The document provides an educational overview of HIV/AIDS and STIs, aimed at enabling learners to define key terms, understand prevention and management strategies, and appreciate the impact of the disease on various populations. It outlines the historical background, prevalence statistics in Kenya, modes of transmission, and the effects of HIV on the immune system. The document also discusses the socio-cultural, biological, and behavioral factors contributing to the HIV epidemic and emphasizes the need for effective communication and community-based care.

1. HIV/AIDS AND STI’s
BY
ROBERT ATAADA
MME (continuing)/BMLS/DMLS
Lecturer, KMTC

2. MODULE COMPETENCE
This module is designed to enable the learner
understand the concepts of HIV/AIDS and STIs

3. MODULE OUTCOMES
By the end of this module, you should have gained sufficient skills to:
1. Define common terms used in HIV/AIDS/STIs
2. Appreciate the fundamentals of HIV and AIDS
3. Understand the preventive measures of HIV and AIDS
4. Describe the management of HIV and AIDS
5. Explain Strategic Behavior Change Communication (SBCC)
6. Understand Home and Community-Based Care (HCBC)
7. Understand the concepts of STIs

4. DEFINITION OF TERMS
 HIV stands for Human Immunodeficiency Virus.
 It is a Retrovirus. HIV Infection is the state where the virus is in the
body. In most instances this is the asymptomatic state, which is a
prelude to AIDS
 AIDS stands for Acquired Immune Deficiency Syndrome.
 “Acquired” means it is transmissible, and “Immune-Deficiency”
means it damages the body defense system “Syndrome” refers to a
group of illnesses

5. HISTORICAL BACKGROUND OF HIV
 1981 – Doctors in the United States recognized it in homosexual males
 1984– The first case in Kenya was described
 1986 – Human Immunodeficiency Virus (HIV) was accepted as the
international designation for the retrovirus in a WHO consultative meeting
 1996 – ARVs became available in the world.
 1997 – ARVs became available in the private sector in Kenya.
 1999 – HIV was declared a national disaster in Kenya
 2003 – ARVs became available in public sector in Kenya

6. HIV EPIDEMIC UPDATE 2018 - KENYA
Kenya Population-based HIV Impact Assessment (KENPHIA) 2018
survey indicated:
 That Kenya’s HIV prevalence now stands at 4.9%.(15-49 yrs)
 The prevalence of HIV in women is at 6.6%, twice that in men at 3.1%.
 The gender disparity in the burden of HIV is even greater than 3 times in
between the ages of 20-34 years.
 The top five HIV high-prevalence counties with a prevalence of more than
9% were Homa Bay, Kisumu, Siaya, Migori and Busia; while prevalence was
lowest in nine counties of Samburu, Tana River, Garissa, Wajir, Mandera,
Marsabit, Kiambu, West Pokot, and Baringo

7. Most at Risk populations for HIV infection
 This are populations at highest risk for sexual acquisition/transmission of
HIV due to either the number of partners that they have or the higher risk sex
that they engage in.
 30% of new infections occur among these populations and the vulnerable
1. Intravenous Drug Users
2. Commercial sex workers
3. Men who have sex with men (MSM)
4. Vulnerable: Prisoners; transgender persons, children, women and girls and
persons with disability
5. Young people and adolescents. WHY?

8. Vulnerable Populations
These are people who because of their circumstances, are at an increased risk of contracting HIV.
They include;
i. Widows and widowers
ii. Opharns and vulnerable children
iii. Families and children living in the streets
iv. Young women aged 15 – 24 years
v. Service men and women
vi. Refuges and displaced migrants persons
vii. Fisher folks
viii. Truckers
ix. Alcoholic

9. Key determinants of HIV Prevalence
 Socio cultural Factors like high HIV stigma and discrimination,
negative attitude towards consistent use of condoms and
gender inequalities.
 High risk sexual behavior characterized by high incidences of
concurrent sexual relations linked to mobility,
intergenerational sex, transactional sex, denial and
marginalization of LGBTQ groups.
 Biological factors including male circumcision and high
prevalence of STIs are among the key risks

10. Origin of HIV
 Scientists believe that HIV originally came from a virus
particular to chimpanzees in West Africa during the 1930s,
and originally transmitted to humans through the transfer of
blood through hunting. Over the decades, the virus spread
through Africa, and to other parts of the world
 However, it wasn’t until the early 1980s, when rare types of
pneumonia, cancer, and other illnesses were being reported to
doctors that the world became aware of HIV and AIDS.

11. Properties of the HIV Virus
 It is an obligate intracellular parasite, that cannot survive outside the host
cell for long
 It depends on the host cell for multiplication/replication.
 It is classified as a prokaryotic – does not have normal cellular organization
 Contains RNA genetic material
 As a retrovirus, it inserts a copy of its RNA genome into the DNA of a host
cell that it invades, thus changing the genome of the host cell
 The structures on its surface (surface antigens) helps the virus attach to
host cells
 It is quickly destroyed by heat, and common disinfectants such as JIK
(Sodium hypochlorite)

13. Cont’d…
 Glycoproteins gp41 and gp120 are responsible for attachment to the host
cell
 p17 helps in replication of the virus
 p24 is a distinctive HIV antigen. It is a structural protein that makes up
most the of the HIV viral core, or capsid.
 Reverse transcriptase is an enzyme that the HIV virus uses to convert its
RNA into viral DNA, in a process known as reverse transcription
 Integrase enzyme helps the virus integrate (incorporate) its viral DNA into
the host genome
 Protease enzyme is used by the virus to manufacture proteins during viral
maturation i.e. processing of the gag and gag-pol polyproteins
 The RNA is the genome of the virus. It plays a central role in viral
replication, serving as a template for Gag/Gag-Pol translation and as a
genome for the progeny virion

14. How HIV Infects the Body
Exponential viral replication
Widespread systemic dissemination to the
brain, spleen, distant lymph nodes, etc. (5-11
Days)
HIV makes contact with cells located within the genital mucosa
Virus is carried to regional lymph nodes (1-2 Days)
5

15. How HIV Affects the Immune System
HIV attaches to cells of the immune system with special surface
markers called CD4 receptors. Immune cells with CD4 receptors
include:
T-helper Lymphocytes
 Macrophages
Monocytes
Dendritic cells
Microglial cells
15

16. cont’d…
 The hallmark of HIV/AIDS is profound immunodeficiency as a
result depletion of CD4+ T lymphocytes.
 The CD4+ T cell dysfunction is two fold ;
Reduction in numbers
Impairment in function
16

17. Immune suppression
• HIV attacks white blood cells, called CD4 cells,
that protect body from illness
• Over time, the body’s ability to fight common
infections is lost
• Opportunistic infections occur
17

18. HIV Disease
Progression of HIV disease is measured by:
1. CD4+ count
Degree of immune suppression
Lower CD4+ count means decreasing immunity
2. Viral load
Amount of virus in the blood
Higher viral load means more immune suppression
18

19. HIV Disease
Severity of illness is determined by amount of virus in the
body (increasing viral load) and the degree of immune
suppression (decreasing CD4+ counts)
Higher the viral load, the sooner immune suppression occurs
When the body’s immunity is suppressed, there will be
increased clinical symptoms (such as opportunistic infections)
19

20. Adult problems
Adults infected with HIV often experience the following clinical problems
 Depending on the stage of HIV infection, PTB can occur at any time.
 As HIV disease progresses, HIV patients develop;
 Bacterial infection ( acute respiratory infection, pneumonia, and skin infection)
 Fungal infection
 More severe conditions occur as immune system deteriorates. Conditions including the following
may develop:
 Chronic diarrhea
 Wasting
 PCP
 Extra pulmonary TB
 Cryptococcal meningitis
 Kaposi sarcoma
20

21. HIV Disease: Summary
• HIV multiplies inside the CD4+ cells, destroying them
• As CD4+ cell count decreases and viral load increases, the
immune defences are weakened
• HIV-infected people become vulnerable to opportunistic
infections
• HIV is a chronic viral infection with no known cure
• Without ARV treatment, HIV progresses to symptomatic disease
and AIDS
21

22. Key Points
• HIV is a global pandemic and the number of people living
with HIV continues to increase worldwide.
• HIV epidemic is especially severe in poor populations
• HIV is a virus that destroys the immune system, leading to
opportunistic infections.
• The progression from initial infection with HIV to end-stage
AIDS varies from person to person and can take more than 10
years.
22

23. Key Points (continued)
• The most common main route of transmission worldwide
is heterosexual transmission.
• Women of childbearing age are at particular risk for
acquiring HIV through unprotected sex
• HIV-positive women who are pregnant are at risk of
passing HIV infection to their newborn.
• Risk of HIV transmission from mother-to-child can be
greatly reduced through effective PMTCT programs
23

24. HIV Life Cycle
1. Binding, fusion and entry
2. Reverse transcription
3. Integration
4. Transcription and translation
5. Assembly, budding and maturation
When the virus infects body, it attacks and multiplies within the host cells (CD4
group of lymphocytes). The host cell eventually gets destroyed when new virus
particles are released and proceed to infect other cells
The steps involved are;

26. 1. Binding, fusion and entry
 During this step, viral gp120 binds to the CD4 receptor and
CCR5 or CXCR4 co-receptor on the host surface
 The binding facilitates the fusion of viral and host cell
membrane thereby facilitating the entry of viral nuclear
material into the host cell

27. 2. Reverse transcription
 Viral RNA is reverse transcribed to viral DNA
 This process is mediated by the enzyme reverse transcriptase
(RT)
 This enzyme has no proof-reading function, and therefore the
process is error-prone and responsible for development of
drug-resistant mutations

28. 3. Integration
 The viral DNA is inserted into host cell DNA using the viral
enzyme integrase
 This is the process that establishes replication-competent
virus in the body and makes HIV incurable even with effective
ART
 Further, drug-resistant virus that occurs in patients on ART
may also be achieved in the same way, establishing a
permanent pool of resistant viruses.

29. 4. Transcription and Translation
 Host cell enzymes transcribe viral DNA into viral RNA
 Viral RNA uses host cell energy and synthetic pathways to
make viral proteins

30. 5. Assembly, budding and maturation
 Viral proteins and RNA aggregate on the cell surface for
assembly into a mature viral particle by budding through host
cell membrane

31. Types of HIV Virus
There are two types of HIV.
HIV – 1
Is found worldwide
Is the main cause of the worldwide pandemic
HIV – 2
Is mainly found in West Africa, Mozambique and Angola.
Causes a similar illness to HIV – 1
 Less efficiently transmissible
 Less aggressive with slower disease progression

32. Cont’d…

33. Body Fluids that may Contain HIV Virus
HIV can be spread only in certain body fluids from a person infected
with HIV:
a)Blood
b)Semen
c)Pre-seminal fluids/pre-ejaculatory fluid/Cowper’s fluid
d)Rectal fluids
e)Breast milk f) Vaginal fluid.

