih.gov/education-materials/fact-sheets/21/56/drug-resistance

WHAT IS TREATMENT FAILURE?

TREATMENT FAILURE IS DEFINED IN DIFFERENT WAYS.

Sometimes this relates to the different treatments and monitoring tests that are available in a country.

- - - Virological failure

If viral load never reaches undetectable, or rebounds and becomes detectable, this is called virological failure.

This is when the drugs are not working to suppress the virus.

With virological failure, you will not necessarily feel more ill in the short term.

- - - Clinical failure

This is when you get symptoms (ie other illnesses). It means that the drugs are not stopping you from getting ill. This is called clinical failure.

How to manage treatment failure depends on the choice of alternative drugs that are available in any country.

MANAGING TREATMENT FAILURE

Before making any decisions about changing treatment it is important to find out why treatment failed.

- - - It may be that you have not been taking treatment on time, or in the way prescribed. Or that you have stopped taking treatment altogether.
    - It may be because of drug resistance[1]. Or because the treatment was not potent enough. Or because the drugs were being poorly absorbed.

Management of treatment failure is different depending on which country you live in. This is related to whether viral load tests are easily available..

Virological failure is used to decide when to change ART in high-income countries. This is when there is access to viral load tests and/or there are several options

[1] Some drugs are very vulnerable to resistance – nevirapine, efavirenz, 3TC, FTC, raltegravir and elvitegravir.

If resistance tests are not available in Jamaica, resistance can sometimes be estimated depending on the client’s viral load and treatment history.

If the client has a detectable viral load on a combination that includes one of these drugs, or his/her viral load rebounds to levels above 2,000 copies/mL, you would assume that the client has developed resistance to one or more of these drugs in his/her combination

Source: http://i-base.info/ttfa/section-3/19-treatment-failure/

WHAT IS TREAT ALL ?

According to the World Health Organisation (WHO), anyone infected with HIV should begin antiretroviral treatment as soon after diagnosis as possible. With its Treat All recommendation, WHO removes all limitations on eligibility for antiretroviral therapy (ART[1]) among people living with HIV; all populations and age groups are now eligible for treatment. ART should start at any CD4 cell count[2].” People with advanced immune suppression or clinical symptoms of AIDS should be prioritised for treatment.

Prior to this new Treat All paradigm, it was people with a CD4 count of less than or equal to 500 cells/mm3 or 350 cells/mm3 in some countries, who received ART.

The expanded use of antiretroviral treatment is supported by recent findings from clinical trials confirming that early use of ART keeps people living with HIV alive, healthier and reduces the risk of transmitting the virus to partners. Expanding access to treatment is at the heart of a new set of targets for 2020 with the aim to end the AIDS epidemic by 2030. These targets include 90% of people living with HIV being aware of their HIV infection, 90% of those receiving antiretroviral treatment, and 90% of people on ART having no detectable virus in their blood.

Notwithstanding, Jamaica has recognised the importance of Treat All and demonstrate its commitment to adhere to the WHO Treatment Guidelines to test and treat everyone. Starting January 2017, the country including JASL, will commence the implementation of Treat All also referred to as Test and Treat or Test and START.

Sensitisation on Treat All is the first step in this process for JASL’s staff while treatment readiness is the organisation’s policy on Treat All for all PLHIV clients not yet on ART. Early ART initiation does not necessarily mean putting people on medication same-day following HIV diagnosis. Individuals who are found reactive to HIV need to understand the implications of test results and preparedness to commence lifelong treatment. Hence why treatment readiness has to come before ART. It has to begin at the post-counselling stage of HIV Testing and Counselling (HTC aka VCT). Before people start ART, it is important to have a detailed discussion with them about their willingness and readiness to initiate ART, the antiretroviral drug (ARV) regimen, dosage and scheduling, the likely benefits and possible adverse effects, and the required follow-up and monitoring visits. Treatment should be started based on a person’s informed decision to initiate ART. Also, retesting of people living with HIV (newly diagnosed and people in care) before initiating ART is recommended to ensure a correct diagnosis of HIV infection.

JASL’s treatment literacy programme should also be strengthened and carried out with all clients living with HIV, including providing information on the benefits of early treatment, the lifelong commitment required, the risks of delaying treatment and available adherence support.

Viral load (VL)[3] monitoring is also critical for retention in care and long term treatment effectiveness; hence VL testing resources should be strengthened although the unavailability or poor turnaround time of VL testing should not be a barrier to ART. All treatment staff including adherence counsellors, as well as peer navigators, should be trained to interpret VL results, recognise regimen failure and provide appropriate clinical interventions based on this.

For more information on Treat All, please see WHO Guidelines at link below.

http://www.aidsmap.com/WHO-guidelines-recommend-universal-antiretroviral-treatment-PrEP-for-those-at-substantial-risk/page/3002998/

WHAT IS PrEP?

Oral pre-exposure prophylaxis (PrEP) is the use of antiretroviral (ARV) drugs for people who do not have HIV infection in order to prevent the acquisition of HIV.

What does WHO recommend?

The World Health Organisation (WHO) now recommends that people at substantial risk of HIV should be offered PrEP containing tenovir disproxil fumarate (TDF). In 2014, the WHO recommended offering PrEP to men who have sex with men (MSM) and other key populations at substantial risk of HIV infection.

PrEP (and education on PreP) should be not be offered to key populations in isolation but as an additional prevention choice in a comprehensive package of services that also includes, HIV testing, counseling, consistent condom usage, lubricants and anti-retroviral (ARV) treatment for partners with HIV infection.

Key evidence

High-quality evidence strongly supports use of PrEP by persons at substantial risk of acquiring HIV

- Twelve trials of effectiveness of oral PrEP have been conducted among MSM, transgender women, serodiscordant couples (one partner being HIV+ and the other is HIV-) and other groups.

- PrEP works, when taken correctly. The level of protection did not differ by age, gender, ARV regimen, or mode of acquiring HIV (rectal or penile/vaginal). The level of protection was strongly correlated with adherence

- Risk of drug resistance is low, occurring in approximately 1 in 1000 PrEP users in clinical trials. Drug resistance occurred almost exclusively among people who already had an acute undetected HIV infection when they started PrEP. Therefore, testing for HIV before people start PrEP is essential to avoid drug resistance. Moreover, offering PrEP reduces the number of new HIV infections, each of which would require lifelong therapy with substantial ongoing risk of drug resistance. This PrEP is expected to decrease the public health burden of HIV drug resistance.

Will PrEP be cost-effective?

Drug costs for PrEP are lower than treatment drug costs both per dose and for the duration of use, which is as needed for PrEP but lifelong for treatment.

Difference between PrEP and HIV treatment

Effective PrEP use is different from adherence to HIV treatment in that PrEP can be started and stopped as a person moves through “seasons of risk”, whereas treatment is lifelong.

The WHO indicates that the decision to use PrEP should always be made by the individual.

For further information on PrEP, please find attached a policy brief from the WHO.

WHAT IS PEP ?

People can be accidentally exposed to HIV through healthcare work or due to exposures outside the healthcare setting, for example, through unprotected sex or sexual assault/rape.
Antiretrovirals (ARVs) have been used to prevent infection in cases of accidental exposures for many years. This intervention is called post-exposure prophylaxis (PEP) and involves taking a 28-day course of ARVs.
PEP should be offered, and initiated as early as possible, for all individuals with an exposure that has the potential for HIV transmission, and ideally within 72 hours. (Although PEP is ideally provided within 72 hours of exposure, people may not be able to access services within this time. Providers should consider the range of other essential interventions and referrals that should be offered to clients presenting after the 72 hours).
If started soon after exposure, PEP can reduce the risk of HIV infection by over 80%. Adherence to a full 28-day course of ARVs is critical to the effectiveness of the intervention.
Recent evidence shows PEP uptake has been insufficient: only 57% of the people who initiated PEP have completed the full course and rates were even lower at 40% for victims of sexual assault. In some countries, the poor uptake for PEP is due to education on it being next to non-existent.

The World Health Organisation (WHO) indicates that:

- - Assessment for eligibility for PEP should be based on the HIV status of the source whenever possible and may include consideration of background prevalence and local epidemiological patterns. (In some settings with high background of HIV prevalence or where the source is known to be at high risk for HIV infection, all exposure may be considered for post-exposure prophylaxis without risk assessment).
  - Exposures that may warrant PEP include:
    - Sexual exposure and splashes to the eye, nose or oral cavity; and
    - the following bodily fluids may pose a risk of HIV infection: blood, blood-stained saliva, breast-milk, genital secretions and cerebrospinal, amniotic and rectal fluids. (These fluids carry a high risk of HIV infection, but this list is not exhaustive and all cases should be assessed clinically and decisions made by the health-care workers as to whether exposure constitutes a significant risk.
  - Exposures that do not require PEP include:
    - when the exposed individual is already HIV positive;
    - when the source is established to be HIV negative; and
    - exposure to bodily fluids that do not pose a significant risk: tears, non-blood-stained saliva, urine and sweat.