34. Modes Transmission of HIV
HIV is can be transmitted through;
1. Unprotected sexual intercourse with infected person: oral, anal, or
vaginal sex
2. Direct contact of open wound with infected blood
3. Direct contact with semen or vaginal and
cervical secretions of infected person
4. Infected mother to her child during
pregnancy, delivery, or breastfeeding
5. Blood transfusion with contaminated/unscreened blood
6. Sharing of needles by injectable drug users
7. Needlestick injury with contaminated needle in hospitals
8. Sharing of personal effects, especially toothbrush

35. Semen and Vaginal
Fluids
Sharing Needles
& Syringes
Through Infected
Blood
During Pregnancy
or Birth
Breast Feeding
Images Courtesy HIV Basics Course for Nurses, I-TECH
Needle Stick
Injury
Modes of HIV Transmission
Natural History of HIV
3

36. HIV cannot be transmitted through;
Insect bites
Coughing or sneezing
Sharing food, drinks or utensils
 hugging or kissing
Handshakes
Work or school contact

37. Exposure Route
Risk of
Transmission
Blood transfusion 90-95%
Perinatal (from pregnancy to 1yr
after birth)
20-40%
Sexual intercourse: 0.1 to 1%
Vaginal 0.05-0.1%
Anal 0.065-0.5%
Oral 0.005-0.01%
Injecting drugs use 0.67%
Needle stick exposure 0.3%
Mucous membrane splash to eye,
oro-nasal
0.09%
HIV Transmission Risk

38. Key determinants of HIV Prevalence
1. Socio-cultural Factors like high HIV stigma and
discrimination, denial and discrimination of LGBTQI
community, inconsistent use of condoms and gender
inequalities.
2. High risk sexual behavior such as anal sex, concurrent
sexual relations, transactional sex
3. Biological factors including non-circumcision of males and
presence of STIs

39. Risk factors for High HIV/AIDS Transmission
in women
i. Inability of women and young girls to negotiate for sex.
ii. Vulnerability to pressure from male counterparts
iii. Trauma and bleeding caused by sexual intercourse at an early age, a time of
physical immaturity, increases exposure to HIV
iv. Early marriages encouraged by some cultures, expose young women to
older men who may be HIV POSITIVE
v. Forced sex through rape, traditional rituals and practices such as wife
inheritance, or wife cleansing which increase the risk of HIV.
vi. Economic pressures which force women to exchange sex for the necessities
of survival- food, shelter and safety.
39

40. Risk factor for HIV/AIDS Transmission in
men
i. Failure to seek proper care for HIV and other STIs due to lack of
knowledge, lack of comfort in Health care setting or stigma
ii. Cultural accepted practices such as polygamy
iii. Men who have sex with men
iv. Ego-driven behaviors to display their manhood including drug and
alcohol abuse that may lead to irresponsible sexual risk practices.
v. Peer pressure from other young men to conform to unsafe sex without
regard to consequences.
40

41. Impact of HIV/AIDS on Communities
1. Economic drawback at personal and community level
2. Reduction of productive workforce
3. Loss of loved ones and bread winners
4. Family conflicts – rejection, divorce
5. Increased budgets for health services
6. Increased number of orphans and vulnerable children
7. Increased number of child-headed families
8. Added responsibilities to grandparents or other family
members who have to care for the sick and OVCs
9. Depopulation of communities

42. Global Impact of HIV
• Negative economic impact to countries
• Increased healthcare costs
• Decreasing life expectancy
• Reversal of child survival gains
• Increased numbers of orphans
42

43. The natural history of HIV infection refers to the stages in the progression of
HIV to AIDS if HIV is left untreated. There are 5 stages;
1. Infection stage – a person gets infected
2. Acute seroconversion: 2-3 weeks
3. Asymptomatic HIV infection (clinical latency): 8 yrs (Avg.)
4. Symptomatic HIV infection/AIDS: 1.3 yrs (Avg.)
5. AIDS
Natural History of HIV Infection
(Natural Progression of HIV Disease)
8
43

44. Cont’d: Progression of HIV Disease
1. Infection stage – no signs and symptoms
2. Acute seroconversion:
• The body begins to produce antibodies against
• Fever, rash and adenopathy
• Usually 3-6 weeks after exposure
3. Asymptomatic HIV (clinical latency):
• Patient often unaware of infection, antibodies detectable.
• Immune system able to control virus to limited extent and CD4 >350/cu.mm
• Able to transmit HIV to others
4. Symptomatic HIV:
• Minor to moderately severe symptoms
• Recurrent symptoms
5. AIDS:
• Severe immuno-suppression associated with opportunistic infections or cancers
44

45. Patterns of Progression of HIV to AIDS
13
Depending on the rate of progression of the HIV infection, there are 4 types
of progressors;
Typical progressors – where AIDS develops in 8-10 yrs
Rapid progressors - where AIDS develops within 3 years of infection
Slow progressors – may take up to 15 years to develop AIDS
Long-term non-progressors - where HIV-infected people maintain high CD4+
and CD8+ T-cell counts. Take longer than 15 years to develop AIDS
45

46. WHO Clinical Staging of HIV/AIDS
There are four (4) clinical stages of AIDS according to
WHO;
WHO Clinical Stage 1
• This is the asymptomatic stage
• However, the patient may have Persistent generalised
lymphadenopathy (PGL)
 Painless enlarged lymph nodes >1 cm In two or more non-contiguous sites (excluding inguinal),
in absence of known cause
 Persisting for 3 months
14
46

47. WHO Clinical Stage 2
Characterized by;
 Unexplained moderate weight loss (<10%
of presumed or measured body weight)
 Recurrent respiratory tract infections (sinusitis,
tonsillitis, otitis media, pharyngitis)
 Herpes zoster
 Angular cheilitis
 Recurrent oral ulceration
 Pruritic popular eruptions (PPE)
 Seborrhoeic dermatitis (scaling of skin, mainly scalp)
 Fungal nail infections
15
47

48. WHO Clinical Stage 3
Characterized by;
 Unexplained severe weight loss (>10%
of presumed or measured body weight)
 Unexplained chronic diarrhoea for longer than one month
 Unexplained persistent fever (above 37.5oC intermittent or
constant for longer than one month)
 Persistent oral candidiasis
 Oral hairy leukoplakia (OHL)
 Pulmonary tuberculosis
 Candidiasis
16
48

49. Cont’d: WHO Stage 3
 Severe bacterial infections (e.g. pneumonia, empyema,
pyomyositis, bone or joint infection, meningitis,
bacteraemia)
 Acute necrotizing ulcerative stomatitis, gingivitis or
periodontitis
 Unexplained
 Anaemia (<8 g/dl)
 Neutropenia (<0.5 x 109 /L) and or
 Chronic thrombocytopenia (<50 X 109 /L)
17
49

50. WHO Clinical Stage 4
This is the last stage that is characterized by;
 HIV wasting syndrome (severe weight loss)
 Pneumocystis pneumonia (PCP)
 Recurrent severe bacterial pneumonia
 Chronic herpes simplex infection (orolabial, genital or anorectal of more
than one month’s duration or visceral at any site)
 Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
 Extra pulmonary tuberculosis – TB affecting other organs other than
lungs
 Kaposi’s sarcoma
18
50

51. Cont’d: WHO Clinical Staging 4
 Cytomegalovirus infection (retinitis or infection of other organs)
 Central nervous system toxoplasmosis
 HIV encephalopathy – affects CNS and immune system
 Extra pulmonary cryptococcosis including meningitis
 Disseminated non-tuberculous mycobacteria infection
 Progressive multifocal leukoencephalopathy
 Chronic cryptosporidiosis
 Chronic isosporiasis
19
51

52. Cont’d: WHO Clinical Staging 4
 Disseminated mycosis (extra pulmonary histoplasmosis,
coccidiomycosis)
 Recurrent septicaemia (including non-typhoidal
salmonella)
 Lymphoma (cerebral or B cell non-Hodgkin)
 Invasive cervical carcinoma (cancer of cervix)
 Atypical disseminated leishmaniasis
 Symptomatic HIV-associated nephropathy
 Symptomatic HIV-associated cardiomyopathy
20
52

53. Summary: WHO HIV Staging in Adults
WHO CLINICAL STAGE SELECTED SYMPTOMS
STAGE 1 1. Asymptomatic
2. Persistence generalized lymphadenopathy
3. Acute retroviral,infection
STAGE 2. 1. Weight loss < 10%
2. Minor mucocutaneous manifestation ( fungal infection,
pruringo, recurrent mouth ulceration
3. Herpes zoster
4. URTIs ( sinusitis, Otis media, pharyngitis)
STAGE 3. 1. Weight loss > 10% of BW
2. Unexplained chronic diarrhea
3. Fever > 1 month
4. Oral thrush
5. PTB,
6. Areal candidiasis
7. Severe bacterial infection
53

54. Adults (2)
STAGE 4. 1. HIV wasting syndrome
2. Pneumocystis pneumonia (PCP)
3. Toxoplasmosis
4. HIV encephalopathy
5. Lymphoma
6. Extra pulmonary tuberculosis
7. Herpes simplex virus
8. Kaposi sarcoma
54

55. WHO HIV staging in children
Clinical stage Selected symptoms
Stage 1 1. Asymptomatic
2. Progressive generalized lymphadenopathy
3. Hepatosplenomegally
Stage 2 1. Skin conditions: jeeps zoster, papular Pruitt
rash eruptions, fungal mail infections
2. Mouth conditions: Angela chelitis, parotid
enlargement
3. Respiratory conditions: URTIs , Ottis medial,
sinusitis.
Stage 3. 1. Unexplained moderate malnutrition
2. Unexplained persisted diarrhea
3. Oral candidiasis
4. Pulmonary tuberculosis
5. Pneumonia
Stage 4 1. Severe wasting
2. Pneumocystis pneumonia
3. HIV encephalopathy
4. Kaposi sarcoma
55

56. OPPORTUNISTIC INFECTIONS IN HIV/AIDS
What is an opportunistic infection?
 An opportunistic infection (OI) is a disease caused by microorganism that
does not normally cause illness in a person with a healthy immune system,
but that may cause serious disease when the immune system is weakened.
 For example, as the immune system of people living with HIV weakens,
they become susceptible to a number of opportunistic infections at
different stages of HIV disease progression
56

57. Common Opportunistic Infections (OIs) in Adults
1. Tuberculosis
2. Bacterial infections e.g. bacterial pneumonia
3. Pneumocystis pneumonia (PCP)
4. Cryptococcal meningitis
5. Toxoplasmosis
6. Candidiasis
7. Infective diarrhoea
8. Infective dermatoses
9. Herpes zoster
10.Karposi’s sarcoma
11. primary CNS lymphoma
12.Carcinoma of the cervix
13.Other lymphoma
57
For adults living with HIV, the common OIs include;

58. Common OIs in Children
1. Respiratory infections
2. Diarrhoea
3. Measles
4. Septicaemia
5. Meningitis
6. Skin infections
7. TB
8. PCP
9. Oropharyngeal candidiasis
10. toxoplasmosis
11. cytomegalovirus
12. karposi’s sarcoma
58

59. Opportunistic infections, Cont’d:
OPPORTUNISTIC INFECTION CLINICAL FEATURES DIAGNOSIS TREATMENT
Acute Bacterial Pneumonia Productive cough, fever,
chest pain,
Clinical and physical
examination. CXR, gene
expert
Antibiotics e.g Erythromycin,
Amoxicillin or
cephalosporins
Pneumocystis carinii
pneumonia
Cough, dry fever,
tachypnoes, cyanosis
High index of clinical
suspicion, CXR
Cotrimoxazole and
predsolone
Pulmonary tuberculosis Cough, fever, weight loss,
night sweats
Sputum and CXR 2RHZE+4RH. Add
pyridoxine
Toxoplasmosis Headache, usually
meningitis
CT scan Cotrimoxazole, folic acid .
Cryptococcal Meningitis Severe headache and fever CT scan, LP IV amphoteric in B
Fluconazole
Esophageal candidiasis Oropharyngeal thrush with
painful swallowing,
dehydration, wasting
Clinical diagnosis and
oesphangoscopy
Fluconazole or ketoconazole
59

60. Cont’d: Opportunistic infections
Orophangeal candidiasis White plaques in mouth,
palate, phrynix
Clinical diagnosis Nystatin, miconazoe
Acute infective Diarrhoeal Diarrhea and abdominal
pain
Stool examination ORS, antibacterial and zinc
Herpes zoster Multi-dermal acute
vesicular lesions, eye
involvement can lead to
blindness
Clinical Acyclovir, calamine lotion,
amitryptiline
CNS lymphoma Headache, confusion,
memory loss,
CT SCAN, MRI Chemotherapy
Papular pruritic eruptions Severe itching with hyper
pigmented papule and skin
scarring
Clinical Chlorhexidine,
antihistamine ointments
Scabies Very itch skin Clinical BB lotion
Cryptococcal meningitis Headache, fever, confusion
or convulsion
Pleural fluid exam Anti-TBs
60

61. Cont’d: Opportunistic infections
TB –Meningitis Headache, confusion MRI, CT scan, CSF Anti TBs
TB lymphadenopathy Constitutional
symptoms,
asymmetrical, enlarged
lymph nodes
FNA, Biopsy, CT scan,
MRI
Anti TBs
Candidiasis Vaginal Anti fugal
Herpes simplex virus
genital
Lesions in the vaginal Clinical Acyclovir
Kaposi sarcoma Firm dark purple
nodules of the skin
Clinical chemotherapy
Cervical cancer Irregular PV bleeding Cervical screening,
biopsy
61

62. Persistent Generalized Lymphadenopathy
62

63. Herpes Zoster
63

64. Angular cheilitis
64

65. Pruritic Papular Eruptions
65

66. Oral hairy leukoplakia
66

67. Source: GHTM, Tambaram, Chennai
22
Oral candidiasis
67

68. Seborrhoeic dermatitis
68

69. Karposis sarcoma
69

70. PREVENTION OF HIV/AIDS
70

71. Introduction
 Although most STIs can be cured except HIV/ AIDS , it is more cost effective
to prevent them
 Community education on the risk factors and promotion of behavior change
in prevention and control of STIs and HIV are important.
 HIV/AIDS/STIs prevention measures revolve around intervention on sexual
behavior of individuals.
 Various intervention measures are needed to control the spread of
HIV/AIDS/STIs

72. HIV/AIDS Prevention Strategies
 Despite many years of research, there is no cure for AIDS.
 Hope for fighting the scourge continues to be in prevention
of transmission.
 Preventive strategies are therefore aimed at curtailing
transmission via known routes of transmission
72

73. Primary Prevention Strategies (activities)
1. Sexual behavior change – promoting the adoption of safe sex practices
2. Condom promotion and availability
3. Early treatment of Sexually Transmitted Infections
4. Voluntary Counseling and Testing of HIV
5. Voluntary male circumcision
6. Prevention of mother to Child Transmission
7. Blood Safety, screening for HIV
8. Stigma reduction through attitude change
9. Harm reduction for Injecting drug users
10. HIV prophylaxis – PEP and PreP
73
Primary prevention strategies seek to prevent transmission of HIV to individuals who
are not infected yet. The measures include;

74. Secondary Prevention Strategies
Secondary prevention strategies target persons who are HIV positive to
become partners in the fight to prevent spread of HIV to the general
population. This is a holistic approach that involves physical, social,
psychological and spiritual interventions. The strategies include;
1. Attitude change – by linking the newly diagnosed to support groups
2. The provision of care for sexually transmitted diseases to PLWHA
3. The provision of Anti-Retro viral medications
4. Provision of care for opportunistic infections
5. Reducing fertility. This alludes to encouraging women who have the
infection not to have children
6. Prevention with positives – involving HIV patients in HIV advocacy
7. Health promotion strategies must be pursued aggressively
74

75. The ABCD of HIV Prevention
1. A – Abstinence
2. B – Be faithful to one partner with known HIV
Status
3. C – Correct and consistent condom use
4. D – Delayed Sexual Debut
75

76. Barrier Methods and Dual Protection
 Both male and female condoms, used correctly and consistently can provide
protection against STIs , reduce the risk of HIV transmission and also prevent
unintended pregnancy.
 Dual protection is the use of one or more methods of contraception that prevent
STIs , including HIV and unintended pregnancies. Examples include: birth control
pills would be a single method while use of birth control pills and Barrier
protection (condoms) would be dual protection.
 The use of dual protection by HIV –infected couples can also protect then from
re- infection with variant strains of HIV and effectively help to space their children.
76

77. PMTCT
 Stands for prevention of mother-to-child transmission of HIV
 Mother to child transmission (MTCT) of HIV may occur at any
stage during pregnancy, labour and delivery, or breastfeeding
 PMTCT can be achieved by:
i. Use of antiretroviral therapy (ART) – PreP and PEP
ii. Appropriate infant feeding practices
iii. Safe obstetrical practices
77

78. Cont’d…
 Mother to child transmission (MTCT) of HIV infection during pregnancy,
labour and delivery or through breastfeeding is also refer to as vertical or
perinatal transmission.
 The overall MTCT rate is approximately 40% without intervention.
78

79. Maternal factors that may increase the risk
of HIV
Pregnancy labour and delivery Breastfeeding
i. High maternal viral load
ii. Viral or bacterial infection
iii. STIs
iv. Maternal malnutrition
v. Anemia
i. High maternal viral load
ii. Ruptured of membranes
iii. Invasive delivery procedures
iv. External cephalon version
v. Premature delivery
vi. Low birth weight
vii. Broken skin
i. High maternal viral load
ii. Duration of breastfeeding
iii. Mixed feeding (food or fluids)
iv. Breast abscesses
v. Poor maternal nutrition status
vi. Oral disease in the baby
79

80. Elements of comprehensive PMCTC
approach
i. Element 1: primary prevention of HIV infection
ii. Element 2: Prevention of unintended pregnancies among women infected with
HIV
iii. Element 3: Prevention of HIV transmission from women infected with HIV to their
infants
iv. Element 4: Provision of treatment,care, and support to women infected with HIV,
their infants and their families
80

81. Feeding Options in PMTCT
Feeding options: exclusive breastfeeding for 6 Months
Benefits of breastmilk;
a) Easily digestable and has all the nutrients and water they need.
b) Available
c) Protects infants against diarrhea and pneumonia
d) Improves brain growth
e) Gives close contact
f) Lowers risk of passing HIV
g) Reduces the mother from getting breast cancer

82. Other methods of feeding
 Exclusive breast feeding and early cessation. There is replacement feeding.
 Wet nursing (to breastfeed another’s child)
 Expressing and heat treatment of milk
82

83. Voluntary Medical Male Circumcision
(VMMC)
 This is complete removal of the foreskin of the skin penis by surgical means.
 Though VMMC may be conducted for a number reasons, evidence from research has
shown that medical male circumcision can significantly reduce (but not eliminate)
men's risk of acquiring HIV through sex.
 HIV prevalence in uncircumcised men (16.9%) was five times higher than that of
circumcised men (3.1%). Among men who had sex across all age groups, HIV
prevalence was approximately seven times higher among uncircumcised men (22.5%)
compared with those who were circumcised (3.4%).
83

84. Pre-exposure Prophylaxis (PreP)
Write short notes on this

85. Post Exposure Prophylaxis (PEP)
 Pre-exposure prophylaxis (PrEP) is the administration of
antiretroviral therapy to HIV- uninfected persons to reduce
their chance of acquiring HIV.
85

86. Overview of HIV Testing and Counselling

87. HIV Testing and Counselling (HTC)
HIV testing provides:
Information about HIV status
Opportunity to identify persons with HIV and
empower them to live normal life
Opportunity to identify persons who are HIV
negative and empower them to remain negative

88. Definitions
 HIV testing: process of determining if client is infected with
HIV
 HIV counselling: confidential dialogue between an individual
or a couple and a healthcare worker (HCW) to help clients
examine their risk of acquiring or transmitting HIV
HIV counselling is tailored to the risk behaviour,
circumstances and special needs of the client

89. Guiding Principles in Counselling
and Testing
1. Confidentiality
2. Informed consent
3. Post-test support and services

90. Guiding Principles (Continued)
1. Confidentiality
 Keeping private information shared between HCW
and client
 It is an essential element in establishing and
maintaining client trust

91. Guiding Principles (Continued)
2. Informed Consent
 Process during which clients receive clear and
accurate information about HIV testing to make
an informed decision about whether to accept or
decline testing
 Consent may be written or oral
The client must give informed consent before
being tested

92. Guiding Principles (Continued)
3. Post-test counselling support and services
 Provide both HIV-negative and HIV-positive clients with
test results and counselling
 Inform client that follow-up treatment, care, support are
available, including support for disclosure when needed

93. Provider-initiated and Client-Initiated
Approaches to HIV Testing
 There are two basic approaches to HIV testing:
1. Provider-initiated
2. Client-initiated
 Both approaches include
 Basic information about providing HIV testing
 Risks and benefits of testing

94. Provider-Initiated Approach
 Also referred to as “opt-out”
 All clients provided with pre-test information
 Testing is still voluntary under the provider-
initiated approach

95. Client-Initiated Approach
 Client specifically requests HIV test
 Also referred to as “opt-in”
 Only clients who specifically request to be tested
are provided with HIV testing
 Client gives verbal or written consent

96. Counselling Skills

97. Role of the HCW in Counselling
Role of Counsellor: to support and assist client’s decision-making process by:
Listening to client
Understanding the choices client needs to make
Helping client explore her/his circumstances and options
Helping client develop self-confidence to carry out her/his
decision about testing

98. Role of the HCW in Counselling
(Continued)
Counsellor is not responsible for:
Solving all of the client’s problems
The client’s decisions

99. Counselling Skills: Active Listening
 It involves:
Listening to and understanding the client
Taking note of client’s non-verbal behaviour
Listening for client’s social and cultural context
Listening to client’s negative comments or
feelings—make note of things that may have to be
challenged
Active listening helps establish a trusting
relationship with the client

100. Listening and Learning Skills
Skill 1: Use helpful non-verbal communication
 Includes all aspects of message not conveyed by literal
meaning of the words
 It includes the Impact of gestures, gaze, posture and
expressions that convey information
 Reflects attitude
 Helpful non-verbal communication encourages client to feel
HCW is interested in her

101. Non-Verbal Communication
R A relaxed and natural attitude with clients
O Open posture should be adopted—it shows that you
are open to the client and to what client is saying
L Leaning forward toward the client is a sign of
involvement
E Maintain culturally appropriate eye contact
S Sit squarely facing client to show involvement

102. Listening and Learning Skills (Continued)
Skill 2: Ask open-ended questions
 Open-ended questions begin with “how?” “what?”
“when?” “where?” or “why?”
 Encourages responses that lead to further discussion
 Try to avoid questions with a “yes” or “no” answer

103. Listening and Learning Skills (Continued)
Skill 2: Ask open-ended questions, examples of closed-ended questions:
 You know what HIV is, don’t you?
 Do you have any other questions about MTCT?
 Are you going to tell your partner that you tested for HIV today?
 Is your husband your only partner?
 Do you plan to replacement feed?
 How would you revise these questions so that they are open-ended?

104. Listening and Learning Skills (Continued)
Closed-ended Open-ended
You know what HIV is, don’t you? What is HIV?
Do you have any other questions
about MTCT?
What other questions do you have
about MTCT?
Are you going to tell your partner
about your HIV test result?
Who are you going to tell about
your HIV test result?
Is your husband your only
partner?
How many partners have you have
in the last 3 months?
Do you plan to replacement
feed?
How do you plan to feed your
baby?