What is the difference to between PrEP and PEP?

Just to be clear, the difference between PrEP and PEP is:

- - PrEP: Short for “pre-exposure prophylaxis,” PrEP is an HIV prevention strategy in which HIV-negative people take an oral pill once a day before coming into contact with HIV to reduce their risk of HIV infection. PrEP must be taken for at least 7 days to reach optimal levels of protection against HIV.
  - PEP: Short for “post-exposure prophylaxis,” PEP is an HIV prevention strategy in which HIV-negative people take anti-HIV medications after coming into contact with HIV to reduce their risk of HIV infection. PEP must be started within 72 hours after HIV exposure.

For more information on PEP, please find attached the Guidelines and a Fact Sheet from the World Health Organisation (WHO).

WHAT IS A PAP SMEAR?

A Pap smear (also called a Pap test) is a screening procedure for cervical cancer. It tests for the presence of precancerous or cancerous cells on the cervix, the opening of the uterus. It is named after the doctor who determined that this was a useful way to detect signs of cervical cancer, Georgios Papanikolaou. During the procedure, cells from the cervix are gently scraped away and then examined for abnormal growth.

Reasons for Getting a Pap Smear

The human papillomavirus (HPV) is a virus that causes warts. There are over 100 different types of HPV. There are 40 that are sexually transmitted. The primary causes of cervical cancer are HPV types 16 and 18. Even though a Pap smear doesn’t test for HPV, it identifies cellular changes caused by the virus. By detecting cervical cancer cells early with a Pap smear, treatment can start before it spreads and becomes a bigger problem.

How Is a Pap Test Performed?

The Pap test is done during a pelvic exam. A doctor uses a device called a speculum to widen the opening of the vagina so that the cervix and vagina can be examined. A plastic spatula and small brush are used to collect cells from the cervix. After the cells are taken, they are placed into a solution. The solution is sent to a lab for testing.

Is it normal to have pain after a Pap smear?

The test is said by some doctors to be painless though some patients indicate experiencing pain and discomfort. There may also be spotting after Pap smear which may cause some pelvic discomfort or pressure on the pelvis. It is also common to experience mild abdominal cramping after the test. The complications won’t last long, and patients may take over-the-counter (OTC) pain medications if abdominal cramping persists. However, before taking any medication for this, it is best to consult the doctor.

How long does it take to get the results of a Pap smear?

The waiting period depends on the lab that examines the sample. Most doctors tell patients it will take a week or two. If a test finds any changes or abnormal Pap test results, the doctor will often follow up with an HPV test.

How often should a Pap smear be done

Historically, Pap smears were recommended to be carried out annually. Since 2012, doctors recommend repeating Pap testing every 3 years for women ages 21-65 regardless of the age of sexual debut (for more information, see https://www.cdc.gov/cancer/cervical/pdf/guidelines.pdf). However, doctors may recommend more frequent Pap smears (eg. annually) for women with certain risk factors such as being HIV positive, a weakened immune system due to chemotherapy, organ transplant, chronic steroid use, have had a history of abnormal Pap tests, among other things. It is important for each woman to do what is right for her body and have a conversation with her doctor as to how often to have a Pap smear done.

Going forward we should still encourage our new clients (and existing ones as we should be doing case management) to come in annually to do their pap smears and then have our doctors provide the recommendation on a per client basis as to when repeat testing needs to be done.

Additional information can be found at the following links:

http://www.cdc.gov/cancer/cervical/basic_info/screening.htm

http://www.womenshealth.gov/publications/our-publications/fact-sheet/pap-test.html

http://www.mayoclinic.org/tests-procedures/pap-smear/basics/why-its-done/prc-20013038

What is Stigma and Discrimination in the context on HIV ?

DEFINITION OF STIGMA

Stigma: Having a negative attitude (or thought, perception or stereotype) toward people we think are not “normal” or “right”. A person is stigmatised when he or she is made to believe that he or she is inferior because of something about him or her.