105. Listening and Learning Skills (Continued)
Skill 3: Use gestures and
responses that show interest
 Gestures: nodding and smiling
 Responses: “Mmm,” “Aha”
 Attending skills: clarifying and
summarizing—invite client to relax,
talk about herself and her problems

106. Listening and Learning Skills (Continued)
Skill 4: Reflect back what the client says
 Encourages client to say more
 Shows HCW is actively listening, encourages dialogue, gives
HCW opportunity to better understand client’s feelings
 Say what client said in a slightly different way

107. Listening and Learning Skills (Continued)
Skill 5: Empathize—show you understand how she feels
 Used in response to an emotional statement
 Encourages mother to discuss the issue further
 If client says, “I just can’t tell my partner that I have HIV,”
HCW could respond with “You sound like you are afraid to
tell your partner your HIV test result”
 HCW is not empathizing if she responds with a question that
has a factual answer

108. Listening and Learning Skills (Continued)
Skill 6: Avoid words that sound judging
 Words like: right, wrong, well, badly, good, enough, properly
 Using these words may make client feels she is wrong, or that
there is something wrong with her baby
 BUT, sometimes HCW needs to use “good” judging words to
build a mother's confidence

109. Common Mistakes in Counselling
Controlling the discussion
Judging the client
Preaching to a client
Labelling a client instead of finding out their
individual motivations, fears or anxieties
Reassuring a client without knowing

110. Common Mistakes (Continued)
 Not accepting the client’s feelings
 Advising before client has arrived at a personal solution
 Interrogating
 Encouraging dependence
 Persuading or coaxing

111. Pre-test Information and Counselling

112. Pre-test Information
 The purpose of the pre-test session is
to provide the client or couple with
adequate information to make an
informed decision about HIV testing

113. Pre-test Information (Continued)
Objectives and components of the pre-test session:
 Help client understand HIV
 Explain importance and benefits of HIV testing
 Explain HIV testing procedures
 Explain importance of partner testing, discordance, disclosure
 Explain risk reduction and available services (sexual, MTCT) and provide
referrals
 Encourage continuous healthcare attendance (ANC and post-delivery)

114. Delivery of Pre-test Information
Pre-test session models:
 Group information
 Individual counselling
 Couple counselling

115. Couple Pre-test Session (Continued)
Advantages of couple counselling:
o Partners hear messages together  shared
understanding
o Environment is safe to discuss concerns
o HCW can ease tension and diffuse blame
o Post-test counselling messages reflect the test
results of both partners
o Neither is burdened with disclosure or partner
referral
o Facilitates risk reduction such as condom use
o Prevention (including PMTCT), care and treatment
decisions can be made together

116. Overview of HIV
Testing Technologies

117. PMTCT Generic
Training Package
Module 5, Slide
117
Overview of HIV Testing
 HIV tests detect antibodies or antigens associated with HIV in whole
blood, saliva, or urine
 Blood sampling is the
most common method
of testing
 HIV tests are very accurate

118. Significance of HIV Testing
HIV testing is important for the following reasons;
1. Helps individuals know their HIV status
2. Helps prevent the spread of HIV – persons who know their status are better
informed on preventive measures
3. Helps assess the prevalence of HIV in general population
4. Facilitates initiation of HIV management in infected persons
5. Helps monitor the effectiveness of ARVs (by testing for CD4 and viral load)

119. Types of HIV Tests
Broadly, rapid and non-rapid tests are used to test for HIV
Assignment:
Differentiate between Rapid and Non-rapid HIV tests

120. HIV Rapid Tests (Antibody Tests)
Examples;
i. Western blot
ii. Determine
iii. Unigold
iv. Genie II
v. Hema-strip
vi. Ora-Quick
o After infection with HIV, the body makes antibodies to fight the virus
o It may take 4 to 6 weeks, but occasionally up to 3 months for antibodies to
become detectable in the blood
o During this time, a person can still transmit the virus to others
o Rapid HIV tests are the most common tests in VCT and PMTCT settings

121.  Accurate results within 20-40 minutes
 Can be done in the clinic setting
 Accurate when performed correctly
 Usually performed on serum or whole
blood (by fingerprick or venous sample);
some rapid HIV tests use saliva
 No batching required
 HCWs can be trained to perform the tests
 Usually do not require special equipment, electricity or refrigeration
Cont’d: Rapid tests

122. Body Fluids Used for HIV Rapid Testing
 Serum
 Plasma
 Whole blood
 Oral fluids

123. There are only three possible outcomes for single HIV
antibody tests:
1. Reactive or “Positive”
 Test band
 Control band
2. Non-reactive or “Negative”
 Control band only
3. Invalid
 No control band present
 Test has failed. Repeat with new device.
Interpreting Rapid Test Results

124. Non-
Reactive
Reactive
Sample
Pad
Reading Results: Determine
Control line
Test line
Lab workers Health workers Counselors

125. cont’d…
 A positive HIV test means that antibodies to HIV are present. It does not
mean that the client has AIDS
 A negative HIV test can mean:
 The person is not infected with HIV, or
 The person is infected with the virus but is in the window period
A negative test does not mean that person cannot
become infected. There is no such thing as
immunity to HIV infection

126. Rapid HIV Testing Algorithms
1. Serial testing
 Blood sample taken and tested once
 If first test result is non-reactive, result is given to client as HIV-negative
 If first test result is reactive, blood sample is tested again using different
brand of rapid test
 If second test is reactive, result is reported as HIV-positive
 If second test is negative, a third test known as a “tiebreaker” is performed

127. Rapid HIV Testing
(Serial testing)
First Test
Positive Negative
Counsel for Negative Result
Second Test
Negative
Positive
Counsel for Positive
Result
Tie-breaker Test
Positive
Counsel for Positive
Result
Negative
Counsel for Negative
Result

128. Rapid HIV Testing Algorithms (Continued)
2. Parallel testing
 Two HIV tests are performed on same sample at the same time, e.g., in
parallel
 If both are non-reactive, client reported HIV-negative
 If both are reactive, client reported HIV-positive
 If one is reactive and the other non-reactive, a “tiebreaker test” is
performed

129. Rapid HIV Testing
(Parallel Testing)
Both Tests Positive
Counsel for Positive Result
Both Tests Negative
Counsel for Negative Result
Tie-breaker Test
Positive
Counsel for Positive
Result
Negative
Counsel for Negative
Result
First AND Second Test
Discordant

130. HIV Rapid Tests: Advantages
i. Rapid tests increase access to HIV prevention (VCT)
and interventions (PMTCT)
ii. Supports increased number of testing sites
iii. Same-day diagnosis and counseling
iv. Robust and easy to use
v. Test time under 30 minutes
vi. Most require no refrigeration
vii. None or one reagent
viii. Minimal or no equipment required
ix. Minimum technical skill

131. Cont’d….
x. On-site testing and same day results
xi. Lower risk of administrative error
xii. Widely accepted by clients
xiii. Fewer resources required:
oHuman resources
oResources at the facility
oFinancial resources

132. HIV Rapid Tests: Disadvantages
i. Only a few tests can be done concurrently
ii. Need for quality assurance/quality control at multiple sites
iii. Test performance varies by product
iv. Refrigeration required by some products, e.g., Capillus
v. There may be reader variability in interpretation of results
vi. Limited end-point stability of test results (results may appear
different after some time)

133. Non-rapid Tests (HIV Viral Tests)
 Viral tests detect the presence of HIV in blood
 Viral tests are performed by trained personnel in the laboratory

134. HIV Viral Tests (Continued)
 There are two types of viral tests:
 p24 antigen test: measures one of the HIV proteins used for screening blood and for
infant diagnosis
 PCR (polymerase chain reaction) tests:
DNA PCR detects presence of HIV in
blood and is used for infant diagnosis
RNA PCR detects and measures
amount of virus in blood (viral load)

135. Assignment
1. What are the advantages of HIV antigen tests over antibody/rapid tests?
2. What are the demerits of HIV antigen tests

136. CD4 T-Lymphocyte Counts
CD4 T-lymphocyte counts used
for:
Determining clinical prognosis
Assessing criteria for antiretroviral
therapy
Monitoring therapy

137. Viral Load Test
The viral load test measures amount of HIV in blood
Used to:
o Predict disease progression
o Assist with deciding when to initiate anti-retroviral therapy
o Monitors response to anti-retrovirals

138. Discordant couple
 Refers to situation where one of the sex partners is HIV positive whereas the other
one is HIV negative.
 The HIV negative partner is at risk for HIV acquisition and so requires a coupe
specific HIV prevention package
 In line with the WHO guidelines , the HIV negative client should be retested 4
weeks after initial testing then after 6 months and thereafter annually

139. Post-test Counselling

140. Post-test Counselling
 All HIV test results, whether positive or negative, must be given in
person, privately (as a single client or couple)
 Put the client or couple at ease
 Where possible, provide a quiet
and private room for the discussion
 Ideally, the same HCW who
conducted the pre-test session
will also conduct the post-test
session

141. Read results in 10 -12 minutes
Positive Negative

142. When Client Tests
HIV-negative
Post-test counselling provides an opportunity for client to:
Learn how to protect themselves from HIV infection

143. When Client Tests
HIV-negative (Continued)
Objectives of the post-test session:
1. Provide HIV test result and assess understanding of result
2. Identify and address client questions
3. Discuss:
 Partner HIV testing and disclosure
 Safer sex and risk reduction
 Exclusive breastfeeding
 Antenatal care, post-delivery care
 Importance of delivering in a healthcare facility
 Infant care
4. Provide referrals, take-home information

144. When Client Tests
HIV-positive
 Client reactions to results can range from acceptance to disbelief
 Remain non-judgemental, supportive and confident throughout the
counselling process
 Encourage client to return for visits and follow-up HIV post-test
counselling

145. When Client Tests
HIV-positive (Continued)
Objectives of the post-test session:
 Same as for post-test session when client tests HIV-negative, but counselor should
additionally discuss:
 ARV therapy or prophylaxis
 Infant feeding options
 Treatment and support services for client and family

146. Disclosure of HIV Status
 Disclosure is informing others of a test result
 Clients who disclose are in a better position to:
 Encourage partner(s) to be tested
 Prevent transmission of HIV to partner(s)
 Access PMTCT interventions
 Receive support from partner(s) and family
It is important to respect client's choice
regarding timing and process of disclosure

147. Management of HIV/AIDS

148. DRUGS FOR HIV/AIDS
 Drugs which suppress HIV have been named antiretroviral drugs (ARVs) due to
their ability to slow down HIV activity. Therapy that uses ARVS is called ART
(antiretroviral therapy)
 ART is once of the components of comprehensive HIV care, it works best when
other components are in place.
 ARVS improve the quality of life by stopping the virus from multiplying and allow
the body to recover.
 Although patients on ARVS may appear healthy, and gain weight, they can still
infect other people.
 Side effects and other problems may occur due to ART

149. Goals of ART
The goal of antiretroviral therapy is to;
i. Reduce the amount of HIV virus in the body
ii. Support and restore the immune system
iii. Reduce HIV illnesses and death
iv. Improve the quality of life
v. Reduce general risk of transmission in the public

150. Types of ARVs and How They Work
 ARVS act on the HIV virus by interfering with its viral cycle.
 There are 5 classes of ARVs currently in use namely;
o Nucleoside and nucleotide reverse transcriptase inhibitors
o Non nucleoside reverse transcriptase inhibitors
o Integrase inhibitors
o Protease inhibitors
o Fusion inhibitors

151. 1. Nucleoside/ Nucleotide Reverse
Transcriptase Inhibitors (NRTIs)
NRTIs inhibit the viral enzyme reverse transcriptase from converting viral RNA
into viral DNA, thereby halting HIV replication.
Examples;
o Abacavir (ABC)
o Zidovudine (AZT)
o Lamivudine(3TC)
o Tenofovir

152. 2. Non- Nucleoside Reverse Transcriptase
Inhibitors (NNRTIS)
NNRTIs inhibit the viral enzyme reverse transcriptase by binding
directly to it, blocking the reverse transcription process
Example are:
o nevirapine (NVP)
o efavirenz (EFV)
o Etravirine

153. 3. Integrase Inhibitors
 They target viral enzyme integrase
 Integrase is responsible for inserting viral DNA into the host chromosome
 Integrase inhibitors stop the virus from inserting itself into the DNA of
human cells
Examples
o Dolutegravir
o Raltegravir
o Cabotegravir

154. 4. Protease Inhibitors (PIs)
 Protease inhibitors work by blocking the activity of the viral enzyme protease
 HIV uses protease to break up large polyproteins into smaller pieces required for
assembly of new viral particle
Examples:
o Lopinavir
o Atazanavir
o indinavir

155. 5. Fusion Inhibitors
 They act by stopping the virus from attaching to the host cell by blocking the CD4
receptors on T cell
 The virus must attach to CD4 receptors to gain entry into the cells
Example (only one available): Fostemsavir

156. HIV STIGMA AND DISCRIMINATION

157. Stigma and discrimination
 HIV is not only the greatest public health challenge of our time, but it is also the greatest human
rights challenges.
 People love going with HIV are burdened not only with the disease but also with stigma and
discrimination
 Stigma and discrimination remain major barriers to,preventing HIV transmission and providing
treatment, care and support to,people who are HIV – infected and their families.
 The most effective responses to HIV epidemic are those that work to prevent stigma and
discrimination associated with HIV and protect the human rights of people living with HIV and
those at risk

158. What is stigma and discrimination?
 Stigma refers to unfavorable attitudes and beliefs directed towards someone or
something .
 HIV related stigma refers to unfavorable attitudes and beliefs directed towards people
living with HIV, their family and friends,,social groups, and communities.
 HIV related stigma is part of a " process of devaluation " off people either love living with
or associated with HIV and AIDS
 HIV related stigma is usually pronounced when behavior causing disease is perceived to
be under individual's control ( sex work or injecting drug use)

159. Cont’d…
 Certain groups ( men who have sex with men, sex workers, people who inject drugs
) bear heaviest burden of HIV – related stigma- people who are HIV – infected are
often assumed to be members of these groups whether they are not or not.
 Members of these groups are already heavily stigmatized and are more likely to
fade desrimination than others when diagnosed with HIV infection, especially when
the behavior linked to the origin of the infections is perceived to be under the
individuals control such as sex work, gay sex or injection of drugs.

161. The main forms of stigma include
i. Physical and social isolation from family,,friends and community
ii. Shaming and blaming people by condemning them for their behavior
iii. Depriving people of their right and decision making
iv. Self – stigma :- when people blame and isolate themselves
v. Secondary stigma :- th bus,ily and friends of people living with HIV are also
stigmatized.
vi. Stigma by looks appearance, or by types of occupation or lifestyle

162. EXAMPLE OF SELF STIGMA
Examples of self stigma and stigmatizing attitude are numerous;
i. Believing HIV is Devine punishment for moral misconduct
ii. Thinking women are responsible for transmitting HIV and other sexually
transmitted infections in the community
iii. Feeling "dirtied" by contact with PLHIV
iv. Stigma in language : referring to AIDS as " that disease" or to PLHIV as "walking
corpses" or "those expected to die"

163. CAUSES OF HIV – RELATED STIGMA
Research conducted all round the world has revealed 3 key causes of HIV –related stigma in
the community setting
i. Lack of awareness of what stigma looks like and why it was damaging
ii. Fear of causal contact stemming from incomplete knowledge about HIV transmission (
with high levels of fear of contagion among health workers) ( fear of death)
iii. Values linking people with HIV to improver or immoral behavior
iv. Fear and ignorance – people do not have clear idea of how HIV can and cannot be
transmitted
v. Gender and poverty: women get stigmatized more than men and rich people.

164. Cont’d…
 Appearance: person living with HIVs appearance e.g thinness, and ski rashes is used
as a basis of stigmatizing
 Media images : images of horrible death make people afraid of people living with
HIV

165. Fear of stigma stops people from;
 Getting tested
 Disclosing to partners
 Accessing treatment for opportunistic infections
 Fear of stigma keeps HIV underground

166. Effect of stigma
 Personal effect : shame, isolation, withdraw, feeling excluded, loss of self esteem ,
rights ,reputation and hope
 Feeling unproductive:- self blame,self hatred, take more risks , stress, anger,
violence, alcoholism, depression, suicide
 Family : family quarrels, blame, and conflicts,,Devore and separation
 Community : fired from work, forced to leave community drop out of school

167. Strategies for fighting stigma
 Deal with the stigmatizer privately not publicly
 Do not get upset
 Do not crisis the stigmatizer
 Help the stigmatizer to know how it feels to be treated like this
 Empower the person living with HIV to speak for his elf
 Get other family members to hep challenge the stigma

168. DISCRIMINATION
 Discrimination: the treatment of an individual or group with prejudice –
preconceived opinion that is not based on reason or actual experience.
 Discrimination includes the denial of basic human rights such as health care,
employment, legal services and social welfare benefits
 People living with HIV are kicked out of the family , home work or organization's

169. Example of discrimination
i. Health care worker denies services to person who is HIV –infected
ii. Family or village rejects wife and children of man who died of AIDS
iii. Man loses job because people Learn that he is HIV –related
iv. Community rejects woman who decides not to breastfeed because they assume she is
HIV – infected.
v. HIV –infected clients receive poor care are clinic because of health care worker's fears
about caring for people infected with HIV.

171. Cont’d…
 Stigma is an attitude directed towards a person but discrimination is an act
 Discrimination follows stigma and is the unfair and unjust treatment of an
individual based on his her real or perceived HIV status.

172. Human rights in relation to HIV
i. All people have a right to make decides about sexual and reproductive health
ii. People have the right to HIV testing and counseling and to know their HIV status
iii. People have a right to chose not to be tested or to choose not to be told their
test results.

173. Manifestations of stigma in health facilities
Many studies around the world have documented stigma and discrimination taking
place in the health care settings here some examples:
i. Neglect
ii. Different treatment
iii. Denial of care
iv. Testing and disclosing HIV status without consent
v. Verbal /abuse/ gossip/ harassment
vi. Avoiding and isolating HIV – positive patient
vii. Referring patients for HIV testing without counseling

174. Other forms of stigma and discrimination
 Informing family members of a patient's HIV status without his her consent
 Doing the following only with HIV – positive patient
 Burning their bedding upon discharge
 Charging them for the cost infection control supplies
 Using gl bed during all interactions,regardless

175. Cont’d…
 Even loving and surprise caregivers may stigmatize and discriminate against people
with HIV ( blaming scolding saying those poodle ) and so may not recognize
behavior of as stigmatizing.
 Stigmatizing happens even among health care workers opposed to HIV related
stigma who are not aware of their attitude

176. Reducing stigma in health facilities
 Stigma and discrimination are now recognized as one of the greatest challenges to
slower no the spread of the diseases key barriers to the delivery of quality services
by health providers and their utilization.
 HIV –related stigma is particularly harmful to any efficient response.
 The pervasive effects of HIV –related stigma and discrimination are devastating in
many ways and have been documented in many studies

177. Cont’d…
So as to reduce stigma and discrimination, especially in health care setting,
interventions must focus on three aspects.
i. Individual level
ii. Environmental level
iii. Policy level

178. Individual level
 At the individual level, it is important to among health care workers on stigma and
its consequences ( reduced quality of care, unwillingness to disclose its HIV status
and adhere to treatment regimens)
 Benefits of reducing stigma for the country
 It is also important to address health care about HIV transmission by giving the
complete information about how HIV is and is not transmitted and enforcing the
use of the universal precautions

179. Cont’d…
Issues of association of HIV and AIDS with assumed immoral and improper behaviors
can be addressed by:
 Helping health care workers to dissociate PLHIV from the behaviors considered
improper or immoral often associated with HIV infection.
 Providing health care workers with a safe space to reflect on the underlying values
that lead to the shame and blame

180. Cont’d…
Health care workers should serve as role model by
 Treat PLHIV same clients assumed to be HIV – negative
 Be aware of own feelings,thoughts attitudes about HIV
 Ensure feelings, thoughts, attitudes do no have negative effect on care provided

181. 2. ENVIRONMENTAL LEVEL
 At the environmental level, it's important to ensure availability to health workers of
the information, supplies and equipment necessary to practice universal
precautions and prevent occupational transmission of HIV
 Gloves for invasive procedures
 Sharp containers
 Adequate water and soap or disinfectant for hand washing
 Post –exposure

182. Cont’d…
At the policy level, policies need to be enacted that protect the safety of patients, as well
as health workers, to prevent discrimination against PLHIV
 Developed in a participatory manner
 Clearly communicated to staff
 Routinely monitored after implementation
 All staff members need to be involved, not just health professional. This included
doctors, nurses, guards cleaners, and supportive staff
 Training needs to be provided on both stigma and universal precautions

183. Summary
 Sometimes, we treat people badly because of how they look or we suspect they do.
We isolate them , e.g refusing to sit beside a person suspected to have HIV in the
clinic, or we gossip about them and call them names because of the way they
look.when we isolate or make fun of other propels, this is called stigma.
 Stigma is the process in which we ( society) create a " spoiled identity" for an
individual or a group of persons. We identify a difference in a person or group, such
as physical differences ( physical disfiguration) or a behavior difference ( people
having lots of sex) and then mark the difference as a sign of disgrace. This allows us
to stigmatize the person or groups. Stigmatized people loose status because of
these assigned signs of shame that other people consider indications or evidence of
sinful or immoral behavior

184. Summary
 Stigma is the belief or attitude that leads to discrimination. The action
resulting from stigma is discrimination unfair treatment such as people
living with HIV getting fire, kicked out of house or they get refused to be
treated at the clinic.
 When we stigmatize people living with HIV, we judge them saying that
they have broken social norms hence they should be ashamed, sad, and
rejected. They feel unwanted and lose confidence. As a result, they might
take less in protecting their health ( e.g stop using clinics and condoms)

185. SOCIAL BEHAVIOUR CHANGE COMMUNICATION
(SBCC)FOR HIV PREVENTION
 Social Behaviour Change Communication is the use of communication to change
behaviours including service utilization, by positively influencing peoples’
knowledge, attitudes and social norms.
 Reducing the spread of HIV and improving care and treatment for people living
with HIV and AIDS requires addressing social factors and behaviors that put people
at risk.
 Social and behavior change communication (SBCC) goes beneath the surface to
uncover the causes of the behaviors as well as the social structures that drive the
epidemic and the factors that increase risk and vulnerability
185

186. Cont’d…
 The key principle of social behaviour change approach is promoting positive
behaviour change. Community engagement, ownership and empowerment at the
community level are needed for the behaviour change approach, which focuses on
activities that create and sustain an enabling environment for behaviour change.
 Behavior change communication (BCC) is an approach used to support individuals’
ability to adopt and maintain a new positive behavior.
 This approach aims at increasing knowledge, stimulating dialogue and ensuring
that people are given accurate and timely information about HIV and AIDS in their
preferred language or medium.
186