Different Forms of Stigma

There are three (3) main forms through which stigma can be experienced, which are:

1. 1. Stigma towards others: Having a negative attitude towards others because they are perceived to be different
  2. Secondary stigma: This occurs when people are stigmatised because of their real or perceived association or support of an individual or a group that have been stigmatized.
  3. Self-stigma: People take on cruel or hurtful views placed on them by others as their own views of themselves.

Some of the most common issues that Peer Navigators/Links and Treatment and Care staff will encounter include stigmatisation based on:

1. 1. Real or perceived health status: For example, a person’s may be stigmatised because of his or her real or perceived HIV status. People may make judgment values that a person is HIV positive because they have engaged in immoral behaviour.
  2. Gender identity: (1) for example, young women may be made to feel embarrassed for accessing sexual and reproductive health services; whereas young men do not face similar levels of chastisement. (2) Additionally, for transgendered persons they may feel stigmatised because they identify with a gender that differs from their biological sex.
  3. Sexual orientation: People who identify as being in same sex relationships – feel that their engagement in same sex activities is immoral or against the norm.
  4. Age: People may be stigmatised because of their age. Health providers may make adolescents and young people feel they are too young to be engaging in sexual activity. Older persons may also experience stigma and may be embarrassed to seek services.
  5. Behaviours and practices: Other than the above-mentioned factors, persons may harbour stigma if they feel that the behaviours or practices of others are immoral or illicit. For example, sex work in Jamaica is criminalised. Sex workers face stigmatisation on account of people feeling that their activity is perceived as being immoral.

DEFINITION OF DISCRIMINATION

Discrimination: This is the action that follows stigma, when someone is treated unfairly because he or she is perceived to be different from the norm.

Some of the most common examples of discrimination are:

1. 1. Being denied access to health care and other services
  2. Being isolated from or rejected by family, friends or community members
  3. Experiencing violence at home or being run out of the community
  4. Being prevented from attending school
  5. Being fired from a job or not being considered for a job
  6. Being rejected from church or other faith-based community

*Please note that while discrimination is usually negative, there is such as thing as positive discrimination. The term ‘positive discrimination’ is sometimes used to refer to ‘positive measures’ or ‘special measures’ aimed at fostering greater equality or giving advantage to those groups of people who face, or have faced, entrenched discrimination so they can have similar access to opportunities as others in the community. Eg. ‘Affirmative Action’ in the allocation of resources or employment or in attending certain educational institutions in places like USA, Canada and the UK.

Stigma is being perceived as different from others while discrimination is being treated differently. Stigma is not a result of discrimination; discrimination can be a result of social stigma. A person cannot take legal actions against stigma but a person can take legal actions against some forms of discrimination.

STIGMA AND DISCRIMINATION AS BARRIERS TO HEALTH-RELATED SERVICES

Stigma and discrimination are significant barriers to people’s access to HIV/STI prevention, and treatment, care and support services. Some of the negative consequences of stigma and discrimination:

1. 1. Can result in an individual being denied or given low quality care at health facilities, which would make it less likely for him or her to access services in the future.
  2. Cause individuals not to be able to access sexual and reproductive health commodities (e.g. male and/or female condoms, lubricants, contraceptives) may result in unwanted pregnancies and/or transmission of HIV and other STIs.
  3. Result in persons not seeking testing and treatment for STIs (other than HIV), which in some circumstances can lead to infertility, and increase chances of contracting HIV.
  4. Can impact willingness to negotiate condom use or engage in safer sex and harm reduction practices or fear that doing so may be seen as abnormal.
  5. Cause unwillingness to get tested for HIV and know his or her HIV status.
  6. Has negative psychological effect and can result in depression, which makes it difficult for persons to seek support, and start to adhere to treatment.
  7. Result in resistance to enrolling in care and getting a CD4 test, which would prevent him or her from accessing antiretroviral medication.
  8. Concealing or not taking antiretroviral medication for fear that others will know he or she is HIV positive therefore be stigmatized.
  9. Can cause fear of disclosing HIV status or having others know his or her status which may impact the amount of support he or she receives and can impact adherence and retention in care.
  10. Can extend to persons’ association with marginalised groups (e.g. caregivers of PLHIV; allies of the transgender community), which may decrease the level of care or support received for fear of being stigmatised.

In the end, stigma and discrimination continue to undermine prevention, treatment and care of people living with the HIV and AIDS. It hinders those with the virus from telling their partners about their status. It threatens their access to health care. It increases their vulnerability to physical violence. And HIV-related stigma affects people’s ability to earn a living, making it even more difficult for them to lift themselves out of poverty.