187. Cont’d…
 The shift in terminology from BCC to SBCC is a recent milestone in health
communication
 SBCC puts emphasis on improving health outcomes through more healthful
individual and group behaviours, as well as strengthening the social context,
systems and processes.
187

188. Evolution of Behaviour Change
Health Education BCC SBCC
 Older approaches tried to persuade individuals to change their behaviours
 Newer approaches try to create an enabling environment to encourage healthy
behaviours
 New approaches look for tipping points of change that need to address social
change as much as individual behaviour change
188

189. Cont’d
 BCC approaches that ensure young people have the knowledge, skills, self esteem
and support (through youth-friendly comprehensive reproductive health services)
to make appropriate and responsible sexuality decisions that empower them to
avoid HIV infection.
 Involving young people themselves, parents, teachers, the religious community and
policymakers is essential in reversing the current trend and changing the
epidemic’s course.
189

190. Key Elements of SBCC
1. Communication using channels and themes that fit the target audience’s needs
and preferences.
2. Behaviour change through efforts to make specific health actions easier, feasible,
and closer to an ideal, that will protect or improve health outcomes.
3. Social change to achieve shifts in the definition of an issue, people’s participation
and engagement, policies, and gender norms and relations.
190

191. THE PROCESS OF BEHAVIOR CHANGE
Stages of behavior change
continuum
Enabling factors channels
Unaware Providing effective communication Mass media
Aware
Concerned Creating an enabling environment –
policies , community values , human
rights
Community networks and traditional
media
Knowledgeable
Motivated to change
Practicing trial behavior Providing user-friendly , accessible
services and commodities
Interpersonal / group
communication.
Practicing sustained behavior
change
191

192. Behaviour Change and Sexual Health
 Behaviour plays an important role in a person’s health.
 Behaviour is the way in which a person acts in response to a particular situation or
stimulus
 Human behaviour determines the health of the individual and the community
 Some of the human behaviours can have a major impact on community mortality
and morbidity (eg: unprotected sexual behaviours can cause Sexually Transmitted
Diseases (STD) including HIV infections and unwanted pregnancies).
 Many health interventions use Behaviour Change Communication (BCC) to change
the behaviour in a positive way to improve the health of the community
192

193. Cont’d…
 Human sexual behaviour is any activity occurring in solitude, between two persons,
or in a group, that induces sexual arousal
 Sexual behaviours are very sensitive and private in each one’s life
 however, it is important to promote desirable sexual behaviours to promote health.
193

194. Cont’d…
Social behaviour change communication aimed to achieve
UNAIDS targets of 90-90-90 by 2020 i.e.
1. 90% of all people living with HIV to know their HIV status
2. 90% of people diagnosed with HIV to receive sustained antiretroviral
therapy, and
3. 90% of people receiving Anti Retroviral Theraphy (ART) to have viral
suppression
194

195. Continuum of HIV Services
 Continuum of HIV services refers to a comprehensive package of HIV prevention,
diagnostic, treatment, care and support services provided for people at risk of, or
living with HIV, and their families.
 Examples of these services include combination of HIV prevention including
preexposure prophylaxis, HIV testing and linkage to care, management of
opportunistic infections and other co-morbid conditions, initiating, maintaining
and monitoring ART, switching to second-line and third-line ART, and palliative
care.
 Continuum of HIV care refers to a comprehensive package of HIV services for
people living with HIV (PLHIV).
195

196. Goals of SBCC
Generally, the goals of SBCC are to;
1. Increase condom use.
2. Increase appropriate STI care seeking behavior.
3. Delay sexual debut.
4. Reduce number of partners.
5. Increase perception of risk or change attitudes towards use of condoms.
6. Increase demand for services.
7. Create demand for information on HIV and AIDS.
8. Create demand for appropriate STI services
9. Interest policymakers in investing in youth –friendly VCT services.
10. Promote acceptance among communities of youth sexuality and the value of
reproductive health services for youth.
196

197. Desirable Behaviors in SBCC
 Acceptance and use of VCT services
 Using condoms and using a separate one for each sexual activity
 Using lubricants for anal sex by MSM
 100% adherence to ART
 Regular CCC follow-ups
 Involving partners/clients in HIV/STI interventions
 Empathy of general population towards people living with HIV/AIDS (PLWHAs)
197

198. Guiding Principles for SBCC
i. SBCC should be integrated with all HIV program goals from the start
ii. Formative BCC assessments must be conducted to improve understanding of the
needs of target populations, as well as of the barriers to and supports for behavior
change that their members face
iii. The target population should participate in all phases of SBCC development and
in much of implementation.
iv. Stakeholders need to be involved from the design stage.
v. Having a variety of linked communication channels is more effective than relying
on one specific one.
vi. Pre-testing is essential for developing effective BCC materials.
vii. Planning for monitoring and evaluation should be part of the design of any BCC
program.
viii. SBCC strategies should be positive and action-oriented.
ix. PLHA should be involved in BCC planning and implementation.
198

199. Steps for developing an HIV/AIDS BCC program
Step 1: Advocacy and stakeholder involvement
Step 2: Identification and segmentation of target populations
Step 3: Formative assessment for SBCC
Step 4: Development of a SBCC strategy
Step 5: Development of communication support materials
Step 6: Implementation of the SBCC program
Step 7: Monitoring and evaluation
Step 8: Feedback and revision
199

200. Components of SBCC
The key components of SBCC are;
i. Advocacy
ii. Behavior communication intervention
iii. Social mobilization
200

201. 1. Advocacy
Aims to secure much needed financial resources and improve existing policies,
guidelines and procedures by influencing concerned public leaders and other stake
holders.
Example of targeted advocacy activities include:
i. engaging policy makers in review of policies and legislation
ii. educating community leaders or sensitization of the media.
201

202. 2. Behavior communication intervention
 Seeks to increase awareness, influence social norms, induced behavior change
among targeted sub-populations and improve interpersonal communication and
Counseling between service providers and the target community.
 Specific BCI activities may include disseminating accurate information and
addressing misconceptions about HIV-related risky behaviors, educating and
encouraging key population groups to individuals to access the available health
services and promoting peer- based approaches that enhance service uptake
202

203. 3. Social Mobilization
 Aims to change societal norms, to improve services and build community support
by bringing groups together to fight stigma and address underlying social
problems at the community level.
 Specific activities may include promoting dialogue and health seeking behavior
through awareness – raising at community level.
203

204. Strategies used in BCC
1. Media campaigns
2. Use of interactive media and multiple channels to facilitate behaviour change
3. Use of mass media to reach a broad audience and introduce new desirable behaviours
4. Combining education with entertainment to engage young people and also connecting youth with
parents or other role models, schools, communities and religious groups.
5. Empowering young people in planning and implementing youth-related HIV and AIDS
interventions
6. Use of peer counseling
7. Use of community outreaches
8. Changing gender norms by building partnerships between men and women that transform
attitudes and beliefs about gender that fuel the epidemic
9. Challenging stigma and discrimination
10. Strengthening local capacity through training, volunteer work etc. to help fight HIV/AIDS
204

205. Intervention Strategies Under SBCC in HIV
Prevention and Control
The following intervention strategies are used for HIV prevention and control under
SBCC;
 Biomedical Intervention strategies to Reduce Exposure, Transmission or Infection
 Behavioural Intervention Strategies to Promote Individual Risk Reduction
 Social and Cultural Intervention Strategies
 Political, Legal and Economical Strategies
205

206. 1. Biomedical Intervention strategies to Reduce Exposure,
Transmission or Infection
These interventions include;
 Male and female condoms
 ART for pre and post prophylaxis and prevention of mother to child transmission
 ART for people living with HIV
 Blood safety- Standard precautions in health care settings
 Male circumcision( available in other countries)
206

207. 2. Behavioural Interventions to Promote
Individual Risk Reduction
Behavioural interventions at individual level include;
 HIV testing and risk reduction counseling
 Behaviour change communication to promote partner reduction, stick to one
faithful partner, condom use
 Cash incentives for individual risk avoidance
 Interpersonal communication, including peer education and persuasion
207

208. 3. Social and Cultural Intervention
Strategies
Social and Cultural Intervention Strategies include;
 Community dialogue and mobilization to demand services
 Stigma reduction programmes
 Advocacy for social justice
 Education and curriculum reforms
 Quality control
 Support youth leadership
208

209. 4. Political, Legal and Economical
Strategies
Political, Legal and Economical Strategies for HIV prevention and control include;
 Human rights programs
 Revision of workplace policies to minimize discrimination
 Strategic advocacy for legal reforms & regulations
 Policies e.g. for access to condoms, sexual education
 Training and capacity building of Police and Judicial sector
 Prevention diplomacy with leaders at all levels
 Community microfinance
209

210. Factors to be Considered in SBCC
 Promoting client-provider Interaction
 Provision of correct information including the benefits and availability of different
forms of treatment or interventions
 Provision of services to all regardless of sex, colour, marital status and sexual
orientation
 Allowing the client to choose which option of the intervention
 Assuring the client of the safety of the intervention
 Assuring the client that any personal information will remain confidential
 Maintaining the clients dignity throughout the interactions
210

211. Benefits of SBCC
 It increases the level of knowledge of HIV and AIDS
 It stimulates social and community dialogue
 It promotes attitude and behaviour change
 It promotes change in social norms in communities
 It helps reduce stigma and discrimination against people living with HIV
 and AIDS
 It creates demand for information and services
 It promotes an effective response to the HIV epidemic
 It promotes services for prevention, care and support of vulnerable populations
 It promotes advocacy/policy change
211

212. HOME AND COMMUNITY BASED CARE
(HCBC)
 Home-based care (HBC) refers to any form of care given to ill people in their
homes, including physical, psychosocial, palliative and spiritual activities
 HBC entails the provision of care to HIV/AIDS patients and their affected families at
home.
 Home and community-based care (HCBC) is used in many countries to increase
quality of life and limit hospital stay, particularly where public health services are
overburdened
212

213. Cont’d…
 HBC includes care extended from health facilities through family participation and
community involvement .
 It involves include strengthening of the patient s individuals responsibility for their
health – positive living.
 HBC integrates care with HIV education which prompted healthy lifestyles.
 HBC can be carried out by a variety of people including qualified healthcare
practitioners, nurses, trained lay community health workers, peer health workers
and HBC volunteers
213

214. Components of HBC
1. Counseling
2. Nutrition
3. Social support systems
4. Nursing care
5. Treatment
214

215. Key players in CHBC
1. Community health workers
2. Family
3. Health worker
4. Spiritual leader
5. CHVs
6. The patient
215

216. Benefits of HBC
1. Patients are nursed in familiar environment
2. Patients can get personalized care
3. Affordable
4. Close support from family and relatives
5. Flexible visitations
6. Easy to access patients
7. Helps in reducing stigmatization
8. Helps reduce burden of health facilities
9. Improves adherence to ART
10. Can provide coordinated care for a number of conditions, for instance combining
HIV and tuberculosis management
216

217. Objectives of HCBC
1. to provide medical care
2. To deliver ARVs
3. To provide psychosocial support
217

218. Comprehensive Care in HIV/AIDS
 Comprehensive care in HIV/AIDS is care that takes into consideration the client’s
spiritual , social , emotional and physical needs.
 The comprehensive care concept refers to the holistic approach towards the
management of a person infected with HIV.
 It addresses the persons wholesomeness in terms of body, mind and spirit.
218

219. 219

220. Elements of Comprehensive Care
Comprehensive care consists of;
1. Psychological support (on-going counseling)
2. Anti-retroviral therapy
3. Treatment of opportunistic infections
4. Nutritional counseling
5. PMTCT
6. Home-based care
7. Palliative care
8. Supportive groups (social support)
220

221. Questions??
221

222. SEXUALLY TRANSMITTED
INFECTIONS (STIs)
222

223. Definition
 The abbreviation STIs stand for sexually-transmitted infections
 They are viral, bacterial or parasitic infections that are spread
from person to person during sexual contact.
 Other modes of transmission may be through blood
transfusion, and from mother-to-child during pregnancy or
delivery
 There are so many STIs in the world which are curable but HIV
is the most serious STI.
223

224. Epidemiology of STIs
 More that 1 million people acquire STIs everyday around the world
 The most common STIs in Kenya are;
i. Chlamydia
ii. Gonorrhoea
iii. Syphilis
iv. Herpes
v. Genital warts
vi. Trichomonas vaginalis
 Chlamydia is the most prevalent, affecting mostly those aged 25- 29 years.
 Candidiasis is not considered a sexually transmitted infection, but it can be transmitted
during vaginal intercourse
224

225. Risk factors for STIs
A. Behavioral risk factors
1. Having multiple sex partners
2. Sex with commercial sex workers
3. Having unprotected sexual intercourse
225

226. B. Biological Risk factors for STIs
Biological risk factors include;
1. Age
2. Sex of the individual
3. Low immune status of the host
4. Virulence of the organism causing STI
226

227. C. Socio-cultural Risk Factors for STIs
1. Occupations involving a lot of travelling e.g. long distance drivers
2. In some societies, where men’s risky behavior of multiple sexual partners is tolerated
3. Early girl-child marriages to adults exposes the girl to infection
4. High numbers of single poorly paid and unemployed young people
5. Rural-urban migration
6. Sexual intercourse for pleasure and gain
227

228. Complications Associated with STIs
Failure to diagnose and treat STIs may result in serious complications
i. Increased risk of acquiring HIV
ii. They may cause infertility in both men and women
iii. Increased risk to cervical cancers
iv. They cause pregnancy complications e.g. ectopic pregnancy
v. Still birth
vi. Neonatal conjunctivitis (ophthalmia neonatorum caused by maternal
gonorrheoa)
vii. Urethral stricture which can lead to renal failure in men
viii. Painful intercourse
ix. Congenital blindness & congenital malformations
x. Death- HIV infection within 10yrs or more or within 1-2yrs after onset of serious
illness
228

229. Reasons why STIs are prevalent
1. Avoiding treatment
 Lack of symptoms- failure to recognise s/s
 Lack of access of health care
 Preference to traditional healers
 Fear of stigma, lack of confidence on health workers
2. Reluctance to refer partners
 People with STI are reluctant to refer their partners
229

230. 3. Reluctance to use condoms
 Lack of familiarity with condoms
 Stigma associated with condom use
 Cultural and religious prohibition
 Fear that sex is less enjoyable
 Fear of side effects (allergy)
230

231. Modes of transmission of STIs
Sexual Exposures
1. Unprotected sexual intercourse (over 80%)
2. Blood transfusion or contact with contaminated blood or blood
products (3 to 5% )
3. Transplant of contaminated organs
4. Use unsterile needles skin piercing implants including surgical
instrument
5. From mother to child during pregnancy, delivery, or
breastfeeding e.g. HIV, chlamydia, gonorrhoea, herpes
231

232. Non sexual exposures
6. Tattooing
7. Traditional circumcision
8. Traditional delivery with unsterile equipment
9. Intravenous (IV) Drug Use (5 – 10% )
10. Occupational Exposure to HIV infected
Material/specimens e.g. accidental needlestick injury
232
Cont’d…

233. Association Between HIV/AIDS and STI/RTI
 STI primarily disrupt the integrity of the skin/mucosal barrier, enabling HIV
easy access to the body.
 The presence of genital ulcers is known to increase the risk of HIV
transmission by upto 10 to 100 times.
 STIs that primarily cause inflammation, such as gonorrhoea, trichomoniasis,
and Chlamydia, and thus weaken the skin barrier to HIV.
233

234. Cont’d…
 Increased viral shedding has been reported in genital fluids of patients
with STI/RTI.
 STI/RTI treatment has been demonstrated to significantly reduce HIV
viral shedding.
234

235. HIV infection effect on STIs:
 HIV alters the response of STIs pathogens to antibiotics. This has been
reported for chancroid and syphilis.
 HIV alters the clinical appearance and natural history of STI/RTI as in
genital herpes and syphilis.
 HIV-infected individuals have increased susceptibility to STI/RTI.
235

236. Cont’d…
 Number of sexual partners and high risk partner selection, and are associated with
increased heterosexual HIV transmission.
 Due to this epidemiological synergy, STI/RTI control is considered a key strategy in the
primary prevention of HIV transmission.
236

237. Classification /Categories of STIs
There are 4 classes of STIs based on aetiology (cause);
1. Bacterial: Chlamydia, Syphilis, Gonorrhoea
2. Fungal: Candidiasis
3. Viral: Hepatitis, Genital Herpes Simplex, HIV, Genital
Warts
4. Protozoa: Trichomoniasis
237

238. Common STIs/STDs
1. Bacterial vaginosis (BV)
2. Chlamydia
3. Gonorrheoa
4. Syphilis
5. HIV
6. Genital ulcer disease (GUD)
7. Ophthalmia neonatorum
8. Genital herpes
9. Genital warts
10. Pubic lice
11. Non-specific urethritis
12. Candidiasis (thrush)
13. Trichomoniasis
14. Chancroid
238

239. 1. Urethral Discharge Syndrome
 Urethral discharge is one of the most common STI/RTI syndromes among
men, and is associated with serious complications.
 This syndrome is commonly caused by Neisseria gonorrhoeae and Chlamydia
trachomatis in over 98% of cases.
 Other infectious agents include Trichomonas vaginalis, Ureaplasma
urealyticum, and Mycoplasma spp.
 Mixed infections, especially of Neisseria gonorrhoeae and Chlamydia
trachomatis, occur.
239

240. Cont’d…
It is characterized by purulent urethral discharge
with or without dysuria.
The amount of discharge varies depending on the
causative pathogens as well as prior antibiotic
treatment.
240

241. Cont’d…
 If the discharge is not readily apparent, it may be necessary to milk the penis
and massage it forwards before the discharge becomes apparent.
 In uncircumcised patients, examination with the foreskin retracted will ascertain
whether the discharge is from the urethra or from beneath the prepuce.
241

242. 242

243. Management
 Norfloxacin 800mg stat (or Ciprofloxacin 500mg stat) and
Doxycycline 100mg BD x 7 days
ALTERNATIVE TREATMENT
 IM Spectinomycin 2g stat (or IM Ceftriaxone 125-250mg single
dose) and Doxycycline 100mg BD x 7 days
 Emphasize 4Cs – counselling, compliance, contact tracing, and
condom use
 Offer or refer for HIV testing services.
243

244. Assignment
Write short notes on the following STIs;
1. Gonorrhoea
2. Chlamydia
3. Candidiasis
For each, include;
o Aetiological agent
o Signs and symptoms
o Laboratory test/s for the STI
o Treatment
o Prevention and control

245. 2. Genital Ulcer Disease
 Genital ulcer disease is one of the most common syndromes that affect men
and women.
 Genital ulcers have an epidemiologically synergistic relationship with HIV.
 HIV alters the natural history of syphilis and chancroid, where more aggressive
lesions may manifest.
 HIV transmission, on the other hand, is enhanced in presence of ulcerative
STI/RTI.
245

246. 246

247. 247

248. Ct’
 In men, GUD occurring under the prepuce may present as a discharge.
 Similarly, GUD in women may also present as a discharge, underlying
the importance of clinical examination.
 Genital herpes manifest with more persistent lesions.
 Single or multiple ulcers can present.
248

249. a. Chancroid
 Chancroid is caused by a bacterium known as Haemophilus Ducreyi.
 Both males and females with chancroid develop painful genital ulcers.
 In males, ulcers are commonly found on the edge of the glans-penis, but
can appear anywhere on the external genitalia.
249

250. Ct’
 In females, ulcers may be found anywhere on the external genitalia
including around the vulva, clitoris, and anus, or inside the vagina and
on the cervix.
 A chancroid ulcer is painful while a syphilitic ulcer is not.
250

251. Clinical features
 Ulcer
 Enlarged, red, hot lymph nodes in the groin, called buboes. They
should be aspirated with a wide-bore needle every two days if
necessary.
 When a bubo is ready for aspiration, the skin overlying it is shiny
and the area underneath it is soft.
251

252. b. Syphilis
 The disease is caused by a bacterium known as Treponema Pallidum.
 It can affect all organs of the body. It occurs in two forms: early (primary)
and late syphilis.
 In early syphilis a client is infectious to his/her sexual partners. During
late syphilis, the client is not infectious to sexual partners.
252

253. 1. Primary Syphilis
 Three weeks after contact with an infected partner, the ulcer develops
at the site of infection. This is the primary chancre.
 It may be found anywhere on the penis in males. In females it is found
on the external genitalia, the vaginal opening, inside the vagina, or on
the cervix.
 In both men and women, it is a painless, single, firm ulcer with a
punched-out appearance.
253

254. Ct, 1⁰ syphilis
 It may heal without treatment but the client can still infect others and may
develop serious cardiac and CNS symptoms later. The client needs to be
treated.
254

255. 2. Secondary Syphilis
 Between two and four months following initial infection, clients may
develop secondary syphilis.
 The first sign is a non-itchy rash all over the body which may become
papular(round, solid raised lesion), pustular(infected pimples), or may
develop into flat warts (condylomata lata).
255

256. Manifestations of 2⁰ syphilis
 There may be whitish lines on the tongue and mucous membrane of the
mouth called snail track ulcers. They may be generalised lymph node
enlargement.
 Neurologic infection- cranial nerve dysfunction, meningitis, stroke, acute
or chronic altered mental status, loss of vibration sense, and
auditory/ophthalmic abnormalities, which might occur through the
natural history of untreated infection
256

257. 3. Latent Syphilis
 During this stage, there are no signs or symptoms but a blood test is
positive and the client should be treated.
Late syphilis
 Untreated syphilis may progress. After two to 15 years, the heart and
brain may be affected.
 The patient may develop mental problems
 At this time the disease cannot be passed to other people.
257

258. C. Genital Herpes
 Infection is caused by the herpes simplex virus.
 In males, the client develops itchiness at the site of infection. This may
be on the foreskin, the shaft of the penis, or the glans-penis. A small
area of redness appears which develops into small blisters. This may
break down to reveal painful, shallow ulcers.
258

259. Ct’
 In the first attack, lesions are more extensive and cause
severe pain. The attacks heal after about two to three weeks.
 In females, the lesions are on the cervix, the labia, the vagina,
or around the anus. During the first attack, there may be
quite extensive inflammation of the cervix, the vulva, and the
vagina.
259

260. Ct’
 Recurrence of lesions occurs in about 50% of clients; lesions are usually
less extensive and heal within five to seven days.
 Recurrences in both males and females may follow sexual contact and
stress. In females they may also follow the menstrual period.
260

261. Ct’
 There is no effective cure. Clients should be reassured, but warned that a
recurrence of ulceration is possible and that they should not have sexual
intercourse while lesions are present.
 Herpes simplex virus can be passed on when there are ulcers.
 Tell the client to keep the lesions clean and dry and wash with soap and
water.
261

262. Management of Genital Ulcer Disease
Erythromycin 500mg TID x 7 days
&
Benzathine Penicillin 2.4 MU IM stat
 If Penicillin allergy:
Use Erythromycin 500mg QID x 14 days
Alternative GUD Rx:
Ciprofloxacin 500mg single dose
262

263. 3. Vaginal Discharge
Physiological discharge: normal
 Clear or white
 Viscous in consistency
 Located in the posterior fornix of the vagina
Microscopy of normal vaginal secretions reveals:
 Superficial epithelial cells
 Lactobacilli with long rods
 Few white blood cells
Physiologic vaginal discharge requires no Rx
263

264. Abnormal Vaginal Discharge
 Abnormal vaginal discharge is one of the most common STI/RTI syndromes
among women, but also one of the most complicated to manage.
 All women have a physiological vaginal discharge which may increase during
certain situations.
 Normally, women will only complain if they perceive the discharge to be
abnormal.
264

265. 265

266. Aetiology
 The symptom of abnormal vaginal discharge is highly indicative of
vaginitis and poorly predictive of cervicitis
 Bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis are
the most common causes of vaginitis
 Gonococcal and chlamydial infections cause cervicitis.
Distinction between the two on clinical grounds is usually difficult.
266

267. Possible causes of vaginal discharge
1. Neisseria Gonorrhoea– Greenish-yellow discharge
2. Chlamydia trachomatis– Scanty muco-purulent or purulent
discharge
3. Trichomonas vaginalis– Frothy, profuse, greenish-yellow
foul-smelling discharge
4. Candida albicans– White, curd-like discharge
5. Gardnerella vaginalis– Profuse foul-smelling and
homogenous greyish-white discharge
267

268. Management
Offer or refer for HIV testing services
VAGINITIS Rx
Clotrimazole 1 pessary intravaginally daily for 6 days Or
Clotrimazole 200mgs pessaries intravaginally daily for 3 days) AND
Metronidazole 400mg
If pregnant
Clotrimazole 1 pessary intravaginally daily x 6 days Or
Clotrimazole 200mgs pessaries intravaginally daily for 3 days)
268

269. Cervicitis Rx
Norfloxacin 800mg stat (or Ciprofloxacin 500mg stat)
&
Doxycycline 100mg BD x 7 days
IF PREGNANT
IM Spectinomycin 2gm stat (or IM Ceftriaxone 250mg single dose)
&
Erythromycin 500mg QID x 7 days
269

270. 4. Lower Abdominal Pain Syndrome (PID)
 This is one of the most common and most serious STI syndromes among
women, with very serious reproductive health and socioeconomic
consequences.
 PID comprises a spectrum of inflammatory disorders of the upper
female genital tract, including any combination of endometritis,
salpingitis, tubo-ovarian abscess, and pelvic peritonitis
270

271. Causes
 Sexually transmitted organisms, especially N. gonorrhoeae and C.
trachomatis, are implicated in many cases; however, microorganisms that
comprise the vaginal flora (e.g., anaerobes, G. vaginalis, Haemophilus
influenzae, enteric Gram-negative rods, and Streptococcus agalactiae)
have been associated with PID
271

272. Clinical manifestations
 Abdominal pain,
 abnormal cervical or vaginal mucopurulent vaginal bleeding
 Dyspareunia
 fever, and sometimes vomiting.
N/B
Patients should be carefully evaluated for abdominal tenderness, cervical motion and
adnexial tenderness, enlargement of uterine tubes, and tender pelvic masses.
272

273. Diagnosis
 A thorough history and examination to exclude other surgical and/or
gynaecological emergencies must be done.
 Bimanual vaginal examination
273

274. Management
 Norfloxacin 800mg stat (or Ciprofloxacin 500mg single dose) AND
 Doxycycline 100mg BD x 7 days
 Metronidazole 400mg BD x 10 days
If pregnant:
 Refer for obstetric evaluation if PID is suspected
274

275. ALTERNATIVE TREATMENT
 Azithromycin 1gm PO single dose or
 Cefixime 400mg PO single dose
 Offer or refer for HIV testing services.
275

276. 5. Ophthalmia Neonatorum
 This refers to conjunctival infection of neonates.
 Neonates acquire this infection during passage through an infected birth
canal during delivery.
 Occurs between 4–7 days of life, but can occur anytime in the first 28
days.
 Caused by Neisseria gonorrhoea(GC) or Chlamydia
trachomatis(Chlamydia).
276

277. Clinical manifestations
 This disease is often characterized by bilateral purulent eye discharge. In
early stages, the discharge may be “sticky,” causing the eyelids to be
stuck together in the morning, rather than the thick, greenish pus seen
later.
 The conjunctiva is inflamed and eyelids swollen.
 Corneal scarring may occur if treatment is delayed.
 Blindness in children is associated with high infant morbidity and
mortality.
277

278. 278

279. Treatment
 1% TETRACYCLINE eye ointment TDS x 10 days
 Treat mother for cervicitis and partner for urethritis
Alternative
Ceftriaxone 62.5mg IM stat and 1%
Tetracycline eye ointment TDS x 10 days and 4Cs
279

280. 6. OTHER STI SYNDROMES
 Inguinal Buboes
 Painful scrotal swelling
 Balanitis
 Bartholin’sabscess
 Genital warts
 Congenital syndromes
280

281. Genital warts
 Genital warts are caused by a virus –human papilloma virus.
 They usually have the appearance of flesh-coloured cauliflower-like growths on
the genitals.
 The penis and foreskin (men) and the labia or vagina (women) are the most
common sites of the warts.
 The warts can be variable in number and size, either few or multiple, small to
very large.
281

282. Clinical manifestations
 Are usually asymptomatic, but depending on the size and anatomic location, they
can be painful or pruritic.
 Genital warts are usually flat, papular, or pedunculated growths on the genital
mucosa
 Genital warts occur commonly at the introitus in women, under the foreskin of the
uncircumcised penis, and on the shaft of the circumcised penis.
282

283. 283

284. 284

285. 285

286. Management
 Warts are treated with local application of podophyllin(10-25% solution) once a
week.
 After treatment of warts, the medication must be washed off within 2-4 hours to
avoid developing sores at the site of treatment.
 Podofilox 0.5% solution or gel
OR
 Imiquimod 5% cream
OR
 Sinecatechins 15% ointment
286

287. Association Between HIV/AIDS & STIs
 STIs primarily disrupt the integrity of the skin /mucosal membrane barrier,
enabling easy HIV access to the body.
 The presence of genital ulcers Is known to increase the risk of HIV
transmission by 10 to 100 times.
 Some STIs cause inflammation such as Gonorrhoea trichomoniasis and
chylamdia thus weakening the skin barrier to HIV
 Increased viral shedding has been reported in genital fluids of patients
with STIs
287

288. Prevention and Control of STIs
Introduction
The prevention and control of STIs are based on the following five major strategies:
i. Education and counseling of persons at risk on ways to avoid STIs through
changes in sexual behaviors and use of recommended prevention services.
ii. Identification of asymptomatically infected persons and of symptomatic
persons unlikely to seek diagnostic and treatment services.
iii. Effective diagnosis, treatment, and counseling of infected persons.
iv. Evaluation, treatment, and counseling of sexual partners of persons who are
infected with an STD
v. Barrier methods – the consistent use of condoms
vi. Pre-exposure vaccination of persons at risk for vaccine-preventable STIs.
Vaccines are available for 2 STIs – Hepatitis B and HPV
288

289. 1. Primary Prevention
 Primary prevention of STIs begins with promoting changes to risky sexual
behaviors that increase the risk of infection.
 Health care providers have a unique opportunity to provide education and
counseling to their patients.
 As part of the clinical interview, health care providers should routinely and regularly
obtain sexual histories from their patients and address management of risk
reduction.
289

290. Primary Preventive Measures
 Some of the measures one can employ to avoid STI include:
1. Abstinence
2. Mutual monogamy
3. Correct and consistent use of condoms
4. Safer sex practices
290

291. 1. ABSTINENCE
 This might be total abstinence from sex or, for groups such as students and youth
not yet married, one should encourage “postponed sex” till one is ready for
marriage.
291

292. 2. MUTUAL MONOGAMY
 Mutually faithful sexual relationship or what is usually termed as “Zero grazing” if
both partners are not already infected.
292

293. 3. CORRECT AND CONSISTENT USE OF
CONDOMS
 This intervention is recommended for those who cannot abstain and yet cannot
have a mutually faithful relationship.
293

294. 4. SAFER SEX PRACTICES
 Safer sex practices are many and varied but all revolve around the principle of
avoiding exchange of sexual or body fluids, yet enabling the individual(s) to
obtain what they desire out of sex.
 Use of condoms is an important safe sex practice
294

295. SECONDARY PREVENTION
1. Early diagnosis and prompt and correct treatment of STI
2. Promotion of STI care-seeking behaviour, including reduction of barriers to
care
3. Notification of partners and treatment/contact tracing
4. Screening for asymptomatic cases
295

296. 2. Secondary Prevention
 Secondary prevention curtails STIs onset and transmission through early diagnosis
and treatment.
 Risk-reduction counseling must screen clients for infection, discourage risky sexual
activities, and encourage partner notification of infections.
 Patient-initiated partner notification may encourage partner referral for STIs
etiological evaluation and treatment.
 Where appropriate laboratory facilities for investigations are unavailable the
syndromic management approach is recommended.
296

297. 3. Tertiary Prevention
 Tertiary prevention requires medical treatment focuses on reduction of
local complications (e.g. urethral stricture) or systemic complications (e.g.
pelvic inflammatory diseases and AIDS), and sequelae associated with
untreated or incompletely treated infections.
297

298. Risk factors for STIs acquisition and transmission
1. Participation in unprotected vaginal, oral or anal
sex(no condom used)
2. Genital to genital sexual contact
3. Previous history of STIs
4. Having multiple sexual partners
5. Use of non-barrier contraceptives, such as
6. Spermicides especially those containing n-9 due
to disruption of the genital epithelium
298

299. Risk factors, Ct..
7. Use of injection drugs, alcohol or other substances
that can impair decision making ability
8. Use of prep which may lead to decreased use of
condoms hence increased risk
9. Inconsistent and irregular use of condoms during sex
10. Vaginal practices e.g. Douching
11. Group sex
299

300. Vulnerable groups / Risk factors for STIs
1. Having primary education or less for an individual and/or their spouse
2. Lack of formal employment
3. Poverty
4. Low income
5. Alcohol and substance abuse
6. Individuals and/or partners with multiple sex partners
7. Gender based violence
8. Mental and physical disability
300

301. Vulnerable groups in STIs
9. Childhood sexual abuse
10. Child marriage
11. Out of school adolescents
12. Early sexual debut
13. Disempowerment of women
14. People living with hiv
15. Conflict situations
16. Refugees/internally displaced persons and immigrants
301

302. Management of STIs
Introduction
STIs can be managed through aetiological, clinical and syndromic approaches;
or through a combination of these approaches. The management of any STI
through all of these approaches should follow these standard steps:
1. History taking
2. Physical examination
3. Establishment of diagnosis and treatment plan
4. Education and counseling to prevent re-infection
302

303. Cont’d…
5. Education and counseling to enhance compliance
6. Condom promotion, demonstration and dispensing
7. Assisted partner notification
The last 4 steps are commonly referred to as 4Cs namely: Counseling,
Compliance, Condoms and Contact Tracing. In addition, irrespective of the
approach of management used, all STI patients should be provided with HIV
testing services.
303

304. What are the 4cs?
i. Counseling : Empathize with the patient
ii. Compliance: Your patients should avoid self medication, take full course
of medicine and not share and follow instructions as advised.
iii. Contact tracing: Encourage disclosure and tell her or his sexual,partners
to seek medication
iv. Condoms
304

305. The End
305